t PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE OBSTETRICS PLATE I. VERTICAL MESIAL SECTION THROUGH BODY OF WOMAN DYING IN LABOR WITH UNRUPTURED MEMBRANES PROTRUDING FROM VULVA. OBSTETRICS A TEXT-BOOK FOR THE USE OF STUDENTS AND PRACTITIONERS BY J. WHITRIDGE WILLIAMS PROFESSOR OF OBSTETRICS, JOHNS HOPKINS UNIVERSITY; OBSTETRICIAN-IN-CHIEF TO THE JOHNS HOPKINS HOSPITAL; GYN/ECOLOGIST TO THE UNION PROTESTANT INFIRMARY, BALTIMORE, MD. THIRD ENLARGED AND REVISED EDITION WITH SIXTEEN PLATES AND SIX HUNDRED AND SIXTY-EIGHT ILLUSTRATIONS IN THE TEXT NEW YORK AND LONDON D. APPLETON AND COMPANY 1915 Copyright, 1903, 1904, 1907, 1909, 1910, 1912, By D. APPLETON AND COMPAiNY PRINTED AT THE APPLETON PRESS NEW YORK, U. S. A. TO Jj 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 ii • • • 211 Breast, lactating...........323 Breech presentation, birth of head in......295-296 dolichocephalic head in ......... 276 Brow presentation, configuration of head in......290 XX11 LIST OF ILLUSTRATIONS IN TEXT FIG PAGB Brow presentation, left anterior........288 290 right posterior...........289 290 Caput succedaneum, disappearance of ..... 269-271 279 Cervical canal, complete obliteration of, external os intact . . . 228 250 Cervix, dilatation of, funnel-shaped obliteration of internal os and cervi- cal canal...........226 249 dilatation of, funnel-shaped obliteration of internal os and cervical canal, further advanced.........227 250 dilatation of (Saxinger).........231 251 dilatation of (Schroeder).........229 251 dilatation of (Tibone)..........232 252 dilatation of (Winter)..........230 251 Cervix at end of pregnancy (Braune and Zweifel) ..... 218 244 (Leopold)............219 244 (Midler's diagram)..........216 243 (Waldeyer)............217 244 Colostrum, human ........... 324 360 Delivery, method of holding back head to protect perineum in . . 311 326 of posterior shoulder . . . . . . . . . .313 328 palpating head through perineum before ...... 309 322 patient in proper position for, and covered by sterile dressings . . 310 323 traction to bring about descent of anterior shoulder in 312 327 Direct pressure exerted by fundus after complete evacuation of amniotic fluid............235 254 Engagement does not occur in transverse diameter of superior strait, dia- grams showing why........247-248 266 Face presentation, configuration of head in ..... . 284 287 delivery of head in.......280, 281-282 285, 286 diagram illustrating impossibility of labor with chin directly posterior . 278 284 diagram of, showing conversion into a vertex by Thorn's manoeuvre . 287 289 diagram showing that, when face is on level of ischial spines, greatest diameter of head is above superior strait ..... 286 288 diagram showing that, when vertex is on line joining the ischial spines, greatest diameter of head has passed superior strait . . . 285 288 distention of vulva in ......... . 279 285 distortion of face after delivery in....... 283 287 occiput long end of head lever........277 284 tumor of neck in...........275 283 Fascia, pelvic and perineal, arrangement of . . . . . . 238 257 Flexion, diagrams showing effect of, conversion of occipito-frontal into sub- occipito-bregmatic diameter......251-252 268 Fcetus, position of, after engagement.......246 265 position of, before engagement........245 265 Fcetus papyraceus...........332 373 Frozen section, just after completion of third stage of labor, showing col- lapse of uterine segment and cervix......322 342 latter part of pregnancy, child in L. S. T.......293 293 second stage of labor, child in R. O. A., membranes unruptured . . 250 268 showing condition of the birth canal in first part of second stage of labor 222 247 showing condition of the birth canal in first part of second stage of labor (Braune)...........241 259 showing condition of the birth canal in last month of pregnancy . . 240 258 showing uterus immediately after delivery......321 339 LIST OF ILLUSTRATIONS IN TEXT xxm Frozen section, third stage of labor, showing twin placenta1 in utero through woman at end of pregnancy, child in R. O. T. through woman dying during second stage of labor, showing contraction ring........... through woman in labor, with child partly delivered . Head, showing suboccipito-bregmatic, suboccipito-frontal, and occipito frontal diameters........ Head lever, diagram showing........ Intra-uterine pressure, diagram showing action of, after rupture of mem branes.......... diagram showing action of membranes not ruptured . Lower uterine segment, diagram illustrating main views as to nature of showing rhomboidal arrangement of muscle fibers . Mento-anterior presentation, left right ...... Milk, human..... Needle holder..... Obstetrical bag..... Occipitoanterior presentation, left . right ...... Occipito-posterior presentation, left . right...... Ovum with double germinal vesicle . Pelvic floor, distended by presenting part, showing superficial muscles of perineum . Been from above . seen from below . Perineal tear, complete deep . needle for repairing repair of, extending up to vagina repair of, sutures tied . superficial .... Placenta, diagram illustrating extrusion of, by Duncan's mechanism diagram illustrating extrusion of, by Sehultze's mechanism . diagram illustrating later stage in extrusion of, by Sehultze's mechanism diagram showing relation of, to membranes in double- and single-ovum twin pregnancy...... double-ovum twins, velamentous insertion of cord expression of •...... relation of, to uterine wall in latter part of pregnancy relation of, to uterine wall in second stage of labor . Posterior rotation, from L. O. P. (diagram) from R. O. P. (diagram) Rotation, internal, showing direction in R Sacro-anterior presentation, left right . . • • ■ Synclitism, diagram illustrating Twins, collision between heads of locked . position of, in utero Vaginal examination, method of covering patient before making spreading apart the labia before making .... S. P FIG. 299 244 220 257 256 253 234 233 221 223 273 274 325 318 306 242 243 261 2(52 326 239 236 237 316 315 317 319 320 314 302 300 301 328 327 305 297 298 265 266 294 291 292 249 333 334 329-331 307 308 PAGE 302 263 245 271 270 268 253 252 246 248 282 282 360 336 315 262 262 .275 275 369 258 256 256 335 334 336 337 337 334 304 303 303 371 370 307 301 301 276 276 295 293 293 267 376 377 372 318 319 xxiv LIST OF ILLUSTRATIONS IN TEXT FIG. PAGE Vertex presentation, configuration of head in . . . . 272 280 delivery of head ........... 258 271 delivery of head...........259 272 delivery of head ........... 2(50 273 delivery of head with occiput in hollow of sacrum . . 267-268 277 OBSTETRIC SURGERY Balloon, Champetier de Ribes's ........ 339 390 Champetier de Ribes's, ready for introduction ..... 340 390 Basilyst, Simpson's, articulated ........ 434 478 Simpson's, disarticulated ......... 433 477 Basiotribe, Tarnier's . . . . . . . . . .431 476 Tarnier's, disarticulated......... 430 47(5 Tarnier's, effect of..........432 477 Blunt hook, Braun's..........435 478 Braun's, decapitation with.........436 479 Braun's, showing mode of action.......437-438 479 Cephalotribe, Tarnier's..........429 476 Cranioclast, Braun's..........427 475 head crushed by...........428 475 Curette.............440 484 Dilator, Goodell's...........337 384 Douche, tube, glass...........439 482 Extraction, breech, delivery of after-coming head, back posterior . . 411 436 introduction of fingers to free posterior arm.....408 434 Mauriceau's manoeuvre, downward traction.....409 435 Mauriceau's manoeuvre, upward traction......410 435 posterior rotation of shoulder........407 433 traction upon feet..........405 431 traction upon thighs..........406 432 Extraction, frank breech, finger in anterior groin.....412 437 fingers in groins...........413 438 Pinard's manoeuvre for bringing down a foot in.....414 439 Forceps, application of, along occipito-mental diameter, pelvic curve tow- ard face...........359 409 application of, obliquely over brow and mastoid region .... 361 410 application of, along occipito-mental diameter, pelvic curve toward occiput...........358 409 application of, one blade over occiput and other over face, forceps re- maining unlocked.........362 410 application of, over brow and occiput, showing extension of head . . 363 410 application of, to face, along occipito-mental diameter .... 360 409 Chamberlen's,........... 350 403 English, lock of...........348 401 French, lock of...........349 401 French, long............354 404 Hermann's............398 425 high, diagram showing defect of cephalic application in .... 395 423 high, Pajot's manoeuvre.........397 424 high, Tarnier's diagram showing defects of ordinary .... 396 424 Hubert's............399 425 LIST OF ILLUSTRATIONS IN TEXT Forceps, inversion of, when anterior rotation is attempted in R. 0. P. position, without re-applying instrument .... 384 low, horizontal traction .... low, horizontal traction, occiput directly posterior low, in place and articulated low, introduction of left blade to left side of pelvis low, left blade in place . low, left blade in place, introduction of right blade low, upward traction ..... low, upward traction, extreme low, upward traction, occiput directly posterior mid, applied in L. O. A.........376- mid, applied in R. O. T. . . . . . . . . 37S- mid, hand in vagina seeking posterior ear mid, introduction of first blade mid, introduction of second blade mid, manner of making traction in mid, rotation in R. 0. A. Morales's ...... ovum ....... Palfyn's...... position of head in floating, high, mid, and low operations Scanzoni's manoeuvre, first application of instrument. . . 386- Scanzoni's manoeuvre, showing difficulty in articulating blades in second application of instrument . Scanzoni's manoeuvre, showing rotation to anterior position, instrument inverted . . ... . . . . . . 390- Scanzoni's manoeuvre, showing rotation to transverse position . 388- Scanzoni's manoeuvre, second application of instrument. . . 392- short ...... Simpson's, cephalic curve Simpson's, pelvic curve Smellie's long .... Smellie's short .... Tarnier's ..... Tarnier's, diagram showing traction with . Tarnier's traction rods in place without handle-bar Tarnier's original axis-traction .... Leg-holder, Robb's ....... Manual dilatation of cervix, Harris's method . Operation, preparation for, showing patient covered with sterile dress ings..... preparation for, showing patient at edge of bed, with legs held in posi tion by leg-holder .... Pack, vaginal and cervix, in position Placenta, manual removal of . Perforating of head...... Pubiotomy, incisions for..... position of patient for, and Gilgi saw . Rotation of occiput to sacrum, diagram showing to symphysis pubis..... Scissors, Smellie's...... Symphyseotomy, diagram showing effect of 385 368 371 367 364 365 366 369 370 372 377 379 373 374 375 381 380 400 338 351 357 387 391 389 393 353 346 347 355 352 403 404 402 401 356 342 419 413 414 412 411 411 412 413 413 414 416 417 415 415 416 418 417 425 384 403 408 420 394 422 421 420 421 104 400 400 404 404 426 427 426 425 407 392 336 380 335 379 341 391 442 487 426 474 423 465 424 466 382 418 383 418 425 473 422 461 XXVI LIST OF ILLUSTRATIONS IN TKXT Uterus, packing of, for post-partum haemorrhage .... Vaginal Caesarean section, exposure of cervix and primary incisions in incision of anterior uterine wall after separation of bladder in . laying sutures in anterior incision, posterior incision already sutured Version, bipolar podalic ......... external cephalic .......... internal podalic, seizure of foot in ...... transverse presentation, back anterior, seizure of lower foot in transverse presentation, back anterior, seizure of upper foot in . transverse presentation, back posterior, seizure of lower foot in, showini arrest of buttocks at pelvic brim ..... transverse presentation, back posterior, seizure of upper foot in FIG. PAGE . 441 485 . 343 395 . 344 396 . 345 397 421 44(5 . 415 442 . 416 443 . 417 444 418 444 . 420 445 . 419 445 PATHOLOGY OF PREGNANCY Abortion, early, showing decidua reflexa and serot ina with degenerative em bryo ..... Albuminometer, Esbach's Amniotic adhesions, amputation by amputation of fingers by encephalocele resulting from Blood mole, section through Chorion, attachment of, to tube wall Chorionic villi, normal, teased out in salt solution syphilitic, teased out in salt solution Compression of fcetus in oligohydramnios Decidua, uterine, from a case of extra-uterine pregnancy . Decidua polyposa ........ Decidual cells in right tube, with pregnancy in opposite tube Deciduoma malignum, showing alveolar arrangement of primary tumor showing syncytial masses invading channel Diverticulum from lumen of tube Eclampsia, urinary chart of; death, forty-eight hours after onset urinary chart of; recovery urinary chart of; recovery . Eclamptic liver .... Endometritis, decidual Endometritis decidua cystica . Fcetal epiphysis, normal . normal, magnified syphilitic ..... syphilitic, magnified . . . Haematoma, tuberous subchorial Hydatidiform mole .... microscopic section of . microscopic section through . (Edema of vulva .... Placenta, battledore, marginal insertion of cord bipartita ..... cyst of ..... duplex, with two succenturiate lobules fenestrata ..... marginata..... 499 630 449 533 481 601 480 601 479 601 501 632 506 649 495 618 496 618 478 600 509 653 470 581 507 650 476 592 477 593 502 642 453 541 454 543 455 544 456 546 472 582 471 581 491 616 493 617 492 616 494 617 500 631 473 584 475 590 474 58(5 443 500 490 611 483 603 489 608 487 605 482 602 488 605 LIST OF ILLUSTRATIONS IN TEXT iod Placenta membranacea ..... normal full-term . . . . scptuplex, corrosion preparation of syphilitic full-term ..... tripartita ....... Placental giant cell and chorionic villus in blood-vessel of tube wall some distance from placental site...... Pregnancy, broad ligament ........ early tubal, showing ovum embedded in wall of tube outside of lumen early tubal, with abortion of ovum into lumen of tube . in accessory tubal ostium .... in horn of uterus contained in inguinal canal in rudimentary left uterine horn . interstitial ....... isthmio; rupture ten days after last menstrual per ovarian, diagram illustrating Thompson's specimen . ruptured ampullar ......... Pregnant uterus, hernia of ....... . prolapsed ........... retrofiexed, incarceration of . retroflexed, sacculation of ....... . Toxaemia, pre-eclamptic, urinary chart of; recovery after accouchement pre-eclamptic, urinary chart of; recovery under milk diet . Tubal abortion, ovum being extruded through fimbrated extremity . Tubal mole, section through ........ Ureometer, Doremus's ......... Uterus bicornis duplex ......... bicornis septus .......... bicornis subseptus ......... bicornis unicollis .......... bicornis unicollis, with rudimentary horn..... pseudo-didelphys . . . . . . ■ • unicornis ........... Vomiting, chart showing ammonia coefficient in two consecutive pregnancies neurotic, urinary chart of...... of pregnancy, liver from case of, showing antral necrosis toxaemic, urinary chart of ..... toxemic, urinary chart of; recovery after induced abortion FIG. PAGE 486 604 497 619 485 604 498 619 484 603 457 547 515 658 508 651 510 1554 503 642 468 578 464 570 505 647 513 656 504 645 514 657 469 579 4(57 577 46(5 574 465 573 452 536 451 535 511 655 656 450 534 460 569 4(51 569 462 569 463 569 463 569 459 569 458 569 448 527 445 525 444 522 447 526 446 525 PATHOLOGY OF LABOR Acromion dorso-anterior presentation, right..... Acromion dorso-posterior presentation, left..... Anencephalus ...•••••••■ Cervix, lacerated, drawn down to vulva, preparatory to repair . Chondrodystrophia fetalis........ Chondrodystrophy' dwarf........ Compound presentation......... frozen section through woman dying at end of pregnancy . Diagonal conjugate, diagram showing effect of position of promontory of sacrum upon length of........ diagrams of, showing it dependent upon heights and inclination of sym- physis pubis.........5 643 821 642 821 637 816 657 856 581 769 582 770 648 827 647 827 528 708 -527 707 LIST OF ILLUSTRATIONS IN TEXT s modifica Dystocia due to hydrocephalus due to ovarian cyst .... following ventro-suspension; sacculation of anterior uterine wall Elephantiasis congenita cystica ..... Epiphysis, in advanced stages of rhachitis, section through in early stages of rhachitis, section through . of child, normal, section through ..... Fcetus with congenital cystic kidneys .... with immensely distended bladder .... Fracture of skull, spoon-shaped ..... Kyphosis, lumbo-sacral, front and side view of patient with Luxation of femora, side and rear view of patient with . Measuring antero-posterior diameter of pelvic outlet, Williams' tion of Breisky's method . conjugata vera with Skutsch's pelvimeter diagonal conjugate .... distance between anterior superior spines distance between tubera ischii external conjugate .... length of diagonal conjugate upon the fingers transverse diameter of outlet with Williams's pelvimeter transverse diameter of superior strait with Skutsch's pelvimeter Overlapping bones of skull ..... Palpation of ischial tuberosities .... of pubic arch....... Parietal presentation, anterior .... anterior, showing passage of, through superior strait posterior ........ posterior, showing passage of, through superior strait Pelvis, assimilation, asymmetrical .... assimilation, generally contracted rhachitic assimilation, high ....... assimilation, low ....... canal of, obstruction of, by cystic enchondroma . chondrodystrophic ...... contracted, due to absence of sacral vertebrae coxalgic, before and after individual has walked . coxalgic, with ankylosed femur .... diagram showing significance of dimensions of anterior and posterior sagittal diameters diagram showing significance of dimensions of anterior and posterior sagittal diameters diagram showing mensuration of anterior and posterior sagi eters by Williams's modification of Klein's pelvimeter flat non-rhachit.ic ..... flat rhachitic..... flat rhachitic, showing double promontor fractured...... generally contracted .... generally contracted flat rhachitic. generally contracted rhachitic, child born spontaneously through generally contracted rhachitic, moulding of head in generally equally contracted rhachitic ...... FIG. 638 517 516 639 543 542 541 641 640 576 612 636 537 530 524 521 535 522 525 536 532 572-573 534 533 565 566 567 568 601 552 595-597 600 635 583-584 594 627 628-630 ttal diam- PAGE 817 693 689 819 726 725 724 S20 820 752 793 809 716 709 706 703 714 704 707 715 711 751 713 712 745 745 746 746 781 729 779 780 810 771 778 805 806 604 784 602 783 . 606 785 538-540 722 544-546 727 549-551 728 . 636 811 578-580 768 553-555 730 . 574 751 571 750 556-558 731 LIST OF ILLUSTRATIONS IN TFXT XX1X gpos- Pelvis, kypho-scoliotic-rhachitic..... kyphotic, longitudinal section through . kyphotic, showing elongation of conjugata vera . kyphotic, showing forces concerned in production of obliquely contracted, anterior view .... obliquely contracted, due to non-rhachitic scoliosis obliquely contracted, due to unilateral luxation of femur obliquely contracted, posterior view of . obtccta ......... osteomalacic ........ osteomalacic, inferior strait ...... outlet of, illustrating necessity for Caesarean section . outlet of, illustrating possibility of spontaneous labor, owing to Ion terior sagittal diameter...... pseudo-osteomalacic ........ rhachitic, diagram showing changes in shape of osteomalacic rhachitic, diagram, showing changes in shape of rhachitic scolio-rhachitic ...... split ...••••• spondylolisthetic ...... spondylolisthetic, vertical section through . transversely contracted assimilation transversely contracted Robert true dwarf .....•• Pelvimeter, Budin's..... Hirst's....... Martin's....... method of holding..... Stein's........ Placenta, premature separation of, with external haemorrhage . praevia, diagram illustrating Hofmeier's theory of formation of previa, fcetus partially extracted from patient dying of . prawia, in which no attempt at delivery has been made . Placental insertion, different modes of..... Pressure marks from promontory...... Pubiotomy, diagram illustrating effect of, in pronounced funnel pelvis Resuscitation, Sehultze's method of..... Rhomboid, Michaelis's...... Sacrum, obliteration of vertical concavity of, in rhachitis accentuation of vertical concavity of, in rhachitis . Spondylolisthesis, author's case of; fourth and fifth lumbar vertebrae front and back views of woman with..... side view of woman with....... vertical section through last three lumbar vertebrae and sacrum Spontaneous evolution, mechanism of..... Denman's mechanism . • • Superior strait, reniform, engagement of head in . showing passage of after-coming head . . • • • Transverse presentation, frozen section through woman dying in through neglect....... Uterus, inversion of, complete...... rupture of, longitudinal section through woman dying from Walchcr's hanging position....... FIG. 617-618 608 . 609 . 611 587-588 613-614 631-633 . 589 610 561-563 . 564 . 605 . 603 559 . 560 . 560 615-616 592-593 620-1522 . 619 598-599 590-591 585-586 518 531 519 520 529 649-650 654 655 653 651-652 575 607 59-660 523 548 547 624 (525 626 623 645 646 569 570 labor 644 656 658 577 PAGE 797 788 789 791 773 795 807 774 790 . 738 739 784 783 733 734 734 796 777 799 798 780 776 772 702 710 702 702 708 830 836 839 834 833 752 786 879 70.') 727 727 800 801 802 800 825 826 746 747 824 848 860 758 XXX LIST OF ILLUSTRATIONS IN TEXT PATHOLOGY OF THE PUERPERIUM FIG. PAGE Colon bacillus endometritis; leukocytic wall not invaded by bacteria . 665 Little's tube for obtaining uterine lochia......668 907 Puerperal endometritis due to colon infection, showing marked develop- ment of leukocytic wall........663 888 Puerperal endometritis due to streptococcus infection, showing slight development of leukocytic wall.......664 888 Streptococcus endometritis, showing invasion of leukocytic wall . • 666 889 Thrombosed pelvic vein, showing streptococci.....667 891 Uterus from woman dying ten days after labor from a mixed infection with streptococcus and bacillus coli.......661 886 from woman dying ten days after labor from streptococcus infection . 662 887 OBSTETRICS SECTION I ANATOMY CHAPTER I THE PELVIS Historical.—As the mechanism of labor is essentially a process of ac- commodation between the fcetus 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 Vesalius (1543) for the first accurate de- scription 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. Vesalius demonstrated the fallacy of this con- ception, and showed that the pelvis, for practical purposes, should be con- sidered as an unyielding bony ring. His work was still 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 pelves. 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 prom- ulgated 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 vari- eties of contracted pelves. At that time he felt called upon to apologize for taking up what was apparently so useless a consideration. Smellie was the first English authority to devote particular attention to the subject. In his work on midwifery, published in 1752, he gave a most accurate description of the pelvis and its various measurements, and 3 1 2 THE PELVIS also introduced the method of determining the antero-posterior diameter which we still employ. A few years previously (1735), Johann Huwe had gone over somewhat the same ground, but his work had not received anything like the consideration which was accorded to Smellie's investiga- tions. Almost simultaneously with Smellie, Levret, the great French obstet- rician, 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 inaccu- racies. Among the Germans, Stein the younger was apparently the first to give a thoroughly accurate description of the pelvis, and since his time cor- rect ideas upon the subject have gradually become popularized. Practically, therefore, an attempt to follow the further development of our knowledge concerning the pelvis would resolve itself into writing a history of ob- stetrics. 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 extremities, but Fig. 1.—Normal Female Pelvis. X i. 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 innomi- nate bones, the last two being united by strong articulations with the sa- crum at the sacro-iliac synchondroses, and with one another at the symphy- sis pubis. The purely anatomical characteristics of the pelvis 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 im- portance in childbearing. THE PELVIS FROM AN OBSTETRICAL POINT OF VIEW 3 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 posteriorly by the lumbar vertebras and laterally by the iliac fossae, while in front the boundary is formed by the lower portion of the anterior abdominal wall. It possesses no particular obstetrical significance, but serves to support the intestines in the non-pregnant woman, and 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 distant 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 measures 4y2 to 5 centimeters, and its posterior wall 10 centimeters. With the woman in the upright position, in its upper portion the pelvic canal is directed down- ward 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 sacro-sciatic notches and ligaments, and by the inner surface of the ischial bones; 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 inclined plane which is directed from above downward and inward, and from behind for- ward. Considerable importance was attached to these surfaces by Hodge, who designated them as the inclined planes of the pelvis, and considered that they exercised a good deal of 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 rep- resents the shortest diameter of the. pelvic cavity. Moreover, since they can be readily felt on vaginal examination, they can be made to serve as valuable landmarks in determining the extent to which the presenting part had 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, and designated as the promontory, can be felt on vaginal examination, and offers a landmark which serves as the basis of internal pelvimetry. Nor- 4 THE PELVIS mally, 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 prom- ontory to the tip of the sac- rum usually measures 10 centimeters, whereas if the concavity be followed the distance averages 12 centi- meters. The sacrum was formerly regarded as the "keystone" of the pelvic arch, but Matthews Duncan showed that this conception was erroneous, and that it represents an inverted key- stone, inasmuch as it is wider along its anterior than along its posterior Fig. 2.—Drawing showing that the Sacrum is not SUTlace, SO tnat It WOUld the Keystone of the Arch. tend to slip downward Modified from Duncan. X i and forward into the pelvic cavity under the in- fluence of the body weight were it not held in position by the strong posterior ilio-sacral ligaments (Fig. 2). In the female the pubic arch pre- sents a characteristic appearance. The descending 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 expe- rienced in rendering clear the exact location of a body occupying it, for greater convenience in description it is customary to construct certain im- aginary planes through it. Those most fre- quently employed are designated as (1) the Fig. 3.—Sagittal Section through Normal Pelvis. X i- 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 PLANES AND DIAMETERS OF THE PELVIS 5 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 by the linea terminalis, are at a lower level than its central portion between the promontory and symphysis. Fig. 4.—Normal Female Pelvis showing Diameters of the Superior Strait. X 3. Four diameters are usually described as traversing the superior strait: the antero-posterior, the transverse, and two oblique diameters. The an- tero-posterior diameter extends from the middle of the promontory of the sacrum to the upper margin of the symphysis pubis, and is designated as the conjugata vera or true conjugate. This term was first employed by Koe- derer, who likened the superior strait to an ellipse, whose shorter diameter ran antero-posteriorlv. Normally, the conjugata vera measures 11 centi- meters, but it may become markedly shortened in abnormal 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 transverse diameter is constructed at right angles to the conjugata vera, and represents 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 meas- ures 13.r> centimeters. Each of the oblique diameters extends from one of the sacro-iliac synchondroses to the ilio-pectineal eminence on the opposite side of the pelvis. They measure 12.7.") 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 the terms right and left, the Germans usually speak of the first and second oblique diam- 6 THE PELVIS eters. The sacro-cotyloid diameters are sometimes described; they ex- tend from the middle of the promontory of the sacrum to the ilio-pec- tineal 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 pelves they may present marked variations. The antero-posterior 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 symphysis pubis, which is along a line drawn from the former to a point on the 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 anatomical or true conjugate, but for practical purposes the distinction is rarely made, and the obstetrician simply speaks of the conjugata vera. Fig. 5.—Diagram showing Pelvic Planes. X \. Unfortunately, in the living woman, the conjugata vera can not be meas- ured directly with the examining finger, and various more or less compli- cated instruments have been devised for its determination, none of which gives perfectly satisfactory results. For clinical purposes, therefore, 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, according to the height and inclination of the symphysis pubis. This diameter is the conjugata diagonalis or oblique conjugate, the importance of which was first empha- sized 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 PLANES AND DIAMETERS OF THE PELVIS greater sacro-sciatic ligaments and the ischial tuberosities, and anteriorly by the lower margin of the pubic arch (Fig. 6). For the pelvic outlet two diameters are described: the antero-posterior and the transverse. The Fig. 6.—Pelvic Outlet former extends from the lower margin of the symphysis pubis to the tip of the coccyx, and the latter between the inner margins of the ischial tuberosities. With the coccyx in its normal position, the antero-posterior 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, Rectus -^TSSW-'Re*t Pubis Obturator foramen Promontory Fig. 7.—Superior Strait (Veit) "Sacrum Fig. 8.—Plane of Greatest Dimensions. 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- phvsis pubis to the junction of the second and third sacral vertebrae, and laterally passes through the ischial bones over the middle of the ace- 8 THE PELVIS tabulum. Its antero-posterior and transverse diameters measure 12.75 and 12.5 centimeters, respectively. Since its oblique diameters terminate in the obturator foramina and the sacro-sciatic notches, they are subject to marked variations in length. 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 antero-posterior diameter measures 11.5 cm. Its transverse diameter ex- tends 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 constructed 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 Pubic ramus Pubic ramus Ischium/^// \i'),'-\\Ischium Ubuirator internus \U Tip of Sacrum Fig. 9.—Plane of Least Dimensions (Veit). Ilium/ rum "S'acrurh Fig. 10.—Veit's Main Plane. 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, inas- much as it is not encroached upon by the pelvic soft parts, but passes above the obturator and pyriformis and below the ilio-psoas 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. Ac- cording to Meyer, the pelvis is in its normal position when the anterior- superior spines of the ilium and the pubic spines are 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. PELVIC INCLINATION 9 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. Miiller and Roederer, and the early state- ments 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 ilio-femoral ligaments. It is therefore apparent that the pelvic inclination must vary according to the degree of tension of these struc- tures; 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 upright position the pelvic inclination is usually estimated at 15 to 50 degrees, but may vary from 40 to 100 degrees, according to the degree of tension exerted by the ilio-femoral liga- ments. In certain diseased conditions 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 work upon this subject was done by Naegele, who measured the distance from the floor to the lower margin of the symphysis pubis and the tip of the sacrum respectively, and in this way estimated the inclination which the inferior strait formed with the horizon. He then placed a normal pelvis in a similar position and estimated the in- clination of its superior strait, which was usually about (>0 degrees. In view of the marked variations to which the pelvic inclination is subject, Meyer introduced a new conception concerning it, and stated that it was considerably influenced by the extent to which the sacrum ro- tated 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, con- structed a diameter extending from the upper margin of the symphysis to the middle of the third sacral vertebra, and designated it the normal con- jugate. Its inclination he estimated at 30 degrees, and stated that it re- mained practically constant in all positions of the body. Except when markedly abnormal, the pelvic inclination possesses 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 de- vised a comparatively simple instrument for determining the inclination of the external conjugate, which for practical purposes gives a fair idea of the degree of pelvic inclination. Since the lower margin of the symphysis occupies a lower level than the tip of the sacrum, the plane of the infei'ior strait is also inclined to the horizon, forming an acute angle, which is usually estimated at 10 de- grees. Much more important, however, is the angle which is formed be- tween the posterior surface of the symphysis pubis and the conjugata vera; 10 THE PELVIS this is usually estimated at 90 to 100 degrees, but varies considerably according to the shape, height, and inclination of the former. This must always be taken into consideration in estimating the length of the conjugata 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 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 impinge upon the promontory of the sacrum. As the pelvic canal is practically cylindrical in shape down to the plane of greatest pelvic dimensions, it is apparent that the head must descend along the downward prolongation of the axis of Fig. 11.—Diagram showing Pelvic Axis. X 3- 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 Hodge, and strongly insisted upon by Sellheim. The Pelvic Joints.—Anteriorly the pelvic bones are held together by the symphysis pubis, which consists of a mass of fibro-cartilage, and by THE PELVIC JOINTS 11 the superior and inferior pubic ligaments, the latter being frequently desig- nated as the ligamentum arcuatum pubis. Luschka demonstrated the presence of a synovial cavity in the fibro-cartilage, and therefore classed the symphysis among the true joints (Fig. 12). Joessel, on the other hand, denies its existence, and states 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 particularly marked during pregnancy. This fact was demonstrated by Budin, who showed that if the finger were inserted into the vagina of a pregnant woman, and she were made to walk, one could dis- tinctly feel the ends of the pubic bones move up and down with each step. Fig. 12.—Frontal Section Symphysis Pubis Fig. 13.—Sacroiliac Synchondrosis (Spalteholz). X 1. (Spalteholz). X 1. The articulations between the sacrum and innominate bones were for- merly described as synchondroses, but Luschka conclusively demonstrated the presence of a synovial cavity within them, and therefore classed them among the true joints (Fig. 13). These articulations possess a certain amount of motility, which plays a not unimportant part in practical ob- stetrics. Walcher, in 1889, stated that the diagonal conjugate varied about 1 centimeter in length, according as it was measured 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, which has since been known as the Walcher or hanging position. His observations have been confirmed by nearly all who have repeated his work, among whom may be mentioned Klein, Wehle and Leopold, and Kiittner. The subject was chosen as one of the main themes for discussion at the International Gynecological and Obstetrical Congress held at Amsterdam in 1899. The speakers, almost without exception, admitted the general correctness of Walcher's statements, differing only as to the extent of the changes, while Bar was the only one to deny their occurrence. This slight amount of motility is utilized in dealing with contracted 12 THE PELVIS pelves; and not infrequently the increase in the size of the conjugata vera brought about by Walcher's position has proved sufficient to permit the engagement of the presenting part, which otherwise could not occur. The effect of Walcher's position upon the size of the pelvic; cavity was studied very carefully by Kiittner in 1898, who showed in three cases that the conjugata vera was re- spectively 1.4, 0.9, and 1 centi- meter 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 these pelves. Further- more, rotation of the .innominate bones upon the sacrum causes changes in the antero-posterjor 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 be increased by from 1 to 2.5 centimeters by placing the woman in an exaggerated Sims position.' Methods of Comparing Pelves.—Inasmuch as the normal pelvis usually. presents slight individual variations in its form and dimensions, and as contracted pelves differ markedly from one another in shape, several de-^ vices have been employed to enable us readily to compare their points of difference. The decimal method, suggested by Litzmann, is very satis- factory 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 of Antero-posterior Diameter of Pelvis in Various Positions (Kiittner). X },• A, lithotomy; B, horizontal; C, Walcher's position. Comparison op Various Diameters DIAMETERS. of Normal Pelves by Litzmann's Dkoimal Method. Antero-posterior. Transverse. Oblique. Superior strait.................... 100 115 105.5 * 105.5 122.7 113.6 95.5 100 113 Plane of greatest pelvic dimension.. . Plane of least pelvic dimension...... Inferior strait..................... Breisky introduced a graphic method for comparing pelves and con- structed three diagrams, representing a vertical mesial section of the pel- vis, 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 SEXUAL DIFFERENCES IN THE ADULT PELVIS 13 pelvis. This is due partly to the fact that it is developed from a consider- able 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 per- fectly normal pelves are rarely seen; so that an accurate conception of the form and dimensions of what may be termed the normal type can 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 particularly in tliat of the cavity itself. In view, therefore, of the varying thickness of the pelvic bones, and especially of the degree of flaring of the ilia, accurate conclusions cannot be drawn from external pelvimetry alone. SP-___________ Sp. Figs. 15-17.—Breisky's Diagrams for Comparing Pelves. T., inclination of iliac bones; I. P., ilio-pectineal eminence; P., promontory of sacrum; S., upper margin of symphysis; S., lower margin of symphysis; S. I., sacro-iliac synchondrosis; 'Sp., iliac spines; T., transverse diameter, superior strait; T. I., tuber ischii; S, bend in body of third sacral vertebra. Sexual Differences in the Adult Pelvis.—The pelvis presents marked sexual dillVrenees. 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 fefmale. 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 aper- ture of ?'<) 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 14 THE PELVIS superior strait is smaller and more triangular in outline, while the pelvic cavity is deeper and more conical in shape. These differences are readily noted in Figs. 18, 19, and 20, and may be especially emphasized by a com- parison of the various measurements in the two sexes. Fig. 18.—Front View Female Pelvis. X §• 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 pelvic cavity are shorter, as is shown by table on page 16. Fig. 19.—Front View Male Pelvis. X | It is therefore apparent that the outlet of the male pelvis is con- tracted to such a degree as to render it very difficult for a living child to pass through it, particularly in being forced out under the pubic angle. SEXUAL DIFFERENCES IN THE ADULT PELVIS 15 Occasionally the female pelvis may approach the male type, and in such circumstances may offer insuperable obstacles to the birth of the child, and necessitate radical operative procedures to effect delivery. 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 Fig. 20.—Diagram showing Difference in Shape of Male [....] and Female [---] Pelvis. their appearance as early as the fourth or fifth month of intrauterine life, so that the sex can be ascertained long before term by examination of the pelvis. Arthur Thompson has made the same statement, and my own investigations have led me to similar conclusions. On the other hand, Schroeder and other authorities attribute the characteristic shape of the female pelvis to the presence of the internal genitalia, and state that the pelves of female eunuchs, as well as those of individuals in whom the uterus is congenitally absent, conform to the male type. While the correctness 16 THE PELVIS of such statements cannot be doubted, it nevertheless seems probable that the greater part of the sexual differences must be due to inherent develop- ment and hereditary factors. Comparison of Male and Female DIAMETERS. Pelvis. Antero-posterior. Transverse. Oblique. Superior strait: Male............ 10.5 11 9.5 11.5 12.5 13.5 8 cm. 11 cm. 12 cm. Female.......... 12.75 cm. Inferior strait: Male................ Female...................... Racial Differences in Pelves.—Considerable variations may be observed 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, Verneau, Topinard, Turner, and others, our knowledge of the subject is still fragmentary. Stein distinguished four groups of pelves: 1. Blunt heart-shaped. 2. Elliptical, with the greatest diameter transverse. 3. Round. 4. Elliptical, with the greatest diameter antero-posterior. 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 pelvis becomes increasingly lower and broader, the more civilized the race from which it is obtained. Turner based his classification upon the relation between the transverse and antero-posterior diameters of the superior strait, and divided pelves into three great groups: dolichopellic, in which the conjugata vera is greater than the transverse diameter; mesatipellio, in which the conjugata vera and transverse diameters are of equal length; and platypellic, 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 infre- quent 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, Hottentots, and the lower classes of negroes; while the platypellic forms are found in all the higher races. But even among civilized whites considerable racial differences are not infrequently noted, and it is generally stated that the pelves of the English and Hol- stein women are broader than those of other nationalities; while the Jew- esses living in the vicinity of Dorpat have extremely small pelves. Gache states that the pelvis is usually normal in the Argentine Republic, while it is imperfectly developed and frequently funnel-shaped in Mexico. While the study of the racial differences in the pelvis presents a marked PELVIS OF THE NEW-BORN CHILD 17 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. Uiggs, has shown that contracted pelves occur several times more frequently among black than white women' in Baltimore (3-1 per cent, to 9 per cent.), while operative delivery is more frequently required among the latter. This is due to the fact that the Fig. 21.—Sagittal Section showing Rela- A., acetabulum; /., ilium; P., pubic bone; S., tive Proportion of Bone and Carti- symphysis pubis; S. A., ala of sacrum; lage in the Pelvis of a Newly Born S. B., body of sacrum; V. A., vertebral Child. X 1. arch. 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 ischio-pubic 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 the innominate bones do not become completely ossified and fully developed until between the twentieth and twenty-fifth years. Each innominate bone is developed from 12 centers of ossification. 4 18 THE PELVIS Three of these are primary and give rise to the ilium, ischium, and pubis. They make their appearance by the end of the first half 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 ((>) ; and 2 for the arches of each vertebra (10). To these must be added the various epiphyseal cen- ters which appear later. The cartilage gradually becomes ossified, and the various component parts of the sacrum fuse together. The alas are the first portions to become united, after which the vertebral bodies grad- ually become welded together, the fusion extending from below upward. According to Litzmann, the bodies of the sacral vertebra? are not entirely united until the seventh year, and complete ossification of the sacrum is not effected until the twenty-fifth year. Fig. Fig. 23.—Disarticulated Pelvis of Three- Fig. 24.—Sagittal Section year-old Girl. X 3. through Pelvis of Five- year-old Girl. X £. 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 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 hori- zontal rami of the pubis are far shorter than in the adult. The pubic arch is much more angular, while the pelvic inclination is decidedly greater. The superior strait is narrower and more angular in shape, the relation between the conjugata vera and the transverse diameter being 100 to 105, TRANSFORMATION OF FCETAL INTO ADULT PELVIS 19 instead of 100 to 122.5, as in the normal adult pelvis. The cavity of the pelvis is relatively much smaller, and is distinctly funnel-shaped. The antero-posterior and transverse diameters of the pelvic outlet, when ex- pressed 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 appearance at a very early period. Fehling 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 results have since been confirmed by a number of observers, among whom Balandin, Jiirgens, and Arthur Thompson may be mentioned; my own work also corroborates their statements. Fig. 25.—Sagittal Section through Body Fig. 26.—Sagittal Section through Adult of Newly Born Child. Woman (Kelly), reduced to the Same Size as Fig. 25 for Comparison. The pelvis of the female fcetus or new-born child presents the follow- ing 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 interest, 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 vari- eties of deformed pelves. 20 THE PELVIS The earliest investigations upon this subject were made by De From- ery and Denman, who were followed by Litzmann, Duncan, Fehling, Schroeder, Veit, 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— developmental 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 differ- ences 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. Moreover, the mechanical influences which come into play after birth are identical in both sexes, but despite this fact the sexual differences become still more accentuated as puberty is approached. The part played by developmental and hereditary influences was clearly demonstrated by Litzmann, who showed that the female sacrum was char- acterized by a marked increase in width as compared with that of the male. At birth, in both sexes, the body of the first sacral vertebra? is twice as broad as the alse (100 to 50), but in the adult the relation becomes 100 to 76 in the female, and 100 to 5C5 in the male, indicating a much more rapid growth of the alas in the former. Fa Ik, in 190S, 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 accessory. The effect' exerted by mechanical influences has been particularly stud- ied by Duncan, Meyer, Veit, and Schroeder, while Kehrer has insisted upon the part played by muscular action. According to Schroeder, three mechanical forces take part in bringing about the final shape of the pel- vis__namely, the body ■ weight, the upward and inward pressure exerted by the heads of the femora, and the cohesive force exerted at the sym- physis pubis. So long as the child remains constantly in the recumbent position these forces are in abeyance, but as soon as it sits up 0r 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 transmitted is- resolved into two components, one of which is directed downward 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 slightly about its transverse axis so that its tip tends to become displaced upward and backward. This displacement, however, is limited, as it is resisted by the strong sacro-sciatic ligaments which permit of only slight extension, with the result that the partly cartilaginous sacrum becomes bent up m 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 alas and thus tend to diminish the transverse cavity 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 TRANSFORMATION OF FCETAL INTO ADULT PELVIS 21 body weight, and would prolapse completely into it were it not held in place by the strong posterior ilio-sacral 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 marked 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 outward rotation is prevented, however, by the cohesive force exerted at the symphysis, but particularly by the upward and inward pressure exerted by the heads of the femora. Practically, then, the iliac bone 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 antero-posterior diameter (Figs. 27, 28). At the Fig. 2S. Figs. 27, 28.—Diagrammatic Representations of Sections through the Infantile and Adult Pelvis (Schroeder). 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 tire 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 fcetal into the adult pelvis, they fail to give a satisfactory explanation of its sexual differences, 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 con- genital tendencies concerning whose nature we are as yet absolutely ig- porant. 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 22 THE PELVIS 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 terminalis, 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 meas- ures 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 bones, and the third from that point to the anterior end of the pubic bone. These portions measure 6.5 to 7, 6 to 6.5, Fig. 29.—Showing Terminal Length Fig. 30.—Showing Terminal Length as seen from Above. X §. as seen from Below. X 5. and 7 to 7.5 centimeters respectively, and therefore are of practically equal length. During the period of development, the sacral portion grows from the cartilage covering the iliac crest, the iliac portion from the upper limb of the Y-shaped cartilage 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 therefore assumes a flattened shape, formally, the iliac portion of the innominate bone in- creases steadily in length, until it has attained its full development just before puberty, while the sacral and pubia portions grow much more slowly. Accordingly, as a result of these variations, combined with the arrested growth of the sacrum, the antero-posterior diameter of the superior strait will equal or exceed the transverse diameter in length, so that some time between the eighth and twelfth year the pelvic inlet will become round TRANSFORMATION OF FOETAL INTO ADULT PELVIS 23 or even oval in shape, with its long diameter extending antero-posteriorly. 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 soon reassumes its typical flat- tened 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 continue to become more and more flattened, until it had attained its ultimate 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 never- theless hold that its occurrence must preclude the acceptance 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 develop- ment of the pelvis. The effect of the mechanical factors is particularly emphasized in cer- tain abnormal types, more especially in the production of certain varieties of contracted pelves, and has been exhaustively studied by Yon Meyer and Schroeder. In rare instances, as in a case recorded by Gurlt, none of the .mechanical forces came into play, and then one has an opportunity of studying the development of the pelvis in their absence. In OurlFs 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 fcetal characteristics. 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 comes into play only when it has to react against that resulting from the body weight. Xor 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 bv Freund, who suspended a cadaver by the iliac crests after cutting through the symphysis, and found that the innominate 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 innominate 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, 24 THE PELVIS can be studied in individuals whose lower extremities are absent, and occa- sionally in cases of congenital dislocation of the hips. Hoist 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 antero-posterior diameter. Owing to the excessive pressure exerted upon the tubera ischii in the absence of the counteracting force exerted by the femora, the innominate bones were rotated in such a manner as to turn their crests inward and the tubera ischii outward, thus producing a marked transverse widening of the inferior strait. More or less similar changes may be observed in the cases of congenital dislocation of the hip in which the patients have never walked. The effect of the various mechanical influences is particularly empha- sized when they are exerted upon pelves whose1 bones are softened by dis- ease, as in rhachitis and osteomalacia. But the consideration of the changes so produced will be deferred until the study of the deformed pelves is taken up. LITERATURE Arantius. AnatomicEe observationes. Venetiis, 1857, Cap. xxxix. Balandin. Klinische Yortrage, St. Petersburg, 1883, Heft. 1. Bar. Influence de la position de la femme sur la forme, 1 'inclinaison et les dimen- sions du bassin. L'Obstetrique, 1899, iv, 529-542. Breisky. Zeitschrift der Gesellsch. der Aerzte. Wien, 18(15, 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, Yenetiis, 1559. De, Fremery. De mutationibus figurae pelvis. D. I., Lugd. Batav., 179.'!. Denman. An Introduction to the Practice of Midwifery. London, 1787-1795. Deventer. Neues Hebammenlicht, etc. HI. 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 Beckons. Berlin, 190S. 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 Rachitisme en Amerique, etc. Annales de gyn, et d'obst., 1903, lx. 175-195. CJurlt. Ueber einige Missgestaltungen des woiblichen Beckens. Berlin, 1854. Hegar. Zur Geburtsmechanik. (Die Beekenaxo.) 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 weib- lichen Amelus. Hoist's Beitrage, 1869, Heft 2, 145-148. Huave. Onderwys der vrouwen, etc. Haarlem, 1735. Joessel. and Waldeyer. Lehrbuch der topographisch-chirurgischen Anatomie. Bonn, 1899. II Theil, Das Becken. Jurgens. Beitrage zur normalen und path. Anatomie des menschlichen Beckens. Virchow's Festschrift, Berlin, 1891. Kehrer. Beitrage zur vergl. u. exper. Geburtshiilfe, 1869, Heft 3; und 1875, Heft 5. LITERATURE 25 Klein. Zur Mechanik des Heosacralgelenkes. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 74-118. Kuttnkk. Experimentell-anat. Untersuchungen iiber die Vcranderlichkeit des Beck- enraumes Gebiirender. Hegar's Beitrage, 1898, i, 210-229. Lkvrkt. 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. Luschka. Die Anatomie des menschlichen Beckens. Tubingen, 1864. Meyer. Statik und Mechanik des menschlichen Knochengeriistes. Leipzig, 1873. Michaelis. Das enge Becken. Leipzig, 1851. Mi'ller, J. J. Diss. sist. casum rarissimum uteri in partu rupti. Basilere, 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. RlGGS. A Comparative Study of White and Negro Pelves. Johns Hopkins Hospital Reports, 19(14, xxi, 421-454. Roederer. De axi pelvis. Goettingsr, 1751. Elmenta artis obstetriciae. Goettingte, 1766. Scuarlau. Das Australier-Becken. Berlin, 1903. Schroeder. Lchrbuch der Geburtshiilfe. XIII, Aufl., 1899. Sellheim. Die Beziehungen des Genitalkanales und des Geburtsobjektes zur Ge- burlsiiiechanisnius. Leipzig, 1906. Smellie. A Treatise on the Theory and Practice of Midwifery. London, 1752. Stein, D. J. Lehre der Geburtshiilfe. Elberfcld, 1S25. Thompson. The Sexual Differences of the Fcetal 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'Anthropologic, 1S75, 504-521. Turner. The Index of the Pelvic Brim as a Basis of Classification. Journal of Anat. and Physiol., 1886, xx. Veit. Die Fntstchung 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. Basila-, 1543. Walcher. Die Conjugata eines engen Beckens ist keine konstante Grosse, etc. Cen tralbl. f. Gyn., 1889, 892-893. Weber. Die Lehre von Ur- und Racen-formen des Schadels und Beckens des Men- schen. Diisseldorf, 1830. Wehle. Die Walcher 'sche lliingelage und ihre praktische Verwerthung bei geburts- hiilflichen Operationen. Archiv f. Gyn., 1894, xlv, 32:5-336. Williams. The Frequency of Contracted Pelves, etc. Obstetrics, 1899, i, Nos. 5, 6. The Funeral Pelvis. Am. J. Obst., 1911, lxiv, 106-24. CHAPTEE 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 fcetus. 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 margin 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 ''escutcheon/' Generally speaking, the distribution of the pubic hairs differs considerably in the two sexes. In the female they occupy a triangular area whose base cor- responds 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 composing it extend triangularly upward toward the umbilicus and downward over the inner surface of the thighs. These differences were described in detail by Ploss, and at one time it was believed that they might be of value in determining the sex in doubtful cases. But 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, 26 THE EXTERNAL GENERATIVE ORGANS 27 but its most noteworthy differences are dependent upon the age of the person and whether or not she has borne children. Labia Majora.—On either side of the vulva extends a rounded mass of tissue, the labium majus. The labia majora vary markedly in appear- ance, according to the amount of fat beneath them. They are less promi- nent after childbearing, and in old age usually assume a shriveled appear- ance. 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 some- what lozenge-shaped, and become narrower at their lower extremities. In children and virginal adults they usually lie in close apposition and com- Fig. 31.—External Genitalia of Nulli- Fig. 32.—External Genitalia of Multi parous Woman, Labia in Contact. parous Woman, Labia spread Apart. pletely conceal the underlying parts, whereas in multiparous women they often gape widely. Until recently it was usually stated that they were con- nected above and below by the anterior and posterior commissures of the vulva, but Luschka has shown that they are directly continuous with the Mons Veneris above, and fade away into the perineum pos- teriorly. 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 multiparse it becomes more skin-like, but is not covered with hair. It is richly supplied with seba- ceous 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 mus- 28 THE FEMALE ORGANS OF GENERATION cular elements. Beneath this layer, which corresponds 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 tissue is supplied with an abundant plexus of veins, which may rupture as the result of external vio- lence or injury sustained during labor, and give rise to an extravasation of blood or hgematoma. The labia majora are analogous to the scrotum in the male, and at their upper ends receive the termination of the round ligaments. Exceptionally 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 nympliai, 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 multi- para?, on the other hand, they project beyond them. The labia minora consist of thin folds of tissue, which when protected present a moist, reddish appearance, similar to that of a mucous mem- brane. 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 in- terior portions are made up of connective tissue, in which are many ves- sels and a few non-striated muscular fibers, so that they are classed amon:» 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 lamellas. 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 fourchette (Luschka, Cullingworth, and Nagel). According to Nagel, the labia minora are homologous with the skin upon the under surface of the penis. Xot infrequently they 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 artificial means are em- ployed to bring about an increase in their size. According to Ploss, the Nubians and many other races practice infibulation as part of their re- ligious 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 THE EXTERNAL GENERATIVE ORGANS 29 -Clitoris Vestibular bulbs large enough to permit the escape of the menstrual flow. In such circumstances a second operation is necessary before marriage can be con- summated. 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 perfo- rated 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 ischio- pubic ramus and fuse together in the middle line, just below the pu- bic arch, to form the body of the clitoris. The clitoris is usually a very rudimentary organ and rarely exceeds 2 centi- meters in length, even when in a state of erec- tion. It is sharply bent on it sell, owing to trac--pIG 33—Preparation showing Clitoris and Its Vascu- tion exerted upon it by lar Supply. the labia minora, whose (Modified from Chrobak and Rosthorn.) anterior extremities, as has already been said, furnish the prepuce and frenulum. As a result, its free end looks downward 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 epithelium, is richly supplied with nerve-endings, and is extremely sensitive. The entire clitoris is very erectile, and its vessels are connected with the vestibular bulbs by means of the pars inter- media. Fig. 33 gives a good idea of the relations of the clitoris, its crura, and the vestibular bulbs. \Ye are indebted to Kobelt for most of our knowledge concerning this organ, and since the appearance of his mono- graph, in 1S44, 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 clitoridectonii/ enjoyed a marked vogue, but has since been completely abandoned. Among many of the aboriginal races the same operation had been performed from time imme- morial as a religious rite, and was designated as "girl circumcision." Oc- casionally the clitoris may become considerably hypertrophied, so as to 30 THE FEMALE ORGANS OF GENERATION markedly resemble the penis, and not a few cases of so-called hermaphro ditism are to be explained by this condition. Vestibule.—The vestibule is the almond-shaped area which is inclosed between the labia minora and extends from the clitoris to the fourchette. 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 describe it as a trian- gular area, bounded above by the labia minora and below by the vaginal opening. The posterior portion of the vestibule, between the fourchette and the vaginal opening, is called the fossa naviculars. This is rarely ob- served except in nulliparous women, as it usually becomes obliterated aftei childbirth. Vestibular Glands.—In connection with the vestibule, certain glandu- lar structures—the glandula vcstibulares majores and minores—are usu- ally described. The former are designated as Bartholin's glands, or the glands of Duvernev, who first described them in the cow. They are twc small structures varying from a pea to a small bean in size, and are situated beneath the vestibule, opposite the lateral margins 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. They are compound racemose glands; their ducts, from 1.5 to 2 centimeters long, open upon the sides of the vestibule just outside the lateral mar- gin 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 not infre- quently harbor gonococci, which may gain access to the gland and cause it to suppurate, so that the entire labium becomes markedly distended by a collection of pus. The glandulse 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 paraurethral duds 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, !/2 millimeter in diameter, of varying length, and in this country are gener- ally known as Skene's ducts. They were, however, 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 lacuna?. Vestibular Bulbs.—Lying beneath the mucous membrane of the vesti- bule, on either side, are the vestibular bulbs. These are almond-shaped, THE EXTERNAL GENERATIVE ORGANS 31 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 ischio-pubic rami, and are partially covered by the ischio-cavernosus and constrictor vagina? muscles. Their lower ends usually terminate about the middle 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 described by Kobelt, and their vascular connections have been exhaustively studied by (lussenbauer. 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 hamiatoma 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 markedly in size and shape in different individuals. In virgins it is entirely hidden 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 differences 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 varving thickness which closes the vaginal opening more or less com- pletely, 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 particularly 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 inexperienced observer for a ruptured hymen, so that this type possesses some little medicolegal interest. According to the embryological researches of Xagel, which have been confirmed by (iellhorn and Taussig, the hymen represents the lowest por- tion of the vagina, which in early embryos is composed of a solid mass of epithelial cells. After proliferating rapidly for a time the most centrally situated cells begin to degenerate and a lumen is produced, except at the lower extremity of the mass, where the cells persist and give rise to the hvmen. The hymen, therefore, is a fold of tissue presenting a structure similar to that of the vagina—namely, a connective-tissue core with nu- merous elastic fibers which is covered on either side by a layer of stratified epithelium, in which are numerous papilla? containing vessels and occa- sionally nerve-endings. The hvmen may vary markedly in consistence in different individuals. According to Dohrn, many types are observed—from a delicate structure 32 THE FEMALE ORGANS OF GENERATION memhrane, resembling a spider's web to a fleshy, ligamentous, or even cartilaginous which in rare instances has even been described as "bony." In the matter of elasticity, again, wide varia- tions are met with, some hymens being so delicate that they rupture upon the slightest touch, while others, though capable of consid- erable distention, still remain unbroken, and later may even regain their original appear- ance. As a general rule the hymen ruptures at the first coitus, tearing at several points, usu- ally in its posterior portion. The edges of the tears soon cicatrize, and the hymen he- comes permanently divided into two or three portions, which arc separated by narrow slits extending 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. Fig. .'51.—Longitudinal Section » in r -, ■ n 1 v i 1 j.i showing Transltion from the . Although, it is generally believed by the Cylindrical Epithelium of laity that its rupture is associated with hem- the Uterus to the Cuboidal orrwe, this is by no means always the case, Epithelium of the Vagina. v . . J J though m rare instances such a profuse loss From a 10-centimeter embryo (Na- » , , -, , n , , . -. gel). U., uterus; V., vagina. of blo0fl mW oecxlT as to ^acl to profound ana?mia and even death. This idea is proba- bly based upon the biblical statement that loss of virginity is always asso- ciated with loss of blood. Nor is it unreasonable to suppose that consider- able bleeding usually occurred among the Hebrews of the biblical period, inasmuch as the girls married very young, and riot infrequently 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 pre- vails full sexual development has usually been attained be- fore marriage. In rare instances the mem- brane may be very resistant and surgical interference be required before coitus can be accomplished. Obertaufer, in 180-2, reported a case in which the hymen was so tough that it creaked under the knife. Fig. 35.—Sagittal Section through the Lower Portion of the Vagina of a 14-Centimeter Embryo (Nagel). U., urethra; H., hymen; Vag., vagina. PLATE II. Infantile. Annular. Semilunar. Vertical. Normal injury at coitus. Carunculae myrtiformes. SHOWING SEVEKAL VARIETIES OF HYMEN. 9 THE EXTERNAL GENERATIVE ORGANS 33 Occasionally, instead of giving way in the middle, it 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. Xeugebauer has collected an interesting series of injuries occurring during coitus, many of which were due to the presence of a very resistant hvmen. The changes in the hymen following coitus are often of medico-legal interest, as the physician is occasionally called upon to testify as to the virginity of an individual. Unfortunately, however, it is not alwavs pos- sible to arrive at a decisive conclusion as to this point. In occasional instances the hymen may be de- stroyed in early childhood, either as the result of masturbation or P 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 a hymen which has been ruptured. Ha- berda, the Professor of Legal Medicine in Vienna, stated that he was able to make a positive diagnosis of loss of virginity in only about 50 per cent, of the medico-legal cases which he had examined in the course of five years. He believes that in many FlG. 36.—Almost Unruptured Hymen after instances it is impossible to de- Childbirth (Budin). termine whether coitus has taken place or not, unless the individual is seen immediately after the attempt, before the torn surfaces have had an opportunity to unite. Achenbach, in 18i)0. collected 25, and Kanony, some years later, 43 instances of pregnancy occurring in women with unruptured hymens. Some years ago I saw a case in which conception had occurred through a hymen which presented only a pin-point opening, and more recently one in which 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 caruncuhr myrtiformes (Plate 11). Their significance was first emphasized by Schroeder. Practically speaking, they are infallible signs 34 THE FEMALE ORGANS <>E GENERATION of previous childbearing, though occasionally they may follow the marked distention and long-continued pressure incident to the removal of large tumors through the vagina. In rare instances the injuries resulting from childbirth are extremely slight, and very exceptionally are entirely lack- ing. Such cases have been reported by Hyerneaux, Tolberg, Hyrtl, and Budin. Fig. 3G shows the external organs of one of Budin's patients who had given birth to a full-term child. LITEEATURE Achenbach. 25 Fiille von Schwangerschaft und Geburt bei undurchbohrtem Hymen. 1). !., Marburg, 1S90. Budin. Eecherches sur l'hymen et l'orifice vaginale. Le Progres Medical, aout, 1*79 Description d'un cas dans lequel l'accouchement n'a determine, chez une primipare, 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 kleinen 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. Dohrn. Die Bildungsfehler des Hymens. Zeitschr. f. Geb. u. Gyn., 188.1, xi, 1-19. Gellhorn. Anato'my, Pathology, and Development of the Hymen. Trans. Am. Gyn. Soc, 1904, xxix, 405-440. Gussenbauer. XTeber das Gef'asssystem der ausseren weibiichen Genitalien. Sit zungsbericht der k. k. Akad. der Wissenschaften, Wien, 1869, lx. Haberda. Ueber den anat. Beweis-der erfolgten Defloration. Monatsschr. f. Geb. u. Gyn., 1900, xi, 69-88. Kanony. De la frequence de cas de persistance de l'hymen et de leur importance en medicine legale. Theue de Montpellier, 1899. Kobelt. Die mannliohe 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. Anatomie, 1881, xix. Nagel. Die weibiichen Geschlechtsorgane. Bardeleben's Handbuch der Anatomie, 1896. Ueber die Entwickelung des Uterus und der Vagina beim Menschen. Archiv f. mikr. Anat., Bd. XX XVII. Neugerauer. Ein Beitrag zur Lehre von den Verletzungen der weibiichen Sexualor- gane sub coitu. Mit Kasuistik von 157 Beobachtungen. Monatsschr. 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. Medizin und Naturwissensch., 1868, iv. Skene. The Anatomy and Pathology of Two Important Glands of the Female Ure- thra. Amer. Jour, of Olisl., lsso, xiii, 265 270. Taussk;. The development of the Hymen. Am. J. Anat., 1908, viii, Sit 108. Webster. The Nerve-Endings in the Labia Minora and Clitoris. Edinburgh Med. Journal, 1891. THE VAGINA 35 THE VAGINA The vagina is a musculo-membranous tube which extends from the vulva to the uterus, and is interposed between the bladder and the rectum. It serves three important functions; it represents the excretoiy 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 pre- sents a somewhat S-shaped curvature. The common 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 corresponding to the curve of the rectum. Anteriorly, the vagina is in contact with the bladder and urethra, from which it is separated by the vesico-vaginal septum. Posteriorly, between its lower portion and the rectum, we have the perineum and recto-vaginal septum; in its median portion it lies in close apposition with the rectum, while its upper portion is separated from it by Douglas's cul-de-sac. In view of these relations, Schauta, for purposes of description, has divided its anterior wall into two parts—urethral and vesical—and its posterior wall into three—perineal, rectal, and peri- toneal respectively. The urethral portion of the vagina is firmly united to the urethra and vesico-vaginal septum, from which it can be separated only with some difficulty; whereas the vesical portion is loosely at- tached to the bladder and can be readily detached from it. The anterior and posterior walls of the vagina lie in contact, a slight space inter- vening between their lateral margins. When not distended, the canal presents an H- shapod appearance on transverse section, as was first pointed out by Henle. The vagina is capable of marked distention, as is mani- fested 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 conveni- ence of description, is subdivided into the anterior, posterior, and two lateral fornices. higher up upon the posterior than upon the anterior wall of the cervix, the posterior fornix is considerably deeper than the anterior. Fig. ,'f5 37.—H-shaped Lumen of Vagina (Henle). As the vagina is attached 36 THE FEMALE ORGANS OF GENERATION 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 respectively. 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 rugce extend ouhvard from and almost at right angles to the vaginal columns, gradually fading away as they approach the lateral walls. They give to the surface a corrugated appearance, which is more marked in the early years of life, and gradually becomes obliterated after repeated childbirth, so that in old multiparae the vaginal walls are often perfectly smooth. The vaginal wall itself is composed of three layers—the mucous, the muscular, and the connective-tissue layers. The mucosa is covered by numerous layers of stratified epithelium, and closely resembles the skin in structure; but, as its surface is not exposed to the air, the horny layer is absent. The lowest layer of epithelium is distinctly columnar in ap- pearance, while the cells immediately above it are polygonal in shape, and gradually become more and more flattened as the free surface is ap- proached. Beneath the epithelium is the submucosa, a thin layer of con- nective 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 Eppinger, Nagel, (iebhard, Pretti, and Waldeyer, the vaginal mucosa is absolutely devoid of glands, nor have I, in any of the large number of specimens examined, ever encountered them. Hennig, THE VAGINA 37 Preuschen, and Cullen, on the other hand, affirm that they are not infrequently present. It is true that in rare instances Veit and David- sohn found a few structures which the latter considered represented aber- rant 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 forma- tion. These, however, are not glands, as they simply represent tags of mucosa which were buried'in the repair of vaginal tears following labor. 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 vagina. 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 vagi- nal secretion is present, which, according to Doderlein and most subse- quent observers, normally consists of a dry, thick, white, curd-like material composed of cast-off epithelium and many bacteria, and presents a markedly acid reaction. A great deal of work has been done upon the bacterial flora of the vaginal secretion in pregnancy, and all observers agree that bacillary forms predominate, though cocci are not infrequently seen. The consensus of opinion is that the ordinary pyogenic organisms are never present in the vaginal secretion of healthy pregnant women (Kronig and Williams). The subject will be considered in detail in the chapter on Puerperal Infec- tion. 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 surrounding 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. The vagina is formed by the fusion of the terminal ends of the Miil- lerian ducts, which, according to Xagel, reach the urogenital sinus in embryos 2.5 to 3 centimeters long. As has already been said, when consider- ing 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 gesta- tion. (See Fig. 34.) 38 THE FEMALE ORGANS OF GENERATION LITERATURE Cullen. Vaginal Cysts. Trans. Am. Gyn. Soc., 1904, xxix, 459-48.3. Davidsohn. Zur Kenntniss der Scheidendriisen, etc. Archiv f. Gyn., 1900, lxi, 418- 433. Doderlein. Das Scheidensekret. Leipzig, 1892. Eppinger. Zeitschr. f. Heilkunde, Bd. III. Gebhard. Path. Anatomie der weibiichen Sexualorgane. Leipzig, 1S99, 494. Henle. Eingeweidelehre des Menschen. Braunschweig, 1873. Kronig und Menge. Bakteriologie des weibiichen Genitalkanales. Leipzig, 1897. Luschka. Die Anatomie des menschlichen Beckens. Tubingen, 1861. Nagel. Die weibiichen Geschlechtsorgane. (Bardeleben's Handbuch der Ana- tomie.) Jena, 1896. Poirier. Lymphatiques des organes genitaux de la femme. Paris, 1N90. I'retti. Beitrag zur histologischen Veranderungen der Scheide. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 250-269. Schauta. Lehrbuch der gesammten Gynakologie. Leipzig u. Wien, 1896, 51. Veit. Cysten der Scheide. Handbuch der Gyn., 1897, i, 341. Von Precschen. Virchow's Archiv, Ixx. Waldeyer und Joessel. Lehrbuch der topographisch-chirurg. Anatomie, II. Theil, 819. Bonn, 1899. Williams, J. Whitridge. The Bacteria of the Vagina and their Practical Signifi- cance. Amer. Jour, of Obst., 1898, xxxviii, 449-483. 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 men- struation, and during pregnancy serves for the reception, retention, and nu- trition 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. Al- most its entire posterior wall is covered by peritoneum, the lower portion of which forms the anterior boundary of Douglas's cul-de-sac, only the upper portion of the anterior wall is so covered, its lower portion 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 appearance, 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 intes- tines, His has suggested that the surfaces be described as vesical and intes- tinal, instead of anterior and posterior respectively. The Fallopian tubes come off 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 being known as the fundus uteri. The lateral margins extend from the insertion of the Fallopian tubes on either side to the pelvic THE UTERUS 39 floor. They are not covered by peritoneum, but receive the attachments of the broad ligaments. The uterus presents marked variations in size and shape, according to Fig. 39.—Anterior Aspect of Uterus. X 1. Fig. 40.—Posterior Aspect of Uterus. X 1. 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 1, and 2 to 2.5 centimeters in its greatest vertical, transverse, and antero-posterior diameters respectively, as compared with 9 to 9.5, 5.5 to 6, and 3 to 3.5 centimeters in nmltiparous women. Virginal and parous uteri also differ considerably in weight, the former ranging from do to 50, and the lat- ter from (i0 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 % 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 between 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. Wit and Aschoff have pointed out that the lower- most portion of the uterine cavity is very con- 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 stricted—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 marked, and its mar- gins become concave instead of convex, as in the virginal condition. Cervix Uteri.—The cervix is the portion of the uterus which lies below the internal os. Externally its upper boundary is indi- cated by the point at which the peritoneum is reflected from the uterus on to the blad- der. It is divided, by the attachment of the vagina, into two parts: the supravaginal and infravaginal portions of the cervix. The former is covered on its posterior surface by peritoneum, while its lateral and anterior surfaces are in contact with the connective tissue of the broad ligaments and bladder. The infravaginal portion of the cervix, which is usually designated as Fig. 42.—Showing Junction of Vagina and Cervix (Skene). Fig. 43.—Uterus and Appendages of Young Child. X f. Fig. 44.—Uterus and Appendages of Four- TEEV-Y.5AR-OLD GlU„. X 3. the portio vaginalis, projects into the vaginal fornix, and at its tip presents a small transverse opening, the ex- ternal os, bounded in front and behind by the so-called anterior 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. Tn the virgin it is a small, oval opening resembling a tench's mouth, when-e the name, os tincce. On vaginal examination it gives a sensation similar Fig. 45.—Uterus and Appendages of Twenty-yea.:.- old Multipara. X f. THE UTERUS 41 Fig. 46.—Virginal Exter- nal Os. Fig. 47.—Parous Exter- nal Os. to that obtained on feeling the cartilage at the end of one's nose. After childbirth the orifice becomes converted into a transverse slit, and when the cervix has been markedly 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 wheth- er a woman has borne children or not (Figs. 40 and 17). The cervix is com- posed of connective tis- sue 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 longi- tudinal ridge upon its anterior and posterior surfaces, from which numer- ous others run off transversely, giving the membrane a corrugated appear- ance—the arbor vitce ulerina or plicce pahnatw. In the adult the arbor vita1 is limited to the cervical canal; but in child- hood it extends throughout the entire cavity of the uterus, from which it begins to disappear as puberty is approached. In time, after repeated childbirth, it gradually becomes obliterated even in the cervical canal, whose walls become almost smooth (see Figs. 43 to 15). The mucosa of the cervical canal, embryologically speaking, is a direct continuation of the lining of the uterine cavity, but has become differen- tiated from it and possesses a character- istic appearance, so that sections through the canal present a honeycomb-like struc- ture'(Fig. 48). The mucosa is composed of a single layer of very high and nar- row columnar epithe- lium, which rests up- on a thin basement membrane. The oval Fig. 48.—Cross-section through Cervical Canal nuclei are situated near the base of the columnar cells, the upper portions of which present a clear, more or less transparent appearance 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 into the stroma. They are of the branching, racemose variety, and are merely reduplications of the surface epithelium, being lined by epithelium of the 42 THE FEMALE ORGANS OF GENERATION same character. Fricdliinder was the first to demonstrate 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 ex- tend down almost to its surface, and, if their ducts are occluded, may be- come converted into retention cysts. which shimmer through it and appear as rounded protuberances the size of small peas. These are the so-called Nabotbian follicles or ovula Nabofhi. Normally, the stratified epithe- lium of the vaginal portion and the cylindrical epithelium of the cervical canal meet at the external os. This, however, is the case only in early life, as in older persons the stratified epi- thelium gradually extends up the cer- vical canal until its lower third, and occasionally its lower half, is covered by it (Friedlander). This change is more especially marked in multipar- ous women, in whom the lips of the cervix are not infrequently markedly everted; and occasionally, in cases of this character, almost the entire cervi- cal 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 desig- nated 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 Ruge in a case of imperforate hymen, associated with harnialokolpos, in which the entire 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 formed by the peri- Fig. 49.—Cervical Gland. X 90. THE UTERUS 43 toneum 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 mu- cous layer, which serves as a lining for the uterine cavity, is commonly known as the endometrium. It is a thin, pinkish, velvety membrane, which on close exam- ination is seen to be 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 2 or 3 millimeters without being necessarily abnormal. It consists of a sur- face epithelium, glands, and interglandu- lar tissue, in which are found numerous blood-vessels and lymphatic spaces. As the endometrium does not possess a submucosa, it is attached directly to the underlying muscular layer in such a manner that its outer boundary presents irregularities in outline correspond- ing with the interstices between the muscle bundles. This arrangement is Fig. 50.—Reconstiu'ction of Utek- us, showing Shape of Its Cav- ity and Cervical ("anal. X 1. Fig. 51. -Normal Endometrium. X 10. of considerable importance in connection with the operation of curettage; for, as Duvelius and Werth first showed, it is from the portions included 44 THE FEMALE ORGANS OF GENERATION between the muscle bundles that the endometrium is regenerated after the procedure. The surface epithelium of the uterine mucosa is composed of a single layer of high columnar ciliated cells, which are closely packed together. Fig. 52.—Endometrium of Newly Born Child. X 150. 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 base- ment 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 nearly all animals. 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. lloehne and Mandl state that they are not present upon all cells, but that those provided with cilia occur in discrete patches, while the secretory activity appears to be limited to the non-ciliated cells. The cilia persist THE UTERUS 45 throughout the entire period of sexual activity, and, according to Parviai- nen. disappear eight or ten years after the menopause. Up to 1S93 it was generally taught that the current produced by them was directed from below upward—namely, from the cervix toward the fundus; but Hofmeier conclusively demonstrated that it is in the opposite direction, and his researches have since been confirmed by Mandl. It may therefore be considered as a definitely established fact that the ciliary cur- rent in both the tubes and the uterus is in the same direction, and extends downward from the fimbriated end of the tubes to the external os. In very exceptional instances the uterine cavity may be lined by strati- fied epithelium, as in the cases reported by Zeller and F. Friedlander. Such a condition readily explains the possible occurrence of flat-celled car- cinoma of the body of the uterus. Projecting down from the surface of the endometrium are large num- bers of small tubular glands—the uterine glands. These must be regarded as mere invaginations of the surface epithelium and, in 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 occasionally penetrate for a short distance. They present the same histological structure as the sur- face 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 uter- ine cavity moist. Following the appearance in 1908 of the monograph of Hitschmann and Adler, many investigators have written upon the anatomy of the endo- metrium. ' The consensus of opinion now is that it is undergoing constant ehano-es, and consequently will vary greatly in appearance, according as the specimen is obtained before, during or after the menstrual flow. In the former case the endometrium is comparatively thick and contains abundant convoluted or cork-screw-like glands; while in the latter case, it is much thinner and contains only a few tubular 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 Mover, which are confirmed by my own studies, show that thev are not infrequently present at birth. At the menopause 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 intcrqlandular'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 oedema it is readily seen that the cells present a stellate appearance, with branching protoplasmic processes which anastomose one with another. The cells are more closely packed around the glands and blood-vessels than elsewhere. On the other 46 THE FEMALE ORGANS OF GENERATION 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 looks upon it as nothing but embryonic tissue, while Nagel sees it in a resemblance to lymphoid tissue, and Arthur \V. Johnstone holds that it is of an adenoid type. On the other hand, Leopold, Uham- pionniere, Poirier, and others consider that it represents a lymphatic sur- face. According to Leopold, the "uterine mucosa should be considered as a tsjh M >**-# *'*%■>'$ Fig. 54.—Uterine Gland and Stroma. X 420. spread-out lymph-gland (Lyniphdrusenflache), which does not contain true lymph-vessels, but consists of spaces lined by endothelium." There is a certain amount of evidence in support of all of these views, but I am inclined to 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 comparatively 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 amount of connective tissue, in which arc found many elastic fibers (Pick THE UTERUS 47 and Anspach). On section the uterine wall presents a thick, felt-like structure, in which definite layers cannot be distinguished. A great deal of work has been done upon the arrangement of the mus- culature both of the pregnant and non-pregnant uterus. Tarnier and Ribemont-Dessaignes were unable to make out definite layers of muscle bundles in the non-pregnant organ, while Bayer, Kreitzer, Veit, and others distinguished several, but did not agree as to their arrangement. 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 bun- dles—stratum vasculare. Koesger studied the question from a developmental point of view, and demonstrated that the muscle libers are developed along the course of the blood-vessels, but failed to distinguish any definite arrangement. Similar studies by Werth and Grusdew show that the musculature of the fcetal and infantile uterus presents a very simple arrangement, which becomes 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. Ligaments of the Uterus___Extending from either half of the uterus are three ligamentous structures—the broad, round, and utero-sacral liga- ments (ligamenta lata, teretia, and utero-sacralia). The broad ligaments, or ligamenta lata, are two wing-like 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 com- partment. 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 infundibulo-pelvic ligament—the suspensory ligament of the ovary (Henle)—and serves to transmit the ovarian vessels. The portion of the broad ligament beneath the Fallopian 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 Rosenmuller (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 longi- tudinal duct, which extends just below the tube to the lateral margin of the uterus, in whose muscular wall it ends blindly 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. Waldever in 1S70, however, showed that it represents only the cranial portion of the latter, and designated it as the epoophoron, and sug- gested the term paroophoron for its caudal portion. The latter is the analogue of the organ of Giraldes, and according to the 6 48 THE FEMALE ORGANS OF GENERATION exhaustive work of Icelander is situated near the free end of the broad ligament between the terminal branches of the ovarian artery just bfore they enter the ovary. The paroophoron consists of a small number of slightly convoluted tubules, lined by non-ciliated epithelium. The organ tends to disappear with advancing years; and is of interest only from the fact that it occasionally gives rise to tumor for- mations. At its lateral margin, the peritoneal covering of the broad ligament is re- flected 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 liga- mentum transversale colli of Macken- rodt, or the retinaculum uteri of Mar- tin—is composed of dense connective tissue which is firmly united to the Fig. 55.—Section through Uterine , . ^ ., . n,. End of Broad Ligament. X f. 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 connective-tissue bands extend from the uterus into the broad ligament. A vertical section through the uterine end of the broad ligament is tri- angular in shape, with the apex directed upward, while its base is broad and contains the uterine vessels; it is widely connected with the connective tis- sue covering the pelvic floor and lying behind the bladder, which is desig- nated as the parametrium. A vertical section through the middle portion of the broad ligament 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 particulars concerning the pelvic connective tissue the student is referred to the careful studies of Jung and Martin. The round ligaments, or ligamenta terctia, 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 art 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 com- posed 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, but 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 utero-sacral ligaments—retractores uteri (Luschka)—are two THE UTERUS 49 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 vertebras. They are likewise composed of connective tissue and muscle, and are covered by peritoneum. They form the lateral boundaries of Douglas's cul-de-sac. and are believed to play a part in retain- ing 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, whether pregnant or not, is one of slight anteflexion. With the woman standing upright, the uterus occupies an almost horizontal position and is somewhat bent upon its vesical surface, the fundus resting upon the posterior surface of the bladder, while the cervix is directed backward toward the tip of the sacrum (see Fig. 2(>). 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 alto- gether satisfactory. According to Xagel and most embryologists, the ante- flexion exists from the earliest stages of development, and is to be accounted for by the fact that the entire body is developed along a curved line. The pressure of the intestines upon the uterus is also believed to play a part, as the light corpus is readily movable, while the comparatively large cervix is held in a fixed position by the small pelvis. 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 utero-sacral 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 only occurs when its deeper portion—the ligamentum transversale colli—is divided. Blood-vessels of the Uterus.—The vascular supply of the uterus is de- rived from two sources: principally from the uterine, and to a lesser extent from the ovarian, arteries. The uterine artery is the main branch 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 cervix, it divides into a larger and a smaller branch, the latter—the cervico-vaginal artery—supplying the lower portion of the cervix and the upper portion of the vagina. The main branch turns abruptly upward 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; 50 THE FEMALE ORGANS OF GENERATION the second, making its way through the mesosalpinx, supplies the tube, and the fundal branch is distributed to the upper portion of the uterus. Fig. 56.—Blood Supply of Uterus (Kelly). The ovarian or internal spermatic artery is a branch of the aorta and enters the broad ligament through the infundibulo-pelvic ligament. On reaching the hiluni of the ovary it breaks up into a number of small THE UTERUS 51 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 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 positively demonstrated that such is not the case. This observer found that when the uterine artery on one side was injected the fluid Fig. 57.—Lymphatics of Uterus (Kelly). escaped from the opposite uterine artery before it began to flow from the veins, thus indicating the presence of numerous arterial anastomoses in the substance of the uterus. The veins from the uterus form an abundant plexus around each uter- ine artery, and unite to form the uterine vein on either side, which then 52 THE FEMALE ORGANS OF GENERATION 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 pampiniform plexus—the vessels 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 Fig. 58.—Nervous Ganglia of Pregnant Uterus (Frankenhauser). A, plexus uterinus magnus; B, plexus hypogastrics; C, cervical ganglion. has given us a fairly definite 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 mav be found, which become better defined as the peritoneum is approached, and form an abundant lymphatic plexus just beneath it, which is especially marked on the posterior or intestinal wall of the uterus. THE UTERUS 53 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. 57). Innervation.—The nerve supply of the uterus is derived partly from the eerebro-spinal, but principally from the sympathetic nervous system. The eerebro-spinal system is represented by a few fibers from the third and fourth sacral nerves, and Herlizka has demonstrated the presence of medullated nerve-fibers in the uterine wall, which showed free endings between the muscle bundles. Herff and Gawronsky have described gan- glionic cells in the muscularis, and the latter has been able to follow iso- lated nerve-fibers into the epithelial cells of the endometrium. The greater portion of the nerve supply, however, is derived from the sympathetic system, and has been studied particularly by Lee, Franken- haeuser, Rein, and Pissemski. According to the authors first mentioned, large nerve-trunks from the inter-iliac plexus pass down on either side of the rectum, and, following the course of the utero-sacral ligaments, termi- nate in the large cervical ganglion. This structure was first discovered by Lee; it lies to the side of and behind the cervix, and from it numerous fibers make their way to the uterus, as is readily seen in Fig. 58. Pissemski in 1903 made extensive investigations upon the subject based upon the careful study of 50 specimens. He concluded that the cervical ganglion of Lee and Frankenhauser does not exist as such, but that a large plexus can be found on either side of the cervix which he designated as the funda- mental plexus of the uterus. This is composed of branches from the sec- ond, third, and fourth sacral nerves, as well as others from the hypo- gastric plexus and the sympathetic. Keiffer has shown that small but definite ganglia are present in the course of the nerves, especially where the various branches cross one another. Development of the Uterus.—It is universally admitted by embryolo- gists 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 margin of each Wolffian body. These gradually become converted into two epi- thelial 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 Fal- lopian tubes, while their lower portions fuse together to form the uterus and vagina. The fusion of the Miillerian ducts is usually completed 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. 54 THE FEMALE ORGANS OF GENERATION LITERATUEE Bayer. Zur physiol. und path. Morphologic der Gebarmutter. Freund's Gynako- logische Klinik, 1885, 369-662. Bruhns. Ueber die Lymphgefasse der weibiichen 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. 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. Fiscihel. Beitrage zur Morphologie der Portio vaginalis uteri. Archiv f. Gyn., 1880, xvi, 192-202. Frankenhaeuser. Die Nerven der Gebarmutter. Jena, 1867. Friedlander, C. Phys. anat. Untersuchungen iiber den Uterus. Leipzig, 1870. Friedlander, F. Abnorme Epithelbildung im kindlichen Uterus. Zeitschr. f. Gt>b. u. Gyn., 1898, xxxviii, 8-16. Gawronsky. Ueber Verbreitung und Endigung der Nerven in den weibiichen Geni- talien. Archiv f. Gyn., 1894, xlvii, 271-283. Herff. Ueber das anat. Verhalten der Nerven in dem Uterus, etc. Miinch. med. Wochenschr., Nr. 4, 1892. Herlizka. Quoted by Joessel-Waldeyer, Das Becken. Bonn, 1899, 764. His. Die anatomische Nomehclatur. 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 weib. Genitalapparates. Zentralb. f. Gyn., 1908, 121-125. Hofmeier. Zur Kenntniss der normalen Uterusschleimhaut. Zentralb]. f. Gyn., 18!):?, 764-766. Johntstone. The Menstrual Organ. Brit. Gyn. Jour., November, 1886. 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. Keiffer. Le systeme nei veux ganglionaire de 1 'uterus humain. Bull, de la soc. d'obst., Paris, 1908, XI, 50-70. Kocks. Die normale und path. Lage des Uterus, etc. Bonn, 1880. Kownatski. Die Venen d. weibl. Beckens. Wiesbaden, 1907. Kreitzer. Anatomische Untersuchungen iiber die Muskulatur der nicht schwangeren Gebarmutter. Petersburg, med. Zcitschrift, 1871, 113. 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 iiber die Uterusschleimhaut. Berlin, 1878. Luschka. Die Anatomie des Beckens. Karlsruhe, 1873. Mackenrodt. Ueber die Ursachen der normalen und path. Lagen des Uterus, Archiv f. Gyn., 1895, xlviii, 39.; 421. Mandl. Ueber die Richtung der Flimmerbewegung im menschlichen Uterus. Zen- trabl. f. Gyn., 1898, 322-328. THE FALLOPIAN TUBES 55 Ueber das Epithel im geschlechtsreifen Uterus. Zentralbl. f. Gyn., 1908, 425-429. Martin. Der Haftapparat der weibl. Genitalien. Berlin, 1911. Meyer. Ueber die fotale Uterusschleimhaut. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 234-249. Minot. Human Embryology, 1892, 3. Nagel. Die weibiichen Geschlechtsorgane (Bardeleben's Handbuch der Anatomie), Jena, 1896, 87-90. Parviainen. Zur Kenntniss der senilen Veranderungen der Gebartmutter. Berlin, 18!) 7. Pick. Ueber das elastische Gewebe in der normalen und path, veranderten Gebar- mutter. Volkman's Sammlung klin. Vortrage, N. F., 1900, Nr. 283. Pissemski. Zur Anatomie des Plexus fundamentals uteri beim Weibe. Monatsschr. f. (ieb. u. Gyn., 1903, xvii, 520-526. Poirier. Lymphatiques des organes genitaux de la femme. Paris, 1890. Rein. Notes sur le plexus nerveux fondamental de 1'uterus. Comptes rendus de la Soc de Biologie, 1S82, 161. Ribemont-Dessaignes. Precis d 'obstetrique. Paris, 1894, 30. Rielander. Das Paroophoron. Marburg, 1905. Roesger. Zur f'otalen Entwickelung des menschlichen Uterus. Festschrift zum 50- jahrigen Jubilaum der Gesell. f. Geb. u. Gyn. in Berlin, 1894, 9-52. Rosenmuller. (,)iuedam de ovariis embryorum et feetuum humanoruin. Lipsiae, 1802. Ruge. Zur Erosionsfrage. Zeitschr. f. Geb. u. Gyn., 1882, vii, 231-233. Schauta. Lehrbuch der gesammten Gynakologie, Wien, 1896, 5-14. Tarnier. Traite de 1'art des accouchements. Paris, 1888, T. I., 106. Veit. Uterusmuskulatur. Miiller's Handbuch 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, :S25-413. 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 duets 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 S 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 nar- row portion of the tube immediately adjoining the uterus, and gradually passes into the wider lateral portion or ampulla. The infundibulum, or 56 THE FEMALE ORGANS OF GENERATION fimbriated extremity, is the funnel-shaped opening of the lateral end of the tube, the margins of which present a dentate appearance (see Figs. 43 to 45, and Fig. 63). 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, cor- responding to the mesosalpinx. The fimbriated extremity opens freely into the abdominal cavity, and one of its fimbriae—the fimbria ovarica— 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, circu- lar, and an outer, longi- tudinal 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 pri- mary layers become less Fig. 59.—Tubal Mucosa. X 280. 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 confirmed by Ballantyne, Mandl, Grusdew, Recklinghausen, and Pick. The lumen of the tube is lined with a mucous membrane whose epithe- lium is composed of a single layer of high, columnar cells, which rest upon a thin basement membrane (Fig. 59). According to Schaffer, only a por- tion of the cells are ciliated. These are arranged in discrete patches, while the non-ciliated cells are supposed to be secretory. There is no submucosa, the epithelium being separated from the underlying muscle by a layer of connective tissue of varying thickness. The mucosa is arranged in folds which become more complicated as the fimbriated end is approached. The appearance of the lumen varies accord- ing to the portion of the tube examined. In the uterine portion four ele- THE FALLOPIAN TUBES 57 vations are seen, which together make a figure resembling a Maltese cross. In the isthmic portion of the tube a more complicated appearance can be noted; while in the ampulla the lumen is almost completely occupied by ' sS■ ■ ■ <>""&3 ■•i.v-t"*>; Fig. 60. ^ A <**?'■ A / £.'• .» -*A w <3 v^ov/>?^h> ^^s=^~* r-^i^s^-s'c*v*»A *; i . • * ._ fe&M *< -V^ X" ^fM&t£N'-W,';Ma •■■:.^''-?.y ■ f~&i ■•' ■• * '•-:» " ■ Fig. 62. ^„~*->. Figs. 60-62.—Sections through Uterine, Isthmic, and Ampullar Portions of Tube X 15. 58 THE FEMALE ORGANS OF GENERATION the arborescent mucosa, which upon careful examination is seen to be made up of four very complicated tree-like folds. (Fig. 63.) 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. Their absence was conclusively demonstrated by Frommel, who showed that the glandular appearance disappeared upon markedly dis- tending the tube, when the greater part of its lumen became perfectly Fig. 63.—Longitudinal Folds of Tubal Mucosa (after Sappey). smooth, with four arborescent folds of mucosa arising from its sides. It is interesting to note that Nature not infrequently performs a similar experiment in cases of hydrosalpinx. The current produced by the cilia of the tube is directed toward the uterus, as was conclusively demonstrated by the experiments of Pinner, Jani, and Lode, who showed that foreign bodies injected into the abdominal cavity of animals made their way into the tubes and were gradually car- ried down into the uterus and thence into the vagina. The tubes are richly supplied with blood-vessels and lymphatics, and the latter sometimes become so dilated as to fill up almost entirely certain folds of the mucosa. Occasionally, as Richard first pointed out, the tube may possess a sec- ond fimbriated extremity, which is known as an accessory ostium (Fig. 64). Again, not infrequently small tube-like structures, with miniature fimbriated extremities, are found projecting from the exterior of the tube. THE FALLOPIAN TUBES 59 As a rule, these are mere culs-de-sac. but occasionally one is met with pos- sessing a lumen which communicates with that of the main tube. Several cases of extrauterine pregnancy have been reported in which the fertilized ovum had been arrested 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 peritoneal covering. Such structures were first described by Landau and Rheinstein 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. Similar structures have also been described by Henrotin and Goebel. 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 certain 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 corkscrew-like appearance, as shown in Fig. 42. This gradually dis- appears with age, but occasionally the fcetal 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. LITEEATTJRE Bab. Ueber Duplicitas tuba? Fallopii. Archiv f. Gyn., 1906, lxxviii, 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. Goebel. Beitrag zur Anatomie und ^tiologie der Graviditas tubaria. Archiv f. Gyn., 1898, Iv, 658-713. Grusdew. Zur Histologie der Fallopia'schen Tuben. Zentralbl. f. Gyn., 1897, 257. Hennig. Ueber die Blindgange der Eileiter. Archiv f. Gyn., 1878, xiii, 156. Jani. Ueber das Vorkonimen von Tuberkelbacillen im gesunden Genitalapparat bei LungenBchwindsucht, etc. Virchow's Archiv, ciii, 522. 60 THE FEMALE ORGANS OF GENERATION 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, 29.1-324. Mandl. Ueber den feineren Bau der Eileiter, etc. Monatsschr. f. Geb. u. Gyn., 1897, v. Erganzungs Heft, 130-140. Pick. Ein neuer Typus des 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. Recklinghausen. Die Adenomyome und Cystadenoma der Uterus und Tuben- wandung. Berlin, 1896. 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. Soc, 1888, xxx, 207-213. Williams. Contributions to the Normal and Pathological Histology of the Fallopian Tubes. Amer. Jour. Med. Sciences, October, 1891. THE OVARIES General Anatomy.—The ovaries are two flattened, more or less almond- shaped organs, whose chief function is the development and extrusion of ova. They vary considerably in size, and during the childbearing 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 when she is on her back. 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 markedly 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 structure. The ovarian ligament extends THE OVARIES 61 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 centimeters long and 3 to 4 millimeters in diameter. It is covered by peri- toneum, and is made up of muscle and connective-tissue fibers, which are continuous with those of the uterus. The infundibulo-pclvic or suspensory ligament of the ovary extends from its upper or tubal pole to the pelvic wall. It represents 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 projects freely into the abdominal cavity, and is not covered by peritoneum except 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 em- phasized by Waldever (Fig. 71), who showed that the ovary above the peri- toneal line was covered by cuboidal epi- thelium. In many of the lower animals the ovary does not project freely into the ab- dominal cavity, but is more or less com- pletely 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. 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 vears. In this layer the ova and Graafian follicles are situated. It is com- posed of spindle-shaped connective-tissue cells, through which are scattered primordial and Graafian follicles in various stages of development, which Fig. 65.—Cross-section Adult Ovary showing Graafian Follicles. X4 . 62 THE FEMALE ORGANS OF GENERATION become less numerous as the woman grows older. The most external por- tion of the cortex presents a dull whitish appearance, and is designated as the albuginea, though it is not analogous with the similarly named struc- ture 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 con- tains large numbers of blood-vessels, both arteries and veins; and, accord- ing 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 monograph 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 not known whether they represent rem- nants of the rete ovarii or of the Wolffian bodies. In the human fcetus collections of epithelial cells are frequently ob- served in the neighborhood of the hilum, which are arranged in masses or strands sharply marked off from the surrounding stroma. These aru the medullary cords (Markstrange) 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 others show, however, that such is not the case, but that they represent the remains of the first proliferation of the germinal epithelium, and are analogous to the seminiferous 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. 69). In the female this is only a transient phenomenon, and usually disappears before birth; while it persists in the male and affords a satisfactory explanation for the em- ployment of the Wolffian ducts as efferent channels for the testicles. On the other hand, the medullary cords are persistent and characteristic struc- tures 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 cells, somewhat resembling those making up the corpus luteum. Limon in 1901 called attention to their existence, and his findings were confirmed 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. The researches of L. Fraenkel and A. Schaeffer show that such structures arc; not present in the adult human ovary, and are not constant in the lower animals, being present in certain species, but absent in others which are closely related. This being the case, it is evident that the "interstitial gland" is not essential to the production of the internal secretion of the ovaries. The nerves of the ovary are derived in great part from the sympathetic plexus which accompanies the ovarian artery, while a few are derived from THE OVARIES 63 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 A^on Herff, Gawronsky, Mandl, Winterhalter, and Vallet. The consensus of these researches shows that the ovary is very richly supplied with non-medullated nerve-fibers, which for the most part accompany the blood-vessels, and are merely vas- cular nerves; whereas a few form wreaths around the follicles and give off many minute branches, which have been traced up to, but not through, the membrana granulosa. Elizabeth Winterhalter has described a collection of ganglionic cells in the medulla of the ovary which she designates as the ovarian ganglion. She believes that these cells play an important part in the production of menstruation, although the majority of investigators do not share her views. 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 fcetal 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 considered in detail by Engstrom, Thumin, Seitz, and Chiari, and cases have been described in which there was found a typical third ovary connected with the uterus by a separate tube. Transplantation of Ovaries.—Experimental studies undertaken by Gri- gorieff, Knauer, Marshall, and others have shown that the ovaries of ani- mals and women may be excised from their original position and trans- planted 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 re- peatedly followed such operations in animals, and Morris states it has even occurred in women. For full literature upon the subject up to 1908 the reader is referred to the article of F. H. Martin. 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 indicates that this secretion is directly concerned in maintaining the integrity of the other generative organs; inasmuch as they have shown that atrophy of the uterus and vagina rapidly follows 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 suc-h cases the absence of atrophy must be attributed to the action of the internal secretion of the transplanted ovaries, since all nerve con- nections were severed at the time of operation. Frankel in 1903, and again in EGO, as the result of ingenious experi- 64 THE FEMALE ORGANS OF GENERATION G.E. P.O., 0. -AW. ments and clinical work, stated that the internal secretion is elaborated in the corpus luteum; though his teachings have not obtained universal ac- ceptance. Furthermore, many believe that the "interstitial gland"' plays an important part in its elaboration, but, as this structure is lacking in hu- man ovaries, such a suppo- sition is untenable at least so far as women are com- cerned. Upon these ideas is based the therapeutic appli- cation of tablets composed of desiccated tissue from the entire ovary or solely from 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 develop- ment. To Waldeyer we are indebted for much of our Fig. 66.—Section through Wolffian Body and Be- knowledge concerning the ginning Ovary and Mullerian Duct (Waldeyer). subject though important preliminary work had been A.W., abdominal wall; G.E., germinal epithelium; M.D., -i k vr l +• i ~r>n •■ beginning Mullerian duct; O., beginning ovary; P.O., rl0ne "J Valmtm and I nu- primordial ova; W.B., Wolffian body. gcr. In 1870 Waldeyer pub- lished his monograph upon the Ovary and Ovum (Eierstock und Ei), which was based in great part upon the embryology of the chicken. He found that by the fourth day of development the coelomic epithelium covering the inner surface of the Wolffian ...H'' ?***£<***» <•■'«■ body is differentiated from the surrounding tissue, its cells be- coming larger and more cu- boidal in shape, and some of them assuming a considerable size. Willi in a short time the epithelium proliferates to such an extent as to form a distinct elevation, which indicates the situation of the future ovary (Fig. 66). This epithelium Waldeyer designated as germi- nal epithelium, and the large, clear cells found within it as pri mod rial ova. As the proliferation 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- Fig. 67.- -tit'*! f/" -Sex Gland of Pig Embryo, 1.2 cm. long (Skrobansky). THE OVARIES 65 vessels from the Wolffian body, the epithelial masses become divided into smaller portions, the so-called egg-nests or Pfluger's tubes, which in turn become broken up into smaller and smaller masses, until eventually isolated primordial ova are found, which are sur- rounded by a single layer of more or less ttotpx *zm flattened epithelium. These represent the ^^M?^------------1. primordial follicles. |§2----- Fig. 68.—Cortex of Pig Embryo, showing Ger- Fig. 69.—Diagram showing Forma- minal Epithelium, Pfluger's Tubes with tion of Ovary (Winiwarter). Oocytes in Various Stages of Develop- 1( germinal epithelium; 2, germ tube; ment (Skrobansky). 3? medullary cord; 4, rete ovarii; 5, epoophoron. 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 thicken- ing of the epithelium on the inner surface of the Wolffian body. These primitive sex cells rapidly proliferate and cive rise to a distinct elevation. which is made up of closely packed undifferentiated epithelial cells and covered by a single layer of cuboidal cells arranged perpendicularly to the 66 THE FEMALE ORGANS OF GENERATION surface of the mass. The latter correspond to the future ovarian epithe- lium and take no part in the formation of ova and follicles (Fig. 67). The cells of the primitive sex gland proliferate rapidly and invade the underlying stroma of the Wolffian body, so that a cortical and medullary portion can be distinguished at an early period. The epithelial cells soon become broken up into ir- G.E., germinal epithelium; S., stroma of Wolffian body, cords. The more superficial cells, however, continue to proliferate, and soon show signs of differentiation, which progresses from below upward. Many retain their original appearance, while in others the nucleus becomes larger and clearer, and its chromatin arranged in a differ- ent manner. These latter cells are the oogonia, from which the ova are to be developed. After a certain period the oogonia cease proliferating, when the result- ing cells become larger, and their chromatin undergoes a series of com- plicated changes, which eventually lead to the formation of the reticulated nucleus of the primordial ovum or oocyte of the first order (Fig. 68). By the continued growth of connective tissue the masses of oocytes and undif- ferentiated 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; these, however, do not give rise to primordial follicles, but degenerate in situ. It would thus appear that the primordial ova or oocytes do not de- velop from the surface epithelium, but rather from the undifferentiated cells of the primitive sexual glands. This process has been observed in rabbits, pigs, and human beings by all recent investigators. For full information the student is referred to the works of Waldeyer, Winiwarter, Skrobansky, and Mcllroy. The ovary, therefore, in its earliest stages, consists of two layers, a single layer of germinal epithelium covering an underlying connective tissue (Fig. 70). In human beings 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. 71 and 72). At THE OVARIES 67 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 oocytes or primordial ova are derived from the germinal or sexual epithelium, but there is still considerable discussion as to the origin of the epithelium surrounding them. According to Wal- deyer and the majority of other observers, the follicular epithelium is de- rived from the cells of the germinal epithelium, which has not been con- verted into oocytes. Kollicker, on the other hand, believed that it origi- nated from the epithelium of the Wolffian bodies, and that the medullary cords in the adult ovary represented portions of the Wolffian body which were not utilized in this way. Foulis, in 1878, stated that the so-called follicular epithelium was derived from the connective tissue of the ovary, Fig. 71.—Ovary of New-born Girl. X 22. and the more recent studies of Wendeler and Clark would seem to confirm this view. Clark bases his conclusions upon his observation that the cells surrounding the primordial follicles are spindle-shaped and differ but little in appearance from the adjacent stroma cells; and more especiaHy upon the fact that in the earlier stages of the ovary many of the oocytes are not surrounded by epithelium at all, but are in direct contact with the surrounding connective tissue. Waldeyer's view, however, has obtained almost universal acceptance, and is placed beyond all reasonable doubt by the work of 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 Von Velits and myself, the follicular epithelium may likewise be found to possess cilia. These 7 68 THE FEMALE ORGANS OF GENERATION observations, in spite of their rarity, speak strongly against the connective- 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. The changes concerned in their disappearance will be considered more fully when we consider the corpus luteum. Before taking up the consideration of the evolution of the mature follicle, it may be well to mention certain historical points in connection Fig. 72.—Ovary at Birth, showing Primordial Follicles. X 300. with it. The Graafian follicle was first described in 1672 by De (Jraaf, a physician of Delft, who not only observed the vesicles, but demonstrated the presence of ova in the tubes of rabbits. The human ovum was first recognized by Von 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 o^fr are synonymous, and should therefore 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 THE OVARIES 69 from then until maturation begins as oocvtes of the first order, after the formation of the first polar body as oocytes of the second order, and as ova or ovia 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 primordial follicles, those nearest the central portion of the ovary showing the most advanced stages of development. As was mentioned above, the majority are destroyed before the time of puberty, and Stevens has given an ex- haustive account of the process. In young women the cortex contains large numbers of primordial folli- cles separated by thicker or thinner 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 epithelium. The oocyte is a single cell, more or less round in shape, with a clear protoplasm and a tolerably large nucleus occupying its central portion. The nucleus pre- sents a marked reticulated network and at one point a well-defined nucleo- us, as well as numerous accessory nucleoli, which are formed at the inter- sections of the nuclear thread-work. According to Nagel, the oocyte remains constant in size from birth until the transformation of the primordial into the typical Graafian follicle, no matter at what period of life this change may occur. These oocytes measure from 48 to 69 microns, and their nuclei from 29 to 32 microns in diameter. The primordial ovum, or oocyte1 of the first order, is sur- rounded 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. 73). Occasionally a primordial ovum may contain two nuclei or germinal vesicles, as has been shown by Xagel, Klein, von Franque, and others. Again, occasionally two and sometimes three distinct ova may be found in a single primordial follicle, and it is from such sti hires that multiple progi eies were formerly supposed ytfU tyt'sp^fcT^tW*7/^■.. ~*V# to develop. *V.£r..'•<*"#■ a.\>V^-W V....■ &fc.$ When, under the ii ence of factors with which 4j /'^, W^/^/^}}l^h^^Vf^i' we are as yet unacquaii to develop, we notice in the **v«SJL^W ? ''H K'tA &• ± < i * y,^-- first place that its epithelium C/3^. ()., gland filled with blood; Ep., surface epithelium; 6'., hypertrophieJ glands; &., stroma. RELATION BETWEEN MENSTRUATION AND OVULATION 85 lion and menstruation. From then on, however, it has generally been be- lieved that menstruation was brought about by the ripening of the Graafian follicles, and that the two processes occurred almost, if not quite, simulta- neously. This doctrine culminated in 1865 with the appearance of Pfluger's article upon the significance and cause of menstruation, in which he stated that the flow resulted from a reflex stimulation, which owed its origin to the pressure exerted by the growing 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. Pfliiger's theory, however, was somewhat shaken by the work of Leo- pold, Proclmwnick, and De Sinety, whose careful studies of the condition of ovaries removed at operation proved conclusively that the two processes were not necessarily synchronous, but might occur quite independently of one another, and accordingly ovulation could not be considered the unvary- ing cause of menstruation. Clinical experience also lent further proba- bility to this view, since it has shown that ovulation and subsequent preg- nancy might take place without menstruation; 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. Moreover, a few cases are recorded in which preg- nancies had occurred in such rapid succession that menstruation did not occur for years. Ahlfeld has reported the case of a woman who gave birth to numerous children, but did not menstruate until her thirty-second year. 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 conceive." 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 difference could be explained only by supposing that the former resulted from conception soon after the last menstrual period, and the latter from conception just before the first period missed. This view is also confirmed by the reproductive history of the orthodox Jewesses, who are noted for their fertility. According to their laws women are con- sidered unclean during the entire menstrual period and the seven days fol- lowing it. so that in them conception probably occurs shortly before the first missed menstrual period. Pinard in 1909 strongly advocated this view, which also seems to receive strong support from the recent work upon the structure of the endometrium, as well as from the fact that my experience 86 MENSTRUATION AND OVULATION shows that practically three-fifths of the young women who are married in the middle of an inter-menstrual 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. Fraenkel stated that menstruation was due to the elaboration of an internal secretion by the corpus luteum, which regulates the blood supply of the uterus. In 1910 he still further elaborated this view, and, as the result of comparative study of the corpus luteum, concluded that ovula- tion usually occurs 19 days after the last period, and that the corpus luteum resulting from the rupture of that follicle attains its highest development during the following week and then gives rise to menstruation. It is in- teresting to note that Villemin in 190S expressed somewhat similar views. Between the years 1885 and 1907 Leopold and his co-workers, Mironoff and Ravano, carefully studied the condition of the normal ovaries removed at operation from 95 women whose menstrual history had been carefully noted. In 59 cases, or 62 per cent., they found that menstruation and ovu- lation were synchronous, while in 36 cases they were not. The following figures give the findings in the 2-1 cases which he studied with Ravano: Ovulation at beginning of menstruation, 12 cases " later in menstruation, 2 cases '' shortly before menstruation, 4 cases '' between two periods, 1 case " without menstruation, 3 cases Menstruation without ovulation, 2 cases Leopold accordingly concluded that, while the two processes are usually synchronous, they are not always so, and that ovulation and consequently conception may occur at any time. Bryce and Teacher have arrived at similar conclusions from the study of the 11 youngest embryos described up to 1908. They hold with Heape and Marshall that menstruation cor- responds to the prooestrum of lower animals, and do not consider that such a view is inconsistent with our clinical or anatomical knowledge; as they hold that the essence of the menstrual cycle is not the mere preparation of a menstrual decidua, but rather the formation of a new endometrium. Gottschalk in 1910 reported a number of cases which clearly showed that conception and consequently ovulation may occur just after the last period; and one observation of my own affords striking proof of its possi- bility. Five days after a menstrual period I removed an ovarian cyst and repaired the outlet of a married woman. She remained in the hospital three weeks and missed the following period. As this was attributed to the operation, no attention was paid to it, but examination after a second period had failed to appear revealed a two months' pregnancy. She was delivered of a seven-and-a-half-pound child 280 days from the beginning of the period which occurred before she entered the hospital. From the evidence before us, we must conclude that ovulation and menstruation usually occur about the same time, but that one not infre- quently antedates the other by a few days, while in exceptional cases they MIGRATION OF THE OVUM 87 may occur quite independently; but in any event that the latter is abso- lutely dependent upon the presence of the ovaries. Mary Putnam Jacobi, in 1876, advanced the so-called menstrual-wave theory, which has been accepted by Stephenson, Webster, Ott, Van de Velde, and others. According to this idea, the metabolic processes in women pre- sent 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 that neither menstrua- tion nor ovulation is directly dependent upon one another, but upon some general and as yet unknown cause. The results following various operations upon the genital tract tend to 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 is generally admitted that the complete removal of both ovaries, which neces- sarily 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 mani- fested 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 occa- sional 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 ovu- lation has been demonstrated by the occurrence, in rare instances, of preg- nancy after the supposed removal of both ovaries by competent operators, cases of which have been reported by Gordon, Meredith, and others. Such observations conclusively demonstrate the fallacy of the view ad- vanced by Tait, Johnstone, and Savage, that menstruation is regulated by the so-called menstrual nerve, and that its persistence after operation was due to the fact that this nerve had not been included within the ligature. Ordinarily, the Fallopian tubes take no part in the menstrual function, 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 which did not heal, and through which a slight amount of bloody fluid exuded at each menstrual period. Migration of the Ovum.—The mechanism by which the ovum gains access to the tube after escaping from the ruptured follicle is a question 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 more or less 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. 88 MENSTRUATION AND OVULATION 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 of this view has been substantiated by the experimental work of Pinner, 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. This experi- mental evidence is reinforced by the fact that in certain amphibians large tracts of the peritoneum become covered by a ciliated epithelium shortly before the time of ovulation. It is more than likely, however, that a considerable proportion of the ova which escape from the ruptured folli- cle fail to gain access to the tubes, and perish in the peritoneal cavity. In 1844 Bischoff directed attention to the fact that not infrequently in animals possessing bicornuate uteri one finds that the corpora lutea are in one ovary, while the embryos are developed in the uterine horn on the opposite side. He 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 correspond- ing 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 down one tube, travers- ing 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 not infrequently observed, whereas PLACE OF MEETING OF THE OVUM AND SPERMATOZOA 8fl there is considerable discussion as to the possibility of the occurrence of internal migration. We are unable to ascertain how frequently external migration takes place in normal uterine pregnancies, though it is probably by no means rare. On the other hand, its occurrence has been repeatedly demonstrated in cases of bicornuate uteri, and those presenting a rudi- mentary horn; and not infrequently in normal uteri, when one tube is markedly diseased and the other more or less normal, as in cases of hydro- salpinx and inflammatory lesions of one tube associated with occlusion of its fimbriated extremity. In such cases, when the corpus luteum is found on the side of the diseased tube, it is inferred that the ovum gained access to the uterus through the normal or only slightly diseased tube of the oppo- site side. Moreover, the same event has not infrequently been observed in extrauterine pregnancy. 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 the woman was delivered at term, and seventeen months after delivery the remaining tube was removed for a ruptured extrauterine pregnancy. I have examined specimens from numerous cases of extrauterine preg- nancv, which apparently offered incontrovertible evidence of external migra- tion of the ovum, the corpus luteum being found in the ovary of one side and the pregnancy in the opposite tube. The same condition was beauti- fully exemplified in a specimen which Dr. II. C. Coo sent me for examina- tion. In this case the right tube had twice been the seat of extrauterine pregnancy. The first pregnancy, which dated from several years before, was situated in the isthmic portion of the tube, the fcetus having become converted into a lithopaedion which completely blocked the lumen. Ex- ternal to this, and occupying the lateral portion of the tube, was a freshly ruptured four months' pregnancy. The right ovary was small, atrophic, and covered by adhesions, while the left contained the corpus luteum of pregnancy. It was apparent in this case that 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 lithopaedion, when it underwent further development. Satisfactory evidence has not yet been adduced in favor of the occur- rence of internal migration of the ovum, and it is hardly possible that such proof can ewer be brought in the future, though its theoretical possibility cannot be denied. Sehaeffer and Veit have conclusively demonstrated that the specimens which were formerly relied upon to establish its occur- rence are open to other and simpler explanations. 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 ? 90 MENSTRUATION AND OVULATION The number of spermatozoa contained in a single ejaculation is marvel- ous, and has been estimated by Lode at 226,257,900. Various explanations 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 muscles of the uterus contract forcibly during coitus and compress the uterine cavity, into which the spermatozoa are aspirated when relaxation 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 may make their way thither by their own activity. Moreover, the observations of Low indicate that the mucous secretion of the uterus possesses a positive attraction for them, as can be verified under the microscope. That this view is correct is demon- strated by the instances of pregnancy following imperfect coitus, and par- ticularly 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. 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 conditions. But in view of the observations of Hofmeier, Mandl, and others, which show that the ciliary current is directed from above downward, in the uterus as well as in the tubes, it is apparent that this theory must be abandoned, and it must be admitted thaf the spermatozoa have to make headway against the cur- rent from the time they enter the internal os. It is probable that spermatozoa can nearly always be found in the tubes of married women, into which they make their way by their own motility. Living spermatozoa have been observed in the tubes of women by Birch- Hirschfeld and Diihrssen, and it is a well-known fact that they re- tain their activity in the tubes of the bat for many months. Years ago Bischoff showed that they could be found on the surface of the ova- ries of animals for a certain length of time after copulation, and the occurrence of ovarian pregnancy demonstrates that the same may occur in women. From the evidence available, it appears to be tolerably satisfactorily demonstrated that in women who copulate at frequent intervals the tube must be regarded as a species of receptaculum seminis, in which spermato- LITERATURE 91 zoa are always present and waiting for the ovum, and that fertilization usually occurs in the tubes and only rarely in the uterus. LITERATURE Ahlfeld. Lehrbuch der Geburtshiilfe, II. AufL, 1898, 2. Alt. Ueber das Vorkommen und die Bedeutung der Menstruation bei den Volkern der Altenwelt. Monatsschr. f. Geburtskunde, 1S55, vi, 161-179. Aveling. Obst. Jour, of Great Britain and Ireland, July, 1S74, 209. Beck. How Do the Spermatozoa Enter the Uterus'? American Jour, of Obst., 1S75, viii, 353-391. Bell. Menstruation and Its Relation to Calcium Metabolism. Proc. Royal Soc. Med., July, 1908. Birch-Hirschfeld. Quoted by Zweifel, Lehrbuch der Geburtshiilfe, II. Aufl., 1889, 20. Bischoff. Die Entwickelung des Kaninchen-Eies. 1842. See literature on the Anatomy of Ovaries. Bryce and Teacher. The Early Development and Imbedding of the Human Ovum. Glasgow, 1908. 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. Duhrssen. Lebendige Spermatozoen in der Tube. Zentralbl. f. Gyn., 1893, 593. Findley. Anatomy of the Menstruating Uterus. Amer. Jour. Obst., 1902, xlv, 509 512. Fraenkel. Die Function des Corpus luteum. Archiv f. Gyn., 1903, lxviii, 438-545. Neue Experimente z. Funktion d. Corpus luteum. Archiv f. Gyn., 1910, xci, 705-761. 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 Removal of Both Tubes and Ovaries. Trans. Amer. Gyn. Soc, 1896, xxi, 104-108. Gottschalk. Ueber d. Beziehung d. Conception z. Menstruation etc. Archiv. f. Gyn., 1910, xvi, 479-497. Halban. Schwangerschaftsreactionen der foetalen Organen, etc. Zeitschr. f. Geb. u Gyn., 1904, liii, 191-231. Haller. Quoted by Ahlfeld, Lehrbuch, II. Aufl., 1898, 1. Heape. The Sexual Season. Quar. Jour. Micr. Science, 1900, xliv. Henle. Lehrbuch der Anatomie. His. Anatomie menschlicher Embryonen. 1880. Hitschmann u. Adler. Der Bau d. Uterusschleimhaut. Monatschr. f. Gob. u. Gyn., 1908, xxvii, 1-81. Hofmeier. See literature on Anatomy of Uterus. Hoppe-Seiler. Ueber den Blutverlust bei der Menstruation. Zeitschr. f. physiol. Chemie, xiii, 545. Jacobi. The Question of Rest for Women during Menstruation. Boyleston prize essay, New York, 1877. Jani. See literature on Anatomy of Uterus. Johnstone. The Menstrual Organ. British Gyn. Jour., November, 1886. J£ahlden. Ueber das Verhalten der Uterusschleimhaut wahrend und nach der Men- struation. Hegar's Festschrift, Beitrage zur Geb- u. Gyn., Stuttgart, 1889, 92 MENSTRUATION AND OVULATION Kehrer. Die Zusammenziehungen des weibiichen Genitalcanals. Beitrage zur ver- gleich. u. exp. Geburtskunde, Heft 1, 1864. Kelly. Operative Gynecology. 1898, vol. ii, 189. Kennedy. Edinburgh Medical Journal, 1882, xxvii, 1085. Kristeller. Berliner klin. Wochenschr., 1871, Nr. 27, 28. Kussmaul. Von dem Mangel, der Vcrkummerung und Verdoppelung der Gebarmut- ter und der Ueberwanderung des Eies. Wiirzburg, 1S59. Leopold. Studien iiber die Uterusschleimhaut. Berlin, 187S. Die Ueberwanderung des Eies. Archiv f. Gyn., 1880, xvi, 22-44. Untersuchungen 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. Neucr Beitrag z. Lehre von d. Menstruation and Ovulation. Archiv. f. Gyn., 1907, Ixxxiii, 566-586. Litzmann. Wagner's Handworterbuch der Physiologie, iii, 53. Lode. See literature on Anatomy of Uterus. Lohlein. Das Verhalten der Uterusschleimhaut wahrend der Menstruation, (iyna- kolog. Tagesfragen, Heft 2, Nr. 6. 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. Mandl. Beitrag zur Frage des Verhaltens der Uterusmucosa wahrend der Menstrua- tion. Archiv f. Gyn., 1896, Iii, 557-578. See literature on Anatomy of Uterus. Marshall. Physiology of Reproduction. London, 1910. Meredith. Pregnancy after the Removal of Both Ovaries for Dermoid Tumour. Brit. Med. J., 1904, i, 1360. Moericke. Die Uterusschleimhaut in verschiedenen Altersperioden und zur Zeit der Menstruation. Zeitschr. f. Geb. u. Gyn., 1882, vii, 84-137. Negrier. See literature on Anatomy of Ovaries. Ott. Gesetz der Periodicitat der physiologischen Functionen im weibiichen Organis- mus. Vehr. des X. internat. med. Congresses, Berlin, 1891, Bd. Ill, Abt. viii, 33. Pfluger. Ueber die Bedeutung u. Ursache der Menstruation. Berlin, 1865. Pinard. La menstruation, etc. Annales de gyn. et d'obst., 1909, vi, 721-733. Pinner. See literature on Anatomy of Uterus. Ploss. Das Weib in der Natur- und Volkerkunde, IV. Aufl., 1895, Bd. I, 266-334. Pouchet. See literature on Anatomy of Ovaries. Prochownick. Fall von Menstruatio praecox. Archiv f. Gyn., 1881, xvii, 330-381. Rouget. Recherches sur les organes erectiles de la femme. Jour, de la Physiologie, 1858, i, 320. Savage. The Female Pelvic Organs. 3d ed., New York, 1880. Schaeffer. Ueber die innere Ueberwanderung des Eies. Zeitschr. f. Geb. u. Gyn., 1889, xvii, 13-42. Schickele. Wirksame Substanzen im Uterus u. Ovarium. Miinchener med. Wochen- schr., 1911, No. 3. Sigismund. Ideen iiber das Wesen der Menstruation. Berliner klin. Wochenschr., 1871, 824, 825. de Sinety. Recherches sur la muqueuse uterine pendant la menstruation. Gazette med. de Paris, 1881, No. 7. Tait. See literature on Anatomy of Uterus. Thompson. Zur Frage der Tubenmenstruation. Zentralbl. f. Gyn., 1898, 1227. LITERATURE 93 Van de Velde. Ovarialfunction. Wellenbewegung u. Menstrualfunction, Jena, 1905. Veit. Die Frage der inneren Ueberwanderung des Eies. Zeitschr, f. Geb. u. Gyn., 1892, xxiv, 327-355. Villemin. Le corps jaune considere comme glande a secretion interne de 1'ovaire. Paris, 1908. Webster. The Biological Basis of Menstruation. Montreal Med. Journal, April, 1897. Wegelin. Der Glycogengehalt d. menschlichen Uterusschleimhaut. Centralbt. f. allg. Path. u. path. Anat., 1911, xxii, 1-8. Wernicii. Ueber die Ereetionsfahigkeit des unteren Uterusabschnittes, etc. Beitrage zur Geb. u. Gyn., Berlin, 1872, 297 307. Westphalen. Zur Physiologie der Menstruation. Archiv f. Gyn., 1896, Iii, 35-70. 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 develop- ment of the embryo the student is referred to the standard works upon embryology. Maturation of Ovum.—The ovum, as it occurs in the mature 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 for- mation and extrusion of the polar bodies, which leads to the reduction in the number of chromosomes to one half of that characteristic of the Fig. 82. Fig. 83. Fig. 84. Figs. 82-84.—Formation of Polar Body (Sobotta). X 500. n., nucleus; V., vitelline membrane; Y., yolk granules; P., polar spindle; »S., head of spermatozoon. somatic cells. The process has not as yet been proved for human beings; but, as it has been observed in all the lower animals which have been studied, it is reasonable to suppose that it also occurs in man. The changes are supposed to begin just before'the rupture of the follicle, and to be completed while the ovum is in the upper portion of the tube, though occasionally they may take place while it is still within the ovary. 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 usually chosen for its demonstration. Sobotta made an exhaustive study of the process in the mouse, and it is from his article that most of our statements are taken. When the process H MATURATION OF THE OVUM 95 of maturation is about to begin, the germinal vesicle approaches 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 area becomes transformed into a typical caryocinetic or mitotic figure, which undergoes the usual changes and soon becomes spindle-shaped. The spindle, when it first 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. 82 to 84). Division rapidly ensues, and the new nucleus nearest the surface, with the portion of protoplasm surrounding it, is cut off from the rest of the ovum and comes to lie between it and the vitelline membrane. In this way is formed the oocyte of the second order and the Fig. 85.—Diagram showing Normal Cell Division with Four Chromosomes. a, cell with four chromosomes; b, formation of spindle; c, splitting of chromosomes in spindle; d, separation of daughter chro- mosomes; e, complete separation into two cells each with four chromosomes. Fig. 86 —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; g, second polar body; h, cells derived from division of first polar body. 96 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM first polar body. As the process is a typical cell division, the nucleus of both the oocyte and the polar body will contain the typical number of chro- mosomes. 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 chromosomes characteristic of the species. One 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 characteristic of the body cells. Under 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 teratomata. It would therefore appear that in the process of maturation six cells may develop from the original oocyte of the first order: by the non-reducing division, the oocyte of the second order and the first polar body; while by the reducing division the former gives rise to the mature ovum and the second polar body, and the latter to two cells homologous with the second polar body (Fig. 86). Maturation is essentially a means of reducing the number of chromo- somes, 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 the pa- ternal chromosomes into the ovum at the time of fertiliza- tion, without increasing the number of chromosomes char- acteristic of the species, as must inevitably occur if some such mechanism were not provided. In any event, the process must be regarded as a necessary preliminary to normal fertilization and further development of the ovum. As the researches of Flemming and Duesberg appar- ently show that the somatic cells of human beings contain twenty-four chromosomes, it must follow that they are reduced to twelve in the mature ovum and second polar body. Fertilization.—By fertilization is understood the union of a spermatozoon and the mature ovum. Each spermato- zoon consists of three portions—the head, tail, and inter- mediate portion. The head is somewhat' triangular in shape and flattened from side to side; it contains a definite amount of chromatin, which is derived from the mother cells of the testicle (Fig. 87). Interpolated between the long tail and the head is a small cylindrical body, the intermediate portion. 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 centimeter in three minutes. Fig. 87.—Human Spermatozoa. h, head; c, inter- mediate por- tion; t, tail. FERTILIZATION 97 In spermatogenesis, changes are observed analogous 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 containing only one half the number of chromosomes characteristic of the species (Fig. 88). These latter are.the spermatids, which later become the spermatozoa. Each spermatozoon, therefore, must be regarded as a distinct cell, which is analogous with the mature ovum and the second polar body. As has already been pointed out, the spermatozoon and ovum usually come together in the lateral portion of the tube, which may be regarded as a species of receptaculum seminis, although in rare instances the meet- ing may take place on the surface of the ovary or even in the Graafian follicle, as is demonstrated by the occurrence of ovarian pregnancy. A Fig. ss.—Diagram showing the Reduc- tion in the Number of Chromosomes in Spermatogenesis in a Species with Font Chromosomes in the Nucleus. a-b-c, spermatocyte of first order in various stages of division; d, spermatocyte of sec- ond order; e, spermatids with two chromo- somes each. Fig. 89.—Diagram showing Fertilization and Segmentation of the Ovum. a, fertilization: 1, male pronucleus; 2, fe- male pronucleus; b-c, formation of spin- dle with chromosomes derived from both ovum and spermatozoon; d-e, cell division showing perpetuation of paternal and maternal chromosomes in body cells. 98 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM 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 membrane, but it appears that 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. 84). This rapidly 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 only one half the number of chromosomes characteristic of the species, their union restores the number to the normal type (Fig. 89). Thus, in ascaris, two of the1 chromosomes of the segmentation nucleus are of paternal and two of maternal origin, while in man twelve come from each cell. Moreover, as the 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 consist merely in the union of so many paternal and maternal chromosomes, but has a much broader significance, in that it brings together nuclear substances derived from the ancestors of both parents, and thus affords a basis for a com- prehensible theory of heredity. In the case of man, where the mature ovum and spermatozoon each contain twelve chromosomes, it is apparent that many different combinations are possible, and Ziegler has calculated that any one of one hundred and sixty-nine possibilities may have to be reckoned with. Ordinarily segmentation does not begin until after fertilization, but it is well known that in many of the lower animals it is not necessarily dependent upon the fusion of the male and female elements—partheno- genesis. It has been repeatedly shown in recent years that segmentation may be inaugurated without the presence of spermatozoa by subjecting the mature ovum to the action of various chemical agents, such as weak solutions of acids or alkalies—artificial parthenogenesis. In such cases development 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. Lefevre. 1907. has shown in Thallasema that the egg under such con- ditions casts off two polar bodies, as usual, but that the cells resulting from segmentation possess only one half as many chromosomes as when fertilization occurs. Accordingly, it would appear that the process of fer- tilization 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 ex- periments upon artificial parthenogenesis in some of the lower species clearly show that the latter may occur absolutely independently of the former. In view of such facts, Loeb in 1909 stated that spermatozoon GENERAL DEVELOPMENT OF OVUM 99 may be regarded as an activator, which serves to stimulate nuclein syn- thesis. For a time it was believed that the centrosome—the structure which 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. Figs. 90-92.—Changes in the Segmentation Nucleus (Sobotta). X 500 P., polar body; s.n.f segmentation nucleus. General Development of Ovum.—Soon after the appearance of the seg- mentation 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. 90 to 9^). 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 Fig. 93. Fig. 94. Fig. 95. Figs. 93-95.—Formation of Mulberry Mass (Sobotta). X 500 segments 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 designated as the morula, or mulberry mass (Fig. 95). Fluid soon appears in the mulberry mass and forces the cells to the periphery, thus giving rise to a vesicular structure consisting 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 animals is still surrounded 100 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM by the vitelline membrane (Fig. 96), whereas in the mouse the latter disappears before the formation of the mulberry mass (Fig. 109). In a short time a collection of cells can be noted at one point on the inner surface of the blastodermic vesicle. This is known as the internal cell-mass, while the single layer of cells forming the wall of the vesicle is frequently spoken of as the primitive chorion (Fig. 96). When viewed by transmitted light the internal cell-mass ap- pears darker than the rest of !0t, the surface of the blastodermic vesicle, and hence is called the macula embryonalis. Sections made through it at this point -i.c.m. show that it is composed of sev- eral layers of cells, those nearest the exterior being ectodermal, and those nearest the segmenta- tion cavity entodermal. The formation of a blasto- dermic vesicle has not as yet been observed in the human ovum, but, as it has been dem- onstrated in the ova of the vari- ous 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 wall. 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; since Hyrtl upon one occasion discovered an ovum in the uterine end of the tube five days after the cessation of the menstrual period. Since the studies of Graf Spee show that in the guinea-pig the blastodermic vesicle is not formed until after the ovum has become im- bedded in the decidua, it is probable that the same holds good for man. If this be the case, it could scarcely be formed before the latter part of the first week, after which it must undergo very rapid changes, as the 13 to 14-day-old human ovum described by Rryce and Teacher, which is the earliest on record, presents a much more advanced stage of development (Fig. 108). Following the formation of the blastodermic vesicle and its internal cell-mass, the further development of the ovum varies greatly according to the intimacy of its attachment to the uterine wall. If this is loose, and there is an abundance of space in the uterine cavity, important changes promptly occur upon the surface of the vesicle, as in the rabbit and dog. On the other hand, if the ovum is very minute, and soon burrows into the depths of the uterine mucosa, these changes are lacking, so that further Fig. 96.—Blastodermic Vesicle of Rabbit (v. Beneden). c, cavity of vesicle; ect., primitive ectoderm; i.c.m., internal cell-mass; z.p., zona pellucida; e., albuminous envelope. GENERAL DEVELOPMENT OF OVUM 101 development takes place in the interior of the vesicle—the so-called "inver- sion" 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, such as the pig, sheep, monkey, and in all probability man. We shall accordingly briefly consider the changes occurring in the rabbit and dog, and then take up in more detail those observed in certain rodents, bats, monkeys, and man. As the cells composing the internal cell-mass proliferate, they give rise to a round or oval area at one point on the surface of the blastoder- mic vesicle—the embryonic area—which at first consists of two layers of cells representing the ectoderm and entoderm respectively. Specimens pre- senting this stage of development are readily obtained from rabbits and dogs. In them the embryonic area, when viewed by transmitted light, is first round, but later oval in shape, and presents a dark center and a light periphery, which are des- ignated respectively as the area opaca and the area pellucida (Fig. 97). This differentiation is due to the fact that the cells composing the for- mer are arranged in sev- eral layers, whereas in the latter only two can be made out. The embryonic area soon becomes slightly ele- vated above the general surface of the blastoder- mic vesicle, and now forms what is known as the embryonic shield. A few hours later a darker exceeds it in size (Fig. 97, M.S.). This is the mesodermic area, which on section is seen to be made up of spindle-shaped and triangular cells. Fig. 99, representing a section through the embryonic area of a dog at this stage, shows distinctly that it is made up of two layers—ectoderm and entoderm. The mesodermic 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 prim Hive streak—which is bounded on either side by a slight elevation—the primitive folds (Fig. 97, P.S.). Shortly after- ward a second depression—the medullary groove—appears in front of zone appears at one end of the shield and soon 102 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM 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 streak, but Fig. 98.—Section through Early Embryonic Area of Dog (Bonnet). X 180. Ec, ectoderm; Ent., entoderm. Fig. 99.—Embryonic Shield of Rabbit, Fig. 100.—Chicken Embryo with Live showing Primitive Streak and Medul- Segments (Kollmann). lary Folds (Kollmann). X 28. Hj^ head-fold; M.f., medullary folds; P., primitive streak; P.s., primitive segments; P.z., parietal zone; S.z., segmental zone. While these changes are taking place on the surface of the embryonic 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 (1ENERAL DEVELOPMENT OF OVUM 103 medullary canal can be observed a slight thickening—the segmental layer (the Stammzone of the Germans)—outside of which is a thinner layer— the parietal zone (Fig. 100). The segmental layer soon becomes divided &*V's - -3* '*&■*"' ■ ^& *-* a, s Ent. ^"^ Fig. 101.—Section through Area of Dog showing Three Layers (Bonnet). X 180. Ect, ectoderm; Ent., entoderm; M., mesoderm; M.G., medullary groove. up into a number of more or less cuboidal masses of tissue on either side of the medullary groove, which are variously designated as protovertebrce, primary segments, or mesoblastic somites; from these the musculature of (<>»,, c •< .; m.(»k £<•/. ''-'AKj £g . ii ■ , ' ' is , .1 Kftl' **e ■ V '•-'• '• ■ t; • A.- s •'■■• ■ ■ D m c. ah D. CM. Fig. 112. — Blastodermic Vesicle of Fig. 113.—Blastodermic Vesicle of Mouse in Mouse. First Half Sixth Day Uterine Cavity, Second Half of Sixth (Sobotta). X 300. Day (Sobotta). X 300. Ect., ectoderm; Ent., entoderm. C, cavity of ovum; CM., cell-mass; Ent., ento- derm; Ep., uterine epithelium; D., decidua. tend outward beyond the cylindrical structure, and eventually come to line the entire interior of the blastodermic vesicle, where they form the epithelial lining of the yolk-sac. While these changes are taking place, the ovum becomes firmly at- tached to the uterus, and, after the disappearance of its epithelium, comes into direct contact with the connective tissue of the mucosa (Figs. 115 and 117). At the same time, the cells at the outer portion of the cell-mass multiply rapidly, and give rise to the eetoplacenta, which, invading the adjacent ma- ternal tissue, opens up its blood-ves- sels, thus bringing the fcetal cells and the maternal blood into di- rect contact. Almost simultaneously, a longitudinal split appears in the underlying cylindrical mass of cells. This rapidly becomes larger and gives rise to a cavity lined by Fig. 114. — Blastodermic Vesicle of Mouse in Uterine Cavity, Second Half of Sixth Day (Sobotta). X 300. U.C., uterine cavity; C, cavity of ovum; CM., cell mass; Ent., entoderm; Ep. uterine epithelium; D., decidua. DEVELOPMENT OF CHORION AND AMNION 109 a single layer of ectodermal cells—the amniotic cavity (Fig. 117). Thus far no trace of the future embryo is apparent, but soon the cells at one point upon the wall of the primitive amnion begin to proliferate, and P give rise to a typical embryonic Fio. 115. — Blastodermic Vesicle of u u Mouse in Uterine Cavity, Seventh Fig. 116. — Blastodermic Vesicle ob Day (Sobotta). X 300. Mouse in Uterine Cavity, First Half . . L . .,, of Seventh Day (Sobotta). X 300. Am., amniotic cavity; Ep., uterine epithe- lium; CM., cell-mass; D., decidua; U.C., Ep., uterine epithelium; C, cavity of ovum; uterine cavity; Ent., entoderm; C, cavity Ent., entoderm; D., decidua; CM., cell- of ovum. mass. cycle of changes as in the rabbit, except that the somatopleure takes no part in the formation of the amnion. With the development of the mesoderm the entoderm becomes separated from the ectoderm, with the resulting for- mation of the yolk-sac, the allantois, and the extra embryonic ccelome. The researches of Graf Spee have demonstrated the occurrence of practically identical changes in the guinea-pig, except in the fact that the ovum becomes embedded in the depths of the uterine mucosa before the development of the blastodermic vesicle. Van Beneden has shown that the development of the amnion and em- bryo occurs in a somewhat similar manner in the bat. In this case, how- ever, the internal cell-mass does not give rise to a cylindrical projection into the cavity of the blastodermic vesicle, but forms a lenticular enlarge- ment upon its inner surface. By the degeneration of the cells in its center a cavity appears, which is that of the amnion, while the embryo is de- veloped from the cells at its base (Figs. 118, 119 and 120). 110 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM In monkeys the earliest stages of development have not been observed, but the early ova described by Selenka leave no doubt as to the mode of origin of the amnion and embryo. Thus, Fig. 122, which represents a section through an early ovum of the gibbon, shows a well-developed chorion and coelomic cavity, while the small amnion and embryonic area hang by a pedicle from the inner surface of the chorion. At the point marked "I" in the drawing is a depression upon the outer surface of the chorion, which in all probability repre- sents the point of inversion. Likewise, Fig. 120, showing a section through a semnopithe- cus ovum, presents a typical early placenta with well-devel- oped chorionic villi. There is a large coelomic cavity, while a very small amnion is loosely attached to the interior of the chorionic membrane. The em- bryo is represented by a min- ute embryonic area and a yolk- sac, and it is evident that the former must have originated at some point on the inner sur- face of the amnion. The earliest human ovum with which we are acquainted was described by Bryce and Fig. 117.—Blastodermic Vesicle of Mouse in Uterine Cavity, Eighth Day (Sobotta). X 225. Am., amniotic cavity; B., blood; C, cavity of ovum; D., decidua; Ect., ectoderm; Ent., ento- derm; E.P., ecto-placenta. Fig. 118.—Blastodermic Vesicle of Bat (Van Beneden). X 275. C, cavity of vesicle; CM., internal cell-mass; E., enveloping layer. Teacher in 1908, and, although we are entirely ignorant concerning its earlier stages, there is every reason to suppose that it became implanted upon the uterine mucosa, as already described. This specimen, which was found in a shred of decidual tissue expelled eleven days after the menstrual period should have begun, measured 0.77x0.63 millimeter, and was probably 13 or 14 days old (Fig. 108). It consisted of a blasto- dermic vesicle filled by mesodermic tissue, which contained two small cavities: the larger, lined by a single layer of cuboidal cells, representing the amnion, and the smaller, lined by flattened cells, representing the yolk- CM Fig. 119.—Blastodermic Vesicle of Bat (Van Beneden). X 200. CM., cell-mass; Ect., ectoderm; Ent., entoderm; Y.S., yolk-sac. Ect. Fig. 120.—Bat Ovum (Van Beneden). X 200. Showing Amnion and Embryonic Area. Am., amnion; C, ccelome; Ch., chorion; E.A., embryonic area; Ect., ectoderm; Ent., ento- derm; Y.S., yolk-sac. V L. /W. £A_JS- Fig. 121.—Ovum of Semnopithecus Nasicus (Selenka). X 90. Am., amnion; Ch., chorion; D., decidua; E.A., embryonic area; G., uterine gland; I.S., in- tervillous space; L., Langhans' layer; M.B.S., maternal blood spaces; S., syncytium; T., trophoblast; U., uterine wall; V., villus; Y.S., yolk-sac. Ill 112 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM sac. Immediately surrounding the vesicle, and representing the early chorion, were several layers of ectodermal cells, presenting all stages of cell division, while springing from their periphery were irregularly shaped branching and interlacing masses of vacuolated protoplasm, not divided into individual cells, which extended to the margin of the implantation cavity and opened up maternal blood-vessels, whose contents then escaped ^^ into the spaces of the proto- plasmic network. This entire tissue is designated as the tro- phoblast, the individual cells probably corresponding to the Langhans cells of the chorion, and the protoplasmic masses to the syncytium. The next earliest human ovum was described by Peters in 1899, and is of special in- terest for the reason that its description formed the basis for our present ideas concern- ing the embedding of the ovum and the development of the chorion ami amnion in man, This specimen, which Peters considered to lie only three or four days old, is actually older than the one just described, and was found in the uterus of a woman who committed suicide three days after miss- ing her menstrual period. It measured 1.6 x 0.8 x 0.9 milli- meter in its various diameters, and presented a well-developed chorion and a very small am- nion. Plate IAT represents a section through the portion of decidua in which it was em- bedded, and shows that the chorion is made up of two layers—a thin inner layer of connective tissue which is poor in cells and forms the lining of the coelomic cavitv, and an outer layer composed of many layers of epithelial cells. The latter form a capsule of varying thickness about the periphery of the ovum—the tropho- blast—which in Peters's opinion represents the primitive ectoderm of the ovum. The majority of the cells possess well-marked roundish or cuboidal Fig. 122.—Section through Young Ovum of Hy- lobates, showing Formation of Amnion (Selenka). X 8. A., amnion; a., amniotic pedicle; B., blood-vessel; C, chorion; C.V., chorionic villi; D., decidua; E., embryo; /., point of inversion of blastodermic vesicle; Int., intervillous space; Y.S., yolk-sac. DEVELOPMENT OF CHORION AND AMNION 113 bodies and vesicular nuclei. Scattered between them are masses of proto- plasm which show no sign of division into individual cells, and contain irregularly shaped, darkly stained nuclei. The trophoblast has invaded the surrounding decidual tissue and opened up numerous blood-vessels, so that many comparatively large blood spaces have been formed in it. From the underlying connective tissue of the chorion numerous small processes pro- ject into the trophoblast and represent the earliest stages in the formation of chorionic villi. Accordingly, in these two specimens we find a well-developed foetal ectoderm, the chorion, and a very rudimentary amnion. In Bryce and Teacher's specimen the latter was a minute cavity lined by a single layer of undifferentiated cells, while in Peters's ovum, as shown in Fig. 123, Fig. 123.—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 ccelum. the small flattened amnion was in contact with the chorion, with the cells upon one side of it differentiated to form a rudimentary embryonic area. As practically identical conditions were found in the ovum of Heine and Hofbauer, it would appear that these structures could not have developed upon the outer surface of the blastodermic vesicle, and consequently we must conclude that the amnion could not be derived from folds of somato- pleure, which are not formed until the embryo has attained quite an ad- vanced stage of development. Furthermore, it seems justifiable to assume that in human beings the chorion represents the outer wall of the blasto- dermic vesicle, and that the amnion is developed by a process of "inversion"; while the embryo is derived from an embryonic area which appears at some point upon the inner surface of the latter. 114 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM An ovum from the third week, described by Graf Spee, gives us important information concerning the amnion, and, although it does Fig. 124.—Microscopic Section, showing Ovum Embedded in Decidua and Surrounded by Decidua Reflexa Probably 17 Days Old (Leopold). not present the earliest stages in its formation, it serves to confirm the views just stated. The entire ovum in this case measured 6 x 4.5 millimeters in diam- eter, and possessed a well- developed chorion, a portion of which is shown in Fig. 125. Projecting from its interior . is a small vesic- ular structure—the beginning embryo. ^c.e. Yig. 126 represents a Nc-m- a section through the ,--' same ovum, and shows clearly the relations of its Fig. 125.—Spee's Human Ovum, Embryonic Area, various parts. The embryo 0.4 Millimeter Long. X 24. ■ „j.i.„„i,„,i +^ ±\ is attached to the inner sur- A., amnion; Bs., abdominal pedicle; C. chorion; c.e., * p ,, , chorionic epithelium; cm., chorionic mesoderm; tace 0I tne Chorionic meill- V., chorionic villi; Y., yolk-sac. brane by a mesodermic pedi- DEVELOPMENT OF CHORION AND AMNION 115 Fig. 126.—Section through Spee's Ovum, shown in pre- ceding Figure. X -4. c, chorionic membrane; ec'., ectoderm; mes., mesoderm; am., amnion; e., beginning embryo; 6s., abdominal pedicle; all., allantois; y.s., yolk-sac. cle, which represents the earliest stage of the abdominal pedicle (the Bauch- -diel of the Germans), which is the precursor of the umbilical cord. The greater portion of the embryo is occu- pied by the yolk-sac, from one end of ect which a small proc- mes ess, lined by ento- derm, which must be considered as a rudi- mentary allantois, ex- tends into the pedi- cle. Occupying one side of the pedicle is a small cavity lined by a simple layer of epithelium, which 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 distin- guished. Fig. 127 repre- sents a highly magni- fied section through the same ovum, and shows that the three germ layers are well devel- oped and, with the ex- ception of the ento- derm, consist of several layers of cells. Figs. 128 and 12!) represent an older ovum, with an embry- onic area 2 millimeters long, which was also described by Graf Spec. and which he believed belonged to the third week of pregnancy. Th ■ embryo is attached to the inner surface of th chorion by the abdomi- nal pedicle, and is macU up in great part of the yolk-sac. The embry- onic area is oval in shape, and presents a definite medullary Fig. 127.—Cross-section through Spee's Ovum. Highly magnified. E.A., embryonic area; P., primitive streak; ect., ectoderm; ent., entoderm; mes., mesoderm. 116 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM groove and primitive 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 embryonic areau Between the two is a small opening, the neu- y.s renteric canal, which serves to connect the ectoderm with the entoderm. Fig. 129 represents a section through the same ovum, and shows a well-developed chorion with typical villi, while the am- nion is a small sac closely applied over the beginning embryo. A highly mag- nified cross-section (Fig. 130) shows the three germ layers and a well-devel- oped somatopleure and splanchnopleure. By the folding of the former it is readily understood how the body walls are formed, and by that of the latter how the primitive gut becomes differen- Fig. 128.—Human Embryo 2 Milli- +- . n ^^^ ,-i „ i, „„^ meters Long (Graf Spee). X 30. tiated fr0m the yolk-SEC. Am., amnion; C, chorion; C.V., chori- onic villi; B.s., Bauchstiel; M.g. medullary groove; N.c, neuren teric canal; P.s., primitive streak Y.s., yolk-sac. Structure of the Cho- rion.—In its very ear- liest stages the chorion probably consists of the single layer of ectoder- mal cells forming the wall of the blastodermic vesicle, which soon be- comes lined by a meso- dermic layer. Soon af- ter the implantation of the ovum in the uterus, however, as shown by the researches of Hu- brecht, Huekelom, Pe- ters and Bryce and Teacher, the chorionic epithelium rapidly pro- liferates and forms the Fig. 128 (Spee). many-layered tropho- °^-> allantois; c.e., chorionic epithelium; cm., chorionic meso- blast. In its earliest derm: Bs., abdominal pedicle; £. beginning embryo; e^., entoderm; n.c, neurenteric canal; p.s., primitive streak; Stages tlie Chorion is v., chorionic villi; ves., vessels in wall of yolk-sac. PLATE IV. D.D' *# *?.„■ °iAA-V :->A>& BIS. ivtfs a at '■' :>e-% » -t •>& •■%•<'■ „" . ••■ • >' • ••*$?* y\4 a .- tx '"-tf- Mes G.1 Tr PETEKS'S OVUM. X50. Cap. ComP- J;/.S., blood spaces; Cap., capillary ; Comp., compact layer of decidua; D. C, decidual cells; Emb., beginning embryo; Fib., muss of fibrin covering point of entry of ovum into decidua; J/.-*., . . . ,. i • w, j- i- •!..- ...jj____. ci..............:...... '/'., *,.«.^i.^ui„„i.. inryo; rto., muss oi norm covering pui ui cuuj ui <_>vum iuu^ uci,i«.iua ww ],.>/,.,• o<' chorion: Kef., decidua reflexa; Sy/i., syncytium; T/:, troph oblast: STRUCTURE OF THE CHORION 117 Fig. 130.—Section through Spee's Ovum. JA Shown in Fig. 128. '" Am., amnion; ect., ectoderm; mes., mesoderm; ent., entoderm; M., medullary groove. probably a smooth membranous sac without villi; but in a short time buds of connective tissue make their way into the trophoblast and give rise to rudimentary villi (Figs. 131 and 132 and Plate IV). Fig. 133 represents a section through the chorion from a three weeks' pregnancy. In it can be distinguished two portions—the cho- rionic membrane and the villi projecting from it. The cho- rionic membrane con- sists of two layers— the inner of connect- ive tissue, the outer of epithelium. Its con- nective tissue is com- posed of spindle and star-shaped cells embedded in a mucoid intercellular substance, and at this period does not contain blood-vessels. Its epithelium is arranged in two layers: an inner one adjoining the connective tissue, which is composed of sharply marked 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. Each villus arises from the chorionic mem- brane as a single stem, which soon gives origin to numerous branches which assume a more or less arborescent form, the complexity of which increases with advancing age. The villi consist of a connective-tissue stroma and an epithelial covering, the former being continuous with and identical in structure with the connective tissue of the chorionic membrane, while the epithelium is composed of the two layers just described. Projecting here and there from the surface of the villi are epithelial buds, usually consisting of a mass of protoplasm which is not divided into distinct cells, and which, when seen in cross or tangential section, resemble giant cells. These buds indicate proliferation of the outer layer of the chorionic epithelium, and represent the first stage in the development of new villous branches. Here and there, in the spaces between the villi, larger and smaller masses of small, clear cells with vesicular nuclei are seen. They are usually described as decid- ual islands, and were supposed to represent sections through decidual septa, which projected upward toward the chorionic membrane. In reality, how- ever, they are masses of trophoblast which have not been converted into villi. Fig. 131.—Early Human Ovum (Leopold). 118 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM In early ova the embryo is connected with the conned ive-tissue layer of the chorion by a mesodermic pedicle, which was (irst described by His as the abdominal pedicle (Bauchstiel), and is the forerunner of the umbilical cord. Through this the umbilical vessels of the embryo make their way to the interior of the chorion, which then becomes vascu- larized. In early pregnancy the villi are pretty equally dis- tributed over the periph- ery of the chorionic mem- brane, but later they be- Fig. 132.—Three Weeks' Human Ovum (Leopold). COllie more abundant over the portion which is in contact with the decidua basalis, the site of the future placenta. This por- tion of the chorion is designated as the chorion frondosum, while the re- Fig. 1J3.—Section through Three Weeks' Human Ovum, showing Chorion, Decidua and Intervillous Spaces. B.V., maternal blood-vessel; CM., chorionic membrane; D., decidua; G., uterine gland; l.S. intervillous space; S., syncytium; T., trophoblast; V., villus. mainder, which is in contact with the decidua reflexa, is termed the chorion lave, since the villi covering it eventually undergo complete degeneration. A certain number of villi extend from the chorionic membrane to the STRUCTURE OF THE CHORION 110 underlying decidua, attaching the ovum to it, and hence are designated as fastening villi. The majority, however, spring from the chorionic mem- brane as arborescent structures, whose free endings do not reach the decidua, and which increase in complexity as pregnancy advances. In early pregnancy the villi are short and plump and represent simply the main stems, but later they give off numerous branches and assume an arborescent appearance. Thus, sections through a young chorion show only a i\'\v large villi, while those through an older one are filled with a multi- tude of smaller branches. This change in appearance is due to the increasing arborescence, and 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 (he chorion. In the earlier stages the cells are 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 (Figs. 13-1 to 136). After the first few weeks blood-vessels appear, and in the Fig. 134.—Chorionic Villus, Fig. 135.—Chorionic Vil- Fig. 136.—Chorionic Vil- Third Week. X 225. lus at Fourth Month. lus at Term. X 225. X 225. later months of pregnancy almost displace the stroma, when the arteries present thick walls possessing the typical three layers. 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. 133). The inner he designated as the cell-layer (Zellschicht), and it is now generally known as Langhans's layer; while the outer layer is usually described as the syncytium. This latter term was introduced in 1S!>3 by Kossmann and Mer.ttens, although the characteristics of the tissue had been recognized years before by Kastschenko, who described it as Plas- modium. 10 120 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM During the first half of pregnancy the two layers are readily dis- tinguished, but in the second half Langhans's layer becomes more and more indistinct, so that at the end of pregnancy the villi are covered only by a single layer of syncytium. Figs. 134, 135, and 136 give a good idea of the successive changes in the stroma and epithelium of the villi at different ages. Careful examination of properly prepared specimens shows that the outer margin of the syncytium does not present a smooth surface, but is made up of a vertically arranged pseudopodia- like protoplasmic process. These struc- tures are too coarse to be considered as cilia, and are designated by Marchand, Bonnet, Hofbauer, and others as bristle- like processes—"Borstenbesatz." The origin of the two layers of cho- rionic epithelium has given rise to a great deal of discussion, but it has been estab- lished by the work of Langhans, Kast- schenko, Minot, Webster, Heukelom, His, Ruge, Peters, and all recent investigators that they are both derived from the origi- nal trophoblastic covering of the ovum, which represents the fcetal ectoderm, Similar conclusions were reached by Hubrecht for the hedgehog, Duval for dogs, Friinkel for many species of animals, and Opitz for the guinea- pig and rabbit, and are now generally accepted. In 1893 Kossmann advanced the the- ory that the syncytium was derived from the epithelium of the uterus, while Lang- hans's layer represented the original fcetal ectoderm. His work was apparently con- firmed by Merttens a year later, who showed conclusively that a certain amount of uterine epithelium was converted into syncytium, and he thought himself justi- fied in concluding that it grew up over the villi, which up to that time were covered by only a single layer of Langhans's cells or foetal ectoderm, and thus gave them their second or outer layer. The work of Kossmann and Mert- tens was very plausibly set forth and accompanied by numerous ex- cellent illustrations, and their conclusions were soon adopted by many authorities, among whom we may mention Marchand and Kollmann. It Fig. 137.—Tubal Mucosa, showing Conversion of Epithelium into Syncytium. Normal epithelium on left, syncytium on right side. STRUCTURE OF THE AMNION 121 would seem, however, that this view is 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 im- plantation of the ovum (FigA 107 and 108). Consequently, it may be positively stated that the syncytial layer of the chorion is not of maternal origin, and that such a view is a relic of old and discarded theories con- cerning the implantation of the ovum. On the other hand, it must be admitted that the small areas of uterine epithelium may occasionally assume a distinctly syncytial appearance, and not a few of my specimens confirm this view (Fig. 137). This occurrence, however, must be regarded as exceptional in man, and, even when portions are so converted, satisfactory evidence has not been adduced to show that the tissue forms the syncytial covering of the villi. Furthermore, the formation of syncytium is not necessarily characteristic of pregnancy, and may occur in other conditions, as Gebhard has shown that it may occasionally be observed in carcinoma of the non-pregnant uterus. The theory of Kossmann and Merttons 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 Waldever, who in 1890 was able to arrange in ten groups the numerous theories which had been advanced up to that time. Structure of the Am- nion.—In the very earli- est stages of pregnancy, as we have already shown (Fig. 109), the amnion is a minute vesicle ; later it forms a small sac which arches over the dorsal surface of the em- bryo, and eventually be- comes larger and com- pletely surrounds it. At first the amnion occupies only a small portion of the entire ovum; but as pregnancy advances it in- creases in size, until eventually it comes in contact with the interior of the chorion and oblit- erates the extra-embryonic portion of the coelome. 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, Fig. 138.- Uterus lined by Decidua, containing an Early Ovum (Leopold). X 1. 122 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM 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, ecto- dermal cells. The mesodermic layer eventually becomes converted into mucoid-like tissue, which does not contain blood-vessels; while the ectoder- mal portion changes into a single layer of small cuboidal epithelial cells, which by their origin represent simply an extension of the skin of the embryo. In somewhat more than one-half of all placentas, at term, small, rounded areas 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 Fig. 139. Fig. 140. Figs. 139, 140.—Diagrams illustrating Hunterian Theory of Formation of Decidua Reflexa. 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 end of pregnancy, although under abnormal conditions it may vary from a few cubic centi- meters to many liters. Its specific gravity ranges from 1.002 to 1.028, and it contains a certain amount of albumin, urea krcatin, and various salts. Its origin and function will be considered when we take up the physiology of the fcetus. Thus far we have been describing the fcetal membranes. Before taking up the study of the placenta, it will be necessary to consider the changes which the endometrium undergoes to prepare it for the reception and nu- trition of the ovum. Decidua.—The decidua is the mucous membrane of the uterus which has undergone certain changes under the influence of pregnancy, to fit it for the implantation and nutrition of the ovum. It is so named from the DECIDUA 123 fact that it is cast off after labor. The older writers usually distinguished between the decidua of menstruation and that of pregnancy, but the em- ployment of the former term is no longer justified, since it has been shown that there is no great loss of tissue at the menstrual period. 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 commences, inasmuch as the premenstrual swelling is accom- panied by marked changes in the structure of the stroma, and more par- ticularly because a fairly well-marked decidua was present in all of the early pregnancies which have thus far been described, being well developed in the specimens of Bryce and Teacher, Peters, and Heine and Hofbauer. Very shortly after conception the smooth velvety endometrium becomes markedly thicker and its surface is indented by furrows of considerable depth, which give the entire membrane a mamelonated appearance. Under the magnifying-glass numerous small openings can be distinguished 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, and Yolk, isolated decidual cells are found beneath the cervical epithelium. For purposes of description the decidua is usually divided into several portions: that lining the greater part of the cavity of the uterus being designated as the decidua vera; that beneath the ovum as the decidua scro- ti na; while the portion which surrounds the ovum and shuts it off from the rest of the uterine cavity is known as the decidua refle.ra. The terms reflexa and serotina date from the time of William Hunter, who gave excellent drawings of the decidual membrane in his atlas. Un- fortunately, the author died just after its appearance and before the com- pletion of the explanatory text, which 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 com- plete cast of the uterine cavity and completely cov- ered the tubal openings. They supposed, there- fore, 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 reflexa had been pushed forward, a new exudate was developed behind the ovum, to which the term serotina was applied (Figs. 139 and 140). This conception was universally accepted until 181(i, when Weber in Germany and Sharkey in England demonstrated that the decidua was not an exudate, inasmuch as it contained glandular structures which they identified with the uterine glands. It having there- fore become necessarv to explain the formation of the reflexa in a different manner, it was assumed that the ovum, on reaching the uterus, found its Fig. 141. Fig. 142. Figs. 141, 142.—Dia- grams showing For- mation of Decidua Reflexa (Coste). 124 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM compact entire cavity lined by decidua vera, to which it became attached at a point on the anterior or posterior wall somewhere in the neighborhood of the fundus; and that immediately after its attachment the vera began to pro- liferate and to form a wall around the ovum, which gradually increased until it completely inclosed and surrounded it. More recent investigation, in turn, showed that this view was not cor- rect, as the ovum in all probability remains up- on the surface for only a few hours. Notwith- standing the new ideas concerning the forma- tion of the decidua, the terms reflexa and sero- tina are still retained, though in the new ana- tomical nomenclature of His they are more properly designated as the decidua capsularis and basalis respect- ively. Decidua Vera.—The microscopic structure of the decidua vera was first studied by Hegar and Maier, but it was not until the work of Friedlander and Kun- drat and Engelmann that its structure was definitely understood. Friedlander in 1870 pointed out that the de- cidua vera was com- posed of two portions: a compact layer super- imposed upon a spongy or glandular layer, the latter being nearer to the muscular wall of the uterus, and forming the main thickness of the membrane. Furthermore, he was of the opinion that the separation of the decidua at the time of labor took place at the junction between the two layers. He showed that the compact layer was made up of large round, oval, or polygonal cells, with large, lightly staining, vesicular nuclei—the decidual cells; while the spongy layer was composed of the dilated and hyperplastic uterine glands. The decidua vera increases markedly in thickness during the first three spongy muscle Fig. 143.—Decidua Vera, Fourth Month. DECIDUA VERA 125 or four months of pregnancy, so that at the end of that time it has attained a thickness of about 1 centimeter. Figs. 51 and 143 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 marked increase in the size of the uterus, the vera gradually becomes thinner, so that at term it is rarely more than 2 millimeters thick. Under the microscope the compact layer is seen to be made up of somewhat closely packed, large, round, oval, or polygonal cells, which are distinctly epithelioid in appearance, and possess round, vesicular nuclei, which stain but slightly with the ordinary reagents. When the tissue has been distended by haemorrhage or oedema, it is seen that many of the de- cidual cells present a stellate appearance, and are provided with long proto- plasmic outgrowths which anastomose with similar processes from neighbor- ing cells. Particularly in the early months of pregnancy, one sees scat- tered 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 Eossi-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 observed between them and typical Fig. 144.—Decidua Vera, Fourth Month. X 420. decidual cells. In the early months of pregnancy the ducts of the uterine o-lands may be seen traversing the compact layer, but 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 126 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM the glands are lined by typical cylindrical uterine epithelium, which, how- ever, gradually becomes more cuboidal in shape and undergoes fatty de- generation, and is cast off in great part into their lumina. A certain amount of epithelium, however, remains intact throughout pregnancy, and from it the endometrium is regenerated after labor. In many instances the stroma between the dilated glands has undergone but little change, and closely resembles that of the non-pregnant uterus. Under the influence of pregnancy, the surface epithelium covering the decidua gradually loses its cylindrical shape and becomes cuboidal or flat- tened, sometimes even resembling endothelium. Klein first directed atten- tion to this condition, and held that it was a characteristic microscopic evidence of pregnancy. All subsequent investigators have confirmed his observations. Fig. 144 represents a section through the compact layer of the decidua vera at the fourth month, while Fig. 145 shows a gland with its surround- Fig. 145.—Gland and Stroma from Non-pregnant Endometrium. X 420. ing stroma from a non-pregnant uterus, drawn under the same magnifica- tion. On comparing them, it is readily seen that the decidua differs from the non-pregnant endometrium by a marked increase in size of the stroma cells, and a marked decrease in size of the epithelial cells. Schick in 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 generally admitted 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 atten- DECIDUA CAPSULARIS 127 tion 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 has been further reenforced by observa- tions made in certain cases of early tubal pregnancy, in which decidual cells may be seen developing in the smaller folds of the tubal mucosa. In such specimens it is clearly seen that they are derived from the ordi- nary connective-tissue cells, and result from the hypertrophy of preexisting units rather than from their proliferation. Furthermore, Schmorl, Kinos- hita, Lindelthal, 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, which are scattered over the peritoneum, covering the posterior surface of the uterus, Doug- las's cul-de-sac, and the anterior surface of the rectum, and occasionally also over the ovaries. Schmorl considers that these structures are always found at full-term pregnancy, and has demonstrated that they are made up of decidual tissue. But, whereas they develop beneath the peritoneum, it is evident that they must be derived from connective-tissue cells. I have studied two specimens which showed an unusually wide distribution of decidual formation. In one instance, in which the pregnant uterus was the seat of an adeno-myoma, typical decidual formation was noted in the interglandular tissue of the endomctrium-like areas far removed from the uterine cavity; while, in a case 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. Before the true nature of the decidual cells was definitely proved, various theories were advanced as to their origin: Hennig believing that they were derived from leukocytes, Frommel and Overlach from the uterine epithelium, and Frcolani from the endothelium of the blood-vessels. At the present time these views are of interest only from an historical stand- point. 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. 138 shows an early pregnancy in which the reflexa is quite apparent, and Fig. 146 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 be- tween it and the vera. This is well shown in Fig. 147, which represents a section through a six to seven weeks' pregnant uterus. At the fourth month of pregnancy, 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 together, when the capsularis gradually degenerates and disappears. This view was first advocated by Minot, and appears to be well founded, inasmuch as sections through the wall of the full-term uterus outside of the placental 28 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM site show that the entire decidua is only 2 to 3 millimeters thick, and no trace of the decidua reflexa can be discovered. (See Fig. 152.) The decidua capsularis usually attains its greatest thickness at about the second month. Sections through it at this time show that it is made up of decidual cells and is covered on its exterior by a single layer of flattened or cuboidal 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 they are present, are seen to open only upon the outer surface of the membrane. DEVELOPMENT OF THE PLACENTA 129 Up to a few years ago it was universally believed that the capsularis originated from the proliferation of the vera, which grew up 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 the cap- sularis is merely the portion of the decidua which covers the ovum (Fig. 109 and Plate IV). Decidua Basalis.— The decidua basalis or serotina is the portion of the decidua which lies immediately be- neath the ovum; from it the maternal por- tion of the placenta is developed. Broadly speaking, it presents the same general structure as the de- cidua vera, except that it has been invaded by fcetal tissue, so that its superficial portions are composed of decidual cells and fcetal ectoderm. 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 it is now known that the majority of the so-called giant cells are not of decidual origin, but repre- sent portions of trophoblast, which have made their way down into the decidua. Fig. 148, 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 thick- ness of the membrane; while many of the veins become markedly dilated and form large sinuses. In Fig. 148 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 fcetus and the uterus, however, will be deferred until we take up the study of the placenta. Development of the Placenta.—When the fertilized ovum reaches the uterus it finds the endometrium transformed into decidua in anticipation of its reception. At this time, as has already been pointed out, it is proba- Fig. 147.—Six Weeks' Pregnant Uterus with Elongation of Cer- vix, showing Extent to which its Cavity is occupied by the Ovum. X I O.E., external os; O.I., internal os; D.V., decidua vera; D.S., decidua serotina; D.R., decidua reflexa; Emb., embryo; P., placenta. 130. MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM bly in the morula stage, and certainly has not advanced beyond that of the blastodermic vesicle, so that it does not possess villi. Its exterior is formed by the primitive chorion, which soon becomes converted into the many- layered trophoblast. The ovum, as a rule, becomes attached to the decidua vera covering the upper half of the anterior or posterior wall of the uterus, and only excep- G Fee. V Fee. V l ,\ ' Fig. 148.—Decidua Basalis, showing Mixture of Fostal and Maternal Cells. X 75. G., gland; V., vessel; F.ec, foetal ectoderm. tionally in the lower portion of the uterine cavity. It is very rarely implanted in the angles, since these present only a slight decidual reac- tion as compared with the anterior and posterior walls. At present we are absolutely ignorant concerning the factors which cause the arrest of the ovum at a given point. Its mode of implantation has already been con- sidered, and from the evidence at our disposal there is no doubt that the ovum rapidly arrodes the uterine epithelium, and sinks down into the decidua, as described by (Jraf Spee in the guinea-pig (Figs. 107 and 108). Shortly after implantation the ovum becomes completely sur- rounded by decidua, the portion separating it from the uterine cavity DEVELOPMENT OF THE PLACENTA 131 being known as the capsularis, and that beneath it as the basalis. Almost immediately its trophoblast begins to proliferate and invade the surround- ing decidual tissue, as was shown by the work of Hubrecht, Heukelom, and Peters. 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 trophoblast and partly by decidua (Plate IV). As the process goes on more vessels are opened up, so that in a short time the trophoblast presents a sieve-like 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 developed. 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 all of the early ova recently studied. Coincidentally with their formation, the irregularly shaped masses of trophoblast are invaded by connective-tissue offshoots from the chorionic membrane, and are thus converted into villi. The cells surrounding them become arranged in two layers, the inner corresponding to Langhans's layer, the outer one being composed 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 (Haftzotten), 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, under- goes 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 devel- opment, and is represented by what are usually known as the cell nodes or cell columns, which are made up of Langhans's cells. Their formation was carefully studied by Heukelom in the early ovum which he described. During the first few weeks of pregnancy branching villi project from the entire periphery of the ovum, as is well seen in the figures taken from Leopold's work. They come in contact not only with the decidua basalis, but also with the capsularis, so that intervillous blood spaces surround the entire ovum. During the first few weeks the chorionic villi are devoid of blood-vessels, and the ovum is nourished 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 is diminished; as a consequence the villi in contact with the former are better nourished and begin to grow more luxuriantly, the process thus leading to the forma- tion of the placenta. At the same time, the other villi develop less rapidly, and eventually atrophy, so that the portion covered by them becomes known as the chorion lave. As the ovum increases in size, the intervillous spaces in the chorion lane become smaller and smaller, and by the fourth month, when the decidua reflexa has come in contact with the vera, they be- 132 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM come obliterated, and the villi which project into them undergo almost complete degeneration. In sections through the fcetal membranes at term (Fig. 152) the chorion lseve consists of several layers of epithelial cells, which represent the chorionic epithelium, and through which are scattered, here and there, round or oblong hyalin 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 epithelium of the chorion lseve comes in contact with the decidual tis- sue, which result in the formation of a fibrin-like 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 become vascularized by branches of the umbilical vessels of the embryo, so that after the first few weeks the foetal circulation ex- tends 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 foetal and maternal tissues. It soon constitutes a distinct structure, although its site is indicated at a much earlier period by the increased thickness of the chorion at that point. According to Benoist, its weight exceeds that of the fcetus for the first three and a half months of pregnancy. We can probably best understand the structure of the placenta by studying sections through it at various points of pregnancy. One from the fourth month is reproduced in Plate V, and shows that the organ is made up in great part of chorionic villi, whose stroma presents a somewhat mucoid appearance, and contains spindle- and star-shaped connective-tissue cells, between which well-developed arteries, veins, and capillaries may be observed. At this stage the villous epithelium is arranged in two layers— Langhans's layer and the syncytium—and from the latter many buds pro- trude, which, when seen 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 larger 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 formation of the early days of pregnancy. The cell nodes are composed almost exclusively of Langhans's cells, as the syncy- tium does not follow them down into the depths of the decidua. The spaces between the chorionic membrane and the decidua, as well as those between the villi themselves, are designated as the intervillous spaces. These are filled with maternal blood and their walls are lined by syncytium. Scattered through them are isolated giant cells—the so-called placental giant cells—whose origin has already been considered. Here and there are seen a few large areas composed of cuboidal or polygonal cells with vesicu- lar nuclei, which frequently present marked signs of degeneration. These are the so-called decidual islands, and are usually supposed to represent sections through decidual septa, Avhich project upward from the surface of the decidua serotina toward the chorionic membrane. But, as has already been pointed out, most of them are masses of trophoblast, into PLATE V. SECTION THROUGH FOUR MONTHS' PLACENTA, SHOWING JUNCTION OF CHORION AND DECIDUA. X 56. C. F-. canalized fibrin; C. X., cell nodes; /)., decidua serotina; D. 7., decidual island; (I. ('.. giant cell; /. S., intervillous space; i'., proliferating villous epithelium; I'., chorionic villi. STRUCTURE OF PLACENTA 133 which the chorionic connective tissue has not grown, and which therefore have not developed into typical villi. At the junction between the cell nodes and the decidual tissue areas are noted which stain deeply with eosin, and which, on closer examination, are seen to be made up of fibrin, honeycombed in various directions by small spaces—the so-called canalized fibrin—which probably results from the degeneration of foetal and decidual cells. This is known as Nitabuch'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, Rohr, Tussenbroeck, Ulesko-Stroganowa, and others, and it is generally considered to mark the border line between the fcetal and maternal tissues. It would seem that degenerative changes occur wherever fcetal and maternal tissues come in contact, and the phenomenon suggests the pos- sibility that the function of the decidua may not merely be to afford a suitable structure for the implantation and nutrition of the ovum, but' also to protect the maternal organism against invasion by fcetal cells. Until comparatively recently the participation of fcetal tissue in the decidua basalis was not recognized, and when foetal cells were found beneath the chorionic membrane they were considered as being of decidual origin. Accordingly, Winckler and other observers believed 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 and maternal tissue. Winckler desig- nated the superficial portion of the decidua as the basal, and the portion covering the chorionic membrane as the closing plate of the decidua. We have already shown that the tissue in question is composed of foetal ecto- derm, and the conception of decidual plates should therefore be abandoned. At one point (Plate V) a maternal vessel is seen which, after reaching the surface of the decidua, opens directly into the intervillous spaces. At present it is universally admitted that the blood in these spaces is exclu- sively maternal in origin. The fcetal blood in the vessels of the chorionic villi at no time gains access to the maternal blood in the intervillous spaces, the two being sepa- rated from one another by the double layer of chorionic epithelium, a portion of the stroma of the villus, and the vessel walls (Plate VI). At the point marked "P" in Plate V, a villus is seen whose tip pro- jects 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 cases portions of villi may become broken off, and thus gain access to the general circulation. He designates the process as deportation, and upon it has constructed an extensive theory concerning many of the abnormalities of pregnancy, to which reference will later be made. Structure of Placenta in Latter Half of Pregnancy and at Full Term. — Except in its increased size, the placenta in the second half of pregnancy differs but slightly from that of the fourth month. Microscopic sections at this period, however, show certain points of difference. These are well 134 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM \'^i'-^J^Sv:""?;T~''r ■''-':'■ ■ '■'': '•'J"-"-.'?-'i'i'-'- '■i-"---.';:"~3SaSFjESi? 'S-vf-f^ illustrated in Fig. 149, ■Decidua. which represents a sec- tion through a seven and a half months' placenta and the adjacent uterine wall. Studying it from below upward, we see that it is composed of the following structures: amnion, chorionic membrane, villi, intervillous blood spaces, and decidua basalis. The amnion covers the inner or fcetal surfaces of the placenta, and consists of a single layer of cuboidal epithelium, below which comes a layer of more or less fibrillar connective tissue, con- taining no blood-vessels. The chorionic membrane presents es- sentially the same struc- -Chorionio ^ure as in the earlier mlervufous months of pregnancy, dif- spaces. fering only in the pres- ence of a large amount of canalized fibrin immediately be- neath its epithelium. The great bulk of the pla- centa is made up of chorionic villi, which are much more abun- dant, but at the same time con- siderably smaller, than at the fourth month. Their stroma, which is made up of spindle- shaped cells, is denser in appear- ance, is occupied in great part by blood-vessels, and differs mark- edly from the mucoid tissue of the earlier months. These changes have already been referred to, and are clearly shown in Figs. 135 and 136. The epithelium covering the villi has also undergone marked change; Langhans's layer has al- most completely disap- -Chcrionic peared and only a thin membrane. . „ "A -Amnion, layer ol syncytium re- Fig. 149.—Section through Placenta at Eighth Month. X 15. Fig. 149. ^^>v—>•-%-» <>.. PLATE VI. KN^»ivXvg"-e,te' TERMINAL CIIOKIONIC VILLUS, WITH INJECTED VESSELS. STRUCTURE OF PLACENTA 135 mains, which gives rise to fewer buds than previously. In many villi immediately under the epithelium, and occupying the former position of Langhans's layer of cells, a thicker or thinner layer of canalized fibrin may be observed. This was first described by Langhans, and is of constant occurrence in the latter half of pregnancy. It appears to indicate senile degeneration of the placenta. At the same time, many of the arteries show marked changes and present all stages of an obliterating endarteritis, to which, in great part, the formation of the tissue in question should be attributed. The superficial portions of the decidua at this period are covered by canalized fibrin, which probably results from coagulation necrosis of the cell nodes and columns. In the deeper layers numerous giant cells are ob- served, 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 varying shapes and sizes extend upward for a greater or less distance into the pla- centa. They are composed of cuboidal or polygonal cells, with round vesic- ular nuclei, and only rarely contain blood-vessels; in many places they have undergone degeneration and become converted into canalized fibrin. They are usually described as decidual septa, but in all probability are derived from fcetal ectoderm or trophoblast. The entire space between the chorionic membrane and the free surface of the decidua serotina is designated as the placental space, into which the chorionic villi dip, thereby subdividing it into myriads of irregularly shaped cavities which communicate freely with one another—the inter- villous spaces. They are lined by the syncytium covering the chorionic membrane and villi, except at those portions of the decidua serotina which have become converted into canalized fibrin, and which are only partially covered by it. The syncytium is thinner than in the earlier months of pregnancy, and under high powers of the microscope its protoplasm pre- sents 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, except for very short distances on the surface of the decidua basalis, over which the endothelium of maternal vessels may extend to a slight extent. It is probable, however, that even this in reality represents thinned-out syncy- tium. Hence, it would appear that the intervillous spaces are lined entirely by fcetal 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 pur- sue 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 the large venous sinuses in its depths. It is therefore apparent that there is a distinct circulation 11 136 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM through the inter-communicating intervillous spaces, though it is neces- sarily more sluggish than elsewhere in the body. The nature of the intervillous spaces and the question as to whether they contained maternal blood have given rise to a great deal of discussion. Vater, Noortwyk, and William and John Hunter, in the eighteenth cen- tury, expressed an affirmative opinion; and the last two investigators conclusively demonstrated it by injection experiments. Similar results were obtained by E. H. Weber in 1842. But this work was gradually lost sight of, and all sorts of theories were evolved concerning their nature and contents. Braxton Hicks, Ercolani, and others believed that they did not contain blood, but some substance derived from the mucous membrane of the uterus which they designated as uterine milk. Correct conceptions as to the nature of the placenta were finally estab- lished by the work of Farre, Turner, Waldeyer, Nitabuch, Kohr, Bumm, Leopold, and others, who showed conclusively that the intervillous spaces contained maternal blood, and that vessels from the mother could be traced into them. This was especially well demonstrated by Waldeyer, who, in five pregnant cadavers, was able to inject them from the maternal vessels. Furthermore the recent work of Peters, Leopold, and others has placed the question beyond all reasonable doubt. In view of these facts, then, the placenta must be regarded as a col- lection of maternal blood, included between the chorionic membrane and the decidua basalis, into which the villi dip and by which they are sur- rounded. Some idea of the complexity of its vascular arrangement may be gained from Plate VII, which represents a corrosion preparation of the fcetal portion of a full-term placenta, which was injected through the umbilical arteries and veins with red and blue celloidin. (Also see Plate VL> Normally there is no communication between the fcetal blood contained 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 syncytium, the process being analogous to that which takes place in the tubules of the kidney and other organs. The effete materials from the fcetus 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 mate- rials needed for the nutrition of the fcetus are taken up from the former and carried by the umbilical 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. The After-birth.—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 % 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 PLATE VII. l 'T COKKOSIOX I'IM'.I'AKATION OF MATURE I'LACK.XTA, TO SHOW l-' Fig. 153.—Epithelium of Umbilical Cord. X HO. 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 in- slanees a large vein, which is usually known as the circular sinus, ex- tends around a consider- able portion of the pe- riphery of the placenta, but only in very rare cases completely encir- cles the organ. The fatal membranes 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 with- out difficulty. The cho- rion is more opaque and thicker than the amnion, though it rarely exceeds 1 millimeter in thickness. It represents the chorion heve of the early months, and under the microscope is seen to possess a num- ber of degenerated villi. Clinging to its outer sur- face are a few shreds of tissue—the portion of the decidua which is cast off after the birth of the child. Fig. 1-Vi is taken from a section through the foetal membranes and the uter- ine wall outside of the pla- cental site, and <:ives a i^ood idea of their composition. 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 rxv. Fig. 154.—Umbilical Cord, Fcetal End. X 5J^. V.A., umbilical artery; U.S., remnant of umbilical stalk; U.V., umbilical vein. 140 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM dull white, moist appearance, and through it shimmer the umbilical ves- sels—two arteries and a vein. It varies from 1 to 2.5 centimeters in diameter, and averages about 55 centimeters in length; though in extreme cases it may vary from 0.5 to 198 centimeters. The average length of 1,000 cords, which were measured ■""»*■ A>Y -. * m ;* f ' 4. 4V VA-A .;*■ V", :'vW'-:. *? *" Yj^K. Fig. 155.—Section through Umbilical Cord, showing Stalk of Umbilical Vesicle. X HO. Fig. 156.—Section through Abdominal Pedicle of 2.25-Millimeter Embryo (His). X 50. All., allantois; M.G., medullary groove; U. A., umbilical artery; U. V., umbilical vein. at the Johns Hopkins Hospital, was 55 centimeters, the shortest being 13 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 desig- nated as false knots. Fig. 157.—Section through Young Um- bilical Cord (Minot). A., artery; All., allantois; U.S., stalk of um- bilical vesicle; V., vein. Fig. 158.—Stalk of Umbilical Vesicle being included in the umbilical cord (His). The cord is covered by several layers of epithelium, which is a direct continuation of the skin covering the abdomen of the embryo; its interior is made up of a mucoid connective tissue—the so-called Whartonian jelly. FMBILIOAL VESICLE 141 Microscopic sections through the fcetal and placental ends of the cord at term present a somewhat different appearance. In the former, besides the vessels, one usually sees two small, darkly staining areas, which under higher magnification appear as small ducts lined by cuboidal or flattened epithelial cells. One is the remnant of the allantois, and the other the duct or stalk of the umbilical vesicle; at the placental end only the latter is ])resent. In most text-books it is stated that the cord is derived from the allan- tois, and is covered by a sheath of amnion. The researches of His have definitely shown that such is not the case in man, but that the fcetus, in the earliest stages of pregnancy, is connected with the inner surface of the chorion by a tolerably thick mass of tissue, only a small portion of which is occupied by the allantois. This he designated as the abdominal pedicle (Bauchstiel), and showed that it represents merely an extension of the caudal end of the embryo. Fig. 156 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 meso- dermic 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 medul- lary groove, while arching over it is the amnion. In its further develop- ment the ectodermal portion, corresponding to the somatopleure, extends downward and inward, eventually inclosing a small portion of the ccelome in a way similar to that in which the abdominal walls are formed in the embryo itself. In this cavity the stalk of the umbilical vesicle or yolk-sac is included. In the meantime the amnion is likewise extending around the entire structure, but is not in contact with it; and as the former be- comes more and more distended by the amniotic fluid, it becomes farther and farther separated from the abdominal pedicle, or, as we may now call it, the umbilical cord. Eventually the amnion is connected only with the por- tion of the cord which is attached to the fcetal surface of the placenta. Fig. 158 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 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 occupies a great part of the interior of the blastodermic vesicle. But, as the embryo 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 coelomic cavity as a rounded sac with a distinct stalk. As pregnancy advances the sac be- comes 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 small oval sac, 3 to 5 millimeters in diameter, which usually lies on the fcetal surface of the placenta, between the chorion and amnion, but occasionally in the mem- 142 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM branes just beyond the placental margin. It is connected with the um- bilical cord by a fine pedicle, which, as has been already indicated, may be seen in sections through the cord at term. Schultze in 1861 was able to demonstrate the umbilical vesicle in 146 out of 150 mature placentae examined. Meyer has found that the vesicle may attain considerable pro- portions, it being 10 to 15 millimeters in diameter in several instances. The intra-abdominal portion of the duct of the umbilical vesicle, which extends from the umbilicus to the intestine, usually atrophies and dis- appears, but occasionally it remains patent, forming what is known as Meckel's diverticulum, which may play an important pathological part in later life. 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 cho- rion 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 allan- tois. 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. As yet we are unacquainted with its functions. LITERATURE Beneke u. Strahl. Ein junger Menschlicher Embryo. Wiesbaden, 1910. Benoist. Des rapports entre 1 'embryon et le placenta dans 1 'avortement. These de Paris, 1906. Bonnet. Ueber Syncytien, Plasmodien und Symplasma in der Placenta. Monatsschr. 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. Glas- gow, 1908. Bumm. Zur Kenntniss der Utero-placentar-gefasse. Archiv f. Gyn., 1890, xxxvii, 1-15. Ueber die Entwickelung der mutterlichen Blutkreislaufes in der menschl. Placenta. Archiv f. Gyn., 1893, xliii, 181-195. Dalrymple. Medico-chir. Transactions, 1842, xv, 21 (quoted by Waldeyer). Duesberg. Sur le nombre des chromosomes chez l'homme. Anat. Anzeiger, 1906, xxviii, 475. Duval. Le placenta des carnassiers. Annales de gyn. et d'obst., 1896, xlv, 167-182. Engelmann. The Mucous Membrane of the Uterus, etc. Amer. Jour. Obst., 1875, viii, 30-87. Ercolani. Delia struttura anat. della caduca uterina, etc. Bologna, 1874. Farre. Uterus and Its Appendages. Todd's Cyclopaedia of Anat. and Physiol., Parts XLIX and L. Fehling. Ueber die physiologische Bedeutung des Fruchtwassers. Archiv f. Gyn., 1879, xiv, 221,224. Fetzer. Ueber ein menschliches Ei. Anat. Anzeiger, 1910, XXXVII. Erg. H. 116-126. LITERATURE 143 Frankel, L. Vergleichende Untersuchungen des Uterus- und Chorion-epithels. Archiv f. Gyn., 1S98, lv, 269-316. VON Franque. 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., 1S97, xxxvii, 480-518. Grafenburg. Beitrage z. Physiologie d. Eieinbettung. Zeitschr. f. Geb. u. Gyn., 1910, lxv, 1-35. Grosser. Vergleichende Anat. u. Entwickelungsgeschichte d. Eihaute u. d. Placenta. Wien u. Leipzig, 1909. Hegar. Beitrage zur Pathologie des Eies, etc. Monatsschr. f. Geburtskunde, 1863, xxi, Supplement Heft, 1-66. Heine u. Hopbauer. Beitrag z. fruhesten Eientwickelung. Zeitschr. f. Geb. u. Gyn., 1911, Ixviii, 665-688. Hennig. Die weissen Blutkorperchen und die Deciduazellen. Archiv f. Gyn., 1874, vi, 508, 509. Herff. Beitrage zur Lehre von der Placenta und von den miitterlichen Eihiillen. Zeitschr. f. Geb. u. Gyn., 1896, xxxv, 268-297 and 325-372. Hekzog. 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. Hicks. The Anatomy of the Human Placenta. Trans. London Obst. Soc, 1873, xiv, 149-189. His. Bauchstiel und Nabelstrang, Anatomie menschlicher Embryonen, 1885, iii, 222- 226. Die Umschliessung der menschl. Frucht wahrend der fruhesten Zeiten der Schwangerschaft. Arch. f. Anat. u. Physiol., Anat. Abth., 1897, 399-430. Hofbauer. Biologie d. menschlichen Plazenta. Wien, 1905. Hormann. Beitrag zur Kenntniss der decidualen Bildungen in den Ovarien. Archiv f. Gyn., 1906, lxxx, 297-305. Hubrecht. The Placentation of Erinaceus Europaeus, with remarks on the Phy- logeny of the Placenta. Quart. Jour, of Microscop. Science, 1889, xxx. Die Rolle des embryonalen Trophoblasts bei der Placentation. Zentralbl. f. Gyn., 1897, 1206. Hunter, John. Observations on Certain Parts of the Animal Economy. London, 1778. Hunter, Wm. Anatomy of the Human Gravid Uterus. London, 1774. Hvrtl. See Kollmann. Jung. Beitrage z. fruhesten Eieinbettung beim menschlichen Weib. Berlin, 1908. Kastchenko. Das menschliche Chorionepithel und dessen Rolle bei der Histogenese der Placenta. Arch. f. Anat. u. Physiol., Anat. Abth., 1885. Kinoshita. Ueber grosszellige decidua-ahnliche Wucherungen auf dem Peritoneum. Monatsschr. f. Geb. u. Gyn., 1898, viii, 500-509. Klein. Entwickelung und Riickbildung der Decidua. Zeitschr. f. Geb. u. Gyn., 1891, xxii, 247-295. Kollmann. Lehrbuch der Entwickelungsgeschichte des Menschen. Jena, 1898. Kossmann. Zur Histologie der Chorionzotten des Menschen. Leuckhart's Festschrift, 1892. Zur Histologie der Extrauterinschwangerschaft, nebst Bemerkungen iiber ein sehr 144 MATURATION, FERTILIZATION, DEVELOPMENT OF OVUM 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 menschlichen Chorions. Beitrage zur Anat. und Em- bryologie (Henle's Festgabe), Bonn, 1882. Lefevre. Artificial Parthenogenesis in Thalassema Mellita. J. Exp. Zoology, 1907, iv, No. 1. Leopold. Studien iiber die Uterusschleimhaut, etc. Berlin, 1878. Ueber den Bau 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 menschlichen Placenta. Arch. f. Gyn., 1899, lix, 516-544. Lindenthal. Ueber Decidua ovarii. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 707-723. Loeb. Die chemische Entwickelungs-erregung des tierischen Eies. Berlin, 1909. De Loos. Das Wachstum der menschlichen 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 menschlichen Eier. Anat. Hefte, 1902, 147. Beitrage zur Kenntniss der normalen u. path. Histologie der Decidua. Archiv f. Gyn., 1904, lxxii, 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. Minot. Uterus and Embryo. Jour, of Morphology, 1889, ii, No. 3. Nitabuch. Beitrage zur Kenntniss der menschlichen Placenta. D. I., Bern, 1887 Noortwyk. Quoted from Waldeyer. Opitz. Vergleich der Placentarbildung bei Meerschweinchen, etc., mit derjenigen beim Menschen. Zeitschr. f. Geb. u. Gyn., 1899, xli, 120-144 and 153-173. Overlach. Die pseudomenst. Mucosa uteri. D. I.j Miinchen, 1885. Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. Rohr. Die Beziehungen der miitterlichen Geiasse 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 wahrend der Schwanger- schaft. Archiv f. Gyn., 1905, Ixxvii, 1-20. Schmorl. Ueber grosszellige (decidua-ahnliche) Wucherungen auf dem Peritoneum u. den Ovarien bei intrauteriner Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1897, v, 46. Schultze. Das Nabelaschen ein constantes Gebilde in der Nachgeburt des aus- getragenen Kindes. Leipzig, 1861. Selenka. Keimblatter u. Primitivorgane der Maus. Studien iiber Entwickelungs- geschichte der Thiere, 1883, H. 1. LITERATURE 145 Die Blatterumkehrung im Ei der Nagethiere, ditto, 1884, H. 3. Studien iiber Entwickelungsgeschichte der Thiere, Wiesbaden, ls'i], Heft 5; Men eehen-Affen, Wiesbaden, 1899, ii. Blattumkehr im Ei der Atfen. Biol. Zentralbl., 1898, xviii, 552-557. Menschen-Affen, 1900, iii, Lieferung. Sharkey. English translation of Midler's Handbuch der Physiologie, according to Schroeders Lehrbuch, XIII. Aufl., 1899. Sobotta. Die Befruchtung und Furchung des Eies der Maus. Archiv f. mikr. Anat., 1895, xlv, 15-93. Die Entwickelung des Eies der Maus. Arch. f. mik. Anat., 1903, lxi, 274-330. Spee. Beitrag z. Entwickelungsgeschichte der friiheren Stadien des Meerschwein- schens, etc. Archiv f. Anat. u. Phys., Anat. Abth., ixx:i, 44-60. Neue Beobachtungen iiber sehr friihe Entwickelungsstufen des menschlichen Eies. Archiv. f. Anat. u. Physiol., Anat. Abth., 1896, 1-30. Beobachtungen an einer menschl. Keimscheibe mit offener Medullarrinne, etc. Archiv f. Anat. u. Phys., Anat. Abth., 1899, 159 176. Die Implantation des Meerschweinschensei in die Uteruswand. Zeitschr. f. Mor- phol. u. Anthropol., 1901, iii, 130-182. Demonstration eines junges Stadium der menschlichen Eieinbettung. Verh. d. deutschen Gesellsch. f. Gyn., 1906, xi, 421-422. Strahl. Die Embryonalhiillen der Siiuger und die Placenta. Hertwig's Hand buch des Entwickelungslehre, 1906, Bd. I, Theil II, 235-368. Turner. Observations on the Structure of the Human Placenta. Jour. Anat. and Physiol., 1873, vii, 120; also 1877, xi. Tussenbroeck. Die Decidua uterina bei ektopischer Schwangerschaft, etc. Vir- chow's Archiv, 1893, cxxxiii, 207-236. Ulesko-Stroganowa. Beitrage zur Lehre vom mikr. Bau der Placenta. Monatsschr. f. Geb. u. Gyn., 1896, iii, 207. Van Beneden. Recherches sur les premieres stades du developpement der Murin. Anat. Anzeiger. 1899, xvi, 305-334. Vater. Quoted from Waldeyer. Volk. Das Vorkommen von Decidua in der Cervix. Arch. f. Gyn., 1903, lxix, 681- 687. Waldever. Bemerkungeniiber den Bau der Menschen- und Affen-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 At- tached Fcetal Structures. Amer. Gyn. and Obst. Journal, 1897, x, 168-204 and 535-662. Human Placentation. Chicago, 1901. vox Weiss. Zur Kasuistik der Placenta praevia centralis. Centralbl. f. Gyn., 1897, 641-649. Williams. Decidual Formation throughout the Uterine Muscularis. Trans. Southern Surg, and (iyn. Assn., 1905, xvii, 119-132. Winckler. Textur, Structur und Zellleben in den Adnexen des menschlichen Eies. Jena, 1870. Ziegler. Die Chromosomen-theorie der Vererbung, etc. Archiv f. Rassen u. Ge- sellschafts-biologie, 1906, iii, 797-812. CHAPTEK V THE FCKTUS The Fcetus in the Various Months of Pregnancy.—It is a matter of considerable importance that the physician be able to tell approximately the age of embryos and prematurely born children, and we shall therefore give a short description of the fcetus at its various periods of development. The average duration of pregnancy, from the commencement of the last menstrual flow to the onset of labor, is two hundred and eighty days, or ten lunar months, 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 two weeks of pregnancy the product of conception is designated as the ovum; from the third to the fifth week— the period during which the various organs are developed and a definite form is assumed—it is known as the embryo; after the fifth week it becomes the fcetus. 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 structures whose most prominent feature was the chorion, to one side of which 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 of these ova Fig. 159. Fig. 160. Fig. 161. Fig. 162. Fig. 163. Fig. 164. Figs. 159-164.—Early Embryos described by His. the embryonic area was covered by a well-developed amnion, and the great bulk of the structure consisted of the yolk-sac. Spee's ovum presented the earliest stages in the formation of the embryo itself—namely, the primitive streak. Figs. 159 to 164 represent early ova described by His. Third I\Teek.—The embryonal period begins with the third week, in the early part of which can be detected the beginning formation of the medullary groove and canal, soon to be followed by the appearance of the 146 THE FCETUS IX THE VARIOUS MONTHS < >U PREGNANCY 147 head-folds. At this stage of development the abdominal pedicle is seen coining 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. A little later the formation of the double heart may be noted; while in the latter part of the week the cerebral and optic vesicles 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 surface, so that its head and tail ends come almost in contact. The rudiments of Figs. 165-168.—Embryos from Fourth and Fifth Weeks (His). X 2. the eyes, ears, and nose now make their appearance, and the 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 em- bryo does not differ essentially in appearance from that of other animals. It is still markedly bent on itself, and the visceral clefts and arches are the most prominent characteristics of its cephalic region, while the ex- tremities are in a very rudimentary condition. In the latter part of the month, owing to the development of the brain, the head becomes consider- ably larger, and assumes a certain resemblance to that of a human being. At the same time the nose, mouth, and ears become less prominent and the extremities more developed, so that it can be seen that they are 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 T 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 show definite signs of sex. 148 THE FCETUS Fourth Month.—By the end of the fourth month the fcetus is from 10 to 17 centimeters long, and weighs about 120 grams. An examination of the external genital organs will now definitely reveal the sex. Fifth Month.—-The fcetus 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 fcetus 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 ^f^^^nm**^ quite large. A fcetus born at this period / \^ will attempt to breathe and move its / V limbs, but always perishes within a short / \ time. f \ Fig. 169. Fig. 170. Fig. 171. Figs. 169-171.—Embryos from Second Month (His). X 2. Seventh Month.—The length during this month varies from 35 to 38 centimeters, and the fcetus 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 fcetus 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 an occasional successful case is found in the records. 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 absolutely erroneous, as the more developed the child the greater are its chances for life. Eighth Month.—At the end of the eighth month the fcetus has attained 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. THE FCETUS IN THE VARIOUS MONTHS OF PREGNANCY 149 Ninth Month.—At the end of the ninth month the fcetus is 46.75 cen- timeters long, and weighs about 2,500 grams. Owing to the presence of considerable fat, the body has become more rotund and the face has lost its previous wrinkled appearance. Children born at this time have a very fair chance of life if properly cared for. Tenth Month.— Full term is reached at the end of this month. The foetus is now fully developed, and presents the appearances which we shall consider in detail when we describe the new-born child. The fcetus 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, ot 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 0.45 time in the last month. Even this comparatively slow rate is not maintained after birth, for if it were the child would neigh 250 kilograms by the time it was one year old. According to Zangemeister, the average length and weight of the fcetus in the various lunar months are as follows: MONTH. LENGTH. WEIGHT. 1st .................... 0.7 2.5 9 13.4 18.9 31.6 34.5 39.3 45.5 49.93 centimeter centimeters i« i« < < 1< i < t < < < «i 1.0 gram 2.5 grams 2nd .................... 3rd .................... 12.4 " 4th .................. 89.8 " 5th .................... 252.7 " 6th ..................... 795.5 " 7th .................... 1,066.0 " 8th ............... 1,540.1 " 9th ................. 2,243.3 " 3,242.4 " These 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 during 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................ 1X1, " " second month ..........,. 2X2, " " third month .............. 3X3, " " fourth month ............. 4X4, " " fifth month .............. 5X5, " " sixth month .............. 6X5, " " seventh month ............ 7X5, " " eighth month ............. 8X5, " " ninth month.............. 9X5, " " tenth month .............. 10X5, 1 centimeter. 4 centimeters. 9 < < 16 (< 25 << 30 << 35 0 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 2 to 7 times wider and from 7 to 11 times longer than those observed in the non-pregnant uterus, measuring 0.009 to 0.014x0.2 to 0.52 millimeter in the former, as compared with 0.005 x 0.05 to 0.07 millimeter in the latter. According to the researches of Luschka and Veit, the formation of new muscular fibers is limited to the first three or four months of pregnancy. 168 UTERUS 169 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 pregnancy, 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, especially the veins, which, in the neighborhood of the placental site, become converted into large spaces, the so-called pla- cental sinuses. Marked hypertrophy of the lymphatic and nervous supply of the uterus also takes place, which is well illustrated by the state- ment of Frankenhauser that the cervical ganglion increases in size from 2 x 2.5 to 4.5 x 6 centimeters. During the first few months the hypertrophy of the uterus results from general systemic changes induced by the pregnancy itself, and, in all prob- ability, is brought about by the circulation of cer- tain substances derived from the ovum or corpus luteum. That it is not di- rectly due to the presence of the ovum in the uter- ine cavity is shown by the occurrence of pre- cisely similar changes in cases of extra-uterine pregnancy, when the ovum is implanted in the tube or ovary. After the third month, however, the increase in size is mechanical to some ex- tent, and is due directly to the 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 uterus is represented by a muscular sac whose walls are rarely above 5, and never more than 10, millimeters thick. Occasionally they are found to measure considerably under 5 millimeters. The enlargement of the uterus is not symmetrical, but is most marked in the fundal region. This can readily be appreciated bv 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 fundus; whereas in the later months their attach- ments are found at points slightly above the middle of the organ. The position of the placenta also exerts a determining influence upon Fig. 175.- Muscle Fibers from Non-pregnant and Pregnant Uterus (Sappey). 170 CHANGES IN THE MATERNAL ORGANISM the extent of the hypertrophy, the portion of the uterus to which it is attached enlarging more rapidly than the others, as is clearly shown by the position of the uterine ends of the round ligaments, which are Fig. 176.—External Muscular Layer of Fig. 177.—Internal Muscular Layer of Pregnant Uterus (Helie). Pregnant Uterus (Helie). 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 inves- tigators whose careful studies on this subject deserve spe- cial mention are William Hunter in England; Ma- dame Boivin, Deville, and Helie in France; Roederer, Luschka, Henle, Hoffmann, Bayer, Hofmeier, and others Fig. 178.—Median Muscular Layer of Pregnant in Germany. Unfortunately Uterus (H*lie). their investigations have not led to uniform results. According to Luschka and Henle, the musculature of the pregnant uterus is arranged in three strata: an external hood-like layer, which arches over the fundus and extends into the various ligaments; and an internal layer, consisting of sphincter-like fibers around the orifices of the tubes and UTERUS 171 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 Euge. In the preface to his monograph Helie tells us that he had devoted twelve years to his investigations, and Bayer has been an indefatigable worker upon the subject since 1886. According to Ilelie, the uterine musculature consists of three main layers, eacli of which is made up of several subsidiary divisions. The ex- ternal layer is composed of two longitudinal or ansiform portions, between which lies a transverse layer. The internal layer is composed of two trian- gular portions running along the inner surface of the anterior and posterior walls of the uterus respectively, and connected by an archiform layer at the fundus, an obicular portion 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 net- work 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 arrangement, it happens that when the fibers contract they constrict the vessels and thus act as living ligatures. Bayer's work is extremely complicated, and those who desire particulars concerning it are referred to his monographs upon the subject. 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 more or less like shingles on a roof, one end of each fiber arising beneath the peritoneal covering of the uterus, and extending obliquely downward and inward, 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 sieve-like appearance, which on closer examination is seen to be due to the presence of innumerable rhomboidal spaces. Euge attaches great importance to this arrangement of the muscle fibers, and believes that it explains very satisfactorily the mechanism of the uterine contrac- tions, and the manner in which the felt-like 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 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 172 CHANGES IN THE MATERNAL ORGANISM 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 vas- cularity, 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. Fig. 179. Fig. 180. Figs. 179, 180.—Same Full-term 1-para in Vertical and Horizontal Position. As the body of the uterus becomes larger, the angle which it forms with the cervix becomes smaller—in other words, its physiological anteflexion is increased. As pregnancy advances the organ soon becomes too lar«T to be contained in the pelvic cavity, and by the fourth month forms a tumor, the upper border of which reaches to a point midway between the symphysis pubis and the umbilicus. As it becomes still larger, it comes in contact with the anterior abdominal wall, displacing the intestines to the sides of the abdomen, and gradually rises up until it almost impinges TUBES AND OVARIES 173 upon the liver. As the uterus leaves the pelvis for the abdominal cavity, considerable tension is exerted upon the broad ligaments, which then be- come 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 longi- tudinal 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. 179 and ISO represent the same woman in the upright and horizontal positions respectively, and give a good idea of the changes in contour of the uterus and 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 opposite 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 usually occupies the left side of the pelvis; though possibly, in a certain number of instances, the condition represents merely an exaggeration of the original position of the non-pregnant uterus, which, as is well known, is not always perfectly symmetrical. From my own observations, I am inclined to agree with Webster, that the fre- quency with which torsion of the uterus occurs has been somewhat ex- aggerated. The uterus soon loses the firm, almost cartilaginous consistence which is characteristic of the non-pregnant condition, and, with the advance of pregnancy, becomes converted into a sac having very thin, soft walls, which are readily compressible. This is well demonstrated by the ease with which the fo'tus can usually be palpated, and by the fact that not infre- quently it is 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. Again, it is noteworthy with what readi- ness the uterine walls yield to the movements of the fcetal extremities. 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 ex- tending outward almost at right angles with the cornua, their long axes become nearly parallel to the margins of the uterus. Of special importance, moreover, is their increase in vascularity, to which the large size of the corpus luteum of pregnancy is in great part due. Except in rare in- stances, ovulation ceases during pregnancy, so that new follicles do not ripen, and, accordingly, only the single large corpus luteum of pregnancy 174 CHANGES IN THE MATERNAL ORGANISM can be found upon the surface of one of the ovaries. Seitz, in 1905, after an exhaustive study, concluded that typical ovulation does not occur, but that many follicles begin to grow and, after reaching a certain period of development, undergo atretic changes, associated with a marked develop- ment of lutein cells in the theca folliculi. 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. It is possible for a decidua to develop in the tubes while the pregnancy is situated in the uterus. Such observations have been made by Webster, Mandl, and Veit, but are of extreme rarity. I have met with such an occurrence in only one instance. VAGINA Increased vascularity is the most marked change in the vagina, and to it are due the more copious secretion and the characteristic violet colora- tion of pregnancy. At the same time there is considerable hypertrophy of the elements composing the vaginal walls, the latter not infrequently increasing in length to such an extent that the lower portion of the anterior wall prolapses slightly through the vulval opening. The papillae of the vaginal mucosa also undergo considerable hyper- trophy, whence results an increased roughness of the membrane, which in occasional instances feels almost like a calf's tongue. Owing to the increased vascularity, the vaginal secretion is considerably augmented, and in the majority of cases 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 in 1908 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 path- ogenic bacteria. 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 conclusively shown by Budin. ABDOMINAL WALLS With the enlargement of the uterus the skin covering the anterior abdominal walls and the adjoining portions of the thighs is sub- jected to considerable tension, which, according to Zeiler, results in the rupture of the elastic fibers of the reticular stratum of the cutis, and the formation of depressed areas which are known as the strice of preg- nancy. In primiparae these present a pinkish or slightly bluish appearance, as is well illustrated in Fig. 181, whereas in multiparae two varieties are ABDOMINAL WALLS 175 observed, some resembling those of primiparous women, while others pre- sent a glistening silvery appearance, the former resulting from the pres- ent condition, and the latter representing cicatrices from previous preg- nancies. The formation of striae is not characteristic of pregnancy, as it is lack- ing, according to Crede, in about 10 per cent, of the cases and is not in- frequently observed in non-pregnant women and occasionally in men, in Fig. 181.—Abdomen of Primipara at Term, showing Strlb. 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. Not infrequently the abdominal walls are unable to withstand the ten- sion to which they are subjected, and the recti muscles become separated 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 con- sisting only of skin, fascia, and peritoneum. In rare instances the separa- tion is sufficiently extensive to admit of a hernial protrusion of the gravid uterus. The enlarged pregnant uterus occasionally presses upon the venous trunks, which return the blood from the lower extremities, the obstruction being sometimes sufficient to cause varicose veins or oedema. The latter is 176 CHANGES IN THE MATERNAL ORGANISM most commonly observed about the ankles and feet, but occasionally occurs to a marked degree in the neighborhood of the vulva, when the labia majora may become immensely distended. 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 them- selves 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 them 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 areohe and nipples assume a pinkish appearance, while in brunettes they become dark brown and occasionally almost black. Scattered 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 pig- mented 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 not infrequently presents striations similar to those observed on the abdomen. CHANGES IN THE REST OF THE BODY Formerly it was believed that direct nervous connection existed between 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 pregnancy. Starling and Lane Claypon in 1906 stated that they were able to produce marked hypertrophy of the breasts of virginal rabbits by the injection of extracts obtained from the bodies of fcetal 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 observation and technique. However that may be, there is at present no doubt that the mammary changes char- acteristic of pregnancy must be due to the action of specific substances circulating in the blood, as was demonstrated by the observations of CHANGES IN THE REST OF THE BODY 177 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 her nulliparous sister. As already 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 conception. 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 con- siderable 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 obtained rapid accept- ance in France, but were received with skepticism in Germany. On the other hand, the researches of Dreysel indicate that it 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 Erics is correct in stating that the total quantity of blood is not increased during pregnancy, and, as the demands of the enlarging uterus and its contents must be met, it would seem that they could be satisfied only by a more rapid circulation of the blood. As the pulse rate is not materially 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 upon the blood pres- sure confirm such a view; as they were able by means of Erlanger's sphyg- momanometer 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 latter months of pregnancy and disappeared during the puerperium; and, as the more extensive observations 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 hydraemia and a diminution in haemoglobin 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, 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, the most important being those of Wild in 1897, Zangemeister in 1903, Payer in 1904, and Dietrich in 1911. These investigations show that in the later months of pregnancy the amount of haemoglobin and of red corpuscles is 178 CHANGES IN THE MATERNAL ORGANISM 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 super- venes. Similar conclusions were reached by W. L. Thompson in my service. 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. In view of the normal quantity of the red cells and haemoglobin, such a condition cannot properly be called hydraemia, so that Zangemeister proposed to designate it as hydroplasmia. Both Zangemeister and Payer noted a decrease in the alkalinity of the blood during pregnancy, but its exact significance is not yet 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 has described an increase in the antitryptic ferment content, Neu an increase in the adrenalin content, Chauffard, Laroche, and Grigaud an increase in the cholesterin content, and Heynemann states that there is a marked dif- ference between the serum of pregnant and non-pregnant women, as the former after heating will induce haemolysis of washed horses' corpuscles in the presence of cobra poison, while the latter will not. 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's areas, and it is stated that at the time of labor the character of the uterine contractions may be altered by intra-nasal manipulations. It has long been known that pregnancy may exert a deleterious influ- ence upon the voice of singers, and Hofbauer has shown that it is asso- ciated with changes in the larynx which occur in three-quarters of all pregnant women. These consist in reddening and cedema of the false vocal cords, as well as of the inter-arytenoid 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 dioxide, 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 toxaemia. 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. CHANGES IN THE REST OF THE BODY 179 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. These conditions will be discussed in detail in the chapter on the toxaemias 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 glycogen, and the dilatation of the biliary channels, the central veins, and the afferent capillaries. No doubt such changes are sometimes noted, and, should they occur as regularly as he believes, they would offer a satisfactory explana- tion for several of the alterations in metabolism which characterize preg- nancy. Urinary Tract.—The kidneys are likewise under a considerably in- creased strain during pregnancy, and slight degrees of nephritis are so common that they are assigned by the Germans to the "kidney of preg- nancy." Such conditions are usually connected with the various disturb- ances of metabolism associated with the toxaemias of pregnancy and will be considered under that heading, while various alterations in the constitution of the urine in normal pregnancy will be taken up below in the section on General Metabolism. The ureters are sometimes compressed by the growing uterus, and under such conditions a mild infectious process, which otherwise might not give rise to symptoms, may eventuate in a pyelitis or pyelonephrosis. 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.—Lange in 1899 reported that the thyroid gland was definitely hypertrophied in 108 out of 133 women examined in 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 disap- pearance of the albumin. He expressed himself very conservatively con- cerning the matter, but his views were promptly taken up by Nicholson and others, and made the basis for a theory concerning the mode of pro- duction and treatment of eclampsia and the toxaemias of pregnancy. My own experience shows that a moderate degree of hypertrophy of the thyroid is a usual concomitant of normal pregnancy, while the effect of its absence will be considered in the chapter upon the toxaemias of preg- nancy. There is considerable evidence that the parathyroids also undergo a 180 CHANGES IN THE MATERNAL ORGANISM similar hypertrophy, whose absence is manifested by the appearance of various untoward symptoms. Since Launois and Mulon, in 1904, directed attention to an hypertrophy of the hypophysis during pregnancy, a great deal of work has been done upon the subject, and the investigations of Eisemann and Stumme, Gushing, Mayer, and others have definitely shown that the anterior lobe of the gland regularly undergoes great hypertrophy during pregnancy, and atrophies after its completion. The hypertrophy, which may double the size of the gland, 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 hypophyseal secretion may supplement a supposed deficiency in that derived from the ovaries. 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-oedematous thickening of the features, as well as of the extremities, which is observed in so many pregnant women. The posterior or infundibular portion of the hypophysis, in addition to its effect upon the blood pressure, possesses the power of markedly stimu- lating uterine contractions, as has been shown by Dale, Bell, Parisot, and others. Whether it is normally concerned in the regulation of uterine con- tractions at the time of labor is not known, but Hofbauer, Parisot and Spire, and others have demonstrated that it may be advantageously em- ployed to stimulate contractions in certain cases of uterine inertia. That the changes in the ductless glands are not limited to those just mentioned is shown by the fact that Neu has demonstrated that the blood in the later months of pregnancy is ten times richer in adrenalin than at other times, which would imply an hypertrophy, or at least an increase, in the secretory activity of the suprarenal capsules. Skeleton and Teeth.—Eokitansky 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 observers who have confirmed his findings are clear as to their significance. Hanau considers that they are most pronounced in those cases in which there oecurs an excessive formation of osteoid tissue in other parts of the body. This he is inclined to attribute to a slight grade of osteomalacia, which he, Gelpke, and Wild regard as physiological in all pregnancies, and associated with the supply of calcium salts to the foetus. Dibbelt estimates that throughout the second half of pregnancy at least 0.17 gram of cal- cium oxide must be supplied to the fcetus each day, while Bar calculates that during the last two months the quantity must be increased to 0.638 gram per day. It is therefore evident, unless the pregnant woman assimi- lates an unusual amount of calcium from her food, that the fcetus must be supplied from her own body, and this is usually effected by partial decalci- fication 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. Owing to the increased vascularity, the various pelvic joints become GENERAL METABOLISM 181 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 physiological. 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 neuro- pathic tendencies the mental equilibrium may be overthrown to a greater or less degree, the patient becoming excitable, morbid, 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, and occasionally irregularly shaped, yellowish patches of varying size appear on the face and neck, the condi- tion being known as cloasma. Very little is known concerning the nature of those conditions, but Wychgel 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 haemoglobin of the maternal blood-cells which have succumbed in the fight against the fcetal tissues. General Metabolism.—Generally speaking, gestation is characterized by improved health. In some instances the improvement in nutrition is noted shortly after conception, but usually does 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 conspicuous for an excellent condition of body and mind. Analogous conditions have been observed in pregnant dogs, rabbits, and guinea-pigs by Hagemann, Ver Fecke, Jageroos, Bar, and Murlin. Those interested in the subject are referred particularly to the monu- mental metabolic studies of Bar, which clearly show that katabolic proc- esses 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 yet we are unacquainted with the metabolic processes in the early months of pregnancy in women, but a number of observations have been made in the weeks immediately preceding delivery. These clearly show that women in the last weeks of pregnancy 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 1862 Gassner studied the changes in weight of his patients during the last three months, and found an average monthly increase of from 3i/2 to 5V2 pounds. The gain was proportional to the weight of the individual, and was relatively larger in 182 CHANGES IN THE MATERNAL ORGANISM multigravida?. Moreover, he considered that the absence of such a gain' in weight was indicative of the death of the fcetus in utero. Confirmatory results were obtained by Baumm, who found that the weekly increase in the last month and a half of pregnancy was approximately 1 per cent, of the body weight. This gain in weight is in great part due to the retention of water, and its extent may be best appreciated by comparing the intake of fluids with the output of urine. In three normal pregnancies, my associate, J. M. Slemons, found that the latter represented from one-half to three-quarters of the fluid taken by mouth, whereas in a patient with dead twins it amounted to 93 per cent., which is approximately the normal non-pregnant ratio. The daily output of urine is subject to so many variations, being influ- enced by climatic, dietetic, and individual peculiarities, that it is difficult to fix a normal standard. Ordinarily the daily quantity varies between 1,000 and 1,500 c. c, though smaller or larger amounts may be excreted without necessarily indicating a pathological condition. Proteid metabolism in the latter months of pregnancy has been studied by Zacharjewsky, Schrader, Hahl, Hoffstrom, Hoogenhuyse, and others, who have shown that considerable quantities of nitrogen are retained when the woman is allowed an adequate diet. Similar observations have been made by my clinic during the last few weeks of pregnancy, and the average daily nitrogenous 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 Fseces. Nitrogen Balance. Primigravida...... Multigravida..... Twin Pregnancy... 1,780 c.e. 1,890 c.e. 2,354 c.e. 1,306 c.e. 1,007 c.e. 1,135 c.e. 13.80 gms. 16.77 gms. 15.00 gms. 12.43 gm. 13.26 gm. 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 fcetus, placenta, uterus, and the maternal organism in general. It is generally 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 fcetal 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 accom- panied by a decrease in the urinary nitrogen. This is clearly demonstrated by the ordinary tests made by means of a Doremus ureometer, when the daily output of urea varies between 16 and 24 grams, instead of the higher figures usually given for non-pregnant women of the same weight. 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, GENERAL METABOLISM 183 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 usu- ally an increase in the percentage of undetermined nitrogen, a part of which, according to Falk and Hesky, is accounted for by a markedly increased elimination of amino acids and peptid nitrogen. Zacharjewsky found that the uric acid excretion was practically normal, while Boni holds that the quantity of purin bases is somewhat diminished. 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 retention of various inorganic substances. The investigations of Schrader, Boni, Hoff- strom, Zangemeister, and others in women show a similar retention, whose object is to supply the calcium, phosphorus, sulphur, chlorine, etc., essential to the up-building of the foetus. That the mechanism 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 the deficit would be made good by the decalcification of the bones and teeth of the mother. Following the delivery of the child or its death in utero, the various constituents soon show a tendency to return to the usual non-pregnant relations. Acetonuria was formerly considered a sign of fcetal 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 dioxide is but little greater than would be expected on account of the in- creased weight of the pregnant woman. Carpenter and Murlin in 1911 reported the results of their investiga- tions 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 kilo- gram 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 fcetus without too great strain upon the mother, but we are as yet 14 184 CHANGES IN THE MATERNAL ORGANISM entirely ignorant of the mechanism by which such changes are rendered possible. LITERATURE Bar. Lecjons de pathologie obstetricale. Paris, 1907. Basch. Ueber exp. Milchauslosung, etc. Deutsche med. Wochenschr., 1910, xxxvi, 981. Baumm. Gewichtsveranderung der Schwangeren, Kreissenden und Wochnerinnen, etc. D. I., Munchen, 1887. Bayer. Zur physiol. u. path. Morphologie der Gebarmutter. Freund's gynakolo- gische Klinik, 1885, i, 369-662. Weitere Beitrage zur Lehre vom unteren Uterinsegment. Hegar's Beitrage zur Geb. u. Gyn., 1898, i, 167. Bell. The Pituitary Body. Brit. Med. J., 1909, Dec. 4. Boivin et Duges. Traite pratique des maladies de 1 'uterus, etc., 2me ed., Bruxelles, 1834. Boni. Quoted from Brit. Med. Jour., 1906, i, 1534-38. 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. Chauffard, Laroche et Grigaud. Evolution de la cholesterinemie au cours de 1 'etat gravidique. L 'Obst., 1911, N. S. iv, 481-492. Crede. Ueber die narbenahnlichen Streifen in der Haul, etc., bei Schwangeren u. Entbundenen. Monatsschr. f. Geburtskunde, 1859, xiv, 321-333. Cushing. Experimental Hypophysectomy. Bull. Johns Hopkins Hospital, May, 1910. Deville. Bull, de la soc. anatomique, 1844, quoted in extenso by Cazeaux, Traite de l'art des accouchements, 3me ed., 1850, 107-111. Dibbelt. Die Bedeutung d. Kalksalze fiir d. Schwangerschafts- und Stillperiode. Ziegler's Beitrage, 1910, xlviii, 147-169. Dietrich. Studien iiber Blutveranderungen bei Schwangeren, etc. Archiv f. Gyn., 1911, xciv, 383-401. Doderlein. Das Scheidensekret, etc. Leipzig, 1892. Dohrn. Zur Kenntniss des Einflusses von Schwangerschaft, etc., auf die vitale Capa- citat der Lungen. Monatsschr. f. Geburtskunde, 1866, xxviii, 457. Dreysel. Ueber Herzhypertrophie bei Schwangeren und Wochnerinnen. D. I., Munchen, 1891. Ver Eecke. Les echanges materiels dans leurs rapports avec les phases de la vie sexuelle. Bruxelles, 1900. Eisemann u. Stumme. Ueber die Schwangersehafts-veranderungen der Hypophyse. Ziegler's Beitrage, 1909, xlvi, 1-142. D'Erchia. Beitrag z. Studium des schwangeren u. kreissenden Uterus. Monatsschr. f. Geb. u. Gyn., 1904, xx, 1-23. Falk u. Hesky. Ueber Ammoniak, Amino-sauern 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. 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. Fries. Ueber Veranderungen der Blutmenge im Schwangerschaft, etc. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 340-350. LITERATURE 185 Gassner. Ueber die Veranderungen des Korpergewichtes bei Schwangeren. Mo- natsschr. f. Geburtskunde, 1862, xix, 1. Gelpke. Die Osteomalacic im Ergolzthale, Basel. 1891. Ukaitaberg. Beitriiye z. Physiologie der Eieinbettung. Zeitschr. f. Geb. u. Gyn., 1910, lxv, 1-35. Hagemann. Ueber Eiweissuinsatz wahrend der Schwangerschaft. Archiv f. Anat. u. Physiol. Phys. Abtheil., 1890, hi, 577. Hahl. Beitrag zur Kenntniss des Stoffwechsels wahrend der Schwangerschaft. Archiv f. Gyn., 1905, lxxv, 31-48. Halban. Schwangorschaftsreactionen der fotalen Orgene, etc. Zeitschr. f. Geb. u. Gyn., 1904, liii, 191-231. Hanau. Ueber Knochenveranderungen in der Schwangerschaft, etc. Fortschritte d. Med., 1892. No. 7. Harnack u. Klein. Werth genauer Schwefelbestimmungen im Harn. Zeitschr. f. Biologie, 1899, 439. Helie. Recherches sur la disposition des fibres musculaires de 1'uterus developpes par la grossesse. Paris, 1864. Henle. Eingeweidelehre, II. Aufl., 476, 187.5. Heynemann. Eine Reaction im Serum Schwangerer. Archiv f. Gyn., 1910, xc, 236-254. Hofbauer. Beitrage zur Etiologie u. z. Klinik d. Graviditiits-toxikosen. Zeitschr. f. Geb. u. Gyn., 190S, lxi, 200-274. Die Graviditats-veianderungen. Volkmann's Samml. klin. Vortrage, 1910, Nr. 5S6. Hoffmann. Morphologische Untersuchungen iiber die Muskulatur des Gebarmutter- korpers. Zeitschr. f. Geb. u. Frauenkrankheiten, 1S76, i, 44s 473. Hoffstrom. Une experience sur les echanges nutritifs pendant la grossesse. L 'Ob- stetrique, 1910, N. S. 1060-1071. IIokmeier. Das untere Uterinsegment in anat. u. physiol. Beziehung. Der schwan- gere und kreissende Uterus, Bonn, 1S86, 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. Hunter. The Anatomy of the Gravid Uterus, 1774. Jageroos. Studien iiber den Eiweiss-Phosphor-u. Salzumsatz wahrend der Gravidi- ty. Archiv f. Gyn., 1902, lxvii, 517. Ueber die Aceton-korper des Harnes, etc. Archiv f. Gyn., 1911, xciv, 656-663. Jaxchke. Blutdruck und Herzarbeit in der Schwangerschaft, etc. Archiv f. Gyn., 1911, xciii, 809-832. Ioessel und Waldeyer. Das Becken. Bonn, 1899, 781. Krause. Quoted by Spiegelberg-Wiener, Lehrbuch der Geburtshiilfe, III. Aufl., IS91, 53. liANDSBERG. Untersuchungen iiber den Gehalt des Blutplasmas an Gesammteiweiss. Archiv f. Gyn., 1910, xcii, 693-720. Lange. Die Beziehungen der Schilddriise zur Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1899, xl, 36-72. Larcher. Quoted from Ribemont-Dessaignes and Lepage, Precis d'obstfitrique. Paris, 1894. Launois et Mulon. Etude sur 1'hypophyse humaine a, la fin de la gestation. An- nales de gyn. et d'obst. 2me Ser., 1904, i, 2-13. Luschka. Die Anatomie des menschlichen Beckens, Tubingen, 1864, 365. Magnus-Levy, von Noorden's Handbuch der Pathologie des Stoffwechsels. 1906, 408. 186 CHANGES IN THE MATERNAL ORGANISM Mandl. Ueber den feineren Bau der Eileiter, etc. Monatsschr. f. Geb. u. Gyn.. 1897, v, (Erganzungsheft, 130-140). Mayer. Ueber die Beziehungen zwischen Keimdriisse u. Hypophyse. Archiv f. Gyn., 1910, xc, 600-625. Murlin. Nitrogen Balance during Pregnancy. Amer. J. Physiol., 1910, xxvii, 177- 205. Neu. Beitrage zur Biologie des Blutes in der Gestationperiode des Weibes. Med. Klinik, 1910, xlvi, 1813. Nicholson. Puerperal Eclampsia Treated by Large Doses of Thyroid Extract. Jour. Obst. & Gyn. Brit. Emp., 1904, v, 32-37. Parisot et Spire. La medication hypophysaire en obstetrique. Annales de gyn. et d'obst., 1911, N. S. viii, 689-706. Payer. Das Blut der Schwangeren. Archiv f. Gyn., 1904, lxxi, 421-459. Roederer. Icones uteri humani. Gbttingen, 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-Schwestern Blazek. Gyn. Rundschau, 1910, iv, 437-445. Schrader. Einige abgrenzende Ergebnisse phys.-chemischen Untersuchungen iiber den Stoffwechsel wahrend der Schwangerschaft u. im Wochenbette. Archiv f. Gyn., 1900, lx, 534. Seitz. Die Follikelatresie wahrend der Schwangerschaft. Archiv f. Gyn., 1905, lxxvii, 203-356. 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 Hop- kins Hospital Reports, 1904, xiii, 111. Slemons and Goldsborough. The Obstetrical Significance of the Blood Pressures. Bull. Johns Hopkins Hospital, 1908. Starling and Lane Claypon. Experimental Inquiry into the Factors Which Deter- mine the Growth and Activity of the Mammary Gland. Proc. Roy. Society, 1905- 06, 505-22. Stolz. Die Acetonurie in der Schwangerschaft, Geburt u. Wochenbette. Archiv f. Gyn., 1902, lxv, 531. Thompson. The Blood in Pregnancy. Johns Hopkins Hospital Bulletin, 1904, xv, 205-209. Veit. Anatomie des schwangeren UteTus. Muller's Handbuch der Geburtshiilfe, 1888, i, 193. Decidual Formation in Tube in a Case of Uterine Pregnancy. Schroeder's Lehr- buch der Geburtshiilfe, XIII. Aufl., 1899, 101. Webster. Ectopic Pregnancy. Edinburgh, 1895. A Criticism of Recent Views Regarding the Lateral Deviation and Rotation of the Uterus. Edinburgh Med. Jour., September, 1897, ii, 254-261. Wild. Untersuchungen iiber den Hamoglobingehalt und die Anzahl der rothen und weissen Blutkorperchen bei Schwangeren und Wochnerinnen. Archiv f. Gyn., 1897, liii, 363-381. Das puerperale Osteophyt. D. I., Lausanne, 1901. 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. LITERATURE 187 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. Zeiler. Zur Pathogenese der Dehnungstreifen der Haut. Miinchener med. Wochen- schr., 1905, iv, 1764-67. Zuntz. Respir. Stoffwechsel u. Athmung Wahrend d. Graviditas. Archiv f. Gyn., 1910, xc, 452-470. Zweifel. Die Scheideneinhalt Schwangerer. Archiv f. Gyn., 1908, Ixxxvi, 564 601 CHAPTER VII DIAGNOSIS OF PREGNANCY—DURATION OF PREGNANCY—ESTIMATION 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 impos- sible to confound a pregnancy, even at full term, with a tumor of some other nature. Such errors are usually the result of hasty or 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 that 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 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 affect the reputation or interests of the patient an expression of opinion should be deferred until the diagnosis is beyond all doubt. The diagnosis is based upon the presence of certain symptoms and signs. The former are chiefly subjective and are appreciated by the pa- tient; while the latter are made out by the physician after a careful physical examination, in which the senses of sight, hearing, and touch 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 three in number, and consist in (1) hearing and counting the fcetal heart beat, (2) perception of the 188 POSITIVE SIGNS OF PREGNANCY 189 active and passive movements of the fcetus, and (3) ability to palpate its outlines. The Fatal Heart.—Whenever we can hear and count the pulsations of the fcetal heart, the diagnosis of pregnancy is assured beyond peradven- ture; 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 fcetal 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 most of our information upon the subject; indeed, so complete is his monograph that subsequent investigations have revealed but Iii tie 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 fcetus 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 113 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 fatal li cart-beat, 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, so that it is advisable for the student to perfect himself in the latter method of aus- cultation. 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 symphysis pubis; but in the later months the situation at which it is best heard varies according to the position and presentation of the fcetus, details concerning which will be given when we consider the methods of obstetrical examina- tion. 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 heart-beats fall below 100 or exceed ICO. Frankenhauser stated that there was a marked difference in the rapidity of the heart-beat in the two sexes, and believed that a rate of 124 or less indicated a boy, and 144 or more £ girl. Further investigation, however, has failed to confirm his conclusions, as the diagnosis of sex 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 in a few cases of breech presenta- tion, in which the genitalia can be differentiated by the examining finger. 190 DIAGNOSIS AND DURATION OF PREGNANCY In women possessing very thin abdominal and uterine walls the im- pulse of the fcetal 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 and counting the fcetal 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 fcetus, 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 fcetal 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 arteries, and subsequent investigations have served to confirm his conclusions. Its mode of pro- duction 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 stethoscope 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 ma- ternal 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 be- lieved 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 Rotter 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 present- ing 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, and he considers that the sounds which are usually so interpreted are produced by spasmodic contractions of the diaphragm, and are analogous to singultus. Not infrequently the maternal pulse can 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 fcetal heart sounds. In addition to the sounds just mentioned, it is not unusual to hear PROBABLE SIGNS OF PREGNANCY 191 certain others produced by the passage of gases or fluids through the intestines of the mother. Mapping Out the Outlines of the Foetus.—In the latter half of preg- nancy it is possible to distinguish the outlines of the fcetus by palpation through the abdominal walls, and this becomes easier the nearer term is approached. When we desire to map out the fcetus we should go about the examination in a methodical manner, and follow the rules for palpation 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 fcetus and distinguish its head, breech, back, and extremities. Subserous myomata occasionally simulate the head or small parts, or both, and their presence has occasionally given rise to serious diagnostic errors. Movements of the Fcetus.—The third positive sign of pregnancy is present whenever the physician is able to feel the spontaneous movements of the fcetus. After the fifth month the active movements may be felt at intervals on placing the hand over the abdomen. These vary from a faini flutter in the early months to quite violent motions at a later period, which not in- frequently are 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 rebound of a fcetal extremity when displaced from its position by the examining finger, whereby a sensation is afforded similar to that produced 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, afterward 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 fcetus 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. When any one of the three positive signs is obtained, the diagnosis of pregnancy is established beyond doubt. 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, and (4) the detection of intermittent contrac- tions of the uterus. Enlargement of the Abdomen.—From the third month onward the uterus can be felt through the abdominal walls as a tumor, which gradually 192 DIAGNOSIS AND DURATION OF PREGNANCY 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. Fig. 182. Fig. 183. Fig. 184. Fig. 185. Figs. 182-185.—Showing Relative Abdominal Enlargement at Third, Sixth, Ninth, and Tenth Month of Pregnancy. 182, 183, 184, and 185 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 multiparas, for the reason that in the latter the abdominal walls 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 becomes markedly anteflexed and 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 Figs. 179 and 180.) PROBABLE SIGNS OF PREGNANCY 193 Changes in Size. Shape, and Consistency of Uterus.—In the first three months tliese are the only physical signs available, and the existence of an enlarged uterus at any time during the childbearing period should be re- garded 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 entirely to the antero-posterior 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 an- gle between the body and cervix becomes markedly accentuated — in other words, the physiological anteflexion is increased. More characteristic than the changes in shape are those affecting its consistency. On biman- ual examination the uter- ine body offers a doughy or elastic sensation, and in many instances be- comes so soft as to be hardly distinguishable. Dickinson has pointed out that these changes can be noted at a very early period, and states that he was able to dif- ferentiate a symmetrical elastic area in the body of the uterus in the latter part of the first week of pregnancy, which he considered almost pathognomonic. According to R. 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 altera- tion between contraction and relaxation of the portion of the organ in which the ovum is situated. At about the sixth week another sign of very considerable value—the so- called Hegar's sign—becomes available. On careful bimanual examination with one hand upon the abdomen and two fingers of the other hand in the vagina, the firm, hard cervix is felt, while above it is the elastic body of the uterus, and between the two the site of the future lower uterine segment is felt as a soft compressible area. Occasionally the change in consistence Fig. 186.- -Pendulous Abdomen of a Multiparous Woman with Normal Pelvis. 194 DIAGNOSIS AND DURATION OF PREGNANCY in this location is so marked that no connection between the cervix and body appears to exist, and in not a few instances inexperienced observers have mistaken the cervix for a small uterus, and the softened body for a tumor of the tubes or ovaries. This sign, first described by Reinl in 1884, was verified lated by Sonn- tag and others. Its value is now universally admitted, and I consider it the most valuable sign of early pregnancy. Tts production probably de- pends upon the forcing of the part 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 compressed between Fig. 1!s7.—Method of detecting Hegar's Sign, the fingers. Fig. 187 gives a good idea of the sensation to be obtained on bimanual examination; and Figs. 188 and 189 show the condition of the uterus which makes it possible. This sign is not, however, absolutely characteristic, as it was definitely present in one of my patients, in whom an abdominal section for the removal of an ovarian cyst revealed a non- pregnant uterus, whose walls were thickened and softened in some un- known manner. Macdonald in 1908 directed attention to a modification of Hegar's sign, which he claims will make possible the diagnosis of pregnancy during the course of the first month. It is based upon the exaggerated flexibility PRESUMPTIVE SIGNS OF PREGNANCY 195 of the isthmus of the uterus, and is manifested by the unusual ease with which the fundus and cervix can be brought together on vaginal manipula- tion. Cervix.—Beginning with the second month of pregnancy, the cervix becomes considerably softened, and in primiparous women the os externum offers to the finger a sensation similar to that obtained by pressing upon the more yielding lips instead of the harder cartilage of the nose, as at other times. In some cases, however, this sign does not become available, as in certain inflammatory conditions, as well as in carcinoma, the cervix may remain firm and hard throughout the entire duration of pregnancy. Intermittent Contractions of the Uterus.—From the first weeks on, Fig. 188.—Ten Weeks' Pregnant Uterus Fig. 189.—-Showing Mode of Production (Pinard). X M- of Hegar's Sign. at intervals of from five to ten minutes, the pregnant uterus undergoes 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 condition. Attention was first called to this phenomenon by Braxton Hicks, and the sign has since been known by his name. It is not, however, infallible, as similar contractions are sometimes observed in haematometra, 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. Presumptive Signs of Pregnancy.—The presumptive evidences of preg- nancy 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) abnormalities in pigmen- tation, (7) disturbances in urination, (8) mental and emotional changes, and (9) changes in the blood serum. 196 DIAGNOSIS AND DURATION OF PREGNANCY Cessation of the Menses.—Most important is the cessation of the men- strual flow. In women exposed to the possibility of pregnancy, and whose menses have previously been regular, a sudden cessation is a most char- acteristic sign; and from it alone the majority of married women do not hesitate to diagnose their condition. But in patients presenting an irregu- lar 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 which conception occasionally occurs. Furthermore, a single menstrual period may be missed by women who fear the possibility of pregnancy. On the other hand, false statements are often made, and a patient who has missed one or more periods may complain of profuse uterine haemorrhage, in the hope of misleading the physician and inducing him to introduce a sound or even to curette the uterus, and thereby provoke an abortion. 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, yet it 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 throughout pregnancy, but the majority of these accounts are apocryphal, or else the condition is associated with uterine disease. At the same time it must be admitted that very exceptionally authentic cases are observed, and in one of my patients the most careful examination revealed no other source for the haemorrhage. Such an occurrence, however, should never be taken for granted, and all other possibilities must be carefully excluded. Changes in the Breasts.— In the chapter upon the Physiology of Preg- nancy reference has already been made to the changes which occur in the breasts. Generally speaking, in primiparae these are quite characteristic, but are of less value in multipara?, since the breasts of the latter not infre- quently 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 possibility of their occurrence excluded in instances of spurious or imaginary pregnancy. Nausea, and Vomiting.—The establishment of pregnancy is frequentlv manifested by disturbances of the digestive system, more particularly mani- fested 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 dis- appears spontaneously after six or eight weeks, although some patients suffer from it for a much longer period. PRESUMPTIVE SIGNS OF PREGNANCY 197 There is considerable discrepancy of opinion as to the frequency with which these symptoms are observed, but my experience is that probably one- half of all pregnant women suffer from them to a greater or lesser degree. In many it amounts to nothing more than an occasional sensation of nau- sea ; others have considerable vomiting, while in rare instances the nausea and vomiting may be so persistent and constant as to interfere seriously with nutrition. Occasionally, similar symptoms result from nervousness or from the fear of an illegitimate pregnancy, as well as in certain cases of pseudocyesis. 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 fcetus, 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 experienced 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.—Under the influence of pregnancy the margins of the vaginal opening and the lower portion of the anterior vaginal wall frequently take on a somewhat dark bluish or purplish, congested appearance. Attention was first called to this condition by Jacquemior and Kluge, but particular stress was laid upon its significance by Dr. .lames R. t'hadwick, of Boston, so that in this country it is known as Chadivick's sign. Its presence supplies valuable pre- sumptive evidence, but is not conclusive, as it may likewise be observed in any condition leading to intense congestion of the pelvic organs. Pigmentation of the Skin and Abdominal Stria.—These manifestations, 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 are sometimes associated with tumors of other origin. Urinary Disturbances.—In the early weeks of pregnancy the enlarging uterus, by exerting pressure on* the bladder, causes a desire for frequent micturition. This is most marked in 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 appetite of the pregnant woman becomes very capricious, and she may evince an almost unconquerable desire for peculiar and sometimes revolting articles of food. T recall one patient who subsisted almost exclusively upon deviled crabs throughout the entire duration of pregnancv, and another who could retain nothing for the first four months except broiled lobster and Bass's ale. We have already referred 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 198 DIAGNOSIS AND DURATION OF PREGNANCY their own temperament with which they have become familiar in previous pregnancies. Changes in the Blood Serum.—In the preceding chapter reference was made to changes in the antitryptic titer, and in the adrenalin and choles- terin content of the maternal serum which are said to characterize preg- nancy; while 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 demonstration of such changes, however, is too complicated for ordinary clinical 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 pregnancy exists, while it remains clear and transparent in non-pregnant women. 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; (b) 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) changes in the cervix; (5) Chad- wick's sign; (6) the abdomen is not prominent, the navel is depressed; (7) auscultation is negative. Second period. Symptoms: (a) menses still absent; (6) more marked changes in the breasts; (c) disappearance or subsidence of gastric and uri- nary disturbances; (d) quickening. Signs: (1) the fundus is felt several fingers above the symphysis at the fourth month, and midway between the symphysis and umbilicus at the fifth month; (2) the cervix is soft; (3) ballottement is obtainable; (4) intermittent uterine contractions are recog- nizable; (5) at the very end of the period the fcetal heart sounds can be distinguished. Third period. Symptoms: (a) menses still absent; (b) changes in the breasts more marked; (c) in the last month frequent urination reappears, often with neuralgic pains in the lower extremities. Signs: (1) pro- gressive enlargement of the abdomen; (2) umbilicus smooth and later protruding; (3) the fcetal heart can be heard; (4) the different parts of the child can be palpated; (5) fcetal movements are perceptible. 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 SPURIOUS PRFGNANCY 199 made. The early periods of pregnancy may be simulated by enlargement of the uterus due to interstitial or submucous myomata, sarcomata, bgematometra, and conditions resulting from inflammatory disturbances. As a rule, the uterus under these circumstances is harder and firmer than in pregnancy, and does not present its characteristic elastic or boggy con- sistency. Moreover, except in haematometra, 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 necessary under an anaesthetic. As the tumor becomes larger and rises up into the abdomen, other points become available for differential diagnosis, notably the inter- mittent contractions of Braxton Hicks and the positive signs of pregnancy. The diagnosis of pregnancy in a myomatous uterus often presents seri- ous 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 consistent with the existence of an uncomplicated myoma, and variations in the consistency of 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 overlooked and a simple cystoma diagnosed; whereas, if the heart sounds are heard, the cystoma may escape recognition and the excessive abdominal enlargement be attributed to a hydramnios. In rare instances hypertrophy of the supravaginal portion of the cervix may seriously increase the difficulties of diagnosis, as the enlarged and hard cervix may be mistaken for the entire uterus, the soft and elastic body being either overlooked or regarded as a tumor of the uterine appen- dages. Careful bimanual examination under anaesthesia should do away with the possibility of this error. Irregular development of the pregnant uterus, associated with a saccu- lation of its anterior or posterior wall, may seriously complicate the diag- nosis, especially if the fcetus be dead; as even after the most careful exam- ination the existence of pregnancy may remain unrecognized and the sac- culation be mistaken for an ovarian cyst. This is especially apt to occur when the pregnancy develops in the posterior wall, as in such cases the anterior wall may remain practically unchanged, and when, under anaesthe- sia, one can feel the fundus with both tubes extending from it, it is almost a pardonable error to conclude that the fluctuant tumor lying posterior to it is an ovarian cyst. Spurious Pregnancy.—Imaginary pregnancv, or pseudocyesis, is a con- dition with which almost every practitioner, sooner or later, will meet. It is usually observed in patients nearing the menopause, or in young women 15 200 DIAGNOSIS AND DURATION OF PR KG NANCY who intensely desire offspring. Such patients may present all the sub- jective symptoms of pregnancy, associated with a marked increase in the size of the abdomen, which is due either to an abnormal and rapid deposi- tion of fat or to the existence of tympanites and 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 con- siders are due to her supposed condition. In many instances the woman may imagine that she detects fietal move- ments, which are sometimes so violent as to make her fearful that they may be visible to onlookers. I recall a patient who imagined herself in the last month of pregnancy, and who, while talk- ing to me, exclaimed at the vio- lence of the movements, but on examination I found that her uterus was normal in size, and that her enlarged abdomen was due to a rapidly increasing de- posit of fat. The supposed f, xxxiv, 180-22:1. Die wahrnehmbaren kindlichen Bewegungen. Lehrbuch der Geburtshiilfe, II. Aufl.,. iM»s, :>(). Bk.xoist. Des rapports ent re 1 Ymbryon et le placenta dans l'avortenient. These de Paris, 1906. Bichebois. Contribution a 1'etude de 1'idee de grossesse, trouble phychopathique. Tliese de Nancy, 1903. Blau ii. Ghristofoletti. Ueber die Dauer der menschlichen Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 190:1, xxi, 163-169. von Braun. Ueber Friihdiagnose der Graviditas. Zentralbl. f. Gyn., 1899, xxiii, 4.S.S-4S9. Budin. HYmmes en couches et nouveau-nes. Paris, 1897, 1-4. Chadwick. Value of the Bluish Coloration of the Vaginal Entrance as a Sign of F'regnaney. Trans. Amer. Gyn. Soc, 1886, xi, 399. Depaitl. Traite d'auscultation obstetricale. Paris, 1847. Dickinson. The Diagnosis of Pregnancy between the Second and Seventh Weeks by Bimanual Examination. Amer. Gyn. and Obst. Journal, 1892, ii, 544 5.1:1. Duval. Palpation of the Foetal Heart Impulse in Pregnancy. Johns Hopkins Hos- pital Bulletin, 1897, viii, p. 207. Fieux et Mauriac. De la possibility d'une toxemic villeuse et d'un sero-diagnostic do la grossesse. Annales de gyn. et d'obst., 1910, N. S. vii, 65-75. Fischel. Ueber ein bisher nicht beobachtetes Phanomen bei Defiexionslagen. Prager med. Wochenschr., 1881, Nr. 12, 13; 1SS2, Nr. 28. Zur intrauterinen Tastbarkeit des fotalen Herzimpulses bei Defiexionslagen. Zen- tralbl. f. Gyn., ix, 1885, 769-771. 206 DIAGNOSIS ANT) DURATION OF PREGNANCY Franck-Albrecht-Goring. Die Triichtigkeitsdauer, Thierarztliche Geburtshiilfe, IV. Aufl., 1901, 153-119. Frankenhauser. Ueber die Herztone der Frucht und ihre Benutzung zur Diagnose 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. Laurie. De 1'influence du repos sur la duree de la grossesse. These de Paris, 1899. 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, Ivii, 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, No. 12. Reinl. 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. Schatz. Klin. Beitrage zur Physiologie der Schwangerschaft. Leipzig, 1910. Sonntag. Hegar's Sign of Pregnancy. Amer. .lour. Obst., 1892, xxvi, 145-157. Spiegelberg. Lehrbuch der Geburtshiilfe, III. Aufl., 1891, 126, 127. Starcke. Ueber Geburten, bezw. Spatgeburten, bei Riesenkinder, etc. Archiv f. Gyn., 1905, lxxiv, 587-619. Winckel. Neue Untersuchungen iiber die Dauer der menschlichen Schwangerschaft. Volkmann's Samml. klin. Vortrage, 1901, No. 292-293. CHAPTER VIII THE MANAGEMENT OF NORMAL PREGNANCY From a biological point of view, pregnancy and labor represent the highest functions of the female reproductive system, and a priori should be considered as normal processes. But when we recall the manifold changes which occur in the maternal organism, it is apparent that the border-line 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 give rise to pathological conditions which 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 un- toward symptoms. The services of an obstetrician should be engaged some months before the expected dale of confinement, so that upon him devolves the duty of advising the patient as to her mode of life during the intervening months. 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 enumer- ated the various abnormal symptoms which may occur and to which the physician's attention should be immediately called. I give below (page 2K») 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. Exercise.—During normal pregnancy the woman should be encouraged 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 her- 207 208 THE MANAGEMENT OF NORMAL PREGNANCY self. Exercise should consist of walking, driving or motoring over good roads, but the ordinary sports should be interdicted, though sea-bathing in many instances is very beneficial. When 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 under- taken unless absolutely necessary, and driving over rough roads should be avoided. Diet.—The diet should be abundant and nourishing, 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. 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 shown that the larger size of the children in the well-to-do classes is in great part attributable to the life of ease and the abundance of food enjoyed by the mothers. Prochownick pointed out, and his experience has been confirmed by Eeeb and Noel Paton, that a diet poor in carbohydrates and fluids exerts considerable influence in lessening the weight of the child without otherwise affecting it, and in not a few cases these precautionary measures may obviate a difficult delivery, or even do away with the necessity for the induction of premature labor. 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. 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 adminis- tration of cascara sagrada or pills containing aloin, belladonna, and strych- nine. 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 marked 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, at least, the ordinary corset should be replaced by a loosely fitting corset-waist or by one of the specially de- signed "maternity" corsets. In multiparous women, when the abdomen is markedly relaxed from previous childbearing, the wearing of an abdom- inal support 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 concerning the possibility of their rupture. Sexual Intercourse.—In healthy persons sexual intercourse in modera- tion usually does no harm, as long as the abdominal enlargement is not too great to make it inconvenient for the patient. But where there is a URINE 200 tendency to abortion it should be strictly interdicted. It should also be positively forbidden in the last month of pregnancy, as I know of at least one ca-se in which a severe puerperal infection has followed coitus during that period. In this instance the patient, who had not been examined internally, had a severe streptococcus infection in the puerperium, and. upon searching for its cause, it was found that she had had sexual inter- course just before the onset of the first stage of labor. The Breasts.—In the last three 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 rendered easier, and the occurrence of fissures and the consequent danger of mam- mary infection in great part prevented. For this purpose the patient, during the last two months, should bathe her nip- ples night and morning with a lotion which tends to make the skin covering them more resistant. A saturated solu- tion of borax or boric acid in 50 per cent, alcohol will answer the purpose Fig. 192.—Wooden Nipple Shield. very well. Where 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 following the wearing of a wooden nipple shield (Eig. 102) for a few hours of each day, which is held in place by adhesive strips. 1 know of no means, however, by which deeply retracted nipples can be made serviceable. Urine.—Owing to the frequency of renal disturbances and the serious consequences which frequently result from them, the urine should be care- fully examined at regular intervals: once a month for the first seven months, and at least twice a month, and 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 be- comes 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. The urine should be examined not only for the presence of albumin and sugar, but also microscopically. If albumin is detected in any quan- tity, or the patient presents symptoms indicative of toxiemia, a twenty- four-hour specimen should be saved and sent to a competent chemist for the determination of the total amount of nitrogen and of the nitrogenous partition. Where this is not feasible, at least the total amount of urea and albumin should be estimated by the physician by means of the Doremus ureometer and Esbach's albuminometer. (See Chapter XXVI.) 210 THE MANAGEMENT OF NORMAL PREGNANCY 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 constipation. In the majority of cases these symptoms are of secondary importance, but occasionally they serve to warn us of the imminence of some serious affec- tion which may be cured or alleviated by appropriate treatment. PRINTED DIRECTIONS FOR 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 an 8-oz. bottle of mixed (night and morning) urine; and for the two months preceding the ex- pected date of confinement send it on the first and fifteenth days of the month. Be sure to send your name with the specimen. (d) From the sixth month onward bathe the nipples night and morn- ing with a solution prepared as follows: Fill a tumbler with equal parts of alcohol and water and add to it a tablespoonful of borax. Keep the solution in a bottle and apply it by means of absorbent cotton. (e) Six weeks before the expected date of confinement buy my "Con- finement Outfit." In this is included everything which will be needed by the nurse and myself, except baby's clothes. At the same provide two pieces of rubber sheeting, % x 1 yard, and 1x2 yards respectively; 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 making bed pads, or 4 ready- made sanitary bed pads. (/) Send for nurse as soon as labor pains commence, 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 call 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. Preliminary Examination.—Four to six weeks before the expected date of confinement a careful examination is indispensable, and to neglect in this respect can be attributed the deaths of untold numbers of women and children. Usually this can be made much more conveniently with the patient in her own home and in bed than at the physician's office. At PRELIMINARY EXAMINATION 211 this time the general condition should be carefully noted, particular attention being also paid 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 examina- tion, 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 pros- pects of a simple and safe delivery, she will feel amply repaid for any inconvenience to which she may have been subjected. 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 generally do well to inform the husband or some other responsible member of her family of the existing condition. If, however, it should happen that, 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 alternative but to decline absolutely to attend the case. The first point in the preliminary examination is careful pelvic men- suration, and Dohrn has well said that the physician who neglects pelvime- try is comparable to one who attempts to treat pulmonary diseases without the aid of auscultation and percussion. In the majority of instances the usual external measurements, including palpation of the pubic arch, are quite sufficient, unless they indicate the possibility of some pelvic abnor- mality. Generally speaking, provided the head is deeply engaged, if the measurements between the iliac spines and crests bear an approximately normal relation to one another, internal pelvimetry is not necessary unless Baudelocque's diameter is 18.5 centimeters or less. But even if the latter diameter is normal the pelvis should be measured internally, and if neces- sary under anaesthesia, 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 at the proper time to suggest the induc- tion of premature labor, or to keep the patient within reach of a competent operator who will be ready to perform Cesarean section at the time of election. After measuring the pelvis, the abdomen should be carefully examined, the duration of pregnancy estimated, and the existence of any abnormality, as hydramnios or twins, noted; after which the size, position and presenta- tion of the child should be determined by external palpation, according to the rules which will be given later. An internal examination is necessary only in those cases in which palpation gives uncertain or unsatisfactory 212 THE MANAGEMENT OF NORMAL PREGNANCY results, or when the head is not engaged in primiparous women. The physician who knows how to utilize all the resources of external palpation and manipulation will find that by these means he can usually not only recognize normal and abnormal presentations in advance, but can also con- vert breech, transverse, or face presentations into those of the vertex. When vaginal exploration is necessary at the preliminary examination, if undertaken prior to the end of the ninth lunar month, rigorous hand disinfection is not necessarv, and the physician may content himself with the use of a nail-brush, soap, and hot water. In the last month of preg- nancy, however, the hands should be as carefully disinfected as at the time of delivery, for we have no means of knowing exactly when labor may supervene, and our neglect may occasionally give rise to puerperal infec- tion. The various abnormalities occurring in the course of pregnancy will be considered in a separate chapter. LITERATURE Dohrn. Ueber Beckenmessung. Volkmarm's Sammlung klin. Vortrage, Nr. 11. Paton, Noel. Influence of Diet in Pregnancy on the Weight of the Offspring. Lan- cet, 1903, ii, 21. Prochownick. Ein Versuch zum Ersatze der kiinstlichen Friihgeburt. Zentralbl. f. Gyn., 1889, xiii, 577-581. Reeb. Ueber den Einfluss der Ernahrung der Muttertiere auf die Entwickelung ihrer Friichte. Beitrage z. Geb. u. Gyn., 1905, ix, 395-411. CHAPTER IX PRESENTATION AND POSITION OF THE FCETUS—METHODS OF DIAGNOSIS PRESENTATION AND POSITION OF FCETUS Irrespective of the relation which it may bear to the mother, the fcetus 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. Thus, it 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. This attitude is usually retained throughout pregnancy, though it is frequently modi lied somewhat by the movements of the extremities, and occasionally the head may become deflected, when a totally different pos- ture is assumed. The characteristic attitude results partly from the mode of growth of the fcetus, and partly from a process of accommodation be- tween 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 distin- guish between longitudinal and transverse presentations. Occasionally dur- ing pregnancy the fcetal may cross the maternal axis at an angle, and thus give rise to oblique presentations; but, as these always become longitudinal or transverse during the course of labor, they are not considered as distinct varieties. Longitud'uial presentations are by far the most frequent, oc- curring in from 99 to 99.5 per cent, of all cases. Considerable confusion has resulted from confounding the term presen- tation and presenting part. By the latter we understand the portion of the fcetus which is felt through the cervix on vaginal examination, or which engages at the superior strait. Accordingly, in longitudinal presentations the presenting part may be either the head or the breech, and we speak of cephalic or breech presentations respectively. When the fcetus lies with its long axis transversely, the shoulder is the presenting part, and we speak of shoulder presentations. 213 214 PRESENTATION AND POSITION OF THE FCETUS Longitudinal presentations are broadly classified as normal, and trans- verse as abnormal, inasmuch as with the former the child is usually deliv- ered by the unaided efforts of Nature; whereas if the latter persist it cannot be born spontaneously, but always requires the aid of the obstetrician. These abnormal presentations will be considered in a separate chapter. Figs. 193-196.—Showing Difference in Attitude of Fcetus in Vertex, Sinciput, Brow, and Face Presentations. Cephalic presentations are divided into several groups, according to the relation which the head bears to the body of the child. Usually the head is sharply flexed, so that the chin is in contact with the thorax. Under these circumstances the vertex is the presenting part—vertex presentation. More rarely the neck may be over-extended, so that the occiput and back come in contact and the face is felt through the cervix—face presentation. Again, the head may assume an intermediate position between the extremes Fig. 197. Fig. 198. Fig. 199. Fig. 200. Figs. 197-200.—Showing Difference in Attitude of Foetus in Frank Breech, Full Breech, Foot, and Knee Presentations. of flexion and extension, being partially flexed in some cases, when the large fontanelle presents—sincipital presentation; or partially extended in other cases, so that the brow becomes the presenting part—brow presenta- tion. The last two are not usually classified as distinct varieties, as they PRESENTATION AND POSITION OF THE FCETUS 215 are usually transient, and become converted into vertex or face presenta- tions 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 abdomen 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 presenta- tion. 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. Accord- ingly, 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 respectively; while in Germany the objective point is the child's back. Variety.—Furthermore, for the purpose of still more accurate orienta- tion, 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 are not persistent, and usually represent only a phase in the mechanism of labor, they need not be taken into account. Nomenclature.—Unfortunately, a universal nomenclature for designat- ing 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 Roesslin's Rosengarten (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 Earabeuf and Varnier. According to the French method, vertex, face, and breech presentations are designated as occipito-iliac (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 nomencla- ture, when it was suggested that the denomination "iliac" be omitted and the various presentations designated as occipital, mental, and sacral re- spectively. The suggestion was quite generally adopted in this country, and Bar in 1903 advocated its universal adoption. As the presenting part in any presentation may be either in the left or 16 216 PRESENTATION AND POSITION OF THE FCETUS Vertex presentations. Position. Left. Right. Presentation. Variety Occipital Abbreviation, (L.O.A.) (L.O.T.) (L.O.P.) (R.O.A.) (R.O.T.) (R.O.P.) Fig. 201. Fig. 202. Figs. 201, 202.—Showing Varieties of Vertex Presentations. Face piesentations. Left. a (t Right. Mental. Anterior. Transverse. Posterior. Anterior. Transverse. Posterior. (L.M.A.) (L.M.T.) (L.M.P.) (R.M.A.) (R.M.T.) (R.M.P.) Fig. 203. Fig. 204. Figs. 203, 204.—Showing Varieties of Face Presentations. Breech presentations Left. Right. Sacral. Anterior. (L.S.A.) Transverse. (L.S.T.) Posterior. (L.S.P.) Anterior. (R.S.A.) Transverse. (R.S.T.) Posterior. (R.S.P.) Fig. 205. Fig. 206. Figs. 205, 206.—Showing Varieties of Breech Presentations. PRESENTATION AND POSITION OF THE FCETUS 217 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 R. 0., L. M. and R. M., L. S. and II. S. Again, as the presenting part in each of the two positions may be directed anteriorly, transversely, or posteriorly, we may have six varieties of each presentation, though the transverse modifications are frequently omitted. Thus, we have the classification given on the opposite page. In Germany considerable confusion exists, as the various authorities si ill employ different classifications. Thus Schroeder, Olshausen and Veit do not distinguish variety at all, and designate the position according to the situation of the back of the child, speaking of first and second posi- tions according as the back is directed to the left or right side of the mother respectively. Ahlfeld, Doderlein, and others employ a different nomen- clature, and designate our L. 0. A.. E. 0. A.. R. 0. P., and L. 0. P. as first, second, third, and fourth positions respectively. The exhaustive articles of Miiller and Schatz deal fully with this subject. The nomenclature which we have adopted presents many advantages over the German, as it is based upon the relation of the presenting part to the maternal pelvis, and enables us 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 thousand 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, 0.4S, 3.!), and 0.9 per cent., respectively. The former figures apply to all periods of pregnancy. But when full term alone is considered the predominance of vertex presenta- tions becomes still more marked, constituting 96 to 97 per cent, of all cases; while breech presentations become less frequent, and occur only once in 62, as compared with once in 30 labors. 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 Schatz has shown that the former becomes more and the latter less frequent the nearer pregnancy approaches term. Naegele first pointed out that the vertex was usually directed anteriorly in left, and posteriorly in right posi- tions; so that the presenting part is usually found at one or other ex- tremity of the right oblique diameter of the pelvis, owing to the fact that the left oblique diameter 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 to 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 218 PRESENTATION AND POSITION OF THE FCETUS head presentations predominated throughout all periods of pregnancy, but became more frequent in the later months. For many years it was taught that the presentation remained constant throughout pregnancy, and it was not until 1861 that Hecker and others demonstrated that it was not un- usual 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 becomes more and more stable the nearer full term is approached. The theories put forward to account for the prevalence of head presenta- tions are divided into two groups, the one being based upon gravitation, 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. Veit, both of whom showed that a fcetus 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 down- ward. This result they attributed to the greater specific gravity of the head, together with the presence of the liver on the right side. Veit 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, provided the experiments of Duncan and Veit held good, 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 left margin of the latter would usually be directed somewhat forward, the frequency of the left anterior presentations could be readily explained. In 1900 doubt was cast upon the conclusions of Duncan and Veit by Schatz, who maintains that, although their results were perfectly correct when experimenting with a medium of the same specific gravity as the foetus, it has yet to be demonstrated that they hold good for the amniotic fluid, which, it must be remembered, possesses a specific gravity of between 1,008 and 1,009, or considerably less than that of the fcetus. Schatz sus- pended a recently dead fcetus 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 gradually in- creased, 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 pre- dominate 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 DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 219 head and body of the foetus, separately, found that the former was rela- tively lighter than the latter in the first eight months, but heavier in the last two months of pregnancy. Consequently, he concluded that gravity could only account for the predominance of head presentation in the lat- ter period. Furthermore, as he found that the specific gravity was identical whether the fcetus 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 Dubois, Simpson, and Scanzoni, according to which cephalic presentations are brought about by a process of accommodation between the fcetal ovoid and the interior of the uterine cavity, the shape of the latter being such that the fcetus is most comfortable and fits it more 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 con- tractions, which tended to restore the head presentation. Pinard is an enthusiastic advocate of this theory. Schatz in 1904 clearly showed that there was a general tendency for the back of the child to lie anteriorly, which increased under the influence of gravity. This he demonstrated by finding that the anterior varieties of vertex presentations occurred more frequently in the evening than in the morning, in a series of women wdiom he examined in the morning before arising, and again in the evening after they had been about all day. 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 the- ory; 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 produc- tion of the reflex movements, which give rise to accommodation, are entirely lacking, and gravity alone comes into play. An exhaustive consideration of the various older theories can be found in the excellent monograph of Cohnstein published in 1868. DIAGNOSIS OF PRESENTATION AND POSITION OF FOETUS The diagnostic methods at our disposal are fourfold: abdominal palpa- tion, vaginal touch, combined examination, and auscultation. Obstetrical Palpation.—Under ordinary circumstances external or ab- dominal palpation is the most reliable and valuable, and I should unhesi- tatingly 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 discom- fort to the patient, and it is not going too far to say that its popularization forms one of the greatest advances in modern obstetrics. Under these cir- cumstances it behooves the student to become thoroughly familiar with 220 PRESENTATION AND POSITION OF THE FCETUS the proper technique, and to avail himself of every opportunity to become proficient in the various manipulations. Although crude forms of abdominal palpation had no doubt been prac- ticed from the earliest antiquity, just as they are still employed by many of the aboriginal peoples, its advantages were first pointed out by Eoederer, Wigand, and Hohl, as late as the latter part of the seventeenth and the early part of the eighteenth century. Its practical importance, however, was not generally recognized until 1S78, when Pinard published his work upon the subject, after which the method became popularized in France, but was not employed systematically in Germany and this country 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 manoeuvres suggested by Leopold. The patient should be on a hard bed or sofa, with the abdomen bared, or at most covered with a thin chemise. During the first three manoeuvres the examiner stands at the side of the bed which is most convenient to him, and faces the patrent, but reverses his position and faces her feet for the last manoeuvre. (See Plates X, XI, XII, and XIII.) First Manoeuvre.—After ascertaining the outlines of the uterus, 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 sensa- tion of a large, irregularly shaped, nodular body, and the head that of a hard, round object, which is freely movable and ballottable. Second Maiueuvre.—Having determined which pole of the fcetus 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 numerous nodulations—the small parts. In women with thin, abdominal walls the legs and arms can readily be differentiated, but in fat persons only irregu- lar nodulations can be felt. In the latter case, or when a considerable quantity of amniotic fluid is present, the appreciation of the back can be facilitated by making deep pressure with one hand while palpating 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 arrive at the position and variety of the presentation. Third Mana-uvre.—The examiner grasps the lower portion of the ab- domen, just above the symphysis pubis, between the thumb and fingers of one hand, and tries to decide 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 we know that the head is extended and that we have a face presentation. On the other hand, DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 221 if the presenting part be engaged, this manoeuvre simply shows that the lower pole of the fcetus is fixed in the pelvis, and the details concerning it are ascertained as follows: Fourth Manoeuvre.—The examiner faces the patient's feet, and with 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 round 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 which the prominence is felt indicates the extent to which descent has occurred. In many instances, when the head has de- scended into the pelvis, the anterior shoulder of the child can be readily differentiated by the third manoeuvre. In breech presentations the informa- tion obtained from this manoeuvre is not so definite as in head presenta- tions. This method of examination is available throughout the later months of pregnancy, and in the intervals between the pains at the time of labor. My 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. At the same time the size of the child can be roughly estimated, and the second fcetus mapped out in twin pregnancy. 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 secondly, by noting their course, as pointed out by Palm and Leopold, we are enabled 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 posterior 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 pas- sage of the child, the contraction ring may be felt as a transverse or oblique ridge extending across the lower portion of the uterus. Moreover, in nor- mal cases, we can differentiate by palpation between the contracting 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, as one is obliged to palpate the presenting part through the lower uterine segment. During labor, on the other hand, after more or less 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 222 PRESENTATION AND POSITION OF THE FCETUS fontanelles; in face presentations, 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 derived from vaginal touch alone is not more accurate than that obtained by ab- dominal palpation, and in vertex presentations the fontanelles are not infrequently mistaken for one another; and occasionally face and breech presentations escape differentiation. Moreover, in the latter part of labor, after the formation of a fluid tumor beneath the skin covering the present- ing part—the caput succedaneum—detection of the various diagnostic points often becomes impossible. A much more serious objection, however, is the danger of puerperal infection, no matter how carefully the obstetrician may have attempted to Fig. 207.—Diagram showing Method of Locating Sagittal Suture on Vaginal Examination. disinfect his hands; for it is now generally admitted that absolute hand disinfection cannot be effected, and, even granting that the use of 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. Moreover, vaginal examination necessi- tates exposure of the patient, and subjects her to more or less serious incon- venience. Accordingly, it is advisable to limit its employment as much as possi- ble, and in normal cases to do away with it altogether. For if the patient has a normal pelvis, and we find by the fourth manoeuvre 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 this can usually be ascertained by rectal examination. Accordingly, vaginal examination becomes abso- lutely necessary only in the few cases in which palpation and rectal exam- DIAGNOSIS OF PRESENTATION AND POSITION OF FCETUS 223 ination do not give satisfactory results, or in those presenting some abnor- mality, or in which the course of labor is unduly delayed. Personally, I conduct more than three-quarters of my private cases in this manner, and do not make a vaginal examination until about to discharge the patient. In attempting to diagnose the presentation and position by vaginal ex- amination, it is advisable to pursue a definite routine, which is readily accomplished by three manoeuvres. First Manoeuvre.—After most careful hand disinfection and appropriate preparation of the patient, two fingers of either the right or left 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 Manoeuvre.—If the vertex be presenting, the fingers are carried ep ls)hind the symphysis pubis, and are then swept backward over the Fig. 208.__Diagram showing Method of Differentiation between the Fontanelles. 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 fontanelle lies at one and the large fontanelle at the other end of it. Third Manauvre.—We then attempt to determine the position of the two fontanelles. For this purpose the fingers are passed to the anterior extremity of the sagittal suture, and the fontanelle 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 fontanelle is felt and differentiated. By this means the various sutures and fontanelles are readily located, and the possibility of error is considerably lessened. In face and breech presentations it is still further minimized, as the varioua 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 appli- 224 PRESENTATION AND POSITION OF THE FCETUS cation 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 internal 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 not infrequently reenforces the results obtained by palpation. Ordinarily, the heart sounds are transmitted through the convex portion of the fcetus, which lies in intimate contact with the uterine wall. Accordingly they are heard loudest through the back in vertex and breech, and through the thorax in face presentations. The region of the abdomen in which the fcetal heart is heard most plainly varies according to the presentation and the extent to which the presenting part has descended. In head presentations 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 occipito-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, however, in right occipito-posterior presentations, the information gained from the position of the fcetal 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, and the heart sounds being transmitted through it would appar- ently indicate a left anterior position. LITERATUEE Ahlfeld. Lehrbuch der Geburtshiilfe, II. Aufl., Leipzig, 1898. Bar. Rapport sur 1'unification de la nomenclature obstetricale. L 'obstetrique, 1903, viii, 103-114. Baudelocque. L'art des accouchements. Paris, 1789, 2me ed. Cohnstein. Die Aetiologie der normalen Kinderlage. Monatsschr. f. Geburtsk., 1868, xxxi, 141-193. Crede. Gesunde und kranke Wochnerinnen. Leipzig, 1886, 80-81. Crede und Leopold. Die geburtshulfliche Untersuchung. Leipzig, 1892. Doderlein. Leitfaden fur den geburtshulflichen Operationskurs. Leipzig, 1893. Dubois. Memoire sur la cause des presentations de la tete. Mem. de I'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 accouche ments. Paris, 1904. Hecker. Klinik der Geburtshiilfe, Leipzig, 1861, i, 17. Statistisches aus der Gebaranstalt Munchen. Archiv f. Gyn., 1882, xx, 378-398. Hohl. Die geburtshulfliche Exploration, Halle, 1834, ii, 144-166. International Medical Congress. Uniformity in Obstetrical Nomenclature. American Jour. Obst., 1889, xx, 1084-1086. LITERATURE 225 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 Goldberg. Ueber die Entbehrlichkeit der Sclieiden-Ausspiilungen, etc., und iiber die grosstmogliche Verwerthung der ausseren Untersuchung in \ this time the perineum has become converted into a deep gutter, 5 to (i centimeters long, at the end of which is the vulval opening, Fig. 212.—Birth of Head, Vulva completely Distended. which looks almost directly upward and is distended by the head of the child, the occiput being pressed firmly against the symphysis pubis. The distention of the vulva is most marked at its perineal margin, and only slight at its 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 becomes impossible, and with the next I wo or three pains the head is rapidly expelled by a movement of extension, the base of the occiput rotating around the lower margin of the symphysis pubis as a fulcrum, while the bregma, brow, and face successively pass over the fourcliette. In the majority of cases the perineum is unable to 238 PHYSIOLOGY AND CLINICAL COURSE OF LABOR 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 serves to bring the bisacromial diameter of the child into relation with the antero-posterior diameter of the pelvic outlet. At this time the perineum is quite tightly retracted around the neck of the infant, whose face in consequence may become markedly congested, so that the inexperienced obstetrician is often seized by an almost uncontrol- ./ o <~S< u V: aj>. ''. «—---..... -.__________ii Fig. 213.—Birth of Head, showing Delivery by Extension. lable 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 curva- ture, corresponding to the axis of the birth canal. Immediately following the child comes a gush of amniotic fluid, which represents the portion which did not escape at the time of rupture of the membranes, and is more or less tinged with blood. In primiparous women the second stage of labor usually lasts about two hours, and a much shorter period in multiparous women, in whom two CLINICAL COURSE OF LABOR 239 or three pains sometimes suffice for the completion of the period of ex- pulsion. 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 marked sense of relief. On glancing at the abdomen it is seen that the uterus has become much smaller and forms a 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 centimeters, while a slight tumefaction appears immediately above the symphysis pubis. (See Figs. 303 and 304.) This indicates that the placenta has become Fig 214.—Birth of Head, Face falling Backward toward Anus. 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 accord- ing to the efficiency of their contraction. In some women the entire pla- cental period may be terminated spontaneously within a few minutes after the birth of the child, while in others the placenta may remain in the lower uterine segment for hours unless forced from it by proper manipu- lation on the part of the obstetrician. During the third stage there is nearly always a slight amount of haemor- rhage, which in normal cases amounts to 300 or 400 cubic centimeters. Not infrequently the patient may have a chill during this period, or im- 240 PHYSIOLOGY AND CLINICAL COURSE OF LABOR mediately after its completion. This, although it may appear somewhat alarming, in itself has no significance, as it is merely a vasomotor phe- nomenon. Duration of Labor.—The duration of labor presents considerable in- dividual variations, and is usually about six hours longer in primipar.T than in multiparas. 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. According to G. Aeit, the average duration of labor is twenty hours Z. o cs< wa 0 0. /-s-c . Fig. 215.—Birth of Head, External Rotation. for primiparae and twelve for multiparas; according to Spiegelberg, seven- teen and twelve hours respectively. The slower course of labor in the former is due to the greater resistance offered by the soft parts. Occa- sionally 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. Labor is usually more prolonged in elderly than in young primiparae —that is. after the thirtieth year. According to Ahlfeld. it averages seven hours longer in the former, though Varnier states that the difference is very much less. At the same time the latter author points out that forceps LITERATURE 241 are much more frequently required in old primiparae, being applied in "25 per cent, and l.G per cent, of the cases respectively, thus indicating that labor would have lasted much longer had it not been terminated by opera- tive means. It is usually considered that labor is likewise prolonged in extreme youth, but the observations of Gache and Bondy prove that such a belief is erroneous. It is generally stated that delivery occurs most frequently between the hours of 2 and 4 a. m. The statistics of Knap p. which are based upon 39.(100 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 cases be divided into two groups, according as de- livery occurs between (I a. m. and (> p. m., and G p. m. and 6 a. m. respec- tively, 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 0 p. m. and 6 a. m. LITEKATURE Ahlfeld. Die Geburten alterer Erstgeschwaugerten. Archiv f. Gyn., 1872, iv, 510 520. Beard. The Span of Gestation and the Cause of P>irth. Jena, ls97. Blumreich. Experiniente zur Frage nach den Ursachen des Geburtseintritt. Archiv f. Gyn., 1904, Lxxi, 135-179. Bondy. Die Geburt in den Entwickelungs jahren. Zeitschr. f. deb. u. Gyn., 1911, lxix, 213-246. Brown-SeQCARd. Experimental Researches applied to Physiology and Pathology, is.".".. 117. t'oi.iEZ. Quelques considerations medico-legales sur les accouchements inconscients et sans douleur. These de Paris, 1S99. 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, 1S97, iv, 265 282. 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, X. S., i, 723-736. Geyl. Ueber die Ursache des Geburtseintrittes. Archiv f. Gyn., 1881, xvii, lis Heide. Exp. biologische Untersuchungen iiber den Geburtseintritt. Miinchener med. Wochenschr., 1911, 1705-1709. .Torux. Memoire sur 1'emploi de la force en obstetrique. Arch. gen. de med., Pm!7, i, 149; 313. Kehrer. Die Zusammenziehungen der glatten Genitalmuskulatur, etc. Beitrage zur vergleich, und exp. Geburtskunde, 1867, Heft II, 41-50. Physiol, u. pharmakol. Untersuchungen an den uberlebenden u. lebenden inneren Genitalien. Archiv f. Gyn., 1907, lxxxi, 160-210. Keiffer. Recherches sur la physiologie de 1'uterus, Bruxelles, ls96. 242 PHYSIOLOGY AND CLINICAL COURSE OF LABOR 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 Yorgang 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 Uterusschleimhaut, etc. Archiv f. Gyn., 1877, xi, 443- 500. Lowenhardt. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. Gyn., 1872, iii, 356-391. Mauriceau. Traite des maladies des femmes grosses, etc., 6me ed., 1721, 203. Mende. Handbuch der gerichtlichen Medicin, 1821, ii, 303. Meyer-Ruegg. Eihautberstung ohne Unterbrechung der Schwangerschaft. Zeit- schr. f. Geb. u. Gyn., 1904, li, 419-468. Naegele. Versuch eines Systems der Geburtshiilfe, 1812, 97. Polaillon. Recherches sur la physiologie de 1'uterus gravide. Paris, 1880. Poppel. Ueber die Resistenz der Eihaute. Monatsschr. f. Geburtsk., 1863, xxii, 1-15. Rein. Beitrag zur Lehre von der Innervation des Uterus. Pfliiger 's Archiv, 1880, xxiii, 68. Routh. Parturition during Paraplegia. Trans. London Obst. Soc, 1897, xxxix, 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 physiologischen Geburtskunde. Archiv f. Gyn., 1872, iii, 58- 144. Ueber die Formen der Wehencurve und iiber die Peristaltik des menschlichen Uterus. Archiv f. Gyn., 1886, xxvii, 284-292. Ueber die Entwickelung der Kraft des Uterus im Verlaufe der Geburt. Verh. d. deutschen Gesell. fur Gyn., 1895, vi, 531-542. Sijemons. Metabolism during Pregnancy, Labor and the Puerperium. Johns Hop- kins Hospital Reports, 1904, xii, 111-144. Spiegelberg. Die Dauer der Geburt. Lehrbuch der Geburtshiilfe, II. Aufl., 1891, 146. 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 I'accouchement. L'Obstetrique journaliere, 1900, 174-181. Veit. Beitrage zur geburtshiilflichen Statistik. Monatsschr. f. Geburtsk., 1854, v, 344-381; 1855, vi, 101-132. Williams, J. Whitridge. The Frequency and Significance of Infarcts "of the Pla- centa. Amer. Jour, of Obst., 1900, xli, No. 6. Wolff. Ueber schmerzlose Geburtswehen. Archiv f. Gyn., 1906, lxxvii, 402-418. CHAPTEE 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 ine 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 this doctrine was incorrect, and that the shortening was only apparent, being brought about by a fusiform dilata- tion of the cervical canal which resulted 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 Ciraaf, and Weitbrecht (1710-'50). At the same time he insisted upon cer- tain modifications, holding that the cer- vical canal remained practically un- changed until the onset of labor. His statements soon received abundant con- firmation from the observations of Hoist, Miiller, Lott, Taylor, Lusk, and many other investigators. Miiller 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 con- clusions were verified by further clinical observation, so that it is now gen- erally admitted that in the great majority of cases the canal remains prac- 243 Fig. 216.—Diagram show- ing Condition- of Cer- vix at the End of Pregnancy (Miiller). 244 THE FORCES CONCERNED IN LAROR Fig 217. -Cervix at the End of Pregnancy (Waldeyer). X \. tically unaltered until the onset of labor, and that it may even be slightly longer than in the non-pregnant condition, thus indicating that the cervix shares somewhat in the general hypertrophy of the uterus. In recent years the results obtained by examination during life have received additional con- firmation from the study of fro- zen sections made through the bodies of women dying, late in pregnancy. Valuable contribu- tions along these lines have been made by Waldeyer, Schroeder, Braune and Zweifel, Pinard and Varnier, Leopold, and others. Lower Uterine Segment.— For a short time after the ap- pearance of Midler's work in ISOS, the • question concerning the behavior of the cervix was regarded as practically settled; but these hopes were shattered in 1S72 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 interior of the uterus was divided into two parts by a projecting circular ridge, 10 to 11 centimeters above the margins of the dilated external os, its situation being marked by a large vein, and by the deflection of the peritoneum from the anterior surface of the uterus (Fig. 220). The portion above it possessed thick walls, while the remainder appeared as a thin-walled, muscular tube through which the head had partially passed. Braune identi- fied this ring or ridge with the internal os, and concluded that everything below 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. Fig 218.—Cervix at the End of Pregnancy (Braune and Zweifel). X \. Fig. 219.—Cervix at the End of Pregnancy, showing Preservation of Canal (Leopold). X \. LOWER UTERINE SEGMENT 245 Bandl, in his work upon rupture of the uterus, which appeared in is;.'), pointed out that when such an accident occurs the point of rupture is marly 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 centi- meters 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 remarkable change possible. He believed that, during the last few weeks of pregnancy, the tissue forming the outer portion of the cervix was gradually shifted, so that it became incorporated with the musculature of the lower portion of the body of the uterus, while the cervical mucous membrane retained its original position. According to his view, then, the true internal os was situated not at the Fig. 220.—Frozen Section through Woman dying during Second Stage of Labor, showing Contraction Ring (Braune). upper termination of the cervical mucosa, but much higher, and at a level corresponding to that of Braune's ring. Although BandFs complicated explanation is no longer accepted, his name will always have a place in the literature of the subject. More particularly, as we are indebted to him for our views concerning the clin- ical 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. 246 THE FORCES CONCERNED IN LABOR Internal os. Internal External Fig External os. 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 sit- uated 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 Braune's ring to the external os, is derived entirely from the cer- vix. The first view has received the indorsement of such authorities as Schroeder, Euge, von Franque, Bar- bour, and Veit, while the correctness of the second explanation is upheld by Bandl, Kiistner, Bayer, Zweifel, Grasel, and others. That the ques- tion is not yet settled is shown by the fact that Bumm and Blumreich, after 221.—Diagram illustrating Main studying a new frozen section in v iews as to Nature of Lower Uterine innrv t,„u . .-i i j, • , • -, Segment (American Text-Book). 1907> hold to the latter Vlew; whlle Barbour is equally positive in stat- ing that it is by no means of universal application. 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 structure of the parts by microscopical examination. If the first view be correct, the inner surface of the portion which is sup- posed to be derived from the uterus should be lined by decidua, and the portion below it, corresponding to the cervical 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 variously 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 phe- nomenon; 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, the majority of the specimens which have been relied upon to settle the question were frozen before being subjected to microscopical examination, so that the finer histological details had become obliterated. In spite of these obstacles, however, the question has gradually approached a solution, and most investigators are inclined to believe that the first view is cor- rect, except in occasional instances. 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 LOWER UTERINE SEGMENT 247 are not agreed as to what constitutes the cervix. He holds that a narrow portion, the isthmus, usually separates the uterine cavity from the cervical canal, and is lined by typical uterine mucosa. It is therefore apparent that those who designate its upper opening 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 likewise correct in holding that the passive portion of the uterus is derived both from its body and cervix. To obviate this difficulty, he proposes to designate the upper and lower openings of the isthmus, re- spectively, as the anatomical and histological internal os. The contrac- tion ring corresponds to the former, while the lower uterine segment is derived from the tissue lying between it and the histological internal os. Plate IX represents a vertical mesial section through the uterus of a woman, seven months pregnant, who died at the Johns Hopkins Hospital Fig. 222.—My Frozen Section, showing Condition of the Birth Canal in First Pari of Second Stage of Labor. X \. C.R., contraction ring; o.e., external os. during premature labor. In this it is clearly seen that the external os is not dilated, but that the cervical canal has become obliterated aiid 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 dis- tance of 3.5 to 4 centimeters from the margins of the external os, whereas above this point the tissue is distinctly uterine in appearance and is cov- ered by decidua. Fig. 222 represents part of a frozen section through a pregnant cadaver, 18 24S THE FORCES CONCERNED IN LABOR shown in Plate I, which was kindly placed at my disposal by Drs. J. Holmes Smith and L. E. Nealc. The woman, who had a slightly generally con- tracted rachitic pelvis, died in labor with the membranes protruding from the vulva. The child presented by the breech, which had not yet become engaged. The cervical canal was obliter- ated and the external os fully dilated, 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. Fnfortunately, the specimen was so macerated that the lining membrane of the cer- I^Ww vical canal and lower uterine segment had disappeared. Microscopical examination revealed only a few cervical glands in the neighborhood of the external os, but gave no information as to whether the portion below the con- traction ring was lined by decidua or cervical epithelium. Hofmeier, in 1SS(>, demonstrated that the structure of the lower uterine segment is not homogeneous, and that the portion which corresponds to the cervix is com- posed of dense connective tissue rich in elastic fibers, while its upper part is made up of muscular lamella- which pursue an almost parallel course, whereas as soon as the contraction ring is reached the uterine muscula- ture takes on its characteristic appearance. Changes in the Uterus during the First Stage of Labor.—Passing from these more or less theoretical con- siderations to the condition of the uterus at the onset of labor, 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 rarely exceeds 5 millimeters in thick- ness, and is lined by decidua and the fcetal membranes. The cervix is softened and very succulent. It presents a more or less fusiform canal, 3 to 4 centimeters long, which is bounded at its upper and lower ends by the internal and external os respectively; its walls rarely exceeding 1.5 centimeters in thickness. The condition of the external os varies considerably, according as the patient is a primiparous or multiparous woman. In the former it is quite tightly closed and barely admits the tip of the little finger; while in the latter it is widely gaping, so that the index finger can be readily passed through the funnel-shaped cervical canal up to the in- ternal os. During labor, under the influence of the uterine contractions, the uterus becomes differentiated into two distinct portions, which are separated from one another by the contraction ring. The upper is the active contractile portion and becomes thicker as labor advances, while the lower plays a merely passive part, becoming converted into a Fig. 223.—Section through Lower Uterine Seg- ment and Cer- vix, showing Rhomboidal Ar- rangement of Muscle Fibers in Former and Dense Struc- ture in Latter (Hofmeier). P., peritoneal cov- ering of uterus; o.e., os externum; o.i., os internum. PLATE IX. SEVEN ANU A HALF MONTHS' PREGNANT UTERUS FROM WOMAN DYING IN THE FIRST STAGE OF LABOR. Xi \ CHANGES IN THE UTERUS, FIRST STAGE OF LABOR 249 thin-walled muscular tube for the transmission of the fcetus (Fig. 225). With the onset of labor pains the fluid contents of the uterus are subjected to pressure. As the lower uterine segment and the cervix will Fig- ^4. Fig 225. Figs. 224, 225.—Diagrams of Birth Canal at End of Pregnancy and during Second Stage of Labor, showing Formation of Birth Canal (Schroeder). naturally constitute a point of least resistance, the fluid pressure, which is transmitted equally in all directions by the amniotic fluid, consequently gives rise to an increased tension and distention of these portions of the uterus. On abdominal palpation, even before the rupture of the mem- Fig. 226.—Dilatation of Cervix, Funnel-shaped Obliteration of Internal Os and Cervical Canal (Leopold). branes, two zones can sometimes be differentiated during a contraction, the upper one of which is firm and hard, while the lower affords a semi- fluctuant sensation. The former represents the contractile portion of the uterus, the latter the passive lower uterine segment and cervix. Again, since the cervix is perforated by its canal, the fluid pressure 250 THE FORCES CONCERNED IN LABOR 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 con- tracting fibers of the upper portion of the body of the uterus. When com- plete dilatation has been effected, the external os is about 10 centimeters Fig. 227.—Dilatation of Cervix further advanced than in Fig. 226 (Leopold). X 1. in diameter, and its margins lie 8 to 10 centimeters below the contraction ring, while no trace of the internal os can be found. 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- ternal os. The obliteration occurs from above downward, the beginning Fig. 228.—Cervical Canal completely obliterated, External Os Intact. X 1. being indicated by a funnel-shaped depression at the region of the internal 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. 226, 227, and CHANGES IN THE UTERUS, SECOND STAGE OF LABOR 251 228, and also in Figs. 229, 230. 231, and 232, which represent reconstruc- tions from the frozen sections of Schroeder, Winter, Siixinger, and Tibone, all of which were made through women who died during the first sta«e of labor. Alter the cervical canal has become obliterated, dila- tation of the external os oc- curs. In many instances its margins become extremely thin, and when tense gives a sensation as if they might cut the examining finger. This change is brought about almost entirely by the force exerted by the bag of of waters, or, when that has ruptured prematurely, by the pressure of the present- ing part itself. The course of events differs considerably according as the woman is in her first or a subsequent pregnancy. In the former case marked resistance is offered by the external os, and a considerable time must elapse before complete dilatation is accomplished; whereas in the latter, the os is gaping Fig. 220—Dilatation of Cervix, Funnel-shaped Obliteration of Internal Os; Canal 2 Centi- meters Long (Schroeder). X J. Fig. 230.—Dilatation of Cervix, all but Lower 10 Millimeters of Canal ob- literated; External Os Unchanged (Winter). X i Fig. 231.—Dilatation of Cervix, all but Lower 3 Millimeters of Canal ob- literated; External Os Unchanged (Saxinger). X §• and verv little force is required for its complete dilatation after the cer- vical canal has become obliterated. Changes in the Uterus during- the Second Stage of Labor.—During the first stage of labor the contractions of the uterus have resulted in its differentiation into two parts, which are separated from one another by 252 THE FORCES CONCERNED IN LABOR Fig. 232.—Dilatation of Cervix, Canal ob- literated; External Os 1.5 Centimeter in Diameter. Placenta Previa (Tibone). X §. the contraction ring. Above is the active, contractile portion, which be- comes thicker as labor advances, and below the thin-walled, passive, lower uterine segment and cervix (Fig. 225). While these changes are being effected, there has been no ad- vance on the part of the fcetus, and, as a rule, the presenting part occupies the same position from the onset of labor until complete dilatation of the cervix. With the commencement of the second stage, however, descent begins, and under normal condi- tions continues slowly but stead- ily until delivery is accomplished. Naturally, the differentiation in- to 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 dilatation 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 greater or lesser quantity of a tolerably clear fluid from the vagina. Occasionally the membranes give way some time before complete dilatation of the cervix has been brought about; whereas in rare instances they may retain their integrity until the comple- tion of labor, so that the fcetus is born surrounded by them, the portion covering its head being desig- nated as a caul. We have already directed attention to the changes in shape which the uterus presents dur- ing 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 con- traction. The increase in length is due partly to the stretching of the lower uterine segment, and partly to a straightening out of the -fcetus; but we are unable to make definite statements as to its extent, for at present we possess no means of ascertaining how far the retraction of the upper portion of the uterus may serve to counterbalance the stretching of its lower segment. In obstructed labors, in which marked disproportion exists between the size of the present- Fig. 233.—Diagram show- ing Action of Intra- uterine Pressure, Mem- branes not Ruptured. FORCES CONCERNED IN LABOR 253 ing 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. With the formation of the lower uterine segment, the upper portion of the uterus increases markedly 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 segment. Forces Concerned in Labor.—As long as the membranes are unruptured and the uterus contains a normal quantity of amniotic fluid—that is, during the entire first stage of labor, and, in the rare instances in which they remain intact, in the second stage—whatever force is exerted by the contracting uterus is transmitted to the liquor amnii, and by it to the foetus. In accordance with the laws of fluid pressure, therefore, it is applied with equal in- tensity to all portions of the child, and, were it not that the lower uterine segment 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 forma- tion of the lower uterine segment and the dila- tation of the cervix, but plays no part in caus- ing 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 considera- ble quantity, which fills out the interstices be- tween the fcetus and the uterine walls. Lahs believed the amount retained was usually suffi- cient to prevent actual contact with the surface of the fcetus, and that therefore extrusion of the latter was brought about by fluid pressure alone. He argued that under such circumstances (Fig. 234) the entire surface of the fcetus, 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 bringing about descent. On the other hand, Lahs held that in all other presentations, as well as in those of the vertex when the amniotic fluid has almost completely drained off, other factors come into play which he regarded as distinctly pathological. In such cases the contracting uterus would come in direct contact with the surface of the fcetus, and the force exerted by the fundus would be directly transmitted to the presenting part by way of the vertebral column. Fig. 234.—Diagram showing Action of Intra-uterine Pressure after Rupture of the Membranes. 254 THE FORCES CONCERNED IN LABOR Most recent writers have not hesitated to accept Labs's interpretation, but Olshausen in 1901 directed attention to the fact that the latter force comes into play even in normal vertex presentations, lie 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 Barbour—and that in three of them the fundus was in direct contact with the breech of the child. He then estimated that at least 300 cubic centimeters of amniotic fluid were re- quired to fill out the interstices between the surface of the fcetus and the uterine wall, and stated that the child could not be ex- pelled solely by fluid pressure unless a greater quantity than this were present. In 200 cases he measured the amount of amniotic fluid escaping when the child was born, which practically represents the quan- tity remaining in the uterus after rupture of the membranes, and found that in 80 per cent, of the primiparae it did not exceed 300 cubic centimeters; while in GO 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 absolutely essential for the proper action of fluid pressure. He therefore concluded that in the circumstances direct pressure must be exerted by the contracting uterus upon the breech, whence it is transmitted through the vertebral column to the head, and that this is rendered possible by the diminution in the transverse and antero- posterior diameter of the uterus, which results in an extension of the child and its conversion for the time being into a comparatively rigid object. In addition to these factors, the contractions of the abdominal muscles of the woman also play no mean part in effecting the extrusion of the child; indeed, according to Schroeder, they alone bring it about. Ols- hausen, on the other hand, 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 the birth of the foetus, for when it is entirely absent, or only partially comes into play, labor is frequently so delayed that resort to forceps becomes necessary. The descent of the presenting part is also partly due to the fact that the child becomes straightened out by the action of the pains during the second stage. 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 estimates that it varies from 7.25 to 13 centimeters in 70 per cent, of the cases. Part of this, it is true, is counterbalanced by the greater length of the uterus, but the remainder is accounted for by the descent of the presenting part. V Fig. 235.—Diagram showing Di- rect Pressure exerted by Fundus after Complete Evac- uation of Amniotic Fluid. PELVIC FLOOR 255 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 becomes smaller and smaller, it necessarily exerts a diminished effect upon the child, so that, in the majority of cases, it becomes essential that the abdom- inal contractions should participate in the work. 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 displaced 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 outward one meets successively with the peritoneum, the subperitoneal connective 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 subcuta- neous tissue and the cutaneous covering of the perineal and vulvar regions. Of these structures the most important are the levator ani muscle and the fascia covering its upper and lower surfaces, which for practical pur- poses 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 centimeters below its upper margin, and 1 to 1.5 centimeters from the symphysis 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 recto- vaginal septum. The greater part of the muscle passes backward and unites with that from the other side of the rectum, while the posterior por- tions meet together in a tendinous rhaphe in front of the coccyx, the most posterior fibers being attached to the bone itself. The muscle fails to fill out the posterior and lateral portions of the pelvic floor, which 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 the internal margins of its pelvic portions can be felt as thick bands extending backward from the pubis, about 2 centimeters above the hymen. On contraction it serves to draw both the rectum and ,*HT Fig. 236.—The Pelvic Floor seen from above (Kelly). Fig. 237.—t-The Pelvic Floor seen from below (Kelly), 256 PELVIC FLOOR 257 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 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 cover- ing of the levator ani, is attached to the margin of the superior 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 ob- turator internus muscle, and is firmly attached to the periosteum covering the lateral wall of the pelvis, the white line indicating its point of de- flection 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 dia- phragm is divided into two parts by a line drawn between the ischial tuber- osities. Its posterior por- tion consists of a single layer which, taking its ori- gin from the sacro-sciatic ligament and the ischial tu- berosity, passes up over the inner surface of the ischial bones and the obturator in- ternus 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 inferior surface of the levator ani, the space included between the latter and the lateral pelvic wall being designated as the ischio-rectal fossa. The structure filling out the 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 anterior portion of the inferior surface of the leva- tor 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 super- ficial perineal fascia which, together with the layer just described, form a compartment in which lie the superficial perineal muscles, with the excep- tion of the sphincter ani, the rami of the clitoris, the vestibular bulbs, and the vulvovaginal glands. THREE LAYERS OF THE PERINEAL FASCIA Fig. 238.—Diagram showing Arrangement of Pel- vic and Perineal Fascia (Tarnier). 258 THE FORCES CONCERNED IN LABOR The superficial perineal muscles consist of the constrictor cunni, the ischio-cavernosus, and the transversus perinei muscles. These structures Urethra Clitoris M. Constrictor cunn M. Ischio-cavernosus 0..y v M. transversus perinei rum tendineum Levator ani Sphincter ani Fig. 239 - Pelvic Floor distended by Presenting Part, showing Superficial Musclef of Perineum (BummJ. are delicately formed and possess no obstetrical significance, except the last-named muscles, which are always torn through in perineal lacerations, when they serve in great part to bring about gaping of the wound. Stud- Fig. 240.—Frozen Section, showing Condition of Birth Canal in Last Month of Pregnancy (Braune and Zweifel). X k. PKIA'IC FLOOR 259 diford hold^s that, anterior and interior to the sphincter ani, the perineal body contains numerous strands of non-striated muscle, which also play an important part in perineal tears. In the first stage of labor the bag of waters takes part in the dilatation and distention of the upper portion of the vagina, but after its rupture the changes occurring in the pelvic floor are due entirely to the pressure Fig. 241.—Frozen Section, showing Condition of the Birth Canal in First Part of Second Stage of Labor (Braune). X §. exerted by the presenting part. As this descends, the anterior portion of the pelvic floor becomes forced against the inferior and posterior portions of the symphysis. On the other hand, the posterior portion undergoes marked changes, becoming pushed downward and forward, and subjected lo 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 demonstrates the important part played by the levator ani and the altogether 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. 222 and 2 11. 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 trans- parent membranous strncture 2 to 4 millimeters thick. At the same time it is pushed down about 2.5 centimeters from its original position. 260 THE FORCES CONCERNED IN LABOR When the perineum is distended to the utmost, the anus becomes markedly dilated, and presents an opening which varies from 2 to 2.5 cen- timeters in diameter, through which the anterior wall of the rectum is seen to bulge. LITERATURE Aschofp. Das untere Uterinsegment. Zeitschr. f. Geb. u. Gyn., 1906, Iviii, 328-332. Ueber die Berechtigung, etc., des Begriffes Isthmus uteri. Verh. d. deutschen path. Gesellsch., 1908, xii, 314-322. Bandl. Ueber Ruptur der Gebarmutter. Wien, 1875. Ueber das Verhalten des Uterus und Cervix, etc. Stuttgart, 1876. Barbour. 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 dorch den KSrper einer Hochschwang- eren. Leipzig, 1890. Bumm u. Blumreich. Gefrier-durchschnitt, 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. Researches in Obstetrics, Edinburgh, 1868, 243-273. Farabeuf. Les vaisseaux sanguins des organes genito-urinaires. Paris, 1905, p. 32, von Franque. 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, Ixix, 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, 1882. Lahs. Zur Mechanik der Geburt. Marburg, 1869; Berlin, 1872. Die Theorie der Geburt. Bonn, 1877. Langhans und Muller. Weiterer anat. Beitrag zur Frage vom Verhalten der Cer- vix 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 ed., 1721, t. i, 97. Muller. Untersuchungen iiber die Verkiirzung der Vaginalportion, etc. Scanzoni's Beitrage, 1868, v, 191-346. Olshausen. Beitrag zur Lehre vom Mechanismus der Geburt. Stuttgart, 1901. Paramore. The Pelvic Floor Aperture. J. Obst. and Gyn. British Empire, 1910, xviii, 95-121. LITERATURE 261 Pinard et Varnier. Etudes d'anatomie obstetricale normale et pathologique Paris 1892. Roederer. Elementa artis obstetriciae. Gottingae, 1766, 26. Ruge. Unteres Uterinsegment u. cervikale Umanderung. Zeitschr. f. Geb. u. Gyn 1906, lvii, 294-313. Svxinger. Gefrierdurchschnitt einer Kreissenden. Tubingen, 1888. Schatz. Der Geburtsmechanismus der Kopfendlagen. Leipzig, 1868. Beitrage zur physiologischen Geburtskunde. 1871. Schroeder. Der schwangere und kreissende Uterus. Bonn, 1886. Stoltz. Considerations sur quelques points relatif a l'art des accouchements. These de Strasbourg, 1826. Studdiford. The Involuntary Muscle Fibres of the Pelvic Floor. Am. J. Obst., 1909, Ix, 21-31. Taylor. On the Cervix Uteri. Amer. Med. Times, 1862, June 21. Tibone. Sulla placenta praevia tavole omolografiche preparate sopra il cadavere con- gelato. Turin, 1894. 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. Waldeyer. Medianschnitt einer Hochschwangeren bei Steisslage des Fotus. Bonn, 1886. Webster. The Female Pelvic Floor. Researches in Female Pelvic Anatomy. Edin- burgh, 1892, 93-112. Winter. Zwei Medianschnitte durch Gebarende. Berlin, 1889. Zweifel. Zwei neue Gefrierschnitte Gebarender. Leipzig, 1893. 19 CHAPTER "XII MECHANISM OF LABOR IN VERTEX PRESENTATIONS Vertex presentations occur in from 96 to 97 per cent, of all cases, and in them, as was first pointed out by Naegele, the sagittal suture nearly always engages 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- posterior presentation. That this is so, and that the first-mentioned pres- entation is the one most frequently observed, practically 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 1,687 cases. L. O. A......... L.O.P......... R.O.A......... R.O.P......... 71 per cent. .63 " 2.87 " 25.6 52.6 per cent. 11 .2 38.8 60.9 per cent. 2.6 19.7 16.8 Mechanism in Left and Right Occipito-anterior Presentations.—We shall consider in the first place the mechanism of labor in the anterior varie- ties of vertex presentations—namely, the left and right occipito-anterior. Fig. 242. -Diagram showing Child in L. O. A. Fig. 243.—Diagram showing Child in R. O. A. Diagnosis.—The way in which the fcetus is presenting 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 in the 262 MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 263 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 deformed by sub- Fig. 244.—Frozen Section through Woman at End of Pregnancy, Child in R. O. T. (Zweifel). peritoneal or intramural myomata, as the latter may occasionally be mis- taken for portions of the child. For purposes of diagnosis we employ the four manoeuvres already de- scribed, and with the foetus in the left occipito-anterior position obtain the following data: First manoeuvre: Irregular breech at fundus. Second manoeuvre: Resistant plane of back in the left and anterior portion of the abdomen, with the small parts on the right side. Third manoeuvre: 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 manoeuvre: Negative if the head be not engaged; otherwise the cephalic prominence is felt on the right side (Plate X). For the right occipito-anterior position the findings are as follows: First manoeuvre: Irregular breech at fundus. Second manoeuvre: Resistant plane of back in the right and anterior portion of the abdomen, with the small parts on the left side. Third manoeuvre: As in L. O. A. Fourtli manoeuvre: Cephalic prominence on the left side. lrnfil the head lias become engaged the information obtained by vaginal examination is extremely meager; and even after engagement satisfactory 264 MECHANISM OF LABOR IN VERTEX PRESENTATIONS results cannot usually be obtained until the cervix is sufficiently dilated to permit of the introduction of the finger, by which the various sutures and fontanelles are differentiated. In the left anterior variety the sagittal suture occupies the right oblique diameter of the pelvis, with the small fontanelle in the neighborhood of the left ilio-pectineal 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 ilio-pectineal eminence, while the large fontanelle looks toward the left sacro-iliac synchondrosis. The diagnostic value of vaginal examination may be still further im- paired when the presence of a marked caput succedaneum makes it im- possible to feel the sutures and fontanelles. In the left anterior positions the fcetal 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 move- ments as if they occurred separately and independently of one another; whereas, in reality, the mechanism of labor consists of a combination of movements, several of which are going on at the same time, it being impos- sible for any one of them to occur without descent of the presenting part. These movements are divided into two classes, according as they are abso- lutely essential to the completion of labor, or as they merely facilitate its progress. To the first group belong the cardinal movements—descent, in- ternal rotation, and extension; to the second the accessory movements— flexion and external rotation. Engagement.—The mechanism by which the presenting part enters the superior strait is designated as engagement. This is best studied in women who have borne one or more children, for the reason that in primiparae the head normally descends into the pelvic canal some weeks before the onset of labor, when the most dependent portion of the presenting part lies just above a line joining the ischial spines; whereas in multiparous women this frequently does not occur until the commencement of labor pains. In most multipara 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 uterus begins to contract and to force it toward the pelvic opening, the cephalic circumference which first engages is the one that passes through the extremities of the fronto-occipital diameter. This normally PLATE X. First manoeuvre. Second manoeuvre. _' oCMYis- OOP /et Fourth manoeuvre. Third manoeuvre. PALPATION IN LEFT OCCIPITO-ANTERIOR PRESENTATION. MECHANISM IN OCCIPITO-ANTERIOR PRESENTATIONS 265 measures 11.*) centimeters; and, as the conjugata vera is only 11 centi- meters in length in the bony pelvis, and is encroached upon by various tis- sues in the living woman, it is apparent that a normal-sized head cannot engage with its sagittal suture directed antero-posteriorly. Accordingly, 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 Fig. 245.—Position of Fcetus before Fig. 246.—Position of Fcetus afteb Engagement. Engagement suture is directed toward the left ilio-pectineal eminence, and the other toward the right sacro-iliac synchondrosis. This is attributed to two fac- tors. In the first place, the foetus, in the later months of pregnancv, usu- ally assumes 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 and 2-l, Fig. 309.—Palpating Head through Perineum. a convenient position at the side of the bed, and upon it a basin of boiled water and another of 1-1,000 bichloride solution, as well as sterilized 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 posi- tion is preferred. I prefer the former, as it affords better facilities for the preservation of an aseptic technique. If the leggings have not been used, they should now be drawn up and pinned to the nightgown, which has been rolled up beneath the patient's back, so that it may not be soiled. The genitalia should again be washed with soap and water, and bathed with a bichloride solution. CONDUCT OF THE SECOND STAGE OF LABOR 323 After having drawn freshly boiled gloves over his carefully disinfected hands, so that he may make an immediate vaginal examination if neces- sary, the physician should place a sterile towel beneath the patient's but- tocks, a second over her abdomen, and others over her legs, and pin them In;. 310.—Showing Patient in Proper Position for Delivery, and Covered by Sterile Dressings. in place so as to cover everything in the neighborhood of the genitalia with which his hands may come in contact, leaving only the vulva and perineum exposed. As the head passes down into the pelvis small particles of faeces 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 bichloride solution. As soon as the head begins to distend the vulva, the patient's sufferings become greatly increased, and are frequently excruciating. At this stage it is advisable to begin to use chloroform, partly to relieve the pain, and partly to aid in protecting the perineum. If the nurse be competent, its administration should be intrusted to her. The patient having been in- structed to give notice as soon as she feels a pain beginning, several drops of chloroform are poured upon an Esmarch inhaler, and she is told to inspire deeply. This is repeated with each pain, the inhaler being removed immediately after its cessation. In this manner, after a short time, the sensation of pain becomes markedly diminished, while the patient retains 324 CONDUCT OF NORMAL LABOR consciousness and is generally able to talk rationally. But, when the head begins to emerge from the vulva, the chloroform should be pushed to com- plete ana-sthesia, during which the head is born. This degree, however, should last only for a few moments. Protection of the Perineum.—As soon as the perineum shows signs of bulging the physician should make preparations for its protection, plac- ing 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 statements 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 respectively; Balandin in 25.99 and 4.19 per cent., and Olshausen in 21.1 and 4.7 per cent. These figures would seem to be rather too conservative, as slight tears implicating the fourchette occur in about two-thirds of all primiparae, and in 10 per cent, of multipara". 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 in- spected the parts after labor, and designates as torn only those cases in which the vagina 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. 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 excessively 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 disproportion between the head and the vulva as to the lack of elasticity of the perineum, which is particularly marked in elderly primipara?. 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 suboccipito-bregmatic or suboccipito-frontal circumference. In a cer- tain number of cases the presenting part may be directed too far bacl^rard —in other words, extension does not occur—and under the influence of the uterine contractions the presenting part is forced directly downward CONDUCT OF THE SECOND STAGE OF LABOR 325 upon the perineal body, instead of being guided upward and forward toward the vulval opening. Frequently 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 occipito-posterior 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 attempts 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 immediately 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 Ritgen'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 ana'sthesia 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 perineum. The student is warned from attempting to protect the perineum by any method which aims at stripping it back over the presenting part. Such a procedure is useless, even if carried out successfully, and hot infre- quently, while it is being attempted, the head will suddenly shoot past the hand and cause a more or less severe laceration. 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 326 CONDUCT OF NORMAL LABOR the protection of the perineum is concerned, but are dangerous in that they contaminate the hand and throw it out of function in case an emer- gency should arise which calls for its prompt introduction into the genital tract. Many obstetricians introduce one or two fingers into the vagina as soon Fig. 311.—Method of Holding back Head to Protect Perineum. as the head reaches the pelvic floor, so that it may not surprise them by a sudden advance. Such a practice is extremely reprehensible, as it markedly 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 either side 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 far- ther, 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 irregu- lar spontaneous tears. Personally, I see no advantage in the procedure, as my experience is that ordinary perineal tears will heal almost uniformly if properly sutured and cared for. Coils of Cord about the Neck.—Immediately after the birth of the CONDH'T OF THE SECOND STAGE OF LABOR 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 the ves- sels are sometimes 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 the cord be too tightly applied to permit of this procedure, and the head appears congested and suffused, the former should be seized and cut between two aiterv clamps, and the child immediately ex- tracted. Fki. 312.—Traction to Bring about Descent of Anterior Shoulder. 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 without difficulty. Occa- sionally, however, a delay occurs and immediate extrac- tion may appear advisable. To accomplish this the occiput and chin should be seized by the two hands, and downward trac- tion 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 will usually drop 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 axilla?, since by the latter pro- cedure the nerves of the arm may be injured and transient or permanent paralysis result. Indeed, even when the former method of extraction is em- ployed, traction should be exerted only in the direction of 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 328 CONDUCT OF NORMAL LABOR 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 pulsate. In securing it, a ligature of sterilized bobbin should be applied 2 centi- meters from the abdomen of the child and tightly tied; a second 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 twin pregnancies , \ double ligation is essential, for when \ the two foetuses are derived from a \ \ tion, thus indicating that that amount was lost to the foetus by early ligation. Schucking 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 fcetus by tho- racic aspiration, while Schucking held that it was driven into it as a result of the compression of the placenta by the contracting uterus. Hofmeier, Zwei- fel, and IJibemont have also shown that the initial loss of weight in the first few days after birth is usually less after late than after early ligation. I have always practiced late ligation of the cord and have seen no CONDUCT OF THE SECOND STAGE OF LABOR 329 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 com- fortable. Ancesthesia.—We are indebted to Sir James A". Simpson for the intro- duction of anaesthesia into obstetrical practice. He employed ether for this purpose in the year 1847, and replaced it by chloroform after he had dis- covered the aiuesthetic properties of the latter drug. Every one agrees as to the marked benefits derived from ana'sthesia when operative procedures are to be undertaken, but there is still considerable difference of opinion as to the advisability of its routine employment in normal labor. The most popular ana'sthetics 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 incident to chloro- form are markedly reduced at the time of labor, and that only a very few deaths have followed its use under such circumstances. It should, however, be remembered that this immunity is limited to the parturient woman, and does not exist either during pregnancy or 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 settled, but it is nevertheless a fact which has been established beyond per- adventure. Generally speaking, chloroform is preferable in normal labor, for by its use obstetrical ana'sthesia can be rapidly and safely produced; whereas ether, owing to its slower action, does not lend itself so readily to this method of employment. As the result of my experience, I believe that chloroform, when properly administered, is practically devoid of clanger, and should be used whenever there is time for its administration. Of course it is contraindicated when the patient has religious scruples against its use, as well as in those cases in which labor is almost painless. 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 visible at the vulva, or at least until the peri- neum begins to bulge. 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. When the distention of the vulva is at its maximum, obstetrical anaesthesia is not sufficient to abolish the pain, and it is my practice, as the head emerges, to render my patient completely unconscious for the moment by increasing the dose of the drug. By this procedure the woman is saved an immense amount of unneces- sary pain, and at the same time the danger of perineal laceration is dimin- ished. For, if the suffering is minimized, and done away with entirely at the critical moment, the patient will lie still instead of tossing in her bed, 330 CONDUCT OF NORMAL LABOR and there will not be the same danger of the head being suddenly 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 is very small, and rarely exceeds 2 or 3 drams. The administration of chloroform should be deferred as long as pos- sible in the second, and never be resorted to in the first, stage, unless ex- ceptional indications call for its employment. Leaving out of considera- tion 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 administra- tion for a considerable length of time, unless he possesses more fortitude than is generally the case. Against the employment of anaesthetics in labor, it has been urged that they diminish the force of the uterine contractions. This statement is partially correct, for when administered for any great length of time they undoubtedly lead to a shortening of the uterine contractions and to a prolongation of the interval between them, as was clearly 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 ob- jection 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 com- pletion of labor. Again, it has been taught that anaesthesia predisposes to relaxation of the uterus after the expulsion of the placenta, and thus increases the danger of post-partum haemorrhage. 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 certainly tends 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 it should be discontinued unless complete anaesthesia is necessary. It should never be used in the first stage of prolonged labors in the hope of hastening the dilatation 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 anaesthetic 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. Moreover, it should be remembered that after the birth of the child the patient does not enjoy the same immunity as when in active labor. Lumbar Ana'sthesia.—Following the rehabilitation by Bier of the sub- arachnoidal injection of cocaine for the production of anaesthesia of the CONDUCT OF THE SECOND STAGE OF LABOR 331 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, who reported the results obtained in 6 cases in Bumm's clinic in Bale. Since then a number of observers have reported series of cases treated in this manner with cocaine or some of its derivatives, and their work was well summarized by Muller in 1905. From their reports, as well as from observations made in my clinic, there is no doubt that most striking results are obtained in a certain proportion 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 cocaine (1/10 to 1/6 grain) is followed 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. Notwithstanding these very wonderful results, I do not hesitate to ad- vise strongly against the employment of the method, and therefore shall not enter into the details of the technique of making the injection. In fhe first place, the results are not always uniform, a certain number of patients appearing to be absolutely 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, however, are the after-effects, the majority of patients suffering severely from headache and nausea, and frequently from an alarming, but transient, elevation of temperature. In view of their comparatively short duration, such symptoms are usually regarded as a manifestation of intoxi- cation, rather than of infection. The most serious objection to the method is the fact that Hahn, in 1901, reported 8 deaths in 1,708 cases in which its use has been recorded in the literature. No doubt, in several instances 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. Scopolamine-niorphine Anaesthesia.—This method of combating the pain of labor was introduced by Steinbiickel in 1902, and soon tried in this country by 0. M. Greene. The former reported that the hypodermic in- jection of 0.0003 gram of scopolamine 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 dilata- tion of the cervix. Numerous reports have since been made of its more or less satisfactory employment in small series of cases. In 19(>7 Gauss reported its administration in 1,000 cases in Kronig's 332 CONDUCT OF NORMAL LABOR 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 desig- nated as "Diimmerschlaf." In this condition the patient appears to appre- ciate pain at the time, but has no recollection of it later. For this pur- pose he administers 0.0003 gram of scopolamine and 0.01 of morphia hypodermically, and repeats the scopolamine, but not the morphia, once or twice 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 con- dition 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 an- other dose should be administered if she possess any recollection of it thirty or thirty-five minutes later. A very considerable literature has accumulated upon the subject, which was well summarized by Bosse and Eliasberg in 1910, and Lequeux in 1911. The former reported favorable results in 60 per cent, of their cases, while the latter concludes that only about one-half of the authors are thoroughly satisfied with their results. I have had no experience with the method, but conclude from my reading that the maternal results are not uniformly satisfactory, while a considerable number of children are born in an apnceic condition, and often require vigorous efforts at resusci- tation. Hypnotism.—Numerous observers, among whom may be mentioned Leichstein, Cocke, Matwjeew, and others, have reported instances in which labor was painlessly conducted under the influence of hypnotism. Per- sonally I have seen it employed successfully in only a single instance. As a rule, its field of usefulness in obstetrics 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.—M»any authorities recommend the administration of a dram of fluid extract of ergot by the mouth immediately after the expulsion of the placenta, as a prophylactic measure against post-partum haemorrhage. This is usually unnecessary, as the drug is called for only in those cases in which the uterus remains soft and flabby, instead of forming a hard tumor beneath the umbilicus. When its employment is indicated, I always administer it hypodermically, and have found the ergotol prepared by Sharp and Dohme preferable to the officinal fluid ex- tract, inasmuch as it is less likely to produce an abscess at the point of injection. Instead of being inserted just under and parallel to the skin, the needle is plunged deeply into the muscle of the thigh, and from 40 to 60 minims are injected, the dose being repeated if necessary. It should be remembered that such injections usually give rise to a slight but pain- ful induration, which persists for several days, but only exceptionally even- tuates in abscess formation. I must insist once more that 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 CONDUCT OF THE THIRD STAGE OF LABOR 333 uterine contractions, but at the present time it is so employed only by ignorant midwives. The danger lies in the fact that 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 ad- ministration in the third stage of labor, before the expulsion of the pla- centa, cannot be too strongly deprecated, as the resulting tetanic contrac- tion 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 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 rare- ly 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 muscle. Usually its course does not quite follow the median line, but is directed 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 posterior 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, even in the practice of the most competent obstetricians, no matter what precautions may be taken to prevent them; but the frequent occurrence of the complete variety indicates that the method employed for protecting the perineum has been at fault in spontaneous, or that the extraction has been too forcible or 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 various 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 the last-named muscles. When the tear extends up the vagina, the levator ani muscle 24 334 CONDUCT OF NORMAL LABOR is likewise involved; while, in lacerations of the third degree, the sphincter ani muscle and the anterior surface of the rectum are implicated in addi- tion to the structures above named. As has been said, the perineal tear commences, as a rule, at the four- Fig. 314.—Superficial Perineal Tear. Fig. 315.—Deep Perineal Tear. chette and extends obliquely downward and outward from it. But in the very rare cases in which the vulval outlet looks markedly upward, or in which the perineum is extremely resistant and the mechanism of expul- sion faulty, the laceration may begin in the central portion of the peri- neum, when the head appears in an opening which is surrounded on all sides by skin. This is known as a central tear, and is of extremely infre- quent occurrence. Ordinarily, as the head is forced down still farther, the central 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 complete 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 separa- tion of certain fibers of the levator ani muscle, which will later give rise to a marked relaxation of the vaginal outlet. Not infrequently the con- dition, although unrecognized at the time, later gives rise to such aggra- vated symptoms as to call for operation years after the birth of the child. No matter what the degree, the immediate closure of perineal lacerations by suture is urgently indicated. Even slight tears through the fourchette CONDUCT OF THE THIRD STAGE OF LABOR 335 are better repaired than left alone, for if not united by suture they are often extremely painful, and furnish a nidus for infection in case the nurse is lax in her care of the patient. In more extensive tears immediate repair is always necessary, unless the condition of the patient be so serious as to contraindicate 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 pla- centa. 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 introduc- ing the sutures during this period a good deal of time is saved, and the temptation to hasty expression of the placenta is diminished, since the phy- sician has plenty to do while waiting for the fundus to rise up. The mode of repairing the wound- ed perineum differs according as the tear extends only through the peri- neal body or is complicated by lacera- tions of the vagina or rectum. In the first case, the wound should be closed by deep sutures of silkworm gut, which are introduced at least 0.5 centimeter from one margin and car- ried 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 and emerge at a considerable distance from the edges of the wound, for, owing to the marked oedema which frequently develops a day or so later, they are very prone to tear through unless this precaution be taken. They should be placed at inter- vals of about 1 centimeter, and if accurate approximation is not secured in this way superficial sutures should be employed between them. Large curved needles, which can make the entire sweep at 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. As a suture material, silkworm gut should be chosen for deep sutures. Silk sutures are objectionable, as they readily become impregnated with the lochial secretion and are more likely to favor infection of the wound. Ordinary, or even chromicized, catgut is not satisfactory for deep sutures, as it is too rapidly absorbed, owing to the fact that the exposed portions are kept moist by the lochia. The latter is very useful, however, for super- ficial sutures, which are only required to remain for a short time. L Fig. 316.—Complete Perineal Tear. 336 CONDUCT OF NORMAL LABOR 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 Fig. 317.—Needle for Repairing ., . ° , .. , , , . n Perineal Tears. Jts ruptured mucosa united by buried cat- gut sutures. Then the ends of the sphinc- ter 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. The after-treatment of tears of all degrees is comparatively simple, and consists in keeping the wound clean and covered by sterile dressings. Whenever the latter are changed the wounded surface should be washed with a 1 to 4,000 bichloride solution for a few days, and later with one Fig. 318.—Needle Holder. of boric acid. The continuous 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 for binding the legs together, unless the patient is very unruly and refuses to keep still. Catheterization may also 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 advisable to prevent an action for the first three or four days, after which a large high enema of sweet oil should be given, followed by calomel or castor oil by the mouth. The results following these operations are usually very satisfactory, and, when the parts have been correctly approximated, 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 by introducing the sutures close to the margins of the wound and tying them snugly. As a result of this short-sighted policy, however, owing to the oedema which usually follows, the majority of the stitches cut through and become useless, so that union LITERATURE 337 by primary intention becomes impossible. On the other hand, when less attention is paid to the first appearance of the wound, the sutures beino- introduced far from its margins and tied somewhat loosely, excellent re- sults almost always follow. Unfortunately, operations for complete tears are by no means so satis- Fig. 319.—Repair of Perineal Tear Fig. 320.—Same, Sutures Tied. Extending up the Vagina. factory, and, as a general rule, not more than two-thirds of the cases heal by first intention, fn the cases of complete or partial failure a secondary operation is indicated before the patient is discharged from treatment. LITEEATURE Balandin. Ueber den Mechanismus der Dammrisse und der verschiedenen Damm- schutzverfahren. Klinische Vortrage, 1883, St. Petersburg, Heft I, 95-127. Bier. Versuche iiber Cocainisirung des Riickenmarkes. Deutsche Zeitschr. f. Chirur- gie, 1899, li, 361. Bosse und Eliasberg. Der Dammerschlaf. Volkmann's Samml. klin. Vortrage, N. F., 1910, No. 599. Budin. A quel moment doit-on operer la ligature du cordon ombilical? Le Progres Medical, 1S75, decembre; 1876; Janvier. (Obstetrique et Gynecologie, 1886, 1-35.) Donhoff. Ueber die Einwirkung des Chloroforms auf den normalen Geburtsverlauf, etc. Archiv f. Gyn., 1892, xiii, 305-328. Furbringer. Untersuchungen und Vorschriften iiber die Desinfection der Hande des Arztes, nebst Bemerkungen iiber den bakteriologischen Character des Nagel- schmutzes. Wiesbaden, 1888. 338 CONDUCT OF NORMAL LABOR Gauss. Geburten im kiinstlichen Dammerschlaf. Archiv f. Gyn., 1906, lxxviii, 579- 631. Die Technik des Skopolamin-morphium Dammerschlafes in der Geburtshilfe. Zen- tralbl. f. Gyn., 1907, xxxi, 33-38. Gifpard. Cases in Midwifery. London, 1734, 396-398. Goodell. A Critical Inquiry into the Management of the Perinamm during Labor. Amer. Jour. Med. Sciences, 1871, Ixi, 53-79. (!reen. Notes on Obstetrical Therapeutics. Medical News, 1903, Ixxxiii, 692-696. Hahn. Ueber subarachnoideale 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 others auf die Wehenthatig- keit des Uterus. Archiv f. Gyn., 1898, lv, 129-177. Hofmeier. Der Zeitpunkt der Abnabelung in seinem Einfluss auf die ersten Lebens- tage des Kindes. Zeitschr. f. Geb. u. Gyn., 1879, iv, 114-132. Kelly. Hand Disinfection. Amer. Jour. Obst., 1891, xxiv, 1414-1419. Kreis. Ueber Medullarnarkose bei Gebarenden. Zentralbl. f. Gyn., 1900, xxiv, 724- 729. Kronig. Versuche iiber Spiritusdesinfection der Hande. Zentralbl. f. Gyn., 1X94, xiii, 1346-1353. Lequeux. La scopolamine en obstetrique. L'obst., 1911, N. S. iv, 165-234. Matwjeew. Hypnose in der Geburtshilfe. Zentralbl. f. Gyn., 1903, xxvii, 121-122. Muller. Ueber Lumbalanasthesie in der Geburtshiilfe u. Gynakologie. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 169-185. Olshausen. Ueber Dammverletzung und Dammschutz. Volkmann's Sammlung klin. Vortrage, 1X72, Nr. 44. Ribemont. Recherches sur la tension du sang dans les vaisseaux du fcetus et du nou- veau-ne. Archives de tocologie, octobre, 1897. Ritgen. Ueber ein Dammschutzverfahren. Monatsschr. f. Geburtsk., 1855, vi, 321- 347. Schroeder. Lehrbuch der Geburtshiilfe, VII. Aufl., 681. Schucking. Zur Physiologie der Nachgeburtsperiode. Berliner klin. Wochenschr., 1877, xiv, 5, 18. 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. Vorlaufige Mittheilung iiber die Anwendung Skopolamin-morphium- Injektionen in der Geburtshiilfe. Zentralbl. f. Gyn., 1902, xxvi, 1304-1306. Schmerzverminderung in der Geburtshilfe, etc. Leipzig u. Wien, 1903. Tuffier. L 'anesthesie medullaire en gynecologie. Revue de gyn. et de chir. abd., 1900, iv, 683-692. Williams, J. Whitridge. The Cause of the Conflicting Statements Concerning the Bacterial Contents of the Vaginal Secretion of the Pregnant Woman. Amer. Jour. Obst., 1898, xxxviii, 807-X17. Zweifel. Wann sollen die Neugeborenen abgenabelt werden? Zentralbl. f. Gyn., 1878, 1-3. CHAPTER XVI 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 onscf of labor and the return of the generative tract to its normal con- dition ; but in common parlance it is restricted to the five or six weeks fol- lowing 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 circumstances does such marked and rapid tissue metabolism occur without a departure from a con- dition 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, usually VI centimeters (-1 :''\ inches) above the lat- ter. At autopsy, short- ly after labor, it con- sists of an almost solid mass of f issue contain- ing in its center a flat- tened cavity, whose walls are in close ap- position, measure four to five centimeters in thickness, and present a markedly anaunic appearance as compared with those of the pregnant organ. The latter is due, according to Webster and Longridge, to com- pression of its vessels by the contracted and retracted muscular fibers, which at the same time express a considerable portion of the tissue juices. 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 cavitv of the true pelvis, and can no longer be felt above the sym- 339 Fig. 321.—Frozen Section, Showing Uterus Immediately after Delivery (Webster). 340 THE PUERPERIUM physis. It reaches 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 recall- ing 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 degenera- tion during involution, and that large numbers of them completely disappeared. The researches of Sanger have shown, however, that only the excess of protoplasm is removed, and that the actual number of in- dividual cells is not materially diminished. In other words, they under- go 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 autolytic 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 time 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 Csesarean sec- tion, found that the characteristic increase in the nitrogen output was lacking, and 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 anaemia of the "blood-tight" uterus. Longridge, who has studied the metabolism of the puerperium, found that the creatinin content of the urine remained normal, which indicates that none of the uterine nitrogen escapes in that form. As has been said before, the separation of the placenta and its mem- branes occurs in the inner portion of the spongy layer of the decidua, and accordingly a remnant of the latter remains in the uterus after their expulsion. It presents an irregular, jagged appearance, and is markedly infiltrated with blood, especially at the placental site. As the result of hyalin 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 mini- ANATOMICAL CHANGES IN THE PUERPERIUM 341 mal amount of connective tissue, from which the new endometrium is regenerated. The processes concerned in its regeneration have been carefully studied by Friedlander, Kundrat and Engelmann, Leopold, Kronig, and particu- larly by Wormser. The latter has shown that, within two or three days after labor, the portion of decidua remaining in the uterus becomes differ- entiated into two layers—one adjoining the uterine cavity being necrotic, and the other adjoining the muscularis being well preserved. 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 endo- metrium 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 irregular, 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 pe- riod, and even six months after childbirth appears as a slightly elevated pigmented area. In the last month of pregnancy some of the sinuses at the placental site undergo thrombosis, but the process becomes more marked in the latter portion of the second and particularly after the completion of the third stage of labor, although many sinuses never become thrombosed, but are simply compressed by the contracting uterine muscles. The thrombi become organized by the proliferation of the intima of the vessels, and eventually are converted into typical connective tissue. As the non-pregnant uterus requires a much less abundant blood sup- ply than the pregnant organ, it is apparent that the lumina of its various arteries must undergo a certain amount of constriction. Formerly it was thought that this was brought about by a compensatory endarteritis, which disappeared in subsequent pregnancies. Now, however, the prevailing be- lief is that the larger vessels are completely obliterated by hyalin changes, and that new and smaller vessels develop in their stead. The absorption of the hyalin material is accomplished by processes similar to those ob- served 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, and Biittner. Changes in the Cervix, Vagina, and Vaginal Outlet.—Immediately af- 342 THE PUERPERIUM ter the completion of the third stage, the cervix is represented by a 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 what remains of the con- traction 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 contraction ring (Fig. 322). Fig. 322.—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; O.I., internal os. 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 repre- sented by a large, smooth-walled passage, which gradually diminishes in size, though it rarely returns to its virginal condition. The ruga' begin to reappear about the third week. The vaginal outlet is also markedly distended, and frequently bears signs of more or less extensive laceration. The hymen, as such, has disappeared, and its place is taken by a number of small tags of tissue, which, as the process of cicatrization goes on, become converted into the caruncuhe myrtiformes, which are character- istic 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 tliese changes are taking place in the uterus and vagina, the pelvic peritoneum and the CLINICAL ASPECTS OF THE PUERPERIUM 343 structures of the broad ligaments are accommodating themselves to the changed condition of affairs. For the first few days after labor the peri- toneum covering the uterus is arranged in folds, which soon disappear. The broad and round ligaments are much more lax than in the non-preg- nant condition, and require considerable time to recover from the stretch- ing 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. Fxcept 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 markedly impaired they never regain their original con- sistency, 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 peri- toneum, 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 Puerperium.—Post-partum, 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 purely 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 or the recrudescence of a malarial attack. Temperature.—The temperature should remain practically normal dur- ing the puerperium; hence any considerable rise should always be consid- ered as a sign of infection, until convincing evidence to the contrary can be adduced. Occasionally the temperature may become slightly elevated toward the end or just after the completion of a difficult labor, but rarely goes above 100.4° F. (38° C), usually falls to normal within twelve hours, and does not rise again. A higher temperature during labor in all proba- bility indicates infection of 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- nate as normal all puerperia in which the temperature remains below 100.4°F. (3K°C), and as febrile all those in which that limit is reached or exceeded, even upon a single occasion. It was formerly believed that the establishment of the lacteal secretion on the third or fourth clay 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 phe- nomenon. But 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 look for the errors of technique which may have led to it. Pulse.—During the puerperium the pulse is usually somewhat slower 344 THE PUERPERIUM 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 not infrequently 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, un- less it can be accounted for by haemorrhage 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 clays before, as well as after, labor, it will usually be found slightly quicker in the puerperium than during pregnancy. Yarnier's investigations failed to confirm Heil's 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 at- tempt to explain its mode of production, but none of them are 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 utero-placental circulation. Kehrer attributed the slowing in great part to the lowering of the blood pressure following delivery; Schroeder, to the sudden diminu- tion of the vascular area after the utero-placental 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, to the absorption of various products set free in the blood during the in- volution 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 haemoglobin immediately after delivery. This is attributable to the loss of blood at the time, and is usually compensated for within the first week, after which the normal condition is restored. Hofbauer has directed attention to the occurrence of a marked leukocy- tosis occurring during and just after labor. He showed that the leukocytes gradually increase in number from the onset of labor and reach a maxi- mum ten or twelve hours after its conclusion, at which time they are nearly twice as abundant as during pregnancy. Having attained their acme, they CLINICAL ASPECTS OF THE PUERPERIUM 345 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 con- traction and retraction cannot be maintained, and it therefore 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 immediately 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 those who suckle their children. Foul-smelling lochia indicate infection with putrefactive bacteria. In many instances the reddish color is preserved for several weeks, but when it persists for a longer period it indicates imperfect involution of the uterus, or the retention of portions of the after-birth. When examined under the microscope during the first few days, the lochia consist of red blood-corpuscles, leukocytes, fatty epithelial cells, and shreds of degenerated decidual tissue. Micro-organisms can always be demonstrated in the discharge gathered at the vulva, but are not always present when it is obtained from other portions of the generative tract. The investigations of Doderlein, Kronig, Dbderlein and Winternitz, Little, and myself have shown that normally the lochia obtained directly from the uterine cavity do not contain bacteria dur- ing the first few days of the puerperium, but that they occur with increas- ing frequency as it advances. They are not, however, of the pyogenic varieties, except in cases of infection. Kronig has demonstrated that the normal vaginal lochia, although rich in harmless parasites, do not contain pyogenic organisms, with the exception of gonococci. The same investiga- tor also showed that the bacterial flora of the vagina undergoes a marked change during the puerperium, when the bacilli, which predominate 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. Genera! Functions.—The function of the skin is markedly accentuated during the puerperium, as is demonstrated by the profuse sweating which 346 THE PUERPERIUM 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 nightgown drenched with perspiration. It passes off spontaneously and does not require treatment. The appetite is usually diminished during the first few days after la- bor, and the patient experiences very 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 marked relaxation of the abdominal walls and their consequent inability to aid in evacuating the intestinal contents. Urine.—There is a marked increase in the urinary output during the puerperium. More important, however, are the changes in the composition of the urine, which afford an index to the profound changes in metabolism which characterize this period. Almost immediately following labor, the total nitrogen increases to nearly double the amount excreted during preg- nancy, while the ammonia nitrogen shows a steady decrease. The nitrogen output continues at a high level for several days and then gradually falls, reaching normal at the end of ten days or two weeks. As has already been ■■'ndicated, this change is associated with the involution of the uterus. In the majority of eases the examination of specimens of urine, re- moved by catheterization immediately after the completion of the third stage of labor, shows a slight amount of albumin and numerous hyalin casts, even though both may have been absent throughout pregnancv. In a series of patients studied in my service by Little, albumin was 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 31 per cent, of the cases traces of al- bumin persisted for some days, but always disappeared by the end of the second week, unless the patients were suffering from toxa?mia or chronic nephritis. Occasionally a small amount of sugar may be found in the urine during the first weeks of the puerperium, coincidently with the establishment of the lacteal secretion. Careful investigation shows 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 nothing to do with diabetes. JSTey observed it in 77 per cent, of his cases, while MeCann 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—4.69 per cent. For a full discussion of the question the reader is referred to my article on the clinical significance of glycosuria in pregnant 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 investigator noted it in 94 per cent, of his cases, and found that it was most abundant (ARE OF THE PATIENT DURING THE PUERPERIUM 347 after difficult and prolonged labors. He attributes its production to the excessive breaking up of carbohydrates resulting from the increased mus- cular 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 6i/> 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 puerperium, which, according to Cassner, amounts to 4,500 grams in the first week. Heil estimates it at 2.000, and Klemmer at only 900 grams. This ap- parent contradiction is due to the fact that Gassnor'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 docs 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 post-partum haemorrhage. But if it becomes soft and flabby, there is imminent clanger of such an occurrence, unless proper measures are taken at once to guard against it. For this purpose the uterus should be palpated through the abdominal walls immediately after the conclusion of the third stage, and if it is found to be firmly contracted the same mano'uvre should be repeated at intervals of a few minutes. If, howTever, any tendency toward relaxation is detected, the organ should be grasped through the abdominal walls and vigorously kneaded until it remains per- sistently contracted; at the same time ergot should be administered hypo- dermically. In normal cases, even although there may be no tendency toward haemorrhage, the uterus should be palpated at intervals for the first hour after the expulsion of the placenta; but if satisfactory contractions do not occur at once, its behavior should be carefully watched for at least an hour after these have been induced. The physician should never leave the patient immediately after the completion of labor, even if it has been perfectly normal, but should remain within call for at least an hour, so as 348 THE PUERPERIUM to be ready should any complication arise. If the patient has a competent trained nurse, the duty of watching the uterus may be delegated to her; but the physician should not leave the house until he has made a final examination, and is satisfied that all reasonable danger of haemorrhage has passed. 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 bichloride solution. A sterilized 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 neces- sary. The number of pads required in the twenty-four hours varies ac- cording 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 washed with cotton pledgets soaked in bichloride solution. Ordinary sponges should never be used for this purpose. The parts should be washed from above downward, so as to avoid contamination from the rectum. 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. Per- sonally, I am not in favor of its routine employment, as I am of the opinion that it occasionally gives rise to retroversion or retroflexion of the enlarged and soft uterus, especially if it be applied sufficiently snugly to exert compression. This objection, however, does not hold good after the organ has descended into the pelvic cavity—that is, after the tenth day. From this time on a well-fitting bandage can do no harm, and some patients find that it adds considerably to their comfort by supporting the lax abdominal walls when they first begin to sit up. Nor can I find any evidence of its value in restoring the figure, which will gradually return without its use, provided the tonicity of the abdom- inal muscles be retained; but when this is seriously impaired I know noth- ing that will bring about the desired result, although massage and gentle gymnastic exercises during the last week the patient spends in bed may do something toward it. As the dangers to be apprehended from the use of the binder are not great, it is perhaps as well to permit its use by those patients who feel strongly that it will aid in restoring the figure, for if it be forbidden the physician will probably be blamed in case a shapeless fig- ure follows. After-pains.—As after-pains usually occur in multiparae, but only in primiparae when the uterus has been subjected to undue distention, it is not usually necessary to provide for their treatment after the birth of the TARE OF THE PATIENT DURING THE PUERPERIUM 349 first child. On the other hand, after the delivery of a multiparous patient, it is advisable to leave with the nurse several tablets of Vi grain of morphine and 1/150 grain of atropine, with instructions to administer them by the mouth at intervals of four or six hours, if the pains lie 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 pa- tient should be kept in bed for the first ten days, but should be permitted to move freely and to be propped up to eat her meals. During this pe- riod, as a rule, only the immediate members of the family should be ad- mitted 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 cus- tomary, and the patient is encouraged to take plenty of plain nourishing 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 in- tervals. 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, sweet- breads, chicken breast, and wine jelly. On the fourth and fifth days as above, with the addition of birds, steak, chops, baked potatoes, and rice, after which the ordinary diet should be gradually resumed. Temperature—The temperature should be carefully watched during the first week of the puerperium, as fever is usually the first symptom of the on^ct of an infectious process. If the patient be in charge of a trained nurse, it should be taken four times daily—at 8 a. m., 1"2 m., 4 p. m., and \J ovary; while in rare instances both may originate ; ? ^£'ff "*$%&*<<*■ £}! in a single follicle. I&'W £V^/'' Formerly it was generally believed that single- J^/Z-fh * jufx-'•'?:'"' ovum twins were derived from the fertilization of ^b«^\' /MM^'V^ an ovum which presented two distinct germinal \t^w*?3~*&>*»l'y the former, we under- stand the fertilization of two ova within a short period of one another, but not at the same coi- tus; whereas in the lat- ter several months may intervene. Superfecundation is a well-recognized occur- rence in the lower ani- mals, and undoubtedly occurs in human beings, although it is impossible to determine its fre- quency. It is probable Fig. 332.—Fcetus Papyraceus (Ribemont-Dessaignes) that in many cases the two ova are not fertilized at the same coitus, but this can be demonstrated only under exceptional circumstances. It is interesting to note that Dr. John Archer, who was the first physician 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 white and the other a mulatto. In my clinic a colored woman gave birth to twins, one being born dead and the other perfectly healthy. Distinct evidences of syphilis were present in the first child and its placenta, while the second remained per- fectly well some months after its delivery. On questioning the patient, it was ascertained that she had had connection with her husband and another man within a period of a few days, and that the former was under treatment for syphilis at the time. The occurrence of superfcetation has never yet been clearly demon- strated, though its theoretical possibility must be admitted, as long as the uterine cavity has not become obliterated by the fusion of the decidua vera 374 MULTIPLE PREGNANCY and reflexa. As this occurs at the end of the third month of pregnancy, superfu'tation 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 fertil- ized. Still more favorable conditions would be afforded by a uterus duplex. The French authorities consider that such an event has been conclu- sively demonstrated, and many of the arguments which have been ad- vanced in its favor are given by Tarnicr. On the other hand, most English and German authors are somewhat sceptical, 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 in- equality of development. Cases occasionally occur which at first glance appear to bear out the possibility of superfcetation, but, upon closer study, fail to do so. Thus, a physician sent me a specimen which he thought afforded conclusive evi- dence 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 evidently been dead for some time, so that there was but little doubt that each had begun develop- ment at about the same period. Even had both fat uses been alive, the evidence would not have been unassailable, unless both placentae presented identical conditions upon examination; as it is conceivable that some le- sion 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 often happens that the presence of twins in the uterus is unsuspected during pregnancy, and the first intimation which the physi- cian has of the true condition 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 preliminary 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 marked relaxation of the abdominal walls following the birth of the first child, women pregnant 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, and touch. 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 fcetal poles. The detection of three fcetal 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 COURSE OF LABOR 375 which a fcetal heart can be heard, twins should be suspected; but a posi- tive 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. (iauss, 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 pregnancy is in- dicated 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. The presence of more than two children can be predicted with certainty only under very exceptional and favorable circumstances, although Ribe- mont-Dessaignes reports the diagnosis of triplets during pregnancy, and its confirmation at the time of labor. Course of Labor.—We have already referred to the abnormal size of the uterus resulting from the presence of twins, which may be still further increased by hydramnios of one ovum. This may give rise to considerable discomfort, the patient suffering markedly from dyspnoea, pressure symp- toms, and oedema. 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 markedly prolonged. The cord of this child should be cut between double ligatures, as failure to ligate its maternal end may lead to the death of the second child from hemorrhage, if the twins are derived from a single ovum. (ienerally speaking, the membranes of the second child appear at the cervix immediately after the first is born and soon rupture. Its expulsion usually follows the first within half an hour, 75 per cent, of the cases collet ted by Kleinwiichter occurring within this period; while in the re- mainder 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 half an hour, interference is indicated, and the practice formerly in vogue of wait- ing 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 detected and the proper measures taken. The condition of the foetal heart should also be care- fully watched, and delivery immediately effected if it becomes abnormal. 376 MULTIPLE PREGNANCY As a rule the placenta of the first child remains in situ until the com- pletion of labor, but in rare instances it may become partly or completely separated and give rise to haemorrhage. Under these circumstances 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 Leonhardt the following' conditions were noted: First twin. Second twin. Per cent Vertex, Vertex, 38..").'J Vertex, Breech, 21.19 Breech, Vertex, 14.3o Breech, Breech, 10.76 Vertex, Transverse, 8.32 Breech, Transverse, 4.29 Transverse, Vertex, 0.87 Transverse, Breech, 0.77 Transverse, ^-~^z^ Transverse, 0.92 Total ......100.00 When the children are small in size, their pre- senting parts may both at- tempt to enter the supe- rior strait at the same time, and thus mutually interfere with one an- other. This complication is known as collision, and may occur when both chil- dren 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 made to push up the pre- senting 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 condi- tion of affairs carefully studied. Occasionally it will be found advisable to apply forceps to the up- permost child and attempt to drag it past the other. craniotomy upon one child may be indicated. Fig. 333.—Diagram Showing Collision between Heads of Twins. In rare instance COURSE OF LABOR 377 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 impos- sible. Under such circumstances, if the head of the second child cannot lie displaced, the first child should be decapitated, as it must inevitably per- ish during any attempt at extraction; after this the body should be brought away and the second child then de- livered by forceps. In rare instances, the first child may present transversely and be strad- dled 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 determined after most careful examination under anaesthesia with the entire hand in the uterus, as the second child cannot be born until the deliverv of the first has been effected. The condition may call for version or decapitation, according to the exigencies of the individual case. Owing to previous overdistent ion, the uterus not infrequently fails to contract and retract satisfactorily during the third stayo of labor, so that ab- normalities in the placental period are not infrequent. If there is any ten- dency 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. Occasionally the area of placental attachment may be so large that abnormalities in its detachment may render necessary its manual removal. This operation, however, should not be resorted to unless urgently indicated. The danger of haemorrhage does not end with the expulsion of the pla- centa, as the uterus sometimes relaxes during the hour immediately follow- ing. Accordingly, the physician should remain in the house for some time after the completion of labor and give his personal supervision to the condition of the uterus, kneading it upon the first indication of relaxation, and reenforcing it by the hypodermic administration of ergot. Neglect in this direction has sometimes led to the death of the patient from post- partum hemorrhage. Fig. 334.—Diagram Illustrating Locked Twins (American Text-Book). 378 MULTIPLE PREGNANCY LITERATURE Ahlfeld. Die Entstehung der Doppelbildungen 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, I, 319-323. Badouin. La grossesse sextuple. Gazette Med. de Paris, 1909, 157-159 and 205-207. Bertillon. Bulletin de la soc. d 'anthropologic de Paris, 1874, ix, 267-290. De Blecourt u. Nijhoff. Fiinflingsgeburten. Groningen, 1904. 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. Gache. La fecondite de la femme dans 66 pays. Buenos Aires, 1904. Gauss. Ein neues Zeichen fiir die Diagnose der Zvvillingsschwangcrschaft. Zentralbl. f. Gyn., 1910, 1281-1296. Hellin. Die Ursache der Multiparitat der uniparen Tiere, etc. Munchen, 1895. Holzapfel. Zur Pathologie der Eihaute. Beitrage z. Geb. u. Gyn., 1903, viii, 1-32. Klien. Ueber mchreiige Graaf'sche Follikel beim Menschen. Miinchener med. Abhandlungen, 1898, IV. Reihe, Heft 4. Klein wachter. Die Lehre von den Zwillingen. Prag, 1871. Larger. Les stimates obstetricaux de la degenerescence. These de Paris, 1901. Leonhardt. Ueber die Kindeslagen bei Zwillingsgeburten. I). I., Berlin, 1897. Mirabeau. Ueber Drillingsgeburten. Miinchener med. Abhandlungen, 1894, IV. Reihe, Heft 5. Patellani. Die mehrfachen Schwangerschaften, etc. Zeitschr. f. Geb. u. Gyn., 1896, xxxv, 37.'! 413. Pinard. Quoted by Kibemont-Dessaignes. Prinzing. Die Haufigkeit der eineiigen Zwillinge. Zeitschr. f. Geb. u. Gyn., 1908, lxi, 296-308. Pueoh. Des grossesses multiples, etc. Paris, 1873. Ribemont-Dessaignes et Lepage. Precis d'Obstetrique, 1894, 864-897. (Grossesse gemellaire.) Saniter. Drillingsgeburten. Eineiige Drillinge. Zeitschr. f. Geb. u. Gyn., 1901, xlvi, 347-3K5. Schatz. Die Gefassverbindimgen der Placentakreislaufe eineiiger Zwillinge, ihre Entwickelung und ihre Folgen. Archiv f. Gyn., 1882-1900, Bde. xix, xxiv, xxvii. xxix, xxx, liii, lv, 1 viii und lx. Sobotta. Neuere Anschauungen iiber die Entstehung der Doppel-(miss) -bildungen, etc. Wiirzburger Abhandlungen, 1901, Bd. 1, Heft 4. Sonntag. Veischlingung u. Knotenbildung der Nabelschniire. D. I., Leipzig, 1905, Tarnier et Chantreuil. Des grossesses multiples. Traite de l'art des accouche ments, Paris, 1888, t. i, 543-563. Veit, G. Beitrage zur geburtshulflichen Statistik. Monatsschr. f. Geburtsk., 1855, vi, 126-132. Viardel. Anmerkungen von der weibiichen Geburt. Frankfurt, 1676, 21. Wappaeus. Allg. Bevolkerungsstatistik. Leipzig, 1859. SECTION V OBSTETRIC SURGERY CHAPTER XIX INDUCTION OF ABORTION AND PREMATURE LABOR—ACCOUCHEMENT FORCE Preparations for Obstetrical Operations.—Owing to the increased ma- nipulation within the generative tract incident to an obstetrical operation, any lack of cleanliness entails even more risk than in the case of normal labor. Accordingly, the maintenance of a rigid aseptic technique is as absolutely imperative as in major surgical operations. The hands of the operator and his assistants should be thoroughly Fm. 335.—Showing Patient at Edge of the Bed, with Legs Held in Position by Leg-Holder. 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 379 380 INDUCTION OF ABORTION AND PREMATURE LABOR essential even for the conduct of normal, and consequently no argument need be advanced as to their necessity at operations. A sufficient quantity of dressings, towels, gauze, absorbent cotton, and ligatures, carefully sterilized beforehand, should be in readiness. All in- struments should be rendered sterile by boiling immediately before the operation. As an emollient, vaseline, which has been sterilized by boiling in small jars, will serve every purpose. The pubic hairs should be shaved, and the external genitalia thor- Operation. oughly cleansed with green soap and hot water, rinsed oif with sterile water, freely irrigated with 95 per cent, alcohol and finally with a 1 to 1,000 bichloride solution, and finally covered with a towel soaked in the same, which should remain in place until the operation is begun. Disinfection with tincture of iodine has not proven satisfactory in my hands, as in some patients it leads to intense irritation, which may persist for some days. If the woman is uninfected, it is not necessary to attempt to disinfect the vagina by means of antiseptic irrigations or other manipulations. But INDUCTION OF ABORTION 381 if the temperature is elevated, or the patient has been subjected to repeated examinations or attempts at delivery, a vaginal douche of a 1 to 0,000 bichloride solution may be given. Before the sterile dressings are put in place, the bladder should be emptied with a sterile rubber catheter. In the early months of pregnancv, a distended bladder interferes with bimanual manipulations, while at labor it may affect the engagement of the presenting part, and after the birth of the child interfere with the proper conduct of the third stage of labor. Obstetrical operations, with the exception of Cesarean section, are usu- ally undertaken with the patient in the lithotomy position. As the ordinary low beds now in use are very inconvenient for the performance of an opera- tion, it is advisable, even in private practice, to place the patient upon a narrow table: one that will answer the purpose quite satisfactorily is usu- ally to be found in every kitchen, but, if a suitable table is not available, a satisfactory makeshift may be obtained by unscrewing the mirror from a bedroom bureau. Anaesthesia is indispensable for all but the simplest oper- ative 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 lat- ter drug. As soon as the patient is fully under its influence, her but- tocks should be 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 stockings made especially for Ibis purpose, and the abdomen and buttocks covered with sterile towels in such a manner as to leave only the genitalia exposed. To avoid the possi- bility of contamination from the rectum, it is advisable to empty the lower bowel by means of an enema, and then cover the anus with a folded sterilized towel, which can be held in place by a strip of adhesive plaster passed over the buttocks, after which a specially prepared sterile sheet should cover everything except the immediate field of operation. Induction of Abortion.—I>\ this term is understood the artificial ter- mination of pregnancy before the fcetus has attained viability—namely, prior to the twenty-eighth week. The operation dates from the most re- mote antiquity, and more or less accurate directions for its performance are to be found in the earliest writings upon medicine. It was so exten- sively practiced in Koine that we find it repeatedly referred 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 full historical details the reader is referred to the works of Levin and Brenning, Brouardel, and Kleinwachter. Indications.—Three groups of cases may offer an indication for the operation. Thus we may think it our duty to induce an abortion: (1) As a direct means of saving the life of the mother; (2) to do away with a condition which may threaten her life if gestation continues; and (3) to avoid certain clangers which may supervene if pregnancy is allowed to progress to full term. 27 382 INDUCTION OF ABORTION AND PREMATURE LABOR Under no circumstances should an abortion be undertaken, unless a careful and thorough examination has demonstrated that the patient is in a really serious condition. Her statements are entitled to but little weight, and the decision to interfere should be based entirely upon objective symptoms and conditions. Moreover, it should never be clone without a consultation with a second physician, who assumes his share of the respon- sibility. This precaution, besides securing for the patient additional advice, will protect the physician from a possible blackmailing on the part of un- scrupulous persons. In the first group, the best-recognized indication for the operation is afforded by pernicious vomiting of pregnancy. In most instances this con- dition is neurotic in origin and can be cured by appropriate measures, particularly by a modified rest cure, dietetic treatment, and suggestion. More rarely, however, the vomiting is a manifestation of a profound toxae- mia, as will be described in the chapter on the toxaemias of pregnancy. If the latter diagnosis be established, and the condition prove refractory to treatment, the prompt induction of abortion is urgently demanded. 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 most cases the vomiting ceased spontaneously, or was re- lieved by treatment. For this reason, the operation was frequently post- poned until the condition of the patient had become so serious that death was the inevitable consequence, whether abortion was induced or not. Now that we know more about it, such delay is not justifiable. The induction of abortion is likewise urgently indicated when the uter- ine contents have become infected, a condition which frequently follows at- tempts 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 clean- ing its cavity. Formerly it was believed that abortion should be induced for incarcera- tion of the retroflexed pregnant uterus, as well as in the rare cases of hernia of that organ, inasmuch as death is the usual result if the patient be left to herself. At present, however, better results are obtained in the former condition by performing laparotomy, freeing the uterus'from adhesions and replacing it in a normal position, after which pregnancy may pursue an uninterrupted course. In the second group, marked renal insufficiency or acute nephritis may necessitate the operation. But inasmuch as such conditions usually develop later in pregnancy, they will be considered when we take up the induction of premature labor. Diseases of the ovum, such as hydatidiform mole, occasionally afford an indication for the operation. Whenever this condition is diagnosticated the uterus should be emptied at once, no matter what be the period of pregnancy, as under such circumstances the fcetus is either dead or very imperfectly developed, and, if the diseased chorion be allowed to remain in the uterus, a chorio-epithelioma may develop. Uterine haemorrhage in the early months of pregnancy is generally a INDUCTION OF ABORTION 383 sign of beginning spontaneous abortion, but if the loss of blood continues for some time, and is not followed by expulsion of the ovum, the uterus should be emptied artificially. The rare cases of missed abortion, in which the ovum is retained for weeks or months after the death of the embryo, demand that the uterus should be emptied as soon as a satisfactory diagno- sis is established. The indications in the third group are afforded by markedly contracted pelvis or tumor formations, and pulmonary tuberculosis. Formerly, the induction of abortion at an early period was considered justifiable when the pelvis was so contracted as to present an absolute indication for Caesar- can section ; but at present, in view of the excellent results which attend the latter operation, this view is no longer held. The same applies when preg- nancy is complicated by the presence of uterine myomata. If the symptoms are urgent, hysterectomy should be performed without regard to the exist- ence of pregnancy; but if the tumor promises to act merely as a mechanical obstacle to labor, pregnancy should be allowed to go on to term, and (Cesar- ean section then performed, followed by removal of the uterus. Ovarian tumors complicating pregnancy do not call for the induction of abortion, but should be removed by laparotomy as soon as the diagnosis is made. In many such cases this can be done without causing interruption of the pregnancy, and spontaneous delivery will occur at term. The induction of abortion is not indicated in malignant growths in- volving the uterus or adjacent organs. In carcinoma of the cervix, the treatment to be pursued differs according to circumstances. If the con- dition be operable, immediate hysterectomy is indicated without regard to the presence of pregnancy; but if the disease has progressed 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 pro- gresses much more rapidly after child-bearing, it is advisable that tuber- culous women take every precaution to avoid the possibility of conception. If this occurs, however, it is the duty of the physician to induce abortion, 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 interference is not only justified, but is almost imperative, in a first pregnancy, 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 at least arrested. Methods of Inducing Abortion.—The methods of inducing abortion vary according to the duration of pregnancy. In the first four months the opera- tion can frequently be completed at a single sitting, if necessary, whereas between this period and the seventh month the methods employed for the in- duction of premature labor are more appropriate. In the first period, if the cervix is somewhat softened, it can usually be sufficiently dilated by means of (JoodelPs or Hegar's dilators to admit one finger. The entire hand, 384 INDUCTION OF ABORTION AND PREMATURE LABOR 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. With the finger within the uterus the placenta is separated from its attachments, after which, accord- ing to the duration of pregnancy, 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. To attempt to empty the uterus blindly by means of a curette and ovum forceps is an unwise procedure, inas- Fig. 337.—Goodell's Dilator. much as many cases are re- ported in which such opera- tions have caused perforation. Still more frequently larger or smaller por- tions of the placenta are left behind in the uterus, giving rise by their presence to serious haemorrhage 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. Accordingly, one can never feel sure that the operation is complete, unless one or more fingers have been introduced into the uterus and carefully palpated its interior. In many cases, and 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. Under such circumstances, if haste is not im- perative, a strip of sterile gauze may be tightly packed into the cervical canal and the vagina C=^ firmly tamponed with the same fig. 338.—Ovum Forceps. material. When the pack is re- moved at the end of twenty-four hours, the entire ovum will frequently follow it; while in other cases the cervix will be sufficiently softened to permit the introduction of the finger, or at least of its dilatation with a suitable instrument. The employment of a laminaria tent has been recommended by many authorities, and affords an efficient means of slow dilatation, but, as it cannot be sterilized satisfactorily, its use adds greatly to the risk of infection. On the other hand, when rapid dilatation is out of the question, 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 Ca^sarean Section. Abortion is sometimes induced by perforating the membranes with a sterile sound and allowing the liquor amnii to drain off. The desired result, however, does not always follow this manoeuvre, and it frequently becomes necessary to supplement it by one of the procedures just described. INDUCTION OF PREMATURE LABOR 385 In the early months of pregnancy exposure to the action of the Rontgen ray sometimes leads to the death and subsequent extrusion of the betas. I'eill'erscheid, however, states that the method is not applicable to the in- duction of therapeutic abortion, as repeated exposures are required and even then the result is not assured. 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 technique is observed. In my hands vaginal hysterotomy has proved a much more satisfactory and less dangerous procedure than forced instrumental dilata- tion 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 per- formed by Cluillemcau, Mauriceau, Justine Siegemundin, and others in isolated cases for haemorrhage, but, according to Denman, it was not gen- erally advocated until 1750, when a conference of physicians was held in London to devise means for doing away with the frightful mortality then following' (Cesarean section for contracted pelves. Indications.—The indications for the operation are twofold: to obviate the dangers attending delivery at term through a contracted pelvis, and to save the life of the mother, when seriously threatened by some disease from which she may be suffering, or on account of some pathological con- dition existing in the ovum. In contracted pelves, 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 performed, but it must be remembered that the child will be less liable to survive, and, even if born alive, its chances of succumbing to complications after its birth will be proportionately greater. Inasmuch, then, as the later the operation the better the outlook, so far as the child is concerned, the induction of pre- mature labor should not be attempted before the thirty-fourth, and pre- ferably not before the thirty-sixth, week of pregnancy. The question as to the propriety of the operation has given rise to an extensive literature. At the International Medical Congress of 18!)0, held in Berlin, 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 fol- lowing the classical Casarcan section, and the development of pubiotomy and extra-peritoneal Cesarean section, a marked change in sentiment has occurred, and the induction 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 pronounced de- formity which require radical interference, will end spontaneously if treated expectantly. With this fact in mind Pinard, Bar, Kronig, myself, and 386 INDUCTION OF ABORTION AND PREMATURE LABOR 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 subjecting the patient to a test of the second stage of labor, and resorting to Caesarean section or pubiotomy should na- ture prove herself inefficient. Following these principles, 829 cases of contracted pelvis of all grades were treated in my clinic up to July, 1910, and 74.76 per cent, of the patients were delivered spontaneously. Three-quarters of the operations were necessary on account of the pelvic contraction, while the remaining quarter were performed for non-pelvic indications. 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 patient, or died from such extraneous causes as syphilis, broncho-pneumonia, etc., the net fcetal mortality due to the pelvic contraction was 4 per cent. The principal difficulty connected with the induction of labor is to recog- nize the cases which will require it, and to choose the correct time for its performance, since we are unable to determine accurately the size of the child's head. The methods of Muller, Ahlfeld, and others, to which refer- ence will be made in the chapter upon the treatment of contracted pelves, do not lead to very accurate results, so that the operation is frequently per- formed unnecessarily, or, owing to the desire of postponing it until the latest possible moment, it is not undertaken until the child's head has attained such proportions as to render its passage through the pelvis diffi- cult or impossible. The results obtained are extremely satisfactory so far as the mother is concerned, the maternal mortality being only 1.03 per cent, in 391 opera- tions performed by Ahlfeld, Bar, Leopold, and Pinard. On the other hand, the foetal mortality is relatively high, varying from 45 to 12 per cent., ac- cording to the statistics from various lying-in hospitals. Kleinwachter, after an exhaustive study of the subject, concludes that 78.3 per cent, of the children are born alive, but that many of them die soon after birth, and only 60.4 per cent, leave the hospital in good condition. According to these fig- ures, then, the net mortality would be 39.6 per cent.; but when we consider that most 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 born alive survive that period. It would, therefore, appear that the ultimate results, so far as the children are concerned, are 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 cra- niotomy whenever operative delivery became necessary. As this would be a manifest absurdity, it follows that the operation should be abandoned. In my entire experience, I have employed it in only one case of contracted pelvis, and have no cause to regret my action. It must, however, be ad- mitted that all authors do not share this view, as Norris, Herff, and others contend that their results are fairly satisfactory. INDUCTION OF PREMATURE LABOR 387 At the present time, then, it seems to me that the only rational indica- tion for the induction of premature labor, so far as concerns the existence of disproportion between the size of the head and the pelvis, is afforded by the rare cases in which the pelvis is normal but the child abnormally large, owing either to excessive development or to an undue prolongation of pregnancy. If excessive development be detected some time previously to term, the operation is clearly indicated, and the same holds good in the exceptional cases of prolonged pregnancy, provided the child appears to be fully developed. 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 gestation. This is particularly true in those cases of toxainia or acute nephritis complicat- ing 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 proportion of the children are born dead, or, if alive, very imperfectly developed. Moreover, one should also take into consideration the possibility that the renal changes may become chronic. Accordingly, if threatening symptoms supervene, labor should be induced at any period of pregnancy without too conservative a regard for the life of the child. In patients presenting toxemic symptoms, the total amount of albumin and urea contained in the twenty-four hours' urine should be determined daily, and whenever there is a steady increase in the amount of albumin and a corresponding decrease in the amount of urea, in spite of appro- priate treatment, labor should be induced in the hope of preventing the onset of eclampsia. If eclampsia supervenes, pregnancy should be ter- minated as soon as possible by accouchement force, provided the medical attendant is a competent operator. Cardiac lesions occasionally demand the induction of premature labor, but this should be resorted to only in cases of broken compensation, which do not yield to appropriate treatment. 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—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 alcoholic origin in which the induction of labor was followed by most happy results. The milder forms of chorea complicating pregnancy are usually readily amenable to treatment, but when the disease assumes a grave type it is attended with great danger, the maternal mortality, according to Fehling, 388 INDUCTION OF ABORTION AND I'WEMATURE LABOR 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 marked improvement. In patients suffering from true diabetes, gestation sometimes exerts a very deleterious influence upon the course of the disease. Accordingly, if the patient's condition becomes alarming, labor should be induced. In the majority of cases, however, the so-called diabetes of pregnancy is merely a lactosuria which is not likely to be attended by serious symptoms, the patients being spontaneously delivered of healthy children at term. According to Craefe and others, the occurrence of pregnancy in patients suffering from pernicious anceuiia or leukamiia 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 discharge, and thus give rise to a pyelo-nephrosis. In such circumstances the induction of premature labor is indicated. In several cases under my care interference was followed by surprisingly good results, the patients recovering without further treatment. Formerly the induction of premature labor was recommended when pregnancy is complicated by uterine or ovarian tumors, or by malignant disease of the uterus or rectum, which would offer an insuperable obstacle to the birth of a full-term child. At the present day, however, the opera- tion can hardly be considered justifiable. What has already been said in connection with the induction of abortion under similar condition also holds good here. In hydramuios, when the abdomen is so distended as to seriously threaten the life of the patient, pregnancy should be terminated without too much regard for the preservation of the child, as in many cases it is so poorly developed as to have but little chance of living, even if born at full term. In cases of hydatidiform mole alarming symptoms usually come on before the fcetus is viable; but even should the twenty-eighth week be safely passed the immediate termination of pregnancy is imperatively demanded. Whenever placenta prwvia is positively diagnosed, the termination of pregnancy is urgently indicated, as it is impossible to predict at what moment uterine contractions may conic on and give rise to profuse or even fatal haemorrhage. 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 fcetal death has occurred in previous pregnancies, in the hope that a living child may be obtained. In such cases the operation may be under- taken 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. Prognosis.—As far as the mother is concerned, the prognosis of the induction of premature labor is excellent, provided a rigorous aseptic INDUCTION OF PREMATURE LABOR 389 technique is observed and her 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 inter- ference. Methods of Inducing Premature Labor.—The simplest method—that of Scheele—consists in perforating the membranes with a sharp instru- ment and allowing the amniotic fluid to drain off. The results, however, are uncertain, so that the procedure is applicable only in a very limited number of cases, more especially in hydramnios, and in marginal placenta pnevia. In the method most usually employed—that of Krause—a bougie is introduced between the membranes and the uterine wall. In earning 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 passed through it and gently carried high up into the uterine cavity, between the membranes and the uterine wall. In place of bougies, I prefer thick-walled rubber catheters, 8 to 10 millimeters in diameter, which can be readily sterilized by boiling. They should be introduced by means of a copper stylet, which is withdrawn after the catheter is in place. The only objection to Krause's method is its uncertainty. In many cases the introduction of a single catheter is followed by uterine contrac- tions within a few hours, which lead to the expulsion of the betus after a longer or shorter period. Not infrequently, however, twenty-four hours may elapse without the appearance of pains. In such circumstances a second or third catheter should be introduced. In rare instances even then the desired result is not accomplished, and it becomes necessary to terminate pregnancy in some other manner. But for the general practitioner, when haste is not essential, this is the safest and best method of procedure. More certain and rapid results are obtained by the use of inflatable rubber balloons. Those of Champetier de Ribes are conical rubber bags with reenforced walls, from whose small end extends a thick rub- ber tube provided with a stopcock. They are made in several sizes, the largest having a capacity of 400 to 500 cubic centimeters. The patient having been placed in the dorsal or Sims's position, the cervix is brought into view. If its lumen 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 then tightly rolled into a cylinder, seized with an appropriately shaped forceps, thickly smeared with sterile vaseline, introduced into the lower uterine segment, and then pumped full of sterile salt solution. Within a few hours it usually so irri- tates 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 ex- 390 INDUCTION OF ABORTION AND PREMATURE LABOR tracted or labor allowed to end spontaneously, according to the exigencies of the case. Where greater haste is necessary, the dilatation may be acceler- ated 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 satis- When the cervix is but slightly dilated, the use of a sterile tampon may be attended by most excellent results. In such cases, under the most rigid aseptic precautions, 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 not be allowed to remain in place for more than twelve hours, and on its removal at the expiration of that period the cervix will be found sufficiently dilated to permit of other manoeuvres. 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 consisted in the injection of 200 to 300 cubic centimeters 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 glycerine, which promptly gives rise to uterine contractions. Its employment, however, is not to be recommended, as it is occasionally followed by serious symptoms of intoxication, haemoglobmuria, albuminuria, elevation of temperature, cyanosis, and occasionally by death. Pfannenstiel was the first to call attention to these dangers, and his warning has been reenforced by similar experiences in the practice of other writers. Full details respecting the various other methods suggested for the indue- ACCOUCHEMENT FORCE 391 tion of premature labor will be found in the monographs of Kleinwachter, Fieux. and Williamson. Accouchement Force.—By this term is understood the forcible dilata- tion, or 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 fell into deserved disrepute; but Fig. 341—Vaginal and Cervical Pack in Position. at the present day it has 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 operation will be found in the disser- tation 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, and its resistance can be better overcome by a cutting operation. On the other hand, when the cervix is soft and its canal practically obliterated, rapid dilatation is readily performed, and is followed by most 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 accouche- ment force is threatened or actual eclampsia. Occasionally it becomes necessary in concealed or accidental haemorrhage, or in other conditions which threaten the life of the mother or child, such as acute oedema of the 392 INDUCTION OF ABORTION AND PREMATURE LABOR lungs, or broken cardiac compensation. It should, however, not be em- ployed in placenta prawia. Manual Dilatation.-—If labor has already begun, the cervical canal is obliterated, and the resistance offered only by the external os, most ex- cellent 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 hard and rigid, the operation is both difficult and dangerous; and if the attempt at dilatation be forcibly persisted in, it frequently 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 haemorrhage or in- liG. 342.—Diagrams Illustrating Manual Dilatation of Cervix (Harris). fection. Generally speaking, unless the cervix is soft and yielding, and its canal at least partially obliterated, delivery should be effected by vaginal hysterotomy. At the time of operation the patient should be profoundly anaesthetized and the aseptic technique most rigorous. The danger of contamination from the faeces can be minimized by moving the bowels freely by means of a rectal enema, and then applying over the anus a sterile towel, which is held in place by strips of adhesive plaster until the completion of the various manipulations. One hand, thoroughly anointed with sterile vaseline, is then introduced into the vagina, and 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 thumb is pushed past the index finger with much the same motion as is employed in snapping one's fingers; then, as dilatation progresses, pass two, three, and finally all four fingers. These manoeuvres are clearly shown in Fig. 342. When the internal os is obliterated, complete dilatation of the cervix can be readily effected by Harris's method; and satisfactory results obtained within half an hour. I employed this method 83 times in the first 5,000 ACCOUCHEMENT FORCE 393 cases delivered in the Johns Hopkins Hospital, and found it very effective, and am able to confirm all that Harris has claimed for it. It should, how- ever, be remembered that it is not devoid of clanger, and even in suitable cases may lead to deep cervical tears. From my own experience, its use is 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 cervical tears 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 overestimate the time consumed in the process, and from my own experience 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 such a tendency by watching the clock, as one should judge of the excellence of an obstetri- cian under such circumstances 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 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. Dilatation by Means of Champetier de Ribes's 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 particularly indicated in cases of placenta pnevia, 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 effect the rapid and complete dilatation of the cervical canal, but to my mind none of them are as satisfactory as manual dilatation. Leopold, in 1902, introduced into Germany the use of Bossi's powerful 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 two years later his assistant, Ehrlich, reported 17 cases in which it had been used in his clinic. This hearty indorsement led to its trial, in various modifications, in all parts of the world; but the verdict concerning it is not unanimous, as Bardeleben, Lewis, Bar, and many others hold that it is a most dangerous instrument, and readily leads to deep cervical tears. I have had no experience with its use; for, while there can be no doubt as to its dilating power, it seems to me that its sphere of usefulness is very limited. If the cervix is undilated and rigid, its employment must be dangerous; whereas, on the other hand, when the resistance of the inter- nal os has already been overcome, equally satisfactory results may be ob- tained by other methods. Moreover, if cervical tears cannot be entirely avoided in manual dilatation, when the resistance of the cervix can be 394 INDUCTION OF ABORTION AND PREMATURE LABOR accurately gauged by the operating hand, they must occur far more fre- quently 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, Nf. 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 technique of the operation is com- paratively 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 haemorrhage and prove most difficult to repair. Vaginal Caesarean Section.—This operation, which is better designated as vaginal hysterotomy, was first described by Diihrssen in 1800, 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 the ideal method for rapidly terminating pregnancy whenever the cervix is undilated and rigid, and is far superior to brutal attempts at manual or instrumental dilatation. Unfortunately, it requires considerable surgical skill on the part of the operator, as well as specially devised specula, and the aid of several trained assistants, so that its use must be limited to hospital practice or 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 incision made through the anterior vaginal wall from a little above the urethra to the anterior lip of the cervix (Fig. 343). The bladder is then separated from the entire anterior surface of the uterus by means of a finger cov- ered by a piece of gauze. The first part of the separation is done by touch alone, but later a large retractor, such as that of Prvor, 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 above 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. 344), and, after removing the speculum, the hand is introduced into the uterus, ruptures the membranes, and turns the child. After its extrac- tion and the expression of the placenta, the speculum is again introduced, and, by making the traction sutures taut, the entire wound becomes 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. 345). VAGINAL CESAREAN SECTION 395 The anterior incision affords sufficient space for the extraction of the child up to the eighth month of pregnancy, but after that period a pos- terior 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 off the peritoneum from the posterior 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 suboccipito-bregmatic circumference of the fully developed head measures Fig. -'MA—Vaginal Cesarean Section. Exposure of Cervix and Primary Incisions. 32 centimeters, so that if only an anterior incision is made, it must meas- ure 15 to 16 centimeters in length to permit the passage of the head without laceration of its upper end; whereas if the incisions are double, each re- quires to be only half so long. In the latter event, the posterior wound should be closed first. In competent hands this operation permits the delivery of the child in ten minutes or less, no matter what the condition of the cervix, and the entire operation requires but thirty to forty minutes for its completion. Us 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 396 INDUCTION OF ABORTION AND PREMATURE LABOR median line, the amount of haemorrhage 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 em- ployed is too small to give a suitable exposure of the field of operation; and, second, that the incision is either too short or not in the mid-line of the uterus. In the latter event laceration occurs at its upper end and extends obliquely outward, giving rise to profuse haemorrhage. Diihrssen Fig. 344.—Vaginal Cesarean Section. Incision of Anterior Uterine Wall after Separation of Bladder. pointed out that there was a tendency to relaxation of the uterus after the operation, and advised that the cavity be packed with gauze as a prophy- lactic 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 technique of the operation could be facilitated by introducing a medium-sized rubber balloon into the uterus, 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. The merits of the operation were discussed at the 1905 meeting of the German Gynaecological Congress, when the consensus of opinion was in VAGINAL CESAREAN SECTION 397 its favor, Bumm stating that he had performed it in 52 instances. Mv own favorable opinion is based upon 50 operations performed in my service up to January, 1912. Peterson advocates it enthusiastically, and Winter reported to the International Medical Congress held at Budapest that the mortality was only a trifle over 1 per cent, in 446 cases which he collected from the literature. A full account of the operation, together with a list of Fig. 345.—Vaginal Cesarean Section. Laying of Sutures in Anterior Incision. Posterior Incision Already Sutured. all cases reported up to 1905, will be found in Diihrssen's article in WinckiUs Handbuch der Geburtshilfe. LITERATUEE Ahlfeld. 118 Falle von Einleitung der kiinstlichen Friihgeburt. Zentralbl. f. Gyn., ]S<)(), xiv, 52!) 5.!4. Lehrbuch der Geburtshiilfe, II. Aufl., 1S98, 498. Bar. Contribution a 1'etude des indications de I'accouchement premature artificial, etc., L'Obstetrique, 1899, iv, 471. L'accouchement par dilatation rapide du col. L'obst., 1909, N. S., ii, 629-651. Bardeleben. Spiitfolgen des Entbindungs-verfahrens mit schneller instrumentellen Muttermundserweiterung. Archiv f. Gyn., 1904, lxxiii, 187-226. Bonn'aire. De I'accouchement inethodiquement rapide. Presse med., 1909, Nos. 66 and 67. 28 398 INDUCTION OF ABORTION ANI) PREMATURA LABOK Brouardel. L'avortement. Paris, 1901. Bumm. Ueber die Methoden dur kiinstlichen Erweiterung des schwangeren u. kreis- senden Uterus. Verh. d. deutschen Gesell. f. Gyn., 1906, xi, 54-68. Burger. Die Bedeutung der Hystereuryse in der Geburtshiilfe. Archiv f. Gyn., 1906, Ixxvii, 4S5-556. Champetier de Ribes. De I'accouchement provoque. Annales 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. Dohrn. See Parvin. D'Outrepont. Beobachtungen u. Bemerkungen. Gemeinsame Zeitschr. d. Geburtsk., 182S, 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 Geburtshilfe 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. Trans. Am. Gyn. Soc, 1906, xxxi, 108-115. Ehrlich. Zur schnellen Erweiterung des Muttermundes nach Bossi. Archiv f. Gyn., 1904, Ixxiii, 439-543. Fehling. Ein Fall von Chorea gravidarum. Archiv f. Gyn., 1874, vi, 137-139. Fieux. Procedes de provocation et de la terminaison artificielle rapide de 1 'accouche- ment. Annales d'obst. et de gyn., 1901, lv, 409-450. Graepe. Ueber den Zusammenhang der peruiciosen Ansemie mit der Graviditat. D. I., Halle, 1880. Guillemeau. De l'heureux accouchement des femmes. Paris, 1594. Harris. A Method of Performing Rapid Dilatation of the Os Uteri, etc Amer. Jour., Obst., 1894, xxix, 37-49. Herpf. Anstaltsgeburtshiilfe und Hausgeburtshiilfe in ihrem Verhaltniss zur kiinst- lichen Friihgeburt. Monatsschr. f. Geb. u. Gyn., 1906, xxiv, 703-722. Kleinwachter. Die kiinstliche Unterbrechung der Schwangerschaft, III. Aufl., 1902. Krause. Die kiinstliche Friihgeburt. Breslau, 1855. Konig. Wie weit soil das Recht des Kindes auf Leben bei der Geburt gewahrt wer- den. Monatsschr. f. Geb. u. Gyn., 1906, xxiii, 303-329. Leopold (Buschbeck). Beitrag zur kiinstl. Friihgeburt wegen Beckenenge. Arbeiten aus der konigl. Frauenklinik in Dresden, 1893, i, 93-1215. Leopold. (Schoedel). Erfahrungen iiber kiinstliche Friihgeburten, eingeleitet wegen Beckenenge. Archiv f. Gyn., 1901, lxiv, 151-164. Zur schnellen vollstandigen Erweiterung des Muttermundes mittels des Dilatorium von Bossi, etc. Zentralbl. f. Gyn., 1902, xxvi, 489-495. Lepage et Sainton. Accouchement provoque pour un cas de nevrite peripherique alcoholique. Comptes rendus de la soc. d'obst., de gyn. et de paed. de Paris, 1901, iii, 93-99. Levin und Brenning. Die Fruchtabtreibung durch Gifte. Berlin, 1899. Lewis. Bloodless Methods of Artificial Dilatation of the Cervix Uteri at Full Term. Surg. Gyn. and Obst., 1906, iii, 756-76. Lott. Instrumental Dilatation of the Cervix in the Last Months of Pregnancy. Amer. Gyn., 1903, iii, 295-299. Mauriceau. Traite des maladies des femmes grosses, etc. 6me ed., 1721, 161. LITERATURE 3fin 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. Pfannenstiel. Ueber die Gefahrlichkeit der intraut. Glycerineinspritzung. Zen- tralbl. f. Gyn., 1894, xviii, 37-49. Pinard. De I'accouchement provoque. Annales de gyn. et d'obst., 1891, xxxv, 1-16; 81-112. Indication de 1'operation Cesarienne considered en rapport avec celle de la sym- physeotomie et de 1 'accouchement premature artificiel. Annales de gyn. et d'obst., 1899, Iii, 81-117. Reifferscheid. Die Riintgentherapie in der Gynakologie. Leipzig, 1911. Siegemundin. Die konigl. preussische und Chur-Brandenb. Hof-Wehe-Mutter. Ber- lin, 1756, 216. Williams. The Induction of Premature Labor and Accouchement Force 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. Williamson. The Induction of Premature Labor. Jour. Obst. and Gyn. Brit. Emp., 1905, viii, 252-271. Winter. Beeiuligung der Geburt durch rasche Erweiterung des CoUum uteri. XVI Congres internat. de med,, 1909, viii, 199.240. 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 latter 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. Cer- tain authorities, however, prefer solid blades in the belief that they can be made less bulky. The cephalic curves should be such as to per- mit the head to be grasped firmly, but without seri- ous 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 forceps is placed upon 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 arrange- ment permits of ready articulation, but does not hold the blades firmly to- 400 Fig. 346.—Simpson's Forceps, Cephalic Curve Fig. 347.—Simpson's Forceps, Pelvic Curve. HISTORY 401 gether. In the French lock a pivot is screwed into the shank of the left branch, while the right presents an opening which can be adjusted to it, the screw being tightened after articulation. The German lock is a com- bination 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 prop- erly articulated the handles should fall to- gether in such a way as to be conveniently grasped by one hand of the operator. Fig. 348.—Lock of English Forceps. Fig. 349.—Lock of French Forceps. History.—Crude forceps were in use from an early period, several varieties having been described by Albucasis, who died in 1112; but, 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 six- teenth, or the beginning of the seventeenth century, by a member of the Cliamberlen family. The invention, however, was not made public at the time, but was preserved as a family secret through four generations, and did not become generally known until the early part of the eighteenth century. Prior to that time version had been the only method which permitted the artificial delivery of an unmutilated child, and, accordingly, when that operation was out of the question and delivery became impera- tive, 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. William Cliamberlen, the founder of the family, was a French physician, who fled from France as a Huguenot refugee and landed at Southampton in Lr)(i!). He died in lf>96, leaving a large family. Two of his sons, both of whom were named Peter, and designated as the elder and younger, re- spectively, 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 proficient. They attempted to control the instruction of midwives, and in justification of their preten- sions 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 distinguish him from 402 FORCEPS 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 Cam- bridge, 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 paper entitled "A Voice in Ramah, or the Cry of Women and Children as Echoed Forth in the Com- passions 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 16K3, the place remaining in the possession of his family until well into the succeeding century. Formerly he was considered the inventor of the forceps, but, as we now know, 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 in- fluential. 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 at- tempted to sell the family secret to Mauriceau for 10,000 livrcs, 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 inability to do so. Notwithstand- ing 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 knowr) have by God's blessing and our own industry 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 Roonhuysen. Shortly afterward the Medico-Pharmaceutical College of Amsterdam was given the sole privilege of licensing physicians to practice in Holland, to each of whom, under pledge of secrecy, was sold Chamberlen's invention for a large sum. This practice continued for a number of years, until Vischer 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 Roonhuysen, 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, re- spected, and philanthropic physician, and numbered among his clients members of the best families in England. He was an intimate friend HISTORY 403 of the Duke of Buckingham, 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. For 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 house- keeper of a rich brewer who had purchased I )r. Peter Chamber- len's country house, found in the garret a trunk containing numerous letters and instruments, among the latter being four pairs of Forceps, to- gether with several levers and fillets. As is evident from the drawings, the forceps were in different Fig. 350.—Chamberlen's Forceps. 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 re- spectively 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 investigated the subject, incline to the same belief. The forceps came into general employment in England during the life- time of Hugh Chamberlen, the younger. The instrument was used by Drinkwater, who died in 1728, and was well known to Chapman and Cill'ard. 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." Fig. 351.—Palfyn's Forceps. In !723 1^1 fyn, a phy- sician of Ghent, exhibited be- fore the Paris academy of Medicine a forceps which he designated as mains de fee. It was crude in shape and did not articulate. In the discussion following its presentation, De la Motte stated that it would be impossible 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 tftttfttBBCfo 404 FORCEPS 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 possessed only a cephalic curve, and is perpetuated in the short or low forceps of to-day. It was Fig. 352.—Smellie's Short Forceps. used, with but little modification, until the middle of the eighteenth century, when Levret, in 1747, and Smellie, in 1751, quite independently 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 instru- ments that the long forceps of the present day is descended—the long French forceps being the lineal de- scendant of the former, and that Fig. 353.__Short Forceps. of Simpson of the latter. As soon as the forceps became public property it was subjected to various modifications, so that Mulder, in his atlas published in 17!)S, was able to give illustrations of nearly 100 varieties. Some idea of the desire to modify and improve the instrument may be gained by glancing at Wit- kowski's Obstet- rical Arsenal, in which are pic- tured several hundred forceps, which, after all, constitute only a Fig. 354.—Long French Forceps (Levret). Small portion of those devised. Poullet's interesting monograph 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 1877, when Tarnier clearly enunciated the principle of axis traction, which has since revolutionized our ideas upon the subject. Choice of Forceps. —Inas- much as it would appear that Fig. 355.—Smellie's Long Forceps. 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 instrument will give satisfactory results, provided it be INDICATIONS FOR THE USE OF FORCEPS 40.1 used intelligently, but for general purposes the ordinary Simpson forceps is probably the best, though, if one expects to do much obstetrical work, a Tarnicr axis-traction forceps becomes essential. IVrsonallv I alwavs em- ploy 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 steril- ized by boiling. Functions of the Forceps.—This subject has been considered in detail by Chassagny. The forceps may be used as a tractor, rotator, compressor. 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, however, particularly in occipito-transverse and posterior presentations, its emplov- nient as a rotator is attended by most happy results. It should never be used primarily as a compressor, though of course it is impossible 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. Certain authors, especially in this country, advocate applying the forceps through a partially obliterated cervix, and assisting dilatation by traction upon the head. Such a procedure, however, is unjustifiable, for, when it becomes necessary to deliver the child under such conditions, the cervix should be stretched manually, and forceps not applied until dilatation is complete. In rare instances one blade of the forceps may be employed as a lever, although at present use is wvy seldom made of this function. Formerly great stress wras laid on the so-called dynamic action of the forceps, by which is meant the irritation of the uterus which follows its introduction. Before the employment of anaesthetics this function was of considerable importance, but at present it 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. On the part of the mother, such conditions are eclampsia, heart lesions attended by broken compensation, acute oedema of the lungs, hae- morrhage from premature separation of the placenta, intrapartum infection. or exhaustion. Whenever there is question of interference for the last- named condition, definite objective symptoms should be present, the condi- tion of the pulse being of especial importance; 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 foetal pulse falling below 100, or exceeding 160 to the minute, indicates that the child is in danger and will perish if not promptly delivered. In vertex presentations the discharge of amniotic fluid tinged with meconium indicates interference 406 FORCEPS with the placental circulation and imperfect oxygenation, manifesting itself bv paralysis of the sphincter ani. In breech presentations, on the other hand, the presence 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 diseases, 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. Occasionally, also it may appear wise to relieve the strain upon a cicatrix resulting from a recent abdominal section. One of the most frequent indications for the operation is afforded by faulty contraction of the uterine or abdominal muscles, the forceps being utilized merely to reenforce the insufficient \is a tcrgo. In occasional in- stances, particularly in elderly primiparae, the resistance offered by the perineum and the vaginal outlet may be so great as to oppose a serious obstacle to the passage of the child, even when the expulsive forces are normal. In uncomplicated cases, 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 much longer. At the same time it must be insisted upon that the operation should never be performed to save the physician's time, but only when distinctly indicated by the condition of the mother or child. 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 diag- nosis be made as to the position and variety, forceps not being available when the chin is directly posterior. The forceps is not applicable to shoulder presentations, nor is it intended to be applied to the breech. 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 centi- meters, but under such circumstances the cervical ring offers marked re- sistance, and, if the head be dragged through it by brute force, deep tears may result, which may implicate not only the cervix but also the lower uterine segment. Even if only gentle traction is made, the practice is not to be recommended, as it is difficult to know exactly when the cervix has become sufficiently wide to permit the passage of the head, and the operator is prone to attempt delivery before complete dilatation. Accordingly, if prompt delivery becomes imperative when the cervix is only partially dilated, its complete dilatation should be effected manually by Harris's method, after which forceps should be applied if the head is deeply engaged. PREPARATIONS FOR OPERATION 407 On the other hand, if it is only partially engaged, or is floating above the superior strait, and serious disproportion does not exist, delivery is best effected after podalic version, provided the uterus is not too tightly con- tracted. 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 still more important, traction upon them may bring about premature separa- tion of the placenta. Ibd'ore applying forceps, particularly when engagement has not yet occurred, the size of the head should be determined as accurately as pos- sible, for if it be unduly large, as in an excessively developed or hydro- cephalic 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 employment of forceps is questionable when the fcetus is small or macerated. 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 if brute force be employed it will result in the death of the child and severe injuries to the soft parts of the mother, and occasionally cause her death. On the other hand, when the contraction is but slight, and especially wdien 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 moderate intensity should be made; if the head follows they should be continued, but if not the forceps should be removed and delivery effected in some other manner. Preparations for Operation.—When the application of forceps becomes necessary, either in the interests of the mother or child, the physician should inform a responsible member of the family of his decision. It is not advisable to inform the patient until the preparations for operation are completed. Whenever possible, the patient should be placed upon a table of suit- able height, as ordinary beds are too low and too soft for convenience. Ana'sthesia should always be employed, and whenever practicable its ad- ministration 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 devoted to watching the general condition, instead of being concentrated upon the operation. 408 FORCEPS Fig. 357.—Diagram Showing Position of in Various Forceps Operations. Head When anaesthesia is complete, the patient's buttocks should be brought to the ed^e of the table, and her legs held in position by an appropriate leg-holder, which is particularly convenient in private practice, as it enables one to dispense with assistants for holding the legs. After the pubic hairs have been shaved, the genitalia should be thoroughly washed with soap and hot water, bathed with alco- hol, and thoroughly soaked in a 1 to 1,000 bichlorid solu- tion, and the bladder emp- tied by catheter. Disinfec- tion of the vagina is not nec- essary, unless the patient is infected or has been sub- jected to previous attempts at delivery. The legs and body should be covered with sterile towrels in such a man- ner as to leave only the geni- talia exposed, special atten- tion being given to covering the anus so as to prevent con- tamination from the faeces. (See Figs. 3:!o and 336.) Except when the outlet is relaxed, it is advisable to dilate it thoroughly by means of the hand before beginning the operation. For this purpose the fingers, anointed with sterile vaseline, are arranged in the form of a cone, and with a rotary motion slowly introduced through the vulva until the entire hand can readily be carried up into the vagina. Application of Forceps.—Forceps operations are designated as low, mid, high, and floating, according to the position of the head. When the presenting part rests upon the perineum, or lies below the line joining the ischial spines, we speak of low forceps; when it presents at or just above the ischial spines, mid forceps; when the head has partially descended into the pelvic canal, but its greatest circumference has not passed the superior strait, high forceps; and when it is freely movable above the pelvic brim the operation is termed forceps upon the floating head. The low forceps operation usually offers but little difficulty, except in certain funnel-shaped pelves, and may be undertaken upon comparatively slight indications. The mid operation is more difficult, but not often exces- sively so. On the other hand, the high operation is always difficult, and should not be attempted unless imperatively demanded by the condition of the mother or child. Forceps upon the floating head is a most serious pro- cedure, and is very rarely indicated. Generally speaking, the fact that the head is not engaged indicates some disproportion between it and the superior strait, so that the operation should not be thought of until accurate infor- mation as to the size of both is available. Moreover, in those cases in which there is no serious disproportion, delivery can usually be accomplished more safely and rapidly by version. APPLICATION OF FORCEPS 400 ment Fig. 358.—-Forceps Correctly Applied along Occi- pito-mental Diameter, Pelvic Curve towards Occiput. The forceps is so constructed that its cephalic curve is best adapted to the sides of the child's head, the biparietal diameter corresponding to the line of greatest distance between the blades. The head is grasped in I manner when the s of the blades cor- - to the occipito- diameter, the fenes- tra 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 for- ceps obtains a firm hold and cannot slip off, and trac- tion can be made in the most advantageous manner. On the other hand, when the forceps is applied obliquely writh one blade over the brow7 and the other over the opposite mastoid region, the grasp is less secure, and the head is exposed to more injurious pressure. If one blade is accurately applied over the face and the other over the occiput, the instru- <^ ment cannot he locked, while if the former is slipped down so as to lie only over the forehead the grasp is very insecure, and each traction tends to extend the head (see Figs. 362 and 363). For these reasons, then. the forceps should be ap- plied, when possible, di- rectly to the sides of the head along its occipito-men- tal or jago-parietal diameter. This is known as the cephalic, in contra- distinction to the pelvic application. The former was recommended by Fig. 359.—Forceps Correctly Applied along Occi- pito-mental Diameter, Pelvic Curve towards Face. Fig. 300.—Forceps Applied to Face along Occipito- mental Diameter. 410 FORCEPS Smellie and Baudelocque, but, as it is more difficult than the latter, it fell into disuse, and was not generally practiced until Pinard, Farabeuf, and Varnier demonstrated the inestimable advantages which it possessed over the pelvic application. In the latter, 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 present- ation, consequently the head is grasped satisfactorily only in the Fig. 361.—Forceps Applied Obliquely over Brow and Mastoid Region. Fig. 362.—Showing that when one Blade is Applied over Occiput and Other over the Face, Forceps cannot be Locked. Fig. 363.—Showing Extension of Head when One Blade is Applied over Brow and Other over Occiput, explaining Tendency of the Instrument to Slip off. simpler cases where the sagittal suture is directed autero-posteriorly. An accurate idea of the exact position of the head is absolutely essential APPLICATION OF FORCEPS 411 to the cephalic application. With the head low down, this can usually be obtained by examining with two fingers; but when it is higher up an abso- lute diagnosis can be made only by locating the posterior ear, which neces- sitates the introduction of the entire hand into the vagina. This of course, requires profound anaesthesia, and is therefore practicable only just befoic introducing the forceps. Ordinarily, 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 rest- ing upon the perineum, when the sagittal suture usually extends antero- posteriorly. or when it is movable at the pelvic brim. Faultv diagnosis not infrequently gives rise to an improper application of forceps, and is one of the most frequent factors in converting what should be a simple procedure into a serious and difficult operation. Forceps Delivery with the Head at the Vulva.—With the head in this position, the obstacle to delivery is usually due to insufficient expulsive force or to abnormal resistance on the part of the perineum. In such circum- stances the sagittal suture usually occupies the antero-posterior diam- eter of the pelvic outlet, with the small fontanelle directed toward either the symphysis pubis or the concavity of the sacrum. In either event I he 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 procedure being somewhat as follows: Two Fig. 364.—Low Forceps; Introduction of Fig. 365.—Low Forceps; Left Blade in Left Blade to Left Side of Pelvis. Place. 412 FORCEPS vagina past the margins of the external os. The handle of the left branch is then seized be- tween the thumb and two fin- gers of the left hand—just as in holding a pen—and the tip of the blade is gently passed into the vagina along the fingers of the right hand which serve as a guide. As it is introduced the handle is held almost vertically at first, but, as the blade adapts itself to the head, it is de- pressed, so that it eventually takes a horizontal position. The guiding fingers are then with- drawn, and the handle is left to itself or held by an assistant. In the same manner, two fin- gers 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 Fig. 366—Low Forceps; Left Blade in Place, ™ the right hand and intro- duced into the vagina. The guiding fingers are now re- moved 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 gently moved until they are brought into such a position as to be articulated with ease. When this has been accom- plished, an examination is made to ascertain 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 cer- tain that the blades are satisfac- torily placed, the handles are Introduction of Right Blade. Fig. 367.—Low Forceps; Instrument in Place and Articulated. APPLICATION OF FORCEPS 413 seized with one hand ana gentle intermittent traction is made in a hori- zontal direction until the perineum begins to bulge. As soon as the vulva becomes distended by the occiput, the handles are gradually elevated. so that they come almost in contact with the abdomen of the patient as the pa- rietal bosses emerge. Dur- ing the latter manoeuvre, the four fingers should grasp the upper surface of the handles and shanks, while the thumb upon their lowrer surface exerts the necessary force. In delivering the head nature's method should be simulated as closely as pos- sible. Accordingly, traction should be made intermit- tently, the head being al- lowed to recede in the inter- vals, as in spontaneous la- bor. Except when urgently indicated, it should be extracted very slowly, so as to give time for proper stretching and dilatation of the perineum, Fig. 368.—Low Forceps; Horizontal Traction. Fig. 360.—Low Forceps; Upward Traction. Fig. 370.—Low Forceps; Extreme Upward Traction. which in primiparous women cannot be satisfactorily accomplished in less than from ten to fifteen minutes. As soon as the vulva is well distended by the head, the forceps should be removed, and the head slowly expressed by pressure upon the pos- 29 414 FORCEPS terior portion of the perineum, in the belief that by so doing the liability to perineal rupture is diminished. Many operators, however, leave the forceps in place until the head is completely born, holding that in this way it is possible to exercise far more control over its advance, the in- creased distention of the vulva due to the thickness of the blades being so slight as to be with- out practical import- ance. When the occiput is directed posteriorly, 1 ml x\\ \ traction should be made in a horizontal direction until the fore- head or root of the nose engages under the sym- Fig. 371.—Low Forceps; Occiput Direct- ly Posterior; Horizontal Traction (Farabeuf and Varnier). physis, after which the handles should be slowdy 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 Fig. 372.—Low Forceps; Occi- put Directly Posterior; Up- ward Traction (Farabeuf and Varnier). chin will successively emerge from the vulva. This extraction 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. Mid Forceps Operations.—When the head lies above the perineum, the sagittal suture usually occupies an oblique or transverse diameter of APPLICATION OF FORCEPS 415 the pelvic canal. In such cases the forceps should 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 posterior 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 Fig. 373.—Mid Forceps; Hand in Vagina Fig. 374.—Mid Forceps; Introduction Seeking Posterior Ear. of First Blade. ear. The guide hand is then withdrawn, when the handle of the forceps may be held by an assistant or left to itself, as it will usually retain its position without difficulty. Two fingers of the left hand are then introduced into the right and posterior segment of the genital canal, no attempt being made to reach the anterior ear. which lies in the neighborhood of the right ilio-pectineal 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 the child. This is accom- plished by gently rotating it anteriorly until it comes to lie directly oppo- site the blade which was first introduced. The two branches being now articulated, one blade of the forceps occupies the posterior and the other the anterior extremity of the left oblique diameter (see Figs. 374 to 377). 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 must be applied (see Figs. 37^ to 380). If the occiput is in a transverse position, the forceps is introduced in a similar manner, the first blade being applied over the posterior ear, and 416 FORCEPS the second being rotated anteriorly until it comes to lie opposite the first. In this case one blade lies in front of the sacrum and the other behind the symphysis. 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 opera- tion being completed in the manner already described. When the occiput is obliquely anterior, it gradually rotates spontaneously to the sym- physis 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 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 di- rected towrard the left, and in the reverse direction when it is directed toward the right side of the pelvis (see Figs. 378, 379). In making traction, before the head appears at the vulva, one or both hands may be em- ployed according to the amount of force required. In the latter case, when the Simpson forceps is used, one hand grasps the handles of the instrument, while the fingers of the other are Fig. 375.—Mid Forceps; Introduction of Second Blade. Fig. 376. Fig. 377. Figs. 376, 377.—Mid Forceps; Instrument Applied in L. O. A. APPLICATION OF FORCEPS 417 hooked over the transverse projection at their upper ends. taken not to employ too much force. To avoid this error should stand or sit with his arms flexed and the elbows held closely against the thorax, as it is not permissible to make use ■if the body weight, and still less to brace the feet against [he side of the bed (Fig. 381). Application of Forceps in Obliquely Posterior Positions. —Prompt delivery may be- come necessary wdien the small fontanelle is directed toward one or other sacro-iliac syn- chondrosis—namely, in R. 0. P. and L. 0. P. presenta- tions. When interference is Care must be the operator "WIT L'll_._ Fig. 378. Fig. 379. Figs. 378, 379.—Mid Forceps; Instrument Applied in R. O. T. required in either of these, the head usually lies at or below the level of the ischial spines, and is usually imperfectly flexed. In many cases, when the hand is introduced to locate the posterior ear, the occiput will ro- tate spontaneously from a posterior to a trans- verse position, and de- livery by forceps is then readily accomplished, 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 Fig. 380.—Mid Forceps; Rotation to R. O. A. to rotate the occiput to 418 FORCEPS a transverse position. This can usually be accomplished with ease, and occasionally even rotation to an anterior position can be brought about. The forceps is then applied as described above. Fig. 381.—Showing Manner of Making Traction in Mid Forceps Operation In a small proportion of cases, however, manual rotation cannot be effected, and the forceps must then be applied with the occiput still di- Fig- 382. Fig. 383. Figs. 382, 383.—Diagrams Showing Rotation of Occiput to Sacrum and Symphysis Puris Respectively. rected obliquely posterior. Under these circumstances, if the instrument be applied to the sides of the head, or even obliquely, and an attempt APPLICATION OF FORCEPS 419 made to effect delivery by making traction in the usual manner, great difficulty is experienced and very powerful traction becomes necessary, which, nevertheless, 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, when- ever unexpected difficulty 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. In the vast majority of such cases, the small fontanelle will be found directed toward one or other sacro- iliac synchondrosis. In order for delivery to occur, the head must be rotated so as to bring its sagittal suture into coinci- dence with the antero-poste- rior diameter of the pelvic out- let. 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 degrees to the symphysis pubis. The latter is much more advan- tageous, for the reason that delivery in the former posi- tion is more difficult and also Fig. 384. Fig- 385- Figs. 384, 385.—Showing Inversion of Forceps When Anterior Rotation From an R. O. P. Position is Completed, more likely to give rise to deep perineal tears (Figs. 382 and 383). Unfortunately, when it is desired to rotate the occiput forward the forceps, if applied to the sides of the head in the usual manner, with the pelvic curvature directed forward, becomes inverted by the time rotation is completed, so that the pelvic curve looks posteriorly, and an attempted delivery with the instrument in this position is liable to cause serious injury to the maternal soft parts (Figs. 384 and 385). In order to avoid this, 'it is best to remove and reapply the instrument. 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 mastoid 420 FORCEPS region; but this is not advisable, as the procedure is more difficult for the operator and far more dan- gerous for the child. The double application of for- ceps, which was recommended by Scanzoni many years ago, has given such excellent results in my hands that I employ it to the ex- clusion of all other methods, when the occiput cannot be rotated man- ually from its obliquely posterior position. As the right occipito- Fig. 386. Fig. 387. Figs. 386, 387.—Scanzoni's Manoeuvre; First Application of Forceps. posterior variety is much the more frequent, I shall describe in detail the steps of the opera- tion. 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. 386 and 387) the right hand is passed into the left posterior segment of the genital tract, and the posterior (right) ear Fig. 388. Fig- 389. Fjcjs. 388, 389.—Scanzoni's Manoeuvre; Showing Rotation to Transverse Position- APPLICATION OF FORCEPS 421 sought for. Over it the left blade is applied. This is held in position by an assistant, wdiile the operator's left hand is passed into the right side of the vagina and over it is in- troduced the right blade, which is then rotated an- teriorly until it comes to lie opposite the blade first in- troduced. The forceps is then locked, its blades now occupying the left and the sagittal suture the right Fig. 390. Fis- 39L Figs 390 391.-Scanzoni's Manceuvre; Showing Rotation to Anterior Position Forceps Inverted. oblique diameter of the pelvis. Downward traction is then made until the head impinges upon the pelvic floor, when a rotary motion is imparted to the forceps by which the occiput is slowly rotated to a right transverse, and later on to an obliquely anterior position (see Figs. 388 and 391). The forceps, having be- come inverted, must be taken off, and reapplied in the usual manner to the head, which now occupies Fig. 392 Figs. 392, 393.—Scanzoni' Fig. 393. Manceuvre; Second Application of Forceps. , ri<.- left and which the right branch of the forceps, it is a good practical rule for a beginner, after hav- ing 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 ap- plied, and which blade is to go over the posterior ear. High Forceps.—As has already been said, the high are much more difficult than the mid or low forceps operations, and should not be under- taken unless urgent in- dications are present. If the head be well engaged, the forceps should be ap- plied 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. 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 should be avoided if possible, as such a condition usually indicates considerable disproportion between the head and the pelvis. If, however, the operation appears to be called for, 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 applying the forceps directly to the sides of the head; but under these circumstances there are several contra-indications. In the first Fig. 394.—Scanzoni's Manoeuvre; Showing Difficulty in Articulating Blades in Second Application of Forceps. APPLICATION OF FORCEPS 423 place, as the pelvis is usually contracted, the sagittal suture will generally lie transversely, and, accordingly the blades of the forceps, if applied to the sides of the head, will occupy the extremities of the conjugata vera, and thus still further increase the disproportion. But more important still Fig. 395.—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). is the fact that, since the shape of the birth canal makes it impossible for the forceps to conform to its axis, the posterior blade bridges over the an- terior concavity of the sacrum and thus prevents the head from entering the pelvic cavity, and so defeats the very purpose for which the operation would be undertaken. Axis-traction Forceps.—With the ordinary long forceps, the high and occasionally even the mid operation is comparatively difficult, strong trac- tion 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 impossible 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 sa- crum ; 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 bringing it downward. Thus, Tar- nier pointed out that a force of 40 pounds employed in an ordinary 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 424 FORCEPS 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 Fig. 396.—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. 1772, suggested that delivery could be greatly facilitated by attaching a lac to the eye of each blade and making traction upon these, as w-ell as with the handles. He also showed that a similar result might be attained Fig. 397.—Saxtorph-Pajot Manceuvre. by making strong downward pressure with one hand in the neighborhood of the lock, while the other was used for traction. This manoeuvre is APPLICATION OF FORCEPS 425 usually attributed to Pajot, but was recommended by Saxtorph forty-four years before his birth. Hermann, of Berne, in 1844, was the first to attempt to overcome the difficulty by devising an axis-traction forceps, his crude instrument being showrn in Fig. 398. 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 su- ture was directed an- tero-posteriorly, but being useless in all other positions. Mo- rales (lSil) added a perineal curve to the forceps, but his inven- tion possessed the same disadvantages as that of Hubert. Xone of these instruments were of much prac- tical value, but they served to emphasize the faults of those in general use. Finally, in 1877, Tarnier solved the problem by attaching a traction-rod to each blade and fastening them to a handle. His original forceps pos- sessed a definite perineal curve, and was very cumbersome. The import- ance of his invention was soon recognized, and obstetricians throughout the world promptly attempted to improve upon it; so that at present one or more modifi- cations of axis-trac- tion forceps, each designated by the name of the modi- fier, are to be found in every large city. One of the most im- portant was devised by Milne Murray and enjoys great popularity in Great Britain, but to my mind it is inferior to the last Tar- nier model. Tarnier himself, not considering his original forceps satisfactory, con- Fig. 400.—Morales's Forceps. Fig. 401.—Tarnier's Original Axis-Traction Forceps. 426 FORCEPS Fig. 402. -Tarnier's Forceps; Traction Rods in Place with- out Handle-Bar. tinued 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 for- ceps without a peri- neal curve, provided with short, detacha- ble traction-rods, one of which is in- serted 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 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. 402 and 403). With this device, traction can be made almost in the axis of the superior strait, and, owing to the presence of numerous joints in the traction attach- ment, the instrument can be used in any position. The handles of the forceps merely serve to indicate the direction in which traction should be made, the force being applied to the handle-bar, which is held horizontally no matter what the position of the blades may be, the traction-rods being kept about one centimeter beneath the handles (Fig. 104). To my mind, this instrument is superior to all other axis-trac- tion forceps, and with it most excellent re- sults can be obtained with a minimum ex- penditure of energy, and by its aid a delivery can occasion- ally be effected which would have been impossible with the ordinary instruments. 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 horizontally, even though the forceps is applied at the ends of the antero-posterior diameter of the pelvis. I use this instrument in all cases, without the traction-rods in low and mid, and with them in 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 varieties, the blades being 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 this position. In Fio. 403.—Tarnier's Forceps. PROGNOSIS 427 exceptional cases, if version is out of the question, and conversion into a vertex presentation cannot be effected, an expert operator may endeavor to rotate the chin to a transverse and later to an anterior position before resorting to pubiotomy or craniotomy, though such attempts are rarely successful. Application of Forceps in Breech Presentations.—Occasionally the ap- plication of forceps is recommended in frank breech presentations, the blades being applied over the trochanters. This is very rarely indicated, as delivery can usually be effected more satisfactorily by the methods to be mentioned in the following chapter. From the time of Smellie, many authors have recommended the ex- Fig. 404.—Diagram Showing Traction with Tarnier's Forceps. .1 B in proper and X Y in improper manner (Ribemont-Dessaignes). traction of the after-coming head in breech presentations 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 be experienced in delivering the after-coming head. Prognosis.—Low and mid forceps operations, when intelligently per- formed upon healthy women under proper aseptic precautions, should not 428 FORCEPS be 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, howTever, should not be the case, provided that the head is extracted sufficiently slowly. Unfortunately, it would appear as though the average operator, as soon as the head ap- pears 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 twent}r 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, 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 haemorrhage or infection. Moreover, the application of forceps 'requires an accurate diagnosis as to the posi- tion and presentation of the child, and when this is lacking, and the for- ceps is incorrectly applied in certain occipito-posterior and brow presenta- tions, delivery can be effected only by brute force, which can hardly -fail to cause serious lesions for mother and child. Similar untoward results often follow an attempt to drag the head forcibly through a markedly contracted pelvic brim. The fcetal mortality depends upon the position of the head and the 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 only two chil- dren whose deaths could be directly attributed to such operations when properly performed. On the other hand, the high forceps operation is attended by a very 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 ves- sels and the subsequent death of the child. In rare instances actual frac- ture 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 stylo-mastoid foramen, through which the nerve leaves the skull. Not every facial paralysis, however, following delivery by forceps, should be attributed to the operation, as such a condition is occasionally encountered after a spontaneous labor, and may be due to intracranial causes quite independ- ent of the use of instruments. Full literature upon this subject up to 1901 will be found in Mace's article. LITERATURE 429 LITERATURE Aveling. The Chamberlens and the Midwifery Forceps. London, 1SS2. Baudelocque. De la maniere de se servir du forceps, etc. L'art des accouche- ments. Nouv. ed., Paris, 1789, t. ii, 300-343. Budin. L'invention du forceps a double courbure. Progres Medical, 1876, iv, 779. Les Chamberlens. Lequel d'entre eux imagina le forceps. Obstetrique et Gyne- cologie, 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. Farabeuf et Varnier. Introduction a 1'etude clinique et a la pratique des accouche- ments. Paris, 1891, 270-466. Giffard. Cases in Midwifery. London, 1734. Hermann. Ueber eine neue Geburtszange. Berne, 1844. Hubert. Note sur 1'equilibre du forceps et du levier. Memoires de I'acad. royale de Belgique, 1860. Levret. Observations sur les causes et les accidents de plusieurs accouchements laborieux. Paris, 1747. Mace. Des paralysies faciales spontanees 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, Iii, 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. Havnias and Lipsite, 1772. Scanzoni. Lehrbuch der Geburtshiilfe, II. Aufl., 1853, 838-840. Smellie. A Treatise on the Theory and Practice of Midwifery. London, 1752. Tarnier. Description de deux nouveaux forceps. Paris, 1877. Witkowski. L'arsenal obstetrical. Paris, Steinheil. 30 CHAPTER NXI 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 technique 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 me- chanical 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, premature extraction is indicated but rarely, and then only in the interests of the mother. Indications for Extraction.—It has already been pointed out that the fcetal mortality is considerably greater in breech than in vertex presenta- tions, since in the former death from asphyxiation is almost inevitable if the head be not delivered in less than eight minutes after the appear- ance of the umbilicus at the vulva. In these cases the untoward result may be due to one or other of several causes. Thus, very often the cord is subjected to pressure .between the pelvic brim and the head, which may be so severe as to check completely 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 becomes inevitable unless extraction is promptly effected. 430 EXTRACTION ■431 In all breech presentations, preparations should be made for extraction as soon as the buttocks appear at the vulva, so that the operation can be promptly resorted to if, after the appearance 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 position of the breech, extraction may be called for by any condition which seriously threatens the life of the mother or child, just as in vertex presentations. When speaking of the latter, how- ever, it was said that the passage of meconium indicated that the child was in danger, whereas in breech presentations such an occurrence is without significance, as it is simply the result of the compression to which the abdo- men of the child is being subjected. Extraction by One or Both Feet.—Before beginning the operation, the patient should be brought to the edge of the bed and subjected to the usual preliminary praparations. Complete anaesthesia is necessary, except in those cases in which the body of the child has already been born and only the head remains to be extracted. As a rule, extraction is an extremely simple operation when the breech has been born spontaneously, whereas it is less so when the feet are in the vagina, or still within the uterus. In the latter case the en- tire hand should be introduced into the vagina and an at- tempt made to seize both feet, the ankles being grasped in such a manner that the sec- ond finger lies be- tween them. They are then brought down into the vagina, and traction is made until they appear at the vulva. . If, however, difficulty is experi- enced in seizing both feet, one should be grasped and extracted in a similar manner. 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, since the vernix caseosa renders them so slippery that they are very difficult to hold. Trac- tion is then made in a downward direction, and as the legs protrude still farther they are grasped higher up, first by the calves and later by the Fig. 405.—Breech Extraction; Traction upon Feet. 432 EXTRACTION AND VERSION thighs. When the breech appears at the vulva, traction is made in an up- ward direction until it is delivered. The thumbs are then applied over the sacrum and the fingers over the manner until the thorax is hips, and traction is continued in the same born, when the arms must be freed in order to effect deliv- ery. If only one foot has been seized, trac- tion should be made upon it until the but- tocks appear at the vulva, when the index finger of the other hand is introduced in- to the posterior groin and aids in traction. As soon as the op- erator begins to pull upon the legs, an as- sistant or the nurse should exert strong pressure upon the uterus in the axis of the superior strait, with the object of pre- serving the flexed at- titude of the head and preventing the arms from becoming ex- tended above it. Be- sides serving these purposes it also aids directly in the expulsion of the child, and thus renders necessary a smaller amount of force on the part of the operator. Downward traction should be continued until the scapulae are at least partially outside of the vulva, and no attempt should be made to free and deliver the arms until this is effected, as failure to observe this rule fre- quently renders difficult what would otherwise be a very simple pro- cedure. In a certain number of cases the anus are delivered spontaneously. With this in view, the child should be seized with the thumbs over the scapula? and the fingers over the sides of the thorax and rotated until the bisacromial diameter occupies the antero-posterior diameter of the outlet. Then by continuing traction downward the anterior shoulder engages be- neath the pubic arch, the hand and arm escaping spontaneously; while upon sharply drawing the feet up over the abdomen of the mother, the posterior shoulder, arm, and hand pass over the perineal margin. In most cases, however, the process is not so simple, and it becomes necessary to free and deliver the arms. Since there is more available space m the posterior and lateral segments of the pelvis, the posterior arm should /^ " I" Fig. 406.—Breech Extraction; Traction upon Thighs. EXTRACTION 433 be freed first. In order to do so, the thorax should be rotated until the bisacromial diameter occupies an oblique diameter of the pelvis (Fig. 40?), and the feet should be sharply drawn up by one hand over the groin of the mother corresponding to the anterior shoulder. Then two fingers are introduced beneath the posterior shoulder and passed along the humerus until the elbow is reached (Fig. 408). 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 delivery of the anterior arm, the body is seized as before and rotated so as to bring the undelivered shoulder into the neighborhood of the nearest sacro- sciatic notch. 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 spon- taneously it is delivered in the same manner as the other. If pressure from above has not been made—and occasionally in spite of it—the arms may become extended over the head. Under such circum- stances their delivery, al- ________ though more difficult, can F be accomplished by the manoeuvres ordinarily em- ployed. In doing this, par- ticular care must be taken to carry the fingers up to the elbow and use them as a splint, for, if the finger be merely hooked over the arm and strong traction made, the humerus or clavi- cle is exposed to great dan- ger of fracture. In other cases the arm is found around the back of the neck, when its deliv- ery becomes still more dif- ficult. 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. Unfortunately, fracture of the humerus or clavicle is very common in such cases, 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. Fig. 407.—Breech Extraction; Posterior Rota- tion of Shoulder. 434 EXTRACTION AND VERSION 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 manceuvre (Figs. 409 and 410). 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 stradding the latter. Two fingers of the other hand are then hooked over the neck, and, grasping the shoulders, make downward traction until the occiput ap- pears under the symphysis. The body of the child is now raised up toward the mother's abdomen, and the mouth, nose, brow, and eventually Fig. 408.—Breech Extraction; Introduction op Fingers to Free Posterior Arm. 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 in many cases the latter slips from the superior maxilla and comes to rest upon the inferior maxilla and base of the tongue, as a consequence of which serious injuries may be done to the child if energetic traction be employed. This manceuvre was first practiced by Mauriceau in the seventeenth 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 pre- ferred the employment of forceps. In the meantime other devices came into use, until G. Veit, in 18C3, directed attention to the inestimable ad- vantages which Mauriceau's method of extraction possessed over all others. nV Fig. 4()(». -Brekch Extraction; Mauriceau's Manceuvre, Downward Traction. Fig. 410.—Breech Extraction; Mai iu< i;ai s Manceuvre, Upward Traction. 433 436 EXTRACTION AND VERSION For this reason in Germany the procedure is frequently called after Veit, or, when greater accuracy is desired, is designated as the Mauriceau-Smellie- Veit manceuvre. Litzmann, however, was certainly right in pointing out the impropriety of such a nomenclature, and insisting that only the name of the original inventor—Mauriceau—should be used in describing it. Nu- merous 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 matter what its original position; but when it does Fig. 411.—Delivery of After-Coming Head, Prague Manoeuvre. not take place spontaneously 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 remains pos- terior 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 Mauri- ceau's manceuvre. When, however, this is impossible, delivery must be attempted, with the head in its abnormal position, by the employment of a modified Prague manoeuvre, 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 century earlier. The procedure is somewhat as follows: Two fingers of one hand grasp the shoulders, while the other hand draws up the feet over the abdomen of the^ mother. As a result the occiput of the child is born first and the perineum is necessarily subjected to greater liability of rupture. EXTRACTION 437 Prognosis.—The prognosis, so far as the mother is concerned, is very favorable, even when considerable disproportion exists between the child and the pelvis, since the pressure of the head upon the maternal soft parts lasts but a few seconds, instead of being prolonged for hours, as in head presentations. Owing to the necessity of intra-vaginal manipulations, there is a slightly increased danger of infection, and, more particularly in the case of a primipara with a rigid vaginal outlet, there is greater liability to laceration of the perineum than in head presentations. For the child, however, the outlook is not so favorable, and becomes more serious the higher the situation of the presenting part at the beginning of the operation. The foetal mortality is in great part due Fig. 412.—Extraction of Frank Breech; Finger in Anterior Groin. As has already been said, fractures of the humerus and clavicle cannot always be avoided, even in the hands of expert operators. Occasionally harnatomata of the sterno-cleido-mastoid muscle are noted after the opera- tion, though these are usually of but slight significance and disappear spon- taneously within a short time. More serious results, however, may follow the separation of the epiphyses of the scapula or humerus. In exceptional cases paralysis of the arm results from pressure exerted upon the brachial plexus by the fingers in making traction, but more frequently is due to an overstretching of the neck in freeing the arms or in effecting extraction by the Prague manoeuvre. As will be shown in Chapter XLIII, the con- 438 EXTRACTION AND VERSION dition usually undergoes spontaneous cure, although in rare instances it persists throughout life. When the child is forcibly extracted through a markedly contracted pelvis, spoon-shaped depressions or actual fractures of the skull may result, which generally prove fatal, and occasionally when great force is employed even the neck may be broken. The application of forceps to the after-coming head, introduced by Smellie, has been extensively practiced. In such circumstances the body of the child is elevated toward the abdomen of the mother and the for- ceps introduced under it, the blades being applied to the sides of the head. Personally, I have never found it necessary to resort to this procedure, and believe that it is but rarely called for if the obstetrician has made himself thoroughly familiar with Mauriceau's manceuvre. Extraction of Frank Breech Presentations.—When indications for de- livery arise after the breech has descended deeply into the birth canal, its ex- traction can usually be effected with- the index finger of one hand into making traction until the buttocks index finger of the other hand the posterior groin in order to out difficulty by hooking the anterior groin and appear at the vulva, the being then inserted into furnish additional aid. Fig. 413.—Extraction of Frank Breech; Fingers in Groins. On the other hand, when the breech is at the superior strait, 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 attempted shortly after rupture of the membranes, but becomes extremely difficult if a considerable time has elapsed after the escape of EXTRACTION 439 the liquor amnii and the uterus has become tightly contracted over the child. In many cases the employment of the following manoeuvre suggested by Pinard will often 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 procedure 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. 414). In view of the fact that it is often very difficult to seize and bring down a foot in the latter part of 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 neces- sary. This can be readily accomplished, but is not advisable as a routine practice, since the frank breech forms a much better dilating wedge than the incomplete breech presentation. The procedure is justifiable, however, in those cases in which it appears probable that rapid extraction may become im- perative; for instance, in patients suffering from heart lesions. If the indication for de- livery is urgent, and it is impossible to bring down a foot, the child must be ex- tracted as it lies. For this purpose the index finger of one hand is hooked into the anterior groin, and strong downward traction made, supplemented, if necessary, by the use of the other hand, which grasps the wrist. This procedure is continued until the poste- rior buttock has almost reached the pelvic floor, when the index finger of the Other hand is hooked into Fjg 414._pINARD's Manceuvre for Bringing Down the posterior groin and A Foot in Frank Breech Presentation. traction made with both hands. As soon as the latter becomes accessible, delivery can usually be readily effected, but, unfortunately, in a considerable number of cases, it is extremely difficult to bring the breech low enough to offer this advantage. For this reason, when the breech is high up, its extraction should not be attempted unless imperatively demanded by the condition of the mother or child; otherwise it is far better to wait until it has descended lower before interfering. 440 EXTRACTION AND VERSION As soon as the buttocks are born, first one leg and then the other is drawn out and extraction accomplished as described above. As was said before, traction must always 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. Prognosis.—The prognosis for both mother and child is less favor- able in frank breech than in foot presentations. In the former the in- creased manipulation affords greater opportunity for infection; while the attempt to reach the posterior groin often gives rise to deep tears before the child has reached the perineum. Again, in view of the longer time required to effect delivery, the child is exposed to more danger, and, in addition to the accidents incident to extraction by the feet, fracture of the femur may follow the attempt to bring down a foot, especially when strong traction is made upon the groin. 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 over the thigh. Up to the present time I have had no experience with this procedure, hav- ing been able to effect delivery in all my cases by traction exerted with a finger in the groin. When this fails, the application of forceps is certainly justifiable, although when the breech is high up it should not be attempted except under pressing indications. The Fillet.—In these cases 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 oper- ator has at his disposal a specially constructed instrument, a fairly satis- factory 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 closed end of 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 only disad- vantage of the fillet is its liability to cut through the skin of the groin; but this accident 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 liv- ing 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, VERSION 441 VERSION Version, or turning, is an operation through which the presentation of the foetus is artificially altered, one pole being substituted for the other, or an oblique or transverse being converted into a longitudinal presenta- tion. According as the head or breech is made the presenting part, the opera- tion 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 fin- gers of the other are introduced through the cervix. Cephalic Version.—This operation was practiced from the most remote antiquity, and only gradually fell into disfavor after the introduction 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 external manipulations, 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 immediate 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 few weeks of pregnancy, its conversion into a vertex should be attempt- ed by external manoeuvres, provided there be no marked disproportion be- tween the size of the child and the pelvis. Cephalic version is indicated by reason of the increased fcetal mortality attending spontaneous delivery in breech presentations; while if the child lies transversely a change of pres- entation 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. Consequently it is some- times necessary for the patient to wear a suitable bandage until the new presenting part becomes engaged. Moreover, the operation can be accom- plished 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 harmless, 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 442 EXTRACTION AND VERSION same indications hold good, and at this time may be extended to oblique presentations as well, though these usually right themselves spontaneously as labor progresses. On the other hand, external cephalic version can be effected but rarely after the cervix has become fully dilated and the mem- branes have ruptured, except in occasional cases of shoulder presentations; and, moreover, better results are obtained from podalic version followed by immediate extraction. This is particularly true in cases complicated by prolapse of the cord or placenta proevia. Serious pelvic contraction is a decided contra-indication, since, although 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 preg- nancy the former is the only method applicable, and at the time of labor it should be employed whenever feasible. The technique has been care- fully described by Pi- nard, 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 Fig. 415.—External Cephalic Version (Pinard). gently stroked toward the superior strait, while the other is moved in the opposite direction. After version has been com- pleted, the child must be held in its new position until engagement occurs. During pregnancy this is accomplished by appropriately fitting pads, which are held in place by a bandage; 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. For carrying out this procedure Hicks gave the following 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 VERSION 443 position of the fcetus and the direction of the head and feet. Should the shoulder, for instance, present, then push it with one or two fingers on the top in the 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 wTell 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. 421). While the credit for popularizing this procedure undoubtedly belongs to Hicks, it is interesting to note that it had been described by Marmaduke Wright, of Cincinnati, in 1834; ten years before the appearance of Hicks's first publication. Busch, D'Outrepont, and others advocated attempting cephalic version after complete dilatation of the cervix, by introducing one hand into the uterus and seizing the head, while the other is employed for external man- ipulations. This is rarely if ever advisable, as under such circumstances it is preferable to perform internal version, which is no more dangerous, and at the same time permits immedi- ate delivery if necessary. Podalic Version.—By this is under- stood 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 deliver- ing unmutilated children. It is inter- esting to note that Guillemeau, one of Fare's students, was enabled by this means to save his master's daughter from dying of haemorrhage due to pla- centa prawia. The value of the opera- tion 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 in- dicated 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 ob- vious. In abnormal head presentations, when the face, brow, or occiput Fig. 416.—Seizure of Foot in Internal Podalic Version (Tarnier). 444 EXTRACTION AND VERSION 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 praevia. More- over, when the child presents some deformity, delivery is sometimes very much facilitated after version. Generally speaking, the operation is in- dicated 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. Under such circum- r>—_<^ stances it is usually a much safer procedure ^ t-3 than the application of high forceps. Fig. 417.—Version; Transverse Presen- Fig. 418.—Version; Transverse Presen- tation, Back Anterior, Seizure of tation, Back Anterior, Seizure of Lower Foot. Upper Foot. One of its widest fields of usefulness is after the dilatation of the cervix in accouchement force, especially in eclampsia and haemorrhage, when version and extraction supply the readiest and most conservative method of delivery. Marked degrees of pelvic deformity contra-indicate the operation. It is true that version can be accomplished, but afterward it is frequently impossible to extract an unmutilated child. It should never be attempted when the child is suffering from hydrocephalus. The most favorable time for the performance of the operation is im- mediately after the rupture of the membranes, before the amniotic fluid has drained off, and while the child is readily movable in any direction. VERSION 445 Generally speaking, podalic version should not be attempted through an imperfectly dilated cervix, except in certain cases of placenta prawia. In many cases the patient is not seen until long after rupture of the membranes, and conditions may 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 rases, 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. Technique.—The patient should be anaesthetized, placed upon a table, and the usual preparations for an operation made. Version should never be undertaken without an accurate diagnosis as to the presentation and Fig. 419.—Version; Transverse Presen- tation, Back Posterior, Seizure of Upper Foot. Fig. 420.—Version; Transverse Presen- tation, Back Posterior, Seizure of Lower Foot, showing Arrest of But- tocks at the Pelvic Brim. position of the child. The abdomen should be covered by sterile dressings so as to allow one hand to be applied over its lower portion without be- coming infected. Podalic version may be accomplished by one of two methods—internal or combined. In the former the entire hand is introduced into the 31 446 EXTRACTION AND VERSION uterus, while in the latter only two fingers are pressed through the cer- vix; but in both methods the other hand is applied over the abdomen and controls the movements of the fcetus. Internal Podalic Version.—This should be attempted only after com- plete dilatation of the cervix. If the membranes are intact, they are rup- tured and the hand is immediately introduced into the uterus; the feet are then seized and drawn through the cervix, the operation being usually, but not necessarily, followed by extraction. The method of procedure varies somewhat, according as one has^ to do primarily with a head or a transverse presentation. In the first instance, the hand and arm must be introduced considerably farther into the genital canal than in the latter (Fig. 41G). If the child presents by the head, the choice of the hand which is to be passed into the uterus de- pends upon the location of the small parts. If the back be di- rected to the left, the feet can be seized most conveniently with the left hand, and vice versa. Gener- ally speaking, it is advisable to at- tempt to grasp only one foot—if possible the anterior one—for wdien traction is made upon it the back will rotate to the front. The feet may be differentiated by tracing the course of the thigh and leg or by noting the relation of the great toe. Having found the proper foot, the ankle should be grasped between the index and second fin- gers, and slowly drawn through the cervix, while the external hand controls and guides the movements of the head. In transverse presentations one foot is seized and version accom- plished in the same manner. The choice of the foot, however, is a matter of very considerable import- ance. 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 the lower foot be seized, although anterior rotation will usually occur, the upper buttock is liable to impinge upon the anterior por- Fig. 421.—Bipolar Podalic Version (Bumm). LITERATURE 447 tion of the pelvic brim, and great force may become necessary to effect its dislodgment (Figs. 117 to 420). Not a few cases of transverse presentation are complicated by the pro- lapse of an arm into the vagina. In such circumstances, a fillet should lie applied around the wrist and held loosely by an assistant, wdiile 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 deliverv. Combined Podalic Version.—In other instances, particularly in placenta pncvia, version may be attempted by the combined or bipolar method of Hicks, as soon as the cervix is sufficiently dilated to admit two fingers. With these the presenting part is dislodged and pushed upward, wdiile the external hand gradually brings the breech downward toward the ex- ternal 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 opera- tion, as extraction 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. 121). Prognosis.—For the mother the prognosis following podalic version is excellent in properly selected cases, provided the patient be in good con- dition at the commencement of the operation. On the other, hand, wdien attempted in the case of a tetanicallv 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 hand, if the operation be undertaken through an imperfectly dilated cer- vix, 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 inevi- table. Moreover, in cases of marked pelvic contraction, the fcetal mor- tality 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 men- tion injuries to the head resulting from pressure. LITERATURE Aiit.peld. 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 l'art des accouchements. 1901, t. iv, 296. De la AIottk. Traite complet des accouchements. Nouv. ed., Leiden, 1729. D'Outrepont. Abh. und Beitrage, Wiirzburg, 1817, Theil I, 69. Guillemeau. De l'heureux accouchement des femmes. Paris, 1609. 448 EXTRACTION AND VERSION Hicks. On combined External and Internal Version. London, 1864. Hubert. Quelques faits sur les presentations vicieuses du fcetus et sur la possibilite de les corriger par les manipulations exterieures. Annales de gyn. et de paed., 1843, aofit. Kiwisch. Beitrage zur Geburtskunde, Wiirzburg, 1846, I. Abth., 69. Litzmann. Der Mauriceau-Levret'sche Handgriff. Archiv f. Gyn., 1887, xxxi, 102- 11 x. Lusk. The Science and Art of Midwifery. New York, 1895, 338-391. Mauriceau. Le moyen d'accoucher 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. Pugh. A Treatise on Midwifery chiefly with Regard to the 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 Fcetus 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 Kindeskopfes. Greifswalder med. Beitrage, 1863, ii, Heft I. Wigand. Ueber Wendung durch aussere Handgriffe. Hamburger med. 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. CHAPTER XXII CESAREAN SECTION, SYMPHYSEOTOMY, AND PUBIOTOMY CESAREAN SECTION In this operation the child is removed from the uterus through an in- cision 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 Ca'sar was brought into the world by this means, and obtained his name from the manner in which he was delivered (a caso malris utero). This explanation, however, can hardly be correct, as his mother, Julia, lived many years after her sou's birth; and, besides, Julius was not the first of his name, since there is mention of a priest named Casar who lived several generations before. The following view, however, would ap- pear to be more plausible. In the Roman law. as codified by Nunia Poin- pilius, it was ordered that the operation should be performed upon women dying in the last few weeks of pregnancy. This lex regia, as it was called at first, under the emperors became converted into the lex casarea, and the procedure itself became known as the Casarean operation. History.—The history of Caesarean section maybe said to extend over three periods, the first lasting from the earliest times to the beginning of the sixteenth century. During this period the operation was occasionally 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 Tal- mud may be so interpreted. The fact that Dr. Felkin saw a (Cesarean section performed among the natives of 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 ir>00 to 1S70, when Porro descrilied his method of amputating the pregnant uterus. According to Caspar Bauhin, the first Ca-sarean 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 Caesarean section, but probably the simple removal of an extra-uterine child from the abdominal cavity. Frangois Rousset, a contemporary of Pare, wrote a treatise upon the 449 450 CESAREAN SECTION subject in 1581, in which he gave the histories of a number of Cesarean sections collected from various sources. Several of them were probably apocryphal, 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 upon the living woman up to 1777, when it became temporarily eclipsed by symphyseotomy, to be taken up again after the latter operation fell into disrepute. During this period, the uterus was simply incised and the child ex- tracted. The uterine walls were not sutured, the contraction and retraction of the organ being relied upon to check haemorrhage. Most of the women perished from haemorrhage or infection. Sutures were first employed by Lebas (1769), but did not come into general use until after the appearance of Sanger's epoch-making article upon the subject in 1882. Before the work of Porro and Sanger, the mortality following the opera- tion was appalling. Meyer (1867) collected 1,605 cases from the literature with a mortality of 54 per cent.; while in 80 cases performed 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 per- formed in Paris between the years 1787 and 187(5. Such poor results were obtained by physicians that Harris pointed out that the operation was more successful when performed by the patient herself, or when the abdo- men was 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 Caesarean sections performed in the city of New York during the same period, only one patient recovered. The third period began with the year 1876, when Porro advised ampu- tating 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 haemorrhage and infection. This procedure, being followed by very satis- factory results, soon became quite popular, so that in 1890 Harris was able to collect 2(54 operations from the literature. Storer, of Boston, in 1868, performed a similar operation upon a pregnant myomatous uterus, with a fatal result, but, inasmuch as he did not appear to recognize the importance of the innovation, the credit for proposing it undoubtedly belongs to Porro. Sanger, in 1882, revolutionized the Cesarean section by directing atten- tion 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 contradistinction to the Porro (Cesarean section. With the increasing perfection of surgical technique, more and more satisfactory results were obtained from the former operation, while the latter became less popular. After the technique for supravaginal amputation of the myomatous uterus had become more 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, INDICATIONS 451 particularly when the cervix was carcinomatous, the entire organ was re- moved. The latter procedure, which was first attempted by Bischoff, has but a limited field of application. Indications.—The most frequent and important indication for Caesarean section is afforded by pelves which are so contracted as to offer a 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 the child cannot be effected by any other means; while in the latter, it is sufficiently marked to render spontaneous labor impossible, but permits delivery after craniotomy. When the conjugata vera meas- ures more than 7 centimeters a living, not overlarge, child, may be delivered after pubiotomy. 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 centimeters, the upper limit for the absolute indication has been extended to that point, provided the patient is in good condition and amid suitable surroundings for a major operation. Kven when the pelvis is less contracted, so that it 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—tin1 operation may likewise be indicated. In pelves of this character, the course of labor de- pends not so much upon the degree of pelvic contraction, as upon the size and consistency of the head and the character of the uterine contractions. Given two women with pelves 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, or craniotomy. Accordingly, when examination reveals the presence of an unusually large child, or the patient presents a history of previous difficult labors with dead children, Ca-sarean section should be performed at an appointed time at the end of pregnancy, or very early in labor, since the prognosis for the mother becomes more serious with every hour interference 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 ob- tained by allowing the patient to go into the second stage, and then re- sorting to pubiotomy 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 Ca'sarean section. If, however, these conditions cannot be fulfilled, the patient should be al- lowed to continue in labor until a definite indication for its termination arises, when craniotomy should be performed. There is a general misconception as to the in nocuous ness of craniotomy, a somewhat general belief existing that it is unattended by maternal mor- tality. The results of Pinard and Bar, however, prove the contrary, as their mortality was 11.5 and 9.39 per cent, respectively. At the same 452 CESAREAN SECTION time, it must be admitted that many of their patients were infected and in bad condition when first seen, and consequently their results were in- finitely worse than they would have been had all been clean cases. But when this fact has received full consideration, their figures still serve to show that the operation is not devoid of danger even when undertaken under favorable conditions. Pelvic contraction involving the superior strait is not the only indica- tion for Caesarean section; in not a few cases abnormalities of the pelvic outlet likewise call for its performance. It is usually stated that a bis- ischial diameter of 7 centimeters or less is a positive indication for the operation. It will be pointed out later, however, that this does not neces- sarily hold good, but that such a measurement is to be regarded merely as a danger signal. It simply indicates that it will be impossible for the head to pass beneath the pubic arch, and that spontaneous labor cannot occur unless there be sufficient space between the bis-ischial diameter and the tip of the sacrum to permit the passage of the child's head. Accord- ingly, in such cases, the necessity for interference will depend entirely upon the length of Klien's so-called posterior sagittal diameter of the inferior strait. Other pelvic deformities which occasionally necessitate the operation will be considered in the chapters upon Contracted Pelves. Obstruction to labor, due to conditions other than 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 which are prolapsed and cannot be replaced under anaesthesia, may so block the pelvic canal as to render Ca-sarean section imperative. The same may be said of certain 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 Caesarean section imperative. Holzapfel reported a case of this character, and Nijhoff collected the litera- ture upon the subject up to 1905. Halbertsma, in 1899, suggested Caesarean section as the best method of delivery in certain cases of eclampsia complicated by an undilated and rigid cervix. Olshausen's experience also favors this view. I, however, consider that vaginal Cesarean section is a more suitable and conservative procedure in such cases, and that the abdominal method should be employed only when the condition is complicated by a markedly contracted pelvis. Dudley, in 1900, suggested the advisability of Ciesarean section in certain cases of placenta pnevia, 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 not decrease the mor- tality of the affection. Contra-indications.—Except in the presence of an absolute indication, Caesarean section should never be performed when the child is dead or in OPERATIVE TECHNIQUE 453 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 op- eration of choice, and Caesarean 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 operation is usually contra-indicated when the patient has been long in labor or subjected to repeated vaginal examinations by one whose technique is questionable, even though no signs of infection are apparent at the time. If, however, the operation should be decided upon in the presence of such risks, the entire uterus should be removed after delivery of the child. Operative Technique.— (a) Conservative Casarean Section.—When un- dertaken for the absolute, or even for the enlarged relative, indication, the operation will give almost ideal results if performed at an appointed time, a day or so prior to the end of pregnancy, or within a fewr hours after the onset of labor. In many cases, however, especially in hospital practice, this is out of the question, inasmuch as the patient is often not seen until she is well advanced in labor. 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, after she has received a full bath, the abdomen should be shaved, disinfected, and covered with a bichloride compress. The bowels should be evacuated by an appropriate cathartic, and an enema given a few hours before she is put upon the table. Just before the beginning of the operation, the bladder is catheterized and the abdomen redisinfected in the usual manner with permanganate of potassium, oxalic acid, bichloride of mercury, alcohol, and ether. 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, 40 minims of ergotole should be administered hypodermically at this time. If the patient is not seen until labor has set in, similar preparations should be made, except that the bath and the administration of a cathartic must, of course, be dispensed with. In addition to the operator, four assistants are needed, one to give the anaesthetic, one to assist directly at the wound, and two to handle the in- struments, ligatures, and sponges. With the exception of the anaesthetist, all should wear rubber gloves throughout the operation. 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, an abdominal retractor, a needle-holder and appropriate needles, as well as the usual sterile dressings, suture materials, and gauze sponges. An incision from 16 to 18 centimeters long should be made in the linea alba about two-thirds below and one-third above the umbilicus. In this way injury to the bladder, wdiich often extends one-third of the distance between the symphysis and umbilicus, is avoided. The abdominal walls are 454 CESAREAN SECT [ON usually very thin and bleed but little, rarely more than two or three clamps being required to check haemorrhage. The uterus will be found immediately beneath the incision. It should then be delivered through the abdominal opening, and not cut into until the edges of the latter have been clamped together posterior to the cervix, and covered with a sterile towel, so that all possibility of contaminating the abdominal cavity may be avoided. The anterior surface of the uterus is opened longitudinally along its middle line. This is best accomplished by making an incision a few centimeters long with a scalpel, and then rapidly enlarging it with the scissors to 16 to 18 centimeters. The membranes are then ruptured, the child is seized by one foot and rapidly 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 and the birth of the child. Many authorities recommend that an attempt be made to locate the position of the placenta beforehand, so that the incision may be made in such a way 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 haemorrhage, but as the operation is necessarily bloody, and as the bleed- ing is only momentary, it is without significance. Immediately after the delivery of the child, the uterus contracts down and haemorrhage practically ceases. If the placenta and membranes have not become separated spon- taneously, 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 operation 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 haemorrhage, Litzmann recommended that an elastic liga- ture be applied about the cervix before opening the uterus. This is, how- ever, an unnecessary precaution; nor is it devoid of danger, as the pro- longed compression predisposes to uterine atony and haemorrhage 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 haemorrhage 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 that, the course of blood-vessels in that location being parallel to the in- cision, the haemorrhage would therefore be less. His proposal was at once tested by many operators, and H. Schroeder has collected 94 cases so oper- ated upon. The results were excellent, but not better than those following the more usual incision. There would appear to be no especial advantage in adopting Fritsch's suggestion, except in the small number of cases in which it is desired to sterilize the patient by excising the tubes. On the other hand, the intes- tines and omentum are more liable to become adherent to the uterine wound OPERATIVE TECHNIQUE 455 than with the longitudinal incision. 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 time, should infection occur with the former incision, virulent material is more liable to gain access to the general peritoneal cavity; while, if it occurs with the latter, the abscess has more chance of opening through the abdominal wound. No matter which incision has been employed, it is then closed by deep and superficial formol or chromicized catgut sutures. The former are in- serted at intervals of about 1 centimeter, and extend through the entire thickness of the muscularis, avoiding the decidua. They are then tied and, if accurate approximation is not secured, the gaping margins of the wound nre. brought together by superficial catgut sutures which extend through the peritoneum and the upper layers of the muscularis. Recently it has been my practice1 to cover in all knots by means of a continuous sero-serous suture. This is readily accomplished, and is preferable to the original procedure of Sanger, in wdiich 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 Cwsarean Section.— Until after the delivery of the child, the operative steps are identical in the Porro and the conservative Caesarean seel ion. In the former, however, as the body of the uterus is to be ampu- tated, it is unnecessary to remove the placenta. As soon as the child is delivered an elastic ligature is tightly tied around the upper portion of the cervix. The infundibulo-pelvio 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 necessary, and the in-drawn scar which results. At present, when it is desirable to remove the body of the uterus, prac- tically the same technique is employed as in an ordinary supravaginal hysterectomy with retention of the ovaries. 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 peritoneal 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, cov- 456 CESAREAN SECTION ered 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. The operation is readily performed, and can be completed in less time than is required for an ordinary Caesarean section; for, owing to the laxness of the pelvic floor and the abdominal walls, 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 Caesarean section, and at the present time, under thoroughly aseptic conditions, the operation gives satisfactory results. The technique is identical with 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 hysterectomy is rarely indicated except in cancer of the uterus, or in occasional cases of infection. (d) Extra-peritoneal Casarean Section.—Frank, of Cologne, in 1907, reported 13 cases upon which he had operated by a new method, which he considers far superior to the typical Caesarean section whenever there is any possibility of infection having occurred prior to the operation. 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 and the child and placenta removed, and the wound closed. By this method the entire operation is done extraperitoneally, and, accord- ing to its inventor, may be safely employed in cases in which the conser- vative Caesarean section would be contra-indicated. The procedure was more or less modified by Latzo, Sellheim, and others, and was enthusiastically taken up in Germany. The results, how- ever, were not as encouraging as anticipated, for Holzapfel, in 1909, reported a gross and net mortality of 8 and 5.5 per cent, in the cases col- lected from the literature, and Roemer, in 1911, one of 7.2 and 6 per cent. In many instances the peritoneum was torn through, thereby depriving the operation of one of its supposed advantages; while the susceptibility of the extensive connective wound to infection soon demonstrated that the opera- tion was not adapted for employment in infected patients. Owing to the disadvantages of supra-symphyseal extra-peritoneal Caesar- ean section, Doederlein and Diihrssen resuscitated the operation of Laparo- elytrotomy, which had been recommended by Baudelocque in 1823, and rehabilitated by Gaillard Thomas in 1871, to be afterward abandoned in favor of the classical Caesarean section. In this operation a long oblique incision parallel to Poupart's ligament gives access to the pelvic connective tissue and to the lateral aspect of the lower uterine segment, which is then incised and the child extracted by forceps. Doederlein, who reported 32 such cases, states that the operation can be readily performed, but that the wound healing is somewhat complicated, and that drainage is always CHOICE OF OPERATION 457 necessary. As neither of these operations are available for use in infected patients, are more difficult to perform, and do not give better results than the classical Ca'sarean section, it is questionable whether they will per- manently displace it after the novelty attending their employment has disap- peared. Choice of Operation.—In the vast majority of cases the conservative Cesarean section is the operation of choice, as it is readily performed and gives very satisfactory results. On the other hand, when there is any pos- sibility of infection, complete, or at least supravaginal, hysterectomy should be done. When the uterus is the seat of tumor formation, as well as in those cases in which osteomalacia is the cause of the pelvic deformity, or in which persistent haemorrhage, resulting from uterine atony complicates the conservative operation, supravaginal hysterectomy is also the operation of choice. In doing a Caesarean section, the question often arises as to the ad- visability 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 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 supravaginal ampu- tation is safer and can be done more rapidly than the conservative opera- tion followed by excision of the tubes or ovaries. Furthermore, the con- valescence following the former operation is more satisfactory, the differ- ence being quite as marked as that observed in the treatment of uterine myomata by supravaginal amputation or by multiple myomectomy, re- spectively. It was formerly believed that sterilization could be effected by ligating the proximal end of either tube; but experience has shown that the liga- tures 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 con- ception, since the ligatures may be absorbed and the cut ends of the tube become united. In order, therefore, to render a woman permanently sterile by an operation upon the tubes, they must be excised by wedge-shaped incisions at the cornua of the uterus and the wounds closed by sutures. When this is to be done, the fundal incision is preferable, as it can readily be extended to the cornua of the uterus after the extraction of the child. 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 haemorrhage result. The opinion of those authorities who consider that sterilization should 458 CESAREAN SECTION form an integral part of every Caesarean section is certainly open to ques- tion. If the patient is intelligent, the decision should be left to her or her family, but at the same time the undesirability of a one child marriage should be strongly urged; whereas with the ignorant it is incumbent upon the physician to do what he thinks is best under the circumstances. Per- sonally, I should be unwilling to sterilize the patient at the first operation, unless she 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 per- fectly justifiable. 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 technique, there has been a corresponding steady improvement in the results: Caruso collected from the literature 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, but even at present it is not as low as many writers would have us believe, and does not average much below 10 per cent. Thus, Routh reported a mortality of 9.7 per cent, in 1058 classical sections performed by 100 English operators who were alive on June 1, 1910; Green and Newell one of 8 per cent, in 100 operations in the Boston Lying-in Hospital, and McPherson a gross and corrected mortality of 16.15 and 4.08 per cent, respectively, in 186 operations performed in the New York Lying-in Hospital. 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 Reynolds and Leopold 23 and 70 operations, respec- tively, wdth no deaths. That such results cannot be permanently main- tained is shown by the results in Leopold's clinic, where a gross and cor- rected mortality of 6.2 and 3.3 per cent, respectively, was noted in 303 operations performed up to 1910. No matter how good the operator, or how perfect his technique, it would appear that the mortality, even in apparently uninfected women, will depend in great part upon the period of labor at which the operation is undertaken. Reynolds analyzed 289 cases in this regard, and, upon divid- ing them into three groups, according as the operations were done before labor, or early or late in labor, found a mortality 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 rup- ture of the membranes, 10.8 per cent, after their rupture, and 34.3 per cent, following repeated examination or previous attempts at delivery. My own experience has been similar, so that I hold that the results following conservative Caesarean section will approximate those obtained in ordinary gynecological laparotomies only when the operation is under- taken at an appointed time at the end of pregnancv or during the first hours of labor; whereas they become rapidly worse with each hour elapsing after rupture of the membranes. In the first period one may reckon upon REPEATED CESAREAN SECTION 459 a mortality of only 1 or 2 per cent., as compared with 10 or more per cent. when the patient has been subjected to a test of the second stage of labor. For these reasons I consider that the conservative operation should be performed late in labor only when the disproportion is so great that a living child cannot be obtained by any other means, and should be replaced by pubiotomy or supravaginal hysterectomy in "border line" cases, which require interference after a test of the second stage. Finally, it should be remembered that when performed by inexperienced operators upon patients in poor condition and amid unhygienic surroundings the results will be most disastrous. The mortality following the typical Porro operation, as well as the supravaginal amputation of the uterus with retroperitoneal treatment of the stump, likewise shows a marked decrease. Thus, the tabulation by Harris of 441 Porro 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 retroperitoneal treat- ment of the stump was reduced from 85.7 per cent, to 16.6 per cent. In 177 operations more recently reported 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. On the other hand, when performed upon infected patients, no matter what method be employed, the results of the operation are still extremely unsatis- factory, ■ Doktor, of Budapest, having collected 22 such cases, with a mor- tality of 23.5 per cent. This marvelous diminution in mortality is due to several factors. Primarily, of course, it must be attributed to the ever-increasing perfection of aseptic technique. At the same time careful examination of the pelvis before labor and the determination to operate wdiile the patient is in good condition, instead of only after the failure of other methods of delivery, have contributed markedly to the improvement. Repeated Caesarean Section.—The performance of conservative Cae- 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 affect recovery at the subsequent operation. Leopold speaks of a pa- tient upon whom he operated four times, while Ahlfeld and Birnbaum have reported cases of women who underwent five Caesarean sections. The sta- tistics of Haven and Young, published in 1903, show 88 cases with 2, 26 with 3, 5 with 4, and 1 case with 5 operations; while Friihinsholz collected 52 instances in which the operation had been performed for a third time upon the same patient. The occurrence of pregnancy after a Caesarean section, however, is not always devoid of danger, as Woyer, Targett, and Kerr have reported cases in wdiich the uterine cicatrix ruptured in the latter part of the subsequent gestation. This, however, is a very unusual occurrence, Brodhead being able to collect but 20 cases from the literature up to 1908. It is also stated that the adhesions wdiich sometimes form between the uterus and the an- 460 SYMPHYSEOTOMY terior abdominal wall occasionally exert a deleterious influence in subse- quent pregnancies. Aside, however, from the slight discomfort incident to their stretching, no serious consequences have been observed, and in not a few cases the subsequent operation has been done through the old adhesions without opening into the general peritoneal cavity. Vaginal Ccesarean section has already been considered in the chapter upon accouchement force. Post-mortem Caesarean Section.—From the earliest times, when a pa- tient died undelivered in the neighborhood of full term, Caesarean section was sometimes performed immediately after her death, in the hope of saving the life of the child. The number of children rescued by the procedure, however, 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 cervix just before or immediately after death is more readily dilatable than at other times. 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 sufficient to permit the passage of a living child. History.—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 pre- viously 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 wras performed 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, Caesareans and Symphyseans. As a result of poor technique and its em- ployment 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 impressed 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 sym- physeotomies had been performed in his clinic. The anatomical 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 EFFECT UPON THE SIZE OF THE PELVIS 461 by a paper entitled The Remarkable Results of Antiseptic Symphyseotomy, read at the 1892 meeting of the American Gynaecological Society. Stimu- lated by this report, Jewett, a few months later, performed the first opera- tion in America, and was soon followed by many others. Since then the question of symphyseotomy has been a burning one, and was the main theme .of discussion at the German Gynaecological Congress in 1893, the International Medical Congress in 1897, and the Obstetrical Society of France in 1899. Effect of Symphyseotomy upon the Size of the Pelvis.—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 de- pressed downward. As a result of these changes the capacity of the pelvic Fig. 422.—Diagram Showing Effect of Symphyseotomy (Farabeuf). canal becomes considerably increased, particularly in its transverse and oblique, and less so in its antero-posterior, 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. According to Farabeuf this estimate is not strictly correct, as the in- crease 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 32 462 SYMPHYSEOTOMY bones gape 6 to 7 centimeters the area of the superior strait is increased by one half. Indications.—As the indications for symphyseotomy are identical with those of pubiotomy, they will be considered under the latter. Method of Operating.—The patient should lie upon her back with the buttocks at the edge of the table, and the flexed legs held by assistants. After the external genitalia, Mons Veneris, and lower portion of the abdo- men have been shaved and cleaned as carefully as for an abdominal opera- tion, everything except the Mons Veneris and lowest portion of the abdo- men should be covered with sterile towels. An incision is made in the middle line from a few centimeters above the upper margin of the sym- physis almost to its lower margin, extending through the skin and sub- cutaneous fat down to the fascia upon its anterior surface. A finger is passed behind the symphysis, and separates the underlying tissues, until its lower margin is perfectly free. This step is frequently accompanied by profuse haemorrhage from the antevesical plexus. The attachments of the clitoris to the lower margin of the symphysis are then separated by blunt dissection, after which a catheter is passed into the urethra and pushes it downward and to one side. The pubic cartilage is then cut through with a strong knife, either from its anterior or posterior surface. In the latter case a blunt-pointed bistoury is passed behind the symphysis and the sec- tion made from below upward. In many cases the pubic bones do not spring apart after the symphysis has been cut through, being held in position by the strong subpubic liga- ment, although as soon as this has been severed they will gape several centimeters. They should not be allowed to separate more than 6 centi- meters, any tendency toward excessive gaping being counteracted by hav- ing the assistants make firm pressure upon the trochanters. Following section of the symphysis, there is usually a profuse venous haemorrhage, which is best controlled by packing the wound with sterile gauze, clamps and ligatures not being available. After symphyseotomy, the child should be delivered by forceps or ver- sion, according to circumstances, although Zweifel and others recommend that the patient be put back to bed, and labor allowed to end spontaneously. During the extraction firm pressure should be made upon the trochanters on either side to prevent too wide a separation of the symphysis and conse- quent injury to the sacro-iliac joints. Owing to the fact that the anterior vaginal wall, bladder, and clitoris have been deprived of their natural sup- port, they are exposed to considerable tension and may be torn through, notwithstanding every precaution. By adducting the thighs after deliverv of the child, the ends of the pubie bones are brought together, so that the ligamentous structures upon their anterior surface can be united by mat- tress or figure-of-eight sutures, and the external wound is closed in the usual manner. Ayres, in 1896, recommended that the operation be performed subcu- taneously by making a small incision immediately over the clitoris through which a blunt-pointed knife is introduced, the symphysis being divided from behind forward and from below upward. Ten years later Zweifel PROGNOSIS 463 advocated that the section be made subcutaneously by means of a Gigli saw, just as in pubiotomy. In either event the employment of sutures is impossible. After the completion of the operation, the wound should be covered with sterile dressings and a broad strap of canvas applied over the tro- chanters and tightly buckled, the latter being well padded with cotton to avoid injurious pressure. The after-treatment is complicated and oner- ous. Frequent catheterization is necessary, and the patient must lie on her back for three or four weeks after the operation. During this period it is well to reinforce the action of the pelvic strap by placing the patient in a hammock bed, especially devised for the purpose, or by allowing the pelvis to rest upon two sand bags. Prognosis.—My experience leads me to consider- that symphyseotomy performed by the open method is a very serious operation, and one not to be lightly undertaken. In many cases the haemorrhage is exceedingly pro- fuse, and is calculated to disconcert an inexperienced operator. Moreover, the vaginal tears frequently extend through to the retropubic wound, and are not easy to repair. Occasionally the bladder is injured by the sharp end of one of the pubic bones, while more frequently the clitoris is wounded and gives rise to alarming haemorrhage. Such lesions should be repaired immediately, so as to avoid communication between the vagina and the pubic wound, or the formation of urinary fistuhv. Moreover, if the bones be allowed to gape too widely, serious injury mav be done to the sacro- iliac joints. If errors in technique have occurred during the operation, or the patient be already infected, the process may extend to the pubic wound and lead to destructive suppuration. Considerable apprehension has been expressed as to the possibility of failure of union at the symphysis pubis, and several cases have been re- ported by Miillcrheim which serve to show that the operation may perma- nently maim the patient. Fortunately, such accidents are extremely rare; although the investigations of Varnier by means of the Rbntgen ray show that there is greater motility at the symphysis than before the operation, the pubic bones being united by a. mass of fibrous tissue several centimeters wide. This does not necessarily lead to disturbances of locomotion, but the patients find that they tire more readily, and are less able to perform hard labor, than before the operation. It appears that symphyseotomy is sometimes followed by a slight but permanent increase in the size of the pelvis, which is sometimes sufficient to permit spontaneous labor in subsequent pregnancies. A number of such instances have been collected by Madame Wulff. Frank and others have suggested that deliberate attempts towrard permanent enlargement should be made by osteoplastic procedures. The analvsis by Neugebauer of 278 symphyseotomies indicated a ma- ternal mortality of 11.1 per cent; while in the 100 cases operated upon in Pinard's clinic there were 12 maternal deaths; and even after deducting a number of instances in which he considered that the fatal termination was due to other causes, the mortality was as high as 5 per cent. Bar, basing his conclusions upon 140 operations performed by himself, Pinard, Kiist- 464 PUBIOTOMY ner, and Zweifel, estimates the death rate at 6.7 per cent. The latter, in 1897, reported a series of 31 successful cases, but had 3 deaths in the fol- lowing 11 operations, a mortality of 7 per cent. The foetal mortality was 13 per cent, in Pinard's, and 9.39 per cent, in Bar's cases. Abel has compared the results obtained in 25 symphyseotomies and 50 Caesarean sections performed in Zweifel's clinic. There were, no maternal deaths in either series, but the convalescence was much more rapid and comfortable after the latter operation; and, what is more important, three to five weeks only were required before the patient was able to take up again her ordinary duties after it, as compared with thirteen weeks after symphyseotomy. • As these results became generally known the enthusiasm for sym- physeotomy gradually disappeared, and most obstetricians came to regard Caesarean section as a safer and more satisfactory operation. The extent of the reaction may be realized from the statement of Kehrer, that in 1905 Zweifel, Frank, and Baumm were the only wrell-known German obstetricians who continued to employ the operation. During the past few years a number of writers have rehabilitated the subcutaneous method of operating, and by limiting its employment to suit- able cases have obtained results comparable to those following pubiotomy. Thus Frank, in 1910, reported 60 such cases with only a single death. PUBIOTOMY This operation, which is more properly designated as hebotomy or hebosteotomy (from to rijs r/j3ris offffovv ), consists in obtaining a temporary 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 infection, 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 difficul- ties, 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 at- tachments 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 generally known to surgeons 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 fol- lowed by Oalderini 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. Technique.—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. TECHNIQUE 465 Then by means of a pair of artery forceps the saw was adjusted to the pos- terior surface of the bone, wdiich was then severed. In 1904 Doderlein modified the operation 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 separat- ing the periosteum, a curved instru- ment, somewhat like a large aneurism needle, was passed behind the bone and ]mshed through the labium ma- jus. The saw was then fastened to the lower end of the instrument, and brought into position by withdrawing it. In 1906 Sfoeckel and Kanncgies- ser reported that their respective chiefs, Bumm and Leopold, had per- formed the operation entirely subcu- taneously. For this purpose the in- strument was thrust through the up- per 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 (he symphysis pubis, the saw being adjusted by withdrawing the instru- ment from above downward. Up to January, 1912, my assist- ants or myself have performed 38 suc- cessful pubiotomies upon 36 patients, two women having been operated upon twice. As Doderlein''s method wras employed in all but the first case, and has proved most satisfactory, I shall describe its technique 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 assist- ants. An incision extending 21/. centimeters inward from the pubic spine is then made just above the upper margin of the pubic 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 posterior surface of the bone. Then a large pair of curved artery forceps, or an especially con- structed needle, is carried down along the posterior surface of the bone until its inferior margin is reached, when its handle is depressed in such a manner that its tip can be 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 is attached, and is drawn into position as the instrument is withdrawn through the up- Fig. 423. -Showing Incisions for Pubiotomy. 46G PUBIOTOMY per wound. The handles are then attached to the saw and a few move- ments suffice to sever the bone. Care should be taken that the bone is severed in the desired direction, and the movements 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, when 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, Fig. 424.—Showing Position of Patient and Gigli Saw. but in all of my cases the haemorrhage was readily controlled by firm pres- sure 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 ad- vantage in waiting for its spontaneous expulsion, as recommended by Doderlein and Zweifel. As traction is made, the ends of the bone will gape more widely, but a separation of more than 5 or 6 centimeters should lie avoided by having the assistants make firm pressure upon the thighs. While waiting for separation of the placenta, a small 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 applied over the upper wound, and a long strip of adhesive plaster six inches wide passed around the body so as to make firm and equal pressure over the sides of the pelvis and upper part of the thighs. This is not 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 wdiich she begins to move freely on the second or third dav. She is not catheterized unless necessary, and is kept in bed for fourteen days, being allowed 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. PROGNOSIS 467 I have had no experience with the purely subcutaneous operation, but Uoemer states that it is followed by injuries to the bladder twice as fre- quently as wdien Doderlein's technique is employed, so that it would seem that the possibility of injuring the bladder is somewhat lessened by separat- ing the tissues posterior to the bone with the fingers. Healing of the bone wound occurs more frequently by fibrous than by bony union, being noted in all of my patients. If the latter has not become established within the first few weeks following the operation, it will not occur at all. This, however, has no effect upon locomotion, as all of my patients, upon reexamination some months later, stated that they were able to walk as wrell and work as hard as previously. Moreover, the occur- rence of fibrous union should be regarded rather as a favorable outcome, for the reason that it sometimes leads to a slight enlargement of the pelvic diameters, which may be still further accentuated in a subsequent preg- nancy by the softening and relaxation incident to the increased hyperemia attending that condition. Occasionally this may be sufficient to permit spontaneous labor, which occurred in several of my patients, although the children were several hundred grams heavier than those which previously necessitated pubiotomy. Such an outcome, however, cannot always be ex- pected, yet it occurs sufficiently frequently to permit it being urged as an argument in favor of the operation. This is especially the case in funnel pelves, and in two of my patients the distance between the tubers became enlarged to such an extent as to overcome the deformity permanently, and thus permit subsequent spontaneous labors. Prognosis.—Maier, in 19»)7, and Schlafli, in 1909, collected 207 and 700 operations from the literature with a mortality of 5.6 and 1.82 per cent, re- spectively. I do not consider that such figures correctly represent the real dangers of the operation, as Schliifli's statistics are based upon the results of 112 operators, many of whom had little experience, and naturally could not be expected to obtain the best results. On the other hand, Doderlein states that in 321 pubiotomies performed in 7 German clinics up to 1910, the mortality was 1.8 per cent., and my own experience and study indicate that it should not exceed 1 or 2 per cent. This is comparable to the re- sults following early elective (Cesarean section, and far superior to those obtained when it is performed after a test of the second stage of labor. Usually the haemorrhage, 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 neces- sary to lay the entire wound open to ligate the bleeding vessel. Very ex- ceptionally, even this is not possible, and one of Rosthorn's patients died from uncontrollable haemorrhage. Moreover, deep vaginal tears occasionally occur during the extraction of the child, and require immediate repair; wdiile less frequently 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 hori- zontal instead of upward traction wdien delivering the bead, and by avoid- ing undue violence, the occurrence of such accidents can be minimized. In 468 PUBIOTOMY only one of my cases was the bladder injured, and in only a few was the vagina torn, notwithstanding the fact that more than one half of the patients were primiparae. Convalescence in general is very satisfactory, and the patients complain of but little pain or discomfort. In nearly one half of the cases the puer- perium is somewhat febrile, but only one of my patients was seriously ill. In many instances there is considerable oedema about the vulva, and occa- sionally haematomata 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 contraindicated when it is dead or the conjugata vera measures 7 centimeters or less. Accordingly, it scarcely enters into competition with Cesarean section, except for the broadened relative indication. As far as my experience justifies conclusions, I feel that one may look forward to pubiotomy practically displacing Caesarean section in the so-called "border- line" cases, when several hours of second-stage pains have demonstrated that the head cannot pass the superior strait. Pubiotomy can be safely per- formed under such circumstances, wdiile the prognosis for Caesarean section becomes progressively worse the later in labor it is performed. On the other hand, if one feels reasonably sure; either from the size of the child or the history of the previous labors, that interference will be necessary, I consider that the patient should not be subjected to the test of labor, but that Caesarean section should be done at an appointed time before its onset. 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 for-' ceps, version, or craniotomy in moderate degrees of contracted pelvis when the mother is in good condition. It is especially indicated in certain cases of funnel-shaped pelvis, as well as in face presentations when the chin has rotated into the hollow of the sacrum. I do not believe that the operation should be undertaken wdien signs of infection are present, as the interests of the mother will be better served by craniotomy or Caesarean section followed by the removal of the uterus. For the present, at least, I feel that the employment of pubiotomy should be limited to well-equipped hospitals or the practice of experts, since sev- eral 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. LITEEATUEE Abel. Vergleich der Dauererfolge nach Symphyseotomie und Sectio Caesarea. Archiv f. Gyn., 1899, lviii, 294-367. Ahlfeld. Lehrbuch der Geburtshiilfe. II. Aufl., 1898, 547. Ayres. Symphyseotomy, etc. New York Polyclinic, 1896, vii, 129-139. Bar. De 1'operation cesarienne conservative, etc. L'Obstetrique, 1899, iv, 193-230. La symphyseotomie. Ses resultats immediates st eloignes, etc. L'Obstetrique, 1899, iv, 305-384. LITERATURE 469 Lemons 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., 17S9, ii, 461-561. Bauhin. 'ycrrepoTonoToiua. Fr. Eousseti, etc. Basil, 1588. Birnbaum. 5 Kaiserschnitte bei einer Person. Archiv f. Gyn., 1885, xxv, 422. Bischoff. Die totale Exstirpation des schwangeren und carcinomatosen Uterus. (!orrespondenzbl. f. Schweizer Aerzte, 1880, Nr. 6. Braun-Fernwald. Ueber den in den letzten 10 Jahren ausgefiihrten Sectiones Caesarea?, Archiv 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 ac- couchements, 1901, iv, 456-489. Caruso. Die neuesten Ergebnisse des conservativen Kaiserschnittes mit Uterusnaht. Archiv f. Gyn., 1888, xxxiii, 211-269. Chrobak. Quoted by Braun-Fernwald. Doderlein. Exp. anat. Untersuchungen iiber die Symphyseotomie. Verh. d. deutschen Gesell. f. Gyn., 1893, v, 27-34. Ueber alte u. neue beckenerweiternde Operationen. Archiv f. Gyn., 1904, lxxii, 275-293. Ueber extra-peritonealen Kaiserschnitt u. Hebosteotomie. Monatsschr. f. Geb. u. Gyn., 1911, xxxiii, 1-21. Doktor. Kaiserschnitt bei Sepsis. Archiv f. Gyn., 1899, lix, 200-216. Duhrssen. Die neue Geburtshilfe und der praktische Arzt. Volkmann's Sammlung klin. Vortrage, 1909, No. 549-550. Farabeuf. Sur la symphyseotomie. Annales de gyn. et d'obst., 1894, xii, 407-431. Felkin. Quoted by Ploss. Das Weib in der Natur- und Volkerkunde, IV. Aufl., 1895, ii, 297. Fraenkel, L. Experimente zur Herbeifiihrung der Unwegsamkeit der Eileiter. Archiv f. Gyn., 1899, lviii, 374-410. Frank. Ueber den subkutanen Symphysenschnitt, etc. Monatsschr. f. Geb. n. Gyn., 1910, xxxii, 680-692. Fritsch. Ein neuer Schnitt bei der Sectio Caesarea. Zentralbl. f. Gyn., 1897, xxi, 561-565. Fruhixsuolz. De 1'operation cesarienne repete 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. Green :md Newell. 100 Caesarean Sections Performed in the Boston Lying-in Hospital. Boston Med. and Surg. Jour., 1909, Dec. 2nd. Halbertsma. Eclampsia gravidarum. Eine neue Indikationsstellung fiir die Sectio Caesarea. Zentralbl. f. Gyn., 1889, xiii, 901. Harris. Eemarks 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. 470 CESAREAN SECTION AND PUBIOTOMY The Remarkable Results of Antiseptic Symphyseotomy. Trans. Amer. <-yn. Soc, 1892, xvii, 98-126. The Porro Cesarean Section Tested by a Trial of Sixteen Years, etc. N. Y. Jour. of Gyn. and Obst., 1893, iii, 273-28.*!. Haven and Young. Repeated Cesarean Section upon the Same Individual. Am. Jour. Obst., 1903, xlviii, No. 4. Holzapfel. Kaiserschnitt bei Mastdarmkrebs. Beitrage zur Geb. u. Gyn., 1899, ii, 59-77. Sectio caesarea abdominalis inferior. Volkmann's Sammlung klin. Vortrage, 1909. No. 534-535. Jewett. A Case of Symphyseotomy. Brooklyn Med. Jour., 1892, vi, 790-792. Kannegeisser. Beitrag zur Hebotomie auf Grund von 21 Fiille. Archiv f. Gyn., 1906, lxxviii, 52-105. Kehrer. Symphyseotomie und Pubiotomie. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 228-372, 361-374. Kerr. Notes on a Case of Spontaneous Rupture of the Uterus during Pregnancy through the Cicatrix of a Caesarean Section Wound. Jour. Obst. and Gyn. Brit. Emp., 1904, vi, 378-383. Kronig. Zur Behandlung der Placenta praevia. Beitrage z. Geb. u. Gyn., 1909, xiii, 477-479. Latzo. Ueber den extra-peritonealen Kaiserschnitt. Zentralbl. f. Gyn., 1909, 275-283. Lebas. Jour de Med. et de Chirurgie, 1770, xxxiv (supplement). Leopold. Welche Stellung nimmt die klassiche Sectio caesarea, etc. Archiv f. Gyn., 1910, xci, 453-460. Leopold und Haake. Ueber 100 Sectiones Caesarea:. Archiv f. Gyn., 1898, Hv, 1-41. Litzmann. Kaiserschnitt mit temporarer Ligatur des Cervix. Zentralbl. f. Gyn., 1879, iii, 289-295. McPherson. Abdominal Caesarean Section, etc. Jour. Amer. Med. Ass., 1908, li, 734-739. Maier. Der gegenwartige Stand der Hebotomie. D. I., Tubingen, 1907. Montgomery. Pubiotomy and Its Relative Indications. Am. Jour. Obst., 1906, liv, 771-781. Morisaxi. De la symphyseotomie. Annales de gyn. et d'obst., 1881, xvi, 444-445. Mullerheim. Die Symphyseotomie. Volkmann's Sammlung klin. Vortrage, 1894, Nr. 91, 1-54. Neugebauer. Ueber die Rehabilitation der Schamfugentrennung, etc. Leipzig, 1893. Pinard. De la symphyseotomie. 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. Du soi-disant foeticide therapeutique. Annales de gyn. et d'obst., 1900, liii, 1-18. Porro. Delia amputazione utero-ovarica, etc. Milan, 1876. Reynolds. Circumstances Which Render the Elective Section Justifiable in the In- terest of the Child Alone. Amer. Med., 1901, ii, 180-49."., September 28. Primary Ca'saiean Section, etc. Jour. Amer. Med. Ass., 1907, xlix, 1329-1333. Roemer. Statistisches zur Hebosteotomie u. zum suprasymphysaren Kaiserschnitt. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 317-327. 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. LITERATURE 471 Schlafli. /OO Hebosteotomien. Zeitschr. f. Geb. u. Gyn., 1909, Ixiv, 85-135. Schroeder, H. Zur Kaiserschnittsfrage. Monatsschr. f. Geb. u. Gyn., 1901, xiii 22-39, und 206 230. Sellheim. Der extra-peritoneale Uterusschnitt. Zentralbl. f. Gyn., 19(is, 133-142. Sigaolt. Discours sur les avautages de la section de la symphyse dans les accouehe- mens, 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. Gyr.., 1906, xxx, 78-84. Storer. Extirpation of the Puerperal Uterus by Abdominal Section. Jour. Gyn. Soc. of Boston, 18(11, i. 223. 'I'argett. Rupture of Uterus in Old Caesarean Section Cicatrix. Trans. Lond. Obst. Soc, 1900, p. 242. Thomas. Gastro-elytrotomy: A Substitute for the Cesarean Section. Amer. Jour. Obst., 1871, iii, 125-139. Trautmann. See Siebold, Yersuch einer Geschicht der Geburtshiilfe, 1815, ii, 108-111. Van de Velde. Die Hebotomie. Zentralbl. f. Gyn., 1902, xxvi, 969-976. Varnier. Etude anat. et radiographique de la symphyseotomie. Comptes rendus de la hoc. d'obst., de gyn., et de ped. de Paris, 1899, i, 208 2-13. Williams. Pelvic Indications for the Performance of Ca'sarean Section. Amer. Med., 1901, September 28; Trans. Amer. Gyn. Soc, 1901, xxvi, 260 276. Is Pubiotomy a Justifiable Operation? (Second communication). Am. J. Obst., 1910, Ixi, No. 5. Woyer. P]in Fall von Spontanruptur des schwangeren Uterus in der alten Kaiser- schnittsnarbe. Monatsschr. f. Geb. u. Gyn., 1897, vi, 192 200. Ueber Symphyseotomie. Monatsschr. f. Geb. u. Gyn., 18!>7, vi, 227. Zweifel. Die subcutane Symphyseotomie. Zentralbl. f. Gyn., 1906, 737-742. CHAPTER XXIII DESTRUCTIVE OPI^RATIONS CRANIOTOMY Under this heading arc included all operations which bring about a decrease in the size of the fcetal head, with a view to rendering its delivery easier. Prior to the introduction of podalic version and forceps, artificial de- livery 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 obstetricians armamentarium. Increased dexterity in the employment of forceps and version, however, brought about a rapid change, and craniotomy upon the living child be- came rarer and rarer. Indications.—Craniotomy is positively contra-indicated when the con- jugata vera measures less than 5.5 centimeters, since in such cases the extraction of the child, even after the skull has been crushed, is attended by a greater maternal mortality than Cesarean section. On the other hand, in pelves above this limit, craniotomy may be indicated under any condi- tions that render the delivery of a mutilated child the most conservative procedure, so far as the safety of the mother is concerned. 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 considerations should never deter the operator from resorting to it. On the other hand, if the child is alive, the operation is justifiable only in exceptional cases; indeed, Pinard and some others go so far as to hold that, in view of the satisfactory results obtained from pubiotomy and Caesarean 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 readily conceivable that conditions may arise under which craniotomy upon the living child may not only be perfectly justifiable, but even imperatively demanded. Generally speaking, craniotomy should not be performed upon the living child if the mother is in good condition, amid suitable surroundings, and in the hands of a competent operator. Under such circumstances, if the 472 CRANIOTOMY 473 obstacle to labor be due to a contracted pelvis or a large child; Caesarean section or, in ceitain cases, pubiotomy is preferable, inasmuch as the slightly increased risk to the mother is more than compensated for bv the rescue of her offspring. On the other hand, if the woman is not seen until she lias been in the second stage of labor for a considerable time, and has been subjected to repeated vaginal examinations, Cesarean section is clearly contra-indicated, as is also pubiotomy if signs of infection be present. In such cases the child should be sacrificed in the interests of the mother. Again, if the child is not in good 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 sum- mon sufficient assistance, and is without the necessary appliances for an aseptic operation, Ca'saroan«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 im- perative in the interests of the mother, and then only after the failure of forceps. If, however, such a patient should again become pregnant, she should be sent to a city where proper treatment can be obtained, as I consider that a physician who repeatedly performs craniotomy upon the same patient is but little better than a professional 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 necessarv, 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 Ca'sarean 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 until the external os has become completely dilated, as the imperfectly opened canal may offer a serious obstacle to the extraction of the child. Method of Operating.—The patient should be brought to the edge of the bed or table, placed in the lithotomy position, and prepared as for an ordinary obstetrical operation. Craniot- /^S oniy usually includes two steps; first. ^W^^pgSMniiefwj. — ^_^ the perforation of the head and evacua- ^^ tion of its contents; and, secondly, the Fig. 425.—Smellie's Scissors. extraction of the mutilated child. Numerous instruments have been devised for perforating the head, the most suitable of which are Smellie's scissors or Blot's perforator. Braun's 474 DESTRUCTIVE OPERATIONS 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 fontanelle, as may be most convenient, is located, and the perforator plunged through it. The opening is then enlarged and the instrument briskly jnoved about Fig. 426.—Method of Perforating Head (American Text-Book). within the skull so as to disintegrate the brain to such an extent that it can be washed out with a douche of sterile water. If, however, the bead is movable above the superior strait, it must be firmly fixed by means of pressure exerted by an assistant through the ab- dominal walls. To avoid wounding the maternal soft parts, the perfora- tion should be made through the portion of the head lying in the neigh- borhood 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 brow. To pierce the after-coming head, the body of the child should be de- pressed, 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 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 evacu- ated by cutting through the arch of one of the cervical vertebra, 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. although the vault of the cranium collapses and offers no further obstacle to labor, the base of the skull still remains unchanged and, as the bimastoid diameter measures between 7 and CRANIOTOMY 175 7.5 centimeters, it is obvious that it cannot be delivered through a mark- edly contracted pelvis until it has been diminished in size. When the conjugata vera exceeds that limit, the collapsed head may be expelled by the uterine contractions alone, or may be extracted by means Fig. 427.—Braun's Cranioclast. of the forceps or a finger introduced through the perforation opening. But even in pelves of this size it is usually advisable to make use of a special instrument for grasping and crashing the base of the skull. The cranioclast, invented by Simpson and modified by Carl Braun, serves the purpose most satisfactorily. One 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 tightened, 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. For crushing and extract- ing the head Baudelocque the younger invented the cephalo- tribe. 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. "FlG.'42s._Heai, ckushed by Ci^moclast The instrument has been sub- (Simpson). jected 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, wdienever it is 476 DESTRUCTIVE OPERATIONS so constructed 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 which combines in one the advantages of the perforator, cranioclast, and Fig. 429.—Tarnier's Cephalotribe. cephalotribe. One blade is spear-pointed, and after serving as a perforator 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 Fig. 430.—Tarnier's Basiotribe, Disarticulated. that the base of the skull is fractured 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. Fig. 431.—Tarnier's Basiotribe. Sir A. P. Simpson, of Edinburgh, devised an instrument known as the basilyst-tractor, wdiich likewise consists of three blades. The tips of two of them come together and form a screw-like instrnment. This first perforates the skull, and by a rotatory motion is then worked into the base, which is CRANIOTOMY 477 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 cranioclast (Figs. 433 and 434). The basi- lvst-tractor gives very satisfactory results, and according to its inventor will compress the base of the skull into a mass 3.5 centimeters 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 only a few millimeters thick. When this is perforated, the fluid filling the dilated ventricles of the brain escapes and the skull collapses, after which delivery is readily effected. Occasionally per- 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 con- tent 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, Pern ice having reported the case of an infant wdio survived craniotomy and grew up an idiot. Prognosis.—Tn moderate degrees of pelvic contraction, craniotomy, if properly performed in uninfected women, is almost devoid of dan- ger. On the other hand, when the conjugata vera measures 5.5 centimeters or less, the mortality exceeds that following Cesarean section. It must be remembered, however, that, if the operation ) Fio. 432.- -Effect of Basio- tribe. Fig. 433.—Simpson's Basilyst, Disarticulated be deferred until infection has occurred, it is a serious procedure, and is attended by a considerable mortality. 33 478 DESTRUCTIVE OPERATIONS 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. Fig. 434.—Simpson's Basilyst, Articulated. At present evisceration is rarely employed, though it occasionally be- comes necessary in order to effect the delivery of certain monstrosities, or children suffering from.unusual enlargement of the thoracic or abdominal cavities, resulting from tumor formation or the accumulation of fluid. 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, suf- ficiently large to admit two fingers, with which the viscera are then 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 exceptionally the condition is overlooked, and assistance is not called for until one shoulder has become firmly impacted in the pelvic canal, the lower uterine segment at the same time being so stretched as to make an attempt at version practically synonymous with rupture of the uterus. Under such cir- Fig. 435.—Braun's Blunt Hook. ^0 CUmstances the child can be delivered only by Caesarean section or decapitation. The former may be indicated if the foetal heart sounds are strong, the mother in good condition and earnestly desirous of a living child; while the latter is urgently indicated if the child is dead, and generally speaking is the operation in most neglected cases. It can readily be accomplished by means of Braun's blunt hook or of John Rams- botham's sickle knife, wdiich is extensively used in England. Fortunately, in neglected shoulder presentations, decapitation is usu- ally materially facilitated by the prolapse into the vagina of one arm. This having been seized and brought through the vulva, firm traction should EMBRYOTOMY 179 be exerted upon it so as to put the neck on the stretch as much as pos- sible. 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 possible. Wrhen in posi- tion, 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, wdiich at the same time is given a rotary movement, by wdiich the cervical verte- bra1 arc disarticulated, and on continu- ation of the motion the neck is readily severed from the body. If any resist- ance is offered by the skin, it may be cut with scissors. 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 manoeuvres similar to those employed for the delivery of the placenta, but if these prove unsuc- cessful a finger is introduced into the uterus and inserted into the mouth of the child, after which, as n rule, extrac- tion is readily effected by traction upon the 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 trachelorhekter, which consists essen- tially 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 decapi- Fig. 436.—Decapitation with Braun's Blunt Hook (American Text-Book). Fig. 437. Fig. 4'AS. Figs. 437, 438.—Showing Mode of Action of Blunt Hook (American Text-Book). 480 DESTRUCTIVE OPERATIONS tation by means of Braun's hook. Again, if the latter be not available, the 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, proposed by Yon Herff and Strassmann, 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. LITERATURE Bar. Embryotomie cephalique. Paris, 1889. Baudelocque. Nouveau moyen pour delivrer les femmes contrefaites et en travail. Paris, 1829. Braun. Ueber das technische Verfahren bei vernachlassigten Querlagen, etc. Wiener med. Wochenschr., 1861, No. 45. Von Herff. Die Zertriimmerung des Schultergiirtels (Kleideotomie). Archiv f. Gyn., 1895, liii, 542-546. 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. Simpson, A. E. Delivery by Basilysis. Scottish Med. and Surg. Jour., 1900 (May). Simpson, J. Y. Cranioclast. Med. News and Gaz., 1860, vol. i. Strassmann. Ueber die Geburt der Schultern und iiber den Schliisselbeinschnitt (Cleidotomie). Archiv f. Gyn., 1897, liii, 135-143. Tarnier. Le basiotribe. Acad, de med. de Paris, 1883, December 11. Annales de gyn. et d'obst., 1884, xxi, 74-77. Zweifel. Ueber die Dekapitation, etc. Zentralbl. f. Gyn., 1895, xix, 521-539. CHAPTER XXIV OPERATIVE PROCEDURES WHICH DO NOT AIM AT DELIVERY In this chapter will be considered a number of procedures usually desig- nated as minor operations, which may become necessary during pregnancy, labor, or the pueqierium. The Douche.—We 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 micro-organisms 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. Experimental work, however, has shown clearly that, with the exception of the gonococcus, the vaginal secretion during pregnancy rarely, if ever, harbors pyogenic bacteria, and that the prophylactic vaginal douche is unnecessary. Fur- thermore, clinical experience has demonstrated that it is not only useless but even directly harmful, as its routine employment is followed by a greater number of febrile cases during the puerperium than wdien it is omitted. This question will be dealt with more fully in the chapter upon puerperal infection. Accordingly, 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 gonorrhoeal infection. In such cases four liters of a hot 1 to 10,000 bichloride 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 in- fection 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. Many authorities recommend the employment of a prophylactic vaginal douche if the patient has been subjected to repeated examinations during labor by persons who habitually neglect ordinary aseptic precautions, and particularly if signs of infection are present. Owing to the impossibility of thoroughly disinfecting the vagina at that time, the value of such a procedure is questionable: but a douche consisting of several liters of hot sterile salt solution can do no harm. 481 482 PROCEDURES WHICH DO NOT AIM AT DELIVERY After the first week of the puerperium, the vaginal douche is frequently employed when the lochia present an offensive odor. It need 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 2y2-per- cent. 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 cul-de-sac, the application of heat by means of abundant douches of a hot fluid markedly alleviates suffering, hastens the maturation of the abscess, and prepares the way for its prompt evacuation. Before giving a vaginal douche, the external genitalia should be care- fully cleansed and the patient placed upon a douche pan as she lies in bedj or brought to the edge of the bed and placed in the obstetrical posi- tion 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 pres- sure. For the first ten Fig. 439.—Glass Douche Tube. days of the puerperium rigid aseptic precau- tions should be observed in the use of the 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 is productive of good. The most usual indication for its employment immediately after labor is afforded by post-partum 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 contraction, provided that fragments of the placenta are not retained in utero. The intra-uterine douche is also frequently employed during the puer- perium, especially in the presence of infection. It has, however, been greatly abused; for, while it must be admitted that it is frequently a most valuable therapeutic agent, 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 give rise to an extension of the process. On the other CURETTAGE 483 hand, wdien the symptoms are due to infection by the so-called putre- factive organisms, associated wdth retention of the lochial discharge, the introduction into the uterus of several liters of hot salt solution is fre- quently followed by an immediate fall of temperature and a permanent improvement in the condition of the patient. Usually a single douche brings about the desired result, though occasionally its repetition may be necessary. Sterile salt solution should be employed for intra-uterine douching, in- stead 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 wdiich have already invaded the endometrium. On the other hand, their use occasionally causes the death of the patient, particularly when bichloride of mercury is employed. On looking over the literature upon the subject some years ago, I collected over 40 cases in which death from mercurial poisoning fol- lowed the use. of such solutions for intra-uterine injection. Inasmuch as the administration of an intra-uterine douche must always be regarded as a serious matter, it should be given by the physician him- self and not delegated to the nurse, no matter how competent she may he; since the most rigid aseptic precautions are necessary, and failure in this regard may result in 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 douche-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 frequently occurs in this period, may become so bent as to offer a considerable 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 mem- brane of the uterus by means of a curette. The operation may be indi- cated 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. 337). The blunt curette is then introduced into the uterus and gently scrapes off the retained structures. The employment of an instrument, howrever, is rarely advisable, as it is far better to peel off the adherent placenta and membranes with one or two fingers, whose movements are controlled by the other hand, through 484 PROCEDURES WHICH DO NOT AIM AT DELIVERY the abdominal walls. After they are once loosened, the retained structures can be readily removed by means of the fingers or an ovum or placental forceps. The former procedure necessitates the introduction of the entire hand into the vagina, and can only be accomplished under anaesthesia. Fig. 440.—Curette. After the uterus has been emptied in such cases, the fingers are again introduced and carefully palpate its cavity, in order to make sure that the offending structures have been entirely removed and thereby to avert all danger of subsequent haemorrhage. If the curette is used, considerable portions of placenta may be left behind, wdiich may later give rise to bleed- ing and necessitate another operation. On several occasions I have seen cases in consultation in which haemorrhage 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 by but little danger, although, if the uterine contents bo 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 prae. tice is the loss of blood during the latter part of the puerperium, result- ing from im perfect involution of the uterus, which is frequently 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 infec- tion, 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 indications, as its routine employment is frequently more dangerous than the original infection, and has led to the death of many hundreds of women. (Generally s]leaking, it is contra-indicated when the infection is due to the strepto- coccus, as under such circumstances the lesions attending its use simply offer new areas for infection. On the other hand, it is often followed by excellent results when the so-called putrefactive organisms are producing the mischief, and particularly when the uterine cavity contains necrotic tissue or larger or smaller portions of degenerated placenta. Neverthe- less, even in this class of cases it is generally better to employ the fingers in emptying the uterus. The Tampon or Pack.—The vaginal tampon is occasionally indicated in the following conditions: inevitable abortion, certain cases of placenta O THE TAMPON OR PACK 4s;, praevia, and to dilate the cervix in the early months of pregnancy. Profuse haemorrhage 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 prwvia, when the lwinorrhage is alarming and the cervical canal is not sufficiently di- lated to admit a finger, certain authorities recom- mend the application of a tight tampon to the cer- vical canal and vagina. This effectually controls haemorrhage, and on its removal a few hours later the cervix will usually be sufficiently dilated to ad- mit two fingers, after wdiich combined version by the Braxton Hicks method can be performed, or a Champetier de Ribes's bal- loon introduced. In the early months of pregnancy a tightly ap- plied pack offers an un- certain means of dilating the cervix in any condi- tion wdiich demands the evacuation of the uterine contents, wdien rapid in- strumental dilatation ap- pears undesirable. This is particularly true in hyda- tid i form mole and in certain cases of so-called missed abortion. The best material for a vaginal tampon is gauze, wdiich is most con- veniently handled in the shape of roller-gauze bandages, 3 or 4 inches wide. which have previously been carefully sterilized. For the introduction of the pack, the patient should be brought to the edge of the bed and pre- Fig. 441.—Packing the Uterus for Post-partum hemorrhage. 486 PROCEDURES WHICH DO NOT AIM AT DELIVERY pared as for an operation. A bivalve, or preferably a Simon, speculum is then introduced into the vagina and the cervix seized with 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 uterus with iodoform gauze as a means of controlling haemorrhage. 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 pres- sure upon the bleeding vessels, but mechanically stimulates the uterus to renewed contraction. Plain sterilized gauze may be substituted for that impregnated with iodoform or other antiseptics. Before resorting to this procedure, however, it is essential that the hand be introduced into the uterus in order to ascertain that the haemor- rhage 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 ster- ilized 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. 441). The pack should be allowed to remain in place for twenty- four hours, after which it can be removed by traction upon its free end. Manual Removal of the Placenta.—When considering the treatment of the third stage of labor, it was pointed out that previous to the intro- duction 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 about 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 haemorrhage 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 haemor- rhage, the operation should not be resorted to merely to hasten the com- pletion of the third stage of labor. Generally speaking, in such cases, repeated attempts at expression by Crede's manceuvre should be persisted in for at least an hour, under anaesthesia, if necessary, and manual removal resorted to only after prolonged effort has shown that more conservative methods are ineffectual. The procedure is attended by grave danger, and offers a greater opportunity for infection than any other obstetrical manipu- lation. In the ordinary operations, such as forceps and version, the hand, when introduced into the uterus, is within the amniotic cavity, and con- sequently micro-organisms which may have been introduced along with it are cast off when the after-birth is expelled; whereas, in manual removal of the placenta the hand is inserted between the fcetal membranes and the MANUAL REMOVAL OF THE PLACENTA 487 uterine wall, and, in separating the placenta from its attachments, comes in direct contact with the thrombosed sinuses. The latter may be re- garded 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 re- disinfected, and encased in fresh rubber gloves. After grasping 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, fol- lowing the umbilical cord. As soon as the placenta is reached, its margin should be sought for, and the inner surface of the hand insinuated be- tween it 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 immediately, the operator waiting until the uterus con- tracts down firmly over the hand, which should then gradually be with- drawn. Once again, the importance of a most rigid aseptic technique in carrying 488 PROCEDURES WHICH DO NOT AIM AT DELIVERY out this procedure must be emphasized. Naturally, when the obstetrician finds himself face to face with an alarming post-partum haemorrhage, 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 carefully redisinfected, or at least encased in a freshly boiled rubber glove, for, if it be introduced into the uterus without proper precautions, the patient, although saved from death from haemorrhage, may succumb to a virulent infection a few days later. SECTION VI PATHOLOGY OF PREGNANCY CHAPTER XXV ACCIDENTAL COMPLICATIONS OF PEEGNANCY 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 preg- nancy, or may have been acquired during its course. As a rule, all diseases which subject the organism to a considerable strain are much 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 diaphragm. 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 influence upon all chronic organic maladies, while its effect is usually less marked in acute infectious processes. The latter, however, frequently lead to pre- mature 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.—Small-pox.— Small-pox complicating pregnancy carries with it a more serious prognosis than at other times. Thus Vinay reported a mortality of 3<> per cent, in 2',V) cases, as compared with 2h per cent, in the non-pregnant condition. The haemorrhagic form of the disease is particularly fatal in pregnant women, Mayer having recorded the loss of 13 consecutive cases. Moreover, small-pox 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 uni- versal in the haemorrhagic, and comparatively infrequent in the discrete, variety. This may be due to haemorrhagic changes in the decidua, or to the direct transmission of the disease to the fcetus, with its subsequent death and expulsion. The occurrence of intra-uterine small-pox is well authenticated, as children are occasionally born in the eruptive stage of the 489 490 ACCIDENTAL COMPLICATIONS DUE TO DISEASE disease or with distinct pock-marks. Mauriceau is said to have been in- fected in this manner, and the condition was well known to .John Hunter and Smellie. It is stated that this is occasionally observed even when the mother presents no sign of the disease. Moreover, in double-ovum twin pregnancy it sometimes happens that one child is definitely pock- marked, wdiile the other show's no signs of the disease. Bollinger first suggested the possibility of the transmission from mother to fotus of the protective influence of vaccinia, and stated that wdien the mothers are successfully vaccinated during pregnancy a certain number of the children fail to take when vaccinated soon after birth. Bebm 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 authorities are sceptical as to the possibility of such an occurrence, and consider that unsuccessful vaccination in young children indicates that they are refractory to its in- fluence, or that the virus was of poor quality. In l(i cases reported by Wolff. Palm, and Cast there was not a single instance of successful intra- uterine transmission. Scarlet Fever.—It is generally believed that the pregnant woman pos- sesses a certain immunity to scarlet fever. Braxton Hicks and others considered that this was demonstrated by the fact that the disease occurs much less frequently during pregnancy than in the puerperium. Ols- hausen, 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 puer- peral 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 intercommunicability of the two diseases, a point that cannot be demonstrated until the mat cries morbi of scarlet fever has been discovered. When occurring in the early months of pregnancy, the disease frequent- ly causes abortion. This accident is usually attributed to the high tempera- ture of the mother, though in very rare instances it may be due to the direct transmission of the disease to the fcetus, Ballantvne having re- corded 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 prog- nosis is much more serious during the puerperium than during pregnancy. It is stated that intra-uterine transmission of the disease to the fcetus 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 Hamburg epidemic of 1892 was 57 per cent. ACUTE INFECTIOUS DISEASES 491 The disease exerts a very deleterious effect upon pregnancy, 54 per cent, of the cases, according to Schiitz, ending in abortion or premature labor. This may be due to various causes. One-third of the women suf- fering from cholera have more or less profuse uterine haemorrhage, which, wdien occurring during pregnancy, gives rise to serious changes in the decidua, Slavjansky having described a peculiar form of haemorrhagic endometritis. Moreover, in nearly every instance, the disease causes uterine contractions, supposed to result from the circulation of toxins in the blood. Most authorities do not believe in the direct transmission of cholera bacilli to the child, Tizzoni and Cantani being the only investigators who have demonstrated it for human beings; but Vitanza's experiments ren- der 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 fcetal mor- tality, 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 characterizing the disease; but it is now believed that it is usually due to the direct trans- mission 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 fcetus aborted by a woman suffering from typhoid fever, we have repeatedly made similar observations, so that it is permissible to conclude that the fotus succumbs to a typhoid septicaemia. 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 usually due to imperfect oxygenation of the fodal blood, though in a small number of cases it is attributable to the direct transmission of bacteria to the fcetus, in whose organs pneumococci have been demonstrated by Levy, Netter, Carbonelli, Lubarsch, 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 frequently results. Influenza.—According to many authorities, influenza exerts a very per- nicious influence upon pregnancy, Felkin and Muller having observed pre- mature labor in G out of 7, and in 15 out of 21 cases, respectively. In most of these cases the interruption of pregnancy was preceded by profuse metrorrhagia, wdiich was supposed to be directly connected with the dis- ease. On the other hand, Bar and Boulle, and Ahlfeld state that the dis- ease is almost without influence upon gestation, the first-named observers having noted premature delivery only twice in 41 cases. It would appear, therefore, that the effects of influenza must vary with the severity of the epidemic, and more particularly with the frequency of pneumonic com- plications. 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. 492 ACCIDENTAL COMPLICATIONS DUE TO DISEASE That this does not always occur is shown by the fact that I have delivered several pregnant women suffering from severe facial erysipelas without infection. Occasionally, as noted by Lebedelf, the streptococci which have given rise to the erysipelas may be transmitted from mother to child, though this is unusual. A general septicaemia sometimes follows a strepto- coccic 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 demonstrated the transmission of colon bacilli from a parametritic abscess. He made similar observations in an infectious process due to an anaerobic bacillus, as well as in several cases of streptococcic infection. Gonorrhoea.—The occurrence of gonorrhoea 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. Conococci have been demonstrated in decidual endometritis by Neumann, Maslovsky, myself, and others. More important, however, are the consequences of gonorrhceal infec- tion at the time of labor and during the puerperium, leaving out of con- sideration, for the present, the frequency of 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 con- dition, although rarely fatal, is always serious, since it frequently leads to involvement of the uterine appendages, which may render the patient permanently sterile, or even necessitate operative measures at a later date. In rare instances the gonococcus may produce a general infection, Dabney and Harris, and J. T. Smith having reported cases of gonorrhceal endo- carditis observed in women delivered 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 ter- minated favorably. Anthrax.—Anthrax, or malignant pustule, is rarely observed in hu- man beings under any circumstances, but is almost always fatal. Rostow- zen met with three deaths in pregnant women, and was able in 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. It remained doubtful, how- ever, whether the case was one of intra-uterine transmission or of post- natal infection. In certain animals, on the other hand, the placental transmission of anthrax can frequently be demonstrated experimentally. The first observations of this character were made by Strauss and Cham- berlent in 1882. Pregnancy Complicated by Chronic Infectious Diseases.-—Tuberculosis. —Formerly it was believed that pregnancy exerted a beneficial effect upon CHRONIC INFECTIOUS DISEASES 493 tuberculosis, the mother improving markedly 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 mother nurses the child, pull such patients down still fur- ther, so that the final result is usually hastened. On the other hand, the disease does not appear to predispose to pre- mature interruption of pregnancy, and it is not unusual for tuberculous pa- tients to give birth to large and 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; while Sitzenfrey in 1909 showed that it occurred quite frequently, being able to demon- strate the bacilli in the blood of two out of a series of 26 children born of tuberculous mothers. In congenital tuberculosis the infection usually occurs through the placenta by means of the blood current, as is proven by the fact that the most advanced lesions arc 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 investigators. Schmorl and (ieipel, and Novak and Ranzel, collected 19 and 39 such cases in 1904 and 1910, respectively. As the former investigators were able to demonstrate lesions in the placenta in 9 out of 20 pregnant women dying from tuberculosis, and the latter 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 confirms the opinion of Baumgarten and Maffucei that the incidence of congenital tuberculosis is generally underestimated. The possibility of germinal infection should also be borne in mind. Friedmann in experiments upon rabbits and guinea-pigs showed that tubercle bacilli may be carried to the ovum by means of the spermatozoa; while Sitzenfrey has demonstrated in women dying from tuberculosis the presence of bacilli in the interior of ova while still within the Craafian follicle. It is, of course, questionable whether such infected ova could go on to development, but if it should occur and the bacilli should lie dormant for some time, such observations would afford a plausible ex- planation for some of the instances in which the tuberculosis docs not become manifest until some time after birth. When one considers, however, the large number of tuberculous women who become pregnant, and the very small proportion of cases in which the transmission of the disease to the fcetus has been demonstrated, it is ap- parent that the latter must be an exceptional occurrence. Presumptive evidence in favor of this view was supplied by one of my patients, who died from tuberculous peritonitis a short time after delivery. At autopsy the exterior of the uterus was found studded with tubercles, while the interior was covered with tuberculous ulcers and caseous material, yet the child presented no signs of the disease, and was perfectly well some^months later. 34 494 ACCIDENTAL COMPLICATIONS DUE TO DISEASE It would appear, therefore, that in the vast majority of cases the dis- ease is not transmitted directly from the mother to the fcetus, and that the latter is born with a tendency to tuberculosis rather than with the disease itself. Hence it follows that the children of tuberculous mothers 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 exac- erbated either during pregnancy or after childbirth, most authorities recom- mend 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 consider that abortion should be induced in the first pregnancy occurring after the onset of the disease, or wdienever 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 climatic conditions as may offer every chance of curing or arresting the disease, rather than to run any risk of its exacerbation after labor. The patient and her husband should then be warned of the danger of future pregnancies until the process has become either arrested or cured, and the propriety should be considered of effecting temporary sterility by operative means. If the latter be not done, and conception should occur in spite of the warning, I hold that repeated abortion is indicated only in exceptional instances; as other- wise the obstetrician may find himself called upon to repeat the operation at frequent intervals. On the other hand, 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, 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. I have observed 15 cases of malaria complicating pregnancy, the diag- nosis being assured by the demonstration of the characteristic plasmodium. None of these patients aborted, and in but two did pregnancy end pre- maturely, and then only a week or so before term. It is probable, how- ever, that the pernicious forms of malaria may have a much more deleteri- ous effect. There is a marked tendency toward recrudescence of the dis- ease during pregnancy and the puerperium, just as is frequently observed after surgical operations. It is generally stated that the disease is frequently transmitted to the fcetus, Runge believing that conclusive evidence of such an occurrence is afforded by the presence of characteristic pigmentation in its organs, while Kolloch says that it is not unusual for the new-born child to have charac- teristic malarial attacks. In a number of our cases the patients were suf- CHRONIC INFECTIOUS DISEASES 495 fering from malaria at the time of labor, but in no instance did the fcetus present signs of the disease, though in all such cases its blood was carefully and repeatedly examined for malarial parasites. Quinine should be administered unhesitatingly to women suffering from malaria during pregnancy, as its oxytoxic properties are apparently 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 one of the most frequent causes of repeated abortion or premature labor. It should be suspected in all cases in which a perfectly satisfactory explanation for this^ accident cannot be adduced. When infection occurs during pregnancy, owing to the vascularity of the parts, the initial sore may assume larger proportions than under ordi- nary circumstances. The secondary lesions, however, are often but slightly marked, and frequently are practically limited to the genitalia, where they appear as large, elevated areas which occasionally undergo ulcerative changes, and sometimes lead to the destruction of superficial portions of the vulva. Hie 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. When inoculation with the specific poison has occurred before concep- tion, the disease nearly always gives rise to abortion or premature labor, more frequently the latter. Le Pilcur 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. In premature labor due to syphilis the child is usually dead wdien it comes into the world; less frequently it is born alive with definite mani- festations of the disease. Again, in a still smaller number of cases, it may be born at full term 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 mani- fest any signs of the disease. When the mother is suffering from the affection at the time of con- ception, the offspring is always syphilitic. The same applies when the infection and conception occur at the same time, but under such circum- stances, however, it is a question whether the child owes the disease to paternal or maternal influences. On the other hand, when syphilis is contracted during pregnancy, its effect upon the fcetus 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 fa-tal syphilis was fre- quently the result of paternal infection, and that a man suffering from the tertiary form might engender a syphilitic child without infecting his wife. This belief was based upon the observation that an apparently 496 ACCIDENTAL COMPLICATIONS DUE TO DISEASE healthy woman might give birth to a definitely syphilitic child, and be able to suckle it with impunity, whereas it would certainly infect an- other woman. Such an occurrence was well stated in the dictum known as Colles's law, wdiich assumed a previous transmission of immunity from the fcetus to the mother. 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 this law, which is now denied by the great majority of investigators. 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 Bab pointed out that the spirochaeta is three times as long as the head of a sper- matozoon, it appeared unlikely that the former could enter the ovum along with the latter, unless some spore-like intermediate form exists with which we are as yet unacquainted. Furthermore, the fact that the ap- parently healthy mothers almost universally present a positive Wasser- mann reaction has led most investigators to conclude that the immunity is only apparent, and is due to the fact that such women are really suffer- ing from a latent syphilis, wdiich does not give rise to symptoms. Notwithstanding these potent arguments, I am not yet prepared to deny the validity of Colles's law, for the reason that it seems to offer a plausible explanation for certain definite clinical manifestations, and also because I cannot rid myself of the idea that the constant casting off into the maternal circulation of fragments of the ovum—in the shape of fragments of chorionic villi—would seem to offer an almost ideal means of bringing about immunity. Further consideration of this question, as well as of the syphilitic lesions of the child and the placenta, will be taken up in the chapter upon Diseases of the Ovum. Wdienever we obtain a history of syphilis in either parent, no matter whether infection has occurred prior to or at the time of 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 iodide of potassium, are readily transmitted through the placenta, the foetus may be also treated, no matter whether its infection be of maternal or ger- minal origin. 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 following con- DISEASES OF CIRCULATORY SYSTEM 497 ditions 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 oedema 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. Guerard records a mortality of 28 per cent, in cases of valvular disease complicating preg- nancy, and considers the condition more alarming than even eclampsia or placenta pncvia. He states further that Schlayer, Leyden, Macdonald, and Lublinsky lost respectively 48, 54, 60, and 100 per cent, of such patients. These figures, however, give an exaggerated idea of the serious- ness of the condition, as they apply only to those cases in which compensa- tion has long since failed and the condition is complicated by renal changes or the toxaemia of pregnancy. Jaschke, on the other hand, states that the danger is greatly overestimated, as in a series of 1,525 cases observed in Vienna the mortality was only 0.39 per cent. Routine examination shows that heart lesions are present in a consid- erable proportion of cases, being observed by Demelin in 1.23, by Vinay in 2, and by Fellner in 2.4 per cent, of all pregnant patients. In a series of 94 cases Fellner observed the following lesions: 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, whereas Demelin noted them in two-thirds of his series. 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 dyspnoea and oedema during the latter part of pregnancy, and occasion- ally 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 the induction of abortion or premature labor 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 cedema. Death was averted by blood-letting and the induction of premature labor; while in two other patients the condition was so alarming that Cesarean section was per- formed. It is generally believed that the most untoward symptoms are observed in mitral stenosis. Lusk regarded this lesion as sufficiently serious to war- 498 ACCIDENTAL COMPLICATIONS DUE TO DISEASE rant the induction of abortion as soon as the diagnosis is made. On the other hand, French and Hicks, after studying the obstetrical records of 300 women treated in Guy's Hospital for this condition, state that it is no more serious than other lesions. The fact that 135 of their patients went through 608 labors wdthout a break in compensation clearly indicates that the condition is less serious than is generally believed. Generally speaking, the prognosis is good so long as compensation is retained. To this, however, there are certain exceptions, 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 appropriate therapy does not bring about an amelioration of the symptoms, the prognosis becomes ominous; for even if the patient be saved from immediate death by the induction of premature labor, serious complications are usually in store for her in the future. Grave heart lesions complicating pregnancy are generally believed to predispose to premature labor, which was noted in 20.2 per cent, of Fell tier's cases, as compared with 5.5 per cent, in those of French and Hicks. This accident may result from uterine haemorrhage directly at- tributable to the cardiac condition, from the death of the fcetus due to insufficient oxidation, or from changes in the placenta. In not a few cases there is more or less profuse haemorrhage 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. The psychical disturbances incident to labor, and the elevation of ar- terial pressure brought about by the abdominal and uterine contractions, render it advisable to make use of an anaesthetic during the 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, though, of course, when the lesion is serious and the compensation faulty, the dangers of childbearing should be carefully explained. Myocarditis.—Owdng 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 DISEASES OF RESPIRATORY SYSTEM 499 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 wdthin a few days after delivery. As a thorough physical and urinary examination failed to reveal any ab- normality, I was forced to make the unsatisfactory and provisional diag- nosis 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 re- ported a case observed in my service and collected the literature upon the subject. It should be regarded as a very serious condition, particularly in view of the fact that incautious manipulations may lead to the detachment of small particles of a thrombus, wdiich 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 great equanimity. Pulmonary Embolism.-—Embolism of the pulmonary arteries is a very rare complication of pregnancy. Barnes reports one case which ended fatally wdthin a few moments, while Sperling has reported a second which eventuated in recti very. The condition 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 dyspnoea may become so intense as to demand its artificial interruption. In a certain number of cases abortion or prema- ture labor occurs spontaneously, the untimely uterine contractions being attributed to insufficient aeration of the blood. Asthma,—The symptoms of asthma are sometimes markedly aggravated during pregnancy. In some patients the disease makes its appearance only during pregnancy or at the time of labor, disappearing spontane- ously 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 existence of a toxaemia. If this is ineffectual, a radical change of air sometimes proves beneficial. Dyspnvea..—Almost every woman in the last few weeks of pregnancy suffers more or loss from shortness of breath resulting from interference with the motility of the diaphragm by the enlarged uterus. Dyspncea occurring in the earlier months of pregnancy is usually due to cardiac or renal disease, and demands a thorough physical examination. Occasion- ally it follows excessive distention of the uterus, as in hydramnios. Varices.—Owing to the pressure of the pregnant uterus upon the veins 500 ACCIDENTAL COMPLICATIONS DUE TO DISEASE returning from the thighs, and the fact that they are but poorly supplied with valves, abnormalities in their circulation are frequently observed dur- ing 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. In rare cases, particu- larly when they are situated at the vulva, their rupture may lead to fatal hemorrhage. When they occur in the legs, marked relief is often obtained by the use of neatly applied bandages or elastic stockings. Active treat- ment is useless in vulval varices, but the danger of their rupture 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- Fig. 443.—(Edema of Vulva. ited to the lower extremities. Occasionally the vulva becomes intensely cedematous. When limited to the extremities, the swelling usually results from pressure exerted by the enlarged uterus upon the veins returning from the legs. On the other hand, if it be generalized, it is likely to be a manifestation of toxa'inia, or even of an acute nephritis, though occasion- ally it may be due to other causes. Similarly, oedema of the vulva may he. purely mechanical or a manifestation of some systemic disturbance. The patient should bo cautioned as to the significance of oedema, and whenever it appears the urine should be carefully examined. If the kid- neys are found to be doing their work properly, the swelling is probably of mechanical origin and usually is not amenable to treatment, though DISEASES OF ALIMENTARY TRACT AND LIVER 501 the condition may be markedly benefited by restricting the movements of the patient, or even confining her to her bed. If the urine be ab- normal, the condition is more serious, as it is a manifestation of toxaemia of pregnancy, and should be treated accordingly. 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 alwavs be clone, under the strictest aseptic precautions, and the labia afterward cov- ered with sterile dressings, inasmuch as infection can readily occur and may he followed by serious consequences. Diseases of the Alimentary Tract and the Liver.—Icterus.—Pregnancv 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 spontaneous 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, toxaemia or eclampsia is indicative of profound le- sions in the liver, and adds greatly to the seriousness of the prognosis; for this reason a careful urinary analysis should be made before diag- nosticating a simple catarrhal icterus. 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 most disastrous in pregnancy, as some of the women died in coma and many more aborted or fell into labor prematurely. More- over, it would seem that pregnancy sometimes predisposes to the occurrence of jaundice, as Van. den Yelden and others have recorded instances in which it occurred in successive pregnancies and was frequently associated with ha'inoglobinuria. It is generally believed that women suffering from jaundice at the time of labor have a tendency to haemorrhage, 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 complica- tion, and operation, if urgently demanded, should be undertaken without regard to the existence of pregnancv. 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 Toxamiias 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 pregnancy. Such cases should be treated without reference to the existence of pregnancy. 502 ACCIDENTAL COMPLICATIONS DUE TO DISEASE In many instances marked relief follows the administration of a wine- glass of cream a half hour before each meal. Constipation.—Owing to distention by the growing uterus, the abdom- inal walls may become so impaired in tonicity that considerable difficulty is experienced in evacuating the bowels. Indeed, it may bo 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 strychnine, the fluid extract of cascara, or compound lico- rice powder. The stronger cathartics should be avoided on account of their tendency to cause abortion. Ent era ptosis.—The neurasthenoid symptoms which so frequently accom- pany enteroptosis are often markedly ameliorated during pregnancy, inas- much 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 applica- tion 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 improvement is sometimes permanent, especially if the relaxation of the abdominal walls be counteracted by the use of a snugly fitting binder during the puerperium and a. suitable abdom- inal 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 seveial weeks, while Lvoff has re- ported several cases in which the secretion in the twenty-four hours varied from 1,000 to 1,000 cubic centimeters. The condition is usually attributed to a reflex neurosis incident to preg- nancy, but sometimes it is a manifestation of auto-intoxication. In the first class of cases the treatment is very unsatisfactory, astringent mouth washes, and even comparatively large doses of atropine, being without effect. On the other hand, wdien the condition results from auto-intoxica- tion, marked amelioration frequently follows placing the patient upon a rigorous milk diet. 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 treat- ment, although in many cases it disappears almost immediately after de- livery. It is best met by the employment of astringent mouth washes, especially those containing tincture of myrrh, combined with general tonic treatment and an abundant diet. Dental Caries—Toothache.—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 DISEASES OF KIDNEYS AND URINARY TRACT 503 evidenced by the saying, "For every child a tooth." It is probable that the condition is somewhat allied to the minor degrees of osteomalacia which occur only during pregnancy. Such patients should be referred to a skill- ful dentist, and at the same time should be placed upon the syrup of the hypophosphites or the lactophosphate of lime. 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 Tox- aemias of Pregnancy. Glycosuria and Diabetes.—Blot, in 1856, stated that sugar could usu- ally be found in the urine of lactating women; but after it was demon- strated that the condition was a lactosiiria, the belief gained ground that the existence of true diabetes was inconsistent with conception. This view was combated first in 1882 by Matthews Duncan, who was able to find in the literature 22 cases in which pregnancy was complicated by the disease, while in 1909 I collected 66 cases. Accordingly the condition is not frequent. Diabetes may exist before the inception of pregnancy, or may appear 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. More- over, about one-eighth of the pregnancies ended in abortion or premature labor, and in one-third of those going to term the children were born dead. Such statistics give too gloomy a picture, as they are based mostly upon the severe cases, and do not take into account the milder ones, which are usually overlooked. 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 demon- strated in the liquor amnii. According to Rossa, 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 can be detected in the fcetal 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 distinct reaction for sugar in about 5 per cent, of all women in the last months of pregnancy. Ordinarily this is due to lactosiiria and is of no clinical significance, but occasionally a true glyco- suria is present. This occurs about once in 100 or 150 cases, and the amount of glucose may vary from 14 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. 504 ACCIDENTAL COMPLICATIONS DUE TO DISEASE If more accurate chemical methods be used, sugar can be detected much more frequently, and Commandeur and Portlier state that traces occur at some time in the course of every pregnancy. They found glucose or lac- tose in 20 and 80 per cent, of their cases, respectively, and occasionally both varieties together. Three theories have been advanced to explain the production of this variety of glycosuria. Payer has 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 increas- ing the amount of sugar ingested. In one of my patients, the glycosuria disappeared upon substituting another aperient in place of a home-made syrup of senna and prunes, which she took in immense quantities for the relief of constipation. Commandeur and Porcher hold that the condition is due to the inabil- ity of the non-functioning breasts to convert glucose into lactose, as nor- mally occurs during lactation; while Hofbauer believes that it is depend- ent upon fatty changes at the periphery of the liver lobules, associated with a diminished ability to store glucose, wdiich he considers a character- istic change accompanying normal pregnancy. I am inclined to regard most cases of slight glycosuria in pregnancy as physiological or alimentary in character. This being the case, the first essential after obtaining a positive reac- tion wdth Fehling's solution is to determine by the fermentation test or by the polariscope whether one has to deal with lactose or glucose. If the former is present no anxiety need be felt, as lactosuria is frequently a per- fectly physiological phenomenon. On the other hand, if glucose is present, the matter is not so simple, as it is most important to determine whether it is a manifestation of true diabetes or merely of an alimentary, physio- logical, or recurrent glycosuria. Unfortunately, this is not always easy. The former should be diagnosticated if the condition existed prior to pregnancy, or if large amounts of glucose are demonstrable, but more par- ticularly if the characteristic symptoms of thirst, emaciation, and dyspnoea are present; while a probable diagnosis of alimentary glycosuria is permis- sible if the glycosuria disappears upon removing sugar from the diet. Oc- casionally, however, slight glycosuria persists notwithstanding the most rigorous anti-diabetic regime; in such cases the patient should be carefully watched and the urine examined daily, and the pregnancy promptly termi- nated upon the first appearance of untoward symptoms. Fortunately, this will rarely be necessary, as the patient will usually go through pregnancy and labor without difficulty, and the glycosuria will disappear during the first days of the puerperium. Hematuria.—The passage of bloody urine is rarely observed during pregnancy, and its occurrence should always lead one to suspect more or less serious lesions of the urinary tract. Nevertheless, Chiaventone has described an idiopathic haematuria due to pregnancy, and has collected 18 similar cases from the literature. He considers that the haemorrhage is probably due to histological changes in the kidney which result from a hepato-toxaemia. He mentions, however, a case described by Albarran in DISEASES OF KIDNEYS AND URINARY TRACT 505 which the bloody urine was probably due to the presence of varicose veins in the wall of the bladder. Pyelitis and Py clone phrosis-.—According to Adnay, attention wTas first called to this complication of pregnancy by Reblaud in 1S92. 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 perfectly well, or has 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 pursuing a hectic course. Urinary examination reveals the presence of pus cells and bacteria. If the process goes on to the development of a pyelo-nephro- sis, palpation shows that the affected kidney is markedly enlarged. After a certain time a large amount of purulent urine is suddenly passed, when, the pain disappears and the kidney becomes smaller, the symptoms re- appearing as the kidney fills again. If allowed to go on without treat- ment, the patient may succumb to a septic process. The condition results from compression of the ureter 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 extension 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 bacillus is sometimes concerned. Ordinarily pain in one lumbar region and the palpation of the1 enlarged and tender kidney, as well as the 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. The patient should be encouraged to drink large quantities of water and milk, and 5 grains of urotropin should be administered every four hours. Ordinarily improvement 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 estab- lishment of which, as a rule, is followed by complete recovery. Occa- sionally, in cases of pyelo-nephritis, the process may continue after empty- ing the uterus, and necessitate nephrotomy or even removal of the kidney. I see several patients each year with this complication, and the great majority recover spontaneously; occasionally the induction of premature labor is necessary, wdiile in two neglected cases death occurred from a general septic process, due in one instance to the streptococcus and 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 506 ACCIDENTAL COMPLICATIONS DUE TO DISEASE rise to intense pain, which may be mistaken for renal colic or appendicitis. 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 wdien 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 bandage should be worn through the puerperium. Dislocation of the Kidney.—Cragin has reported an instance in which one kidney occupied the pelvic cavity, and has collected 5 more or less similar cases from the literature. The condition is rarely diagnosed before the onset of labor, though in Cragin's case symptoms of incarceration led to vaginal examination and the diagnosis of the presence of a tumor, which was removed and found to be a kidney. Pregnancy After Removal of Kidney.—Conception sometimes occurs in women from whom one kidney has been removed on account of tubercu- losis, pyelonephritis, or some other lesion. Provided the remaining organ performs its functions properly, pregnancy may progress uneventfully, and in several of my cases the patient was delivered at term without incident; while Bleynie in 1910 was able to collect 35 similar cases from the litera- ture. At the same time it should be borne in mind that the single kidney may bear the strain of a toxaemia poorly; consequently the urine should be examined frequently, and the pregnancy interfered with at the first appearance of untoward symptoms. Cystitis.—Pregnancy is occasionally complicated by cystitis, which is usually due to gonorrhceal infection, though the colon bacillus may be the infective agent. In view of the possibility of an ascending ureteritis and a resulting pyelonephritis, the condition demands prompt treatment. Floating Spleen.—Occasionally an enlarged spleen occupying the low7er abdomen may be mistaken for the pregnant uterus. If pregnancy super- venes, it is usually uninfluenced by the floating organ, which is gradually forced into its normal position as the uterus enlarges. Occasionally, how- ever, 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 frequently associated with toxaemic or septic processes. Thus, in the toxaemias of pregnancy and eclampsia, serious disturbances may follow oedema 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 toxaemia, is not directly dependent upon the existence of pregnancy. It does not appear that spinal paraplegias interfere with conception, as women suffering from them frequently become pregnant. In either event the condition is without influence upon the course of pregnancy, and in DISEASES OF THE NERVOUS SYSTEM 507 many such cases, including advanced tabes dorsalis, labor is easy and comparatively 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, wdiich is sometimes accompanied by intense muscular spasm. Ow- ing to its mode of origin, this form of sciatica is not amenable to treat- ment. 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 toxaemic origin of the latter has become recognized, the neuritis is considered as a mani- festation of the same process, and not 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, wdiich is frequently associated with shooting pains. Sensibility of the parts is markedly impaired, and the patients frequently suffer from parastbesiae. Occasionally the symptoms are so severe that the induction of premature labor may be justifiable. Chorea.—Pregnancy occasionally occurs in choreic individuals, while in rare instances thee disease does not appear until after conception. In the first class of cases it is comparatively unimportant, wdiile 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 appearance of fever is of serious import, and at autopsy evidences of malignant endocarditis are present. Schrock has collected 154 cases of chorea complicating pregnancy, with a mortality of 22 per cent., and Buist 255 cases, with a mortality of 17.5 per cent. French and Hicks in 1906 reported 29 cases wdiich had been ob- served in Guy's Hospital in the previous thirty years, with a mortality of 10 per cent. Many of the cases did very well upon the usual medicinal treatment. They are skeptical as to the value of the induction of prema- ture labor, but lay great stress upon the serious prognostic import of the appearance of fever. Jolly, on the other hand, recommends interference in all aggravated cases. The only case of the grave variety wdiich I have seen died, in spite of the fact that she fell into premature labor spon- taneously shortly after entering the hospital. 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 bromide and treated just as at other times. As a rule, it is not advisable to allow the mother to nurse her 508 ACCIDENTAL COMPLICATIONS DUE TO DISEASE child, as lactation sometimes appears to aggravate the disease, while se- rious 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 vomit- ing of pregnancy to hysteria. This is no doubt true in many cases, but certainly cannot be regarded as the sole cause of the condition. Tetany.—In rare instances tetany may occur during the course of preg- nancy, Meinert, in 1898, being able to collect 20 cases from the literature. In some patients the disease appears only during pregnancy and is absent at other times. H. M. Thomas observed a case at the Johns Hopkins Hos- pital, in wdiich the condition had appeared in 6 successive pregnancies. A full resume of the literature is to be found in his article. Formerly tetany was thought to be connected in some way with ab- normalities of the thyroid gland, as it sometimes occurred after the re- moval of that organ. Following the experimental work of Frommer, Ad- ler and Thaler, and others, it is now believed to be due to the absence or imperfect secretion of the parathyroid bodies. The last-named investiga- tors demonstrated that portions of the parathyroids could be removed from wdiite rats without effect, but that symptoms of tetany would appear when- ever the animals became pregnant. Goiter.—We have already referred to the slight enlargement which the thyroid frequently 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 preg- nancy, the enlargement reaching such proportions that death resulted from suffocation. In rare instances pregnancy appears to cause a rapid increase in the size of a thyroid tumor, which had been present before its inception, and Ahlfeld, Albers-Schonberg, and Meinert have reported cases in which a goiter, wdiich had previously grown only slowly or had remained stationary in size, became so large during pregnancy as to render tracheotomy or the operative removal of the growth necessary in order to prevent death from suffocation. In my experience pregnancy plays little or no part in the production of exophthalmic goiter, but there is no doubt that it exerts a deleterious influence upon the condition when it already exists. In sev- eral instances the tachycardia was greatly exaggerated, but became less marked after induced or spontaneous labor. Apoplexy.-—Apoplexy is rarely observed during pregnancy, though it is a not infrequent 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 DISEASES OF THE BLOOD 509" cautioned concerning their diagnostic significance if they appear. Amauro- sis or total blindness occurring at this time is generally due to albuminuric retinitis, and the first indication of a serious renal affection is sometimes afforded by an ophthalmoscopic examination. Diseases of the Blood.—Pernicious Anwmia.—According to Osier, this complication was first described by Channing in 1812. Since then a con- siderable literature has accumulated upon the subject, which is well re- viewed in Findley's article. The disease occasionally appears during preg- nancy, but most frequently not until after labor. It is characterized by marked pallor and anaemia, which are associated with weakness and short- ness of breath, the extremities also becoming ©edematous. A positive diagnosis is made by the microscopical examination of the blood, when the number of red blood-cells is found to be markedly dimin- ished. Many of the corpuscles are irregular in shape, while nucleated varieties are not infrequently observed. At the same time there is a rela- tive increase in the amount of haemoglobin, 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. Excellent results are obtained by the administration of Fowler's solution in increasing doses, beginning with 5 drops 3 times a day. Leukemia.-—Leukaemia is a very rare complication of pregnancy, Her- man 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 incep- tion. It exerts no direct effect upon gestation, though the association 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 anaemia associated with enlargement of the spleen, and is placed beyond doubt by a differential blood count. Examinations of the foetal blood by Sanger, Cameron, and Laubenberg indicate that the characteristic leukocytes are not transmitted to the foetus. In view of the good results wdiich some- times follow spontaneous premature labor, pregnancy may be terminated artificially in serious cases. Hemophilia.—Although the existence of a haemophilic diathesis may bo without effect upon gestation, in the third stage of labor it predisposes to obstinate post-partum haemorrhage. In view of this danger, in the rare cases in which the conditions are associated, Kehrer recommended the induction of abortion, though it is probable that the bleeding would be as difficult to check after that operation as after full-term labor. In a case of extra-uterine pregnancy under my observation haemophilia proved a most serious complication at the time of operation. Lead. Poisoning.—C. Paul studied the histories of 111 pregnancies occurring in women suffering from chronic lead poisoning, and found that 86 ended in abortion or premature labor. Moreover, a large number 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 35 510* ACCIDENTAL COMPLICATIONS DUE TO DISEASE lead is transmitted through the placenta, as in a premature child exam- ined by Lewin 16 per cent, of the total weight of the liver was due to it. Frongea states that lead poisoning not only leads to abortion or prema- ture labor, but is a potent cause of sterility; as in the lead works of Sar- dinia 20 per cent, of the married women are sterile, and an additional 23 per cent, have only one child. 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 inflam- matory 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 mortality is about 75 per cent., Debreuihl having collected 24 cases occurring in Austria and Ger- many 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 unde- livered. According to Scheuer, it is toxaemic 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 quantities of blood serum obtained from normal pregnant women. Herpes Gestationis.—This disease, more frequently known as dermatitis herpetiformis, is an inflammatory, superficially seated, multiform, her- petiform eruption, which is characterized by erythematous, vesicular, pus- tular, 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 ends in death. Diihring believes that it is probably toxaemic 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 contain- ing oil of cade, carbolic acid, or similar substances. Pruritus.—Itching is often a distressing complication of pregnancy. It may extend over the greater part of the body or be limited to the genitalia. General pruritu» should be regarded as a neurosis, which is probably tox- aemic 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 con- trolled by the administration of nerve sedatives and general tonic treats ment. A rigid milk diet is sometimes followed by excellent results. When the condition is not amenable to treatment and the patient shows marked signs of exhaustion, the termination of pregnancy may be justifiable. Genital pruritus—pruritus vnlrte—may be due to several causes, among wdiich are irritating vaginal discharges, parasites or glycosuria. When due to the first-named cause, the condition is best treated by the adminis- tration of astringent vaginal douches and the maintenance of absolute ACCIDENTS DURING PREGNANCY 511 cleanliness. At the same time the itching may be allayed by the employ- ment of ointments containing cocaine, menthol, or carbolic acid. Pruritus of diabetic origin is observed but rarely, but the possibility of its occur- rence 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 rigid anti-diabetic diet, while at the same time the appropriate ointments should be employed. Occasionally intense itching about the anus may be due to the presence of seatworms, 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 Rochelle salts the next morn- ing, will often bring about the desired result. Abnormalities of Pigmentation.—During pregnancy abnormalities in pigmentation are not infrequently noted, which are particularly marked along the linea alba and about the breasts. In other cases unsigbtlv yel- lowish splotches—cloasma—appear upon the face. They are not amenable to treatment, but usually disappear promptly after childbirth. Ilcemaloma of the Abdominal Walls.—Stoeckel has reported two cases of haematoma 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, which 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 inci- dent to pregnancy, the various pelvic joints always show a somewhat in- creased motility. Occasionally, however, the softening of the interarticular 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 of a tightly fitting bandage about the thighs is followed by marked improve- ment, though occasionally the symptoms are so pronounced that the patient is obliged to take to her bed. The condition usually disappears sponta- neously during the course of the puerperium, but in exceptional instances it may persist and give rise to such great discomfort that it may become necessarv 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 Goldtbwait 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, the prognosis not being mate- rially altered cexcept that abortion frequently occurs. Pregnancy itself may be complicated by accidents which are incident to that condition, the most important being rupture of an extra-uterine pregnancy, rupture of the uterus, and premature separation of the placenta—all very serious com- 512 ACCIDENTAL COMPLICATIONS DUE TO DISEASE plications. 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 in- evitably bring about abortion or premature labor, even the extraction of a tooth being considered a serious procedure. At present, however, thanks to anaesthesia and a perfected surgical technique, many operations can be performed at this time wdth but little additional risk. Accordingly, when- ever 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 ad- visable 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. Several observers, notably Polk and Cragin, have removed the kidney without terminating pregnancy, and 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 Pregnancy by Diseases and Abnormalities of the Generative Tract. Appendicitis.—Appendicitis probably occurs as frequently during preg- nancy as at other times, but until recently it was comparatively overlooked, in great part, no doubt, because of the difficulty of diagnosis. Renvall in 1908 recorded 25 personal cases, and collected 253 cases from the litera- ture. It should be regarded as a very serious complication, as many women die if not operated upon, wdiile 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 forma- tion, 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 overlooked, as the pains are often considered as being due to the pregnancy itself, while the distention of the abdominal walls by the enlarged uterus makes difficult the appreciation of the rigidity and muscle-spasm, which are usually valuable diagnostic aids. One should always consider the possibility of appendicitis when a preg- nant woman complains of pain in the right side of the abdomen, asso- ciated with an elevation of temperature and pulse, provided some more satisfactory explanation for the condition cannot be found. It should, how- ever, be remembered that pyelitis or inflammatory conditions of the ap- pendages may give rise to identical symptoms. At the time of labor and during the puerperium its recognition is still more difficult, and many LITERATURE 513 women have died from perforative peritonitis with the diagnosis of puer- peral infection. Operation is indicated in all cases in the early months. Later in preg- nancy 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 difficulty, it has been suggested that the uterus be emptied by accouchement force before opening the abdomen. I, however, do not believe that it is necessary, and am convinced that its general adoption will add to the gravity of the operation. In the early months abortion is not likely to occur, provided the uterus has not been subjected to much manipulation; in the latter months premature labor is frequently observed, particularly in cases of abscess formation. It may be due to ono of several factors—manipulation of the uterus, fever, and, when an abscess has formed, to the direct transmission of bacteria from it to the fcetus. Intestinal Obstruction.—This rare complication of pregnancy should lie 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 delivered at term, but died some weeks later from miliary tuberculosis. LITERATUEE Adleb u. Thaler. Exp. und. klin. Studien iiber die Graviditats-tetanie. Zeitschr. f. Geb. u. Gyn., 1908, 194-223. Ahlfeld. Schwangerschaft und Geburt complicirt durch Struma. Berichte u. Arbeiten, 1885, ii, 131. Ahlfeld und Marchand. Ahlfeld's Lehrbuch der Geburtshiilfe, II. Aufl., 1898, 239. Albers-Sc honberg. Kompression der Trachea in Folge von Schilddriisenschwellung in der Graviditat, Tracheotomie. Zentralbl. f. Gyn., 1895, xix, 454-4.1S. Archambaud. Le tetanos pendant la grossesse. La Revue vied., 1896, 413. Bab. Bakteriologie u. Biologie der kongenitalen Syphilis. Zeitschr. f. Geb. u. Gyn., 1907, Ix, 161-211. Baisch. Erfolge und Aussichten der Behandlung der hereditaren Lues. Monatsschr. f. Geb. u. Gyn., 1911, xxxiv, 273-283. Ballantvne and Milligan. A Case of Scarlet Fever in Pregnancy, with Infection 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. Bkiim. Ueber intrauterine Vaccination. Zeitschr. f. Geb. u. Gyn., 1882, viii, 1-21. Bignami. Tiroidismo e gravidanza. Ref. l'Obstetrique, 1896, i, 174. Bleynie. De l'avenir des femmes nephreetomisees qui deviennent enceintes. These de Paris, 1910. Blot. De la glycosurie physiologique chez les femmes en couches, etc. Comptes ren- dus de 1 'acad. des sciences, 1856, xliii, 676. Bollinger. Ueber Menschen- und Thierpocken. Volkmann's Sammlung klin. Vor- trage, 1877, Nr. 116. 514 ACCIDENTAL COMPLICATION DUE TO DISEASE BuiST. Chorea Gravidarum. Trans. Edinburgh Obst. Soc, 1892, January 12. Cameron. The Influence of Leukaemia upon Pregnancy and Labor. Amer. Jour. Med. Sciences, 1888, N. S., xcv, 28-34. Carbonelli. Quoted by Lubarsch. Chiaventone. De l'hematurie de la grossesse. Annales de gyn. et d'obst., 1901, Ivi, 196-219. Commandeur et Porcher. Recherches sur les sucres urinaires chez la femme enceinte. Archives gen. de med., 1904, cxciv, 2241 and 2325. Cragin. Congenital Pelvic Kidney Obstructing the Parturient Canal. Amer. Jour. Obst., 1898, xxxviii, 36-41. Pyelitis Complicating Pregnancy. Trans. Am. Gyn. Soc, 1904, xxix, 118-128. Dabney and Harris. Report of a Case of Gonorrhceal 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 derma- tologique, 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. Eulenberg. Ueber puerperale Neuritis, etc. Deutsche med. Wochenschr., 1895, 118-121 and 140-146. Felkin. The Influence of Influenza upon Women. Trans. Edinburgh Obst. Jour., 1892, xvii, 12. Fellner. Herz u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 370-417 and 497-520. Findley. Pernicious Anaemia and Pregnancy. Am. J. Obst., 1908, lviii, 51-57. Fiori. Un caso di transmissione di morbillo della madre al feto. Frommel'a 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. and Gyn. Brit. Empire, 1906, x, 201-246. Friedmann. Exp. Beitrage z. Frage kongenitaler Tuberkelbazilleniibertragung, etc. Virchow's Archiv, 1905, clxxxi, 150-179. Frommer. Exp. Versuche zur parathyreoidealen Insuffizienz in Bezug auf Eklampsie 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 Jahrbiicher, 1879, clxxxiii, 201. Gaulard et Bue. Tuberculose pulmonaire. Accouchements et maladies des femmes en couches, 1901, 207-220. Goldsborough. Johns Hopkins Hospital Bull., 1904, xv, 193. Goldthwait and Osgood. A Consideration of the Pelvic Articulations from an Anat., Path., and Clinical Standpoint. Boston Med. and Surg. Jour., 1905, cliii, 593-601. Goth. Ueber den Einfluss der Malariainfection auf Schwangerschaft, etc. Zeitschr. f. Geb. u. Gyn., 1881, vi, 17-34. Graefe. Die Einwirkung des Diabetes mellitus, etc. Graefe's Sammlung zwangloser Abhandlungen, 1897, ii, Heft 5. Guerard. Herzfehler u. Schwangerschaft. Monatsschr. f. Geb. u. Gyn., 1900, xii, 571-577. Hauser. Zur Vererbung der Tuberkulose. Deutsches Archiv f. klin. Med., 1898, lxi, 221. LITERATURE 515 Hebra. Ueber einzelne wahrend der Schwangerschaft zu beobachtende Hautkrank- heiten. Wiener med. Wochenschr., 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. Lon- don Obst. Soc, 1871, xii, 44-113. Hofbauer. Beitrage zur ^Etiologie u. klinik der Graviditats-toxicosen. Zeitschr. f. Geb. u. Gyn., 1908, lxi, 200-274. Jaschke. Die Prognose von Schwangerschaft, etc., bei Herzfehlern. Archiv f. Gyn., 1910, xcii, 466-512. Jolly. Die Indikation des kiinstlichen Abortus bei der Behandlung von Neurosen und Psychosen. Zentralbl. f. Gyn., 1901, xxv, 1169-1170. Kehrer. Die Haemophilie bei weiblichem Geschlechte. Archiv f. Gyn., 1876, x, 201-237. Die phys. u. path, Beziehungen der weibiichen Sexualorgane zum Tractus intes- tinalis. Berlin, 1905. 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 puerpe- ralen Frau, 1897, 180. Lebedeff. Ueber die intrauterine Uebertragbarkeit des Erysipel. 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. Path- ologie, 1896, xxvi, 595. Lewin. Ueber die Wirkung des Bleis auf die Gebarmutter. Berliner klin. Wochen- schr., 1904, xii, 1074-1078. Liepmann. Diabetes mellitus und Metritis dessicans. Archiv f. Gyn., 1903, lxx, 426-444. Lomer. Ueber die Bedeutung des Icterus gravidarum, etc. Zeitschr. f. Geb. u. Gyn., 1886, xiii, 169-185. Miisern 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. Maffucci. Richorche sperimentale intorno al passaggio del veneno tubercolare dai genitori alia prole. Revista critica di clinica med., 1900, i, 221-229. Maillart. Ueber den gunstigen Einfluss der Schwangerschaft auf die Enteroptose. 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 Schwangerschafts- dermatosen. Zentralbl. f. Gyn., 1911, 350-354. 516 ACCIDENTAL COMPLICATIONS DUE TO DISEASE Muller. Weitere Beobachtungen beziiglich des Einflusses der Influenza auf dem weibl. Sexualapparat. Miinch. med. Wochenschr., 1895, Nr. 41, 952. Netter. Transmission intrauterine de la pneumonie, etc. Comptes rendus de la soc de biologie, 1889, Mai 15, 187-194. Neumann. Ueber puerperale Uterus-gonorrhoea. Monatsschr. f. Geb. d. Gyn., 1896, iv, 109-115. Novak u. Ranzel. Beitrag zur Kenntniss deT Placentartuberculose. Zeitschr. f. Geb. u. Gyn., 1910, Ixvii, 719-751. 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 Scharlach. Archiv f. Gyn., 1876, ix, 169-195. Opitz. Die Pyelonephritis gravidarum et puerperarum. Zeitschr. f. Geb. u. Gyn., 1905, Iv, 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, 7S4-S06. Peterson. Gall Stones During Pregnancy. Trans. Am. Gyn. Soc, 1910, xxxv, 4-120. Pinard. L'appendicite dans ses rapports avec la grossesse. Annales de gyn. et d'obst., 1900, liii, 357-388. 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 die Uebergang von Milzbrandbacillen beim Menschen von der Mutter auf die Frucht bei Pustula maligna. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 542-552. Runge. Die acuten Infectionskrankheiten in atiologischer Beziehung zur Schwanger- schaftsunterbrechung. Volkmann's Sammlung klin. Vortrage, Nr. 174. Sanger. Ueber Leukamie bei Schwangerschaft, etc. Archiv f. Gyn., 1888, xxxiii, 161-210. Scheuer. Zur Frage der iEtiologie der Impetigo herpetifornis. Archiv fiir Der- matologie, 1910, ciii, 285-304. Schmorl u. Geipel. Ueber die Tuberculose der menschlichen Placenta. Miinchener med. Wochenschr., 1904, li, 1676-1679. Schrock. Ueber Chorea gravidarum. D. I., Konigsberg, 1898. Schroeder. Ueber wiederholte Schwangerschaft bei linealer Leukamie. Archiv f. Gyn., 1899, lvii, 26-35. Schutz. Ueber der Einfluss der Cholera auf Menstruation, Schwangerschaft, Geburt u. Wochenbett. Zentralbl. f. Gyn., 1894, xviii, 1138. 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 Lugenarterie wahrend der Schwanger- schaft, etc. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 439-465. LITERATURE 517 Stengel and Stanton. The Heart and Circulation in Pregnancy and the Puer- perium. Univ. of Pennsylvania Med. Bull., 1904, xvii, 202. Strauss et Chamberlent. Comptes rendus de la soc. de biologie, 1882, novembre 11 et decembre 16. Thomas. Tetany in Pregnancy. Johns Hopkins Hosp. Bull., 1895, vi, 85. Tizzoni et Cantani. Recherches sur le cholera asiatique. Ziegler's Beitrage zur path. Anat. u. zur allg. Path., 1888, iii, 189-237. Vixay. Maladies valvulaires et grossesse. Archives de Tocologie, 1893, 805. Vaccinia et variole an cours de la grossesse. Lyon Med., 1900, mars 25. Vinay et Cade. La pyelo-nephrite gravidique. L'Obstetrique, 1899, iv, 230-256. Vitanza. Sulla transmissibilita dell' infezione colerica della madre al feto. Riforma medica, 1890, Nos. 48 and 49. Von den Velden. Icterus gravidarum. Beitrage zur Geb. u. Gyn., 1904, viii, 448-464. 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. 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. Wolff. Ueber Vererbung von Infectionskrankheiten. Virchow's Archiv, cxii, 177. Zweifel. Ueber plotzliche Todesfalle von Schwangeren u. Wochnerinnen. Zentralbl. f. Gyn., 1S97, xxi, 1-16. Kiinstlicher Abortus bei Chorea gravidarum. Zentralbl. f. Gyn., 1901, xxv, 1170. CHAPTER XXVI THE TOXAEMIAS OF PREGNANCY Fortunately, in the vast majority of cases gestation pursues a perfectly 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 con- ducted upon much more economical lines than formerly. Moreover, it is probable that the excretory functions are more liable to serious derange- ment, since they are called upon to care for the elimination of the waste products of the foetal as well as the maternal organism. For this reason many women, who are perfectly well at other times, may suffer from the retention of certain metabolic products. Formerly it was believed that the retention of such substances gave rise to abnormalities in the function of the liver and kidneys, and led to the production of the condition which we now designate as pre-eclamptic toxsemia, or even eclampsia. Following the statement of Bouchard that all pregnant women suffer to a greater or lesser extent from auto-intoxica- tion, certain French observers, notably Pinard and Bouffe de Saint-Blaise, advanced the supposition that practically all of the abnormal manifesta- tions of pregnancy rest upon such a basis, and that such mild conditions as slight headache, salivation, or certain skin eruptions, on the one hand, and such a serious disease as eclampsia on the other, represent, respectively, the early and the advanced stages of one and the same process, which they designated as hepato-toxaemia. Veit held that all of the disturbances of pregnancy result from cytolytic processes following the entrance of chori- onic tissue and fcetal ectoderm into the maternal circulation. Moreover, Stone, Strauss, Ewing, and others teach that albuminuria, vomiting of pregnancy, yellow atrophy of the liver, and eclampsia are all manifesta- tions of disturbed metabolism, and should be grouped together under the common heading of toxaemia of pregnancy. As the result of my investigations, 1 am convinced that such views are erroneous and only render more difficult the appreciation of the several conditions concerning which our knowledge is still very fragmentary and uncertain. Chemical analysis of the urine, as well as the histological study of tissues obtained at autopsy, clearly indicates that essential and charac- 518 PERNICIOUS VOMITING OF PREGNANCY 519 teristic differences exist between the various conditions thus grouped to- gether; and I believe that the probability of the eventual discovery of their ultimate causes will be greatly increased by considering them separately, and at the same time candidly admitting that we are just beginning to realize.our profound ignorance of the subject. Moreover, it should be borne in mind that totally different pathological 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 dem- onstrate 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 "toxaemia of pregnancy:" (a) Pernicious vomiting; (6) acute yellow atrophy of the liver; (c) nephritic toxasmia; (d) pre-eclamptic toxaemia; (e) eclampsia; (f) presumable toxaemias. 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 one third to 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 more frequent intervals, and occasionally lasts for a longer period, while exceptionally it continues 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 conclu- sive 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 wdthout result. Relief sometimes follows the administration before each meal of a capsule consisting of 2 grains of pepsin and 14 grain nitrate of silver. Oxalate of cerium in 5-grain capsules, or as an effervescing preparation, dilute tincture of iodine, dilute hydrocyanic acid, cocaine, or bismuth are also recommended. Tn 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, but he should impress upon the patient that vomiting is not a necessary accompaniment of pregnancy, as is shown by the fact that con- siderably 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 adop- 520 THE TOXEMIAS OE PREGNANCY tion of suitable hygienic and dietetic measures. He should then inquire carefully into her mode of life, and see that proper exercise, occupation, amusement, and rest are obtained. The diet should be carefully regulated. I lay great stress, particularly on account of its suggestive influence1, 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. After- wards 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 prescribe 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 implicitly, the condition will usually pass off within a few days and the employment of drugs will be unneces- sary. 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 extremely serious, and sometimes leads to a fatal issue, no matter how treated. According to Pick and Lwow, pernicious vomiting occurs about once in every thousand pregnant women, but as their statistics are based upon hospital work they give no clue as to its incidence in private practice. Among the neurotic women of the upper classes in this country and France, I believe that it is encountered once in every several hundred preg- nancies, but it appears to be less frequent in England and Germany. Etiology.—'Until comparatively recently our knowledge concerning the nature of the affection was extremely defective, and even now our informa- tion is not entirely satisfactory. In my monograph, wdiich appeared in 190(>. I stated that the evidence then available justified the differentiation of three types of serious.vomiting, namely, reflex, neurotic, and toxaemic. At present, although I believe that a toxaemic element is the underlying factor in all varieties, as well as in the ordinary morning sickness, I hold that the same terminology should be employed; as, in reflex and neurotic vomiting, the toxaemia seems to act merely as a predisposing cause and usually gives no trouble after the anatomical or neurotic condition is over- come or removed. The reflex variety, as the name implies, results from the presence of structural abnormalities in other portions of the body, and particularly in the generative tract. Thus, it is sometimes associated with retroflexion of the uterus, an ovarian tumor, or some other lesion of the generative organs, and immediate relief may followr the replacement of the uterus, the removal of the tumor, or the correction of the abnormality. I must, however, confess that wdth more extended experience I believe less and less in the reflex factor, and am inclined to attribute to suggestion many of the cures which appear to follow its correction or removal. Attention was particularly directed to the neurotic variety by Kalten- bach, who stated in 1891 that the vomiting of pregnancy is usually a PERNICIOUS VOMITING OF PREGNANCY 521 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 as the result of vomiting, suddenly become better spontaneously following a threat to induce abortion. Moreover, prompt cure sometimes follows the mere administra- tion of an anaesthetic, or the employment of the most varied and unsci- entific methods of treatment, such as the use of an electrical battery, which is entirely out of order, or the application of leeches or of various medica- ments 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. In the true toxaemic variety, on the other hand, the reflex and neurotic elements are absent, and the condition is associated with a profound dis- turbance of metabolism, which is manifested by striking changes in the urine, and in fatal cases by the presence of definite lesions in the liver and kidneys. It was first shown in my clinic that the urine in such cases presents a high ammonia coefficient, indicating that a much larger propor- tion of the total nitrogen is excreted in the form of ammonia than usual, while lowing believes that the same may be said of the "undetermined or rest" nitrogen. Normally, during pregnancy the ammonia coefficient varies between 4 and 5 per cent., but in toxaemic vomiting it may rise to great heights—from 20 to 50 per cent. (Figs. 44G and 447.) While I do not believe that such an occurrence is pathognomonic, as wdll be indicated below, it undoubtedly indicates a profound perversion of metabolism, which must be associated with grave danger to the patient. Matthews Duncan in 1S79 pointed out that the condition was some- times 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 lesions were present in the liver identical with those occurring in acute yellow atrophy. In such cases there is profound necrosis of the central portion of the lobules, while the periphery remains intact, and in one of my specimens the destruction of tissue was so great that practically nine-tenths of the entire organ was thrown out of func- tion (Fig. 444). 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 and Czyzewicz. and many others have de- scribed 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 absolutely different from those observed in eclampsia, in which the process is essentially one of thrombosis and begins in the periportal spaces, I hold that toxaemic vomiting is an entirely dis- tinct process, and that the two diseases have only two points in common, namely, that both occur in pregnant women and are manifestations of dis- turbed metabolism. It should not, however, be believed that the essential 522 THE TOXEMIAS OF PREGNANCY process in the former consists in the lesions just described, but rather in the underlying toxaemia to which they are due. Furthermore, while it is probable that the extensive destruction of liver tissue may account for a part of the urinary changes, by so interfering with the intermediary stages of proteid metabolism that ammonia and other incompletely oxi- dized substances are excreted instead of urea, I am inclined to hold that the greater part of the change is dependent upon the underlying toxaemia, concerning whose nature we are as yet ignorant. These views have not gone unchallenged, as Longridge, Leathes, and others urge that the high ammonia coefficient is simply a manifestation of an acidosis; Underhill and Rand consider it merely an accompaniment of inanition and in no way connected with a toxaemic process; while Whip- ple and Sperry and others suggest that the hepatic and renal lesions may result from poisoning by the chloroform used at the induction of abortion. The high standing of such critics entitles them to consideration, and I admit that their views are partially correct, but at the same time I contend that they are not of universal application, and by no means invalidate the conclusions I have drawn. There is no doubt that pregnant women, just as other individuals, suf- fer from acidosis from various causes, which will naturally be accompanied by a high ammonia coefficient. Such an admission, however, does not indicate that a high ammonia coefficient in women suffering from per- nicious vomiting is always susceptible to such an explanation. That this is not the case is shown by the fact that in many instances I have found that the employment of copious rectal enemata of sodium bicarbonate, and in one instance even its intravenous administration, had no effect upon the ammonia coefficient nor upon the reaction of the urine, which would have been materially altered were we dealing with a mere acidosis. Furthermore, I am perfectly willing to admit that an acidosis incident to starvation may be accompanied by a high ammonia coefficient, and Fig. 447 gives an illustration in point. On the other hand, I contend that all cases presenting a high ammonia coefficient are not of this char- acter. That this is so, is clearly illustrated by the history of the patient whose urinary analysis is represented in Fig. 44G. In this instance no food had been taken for some time prior to the induction of abortion, nor for several days afterward, and yet the ammonia coefficient fell from 33 per cent, to practically normal, while the inanition still continued. It seems to me that the only explanation for such an occurrence is that the high ammonia was a manifestation of a toxaemia, which ceased as soon as the pregnancy which caused it was ended. Likewise, the fact that one of my patients died several days after the vomiting had ceased, and while taking a satisfactory quantity of nutriment, would indicate that starvation is not the only factor concerned. In other cases the appearance of jaundice or the findings at autopsy would point to a similar conclusion; as no one contends that such conditions are ordi- nary manifestations of inanition. Finally, I am quite prepared to admit that the liver lesions may result from chloroform poisoning if that drug were used as an anaes- PERNICIOUS VOMITING OF PREGNANCY 523 tlietic when the abortion was induced. But when similar lesions are ob- served when ether or nitrous oxide are employed, and more particularly in patients who die before an attempt at abortion has been made, it is evident that in such cases the lesions must be due to some other factor. After making all of these allowances and admissions, I have no hesita- tion in stating that there is abundant evidence to prove that certain cases F.L.C. Fio. 444.—Liver from Vomiting op 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. of pernicious vomiting are due to a toxaemia, which is associated with a high ammonia coefficient, a marked reduction in the output of urea, and with profound degenerative lesions in the liver and kidneys. Symptoms.—Ordinarily, pernicious vomiting begins as the simple nausea and vomiting of pregnancy, which gradually becomes so frequent and 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 toxaemic type. In the former the vomiting may continue for weeks, and the patient gradually becomes more and more 524 THE TOXEMIAS OF PREGNANCY emaciated, and eventually dies of starvation if suitable treatment be not instituted. Toxaemic 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 vomitus, soon passes into a somnolent or comatose condition, and dies wdthin a week or ten days without emaciation. In the latter, and much more frequent, variety constant vomiting may persist for weeks, the patient becoming markedly emaciated before the seriousness of the condition is appreciated. Then she begins to vomit coffee-ground-like material, which she rejects in large quantities and without apparent effort. At this time symptoms indicative of toxaemia appear, the patient becoming torpid or violently excited and soon passes into a condition of coma, which is occasionally accompanied by convulsions. In some instances slight jaundice may de- velop, 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 my experience, 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 of 120 or over, 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. Diagnosis.—Acute toxaemic vomiting is readily recognized, but from my experience it is impossible by a single clinical examination to diag- nosticate the chronic variety. Thus, it may happen that two women may appear to be equally ill and to present the same degree of inanition, yet careful examination will show that one is suffering from neurotic and the other from toxaemic vomiting, and the former will recover 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 differen- tial 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 one has to deal with reflex vom- iting. On the other hand, if no lesion can be detected, the diagnosis lies between the neurotic and toxaemic types; but, unfortunately, a positive diagnosis is not always easy. Great help may be obtained by determining the ammonia coefficient; namely, the ratio of the nitrogen contained in the ammonia to the total nitrogen content of the urine. Normally, this varies between 3 and 5 per cent., but under pathological conditions it may rise as high as 30, 40, or even 50 per cent. Unfortunately, such investiga- tions cannot be made by the physician in his office, but require the services of a trained diemist, as they necessitate the determination of the total quantity of nitrogen and of the ammonia by the methods of Kjeldahl and Folin, respectively. PERNICIOUS VOMITING OF PREGNANCY o2o In my monograph I stated that a normal ammonia coefficient indi- cated neurotic, and one exceeding 10 per cent, toxaemic vomiting. Unfor- 16 1 2 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 28 28 27 20 25 21 23 22 21 20 19 18 17 16 15 14 13 — - ~ - 12 11 10 7 5 * s Fig. 445.—'Urinary Chart, Neurotic Vomiting. In this and the following charts each square cor- responds to 1 gram of nitrogen and 1% of ammonia. Total Nitrogen: Black. Ammonia: Red. L)a 46 45 44 43 42 41 40 39 38 37 36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 y l 2 3 I ... \ \ \ \ I a .0 \ \ © < \ \ \ \ li 16 15 14 13 12 11 10 9 8 \ \ , \ - ^— ■ 'i 6 5 / 1 Fig. 446.—Urinary Chart, Toxemic Vomiting, Recovery After In- duced Abortion. Total Nitrogen: Black. Red. Ammonia: tunatelv the matter is not quite so simple, as increased experience has taught me that a high ammonia coefficient may be due to the inanition accompanying prolonged neurotic vomiting, as well as to the perverted 36 526 THE TOXAEMIAS OF PREGNANCY metabolism characterizing the purely toxaemic type. Notwithstanding these qualifications, such determinations are of great value. If the ammonia Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 | \j \\ 1 1 i \ ' i 1 I 1 ' 1 1 1 I / \l j / 1 \ 1 J / \ / \ j / 1 / A / '\ / \ / / J / 1 h V 1 1 \ L_ \ V / A J \l v yy / \ V Fig. 447.—Urinary Chart, Neurotic Vomiting with Starvation. Cure by suggestion and forced feeding. Grams Total Nitrogen: Black. Percentage Am- monia Coefficient: Red. coefficient is 5 per cent, or less, the vomiting is neurotic in character, can be controlled by rest in bed and suggestion, and never requires the induc- tion of abortion. On the other hand, a high ammonia coefficient does not PERNICIOUS VOMITING OF PREGNANCY neccssariiv predicate the existence of toxaemic vomiting; but when it exceeds 15 or 20 per cent, it clearly indicates that the patient is seriously ill. In such cases a differential diagnosis can usually be made by carefully watch- ing the patient. If the coefficient falls after a few days* rest in bed, ener- getic rectal feeding, and moral suasion, a diagnosis of neurotic vomiting is permissible; but if the coefficient remains stationary or rises, one probably A. No. 2310 Sept. 14-Oct. 2nd, 1905. B. No. 2519 March 9 - 19th, 1905. 32 30" 28 2G 24 22 20 18 16 14 12 10 Normal Ammonia —- 1 2 3 4 ;, 6 7 8 9 10 11 12 13 14 15 ir, 17 18 li) 1 t 3 4 5 G _ 11 1 r I : "3\ - r 3 X ■) .=! < V - 1 6.02 0.C8 0.4 8.0 5.6 1U.3C 13.2: 14.71 0.03 14.6C 6.0 8.0 6.8 7.1 7.2 8.4 1J3.60 590 680 ? 50(1, 500, 550, 170< 070 630 1090Jl320| 840Jl24oJ200, 1370 010, ? ? 575 725 1125 750 725 - Fig. 448.—Chart Showing Ammonia Coefficient in Two Consecutive Pregnancies. A, toxaemic, and B, neurotic vomiting. has to deal with the toxaemic variety, and the diagnosis becomes absolute if torpor, coma, or coffee-ground vomit appear. Prognosis.—The prognosis is extremely satisfactory in the reflex and neurotic varieties. In the former relief promptly follows the correction of the genital abnormality, while in the latter cure can usually be effected within two or tliree days by suggestive treatment, provided the physician is sufficiently sure of himself to be able to impress his belief upon the patient. On the other hand, the prognosis is always grave in the toxaemic variety, as we have no means of determining to what extent the internal lesions have progressed, or whether it is possible for them to undergo repair^ even if the underlying cause of the toxaemia be removed by terminating the pregnancy. In any event, it should be remembered that a certain propor- tion of such cases will die no matter what may be done. Pernicious vomiting sometimes recurs, and many women suffer repeat- edly from the neurotic variety in succeeding pregnancies. Unfortunately this may also occur in the toxaemic 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 suf- fered from toxaemic vomiting in the first pregnancy, and from the neurotic variety in the second (Fig. 418). 528 THE TOXAEMIAS 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 cures 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, when it was determined to interfere, the patient was usually 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 sometimes performed unnecessarily in neurotic, and frequently deferred too long in toxaemic vomiting. In the reflex variety, 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. She should be assured by the physician that her condition is not serious, and will not require active interference. At the same time she should receive large amounts of saline or one per cent, glucose solution by the rectum, and occasional nutrient enemata, but for a day or so no attempt should be made to administer nourishment by mouth. After a few days' rest, how- ever, small quantities of fluid nourishment should be administered at frequent intervals, 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 absolute confidence of the patient, this result will usually fol- low; but in exceptional instances more radical treatment is necessary, and an absolute rest cure should be insisted upon. In such cases the patient should be isolated from her family, and placed in a well-conducted hos- pital in the hands of a competent and trusted nurse. In such condi- tions, the regime just indicated will bring about the entire disappearance of symptoms within a few days. In the toxaemic 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, anaesthesia should be induced by means of ether or nitrous oxide, and the uterus emptied by the most con- servative method: vaginal hysterotomy if the cervix is rigid, or dilatation by means of GoodelPs or Hegar's dilatators 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. Great relief is some- times obtained by gastric lavage and leaving 500 cubic centimeters of a 1-per-cent. solution of sodium bicarbonate in the stomach. ACUTE YELLOW ATROPHY OF THE LIVER This condition, which has been variously designated as icterus gravis, typhoid icterus, etc., is a rare but very serious complication of pregnancy. Kerkring in 1700 was the first to report a fatal case in a pregnant woman, ACUTE YELLOW ATROPHY OF THE L1YER 529 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 113 cases which he collected from the literature had occurred in pregnant women, while Quincke placed the incidence at 60 per cent. 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 disease. 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 layer of cells presenting more or less ad- vanced 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 tubules are but little changed. Acute yellow atrophy of the liver may occur at any period of preg- nancy. Heatty and Masson having described cases at the sixth and eighth weeks respectively. Usually, however, it appears during the later months of pregnancy or in the first days of the puerperium. Symptoms.—In acute cases the symptoms may come on so suddenly as to arouse a suspicion of poisoning, and in some instances 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 abdomen, intense headache, and possibly severe vomiting and purging. In a short time she becomes torpid or vio- lently delirious and soon passes into a condition of coma, which may or may not be disturbed by convulsions. In most eases the coma continues for a few hours or days until death supervenes, but recovery may occasion- ally occur. There is generally a certain amount of jaundice, which may vary from a mere discoloration of the conjunctivae to pronounced general icterus. The vomited matter is frequently blood-stained, and sometimes assumes a colfee-ground appearance. The urine is diminished in amount, very high-colored, and contains albumin, all varieties of casts, and fre- quently large quantities of blood. The symptoms are identical whether the condition occurs during preg- nancy or the puerperium, and, if convulsions appear, it is usually mis- taken for eclampsia. In other cases the course of the disease is less rapid, and in its early stages may simulate an ordinary pre-eclamptic toxaemia. Slight jaundice, however, soon appears, and the patient gradually becomes more and more apathetic and torpid, and eventually passes into a condi- 530 THE TOXJEMIAN OF PREGNANCV tion 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 dulness became diminished by more than one half in the course of a week. Spontaneous birth of a dead child is not unusual. Chemical examination of the urine shows changes analogous with those already described in toxaemic vomiting, and similar to those observed in acute phosphorus poisoning. The total nitrogen may or may not be diminished, but 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 tvrosin may be demonstrated by appropriate procedures. It is evident that, just as in toxaemic vomiting, the underlying factor in the production of acute yellow atrophy of the liver must be a profound toxaemia, concerning whose origin we are as yet absolutely ignorant. Like- wise, the changes in the liver and kidneys must be regarded as secondary to it, and not as the primary manifestation of the disease. Diagnosis.—The diagnosis cannot always he made from the clinical manifestations, and as already indicated the condition is frequently mis- taken for eclampsia, although the appearance of jaundice should always be suggestive. On the other hand, the pronounced changes in the urine should lead to a positive diagnosis; but in the absence of a thorough chemical examination it is possible only at autopsy. 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 be 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 avail- able. NEPHRITIC TOX/EMIA 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, and should be regarded as analogous with the so-called ursemic poisoning. I also believe that it is the underlying factor in- women who repeatedly give birth to premature infants and pre- sent a history of being perfectly well up to a certain period of pregnancy, when ci'dema and albuminuria suddenly develop. In such cases, the urinary symptoms may persist for some months after delivery, but eventually dis- appear, to reappear at about the same period in each subsequent pregnancy. This condition differs markedly from the pre-eclamptic toxaemia, and is ex- plicable by assuming that the individual has slightly defective kidneys, which are efficient under ordinary conditions, but break down under the strain of pregnancy. Fortunately nephritic toxaemia is not of very fre- NEPHRITIC TOXJEMIA 531 quent occurrence, though it should be feared in women suffering from chronic nephritis. Symptoms.—The condition may appear at any period of pregnancy, but most frequently in its later months. It is usually accompanied by lassitude, general malaise, headache, and marked oedema, and occasionally by the ocular symptoms associated with albuminuric retinitis. In other cases. however, the patient may complain of little except oedema, and with the exception of 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 accompanied by convulsions, and either die or slowly recover. In the more chronic forms of this variety of toxaemia both red and white infarcts are frequently noted in the placenta, and occasionally occupy so great a part of it as to interfere seriously with its function; as a result the child, whose vitality is already seriously im- paired by the toxaemia, is imperfectly nourished and frequently dies. In- deed, it may be said that, with the exception of syphilis, chronic nephritis is the most common cause of spontaneous premature labor. Diagnosis.-—In many instances it is impossible to differentiate this form of toxaemia from the ordinary pre-eclamptic variety, although the urinary findings are sometimes strikingly different. In the former the quantity of urine may be normal or even increased, although large amounts of albumin and casts are present. The total nitrogen, the urea, and the ammonia coefficient are usually unchanged, though when the latter falls much below the usual limits it frequently indicates that a uraemic attack is impending. In pre-eclamptic toxaemia, on the other hand, the output of urine is usually decreased, and the total nitrogen and urea correspond- ingly diminished. In doubtful cases a hint as to the true condition may occasionally be gained by studying the catalytic activity of the blood. YVinternitz and Ainley in ■ my service found that the reaction is usually abnormally low in cases of pure renal insufficiency, but normal in pre- eclamptic toxaemia and eclampsia. If the patient is not seen until after the onset of convulsions and coma, the condition is usually mistaken for eclampsia. After delivery, if the urine rapidly clears up. it may be assumed that one had to deal with eclampsia; while if albuminuria and casts persist for months a probable diagnosis of renal insufficiency should be made. In many instances, how- ever, one remains uncertain as to the nature of the attack unless the patient dies and comes to autopsy. Prognosis.—Provided convulsions and coma do not appear, the prog- nosis in this variety of toxaemia 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. Naturally the ultimate prognosis is bad, as the strain of pregnancy usually accentuates the original nephritic process. Treatment.—The treatment is identical with that which will be laid down for pre-eclamptic toxaemia, while if convulsions or coma occur it is along the same general lines as for eclampsia. 532 THE TOXAEMIAS OF PREGNANCY PRE-ECLAMPTIC TOXAEMIA This is the most frequent variety of toxaemia 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 readily amenable to treatment, though if neglected, and occa- sionally even notwithstanding the most rational treatment, it may termi- nate in eclampsia. Symptoms.—Pre-eclamptic toxaemia usually appears in the latter part of the second half of pregnancv, and occurs but rarely in its early months. It should be suspected whenever the patient complains of headache, lassi- tude, or oedema, and particularly if the urine is diminished in amount or contains albumin. The symptoms vary from slight malaise to those indicative of profound auto-intoxication. In this event the patient may complain of severe and persistent headache, violent epigastric pain, or visual disturbances which may vary from slightly impaired vision to com- plete amaurosis. In many cases the ophthalmoscope may reveal the char- acteristic lesions of albuminuric retinitis; but when they are 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 gradually deepens into coma, usually followed by death; but more commonly typical eclampsia supervenes. When the toxaemia 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 premature foetus. The total amount of urine may be greatly diminished, and sometimes falls as low as 200 to 300 cubic centimeters in the twenty-four hours. It contains a variable quantity of albumin, numerous casts, and in severe cases blood cells. Chemical examination gives varying results, according to the gravity of the toxaemia. In mild cases the amount of total nitrogen and the relative proportion of its various constituents is but little changed, but in more pronounced cases there is a considerable diminution in the total nitrogen, with a decrease in the percentage of urea and of sodium chloride, associated with a slight increase in the amount of ammonia and the amino acids. Diagnosis.—The clinical differentiation between the nephritic and pre- eclamptic types of toxaemia is not always easy, and is considered in the preceding section, but in the absence of a definite history of pre-exist- ing nephritis it is sometimes impossible. 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. When Geraghty and Eoundtree pointed out the value of phenol-sulphone- phthalein in testing the functional activity of the kidneys, it was hoped it might prove useful in this condition, but the observations of Goldsborough upon normal pregnant women in my clinic showed that conclusions based upon it should be taken with great reserve. PRE-ECLAMPTIC TOX.EM 1A 533 Prognosis.—The prognosis in pre-eclamptic toxaemia is usuallv fair, but it is entirely dependent upon the amenability of the symptoms to treatment. If marked improvement does not occur, premature labor should be induced in the hope of preventing the onset of eclampsia. Even in severe cases the nitrogenous constituents of the urine assume their normal relations within a few days after spontaneous or induced labor, while the albuminous content may persist for weeks before gradually disappearing. Chronic renal disease rarely results from this type of toxaemia, and it is my experience that it is unusual for it to recur in succeeding pregnancies. This, of course, 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 toxaemia occurs in repeated pregnancies it may be inferred that it is of the nephritic type and is dependent upon the exist- ence of a chronic nephritis. Treatment.—In the chapter upon The Management of Pregnancy attention was directed to the necessity for the frequent and routine exami- nation 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 dur- ing the first six months, and every two weeks during the last three months of pregnancy. The patient should also be cautioned to notify the phy- sician whenever she suffers from headache, disturbance of vision, or oedema. If the presence of albumin is detected, or the phy- sician does not feel satisfied with the condition of the patient, the entire amount of urine passed in the twenty- four hours should be measured, and the output of albu- min, as well as the total amount of nitrogen, determined and its partition studied. Unfortunately this is practica- ble only where the services of trained chemists are avail- able, but in general practice approximate results may be obtained by the use of Esbach's albuminometer and Dore- mus's ureometer, and, as the urine contains but small amounts of ammonia, such estimations are far more reliable than in toxemic vomiting and acute yellow atro- phy of the liver. For practical purposes the amount of total nitrogen may be approximately estimated by divid- ing the urea reading by two. Esbach's albuminometer is a graduated test-tube pro- vided with a stopper (Fig. 119), in which the albumin- ous substances are precipitated by a solution consisting of picric acid 10, citric acid 20, and distilled water 1,000 grams. In order to make the determination, the tube is filled to the mark U with urine and afterward to R with the reagent. It is then corked and gently inverted ten or twelve times, after which it is allowed to stand for twenty-four hours, when the amount of precipitate is read off on the scale, each division corresponding to 1 gram of albumin to the liter, or one tenth of one per cent. Fig. 449.—Esbach's Albuminometer. 534 THE TOXEMIAS OF PREGNANCY Doremus's ureometer, which is represented in Fig. l.">0, enables one to estimate indirectly the amount of urea after decomposing it by means of sodium hypobromite, the reaction being shown by the following formula: t*\ C0X,H4 -f 3XaOBr = 3XaBr + CO, + 2H20 A- X2 The potassium bromide and carbon dioxide are dis- solved, while the nitrogen gas rises to the top of the tube, where it can be measured. Each division on the scale indicates the presence of 0.001 gram of urea to each cubic centimeter of urine. Ordinarily, if the urea output is normal (1G to 21 grams per diem), the presence of a slight amount of albumin may be regarded with indifference; whereas, if a considerable quantity is present—5 grams or more to the liter—and the urea at the same time falls below 10 grams, the patient should be re- garded as in silrious. danger and should be kept under close supervision. During this time the twenty-four-hour specimen of urine should be examined daily, and the treatment based upon the relative amounts of albumin and urea present, as well as upon the subjective symptoms. (See Fig. 451.) The sudden appearance of amaurosis, and more particularly of pain in the epi- gastrium, should always be regarded with suspicion, as it is frequently the precursor ^Doremus's Ureometer. of eclampsia, and the same may be said of a sudden increase in the blood pressure, which sometimes rises as high as 200 or more millimeters. If the total nitrogen and its partition be determined, a rise in the ammonia coefficient should be considered as favorable. 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 inter- dicted; or, better still, for a while she should depend solely upon milk, which is not only an excellent food, but also a most efficient diuretic. At least two 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 amelioration of the symptoms, an increased urinary secretion, a decrease in the amount of albumin, a rise in the amount of urea, a decreased blood pressure, and a prompt return to normal conditions (Fig. 1~>1). If the desired result is not promptly obtained, a brisk purge of Eochelle or Epsom salts should Fig. 450. PRE-ECLAMPTIC TOXAEMIA 535 be given, and the cutaneous functions stimulated by a hot pack or sweat bath. If under treatment the symptoms disappear, the albumin becomes less and the urea increased in amount, the outlook mav be considered excellent. On the other hand, if the albumin steadily increases, and the urea decreases in amount, while the subjective condition of the patient remains unchanged or becomes more serious, the prognosis becomes Fig. 451.—Urinary Chart. Pre-eclamptic toxaemia; recovery under milk diet and rest in bed. ominous, and the appearance of somnolence and coma or eclampsia can probably be avoided only by emptying the uterus, no matter what be the period of pregnancy. In my experience, an output of 8 to 10 grams of albumin per liter, irrespective of other symptoms, justifies interference. 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 hysterotomy, unless the cervix be so soft, and its canal so obliter- ated, that manual dilatation by Harris's method can be safely effected. 53G THE TOXAEMIAS OF PREGNANCY Unfortunately, we are not yet acquainted with the actual toxic agent or agents concerned in the production of this variety of toxsemia or of eclamp- Day. Ch 46 45 44 43 42 41 40 39 38 37 ,36 35 34 33 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 h.i 16 15 14 13 12 11 10 3 a s & s s « S -a>-~-P o o < ! - 1 - - i_ \ ! I I -\-j——j—j— j— i ~ - 4 1 i / |_| \ 1 1 ! 1 V'i " — \\ ' l/l ~ A j | X 1 l 1 1/ !i _]/ 1 1 / \ *\ y •— / \, ~1 / \ ' \ / I \ \ \ i *- - i -- — — ►— •-. --*■ -■ • Fig. 452.—Urinary Chart. Pre-eclamptic Toxaemia, Recovery After Accouchement Force. Total Nitrogen -------- Ammonia: Red. Albumin------- (Each square corresponds to 1 gram of nitrogen, 1% of ammonia, and ro% of albumin.) sia, and consequently the indications for interference are only relative. Thus, it sometimes happens that the urinary findings and clinical symp- ECLAMPSIA 537 toms so improve under treatment that one is inclined to feel that 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 unex- pectedly make a most satisfactory recovery without any untoward manifest- ation. Such experiences indicate that our knowledge of the subject is far from complete; but at present all that is possible is to follow the direc- tions just given, and to interfere whenever the urinary findings and clin- ical 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 toxaemia constitutes our only available means of preventing this dreaded disease. Some authorities go as 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 with- out exceptions; as upon several occasions I have seen eclampsia occur in women awaiting delivery in my wards, where the urine had been nega- tive only the day before the outbreak of convulsions. ECLAMPSIA Eclampsia is an acute toxaemia occurring in the pregnant, parturient, or puerperal woman, and is usually accompanied by clonic and tonic con- vulsions, during which there is loss of consciousness followed by more or less prolonged coma. Generally, convulsions and eclampsia are considered as synonymous terms, but such a view is not correct, inasmuch as a num- ber of well-authenticated cases of eclampsia without convulsions have been recorded, and other toxa?mic conditions occasionally occur in obstetrical practice which are likewise accompanied by convulsions or coma. Accord- ingly, the only absolutely characteristic feature of the disease is the pres- ence of the hepatic lesions which will be described later. Frequency.—Statistical tables go to show that eclampsia occurs about once in every 500 labors, but it is almost impossible to determine its inci- dence 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 con- vulsions. The following table would indicate that eclampsia occurs in about 1.0 per cent, of the women entering lying-in hospitals. Goldberg (Dresden, 1S91) in 10,717 labors, 81 eases of eclampsia (0.75%) Cassamayor (Paris, 1S92) " 16.225 " 99 . . (0.61%) Knapp (Prag, 1900) " 7,636 41 i < (0.53%) Newell (Boston, 1900) " 6,700 " 99 < i (1.17%) Reinburg (Paris, 1905) " 26,511 " 90 11 (0.34%) Lielitcnst.-in(Leipzig,1911)" 14,836 400 '' (2.6S%) Williams(Baltimore,1912)" 11,000 110 < < (1.0%) 538 THE TOXEMIAS OF PREGNANCY The larger tabulations made by Yeit in lS!)fi, which are based upon statistics from the various clinics in Germany, show that 905 cases of eclampsia occurred in 149,366 labors—a percentage of 0.6, or 1 in 166. These statistics include all cases of eclampsia, but Lichtenstein differen- tiated between the total number of cases and those occurring in patients who were in the hospital at the onset of the disorder, and found that in the latter the ratio was only 0.15 per cent., or 1 in 600. Eclampsia varies markedly in frequency at different times, Cassamayor stating that in Tarnier's clinic in Paris it was observed many times more frequently in some years than in others. Thus, in 1872, there was 1 case to every 47 labors, as compared with 1 to 730 and 1 to 130 in the years 1882 and 1891, respectively. Clinical History.—Zweifel has reported a case of eclampsia occurring in the third month, but as a rule it is not encountered before the second half of pregnancy, and becomes more frequent the nearer term is approached. It is generally stated that 70 to 80 per cent, of all cases occur in primi- parous women, Ivnapp, Olshausen, Cassamayor, and Goldberg reporting a proportion of 71, 75, 77, and 86.4 per cent, respectively. In all probability these figures are somewhat too high, inasmuch as they are based upon hos- • pital practice. Nevertheless, be this as it may, it is certain that in the main primiparous women are much more liable to the disorder. Twin pregnancy and hydramnios appear to act as predisposing factors, the former condition being noted by Olshausen and Cassamayor in 8 and 5.7 per cent, of their cases of eclampsia respectively, whereas for all labors the usual ratio is 1.5 per cent. It is possible that heredity sometimes plays a part in its production, and Elliot, Olshausen, and Pinard have reported cases which apparently confirm this view. An eclamptic convulsion sometimes occurs without warning, "like 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 longer or shorter period by premonitory symptoms indicative of pre-eclamptic toxaemia. The attack may come on at any time, sometimes while the pa- tient is sleeping. If she is awake, the first sign of the impending convul- sion 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 con- vulsive 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 sometimes they take on a tonic form and the patient becomes rigid. The 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 observed. Oftener, however, the first is the forerunner of other convulsions, which may vary in number from 1 or 2 in mild, to 10 or 20 or even 100 or more ECLAMPSIA 539 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 prolonged, almost continuous convulsion. The duration of the coma is very variable. When the convulsions 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 oedema of the lungs or apoplexy, though if the fatal issue is postponed for several days, it is usually attributable to an aspiration pneu- monia or a puerperal infection. In most cases during the seizure the arterial pressure is markedly in- creased, and may reach 210 or 260 mm., while the pulse is full and bound- ing. In severe cases, however, it is weaker and more rapid, becoming more compressible and filiform with each succeeding convulsion. In some cases the temperature rises to a very considerable height from the onset of the disease and rapidly falls as the patient improves; more often, however, it remains normal. A temperature of 101 or 105 degrees is not unusual, and in one of my fatal cases it reached 100.5 degrees just before the end. As regards the cause of this elevation there is much discrepancy of opinion. Olshausen believes that the poison which gives rise to the eclampsia also stimulates the thermal centers, while Zweifel holds that the fever is nearly always of infectious origin. I incline toward the former view, for the reason that the uterine lochia were always sterile whenever I made a bacteriological examination in patients presenting a transient elevation of temperature. On the other hand, the fever is practically always infectious in origin if it persists for more than 21 hours after the cessation of the seizures, and it would seem that women suffering from the disease are more susceptible to infection than usual. While the convulsions are by far the most striking clinical manifesta- tions of eclampsia, and even give the disease its name, instances are occa- sionally met with in which they are absent, the patients dying in coma and presenting at autopsy the hepatic and renal lesions characteristic of the affection. Three such cases were reported by Schmorl in 1902, and I have seen two examples, which were recorded by Slemons in 1907. Since then the condition has been more generally recognized, so that Schmid in 1911 was able to collect 21 cases from the literature. 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 livrjr. 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 lirst hours of the puerperium, it is designated as ante-partum, intra-partum, or post-partum eclampsia. It is generally stated in the text-books that the 540 THE TOXAEMIAS OE PREGNANCY last is the least common; but that the conclusions as to the relative inci- dence of the different varieties are by no means unanimous is shown by the following table: Ante-partum. Intra-partum. Post-partum. 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% Newell and McPherson state that one third of their cases occurred after the birth of the child. Personally, I have observed an incidence of 23 per cent, for the post-partum variety. It would appear from the statistics just cited that ante-partum eclamp- sia occurs less frequently than the intra-partum variety, but this does not correspond with my own experience. Olshausen has reached a similar conclusion, and considers that the contrary statements of most authors are due to the fact that they have failed to remember that eclampsia usu- ally supervenes before the estimated end of pregnancy and that uterine contractions set in with the first convulsion, so that if the patient is not seen before the seizure it is often very difficult to determine with which variety one has to deal. Ante-partum eclampsia may terminate in several ways. As a rule, labor sets in and a premature child is born spontaneously, or the uterus is emptied by operative procedures. Sometimes the patient dies undelivered. Lichtenstein has directed particular attention to the fact that labor does not always supervene, but that the woman may recover and give birth to a dead or macerated fcetus some time afterwards, or may even go on to term and bear a living child. He has collected from the literature 56 examples of the former and 61 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 de- scribed 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 be 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 undertaken. In post-partum eclampsia the attack usually comes on soon after de- livery, 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 compara- tively benign is denied by Olshausen and Lichtenstein, who noted a mor- tality of 25 and 27 per cent., respectively. ECLAMPSIA 541 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 Yan der Yelde, that such conditions were not eclamptic at all, but are due to hysteria, uraemia, or other causes. Occasionally the onset is preceded by a distinct aura (Olshausen), but this is usually lacking. In rare instances the convulsion comes on with- out warning, but it is generally preceded for some davs or even weeks by symptoms indicative of pre-eclamptic toxaemia. As has been pointed out by Olshausen, severe epigastric pain 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 previous to it. This is a not altogether uncommon observation, and may sometimes have an important bearing from a medico-legal point of view. In 5 per cent, of Lohlein's and in 7 per cent, of Lichtenstein's cases eclampsia was followed by marked mental derangement. In my own expe- 3. 2 2.6 2.4 2.2 2. 1.8 1.6 1.4 1.2 1. January 20th January 21st 1C hours j 8 hours 6 hours 12 hours 3 hours 3 hours 15 14 IS I1 = \ ^ E a 3 1 J \ U O 5 2 .a 1? A f \ s \,aj « 5 0 jfc 11 1(1 i \ 9 / \ 8 7 6 5 4 3 2 1 / . / \ / / / \ t • \ \ r.N. 1.75 Grams 11.73 Grams 75 c c 125 c c 200 c c | 325 C C | 100 c C | 100 C C Fig. 453.—Urinary Chart. Eclampsia, Death 48 Hours After Onset. Total Nitrogen --------- Ammonia: Red. Albumin ■-------- (Each specimen analyzed separately. Figures on left side indicate grams of nitrogen and percentage of ammonia; on right side, percentage of albumin.) rience this complication has occurred much less frequently; although it must not be forgotten that psychosis following eclamptic convulsions is 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. 542 THE TOXJEMIAS OF PRKGNANCY In rare instances, as the result of cerebral lesions incident to eclampsia, a hemianopsia may develop during the puerperium. A case of this char- acter, 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 an albuminuric retinitis. As this is an accompaniment of an acute nephritis, eclampsia does not always develop, and the outcome is dependent upon the further course of the underlying disease. In other cases the visual disturbance is unattended by demonstrable changes in the retina or optic nerve, and is to be regarded merely as a manifestation of the gen- eral toxaemia, complete recovery usually following within a few days after the termination of pregnancy. 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, and indicates serious hepatic involvement. Eclampsia may occur not only during the course of an ordinary gesta- tion, but was observed by Maygrier in the false labor accompanying extra- uterine pregnancy. Falk, Sitzenfrey, and others have reported cases oc- curring in association with hydatidiform mole, and the possibility of such an occurrence has been urged as evidence that the metabolic processes of the foetus play no part in the aetiology of eclampsia. 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, as in the case charted in Fig. 153, in which only 75 cubic centimeters of urine was passed in sixteen hours. On microscopical examination various types of casts are found in great abundance, although the hyaline and granular varieties predominate. Epi- thelial casts also occur, as well as isolated renal cells, while blood is nearly always present. Haemoglobinuria 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 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 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 precipitate 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 31 per cent. The high albumin output is only temporary. Usually it falls to a fraction of one gram per liter within 36 or 48 hours after delivery, and then rapidly disappears, though in other cases traces may be observed for weeks (Fig. 451). 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 com- pared with 0.25 per cent, twelve hours later. It is interesting to note that these high grades of albuminuria do not necessarily indicate profound renal lesions, as in several of my cases, in which the urine contained large ECLAMPSIA 543 amounts of albumin, as well as quantities of casts, only a mild degenerative nephritis was found at autopsy. The total nitrogen of the urine, estimated by the Kjeldahl method, is markedly diminished in eclampsia, and at the same time there occurs a profound alteration in the proportions of its various constituents. Thus Fig. 454.—Urinary Chart. Eclampsia with Recovery. Total Nitrogen —-----Ammonia: Red. Albumen --- (Figures on right and left as in Chart 453.) the urea, which normally makes up about four fifths of the total, is reduced to less than one half. On the other hand, there is a relative increase in the amount of the amino acids and the various substances which are precipitated by phospho-tungstic acid, such as creatinin, uric acid, etc. The study of the behavior of the ammonia coefficient is of particular inter- est. With the onset of convulsions a decrease is usually observed (Fig. 455), which is soon followed by a marked rise, so that the ammonia coefficient usually remains relatively high for a variable length of time. In our experience this condition is of favorable import, as in several fatal cases the ammonia coefficient was low. During convalescence the urine usually returns to a normal condition, 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 544 THE TOXAEMIAS OP PREGNANCY high nitrogenous 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. On the other hand, its persistence for several months indicates the existence of a chronic nephritis, which in most cases antedated the eclamptic attack, but occasionally appears to have resulted from it. Urine Fig. 455.—Urinary Chart. Eclampsia With Recovery. Total Nitrogen---------Ammonia: Red. Albumin------- (First reading, day preceding attack. On day of attack, each specimen analyzed separately. Figures on right and left as in Chart 453.) Pathology.—After Bayer and Lever had demonstrated the presence of albumin in the urine of women suffering from this disorder, it was gen- erally believed that the fundamental pathological lesion in eclampsia was a nephritis, and for a long time the condition was considered to be identical with uraemia. This view, however, was gradually abandoned when it was found that ECLAMPSIA 545 only a small proportion of the women suffering from chronic nephritis had eclampsia; and still further modifications became necessary after it had been shown that the urine did not necessarily contain albumin at the time of the eclamptic attack, Schroeder, Ingerslev, and Oharpentier having col- lected respectively 62, 112, and 113 such cases from the literature. Its absence, however, does not necessarily disprove the renal origin of the disease, since Yan der Velde has reported two instances of eclampsia in which the kidneys were markedly diseased, notwithstanding the fact that albumin was not demonstrable in the urine. 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 renal epithelium. Ordinarily, this is the only renal lesion, though occasionally it may be engrafted upon a chronic process. Prutz found kidney changes in all but 7 out of 368 cases collected from the literature, in which the description was sufficiently accurate to be of value. Forms of acute or chronic nephritis were present in 46 and 11.6 per cent, of his cases respectively, while degenerative changes were observed more frequently. His conclusions are stated as follows: "Notwithstand- ing the frequency of renal lesions, we are not justified, even in the majority of cases, in considering them as the anatomical substratum of eclampsia, for in many instances they are too insignificant; accordingly, it must remain a question whether they are not purely secondary in the greater proportion of the cases." This view is also endorsed by Pollak and Bar. The former noted renal changes in 98.4 per cent, of 139 cases, and the latter in all of his 38 autopsies, but in approximately half the cases the lesion was very slight in character. More or less similar results were obtained by Olshausen, Goldberg, Hughes and Carter, Lubarsch and Schmorl, all of whom stated that renal lesions were absent in a small proportion of their cases; although Bouffe de Saint Blaise states that these organs 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. Guenard and Potocki attempted to determine the permeability of the kidneys by administering methylene blue to 7 eclamptic patients. As the drug could always be demonstrated in the urine a short time after its administration they concluded that the renal function was not markedly impaired, even though anatomical lesions might be present. On the whole, the evidence at hand would seem to indicate that 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 enlarged 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. 37 546 THE TOXAEMIAS OF PREGNANCY In 1886 Jiirgens and Klebs pointed out the existence of a haemorrhagic hepatitis in certain cases of eclampsia. Their observations, however, cre- ated very little interest, and it remained for Pilliet, in 1888, to direct our attention to certain haemorrhagic lesions in the eclamptic liver. His work was abundantly confirmed by Schmorl in 1893, who, in a monograph based upon 17 autopsies, stated that he had found in every case lesions of the liver which he held to be more characteristic than those observed in the Fig. 456.—Eclamptic Liver. X 50. B. D., bile duct; C. V., central vein; N., periportal necroses. kidneys. These consist of irregularly shaped, reddish or whitish areas scattered through the entire organ in the neighborhood of the smaller por- tal vessels. Ordinarily they are readily seen with the naked eye, and on section give the liver a mottled appearance. Under the microscope they are recognized as areas of necrosis, involving the periphery of the indi- vidual lobules and the portal spaces, in which blood-cells may or may not be present. Schmorl attributed their formation to degenerative changes following thrombotic processes in the smaller portal vessels, and considered ECLAMPSIA 547 that their presence justified the diagnosis of eclampsia without further knowledge of the history of the case (Fig. 456). 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 Lubarsch, Prutz, Bar and Guyeisse, Bouffe de Saint Blaise, and many others; and Schmorl, in 1902, observed them in 71 out of 73 autopsies, while in the two negative cases tbere was a fresh thrombosis of the portal vein. I have been able to dem- onstrate similar lesions in all the eclamptic livers which I have examined, and consider that they are absolutely characteristic; 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. Konstanti- Fig. 457.—Placental Giant Cell and Chorionic Villus in Blood-vessel of Tube Wall Some Distance from Placental Site. X 80. nowitsh reviewed the subject very thoroughly in 1907, basing his conclusions upon 30 specimens studied in Marchard's laboratory. While generally en- dorsing Schmorl's teaching, he holds that the initial change consists in the dilatation and thrombosis of the capillaries at the periphery of the lobules, which is followed by necrosis of the liver cells and an extension of the process to the portal spaces. Several observers have described the presence of haematomata of vary- ing size, just beneath the capsule of the liver, Prutz having recorded a fatal intra-peritoneal haemorrhage from the rupture of such a structure. Yarious statements have been made concerning the pathological find- ings in the brain—oedema, hyperaemia, anaemia, thrombosis, and apoplexy l>eing described as the main lesions. Prutz noted oedema in 12 per cent., hyperaemia in 35 per cent., and apoplexy in 13 per cent., while the brain was apparently normal in only 10 per cent, of his cases. Schmorl, in 58 548 THE TOXEMIAS OF PREGNANCY 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 Pollak. Ac- cording to Schmorl, the changes usually consist in degenerative processes in the myocardium, which are generally regarded as being due to eclamp- sia, though at times they may be attributed to the use of chloroform in its treatment. Following Schmorl and Winckler, all investigators have demonstrated in the pulmonary capillaries the presence of giant cells, which they have identified with the so-called giant cells of the placenta—namely, masses of syncytium. Schmorl formerly believed that their presence probably ex- plained the origin of the thrombotic processes observed in various organs. But at present they are regarded as having no significance, as they can always 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, broncho-pneumonia 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 relative 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 substance in the blood, which gives rise to lesions of varying intensity in the several organs. .Siltiology.—So many hypotheses have been advanced concerning the aetiology 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 far less stable equilibrium during pregnancy than at other times. This fact has been conclusively demonstrated by Blumreich and Zuntz, who showed that convulsions could be produced by the application of far smaller quan- tities of powdered creatinin to the cerebral cortex in pregnant than in non- pregnant animals. Following the discovery by Lever that the urine of eclamptic patients contained albumin, the disease was identified with uraemia, and this view was only slowly abandoned after it had been conclusively demonstrated that the two conditions had but little in common. Spiegelberg, in 1870, advanced the theory that the circulation of ammo- nium carbonate in the blood was responsible for the seizures, but, chemical analysis having failed to substantiate this statement, the idea was soon abandoned. The Traube-Posenstein theory, which held that the convulsions were the result of anaemia and oedema of the brain, found widespread accept- ECLAMPSIA 549 ance for many years, but was ultimately abandoned in view of the fact that sucb conditions could not always be demonstrated at autopsy. Delore and liodet, of Lyons, in 1884 suggested bacterial invasion as a possible aliological factor, but adduced no evidence in support of such a view. The first investigations were made by Doleris in 1885. Following him, a large number of observers reported that they had cultivated various bacteria from the blood, urine, and tissues of eclamptic women, but their results were so contradictory as to be of but little value. On the other hand, Haegler, Doderlein, Schmorl, Lubarsch, and Bar and Guyeisse ob- tained uniformly negative results, and, as my own experience has been similar, I feel justified in concluding that satisfactory proof has not been adduced in support of the bacterial nature of the disease, nor does it seem likely to be forthcoming. A much more promising field of investigation was opened up by the work of Bouchard upon auto-intoxication. Piviere, in 18S8, was the first to put forward the theory that eclampsia was an auto-intoxication resulting from the heaping up of some substance in the system during pregnancv, holding that its presence was indicated by an increase in the toxicity of the blood serum and a decrease in that of the urine. This conception was placed upon an apparently solid foundation by the work of Chamberlent and 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 far less toxic than usual, while the toxicity of the blood serum was markedly increased. They concluded, therefore, that some poisonous substance, which should have been excreted by the kidneys, was accumulating in the system and increas- ing the toxicity of the blood serum, which in turn gave rise to the renal and hepatic lesions, thereby still further accentuating the condition. Their investigations were apparently confirmed by the work of Ludwig and Savor, who considered the offending product to be carbamic acid, which they believed was formed as the result of imperfect metabolic processes, especially in the liver. The studies of Volhard in 1897 failed to substantiate these findings, as he was unable to show that the blood serum was more toxic in eclampsia than in other conditions. Furthermore, the doctrine in general received a severe blow when the work of Yan der Bergh, Forehheimer, Stewart, and Schumacher showed the results obtained by the injection of blood serum and urine into animals to be so variable and dependent upon so many factors that they must be received with the greatest caution. The experiments of the last named in- vestigators proved that death depends in great part upon the rapidity with which the injection is made, as well as the fact that the toxicity of the urine is principally due to bacterial products rather than to a definite organic poison ; since they found that large quantities could be injected into animals with impunity, provided it is thoroughly sterilized; whereas, if such precautions are not taken, small quantities of the urine led to uniformly fatal results. An even more potent argument against the acceptance of such experiments is the generally recognized fact that the injection of blood serum into an animal of another species is usually 550 THE TOXiEMIAS OP PREGNANCY followed by various biological reactions, such as agglutination, haemolysis, etc. To overcome this difficulty, Semb immunized rabbits to normal hu- man blood serum, and then injected into their circulation serum from eclamptic women. None of his animals had convulsions, but in many instances more or less characteristic lesions were found in the livers and kidneys. He believed that his experiments demonstrated an increased toxicity of eclamptic serum, but further investigations have not borne out his conclusions. The most enthusiastic advocate of the doctrine that eclampsia is due to the heaping up of poisons in the blood are the students of Pinard. Thus, Bouffe de Saint Blaise considers that the essential feature of the disease consists in an alteration in the function of the liver, which fails to render innocuous certain poisonous products of metabolism, and that these in turn give rise to an auto-intoxication, or hepato-toxaemia. When the dis- turbance is slight, the patient merely suffers from nausea or headache; but when it is marked, secondary renal changes develop which in turn lead to a still further retention of the poison and the ultimate production of eclampsia. Following the failure to demonstrate experimentally an increased tox- icity of the blood serum, the aetiology of eclampsia has been extensively investigated and has given rise to a voluminous literature, which abounds in contradictions and has not led to generally accepted conclusions. Generally speaking, the investigations have been undertaken in the hope of demonstrating that the disease is due to one or more of the following factors: I. Foetal metabolism. II. The entrance of fcetal or placental elements into the maternal circulation. III. Poisoning by substances formed or retained in the placenta. IV. Disturbances of the maternal metabolism. V. Anaphylactic reaction. VI. Mammary toxaemia. I. Fehling in 1899 and Dienst in 1902 advanced the theory that eclamp- sia was due to intoxication by certain products of fcetal metabolism,' the maternal organism being unable to accommodate itself to the increased strain incident to their elimination. The advocates of this view lay great stress upon the fact that convulsions sometimes appear in the children of eclamptic mothers shortly after birth, and are accompanied by thrombotic changes, as well as by lesions in the liver and kidneys identical with those in the maternal organs. Observations of this character have been made by Schmorl, Chamberlent, Bar and Guyeisse, Knapp, myself, and others, and are considered critically in Dienst's monograph. Furthermore, the demonstration by Kronig and Fiith, Zangemeister, Szili, and others that the osmotic pressure and electrical conductivity are identical in both ma- ternal and fcetal blood indicates that there is no fundamental objection to the acceptance of such a theory. This view also receives a certain amount of support from clinical expe- ECLAMPSIA 551 rience, since, as is well known, the convulsions usually cease soon after delivery; while spontaneous recovery is the rule when the fcetus dies during pregnancy. Moreover, Baron and Castaigne have shown that the transmis- sion to the mother of substances injected into the fcetus ceases almost immediately after its death. On the other hand, observations of this character are not necessarily convincing; as it may be urged that recovery is due not so much to the delivery or death of the fcetus as to the coincident elimination of the maternal metabolic processes peculiar to pregnancy. Furthermore, several writers have contended that the association of eclampsia with hydatidiform mole affords conclusive evidence that the foetus is in no way concerned. To my mind, however, this contention does not appear to be well founded, as it is quite conceivable that the metabolic processes incident to the con- tinued growth of the chorionic epithelium may be practically identical with those of the normal fcetus. II. Veit in 1902 promulgated an hypothesis along the lines of Ehrlich's side-chain doctrine, which for a time bid fair to solve the problem. Not- withstanding its failure to do so, his work has served to direct attention to the "biological" aspects of the question, and has been the incentive for a large amount of investigation. This theory was based upon the fact that even in normal pregnancy varying amounts of fcetal ectoderm, and even fragments of chorionic villi, are constantly becoming separated from the placenta and gain access to the maternal circulation, the process being designated as "deportation." Veit contended that the fcetal elements give rise to a poison—syncytio-toxin, which is normally rendered innocuous by a supposititious antibody—syncy- tiolysin, 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 poisoning 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 experiment whenever the rupture of a tubal pregnancy leads to the extrusion of the ovum into the peritoneal cavity. The fact that eclampsia does not super- vene under such conditions speaks strongly against the correctness of this view. Ascoli, on the other hand, held that the disease was due to an excessive production of syncytiolysin. These theories are at present regarded as untenable, more particularly as Frank and Heimann in 1911 were unable to demonstrate by means of the deviation of complement and other reactions that the maternal serum formed specific antibodies when human chorionic villi were employed as antigen. III. Following Veit's theory, numerous investigators, including Liep- mann, Weichhardt and Piltz, Freund, Guggisberg, and others, attempted to 552 THE TOXiEMIAS OF PREGNANCY prove that eclampsia is due to endotoxins contained in the chorionic villi, and more particularly in the syncytium. They found that the intravenous injection into animals of emulsions or extracts of placenta were usually followed by rapid death and some- times by convulsions. At autopsy widespread thrombosis was observed, together with variable lesions in the liver and kidneys. Freund accord- ingly concluded that the placenta contained a definite poison which was made up of at least two components—one giving rise to thrombosis, and the other acting on the nervous system. Probably the most serious blow to this theory was struck by Lichten- stein in 1908, when he demonstrated that the results obtained were in great part mechanical, and could be produced equally well by the injection of indifferent materials, and furthermore that placental emulsions and extracts could be injected with impunity provided all suspended particles were removed by efficient filtration. Subsequent writers have failed to meet his criticism, nor do I believe that Guggisberg has refuted his con- clusions. Schmorl in his original monograph suggested that it was possible that the extensive thrombosis accompanying the disease might be due to the action of fibrin ferment. This view was practically abandoned until the chemical investigations of Hofbauer, Drvfuss, and others revealed the presence of amino acids and other substances in the placenta, which are in all probability due to the action of ferments. These authors accordingly suggested that a part of the lesion, at least, might be due to the escape of such ferments into the circulation. Dienst in 1912 still further elaborated this view, and holds that eclamp- sia is due to an increase in the fibrogen and fibrin ferment content of the blood. He and Kollmann have demonstrated that both of these substances are nearly twice as abundant during pregnancy as at other times, and are still further increased in eclampsia. Dienst believes that normally coagu- lation of the blood is prevented by the elaboration of antithrombin in the liver, but, whenever, as the result of circulatory changes incident to preg- nancy, that organ becomes insufficient, antithrombin is no longer excreted in sufficient quantity to neutralize the fibrin ferment, which consequently combines with the fibrinogen and inaugurates thrombosis. While this hypothesis is very clearly set forth, it is nevertheless probable that it will meet the same fate as its predecessors. After Flexner had shown the part played by agglutination of the red corpuscles in the production of thrombosis, and Pearce had demonstrated the effect of haemolysis upon the liver and kidneys, an attempt was made to isolate and explain the mode of production of such substances. Leith Murray believed that they are the essential factors in the production of the disease; while Freund and Mohr considered that they had solved the prob- lem of haemolysis by the isolation of oleic acid or sodium oleate in the placenta. It is generally believed, however, that the substances in question are merely constituents of the fat normally present in the placenta. IV. The study of the metabolism of the mother during the eclamptic state and particularly the clinical examination of the urine have added ECLAMPSIA 553 considerably to our knowledge, but have not yet given us a clue as to the ultimate cause of the disease. Massen in 1895 found the relative amount of urea greatly diminished, and Helouin a few years later stated that the rapport azoturique—the relation of the amount of nitrogen contained in the urea to the total nitro- gen—was profoundly altered. Normally the ratio varies between 80 and 90 per cent., but is greatly reduced in pre-eclamptic toxaemia and eclampsia. These findings were abundantly confirmed, and in several instances we have found that less than one half of the total nitrogen was excreted as urea. Furthermore, study of the "nitrogenous partition" by Whitney, Zweifel, Stone, Ewing and Wolf, and others, as well as in my service, shows a marked increase in the amino acids, as well as in the substances pre- cipitated by phospho-tungstic acid, such as uric acid, creatinin, and the xanthin bases. The sum total of these substances, however, does not equal the entire amount of nitrogen contained in the precipitate, so that the deficit is designated as the "N rest." This is greater in eclamptic than in normal urine, but whether it bears any relation to the production of eclamp- sia cannot as yet be stated. In any event, the study of the nitrogenous metabolism gives evidence of a profound derangement, and indicates im- perfect oxidation and desamidation. Recognizing these facts, Zweifel attempted to find some imperfectly oxidized body in the urine which might possibly give rise to eclampsia, and succeeded in demonstrating considerable quantities of sarcolactic acid, which was also found in the eerebro-spinal fluid by his pupils, Fiith and Lockemann. Notwithstanding Zweifel's careful work, it does not seem that we are justified in considering lactic acid as the cause of the disease, as it is probably only a result of the muscular work incident to the con- vulsions. The intimate relation existing between the thyroid gland and metab- olism led Nicholson to assume that eclampsia might be due to thyroid insufficiency, and to recommend the use of its extract in the treatment of the disease. Lange found that hypertrophy of the thyroid was one of the usual concomitants of normal pregnancy, and that its absence predisposed to the occurrence of a toxaemia. A considerable amount of work has been done in this direction, but lias not yet led to definite results. Yassale and Zangfrongini in 1905 ascribed a similar function to the parathyroid glands. It has, however, been indicated that insufficient secretion on their part leads to the production of tetany, and I think it permissible to agree with Seitz that they are not concerned in the aetiology of eclampsia. V. Posenau and Anderson in 1908 suggested that eclampsia might possibly represent an anaphylactic reaction. This idea was still further elaborated in 1910 and 1911 by Tides and Lockemann, and Grafenburg, who, after an extensive series of experiments, held that the mother was sen- sitized during pregnancy by small quantities of fcetal protein and would go into anaphylactic shock if a quantity of fcetal blood were suddenly intro- duced into her circulation. They identified the condition with eclampsia and claimed that the liver and kidneys presented characteristic lesions. 554 THE TOXEMIAS OF PREGNANCY Notwithstanding the plausibility of these contributions, I feel that they have not solved the problem, more particularly as Johnstone and Fellander failed to verify them. VI. As practically all other organs had been considered in connection with the aetiology of eclampsia, Sellheim suggested the possibility of its mammary origin. He based his supposition in great part upon the experi- ence of veterinarians that the so-called paresis of cattle is relieved by the injection of air or of various medicaments into the breasts. In a patient in whom relief did not follow delivery, he felt justified in amputating both breasts, and, as she eventually recovered, he held that the mammary theory deserved further consideration. It is interesting to note in this connection that Healy and Kastle of the Kentucky Agricultural Experiment Station, in 1912, consider that the so-called parturient paresis, or milk fever, of cows is identical with human eclampsia. This disease is characterized by coma, convulsions, albuminuria, a pronounced change in the nitrogen partition, and by the presence of casts. Its pathology is as yet unknown, but its mortality has been reduced from 60 to 0.5 per cent, by injecting the udders with oxygen. Furthermore, by the injection into guinea pigs of small quantities of colostrum, obtained from cows suffering from the disease, they were able to kill the animals and to find lesions highly suggestive of those characterizing eclampsia. Conse- quently, they suggest the possibility that eclampsia may be clue to intoxica- tion by poisons elaborated in the breasts, and thus add an experimental basis to Sellheim's apparently absurd suggestion. In summing up the aetiology of eclampsia, it is evident that its cause is still undiscovered. All that we know positively is that the disease is accompanied by characteristic lesions in the liver and by striking changes in metabolism. Our clinical experience leads us to believe that it is de- pendent upon a profound toxaemia, which is probably metabolic in origin, but we are as yet ignorant whether the changes originate in the maternal or foetal organism or both. Diagnosis.—The recognition of eclampsia usually offers no difficulty. It might be confounded with acute poisoning from strychnine, 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 uraemia, epilepsy, acute yellow atrophy of the liver, and even hysteria may simulate it. Consequently they should be borne in mind whenever convul- sions or coma appear during pregnancy, labor, or the puerperium, and must be excluded before a positive diagnosis is made. Occasionally it is impos- sible to make an accurate clinical diagnosis, 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. The maternal mortality varies from 20 to 25 per cent., and that of the fcetus from 33 to 50 per cent., although Stroganoff reports a maternal mortality ECLAMPSIA 555 of 6.6 per cent, in a series of 400 cases. Such favorable results, however, are very exceptional. The prognosis is generally considered to be more gloomy when the seizures come on before or during parturition than after delivery. Recent statistics, however, indicate that post-partum eclampsia is quite as serious, Olshausen and Lichtenstein having lost 25 and 27 per cent, of their cases, respectively. There is considerable discrepancy of opinion concerning the relative prognosis in primiparous and multiparous women. Thus, Veit in 902 cases gives a corrected mortality of 14.3 per cent, for the former and 19.1 per cent, for the latter, and Goldberg and Lichtenstein state the disorder is twice as dangerous in the latter. Olshausen, on the other hand, believes that there is no difference in the two groups. In all probability the prog- nosis 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 extremely 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 grav- ity 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 are 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 temperature is high. The persistence of a high arterial pressure is always of bad prognostic signifi- cance, 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 oedema of the lungs are most serious complications and usually end in death. If the eclampsia comes on during pregnancy the prognosis is very favorably affected by the death of the fcetus, the convulsions usually ceasing soon afterward. If the patient recovers, it is unusual for eclampsia to occur in subse- quent pregnancies, as one attack apparently confers a relative immunity. On the other hand, in patients suffering from chronic nephritis the recur- rence of uraemic convulsions is not uncommon. Treatment—(a) Prophylactic.—The prophylactic treatment is most important, and is identical with that recommended for pre-eclamptic tox- amiia (p. 532). 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, and the immediate insti- tution 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 dimin- 556 THK TOXAEMIAS OF PREGNANCY ished 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 treat- ment. Thus, I could cite several instances in which, under appropriate measures, the subjective symptoms disappeared, the urine and its nitroge- nous content increased in quantity and the albumin decreased, and yet, just as I was congratulating myself upon a most satisfactory result, a convulsion occurred. Moreover the outbreak of eclampsia is not always preceded by premonitory symptoms, as several of my patients who were apparently perfectly well, and whose urine had shown no abnormality the day before, had a seizure during labor. Such experiences have convinced me that prophylactic treatment, while productive of untold good, is not invariably successful or always applicable, nor can I agree with Davis and Edgar that eclampsia is always a prevent- able affection. Experience goes to show that cases of pre-eclamptic toxaemia accom- panied by oedema are more amenable to treatment, and less likely to even- tuate in eclampsia, than those in which it is absent. This point was emphasized many years ago by Stolz. (b) Curative.—Wdien convulsions occur during pregnancy or labor, I believe that the best results are obtained if delivery is effected as soon after the first convulsion as is consistent with the safety of the patient. Unfor- tunately, perfectly definite rules cannot be laid down, as the treatment should vary materially according as the patient is in a hospital or in her own home, and is under the care of a competent obstetrician or of an average general practitioner. . If the obstetrician is prepared to meet any emergency, delivery should be promptly effected irrespective of the condition of the cervix, or whether labor has begun or not. The patient should be anaesthetized with ether, placed upon the operating table, and carefully examined for the purpose of determining the most conservative method of procedure. If the cervix is fully dilated, the child should be delivered by means of forceps or version and extraction, as may seem best. If, however, this is not the case, the choice of operation will depend upon the condition of the cervix. If it is partially dilated, or if its canal is obliterated and resistance is offered only by the external os, dilatation can usually be safely and rapidly completed by Har- ris's manual method. On the other hand, if labor has not begun and the cervix is hard and its canal not obliterated, neither manual nor instrumental dilatation should be attempted, but vaginal hysterotomy should be per- formed, and the child delivered after version and extraction. In the treatment of such cases, I prefer vaginal hysterotomy, instead of abdominal Caesarean section as recommended by Halbertsma, for the reason that the former is less dangerous, and is followed by a more rapid convalescence. T believe that the latter is indicated only when the eclampsia is complicated by contracted pelvis, tumor formations, or some other condition which would necessitate its performance irrespective of its existence. If the medical attendant is not a competent operator, or is unable to ECLAMPSIA 557 secure the services of one, treatment should be far less radical. If the patient is in labor, delivery should be completed by forceps or version if the condition of the cervix will permit; while if it be partially dilated, the process may be completed by Harris's manual method. On the other hand, if labor has not set in, no attempt should be made to dilate the rigid cervix, and, as vaginal hysterotomy is out of the question, the physician should be content with purely medical treatment, as will be outlined below. I give this advice, as I know from my own experience that forcible at- tempts at accouchement force will expose the patient to risks of laceration, haemorrhage, or infection quite as great as those of the underlying disease, and it is far better, if she is to die, that she succumb to the eclampsia rather than to misdirected efforts on the part of the physician. The question as to the advisability of early operative interference, in my opinion, can only be decided by determining the proportion of cases in which the convulsions cease after the birth of the child. Statistics bearing upon this point have been adduced by Diihrssen. Olshausen, and Zweifel, who noted a cessation of the seizures either immediately or soon after delivery in 93.75 per cent., 85 per cent., and 66 per cent, of their cases respectively. Zweifel and Seitz report a mortality of 28.5 and 11.25, and of 28.6 and 6.5 per cent, under expectant and active treatment, respectively. Judging from these figures, it would appear that prompt delivery is indicated whenever it can be accomplished in a conservative manner. On the other hand, Lichtenstein contends that the benefits of early operation are in great part illusory, and depend almost entirely upon the extra amount of blood lost during the operative procedure, and he holds that equally good results would follow venesection and the spon- taneous termination of labor. In his 100 cases the total mortality was 18.5 per cent. Included in the entire scries were 70 post-partum cases with a mortality of 27 per cent., and he plausibly inquires why this should be the case if early delivery so favorably affects the prognosis;'as in this group of cases delivery was effected some time before the outbreak of the first convulsion. He believes that the answer is to be found in the fact that most of tliese women were delivered spontaneously and consequently had lost only a minimum amount of blood. For years Veit, Charpentier, de la Harpe, and others have advocated the administration of large doses of morphia, and do not interfere until the cervix is completely dilated. Stroganoff has gone a step further, and between the years 1897 and 1910 has treated 100 cases of eclampsia with a net mortality of 6.6 per cent. He administers a large dose of morphia and chloral immediately after the first convulsion, repeating the dose suf- ficiently often to keep the patient narcotized, and interferes only after the cervix has become completely dilated. Roth in 1910 reported a simi- lar experience in a small series of cases from Leopold's clinic, but with this exception no one seems to have taken Stroganoff's suggestion seri- ously. Notwithstanding the claims of Lichtenstein and Stroganolf, I am still a firm believer in early delivery, and do not expect to give it up until the claims of its opponents appear more convincing. Following the delivery 558 THE TOXAEMIAS OF PREGNANCY of the child, no attempt should be made to hasten the third stage of labor, as a moderate loss of blood should be encouraged rather than checked. After the completion of labor, or in the cases in private practice in which rapid delivery appears to be contra-indicated, as well as in post- partum eclampsia, the various organs of elimination should be stimulated as energetically as possible. If the bowels have not moved, 1 drop of croton oil in a half dram of olive oil should be administered by mouth, or 2 ounces of Epsom salts should be given through a stomach.tube. Sweating should be encouraged by hot packs, or at least by covering the patient with a rubber sheet and surrounding her with bottles filled with hot water, but taking every precaution to prevent her from being burned. Pilocarpin should not be used on account of its tendency to produce oedema of the lungs. Diuresis should be promoted by the subcutaneous injection of salt solu- tion, as well as by copious high rectal enemata. In view of the supposedly acid nature of the eclamptic poison, Zweifel advocates replacing the salt solution by one containing 5 grams each of sodium chloride and sodium bicarbonate to the liter. Mace and Pierra, in consequence of their observa- tions upon the freezing point and chloride content of the blood and urine, object to the use of salt solution in the treatment of eclampsia. Their teachings, however, do not accord with my clinical experience. If the patient does not soon show marked signs of improvement, from 500 to 600 cubic centimeters of blood should be withdrawn. If beneficial results follow, the procedure may be repeated if necessary. As the average woman possesses from 8y2 to 9 pounds of blood, 500 cubic centimeters would represent from 1/8 to 1/9 of its total bulk. Accordingly, if that amount of blood is drawn off and replaced by an infusion of an equal quan- tity of salt solution, the remainder of the blood is so diluted that y± or % of the total poison has been temporarily removed, and this aid is often sufficient to tide the patient over sufficiently long to allow Nature to reassert herself. It is generally stated that bleeding is indicated only when the pulse is full and bounding. Personally, I have bled with most excellent results a number of patients whose pulse was thin and weak. This experience would certainly seem to show that venesection is indicated in all cases in which delivery of the child is not followed by a cessation of the convulsions, no matter what the condition of the pulse, and it should form our main reli- ance in cases of post-partum eclampsia. If the convulsions persist, inhalations of ether may be given during the seizures, in the hope of cutting them short, although I believe that they are useless. Chloroform was formerly freely used, but, in view of its well known deleterious action upon the liver, I advise against its employment. During the attack a thick cord or folded towel should be placed between the teeth in order to prevent the patient from biting her tongue. No food, and as little medicine as possible, should be administered by mouth as long as the patient is unconscious, since particles may find their way into the air passages, instead of being swallowed, and later give rise to an inspira- tion pneumonia. As soon as the patient regains consciousness, fluids ECLAMPSIA 559 should be forced, and she should be encouraged to drink 4 or 5 liters of water or milk for each of the first few days of the puerperium. Thyroid extract has been advocated in the treatment of eclampsia by Nicholson, who advises that 70 to 80 grains be given daily during the attacks. It was used by Strumer in a series of 41 cases with 5 deaths, and by Lobenstein in 6 cases with 1 death. Since other therapeutic measures were employed as well, it is impossible to judge of its efficiency. In the few instances where it was used in my clinic favorable results were not obtained. In 1904 Kronig employed lumbar puncture in 3 cases of eclampsia with apparent beneficial results. He found the eerebro-spinal fluid under increased tension, and noted a pressure of 400 to 500 milli- meters of mercury compared with the normal of 120 millimeters. Henkel, Tides, Pollack, and others who have employed the procedure are very sceptical as to its value. Renal decapsulation was performed in a case of eclampsia by Edebohls in 1902, although it had previously been suggested by Sippel. Edebohls considers that it acts favorably by relieving the intrarenal tension, and thereby favors the resumption of urinary section. The subject has been reviewed 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. The use of veratrum viride, which is highly praised by so many Ameri- can writers, has never appealed to me upon theoretical grounds, and Stur- mer's statistics from the East India Medical Service, where it was used for twenty years, show a maternal mortality of 15 per cent. After reading the enthusiastic report of Mangiagalli and of Cragin and Hull concerning its merits, I felt that I was perhaps not doing my duty to my patients by 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 led to a marked slowing of the pulse, and occasionally to an almost alarm- ing fall in blood pressure, the patients did neither better nor worse than those who did not receive it. For this reason I have abandoned its use. Fngelmann 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. En- gelmann recommends its employment particularly in severe cases of post- partum eclampsia, but admits that further experience will be necessary before its merits can be fully determined. 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 and the hands of the operator by faecal material. 560 THE TOXAEMIAS OF PREGNANCY PRESUMABLE TOXAEMIAS 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 toxaemia, and disappear as the underlying condition becomes ameliorated. I recall one patient who, during the later months of pregnancy, suf- fered from delusions of persecution. At such times large amounts of albu- min were present in the urine, while the urea output was greatly dimin- ished. 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. Again, some cases occur' in which the most careful study of the urine fails to reveal the slightest evidence of toxaemia, and yet the mental de- rangement promptly disappears upon the employment of milk diet, rest, and eliminative treatment. On the other hand, most of the psychoses occurring during the puerperium are to be regarded as manifestations of infection, and are directly due to the absorption of poisonous materials generated by infectious micro-organisms. Many cases of peripheral neuritis should also be regarded as due to toxaemia, 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 tox- aemia 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 resists 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 of pregnancy are due to such a condition, and considers that the presence of indican, indol, skatol, and ethereal sulphates 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 LITERATURE 561 dogs by reversing the direction of intestinal peristalsis. In such eases marked changes are manifested in the urine, which consist particularly in a distortion of the relative proportions 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 toxaemia. Thus, I have seen sev- eral patients in whom the condition was not relieved by medicinal treat- ment, yet yielded readily to milk diet and eliminative measures; though at no time could changes be demonstrated in the urine in support of its toxa?niic origin. On the other hand, in one of my cases the condition was associated with pre-eclamptic toxaemia, 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 toxamiia. 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 persisted for sev- eral 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 jaun- dice, and the clinical symptoms were such that one was forced to consider the possibility of acute yellow atrophy of the liver. 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 profound toxa-mia. This being the case, it must be admitted that we occasionally have to deal with conditions which in all probability are toxaemic 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'Obstetrique, 1898, iii, 4S1-505. Les reins des eclamptiques. L'Obstetrique, 1903, viii, 193-215. Bar et Guyeisse. Lesions du foie et des reins chez les eclamptiques et les foetus issus des femmes eclamptiques. L'Obstetrique, 1897, ii, 263. Baron et Castaigne. Contribution a 1'etude de la pathogenie de l'eclampsie puer perale, etc. Archives de med. exp. et d'anat. path., 1898, x, 693-711. Beatty. A Case of Acute Yellow Atrophy of the Liver. Medical Record, 1895, xlviii, 274-275. Blumreich und Zuntz. Exp. und kritische Beitrage zur Pathogenese der Eklampsie. Archiv f. Gyn., 1902, Ixv, 736-785. Bouchard. Lemons sur 1'auto-intoxication. Paris, 1887. Bouffe de Saint Blaise. Lesions anat. que 1 'on trouve dans 1 'eclampsie. These de Paris, 1S91. Foie et Eclampsie puerperale. Annales de gyn. et d'obst., 1891, xxxv, 48. 38 562 THE TOXiEMIAS OF PREGNANCY Les auto-intoxications gravidiques. Annales de gyn. et d 'obst., 1898, 1, 342-374 et 432-455. Quelques cas d'acces eclamptiques sans albuminuric Annales de gyn. et. obst., 1900, liv, 76-77. Cassamayor. Contribution a, 1 '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 fcetus dans 1'eclampsie puerperale. Nouv. arch, d'obst. et de gyn., 1895, 175. Chamberlent et Demont. Recherches exp. sur la toxicite de 1'urine dans les der- niers mois de la grossesse. Comptes rendus soc. de biol., 1892, iv, 27-35. Charpentier. Eclampsie sans albuminurie. Traite pratique des accouchements. Paris, 1883, i, 699. Traitement de 1'eclampsie. Annales de gyn. et d'obst., 1896, xliv, 488. Cofeman. 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. Czyzewicz. Hyperemesis Gravidarum. Sammlung klin. Vortrage, 1908, Nr. 485. Davis. The Prophylaxis and Treatment of Eclampsia. Therapeutic Gazette, July 15, 1895; also Trans. Amer. Gyn. Soc, 1895. Eclampsia, Ante- and Post-partum. Amer. Jour. Obst., 1898, xxxvii, 467-480. De la Harpe. Treatment of Eclampsia. Jour. Obst. and Gyn. Brit. Emp., 1906, ix, 102-105. Delore et Rodet. Memoire sur I'etiologie bacterienne de 1'eclampsie. Resume dans 1'arch. de tocologie, 1884, ii, 921. Dienst. Kritische Studien iiber die Pathogenese der Eklampsie, etc. Archiv f. Gyn., 1902, lxv, 369-464. Das Eklampsiegift. Zentralbl. f. Gyn., 1905, xxix, 354-364. Exp. Studien iiber die aetiologische Bedeutung des Fibrinferments u. Fibrinogen fiir d. Eklampsie. Archiv f. Gyn., 1912, xcvi, 43-170. Dirmoser. Der Vomitus gravidarum perniciosus. Wien, 1901. Doderlein. Zur Frage der "Eklampsie." Zentralbl. f.. Gyn., 1893, xvii, 1. Dryfuss. Chemische Untersuchungen iiber die iEtiologie der Eklampsie. Biochem- ische Zeitschr., 1908, vii, 493-526. 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. Edebohls. Surgical Treatment of Bright's Disease. New York, 1904. Edgar. The Treatment of Puerperal Eclampsia. Medical Record, December 2, 1896, and January 2, 1897. Elliot. Obstetrical Clinic, New York, 1873. Engelmann. Ueber die Behandlung der Eklampsie mittels intravenose Hirudin- injektionen. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 640-664. Ewing. The Path. Anatomy and Pathogenesis of the Toxsemia 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. Fehling. Die Pathogenese und Behandlung der Eklampsie im Lichte der heutigen Anschauungen. Volkmann's Sammlung klin. Vortrage, N. F., 1899, Nr. 248. LITERATURE 563 Begriff und Pathogenese der Eklampsie. Verh. der deutschen Gesell. f. Gyn., 1901, 239-261. Fellander. 1st die Eklampsie eine anaphylaktische Erscheinung. Zeitschr. f. Geb. u. Gyn., 1911, lxviii, 26-46. Flexxer. Thrombi Composed of Agglutinated Red Blood Corpuscles. Univ. of Pennsylvania Med. Bulletin, 1902, No. 9. Forchheimer and Stewart. On the Toxicity of the Urine. Amer. Jour. Med. Sciences, September, 1899, xv, 297-303. Frank and Heimann. The Placental Theory of Eclampsia. Surg. Gyn. and Obst., 1911, xii, 451-457. Freund und Mohr. Pathogenese der Eklampsie. Berliner klin. Wochenschr., 1908, xiv, No. 40. Futh u. Lockemann. Ueber den Nachweis von Fleischmilchsaiire in der Zerebro spinalfliissigkeit Eklamptischer. Zentralbl. f. Gyn., 1906, xxx, 41-43. Glaessner. Experimentelles iiber die Obstipation. Weiner klin. Wochenschr. 1904, xvii, 1205-1206. Goldberg. Beitrag zur Eklampsie auf Grund von Si Fallen. Archiv f. Gyn., 1891, xii, 295-329; and 1892, xiii, 87-102. Goldsborough and Ainley. The Renal Activity as Revealed by the Phenol-Sul- phone-phthalein Test. Jour. Am. Med. Assn., 1910, Iv, 24. Grafenburg. Die anaphylaktische Beziehungen zwischen Mutter und Kind. Zeit- schr. f. Geb. u. Gyn., 1911, lxix, 270-282. Guenard. Etude de la permeabilite renale chez les eclamptiques par le procede du bleu de methylene. These de Paris, 1898. Guggisberg. Exp. Untersuchungen iiber die Toxikologie der Placenta. Zeitschr. f. Geb. u. Gyn., 1910, Ixvii, 84-112. Haegler. Zur Frage " Eklampsiebacillus" Gerdes. Zentralbl. f. Gyn., 1892, xvi, 996-998. Halbertsma. Ueber die .ZEtiologie der Eklampsia pucrperalis. Volkmann's Samm- lung klin. Vortrage, 18S-4, Nr. 212. Eklampsia gravidarum. Eine neue Indikationsstellung fiir die Sectio Caesarea. Ref. Zentralbl. f. Gyn., 1SS9, xiii, 901. Healy and Kastle. Parturient Paresis (Milk Fever) and Eclampsia. Jour, of Infectious Diseases, 1912, x, No. 2. Helouin. Contribution a 1'etude du diagnostic de 1'hepato-toxemie gravidique. These de Paris, 1899. Henkel. Ueber Lumbarpunktion bei Eklampsie. Zentralbl. f. Gyn., 1904, xxviii, 1329-1334. Hofbauer. Graviditats-toxikosen. Zeitschr. f. Geb. u. Gyn., 1908, lxi, 258 271. Hughes and Carter. A Clinical Experimental Study of Uraemia. Amer. Jour. Med. Sciences, 1894, cviii, 177-193; 265-295. Ingerslev. Beitrag zur Albuminuric wahrend der Schwangerschaft, der Geburt und der Eklampsie. Zeitschr. f. Geb. u. Gyn., 1881, vi, 171-212. Jardine. Eclampsia during and after Labor. Jour. Obst. and Gyn. British Emp., 1906, July. Johnstone. Exp. Study of the Anaphylactic Theory of the Toxaemia of Pregnancy. J. Obst. and Gyn. British Emp., 1911, xix, 253-260. Jurgens. Fettemboli und Metastase von Leberzcllen bei Eklampsie, etc. Berliner klin. Wochenschr., 1886, xxiii, 519. Kaltenbach. Ueber Hyperemesis gravidarum. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 200-208. Klebs. Multipel Leberzellen-thrombose. Zeigler's Beitrage, 1888, iii, 1-30. 564 THE TOXJEMIAS OE PREGNANCY Knapp. Klinische Beobachtungen iiber Eklampsie. Berlin, 1896. Ueber puerperale Eklampsie und deren Behandlung. Berlin, 1900. Kollmann. Zur iEtiologie und Therapie der Eklampsie. Zentralbl. f. Gyn., 1897, xxxi, 341-346. Konstantinowitsch. Beitrag zur Kenntniss der Leberveranderungen bei Eklamp- sie. Beitrage z. path. Anat., etc., 1907, xl, 483-533. Kronig. Ueber Lumbarpunktion bei Eklampsie. Zentralbl. f. Gyn., 1904, 1153- 1156 and 1511-1512. Kronig und Futh. Experimentelle Untersuchungen iiber Eklampsie. Verh. d. deutschen Gesell. f. Gyn., 1901, 313-332. Leathes. Acidosis in Pregnancy. Proc Royal Soc. Med., 1908, March. LeMasson. Les icteres et les coliques hepatiques chez les femmes en etat du puer- peralite. These de Paris, 1898. Lever. Cases of Puerperal Convulsions, with Remarks. Guy's Hospital Reports, 1843. Lichtenstein. Im Kampfe gegen die placentare Theorie der Eklampsieaetiologie. Zentralbl. f. Gyn., 1909, 1313-1325. Zur Klinik, Therapie u. ACtiologie der Eklampsie, Archiv f. Gyn., 1911, xcv, 183-368. Liepmann. Zur iEtiologie 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., .1982, iii, 625-630. Lobenstein. Use of Thyroid Extract in Eclampsia. Bull. Lying-in Hospital, N. Y., 1905, p. 68. Lohlein. Zur Haufigkeit, Prognose und Therapie der Eklampsie. Verh. der deutschen Ges. f. Gyn., 1891, 177-179. Longridge. The Relation of the Alterations in the Ammonia Coefficient to the Toxaemias of Pregnancy. J. Obst. and Gyn. British Emp., 1907, xii, 48 65. Lubarsch. Die Puerperal-eklampsie. Ergebnisse der allg. Path, und path. Anat., 1896, i, 113-134. Ludwig und Savor. Experimentelle Studien zur Pathogenese der Eklampsie. Mo- natsschr. f. Geb. u. Gyn., 1895, 447-473. Lwow. Hyperemesis gravidarum. Deutsche Medicinal-Zeitung, 1900, xxi, 1013-1015. Mace et Pierra. Du point de congelation et de la tenure en chlorures du sang et de Purine, etc. Bull, de la soc. d'obst. de Paris, 1905, viii, 232-271. Maxgiagalli. Veratrum viride in eclampsia. British Med. Jour., 1908, Sept., 19. Massen. Zwischenprodukte des Stoffwechsels als Ursache der Eklampsie. Ref. Zen- tralbl. f. Gyn., 1896, xx, 1208. McPherson. A Study of Eclampsia. J. Amer. Med. Assn., 1907, liii, 1362-1363. Murray. Nature of Eclampsia. J. Obst. and Gyn. British Emp., 1910, xviii, 225- 245. Newell. Eclampsia in the Boston City Hospital for the Past Fifteen Years. Bos- ton Med. and Surg. Jour., November 9, 1899. Nicholson. Case of Puerperal Eclampsia Treated by Large Doses of Thyroid Ex- tract. Jour. Obst. and Gyn. Brit. Emp., 1904, v, 32-37. Olshausen. Ueber Eklampsie. Volkmann's Sammlung klin. Vortrage, N. F., 1891, Nr. 39. Sectio Caesarea wegen Eklampsie. Zentralbl. f. Gyn., 1900, xxiv, 63. Opie. Zonal Necroses of the Liver. Jour. Medical Research, 1904, xii, 147-167. LITERATURE 565 Pearce and Jackson. Experimental Liver Necrosis. Studies from the Bender Hygienic Laboratory, 1907, iv, 35-51. Pels Leusden. Beitrage zur path. Anatomie der Puerperal-eklampsie. Virchow's Archiv, 1895, cxlii, 1-45. Pick. Ueber Hyperemesis gravidarum. Volkmann's Sammlung klin. Vortrage, N. F., 1902, Nrs. 325-320. Pilliet et Letienne. Lesions du foie dans 1 'eclampsie avec ictere. Nouv. arch. d'obst. et de gyn., 1889, iv, 312-367. Pinard. De la decapsulation renale dans 1 'eclampsie. Annales de gyn. et d 'obst., 1906, 2me 8., iii, 193. Des vomissements de la gestation. Annales de gyn. et d 'obst., 1909, N. S. vi, 385-399. Prutz. Ueber des anat. Verhalten der Nieren bei der Puerperal-eklampsie. Zeitschr. f. Geb. u. Gyn., xxiii, 1892, 1-52. Ueber Eklampsie. Vereins-Beilage der dentsch. med. Wochenschr., 1897, 194. Quincke. Acute Leberatrophie. Nothnagel 's specielle Path. u. Ther., 1899, xviii, 294-315. Rayer. Traite des maladies des reins. Paris, 1839. Reinburg. Les acces dits eclamptiques. Tliese de Paris, 1905. Riviere. Pathogenie et traitement de 1'eclampsie. Paris, Issh. Rosenau and Anderson. Further Studies upon Anaphylaxis. Hygienic Lab. Bull., 1908, No. 45, p. 55. Roth. Ueber die Behandlung der Eklampsie nach Stroganoff. Archiv f. Gyn., 1910, xci, 461-478. Rosenstein. Ueber Eklampsie. Monatsschr. f. Geburtsk., 1864, xxiii, 413-430. Schild. Sechs Falle von Nitrobenzol-vergiftung. Berliner klin. Wochenschr., 1895, xxxii, is7 189. Schmid. Eklampsie ohne Krampfe. Zeitschr. f. Geb. u. Gyn., 1911, lxix, 143-164. Schmorl. Path. anat. Untersuchungen iiber Puerperal-eklampsie. Leipzig, 1893. Zur Lehre von der Eklampsie. Archiv f. Gyn., 1902, lxv, 504-529. Schroeder. Quoted by Ingerslev. Schumacher. Exper. Beitrage zur Eklampsie-frage. Beitrage zur Geb. u. Gyn., 1901, v, 257-309. Seitz. Eklampsie und Parathyroidea. Archiv f. Gyn., 1909, lxxxix, 53-75. Zur Klinik, Statistik u. Therapie der Eklampsie. Archiv f. Gyn., 1909, lxxxvii, 78-130. Sellheim. Die mammare Theorie iiber die Entstehung der Eklampsiegiftes. Zen- tralbl. f. Gyn., 1910, 1609-1615. Semb. Exp. Untersuchungen zur Pathogenese der Eklampsie. Archiv f. Gyn., 1906, Ixxvii, 63-98. Sippel. Die Nephrotomie bei Anurie Eklamptischer. Zentralbl. f. Gyn., 1904, xxviii, 1341. Sitzenfrey. Eklampsie im 6sten Schwangersehaftsmonat bei Blasenmole, etc. Zen- tralbl. f. Gyn., 1911, 343-346. Slemons. Eclampsia without Convulsions. Johns Hopkins Hospital Bull., 1907, xviii, 448-455. Spiegelberg. Ein Beitrag zur Lehre von der Eklampsie. Ammonia im Blute. Archiv f. Gyn., 1870, i, 383-391. Stewart. Toxicity of the Urine in Pregnancy. Amer. Jour. Obst., 1901, xliv, 506- 575. Stone. Toxaemia of Pregnancy. Amer. Gyn., 1903, iii, 518 550. Stroganoff. Die Behandlung der Eklampsie. Zentralbl. f. Gyn., 1910, 756-762. 566 THE TOXAEMIAS OF PREGNANCY Strauss. The Toxaemia of Pregnancy. Amer. Jour. Obst., 1905, Ivii, 145-164. Stroganoff. Ueber die Behandlung der Eklampsie. Zentralbl. f. Gyn., 1901, xxi, 1309-1312. Sturmer. Forty-one Cases of Eclampsia Treated by Thyroid Extract. Trans. Lon- don Obst. Soc, 1904, xlvi, 126. Tarnier et Chamberlent. Note relative a la recherche de la toxicite du serum san- guin 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 Practice of Medicine. Amer. ed., 1880, ix, 242-305. Thies. Ueber Lumbarpunktion bei Eklampsie. Zentralbl. f. Gyn., 1906, 649-658. Zur ^Etiologie der Eklampsie. Archiv f. Gyn., 1910, xcii, 513-536. Thompson. The Influence of Sodium Chloride on the Secretion of Urine. British Med. Jour., 1899, i, 793. Underhill and Rand. Peculiarities of Nitrogenous Metabolism in Pernicious Vom- iting of Pregnancy. Archives of Int. Med., 1910, v, 61-91. Van der Bergh. Ueber die Giftigkeit des Harns. Zeitschr. f. klin. Medizin, 1898, xxxv, 52-79. Van der Velde. Eklampsia puerperalis tardiforma. Ref. Frommel's Jahresbericht, 1897, 752. Vassale. Ref. Frommel's Jahresbericht, 1905, xix, 404. Veit. Ueber die Behandlung der Eklampsie. Ruge's Festschrift, 1896, 101-120. Ueber Albuminuric in der Schwangerschaft. Berliner klin. Wochenschr., 1902, xxxix, 512-540, Nrs. 22 and 23. Die Verschleppung der Chorionzotten. Wiesbaden, 1905. Volhard. Exp. und kritische Studien zur Pathogenese der Eklampsie. Monatsschr. f. Geb. u. Gyn., 1897, v, 411-437. Weichhardt u. Piltz. Exp. Studien iiber Eklampsie. Deutsche med. Wochenschr., 1906, xxxii, 1854-1856. Whipple and Sperry. Chloroform Poisoning, etc. Johns Hopkins Hospital Pull., 1909, xx, 278-289. Whitney and Clapp. Urine Changes in Pregnancy and Puerperal Eclampsia. Amer. Gyn., 1903, iii, 121-180. Williams. Pernicious Vomiting of Pregnancy. Johns Hopkins Hospital Bulletin, 1906, xvii, 71-92. Toxaemic Vomiting of Pregnancy. Am. Jour. Med. Sci., 1906, cxxxii, 343-354. Winckel. Lehrbuch der Geburtshiilfe, 1893, II. Aufl., 536-547. Winckler. Beitrag zur Lehre von der Eklampsie. Virchow's Archiv, 1898, cliv, 187-233. Winter. Zur iEtiologie der Hyperemesis gravidarum. Zentralbl. f. Gyn., 1907, 1497-1504. Winternitz and Ainley. Catalytic Activity of the Blood in the Toxaemia of Preg- nancy. Amer. Jour. Obst., 1910, lxii, 961-973. Zanfrognini. Ref. Frommel's Jahresbericht, 1905, xix, 804. Zangemeister. Untersuchungen iiber die Blutbesehaffenheit und die Harnsekretion bei Eklampsie. Zeitschr. f. Geb. u. Gyn., 1903, 1, 385-407. Zweifel. Zur Behandlung der Eklampsie Bericht iiber 129 hier beobachtete Falle. Zentralbl. f. Gyn., 1895, xix, 1201-1218; 1238-1256; 1265-1277. Zur Aufklarung dor Eklampsie. Archiv f. Gyn., 1904, Ixxii, 1-97, and 1905, lxxvi, 536-585. Das Gift der Eklampsie u. ihre Consequenzen fiir die Behandlung. Miinchener med. Wochenschr., 1906, liii, 297-299. CHAPTER XXYTI COMPLICATIONS DUE TO DISEASES AND ABNORMALITIES OF 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 acci- dent is more frequently observed at the time of labor, when profuse and sometimes fatal haemorrhage may result if appropriate surgical treatment is not available. Inflammation of Bartholin's Glands.—Pyogenic micro-organisms may gain access to Bartholin's glands and give rise to abscess formation. In such cases the labium majus on the side affected becomes swollen and painful, and incloses a large collection of pus. Most often the infection is gonorrhceal in origin, though other bacteria are sometimes associated with the gonococcus. Aside from the pain and discomfort, this complica- tion is a possible source of danger during labor and the puerperium, since it may be the starting-point of a puerperal infection. For these reasons, whenever a labial abscess develops during pregnancy it should be opened up and drained; or, better still, the entire pus sac should be excised. Relaxation of the Vaginal Outlet.—In multiparous women the conges- tion incident to pregnancy not uncommonly causes the anterior or posterior vaginal wall to protrude through the relaxed or torn outlet as a distinct cystocele or rectocele. This condition is generally associated with dragging pains in the back and lower abdomen, and often interferes with locomotion. It is not amenable to treatment during pregnancy, though the symptoms mav be temporarily relieved by rest in bed. Vaginitis.—This complication has already been considered in Chapter XXV, under the heading of Gonorrhoea. Colpo-hyperplasia Cystica.—This rare condition, first described by Winckel, is characterized by the presence in the vaginal mucosa of numer- ous small cavities filled with clear fluid or gas and forming elevations upon its surface. Although not amenable to treatment during pregnancy, it usually disappears soon after childbirth. The researches of Lindenthal render it probable that the disease, in many cases at least, is due to infec- tion with Bacillus acrogenes capsulatus, and Jaeger has been able to produce it experimentally in animals. 568 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT DISEASES OF THE CERVIX Cervical Endometritis.—Gonorrhceal infection of the cervical canal is frequently observed during pregnancy, the most prominent symptom being a profuse and persistent leucorrhcea. The treatment has already been considered. Carcinoma.—About once in 2,000 cases, according to Sarwey, 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 concep- tion, but it may make its appearance during pregnancy. A bloody, foul- smelling vaginal discharge is suggestive of malignant disease, but unfor- tunately the early stages are often unaccompanied by symptoms, and may escape detection unless a vaginal examination is made for some other reason, and an indurated and excavated ulceration of the cervix is discovered. Pregnancy tends to bring about rapid growth and extension of a pre- existing carcinoma. On the other hand, the malignant disease influences pregnancy very unfavorably, abortion being noted in 30 to 40 per cent. of the cases. It likewise predisposes to the occurrence of placenta praevia, and at the time of labor markedly increases the risks of infection or of spon- taneous rupture of the uterus. In advanced cases the cervix may be so indurated by carcinomatous infiltration that dilatation is either impossible, or may be accompanied by 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 is detected in the first half of pregnancy and has not extended beyond the cervix, imme- diate hysterectomy should be performed without regard for the chances of the fcetus. Sarwey has reported 26 vaginal operations without a death; but I consider that a radical abdominal operation will materially increase the probability of a permanent cure. On the other hand, if the case is inoperable, gestation should be allowed to continue in the interests of the child. In the second half of pregnancy the large size of the uterus materially complicates vaginal hysterectomy. Hence, if a radical operation appears advisable, laparotomy should be performed and the uterus removed un- opened. In inoperable cases pregnancy should be allowed to go on to term, and then, if spontaneous delivery is out of the question, Cesarean section should be performed in the interests of the child. For particulars concern- ing operative treatment the reader is referred to the articles of Sarwey and Noble, the latter having collected the results obtained in 166 cases observed between the years 1886 and 1896. DEVELOPMENTAL ABNORMALITIES OF THE UTERES 569 DEVELOPMENTAL ABNORMALITIES OF THE UTERUS Abnormalities in the development or fusion of one or both Mullerian ducts may result in malformations, which sometimes possess an obstetrical significance. A'arious degrees of malformation—from an almost total absence of the uterus on the one hand to its duplication on the other (uterus didelphys)—are encountered. The ac- companying diagrams (Figs. 458 to 463) give an idea of the nature of the more important va- rieties. Pregnancy may be associated with any one of tliese; malformations, provided an ovum be cast off from the ovaries and no serious obstacle be opposed to the upward passage of the sperma- tozoa 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. We owe to Mauriceau the first description of a case Fig. 458.—Diagram of Uterus Unicornis (Kehrer). Fig. 459.—Uterus Pseudo-Didelphys (Kehrer). Fig. 460.—Utehus Bicornis Duplex (Kehrer). Fig. 461.—Uteiu s Bicornis Septus (Kehrer). Fig. 462.—Uterus Bicornis Subseptus (Kehrer). .463. Uterus Bicornis Unicollis (Kehrer). Uterus Bicornis Unicollis with Rudimentary Horn (Kehrer). 570 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT of this character, but since his time quite a number of 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 communicate with the uterine cavity, so that in them pregnancy must have followed external migration of the spermatozoa or the ovum. The occurrence of pregnancy in a rudimentary horn is dependent upon the development of normal decidual and placental tissue, and is also Fig. 464.—Pregnancy in a Rudimentary Left Uterine Horn External Migration of Ovum (Kelly). The specimen is viewed from behind. To the right is the well-developed uterus, which, after reaching the internal os, deviates to the right side. Attached to the cornu is the right tube, which is normal. The ovary is of the usual size, and at its inner and lower portion is the corpus luteum of pregnancy. Springing from the left side of the uterus at the internal os is a muscular band; on tracing this to the left it merges into the rudimentary uterine horn. On the posterior surface of this horn is a long slit representing the point of rupture. Protruding through the rent are placental remains. The left tube passes off from the outer side of the rudimentary horn. The left ovary is flattened. The lines on the well-developed uterus indicate the size of the uterine cavity. The line b, c, d, e indicates the course of the left Miiller's duct. Between c and d it contains a lumen; where it is represented by dotted lines it consists of a solid muscular cord. accompanied by the formation of a decidua in the non-pregnant horn, as well as by a marked increase in its size. Unless there is free communica- tion 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 devel- oped, as is usually the case, spontaneous rupture occurs within the first four months and may lead to the death of the patient from intra-peritoneal hasmOrrhage. This accident was noted in 87, 47.6, and 5.5 per cent, of the cases collected by Sanger, Kehrer, and Beckmann, respectively, in DEVELOPMENTAL ABNORMALITIES OF THE UTERUS 571 1884, 1900, and 1911. The marked difference in the percentages is attributable to greater accuracy in diagnosis and more frequent recourse to operative 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 fcetus may be gradually eliminated by suppurative processes, or be converted into a litho- paedion. The existence of pregnancy in a rudimentary horn can occasionally be recognized during the early months, a positive diagnosis having been made in L;0 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 re- member 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 1884, and has since been re- peated 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 13.3 and 4.3 per cent., respectively. Too fre- quently, however, the first suggestion of the existence of the abnormality is afforded by the symptoms of intra-peritoneal haemorrhage, and an operation is usually undertaken in the expectation of finding 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 condition is only accidentally recog- nized at the autopsy table. Pregnancy in Uterus Bicornis.—When the two horns of the uterus are well developed, but no connection exists between them, as in uterus didel- phys, 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 ova may occupy the same horn, although now and again an ovum has been found in each. When pregnancy occurs in one horn of a bicornuate uterus, the other undergoes sympathetic hvpertrophy 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 partially fill up the pelvic cavity, and give rise to serious 572 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT dystocia similar to that produced by tumors of other origin. Nagel men- tions three cases in which labor could not proceed until this structure had been pushed out of the pelvic canal. In two other instances—one reported by Lohlein and one observed in my clinic and reported by Bettman—the non-pregnant horn obstructed the pelvic cavity and gave rise to rupture of the uterus. Werth has reported a case in which the non-pregnant horn became retroflexed. The diagnosis is usually not made, as in the majority of cases spon- taneous labor occurs at term; although Halban states that a pathognomonic sign is afforded by the palpation of the vesico-reetal 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, or at least a bicornuate, uterus. When there is only a single cervix, as in uterus bicornis unicollis, the condition always escapes ob- servation, 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 extremely difficult to recognize such a condition, unless the fingers were introduced into the uterine cavity, and that it may give rise to serious complications at the term of labor. DISPLACEMENTS OF THE UTERUS Anteflexion.—Slight degrees of anteflexion are frequently observed in the early months of pregnancy, but are usually without significance. 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 marked 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 exertion and dragging pains in the back and lower abdomen. Marked amelioration frequently follows the wearing of a properly fitting abdominal supporter. Anteversion of the pregnant uterus is occasionally observed in patients 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 ventro- DISPLACEMENTS OF THE UTERUS 573 suspension, 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 inconvenience, though occasionally the condition may exist for years without any abnormal manifestation. In women who have never borne children inflammatory or other changes in the endometrium, resulting from circulatory disturbances incident to the displacement, offer a serious obstacle to the occurrence of pregnancy. 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 ret rod is- placements the uterus was already out of place before conception; although, as has been pointed out by Keitler and others, the abnormality may arise during gestation. Pregnancy is more frequently complicat- ed by retroflexion than by retroversion, though the latter may give rise to more seri- ous symptoms. In either case several eventualities are pos- sible: the displace- ment may undergo spontaneous reduction without any interrup- tion to pregnancy; abortion may occur: or, if neither takes place, the uterus may become incarcerated in the pelvic cavity Fig. 465.—Sacculation of Rktroflexed Pregnant Uterus (piciices follow. (Oldham). If the displaced uterus is not adherent, spontaneous reduction usually occurs during the second or third month. This is rendered possible by an eccentric hyper- trophy of the organ, owing to which the anterior wall becomes more rapidly distended than the posterior, and emerging above the superior strait eventually draws up the rest of the uterus. After the fundus has once passed the promontory of the sacrum there is no fear of 574 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT a recurrence of the condition. Moreover, spontaneous reduction is not wholly out of the question, even when adhesions exist, since they often be- come stretched and occasionally disappear without any treatment. Retro- flexion offers better prospects than retroversion; indeed, as Diihrssen and Keitler have 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 a certain number of cases, especially when the fundus is firmly adherent, pregnancy may remain uninterrupted for a long while. This prolongation is rendered possible by the marked upward growth of the anterior wall of the uterus, while the posterior wall retains its original situation and forms a cavity in which one pole of the fcetus is retained. Fig. 466.—Incarceration of Retroflfxed Pregnant Uterus (Swytzer). 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 diffi- culties are to be expected at the time of labor, which will be considered in Chapter XXXII. Abortion is common in pregnancies complicated by retrodisplacements. 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 the ovum. This termination is particularly likely to occur when the sacrum possesses a marked 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 com- DISPLACEMENTS OF THE UTERUS 575 pletely 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 retroflexion, for the reason that in the former the cervix compresses the lower portion of the bladder at an earlier period. Incarceration is accompanied by char- acteristic 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 intense as to cause retention of the urine with consequent over- distention. Reed, however, holds that the ischuria should not be attributed to mere mechanical pressure upon the urethra, 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 a small amount of urine at frequent intervals, but never empties itself— paradoxical incontinence. If the condition is not soon relieved, the symp- toms become more intense, cystitis develops, and the bladder walls become thick and cedematous, the urine becomes bloody, and eventually gangrene of the bladder may result, necrotic portions of its lining membrane being cast off and finally expelled through the urethra with intense cramp-like 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 the uterus may undergo inflammatory changes as the re- sult of the pressure to which it is subjected, and become densely adherent to the surrounding 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 Uraemia .................. Rupture of the bladder.... Septicaemia of vesical origin Gangrene of the bladder.. . . A retrodisplacement of the 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 pregnancy is a most suggestive sign, and always calls for a thorough vaginal examina- tion. 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 sym- physis 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 17 16 11 4 3 576 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT not be ruled out until careful examination has shown that the slightly enlarged uterus does not lie in front of the soft mass. Treatment.—If the condition be 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 manoeuvres fail, the patient should be left alone until well on into the third month, in the hope that spontaneous reduction may still 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 unsuc- cessful, reduction can usually be effected by bimanual manipulations under anaesthesia. When dense adhesions are present, various procedures have been recom- mended—the forcible attempt to break them up under anaesthesia, 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 anaesthesia, laparotomy should be per- formed and the adhesions separated under the guidance of the eye, as recommended by Mann and Fry. In several of my cases this course was pursued with most satisfactory results. On the other hand, if symptoms of incarceration supervene, prompt treatment is imperative. 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. 466), so that in many cases a long, flexible instrument must be employed. Its introduction may often be facilitated by making traction upon the cervix with a tenaculum. After the bladder has been emptied, attempts should be made to replace the uterus—under anaesthesia, if necessary. But if this cannot be effected, most authors advise emptying it immediately, either by dilating the cervical canal or by punc- turing the corpus through the vaginal vault. I believe that better results will be obtained in such cases by laparotomy, as recorded by Lobenstine. This operation, however, should never be attempted if symptoms of infec- tion or gangrene are present, 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 in the most conservative manner, which sometimes is best effected by incising its posterior wall, as in vaginal hysterotomy, and then rely upon palliative treatment. Lateral Displacements 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, however, be borne in mind that similar conditions are DISPLACEMENTS OF THE UTERUS 577 sometimes mistaken for tubal pregnancy. In two cases reported by Loh- lein and Gottschalk the uterus had undergone a considerable decree of torsion, its left margin showing marked rotation toward the right, which in the second case was associated with retroflexion. Prolapse of the Pregnant Uterus.—Impregnation in a totally prolapsed uterus is very rare on account of the difficulties attending a success- ful coitus, but if the prolapse is only partial it is comparatively frequent. In such cases the cervix, and occasionally a portion of the corpus, may pro- trude to a greater or lesser extent from the vulva during the early months, but as pregnancy progresses the uterus gradually rises up in the pelvis, and, as soon as it has passed beyond the superior strait, prolapse is no longer possible. On the other hand, if it retains its ab- normal position, symptoms of incarceration appear during the third or fourth month, and abortion is the inevitable result, there be- ing no cases on record in which pregnancy has pro- gressed 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, however, the pelvic floor be too relaxed to permit its retention, the patient should be kept in a recumbent position as far as possible until after the fourth month. When the cervix reaches to or slight- ly protrudes from the vulva, the greatest cleanliness is necessary, as several cases of fatal infection have been reported as occurring even without any internal examination. If the uterus lies outside of the vulva and cannot be replaced, 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 condition may give rise to considerable discomfort and interfere with locomotion. It is not amena- ble to treatment until after delivery. At the time of labor these structures 39 Fig. 407.—Prolapsed Pregnant Uterus (Wagner). 578 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT 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 anterior 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 cer- vix seriously interferes with the occurrence of conception, but, as a rule, _____________ _________._____does not complicate 5*\ I>^ ~ the COurs* ,of P«f nancy or labor. The canal usually becomes shorter and more di- latable as term is ap- proached. In one of my patients the vagi- nal portion of the cervix in the early months was 5 centi- meters in length and the external os pro- truded from the vul- va, whereas later it had undergone marked softening and become reduced to normal di- mensions, so that la- bor occurred sponta- neously. Acute (Edema of the Cervix.—In very rare instances the cer- vix, particularly its anterior lip, may be- come acutely cedema- tous and attain such proportions as to pro- trude from the vulva. This condition is referable to an angio-neurosis, and may disappear almost as suddenly as it developed. Jolly, in 1904, was able to collect 10 cases from the literature. Hernia.—Pregnancy occurring in women suffering from inguinal her- nia is not influenced by the condition, although, owing to the increased Fig. 468.—Pregnancy in Horn of Uterus Contained in Inguinal Canal (Eisenhart). DISPLACEMENTS OF THE UTERUS 579 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 concep- tion 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' pregnant bicornuate uterus occupied the right inguinal canal. Umbilical hernia' are frequently noted during pregnancy, but are usu- ally 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 Fig. 469.—Hernia of Pregnant Uterus (Adams). range of possibility, and several such instances are on record. Much more common are the cases in which the cicatrix of an abdominal incision yields to the increased intra-abdominal pressure incident 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 marked diastasis of the recti muscles. Fig. 469 represents a patient in whom a hernia of this kind occurred suddenly during labor. Ordinarily, such hcrniae have no effect upon pregnancy, although they may add mark- edly to the discomfort of the patient. Temporary relief is frequently 5S0 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT 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 em- ployment of forceps is often called for. 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. Careful histological examination shows, however, that the term is usually a misnomer, as the changes are generally trophic rather than inflammatory in character. The most important varieties are: 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 occur- ring in the decidua, except, of course, that the latter are modified by the histological characteristics incident to pregnancy. In the vast majority of cases, as was first pointed out by Veit, the decidual affection represents the extension of a lesion already existing at the time of pregnancy, conception occurring in a uterus affected by one of the various forms of so-called endometritis. In rare cases, however, it may be primary. It is generally believed that endometritis is almost necessarily associated with sterility, the abnormal secretion of the uterine glands interfering with impregnation, and, even if conception occurs, the diseased mucosa does not offer a favorable nidus for the implantation of the ovum. Generally speak- ing, this belief is justified whenever the endometrium is the seat of an acute inflammatory process, and every physician can recall instances in which sterility persisted until more or less normal conditions were restored. On the other hand, slight degrees of chronic endometritis, or of hyperplastic condition, do not, as a rule, interfere with conception. Diffuse Thickening of the Decidua.—Hegar, 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 in- tended for the fcetus is diverted to nourishing the decidua. After abortion or labor, a thickened decidua may cause abnormalities in the separation of the placenta. Localized Thickening of the Decidua (Decidua Polyposa).—In this affection the entire decidua is somewhat thickened, but its characteristic feature consists in the projection of irregularly shaped, knob-like masses from the inner surface. 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 ob- DISEASES OF THE DECIDUA 5S1 served, and Xyulasy of Melboui own practice. Bui ins holds that with an instance. Glandular Hyperplasia of the Decidua (Endometritis Decidua Gltnulularis).—()c- casionally marked hyperpla- sia of the glandular struc- tures of the decidua is pres- ent, and is usually associated with persistence of the gland- ular ducts. This affection commonly manifests itself by a profuse secretion of clear fluid, which may dribble away as rapidly as it is pro- duced, or be retained in the uterus to be suddenly dis- charged in large quantities at variable intervals—luplror- rhaia gravidarum. The amount of fluid expelled va- ries considerably, though Ahlfeld has reported a case in which it exceeded 500 cu- hic centimeters on several oc- casions. This condition pre- cludes the fusion of the de- cidua vera and reflexa, and therefore in the occasional instances in which it con- tinues throughout pregnancy it ne has noted more than 1<>0 cases in his it occurs but rarely, and 1 have never met ( -y*" . "3' -, k / / if /? Fig. 471.—Endometritis'Decidua Cystica (Breus). one hundred and twenty days membranes and the termination Fig. 470.—Decidua Polyposa (Bulius). must be assumed that these structures had failed to unite as usual. During the last few years considerable discussion has arisen concerning the nature of hydrorrhea gravidarum. Stoeckel, Myer-lliiegg, and others believe that it does not result from changes in the de- cidua, but is due to premature rupture of the fcetal mem- branes. The latter observer, in 1901, collected 15 cases from the literature in which a period varying from fifty to had elapsed between the rupture of the of pregnancy. In such cases there occurs a 582 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT constant trickling of amniotic fluid, and examination of the placenta shows that the membranes have become 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 retention cysts being formed which project from the surface of the decidua, giving it a nodulated appearance. The affection has been de- scribed by Hegar and Breus as endometritis cystica. Atrophic Endometritis Decidua.—Under this heading Hegar, Ahlfeld, and others have described a disease in which large portions of the decidua vera and serotina undergo atrophic changes similar to those which occur :.&'■ > . ■ ~'_£J -^V^C >*. a_*" A , -• ■ jf ■ " (g-'Ast.,. _k .^ A <$* ^•i-*-^§p__f.-,o '" "S-.v.i.'Vk«>jvX».^.«A« Fig. 472.—Decidual Endometritis. X 280. normally in the portions corresponding to the lateral margins of the uterus. They offer no suggestion as to its aetiology, but consider that it interferes with the nutrition of the ovum and is a frequent cause of abortion. Acute Endometritis Decidua. —Acute inflammatory lesions of the de- cidua 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 Wittkowsky, and others. Reference has already been made to the lesions of the endometrium associated with gonorrhoea and occasionally with the 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 observations prove beyond doubt the bacterial origin of the lesions, but it is usually very difficult to decide whether the inflammatory process preceded, or was merely coincident with, the abortion. In such cases the decidua vera and serotina are thickened and their external surface covered with a yellowish purulent exudate- Under the microscope the tissue is found to be infil- LITERATURE 583 trated with leukocytes, and presents the typical picture of acute inflamma- tion, with here and there areas of necrosis. More commonly, however, the changes are less marked, and only a few collections of leukocytes are seen lying between the decidual cells. Maslowsky and Neumann have been able to demonstrate the presence of gonococci in several cases of acute inflammation of the decidua; and it is probable that such conditions are quite common. The various forms of endometritis decidua complicating pregnancy are the 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 associated with a slightly blood-stained or dirty brownish discharge, particularly when there is a history of gonorrhceal infection or of repeated abortions. It is permissible to assume that such conditions, particularly the hyper- plastic forms, play a part in the production of placenta praevia, or, when the organ is implanted normally, seriously interfere with the mechanism of its separation. 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 at once be 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 com- plication of pregnancy, and when it exists was usually present before con- ception. It predisposes to abortion and is not amenable to treatment dur- ing pregnancy. Peri-uterine Inflammation.—When pregnancy occurs in women suffer- ing from peri-uterine inflammation, considerable discomfort may result 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 exceptionally rupture may occur and give rise to acute peritonitis, which usually ends fatally unless appropriate operative measures are promptly undertaken. Pregnancy Complicated by Tumors.—Pregnancy 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 m detail in Chapter XXXII. LITERATUEE 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. Hydrorrhea gravidarum. Endometritis atrophicans. Lehrbuch der Geb., II. Aufl., 1898, 253. Beckmann. Weiterer Beitrag zur Gravidity im rudimentaren Uterus Horn. Zeit- schr. f. Geb. u. Gyn., 1911, lxviii, 600-639. 584 DISEASES AND ABNORMALITIES OF GENERATIVE TRACT Bettman. A Case of Labor in a Bicornuate Uterus. Bulletin Johns Hopkins Hosp., 1902, xiii, 57. Breus. Ueber cystose Degeneration der Decidua vera. Archiv f. Gyn., lss:., xix, 483-489. Bulius. Ueber Endometritis decidua polyposa et tuberosa. Miinchener med. Woch- enschr., 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, 1S7-198. Emanuel und Wittkowsky. Ueber Endometritis in der Graviditat. Zeitschr. f. Geb. u. Gyn., 1895, xxxii, 98-111. Fry. Cceliotomy in the Treatment of the Incarcerated Pregnant Uterus when Irre- ducible. Amer. Gyn. and Obst. Jour., 1899, xiv, 25-27. Gottschalk. Zur Lehre von der Retroversio uteri gravidi. Archiv f. Gyn., 1894, xlvi, 358-383. ' Halban. Ein diagnostisches Zeichen fiir Schwangerschaft in einem Uterus bicornis. Zentralbl. f. Gyn., 1904, 9-11. Hegar. Kysten-bildung in der Decidua. Monatsschr. f. Geburtsk., 1863, xxi, Sup- plement-Heft, 11. Die Driisen der Decidua und die Hydrorrhoea gravidarum. Monatsschr. f. Ge- burtsk., 1863, xxii, 420-451. Hegar und Maier. Beitrage zur Pathologie des Eies. Virchow'a Archiv, 1871, Iii, 161-192. Hirst. Vaginal Enterocele in Pregnancy and Labor. Trans. Amer. Gyn. Soc, 1893, xviii, 351-357. Jaeger. Das Tntestinalemphysem der Suiden, etc. Archiv f. Tierheilkunde, 1906, xxxii, H. 425. Jolly. Ueber aciites CEdem der Portio vaginalis. Zeitschr. f. Geb. u. Gyn., 1904, Iii, 396-401. Kaltenbach. Diffuse Hyperplasie der Decidua am Ende der Graviditat. Zeitschr. f. Geb. u. Gyn., 1878, ii, 225-231. 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 Retroflexion und Retroversion der schwangeren Gebar- mutter. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 285-305. Lindenthal. iEtiologie der Kolpohyperplasia cystica. Wiener med. Wochenschr., 1897, Nrs. 1-2. Lobenstine. Incarceration of the pregnant uterus. Amer. Jour. Obst., 1909, lx, 1003-1016. Lohlein. Ueber Achsendrehung des Uterus, besonders des graviden Uterus. Deutsche med. Wochenschr., 1897, Nr. 14. Mann. The Surgical Treatment of Irreducible Retroflexion of the Gravid Uterus. Trans. Amer. Gyn. Soc, 1898, xxiii, 135-140. Maslowsky. See Chapter XXV. Mauriceau. Histoire d'une femme, etc. Traite des maladies des femmes grosses, 6me ed., 1721, T. I., 86-91. LITERATURE 585 Meyer-Ruegg. Eihautberstung ohne Unterbrechung der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1904, li, 419-468. Xagel. Entwickelungsfehler des Uterus und der Scheide. Veit's Handbuch der Gyn., 1897, i, 563-604. Neumann. See Chapter XXV. Noble. One Hundred and Sixty-six Cases of Cancer of the Pregnant Uterus, etc. Amer. Jour. Obst., 1896, xxxiii, 873-X82. Nyulasy. Polypoid endometritis. Jour. Obst. and Gyn. British Emp., 1909, xvi, 9 -15. Oldham. Case of Retroflexion of the Gravid Uterus. Trans. London Obst. Soc, I860, i, 317-322. Reed. The ^Etiology of Ischuria in Retroflexion of the Gravid Uterus. Amer. Jour. Obst., 1904, xlix, 145-156. Reifperscheid. Beitrag zur Lehre von der Hydrorrhea uteri gravidi. Zentralbl. f. Gyn., 1901, xxv, 1143-1145. Sanger. Ueber Schwangerschaft im rudimentaren Nebenhorn bei Uterus duplex. Zentralbl. f. Gyn., 1883, vii, 324. Sarwev. Carcinom u. Schwangerschaft. Veit's Handbuch 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 Retro-flexio-versio Uteri Gravidi. Trans. London Obst. Soc, 1900, xiii, 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. Veit. Ueber Endometritis decidua. Volkmann's Sammlung klin. Vortrage, 1885, Nr. 254. Allgemeines iiber die iEtiologie 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, xii, 317-365. Werth. Retention einer Ausgetragenen Frucht in dem unvollkommen entwickelten Home eines Uterus bicornis. Archiv f. Gyn., 1881, xvii, 281-297. 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 fcetus 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 extremi- ties of the chori- onic villi are con- verted into trans- parent vesicles with clear, viscid con- tents. 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 con- nected by thin ped- icles, giving to the external surface of the chorion a grape- like appearance. The formation may involve the entire periphery of the membrane, but more frequently is limited to portions of it. It is generally stated that the condition was first described by Schenck 586 Fig. 473.—Hydatidiform Mole (Bumm). HYDATIDIFORM MOLE 587 von Grafenberg in 1565, but Kossmann has pointed out that iEtius, of Amida, in the early part of the sixth century, wrote intelligently about an hydatidiform mole, although he had no clear idea of its nature. Owing to its peculiar appearance and the fact that it frequently con- tained no trace of a fcetus, the hydatidiform mole was a source of not a little speculation to the early writers upon medicine, and all sorts of theo- ries were advanced concerning its origin. As the name implies, the condi- tion was long considered to be analogous to the hydatid cysts observed in other parts of the body, Goeze, Percy, and others believing that the vesicles contained worm-like structures. De Graaf held that the vesicles were Fig. 474.—Section op Hydatidiform Mole, Showing Proliferation of Syncytium and Langhans's Cells. X 75. S., syncytium; V., normal chorionic villi; Z., Langhans's cells. mature ova, while some authors thought that each represented an early pregnancy. It is probable that many of the extraordinary 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 Madame Boivin in 1827, and since then it has been universally admitted to he 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 588 DISEASES AND ABNORMALITIES OF THE OVUM chorionic villi, and designated it as myxoma chorii. This view obtained immediate acceptance and held its ground until 1895, when Marchand demonstrated that the essential feature of the affection was to be found not so much in the stroma as in the epithelial covering of the villi. He showed that both the syncytium and Langhans's layer of cells underwent 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 disappeared and the stroma degenerated, so that in advanced cases its cells became necrotic and their nuclei failed to take up the usual histological stains. Moreover, inasmuch as the fluid contents of the vesicles failed to give the characteristic reaction for mucin, Marchand felt justified in attributing them to oedema. This work obtained almost immediate acceptance, and was promptly confirmed by many investigators, among whom Neumann, Fraenkel, Pick, Ouvry, Schwab, and Larrier and Brindeau may be mentioned. Fig. 474 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 the recorded cases by the expulsion of an hydatidiform mole, great interest arose.as to the nature of the latter condition and the relation which it bore to the production of the former. The similarity in the microscopic struc- ture 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, while in the latter it was limited to the periphery of the villus. His observations, how- ever, have not been confirmed, although Pick, Findley, Larrier and Brin- deau, and most 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. Stooekel, in 1902, showed that one or both ovaries might become converted into polycystic tumor? of varying size, sometimes attaining a diameter of 10 or 15 centimeters. The individual cysts may vary from a few millimeters to 5 or 6 centi- meters 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, accompani- ment 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 HYDATIDIFORM MOLE 589 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, chancres occur in normal pregnancy. I am not prepared to express a decided ojiinion upon the subject, but consider that the demonstration by Fraenkel and Santi, that lutein eystoinata sometimes undergo spontaneous involu- tion 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 centi- meters in diameter. They were success fully removed after laparotomy, and constitute my sole experience with this type of tumor. Causation.—Virchow and Veit agree that the development of the con- dition is dependent upon endometritic changes. At the 1901 meeting of the German (iymeeological Congress Aichel stated that he had been able to produce the condition experimentally in dogs by destroying the vessels going to the decidua, and thereby interfering with the nutrition of the chorionic villi. On the other hand, Marchand and most recent writers are inclined to consider the changes in the endometiium as secondary, and to search for 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. Mine. Boivin was acquainted with the fact, and cases have been reported by Birnbaum and Fiilgowski. 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 cases. On the other hand, the statistics of Williamson would indicate that it may be found about once in 2,100 eases. It may occur at any period of reproductive life, but is par- ticularly frequent in the third decade, having been noted between the twentieth and thirtieth years in 41 and 38 per cent, of the cast's collected by Dorland and Kehrer respectively. It likewise appears with comparative frequency after the fortieth year—in 16 and 22 per cent, of the cases, according to the same authors. The process usually comes on early in pregnancy, rarely making its appearance after the third month. When it develops comparatively late it does not implicate the entire chorion; but whenever a considerable portion of the membrane is involved, atrophic changes affecting the fcetus are con- stantly found, and its development is materially influenced even when the disease is relatively mild in character. In the former class of cases the fotus dies at an early period, and often 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 usually continues to grow after the death of the fcetus, and ma\ attain considerable proportions, though spontaneous expulsion is rarely delayed after the sixth month. 590 DISEASES AND ABNORMALITIES OF THE OVUM The clinical history is very characteristic. The uterus enlarges much more rapidly than usual, so that the fundus is often found at the level of or above the umbilicus in a woman who gives a history of being only a few months pregnant. After a longer or shorter period more or less profuse haemorrhage 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, Volkmann, Jarotsky, and Waldeyer. Now and again the growth reaches the peritoneal surface of the uterus and gives rise to perforation, followed by fatal intra-peritoneal haemorrhage. This compli- cation 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 con- sist 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 perfectly 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-epithelioma Fig. 475.—Hydatidiform Mole. X 50. Invasion of blood-vessel. D. V., dropsical villus; Syn., proliferating syncytium U. W., uterine wall; V., vein. or a malignant hydatidiform mole, or whether they are merely due to the accidental transportation of particles of a benign growth. Neumann and Schmidt take the former, while Pick and Sehlagi nhauser incline to the latter view. The observations of Veit, Poten, and myself, concerning the transportation of villi in normal pregnancy, lend a certain probability to the latter theory, although the question mnst remain to be settled by future investigations (see Fig. 475). CHORIO-EPITHELIOMA 591 Aside from the possibility of the development of a chorio-epithelioma which occurred in 16 per cent, of the 210 cases analyzed by Findley, the hydatidiform mole is a serious affection, since Dorland noted an imme- diate mortality in 10 per cent, of the 100 instances which he collected from the literature, death being due to haemorrhage 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. Diagnosis.—Hydatidiform mole should always be suspected when haem- orrhage occurs in a patient whose uterus is considerably larger than it should be for the duration of pregnancy, though in not a few cases similar symptoms are noted in hydramnios. A positive diagnosis may be made when one finds one or more vesicles in the uterine discharges, or when the ringer introduced through the cervical canal is able to palpate the charac- teristic grape-like 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. Every woman who has suffered from a hydatidiform mole should be carefully watched for the next few months, and if haemorrhage makes its appearance the uterus should be curetted and the scrapings subjected to microscopic examination; and, if the lesions characteristic of chorio-epithe- lioma 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 involvement of the uterus. Under such circumstances, if the uterine scrap- ings are negative, 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 (Deciduoma Malignum).—This term is applied to a very malignant variety of uterine tumor which develops after a full-term labor, abortion, or hydatidiform mole, and in rare instances before the last is expelled from the uterus. The nature of the growth has given rise to a great deal of discussion, and various appellations have been suggested for it, the most important being sarcoma deciduo-cellulare, syncytioma malignum, and carcinoma syncytiale. Sanger read his first paper upon the subject in 1S92. and based his report 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 metastases exhibiting similar characteristics in the lungs, diaphragm, tenth Jib, and right iliac fossa, Microscopic examination showed that the tumor 592 DISEASES AND ABNORMALITIES OF THE OVUM was made up in great part of blood spaces bounded by large cells, which Sanger 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 deciduo-cellulare. 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 fol- lowed 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 was a Fig. 476.—Chorio-Epithelioma, Showing Alveolar Arrangement of Primary Tumor. X 60. colored woman who had a spontaneous full-term labor. A week later she noticed a small painful nodule upon the right labium majus. This resem- bled a haematoma 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 dis- charge. The patient gradually grew worse, eventually developed 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 appearance. Similar but smaller growths were present in the kidneys, spleen, and ovary, while a small nodule about 1 centimeter in diameter was found in the uterus. Microscopic examination showed that the uterine growth and the meta- stases were made up in great part of blood spaces, whose walls were formed by large clear cells with definite vesicular nuclei. At the margins of the primary growth, invading the adjacent musculature, were large masses of CHORIO-EPITHELIOMA 593 syncvtium; 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 a most important monograph upon the subject. He identified the protoplasmic masses with the syncytium, and the individual cells with those of Langhans's 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 fcetal tissue. Hence it followed that such tumors could not correctly be described as deciduomata or de- Fig. 477.—Chorio-Epithelioma, Showing Syncytial Masses invading a Venous Channel. cidual sarcomata; and, after it had been demonstrated that both layers of the chorionic epithelium—syncytium as well as Langhans's layer—were fcetal in origin, Marchand (1898) proposed the term chorio-epithelioma, which has since been generally accepted. Marchand's conclusions have received abundant confirmation at the hands of all who have studied the subject, with the exception of Veit and certain English authorities. For a time these held that the tumor was simply a sarcoma whose cells had undergone changes in appearance under the influence of pregnancy; but in the discussion following Teacher's admirable paper before the London Obstetrical Society in 1903 this view was abandoned and Marchand's teachings fully accepted. The monographs of Sanger and Marchand were the beginning of an 40 594 DISEASES AND ABNORMALITIES OF THE OVUM 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 1906 analyzed 28 cases which had been reported in America; while Risel in 1907 and Veit in 1908 carefully reviewed the entire subject. Risel, working in Marchand's laboratory, contends that chorio-epitheli- oma may occur in a typical and an atypical form. In the former the tumor cells present an appearance identical with that observed in the chorionic epithelium in early pregnancy, while in the latter the fcetal cells merely infiltrate the uterine wall, without necessarily giving rise to a true tumor formation. Both varieties are equally malignant and give rise to meta- stases. In other instances, the primary growth may originate in a pregnant tube, as observed by Davidson and myself, or in the ovary, as reported by Iwase, Fairbairn, and others. In the latter event, it is not known whether the process was preceded by an ovarian pregnancy or not. In still other cases, as reported by Schmorl, Htibl, Findley, and others, there is no primary growth in the uterus, tubes, or ovaries, but the patient never- theless died from metastases in various organs. At first it was attempted to explain such an occurrence by assuming that the primary growth was limited to the placenta, particles of which became broken off and were carried into the circulation, giving rise to metastases wherever they were arrested, while the primary tumor itself was cast off with the afterbirth. Later, however, as the frequency of the "deportation" of chorionic villi became more fully recognized, it was assumed that metastases might be formed in any case in which the chorionic epithelium possessed malignant properties. Poten and Vassmer have reported a case in which vaginal metastases appeared while an hydatidiform mole was still in the uterus. The chorio-epithelioma rapidly gives rise to abundant metastases, par- ticularly in the lungs, vagina, and brain. They develop along the course of venous channels, which is explained by the tendency of the foetal ecto- dermal cells to erode, and eventually invade, the blood-vessels with which they come in contact. In the 52 cases collected by Dorland, metastases were observed in the lungs of 78.38 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 significance, and occasion- ally are the only manifestation of the condition. In some cases, as reported by Hormann and others, their excision may be followed by complete re- covery. Runge 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 formations in 24 instances; but, just as is the case in hydatidiform mole, neither he nor subsequent investigators have been able to adduce a satisfactory ex- planation of their significance. In 1902 Wlassow and Schlangenhaufer made a contribution, which for a time threatened to overturn our ideas concerning the significance and CHORIO-EPITHELIOMA 595 mode of origin of chorio-epitheliomata. They described generalized meta- stases following certain teratomata of the testicle, which were made up of syncytium, Langhans's cells, and even of structures resembling chorionic villi. Their observations have been abundantly confirmed by Risel, Teacher, Frank, and others; while Pick and others have reported similar condi- tions associated with ovarian teratomata. In such eases, Schlangenhaufer assumed that portions of fcetal mem- branes had been included in the teratoma, and suddenly began to prolifer- ate after lying dormant for years. Risel and all subsequent writers, on the other hand, hold that such an assumption is not necessary, and consider that such a formation may develop from undifferentiated fcetal ectoderm contained in the teratoma. Clinical History.—Chorio-epithelioma may occur at any age during the childbearing period, and always follows a pregnancy, whether the latter terminates in full-term labor, abortion, or hydatidiform mole, the last association being noted in nearly 50 per cent, of the eases. In several in- stances it originated from a tubal or ovarian pregnancy. 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 haemorrhage 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. In more than one half of the cases the first indication is the appearance of vaginal or vulval metastases. These are usually not noted until some weeks or months after the puerperium, though in Poten and Vassmer's case they appeared before the extrusion of the mole, and in my case one week after a full-term labor. The development of metastases in the lungs is usually associated with pulmonary symptoms, cough, and bloody expectoration. Occasionally, as reported by Hormann and others, the growth may perforate the uterine wall and give rise to fatal intra- peritoneal haemorrhage. 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 sim- ple curettage, but such a favorable outcome occurs so rarely that it does not justify the postponement of radical operative treatment. Diagnosis.—In a considerable number of cases the diagnosis is not made until uterine haemorrhage, occurring at a varying period after the puerpe- rium, necessitates curettage, when the microscopic examination of the scrap- ings reveals characteristic changes. In other instances the occurrence of vaginal metastases is the first indication of the existence of the growth. The possibility of its development should always be borne in mind whenever a woman has expelled a hydatidiform mole, and the subsequent appearance of haemorrhage, or of other more obscure symptoms, should be an imperative indication for curettage and the microscopic examination of the scrapings. 596 DISEASES AND ABNORMALITIES OF THE OVUM Treatment.—If currettage reveals the existence of characteristic lesions, immediate hysterectomy is imperative. On the other hand, when vaginal metastases are present, the indications for radical operation are not so clearly marked, as we know that in some such cases the uterus contains no growth, and 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. Diffuse Myxoma of the Chorion.—Breslau and Eberth have called at- tention to a rare affection of the chorionic membrane, in which its con- nective tissue layer undergoes myxomatous degeneration and becomes converted into a jelly-like 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. Myxoma Fibrosum of the Chorion.-—Virchow called attention to the fact that a greater or lesser number of the chorionic villi, which enter into the formation of the placenta, may lose their original structure and take part in the formation of a tumor made up of dense connective tissue with larger or smaller areas of myxomatous tissue scattered through it. As the change is limited to the placenta, its consideration will be deferred until the tumors of that structure are studied. DISEASES OF THE AMNION Hydramnios.—By hydramnios is understood the presence of an ex- cessive quantity of liquor amnii. Exactly when the proper limit is passed cannot be 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, but the more marked grades are not frequent. In rare cases the uterus may contain an almost incredible amount of liquor amnii, Kiistner 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 composi- tion with that normally present in the amniotic cavity, although Pro- chownick 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 by the secretory action of the amniotic epithe- lium; wdiile the foetal kidneys take no part in its production, except under abnormal conditions. This being the case, it is manifestly impossible to HYDRAMNIOS 597 give an explanation for its excessive production which will be universally applicable. Generally speaking, writers upon the subject state that the excess of amniotic fluid may be derived from several sources—from the fcetus from the mother, from both fcetus and mother, and in rare cases from the am- nion itself. In something less than one half of the cases careful examination of the fcetus after death reveals the presence of some abnormality which mav or may not bear a causal relation to the disease. Thus, hydramnios is sometimes, though not always, noted when the fcetus presents some abnor- mality or deformity, particularly hemicephalus or spina bifida. Under such circumstances, it is believed that the superabundant fluid is the result of an excessive urinary secretion, which is brought about bv the stimula- tion of cerebral or spinal centers wdiich have been deprived of their usual coverings, just as happens in the piquvc experiments of the phvsiologists. Hydramnios is also found associated with other deformities, such as hare- lip, the various varieties of cdub-foot, ectopia of the bladder, etc., as well as certain tumors of the kidneys. More frequently, however, the abnormality wdiich 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 instances 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 umbil- ical vein is accompanied by an exudation of fluid from the external sur- face of the umbilical cord and from the fcetal surface of the placenta. This be 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 preg- nancy. 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 fcetus. Thus Opitz observed cirrhotic changes in the liver in all of his cases. Others have attributed it to syphilitic changes, though my experience leads me to be- lieve that lues is an unimportant factor, as hydramnios does not appear to occur much more frequently in syphilitic than in normal children. In a considerable proportion 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 pulmonary arteries; Lebcdeff, aortic stenosis, and Nicberding, a narrowing of the ductus Botalli. Many authorities believe that hydramnios is due to an excessive urinary secretion resulting from renal or cardiac lesions. As has already been pointed out, this mode of origin cannot be accepted for all eases. Opitz thought he had demonstrated that in hydramnios the liquor amnii con- 598 DISEASES AND ABNORMALITIES OF THE OVUM tained a lymphagogue substance, which is normally absent. He consid- ered 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 resulted in its hypertrophy. As a consequence a larger amount of fluid circulated through the kidneys, giving rise to an increased urinary secretion. It is generally believed that the aetiological importance of increased renal activity is strikingly illustrated in hydramnios occurring in single- ovum twins. Wilson (1899) analyzed the histories of 51 cases of hydram- nios occurring in multiple pregnancy—46 twins and 4 triplets. Twenty- two of the twins were uniovular in origin, and, when one considers that these are much less frequently observed than double-ovum twins, it is apparent that something connected with the former must exert an appre- ciable influence in the excessive production of amniotic fluid. In such cases, as a rule, the hydramnios is limited to a single amnion, while the other contains a normal or diminished amount of fluid. At autopsy the heart and kidneys of the fcetus suffering from hydramnios are found to be both relatively and actually larger than those of the normal 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 wdiich still further accentuated the condition, and in turn was followed by renal hypertrophy with increased secretion. He considered that the primary cause for the difference 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 narrowdng. The mode of production of hydramnios in such cases has been consid- ered in detail by Schatz, Werth, Strassmann, 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 um- bilical 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 nsevus, through which he believed excessive exuda- tion occurred. Furthermore, Wilson and others consider that excessive cutaneous activity is ofttimes associated wdth cardiac hypertrophy. In a small number of cases inflammatory conditions of the amnion it- self are believed to play a part in the production of the condition, leading to increased exudation through that membrane. HYDRAMNIOS 599 Occasionally diseases of the mother which are attended by circulatory disturbances, particularly cardiac and renal affections, or visceral syphilis, lead to cedema of the placenta, with increased transudation into the am- niotic cavity. The demonstration by Wolff that nephrectomy in pregnant rabbits was followed by increased renal activity on the part of the fcetus with consequent hydramnios, also indicates the possibility of a similar occurrence in pregnant women suffering from serious renal disease. 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 reyeal the presence of any lesion which can be supposed to play a part in the production of the anomaly. Symptoms.—The symptoms accompanying hydramnios 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 excessive, the patient may suffer from severe dyspnoea and cyanosis, and in extreme cases be able to breathe only in an upright position. CEdema often occurs, especially in the lower extremities and about the vulva. It is surprising what great degrees of abdominal distention can some- times be borne by the patient with comparatively little discomfort, although this is the case only when the accumulation of fluid has taken place gradu- ally. 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 percus- sion enable one to feel confident that the fluctuant tumor is the distended uterus, in which a readily ballottable fcetus 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 impossi- ble; 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 wdth it often passes unnoticed. On the other hand, in a multiple pregnancy not complicated by hydramnios, the diag- nosis is comparatively easy, inasmuch as the uterus offers a firm consist- ence to the touch, and careful palpation will reveal the presence of several fcetal poles and an unusual number of small parts, as contrasted with the marked fluctuation and the difficulty of mapping out the fcetus in hydram- nios. When the uterine distention is excessive the diagnosis of hydramnios becomes even more difficult, and many cases are recorded in which the con- dition was mistaken for a large ovarian cystoma, with the result that the contents of the amniotic cavity were evacuated by means of a trocar, or laparotomy was performed. Inquiry as to the possibility of pregnancy and careful examination wdll generally serve to prevent such an error. Excessive abdominal enlargement due to ascites can usually be differ- 600 DISEASES AND ABNORMALITIES OF THE OVUM 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 correspond- ing 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. 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 children are often so poorly developed or so deformed that their chances of living are minimal. In such cases the symptoms can be promptly relieved by perforating the membranes through the cervix, after which the amniotic fluid drains off and labor pains set in. When the abdomen has been enormously dis- tended, and the course of labor is particularly rapid, there is an increased risk of atonic haemorrhage 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. Oligo-hydramnios.—In rare instances the amount of amniotic fluid may fall far below the normal limits, and occasionally be represented by only a few cubic centimeters of clear, viscid fluid. The aetiology is even less well understood than that of hydram- nios. Jaggard, in 1894, reported a case in which the fcetus pre- sented an imperforate urethra with absence of one and cystic de- generation 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 in- stances from the literature, in which the anomaly was associated with complete absence of both Fig. 478.—Compression of Fcetus in Oligo- •' ' hydramnios (Ahlfeld) When oligo-hydramnios occurs early in pregnancy it is attended by serious consequences to the fcetus, 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 fcetus, 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. 478). In some cases of oligo-hydramnios the skin of the fcetus is markedly AMNIOTIC ADHESIONS 601 thickened, and presents a dry, leathery appearance. Most authorities at- tribute this to the lack of amniotic fluid, but Ahlfeld is inclined to believe that it is the cause and not the result of the condition, since the 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 oligo-hydram- nios, and occasionally even when the liquor amnii is present in normal amounts, ad- hesions 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 by Mont- gomery, G. Braun, Kiistner, Ahlfeld, Chi- ari, and others. The effects of amniotic adhesions are variable and depend in great measure upon their location. As a rule, when they de- velop early in pregnancy they give rise to serious deformities of the fcetus. The fol- lowing abnormalities have been directly traced to the condition: Encephalocele 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 sponta- f" neous amputation. Fig. 480 represents Fig. 479.—Encephalocele Result- ing from Amniotic Adhesions (Ahlfeld). A Fio. 480.—Amputation of Fingers by Am- niotic Adhesions (Kiistner). Fig. 481. Amputation of Arm by Amni- otic Adhesions. intra-uterine amputation of the fingers, and Fig. 481 amputation of the arms, produced in this way. Braun has reported two cases in wdiich the death of the foetus was attributable to strangulation of the umbilical cord 602 DISEASES AND ABNORMALITIES OF THE OVUM by such bands. Exceptionally amniotic adhesions may give rise to dystocia, and Bardeleben and myself have seen instances in which firm adhesions extending from the placenta to the child seriously interfered w ith 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 re- sult from attempts at criminal abortion or from the extension of an infection that has originated in the decidua. Cysts of the Amnion.—Now and again small cystic structures, lined by typical epithelium, may be formed in the amnion. They gen- erally result from the fusion of amniotic folds with subsequent re- tention of fluid. Special attention Fig. 482.—Placenta Fenestrata (Hyrtl). 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. ABNORMALITIES OF THE PLACENTA Abnormalities in Size, Shape, and Weight.—The normal placenta is a flattened, roundish, or discoid organ, which averages from 15 to 20 centi- meters in diameter, and from 1.5 to 3 centimeters in thickness. It is rela- tively larger in the earlier than in the later months of pregnancy, and varies considerably in size at term, though, generally speaking, 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 horseshoe-like appearance, its two branches running partially around the orifice. In very rare instances, as in one reported by Taurin, it may be a broad annular organ which encircles the uterine cavity just as in carnivorous animals. 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. ABNORMALITIES OF THE PLACENTA 603 Exceptionally it may be considerably heavier, Levy having reported a num- ber of cases in which it exceeded 1,000 grams in weight. In diseased 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 fcetus. In al- buminuria similar ratios obtain, which are due al most entirely to the imper- fect development of the fce- tus which characterizes such conditions. The largest pla- centa' with which we are fa- miliar are observed in cases of general dropsy of the foe- tus and placenta. In one of my cases of this character the foetus and placenta weighed 1,140 and 1.200 grams, respectively, and Go- FlG. 483.—Placenta Bipartita. hen has reported a case in which the latter weighed 2,900 grams. Multiple Placenta in Single Pregnancies.—Occasionally in an ordi- nary single pregnancy the placenta is divided into several parts, which may be absolutely distinct, or more or less closely united. Such abnormalities have been studied more particularly by Hyrtl and Ribemont-Dessaignes, the latter stating that they occur about once in 1552 cases. In rare instances the placenta may be oblong in shape, with an aper- ture 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 di- vided 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 dim idia la or bipartita. Accord- ing to Ahlfeld, this Fig. 484.—Placenta Tripartita (Hyrtl). anomaly is noted 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 (see Fig. 4S7). Occasionally the organ may be made up of three distinct lobes—placenta triplex; while in very rare instances it may 604 DISEASES AND ABNORMALITIES OF THE OVUM Fig. 485.- -Oorrosion Preparation of Placenta Septuplex (Hyrtl). consist of a number of small lobes, Hyrtl having described as many as seven—placenta- septuplex. All of these conditions result from abnormalities in the blood supply of the decidua. Generally speaking, the portion of the ovum which is to become converted into the chorion frondosum, and later into the fcetal 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, develops in several separate portions of the decidua, some such anomaly is bound to occur. Kiistner believes that cer- tain cases of placenta bipar- tita or duplex owe their origin to extensive infarct formation by wdiich the intervening tissue is de- stroyed; but such an explanation cannot be accepted when the several lobules are separated from one another by apparently normal membranes. Placenta Membranacea.—In rare instances the decidua re- flexa is so abundantly supplied with blood that the chorion beve in contact with it fails to undergo atrophy. In such cir- cumstances, the entire periphery of the ovum is covered by func- tioning villi, so that the pla- centa, instead of being a dis- coid organ limited to the de- cidua serotina, corresponds to the entire chorion—placenta membranacea. This abnormal- ity does not interfere with the nutrition of the ovum, but oc- casionally gives rise to serious complications during the third stage of labor, since the thinned- out placenta is not readily separated from its area of attachment, and usually necessitates manual removal. Placenta Succenturiata.—An important, and not infrequent, anomaly is the so-called placenta succenturiata, in which one or more small accessory Fig. 486.—Placenta Membranacea (von Weiss). ABNORMALITIES OF THE PLACKXTA 005 at some distance from the periph- they are united to the latter by /£2 Fig. 487.- -Placenta Duplex, with Two Succenturiate Lorn-lios. X h. lobules are developed in the membranes cry of the main placenta. Ordinarily vascular connec- tions. Occasionally, however, these are lacking, and as a result we have what are known as pla- centa spuria. The placenta succenturiata is of considerable clini- cal importance, be- cause the accessory lobules are some- times retained in the uterus after the expulsion of the main placenta, and may give rise to se- rious haemorrhage. For this reason, one should always bear in mind the possi- bility of their existence, and, in examining the after-birth, the membranes should be inspected, as well as the placenta. Should small, roundish defects be present a short dis- tance from the placen- tal margin, the reten- tion of a succenturiate lobe should be suspect- ed, and becomes a cer- tainty if vessels extend from the placenta to the margins of the tear. If, in such cases, even slight haemorrhage oc- curs, the hand should be introduced into the uterus for the purpose of locating and remov- ing the offending struc- ture. 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 fcetal surface of Fig. 4S8.—Placenta Marginata. X i. 606 DISEASES AND ABNORMALITIES OF THE OVUM the placenta may present a central depression surrounded by an elevated portion, the amnion extending from the edges of the former. This condi- tion 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 Praevia.—Once in several hundred cases the placenta, instead of being inserted upon the lateral wall or the fundus of the uterus, is im- planted 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 haemorrhage 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, fatty and fibro-fatty degeneration of the placenta, etc., but which are most appropriately described as placental infarcts. These structures vary materially in size, shape, and appearance, and' are best described under the following headings: 1. Small, whitish, or yellowish fibrous formations occurring upon either the fcetal 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 millime- ters, and are sharply differentiated from the surrounding placental tissue. 2. Wedge-shaped or irregularly round areas, in the interior of the pla- centa. These are usually dull white in color, exhibit a striated, fibrous appearance, and present a striking contrast to the surrounding tissue, which appears to be perfectly normal. 3. Less commonly, considerable portions of the placenta are implicated 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 some- times nearly its entire substance being implicated. 4. A broad rim of opaque, whitish, or yellowdsh-white material may extend for a varying distance around the margin of the foetal surface of the placenta, and occasionally forms a complete ring around it—placenta mar- ginata. 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 number 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 separated from it by apparently normal placental tissue. To this condition the term margo placenta is sometimes applied. 5. Pinkish or brickdust-colored, irregularly shaped, more or less solid INFARCT OF THE PLACENTA 607 masses, sharply marked off from the surrounding tissue, may occupy a larger or smaller portion of the placenta. They are usually most promi- nent on the maternal surface, and frequently extend through its entire thickness; they are sometimes termed red infarcts. Still more rarely, roundish areas varying from bright red to almost black in color, and measuring from one to three centimeters in diameter, are scattered through the substance of the placenta. They are composed almost entirely of blood, and are sharply differentiated from the surround- ing tissue by a capsule which presents a more or less fibrous appearance. They may occur in considerable numbers, so that the entire placenta is studded with them and presents a nodular surface, 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 to be found in every placenta, while similar areas, measuring 1 centimeter or more in diameter, were observed in 63 per cent, of 500 consecutive placentae which I examined. If not present in excessive numbers, they 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. Mode of Formation.—According to the researches of Ackermann, Orth, Eden, Kermauner, and myself, infarct formation is the ultimate 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, Fig. 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 themselves as coagulation necrosis of Langhans's layer of cells or the tissue which has replaced it. As the process becomes more marked, this is gradually converted into the so-called canalized fibrin. A little later the syncytium becomes implicated and undergoes a similar change, the fibrin I lien coming in direct contact with the maternal blood in the intervillous spaces. As a consequence, the blood immediately adjoining the necrotic tissue coagulates with eventual fibrin formation. When necrotic changes occur simultaneously in several adjacent villi, the maternal blood lying between them undergoes coagulation, so that even- tually a number of villi become fused together by fibrin. Still further changes then occur in the stroma of the incarcerated villi, the cells undergo coagulation necrosis, and finally the conversion into fibrin becomes so ex- tensive that large areas are produced in wdiich only the shadows of degen- erated villi can be distinguished (Plate XIV, Fig. 1). Ultimately the outlines of the villi disappear, and the entire mass takes on a homoge- 608 DISEASES AND ABNORMALITIES OF THE OVUM neous 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. Steffeck and many recent writers are inclined to attribute the starting- point of the process to inflammatory and degenerative changes in the de- cidua. It would seem, however, that there are no grounds for such a belief, and that their conclusions were based upon faulty premises, in that these authors considered that the cells making up the so-called decidual septa were of maternal instead of fcetal origin, as has been rendered probable by recent investigations. Sfamcni states that placenta marginata is noted in 15 or 20 per cent. of all after-births, and is inclined to attribute its origin to mechanical factors. Red infarcts of the placenta are less frequently observed. They are 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, Rossier, and Martin respectively. Unlike white infarcts, they possess a considerable clinical significance and, whenever well marked, are associated with imperfect development of the fcetus, and sometimes cause its death. Unfortunately, we are not in a position to explain satisfactorily their mode of formation, and must be content with pointing out the re- lation which they bear to albuminuria on the one hand, and to imperfect devel- opment of the child on the other. I Red infarcts are I not, as a rule, ob- served in the pla- centae of eclamptic women, being noted only in those cases in which the onset of the disease has been preceded by dis- tinct nephritic toxae- mia. Fig. 489.—Cyst of Placenta (Ehrendorfer). X §. Cysts of the Pla- centa.—Cystic struc- tures are frequently observed upon the fcetal surface and occasionally in the depths of the placenta. Small cysts a few millimeters in diameter were noted in 56 per cent, of the placentae studied by Kermauner. Larger ones, occasionally attaining the size of a lemon, are observed but rarely. Cysts projecting from the fcetal surface of the placenta are derived from the chorionic membrane, as is shown by the fact that the amnion PLATE XIV. ■* . V ^ ■• » or- *> * ■ :A^ •■■.':---.- *' .-.v Fi--. 1.M-;; [1 ' -■■■ • >;•., ■■■ * ''t/A z- «•' • -.:-''^r^P'<. %•*•'?.....*»■• * ""^ 7,'■',•' "'*•'•*• >VV:'1 ' '' :'" ^W-'-^ ' ' ' > .; ;■*?''$/ . v V, / V ^'4 Va ; • jL "fit.''- /*!^ - /• t%V ^ ",,„_. ..-JKW* , > a h ^----*= /« *|. ■ '*' * • A;/ ..,- Vf .. A. -^'l,...'*."*^ *'*/^'" - '*vl.--^ . -,. -yf^r* K MouVi^ue \at B. End. • *b -7-. vir l' '*i "^\:.:-i ' '/ 'vbi*' ■B. *..>k..U.«TA.%.^tt.* INFAKCT FORMATION. X CO. Fkl i._Fuiiy developed infarct. *'"• 2.—('hoi-ionic viHi1^liu\utn; endarteritis and formation of canalized lilirin. B., blood ii fj?^^^^^d 044/., >ai 'feed lilirin; L'ud.^ arteries sliowin^ obliterating endarteritis. TUMORS OF THE PLACENTA 609 can be readily stripped off from them. Their contents are usuallv 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 membrane, while occasionally a portion is occupied by a white infarct. On microscopic examination, the lining membrane is found to be made up mainly of one or more layers of tolerably large epithelial cells with round vesicular nuclei, which frequently present various degrees of degen- eration. Here and there, corresponding to the situation of a white infarct, tbe cells are absent and the wall consists of fibrin. The researches of Ehrenj dorfer, I'eiser, De Jong, Vassmer, and Schickele have clearly shown that the cells in question correspond to those of Langhans's laver, 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 centi- meter in diameter. They frequently occupy the center of an infarct, are filled with grumous contents, and were mistaken by the older writers for abscesses. In other cases the contents are clear. Such structures mav 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 septa." In the latter case the walls are composed of cells identical with those observed in the cysts occurring upon the fcetal sur- face of the placenta. So far as present experience goes, cystic formations, whether occurring upon the fcetal 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 tu- mor about the size of a man's fist, which made up a large part of the placenta. Since then a number of tumors, varying in size from that of a pea to that of a man's fist, have been described, particularly in recent years. Dienst and Schindler in 1903 and 190S, respectively, were able to collect IS 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 scattered through it. Until recently the placental tumors have been variously desig- nated, and the 3G examples collected by Albert were classified as follows: Myxoma fibrosum ......... Fibroma .................. Angioma .................. Sarcoma .................. Hyperplasia of chorionic villi The researches of Dienst, Pitha, and Schindler. however, show that they are practically all of one type, and consist of masses of chorionic villi with immense hypertrophy and hyperplasia of the terminal vessels, so 41 14 10 !) 2 1 610 DISEASES AND ABNORMALITIES OF THE OVUM that they may be designated as chorio-angiomata. Dienst suggested that they be designated as chorioma angiomatosum, or fibrosum, according an dilated vessels or connective tissue predominate. In many instances the tumor is connected with the chorion by a small pedicle, in which an artery and vein can usually be distinguished, and Pitha holds that the aetiological factor is to be sought in interference with the circulation in these vessels. As the chorio-angiomata do not affect the surrounding placental tissue, 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 pregnancy and labor. 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 originated during preg- nancy. If his interpretation is correct, the observation represents a unique pathological condition. The only placental tumor which I have seen was a lobulated structure, about the size of a hen's egg, which occupied the maternal surface of the organ. Histologically it was a sarcoma. 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 occa- sionally met with. It is not a primary condition, but is due to the exten- sion of a similar process from the decidua, the latter resulting from an exacerbation of a preexisting chronic gonorrhoea, or from an acute infec- tion due to the gonococcus or other pyogenic bacteria. Very exceptionally, abscess formation may be a manifestation of a general infection originating in any portion of the body. 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 fcetus. 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 Fcetus 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 cause it to resemble a piece of coarse sand-paper. Frankel showed that the chalky material was usually deposited in the necrotic tissue surround- ABNORMALITIES OF THE UMBILICAL COIN) 611 ing the ends of the "fastening" villi, as well as in the superficial layers of the decidua serotina. When the almost universal 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 formation 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 in- stances, on the other hand, the adhesions may be so firm and extensive that spontaneous separation becomes impossible, and occasionally cannot he effected even at autopsy except by tearing either the placenta or the uterine wall. Neumann and Hense have recently examined uteri in which this con- dition obtained. Microscopic examination showed that the decidua sero- tina was almost entirely absent, and that the chorionic villi were in direct contact with the uterine muscle and the connective tissue separating its fihers. Under such circumstances the absence of the spongy layer of the decidua readily explains the clinical phenomena. ABNORMALITIES OF THE UMBILICAL CORD Variations in Insertion.—The umbilical cord is usually inserted eccen- trically upon the fcetal surface of the placenta, somewhere between its center and periphery. A central insertion is less common, while in a still smaller num- ber of cases the junc- tion has taken place near the margin, giv- ing rise to a condition known as battledore placenta. In a series of '2.000 placentas, which I studied in this regard, the insertion was ec- centric in 73."25 per cent., central in 1S.25 per cent., and margi- nal in 7.25 per cent. These variations pos- sess no clinical signifi- cance. On the other hand, the so-called vclamentous insertion of the cord—insertio velamentosa—is of considerable practical importance. In this condition the vessels of the ford separate some distance from the placental margin and make their Fig. 490.—Marginal Insertion of the Cord. Battledore Placenta. 612 DISEASES AND ABNORMALITIES OF THE OVUM way to the latter in a fold of amnion (Fig. 327). This mode of insertion was noted in 0.84 per cent, of 15,894 placenta', examined by Lefevre, and in 1.25 per cent, of our cases. According 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, Sehultze's explanation obtained almost universal acceptance. According to this, the anomaly was the result of abnormal adhesions between the umbilical vesi- cle and the chorionic membrane, whereby the amnion was prevented from applying itself in the usual manner to the cord. At present, however, this explanation is not regarded as satisfactory, as the researches of His clearly show that the allantois plays an insignificant part in the formation of the cord in human beings. Franque in 1900 advanced the following theory as to the mode of origin of the velamentous insertion. In the vast majority of cases the abdominal pedicle extends from that portion of the chorion which is in con- tact with the most richly vascularized portion of the decidua—ordinarily the decidua serotina—so that the cord becomes inserted upon the placenta. Occasionally, however, during the first few days of pregnancy, the area of greatest vascularization may be in the decidua reflexa, and the abdominal pedicle then takes its origin from the portion of chorion in contact with it. With the advance of pregnancy, however, the area of vascularization shifts to the decidua serotina—the site of the future placenta—while the abdom- inal pedicle retains its original position, and from its maternal end the vessels extend to the placental margin. Peters, while recognizing the fal- lacy of Sehultze's explanation, is not prepared to accept that proposed by Franque. t When the placenta is inserted low down in the uterus, the velamentous vessels may extend partially across the internal os—vasa praevia—and as dilatation progresses be pressed upon by the presenting part, the interfer- ence with the circulation causing asphyxia of the fcetus. In rare cases such vessels are torn through when the membranes rupture, and the fcetus bleeds to death. The full literature upon this subject up to 1898 has been collected by Peiser, while Knapp has reported a case in which the accident led to the death of both twins developed from a single ovum. 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 almost 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. As a matter of fact it rarely measures less than 25 centimeters. ABNORMALITIES OF THE UMBILICAL CORD 613 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 become practically too short. Accordingly, one distinguishes between abso- lute and accidental or relative shortness of the cord. Either of these conditions may give rise to serious dystocia. Brickner, who has carefully studied the subject, states that delivery cannot occur under such circum- stances unless one of the following accidents occur: separation of the pla- centa, 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 fcetus. 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 (hey 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 por- tions of the fcetus, 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 Ihesc 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 af- fected part. In single-ovum twins in which the amniotic partition wall has been broken through it not infrequently 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 tor- sion is so marked as to interfere seriously with the circulation. The most extreme degrees are observed 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 is found to be infiltrated with leukocytes. Particularly in syphilis, oblitera- tive changes occur in the vessels, the lumina becoming almost completely 614 DISEASES AND ABNORMALITIES OF THE OVUM occluded, although it is observed in other conditions; and, as has already been pointed out, is believed to be an occasional factor in the production of hydramnios. Varices of the Cord.—In rare instances varices of the cord may rupture as the result of undue pressure. Meier has reported a case in which the death of the fcetus was attributable to such an accident. Tumors of the Cord.—Tumor formations implicating the cord are rarely seen. Htematomata occasionally result from the rupture of a varix with subsequent effusion of blood into the cord. In one instance I ob- served such a tumor, 5 centimeters in diameter, at the fcetal 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 an apparently typical dermoid. 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 described a case of the latter variety and collected the literature upon the subject up to 1906. As a rule they 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 cedematous conditions of the fcetus. 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 diam- eter and resembled an eel in appearance. Microscopic examination showed that the condition was simply due to an increase in the amount of Whar- tonian jelly. DISEASES OF THE FCETUS Foetal Syphilis.—Syphilis is the most frequent cause of fcetal death in the later months of pregnancy, and may be maternal, or possibly paternal, in origin. The mother may be suffering from the disease at the time of conception, or may contract it during the course of pregnancy. In the first case, it is believed that transmission to the fcetus occurs through the ovum, whereas in the other it takes place through the placenta. As a rule, the latter mode of infection is possible only when the mother is inoculated during the early months of pregnancy, though exceptions are occasionally noted. Contrary to the present trend of opinion, as was stated in Chapter XXV. I am inclined to believe that in certain instances the disease is pa- ternal 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 present infectious lesions at the time of coitus. Since these are usually absent, the mother escapes, while the fcetus ordi- narily becomes inoculated—Colics' law. The fact that, in the majority of such cases, the mother presents a positive Wassermann reaction does not, FCETAL SYPHILIS 615 le my mind, necessarily indicate that she is suffering from latent syphilis. At present we know too little of the significance of this reaction to be dogmatic, but I consider it quite within the range of possibility that, in the future, it may be demonstrated that it may be due to the transmission of anti-bodies through the placenta, quite as well as to the presence of living spirochaeta) in the mother. It has long been known that a syphilitic infection exerts a most dele- terious influence upon the product of conception. Usually it leads to the premature expulsion of a macerated fcetus. Less commonly the child is born alive showing distinct manifestations of the disease, while in other cases they do not appear until a later period. It is of the greatest importance that the practitioner should become thoroughly familiar with the characteristic lesions of fcetal 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 has 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. Syphilis not only gives rise to characteristic lesions in the fcetus, 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 importance 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 fcetus 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 presents a dry, drawn appear- ance, 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 upon the palms of the hands and soles of the feet. If intra-uterine death has occurred, the foetus rapidly undergoes ma- ceration, 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, the condition 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 examined. Usually the lungs are enlarged, pale, and scarcely float when thrown into water. On microscopic examination the alveoli are found filled with cast-off epithelial cells in all stages of fatty degeneration— 616 DISEASES AND ABNORMALITIES OF THE OVUM catarrhal pneumonia, the pneumonia alba of Virchow. In other cases the lesion consists in an increase in the interstitial tissue associated with pro- nounced round-cell infiltration, by which the alveoli are compressed, but do not become quite impervious to air. These changes have been exhaust- ively studied by Heller. As the result of hypertrophic cirrhosis, the liver undergoes a marked increase in size, and, according to Puge, 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 connective tissue surrounding the individual lobules and acini, with here and there small areas of round-cell infiltration. The spleen likewise undergoes interstitial changes and increases mark- edly in size, so that it frequently weighs two or three times as much as Fig. 491. Fig. 492. Figs. 491, 492.—Normal and Syphilitic Fcetal Epiphysis. X 2. 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 sixth month, Tissier and Girauld state that the spiro- chaeta pallida is rarely found, but after that period the fcetus may be said to suffer from a spirochaetal septicaemia, when the parasites may be dem- onstrated in large numbers in the various organs and blood. They are most abundant in the adrenals, occurring in 97.5 per cent, of all cases, according to Trinchese, and progressively less so in the following organs: lungs, pancreas, liver, and internal genitalia. The recognition of these lesions requires some little pathological expe- rience, though if thS liver and spleen are found markedly increased in size and weight the diagnosis of syphilis is permissible. An equally characteristic sign, and one which is readily detected, is afforded by changes occurring at the junction of the epiphysis with the FCETAL SYPHILIS 617 Fig. 493.—Normal Fcetal Epi- physis. X 60. 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 millimeter in diameter—Guerin's line—representing the zone of preliminary calcification, which constitutes the scaffolding upon which the new bone is de- veloped. In syphilis, on the other hand, this becomes converted into an irregular, jagged, yellowish zone 2, 3, or more millimeters in thickness. In advanced cases this alteration is associated with considerable softening and the formation of a soft pultaceous material, which occasionally leads to complete separation of the epiphysis (Figs. 491 and 492). Upon microscopical examination of the nor- mal epiphysis, as shown in Fig. 493, the carti- lage cells are found to be arranged in parallel columns at right angles to Guerin's line, while below it is the typical bony structure of the diaphysis with its marrow cavities. The line itself is formed by a deposit of lime salts be- tween 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. 494. the changes are due to an osteo- chondritis, 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 irregu- larly through the lower portion of the epiphy- sis, giving an irregular appearance to this re- gion. These changes,which have been carefully studied by Wegner and Pi. Muller, are most readily recognizable at the lower end of the fe- mur, and fairly well at the lower ends of the ti- bia and radius. They are less clearly defined at the upper ends of the tibia, fibula, and femur, and only in rare in- stances can they be 494.—Syphilitic Fcetal Epiphysi X 60. 618 DISEASES AND ABNORMALITIES OF THE OVUM made out at the ends of the ribs. They are extremely characteristic, and their detection justifies one in making a positive diagnosis and placing the mother under specific treatment. Placental Syphilis.—Under the influence of syphilitic infection the pla- centa undergoes very characteristic changes. It becomes larger and paler in color, and, if the foetus is dead, often presents a dull, greasy appearance. It is always relatively, and frequently absolutely, increased in size, and, according to the researches of Correa-Dias and Schwab, which I have been able to confirm, instead of one sixth it may represent as much as one fourth, or even a larger fraction, of the entire body weight of the fcetus. Still more characteristic, however, are the changes in the chorionic villi, Fig. 495. Fig. 496. Figs. 495, 496.—Normal and Syphilitic Chorionic Villi Teased Out in Salt Solution, Slightly Magnified. to which Frankel called attention in 1873. In syphilis the villi, when teased out in salt solution, are seen to have lost their characteristic arbores- cent appearance and to have become thicker and more club-shaped (Figs. 495 and 496). At the same time there is a marked decrease in the num- ber of blood-vessels, which disappear almost entirely in advanced cases. This results partly from endarteritic changes, but principally from a pro- liferation of the stroma cells, which lose their normal stellate appearance, becoming round or oval in shape, and closely packed together. Similar changes are observed in sections made from hardened speci- mens. As will be seen on comparing Figs. 497 and 498, the individual villi are markedly increased in size and almost devoid of blood-vessels, while their stroma is made up of closely packed, round, or oval cells. This ap- pearance is so characteristic as to enable one with a little practice to make PLACENTAL SYPHILIS 619 a probable diagnosis, and at the same time affords a satisfactory explana- tion for the poor development of the foetus. The work of Nelis, Thomsen, Mohn, and others tends to show that the changes just described, while very suggestive, are not absolutely character- istic; and the latter holds that a positive diagnosis cannot be made unless the pres- ence of the spirochaeta pallida of Schaudinn is demonstrated. This has been done by many investigators; although they are so sparsely scattered through the organ that their recognition is most difficult, even when they are present in large numbers in the fcetal organs. Trin- chese states that they can always be found, if one is willing to study several hundred sec- tions, but in my clinic Pauli and Emmons were not so successful. 1 n my experience a positive Wassermann can always be ob tained when the ph cental lesions are typ- ical, but, on the other hand, it may be pres ent when histological changes are too slight to permit a positive diagnosis. It is generally stat- ed that distinct syphi- litic lesions, varying from a marked thick- ening of the membrane to distinct gumma for- mation, are frequently noted in the decidua. I am inclined to be- Fig. 497.—Normal Full-Term Placenta. X 50 Fig. 49S -Syphilitic Full-Term Placenta. 620 DISEASES AND ABNORMALITIES OF THE OVUM lieve, however, that many of the conditions described as such have no con- nection with lues, but represent various hyperplastic conditions. Zilles, and many of the earlier writers, described gummata occurring in the fcetal portion of the placenta. I have never met with such lesions, and am of the opinion that careful histological study will show that the structures designated as such are merely infarcts in various stages of de- velopment or degeneration. Bondi in 1903 directed attention to changes in the umbilical cord, which he considered very characteristic, and his findings have been con- firmed by most subsequent writers. These occur in the vessels, and consist in oedema of their walls, and leukocytic infiltration of the spaces between the muscle fibers. Similar changes are noted in the adventitia, while the intima is more or less thickened. Mohn stated that he was able to demonstrate the presence of the spirochaeta in 50 per cent, of his cases, but subsequent study has shown that he was in error. They are sometimes present in the fcetal 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 Fcetus.—In this rare condition, 65 instances of which have been collected by Ballantyne, the foetus and placenta are mark- edly cedematous. 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 fcetus, 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 cedematous 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 pro- duction of the condition. It is interesting to note that in several cases collected by Seifert it was attributed to foetal leukaemia. The disease always leads to the death of the fcetus, 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 increased size of the foetus and the placenta may give rise to dystocia. Other Diseases of the Fcetus.—In most text-books upon obstetrics nu- merous morbid conditions of the foetus are described under the heading Diseases of the Foetus. The majority of them, however, are of interest mainly from a pathological point of view, and have no obstetrical signifi- cance, except in those cases in which 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, though certain of them will be referred to in the chapter upon Foetal Dystocia. LITERATURE 621 LITERATURE Ackermann. Der weisse Infarct der Placenta. Archiv f. path. Anat., IS^4, xcvi, 439-452. Zur normalen u. path. Anat. der menschlichen Placenta. Virchow's Festschrift, Berlin, 1891, 585-616. Ahlfeld. Multiple Dermoidcysten des Amnion. Berichte u. Arbeiten, lss.y ii, 200- 202. Die Veruachsungen des Amnion mit der Oberflache der Frucht. Berichte u. Ar- beiten, 1887, iii, 158-165. Zerreissung der Nabelschnur eines reifen Kindes wahrend der Geburt. Zeitschr. f. Geh. u. Gyn., 1897, xxxvi, 467-472. Mangel des Fruchtwassers. Lehrbuch der Geb., IsilS, II. Aufl., 271. Aichel. Ueber die Blasenmole, eine experimentelle Studie. Habilitationsschrift, Erlangen, 1901. Albert. Ueber Angiome der Placenta. Archiv f. Gyn., 1N9S, lvi, 144-159. Ballantyne. General Dropsy of the Fcetus. The Diseases of the Foetus, Edinburgh, 1892, i, 102-164. BAR/ Recherches pour servir a 1'histoire de 1'hydramnios. These S. Larrier et Brindeau. Nature de la mole hydatidiforme. Revue de Gyn., 190s, xii, 203-214. Lebedeff. Quelques donnees sur la fonction physiologique de 1'amnios. Annales de gyn. et d'obst., IS78, ix, 241 251. Lefevre. De 1'insertion velamenteuse du cordon. These de Paris, 1896. Levison. Fruchtwasser und Hydramnios. Archiv f. Gyn., 1876, ix, 517-519. Levy. Rapports existant eutre le poids du foetus et celui du placenta. These de Paris, 1900. Marchand. 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 fretus. These de Paris, 1896. Moiin. Die Veranderungen an der Placenta, bei Syphilis u. ihre Beziehungen zur Spirochteta pallida. Zeitschr. f. Geb. u. Gyn., 1907, lix, 263-312. Montgomery. On the Spontaneous Amputation of the Fcetal Limbs in Utero. An Exposition of the Signs and Symptoms of Pregnancy. 2d ed. (reprinted), 1863, 625-695. Mt'LLER, R. Beitrag zur path. Anatomie der Syphilis hereditaria. Virchow's Archiv, 1SS3, xcii, 523-556. Nelis. Le placenta au cours de I'infection syphilitique. L'obstetrique, 1904, ix, 385-412. Neumann. Beitrag zur Lehre von der Anwachsung der Placenta. Monatsschr. f. Geb. u. Gyn., 1896, iv, 307-318. 624 DISEASES AND ABNORMALITIES'OF THE OVUM Beitrag zur Kenntniss der Blasenmole, etc. Monatsschr. f. Geb. u. Gyn., 1897, vi, 17-36; 157-177. Nieberdixg. Zur Genese des Hydramnios. Archiv f. Gyn., 1882, xx, 310-316. Opitz. Beitrage zur ^Etiologie des Hydramnios. Zentralbl. f. Gyn., 1898, 553-560. Orth. Infarct der Placenta. Lehrbuch der spec. path. Anat., 1893, ii, 603-607. Ouvry. fitude de la mole hydatidiforme. These de Paris, 1S97. Pauli. Placental Syphilis, etc. Bull. Johns Hopkins Hospital, 1908, xix, 326-28. Peiser. Verblutungstod der Frucht in folge Ruptur einer Umbilicalarterie bei Inser- tio 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. Peters. Beitrag zur Casuistik der Vasa prgevia, etc. Monatsschr. f. Geb. u. Gyn., 1901, xiii, 1-21. Pick. Von der gut- und bos-artig metastasirenden Blasenmole. Berliner klin. Wochenschr., 1897, xxxiv, 1069-1073; 1097-110.2. 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, lxvi, 590-617. Poten und Vassmer. Beginnendes Syncytiom mit Metastasen, beobachtet bei Blasen- molenschwangerschaft. Archiv f. Gyn., 1900, Ixi, 205-276. Ribemont-Dessaignes. Des placentas multiples dans les grossesses simples. Annales de gyn. et d'obst., 1887, xxvii, 15-52. Risel. Ueber das maligne Chorion-epitheliom, etc. Leipzig, 1903. Das Chorio-epitheliom. Ergebnisse der allg. Path, und path. Anat., 1907. Rossier. Klin. und. histolog. Untersuchungen uber die Infarcte der Placenta. Ar- chiv f. Gyn., 1888, xxxiii, 400-412. Ruge. Ueber den Fcetus sanguinolentus. Zeitschr. f. Geb. u. Gyn., 1877, i, 57-119. Runge. Ueber die Veranderungen der Ovarien bei synctialen Tumoren und Blasen- mole, etc. Archiv f. Gyn., 1903, lxix, 33-70. Sallinger. Ueber Hydramnios, etc. D. T., Zurich, 1875. Sanger. Deciduoma malignum. Verh. 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 Chononektodermwucherungen der menschlichen Placenta. Beitrage zur Geb. u. Gyn., 1905, x, 63-114. Schindler. Zur Kenntniss der Angiome der Placenta. Archiv f. Gyn., 1908, lxxxiv, 423-442. Schlagenhaufer. Zwei Falle von Tumoren des Chorionepithels. Wiener klin. Wochenschr., 1899, Nr. IS. Ueber das Vorkommen chorionepitheliom- und traubenmolenartigen Wucherungen in Teratomen. Wiener klin. Wochenschr., 1902, Nos. 22 and 23. Schmidt. Zur Kasuistik der chorio-epithelialen Scheidentumoren. Zentralbl. f. Gyn., 1900, xxiv, 1257-1265. LITERATURE 625 Ein neuer Fall von primaren Chorio-epitheliom der Scheide. Zentralbl. f. Gvn.j 1901, xxv, 1350. Schmorl. Demonstration eines syncytialen Scheidentumors. Zentralbl. f. Gvn., 1897, xxi, 1217. Schneider. Quoted by Kiistner. Schultze. Die gcnetische Bedeutung der velamentalen Insertion des Nabelstranges. Jenaische Zeitschr. f. Med. u. Naturwiss., 1867, iii, IDS. Ueber velementale u. placentale Insertion der Nabelschnur. Archiv f. Gyn., 1887. xxx, 47-56. Schwar. De la syphilis du placenta. These de P'aris, 1896. De la mole hydatidiforme. L'Obstetrique, 1898, iii, 405-427. Seitz. Die Luteinzellenwucherung in atretischen Follikeln. Zentralbl. f. Gyn., 1905, xxix, 257-2(53. Sfameni. Die Placenta Marginata. Berlin, 1908. Simonart. Note sur les amputations spontanees. Archiv de medecine Beige, 1845, xviii, 112-119. Steffeck. Der weisse Infarct der Placenta. Hofmeier, "Die Placenta," Wies- baden, 1890, 91-116. Stoeckel. Ueber die cystische Degeneration der Ovarien bei Blasenmolen. Beitrage zur Geb. u. Gyn., Festschrift dem Prof. Fritsch. Leipzig, 1902, 136-164. Strassmann. Oligo- und Polyhydramnie. Winckel's Handbuch der Geb., 1904, i, 2 Halite, 797-812. Teacher. On Chorion-epithelioma, etc. Trans. London Obst. Soc, 1903, xiv, 256- 302. Thomsen. Path. anat. Veranderung in den Nachgeburt bei Syphilis.- Ziegler's Bei- trage, 1905, xxxviii, 1 and 3. Tissier et Girauld. Syphilis congenitale. Bull. Soc. d'Obst. de Paris, 1908, No. 1. Trinchese. Bakteriologische u. histologische Untersuchungen bei kongenitaler Lues. Miinchener med. Wochenschr., 1910, lvii, 570-574. Vassmer. Zur AUtiologie der Placentarcysten. Archiv f. Gyn., 1902, lxvi, 49 69. Veit. Ueber Deportation vom Chorionzotten. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 466-504. Die Chorio-epitheliom. Veit's Handbuch der Gyn., ii Auf., 1908. Vklpeau. Quoted by Virchow. Virchow. Myxom der Placenta. Die krankhaften Geschwulste, 1863, i, 405-414. Myxom fibrosum placentae. Die krankhaften Geschwulste, 1S63, i, 415. Volkmann. Ein Fall von interstitieller Molenbildung. Virchow's Archiv, 1867, xii, 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 Kindern. Virchow's Archiv, 1S70, 1, 305-323. Werth. Einseitiges Hydramnion mit Oligohydramnie der zweiten Frucht. Archiv f. Gyn., 1SS2, xx, 353-377. Williams, J. Whitridge. Deciduoma malignum. Johns Hopkins Hosp. Reports, 1895, iv, No. 9. The Frequency and Significance of Infarcts of the Placenta. Amer. Jour. Obst., 1900, xii, 775-801. Williamson. The Pathology and Symptoms of Hydatidiform Degeneration of the Chorion. Trans. London Obst. Soc, 1900, xii, 303-338. 42 626 DISEASES AND ABNORMALITIES OF THE OVUM Wilson. Hydramnion in Cases of Uni-oval or Homologous Twins. Trans. Lond. Obst. Soc, 1899, xii, 235-272. Wilton. Hydatids, terminating Fatally by Hasmorrhage. Lancet, 1840, i, 691-693. Winckel. Teleangiektatisches Myxosarkom der Nabelschnur. Zentralbl. f. Gyn., 1894, xviii, 397. Wlassow. Ueber die Patho- und Histogenese des sogenannten Sarcoma angio- plastique. Virchow's Archiv, 1902, clxix, 220. Woerz. Ein Fall von Hydramnios. Zentralbl. f. Gyn., 1895, xix, 580 .181. Wolff. Ueber exp. Erzeugung von Hydramnion. Archiv f. Gyn., 1904, lxxi, 224-. 257. Fruchtwasser. Handbuch d. Biochemie, 1910, iii, 709-741. Zilles. Studien iiber Erkrankungen der Placenta bedingt durch Syphilis. Tubingen, 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. Thus, it is customary to speak of abortion, of miscarriage, or of premature labor, respectively, according 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 fcetus, as a rule, being extruded first, and followed after a longer or shorter period by the placenta and membranes. After the twenty-eighth week the course of labor differs but little from that observed at full term, and the child, if properly eared for, may survive; its chances of so doing increasing in almost geometrical 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. Frequency.—It is difficult to arrive at accurate conclusions concerning the frequency with which spontaneous abortion occurs. Inasmuch as only such women as are more or less seriously ill enter lying-in hospitals, 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, sufiiciently large scries from private practice are not available; though Malins found that V.).23 per cent, of the pregnancies of 2,000 patients ended in abortion. Franz states that abortion occurred in 15.4 per cent, of the cases admitted to the lying-in hospital at Halle, the accident being more than twice as frequent in multipara? as in primiparae. A conservative estimate would indicate that about every fifth or sixth pregnancy in private practice ends in abortion, and the percentage would be increased considerably were the very early cases taken into account, in which there is profuse loss of blood following the retardation of the menstrual period for a few weeks. Taus- sig estimates that one abortion occurs to every 2.3 labors, and considers that considerably over one quarter of all abortions are criminally induced. It is difficult to give accurate figures in this regard, but it is generally 627 628 ABORTION, MISCARRIAGE, PREMATURE LABOR admitted that the practice is becoming more and more frequent in all strata of society throughout the civilized world. iEtiology.—In the early months of pregnancy spontaneous expulsion of the ovum is nearly always preceded by the death of the fcetus. For this reason, the consideration of the aetiology of abortion practically resolves itself into determining the cause of foetal death. In the later months, on the other hand, the fcetus is frequently born alive, and other factors must be invoked to explain its expulsion. Fcetal death may be due to abnormalities occurring in the ovum itself, or to some 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 fcetus 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. In another group of cases it results from changes in the fcetal appendages, such as excessive torsion of the cord, hydramnios or hydatidiform mole. In the last named affection 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. Particularly in the later months of pregnancy, syphilis and 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 inter- feres with the fcetal 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 fcetus. Such abnor- malities as placenta prawia, low implantation of the placenta, or vela- mentous insertion of the cord, as well as premature separation of the placenta, may likewise bring about circulatory conditions inconsistent with fcetal life. Diseases of the heart and kidneys may likewise play a prominent part in the causation of fcetal death. In the former it is attributed to imperfect aeration of the blood; in the latter it may result directly from the accumu- lation of excrementitious substances in the maternal blood and their subse- quent transmission to the fcetus; or, indirectly, from the fact that large portions of the placenta are thrown out of function by extensive infarct formation. Less commonly diseases of the liver or lungs of the mother may be indirectly responsible. (b) As was pointed out in the chapter upon the Accidental Complica- tions 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 occasion- ally of the specific micro-organisms from the mother to the child. Poison- ing with phosphorus, lead, illuminating gas, and other substances may lead to similar results. Fcetal death is sometimes attributable to malnutrition on the part of AETIOLOGY 629 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 aetiology 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 im- plantation of the ovum and later for the development of the placental circu- lation. Chronic metritis is also supposed to act in the same way. Dense ndhesions about the tubes and ovaries, resulting from inflammatory proc- esses, only rarely interfere with the expansion of the uterus sufficiently to rive 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 ab- normal position of the uterus than to lesions of its endometrium resulting from circulatory changes incident to the displacement. In the rare cases of incarceration, however, the accident must be attributed to the persistent abnormal position of the 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 forms of decidual endometritis—decidua polyposa—the bulk of the maternal blood brought to the placental site goes to nourish the hyperplastic decidua, while in the atrophic forms the condi- tions are unfavorable for the implantation of the ovum and the develop- ment of the placenta. More important still is the part played by chronic glandular endometritis and acute inflammation of the decidua. These conditions are frequently accompanied by haemorrhagic changes, and are the most frequent cause of abortion in the early months. Histo- logical examination demonstrated the presence of acute or chronic decidual endometritis in 70 per cent, of my specimens, but in many instances it was impossible to determine whether it was the primary cause, or merely an accidental complication. The presence of myomata in the walls of the uterus must be looked upon as an occasional factor, abortion resulting less from the mechanical effect of the tumor itself than from the changes in the decidua incident to it. McFayden and Bang have directed attention to epidemics of abortion occurring in cattle, and have shown that they are due to a specific micro- organism, which leads to the interruption of pregnancy when inoculated into the genitalia of healthy animals. H. L. Russell has shown that similar conditions obtain in this country, and holds that the economic loss con- nected with it is exceeded only by the ravages due to tuberculosis. Appar- ently, such infections do not occur in women, and although bacteria are frequently present, they are simply the well-known pyogenic or putrefactive varieties. In a few cases the cause of abortion is to be sought for in reflex influ- ences, which take their origin from lesions of the generative tract or from 630 ABORTION, MISCARRIAGE, PREMATURE LABOR irritative conditions about the breasts. In very rare instances the accident is attributable 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 statements 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 interruption of pregnancy. 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 misstep, tripping over a carpet, or a ride over a rough road, may bring on an abor- tion; while in others the most violent exercise and the rudest manipulations may be borne with impunity. Occasionally a simple bimanual examination may be followed by an abortion; while, on the- other hand, every physician can recall cases in which a sound has been introduced into the pregnant uterus without ill effects, and in rare instances, in the later months, the repeated introduction of a large bougie, or even of a Champetier de Ribes balloon, will fail to bring about satisfactory uterine contractions. (d) Practically the only paternal cause of abor- tion is syphilis, which, as has already been said, frequently leads to the changes in the placenta and the organs of the fcetus, which bring about its death and premature expulsion from the uterus. To sum up, the most important aetiological fac- tors in the interruption of pregnancy in the first four months are endometritis, uterine displace- ments, and abnormalities in development, while after this period syphilis and Bright's disease play a similar role. Thus, Scntex, in 485 cases of intra- uterine death occurring in the later months of pregnancy in Pinard's clinic, found the underlying cause to be syphilis in 42.7, albuminuria in 19.8, and diseases and abnormalities of the fcetus in 11.1 per cent. It is not unusual to meet with women who give a history of repeated abortion or premature labor occurring at about the same time in a number of successive pregnancies. If the interruption has oc- curred in the first half of pregnancy, careful exam- ination will usually demonstrate the existence of an endometritis or a uterine displacement; and it is only after the cure of the underlying condition that subsequent pregnancies can be expected to progress to full term. When repeated premature labor has occurred in the second half of gesta- tion, signs of albuminuria, Bright's disease, or syphilis will usually be dis- covered, though occasionally no satisfactory explanation can be adduced. Fig. 499.—Early Abor- tion, Showing De- cidua Reflexa and Serotina with De- generate Embryo. XI. PATHOLOGY 631 Pathology.—In the first half of pregnancy, the immediate cause of the expulsion of the ovum is to be found in haemorrhagic changes in the decidua. Concerning their mode of production we must confess a profound ignorance, although when endometritis is the underlying cause their origin is readily understood. These changes, which are most marked in the decidua serotina, are followed 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 gives rise to uterine con- tractions, which, after a longer or shorter period, lead to its expulsion. Fig. 500.—Tuberous Subchorial Hematoma (Breus). XL. Especially in tKe 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 at the same time. In such cases a triangular sac comes away which represents the decidua vera, which contains in its interior the rounded vesicular ovum, covered by the decidua reflexa. More frequently, however, the decidua vera remains in utero, while the ovum, surrounded by the decidua reflexa, is expelled. Occasionally the reflexa is torn through, and, together with the decidua vera and serotina, is retained in utero, while a shaggy, more or less spherical structure is cast off—the ovum surrounded by the chorionic villi. 632 ABORTION, MISCARRIAGE, PREMATURE LABOR 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 mem- branes to rupture and the fcetus to be expelled by itself, to be followed, or not, by the placenta and membranes. Occasionally the entire ovum may be expelled even at a later period, and I have seen several cases in which this occurred as late as the seventh or eighth month. This, however, is very unusual, the course of premature labor being identical with that observed at full term. In many early abortions, the expelled ovum is a thin-walled cystic struc- ture, filled with clear fluid and containing a minute degenerated embryo, or only a remnant of the umbilical cord. This condition represents 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 umbilical cord and the partially degenerated fcetus. Such structures are classified as blood or carneous moles, according to their appearance. In the former the cap- sule of coagulated blood is red in color, while in the latter it presents a paler appearance, the result of fibrin formation (Fig. 501). Now and then, the interior of such structures, instead of being lined by the smooth amnion, may present an irreg- ular nodular appearance, which is due to the formation of haematomata of varying size beneath the amnion and chorion. This condition, to which Granville applied the term ovum tuberculosum, has been more particularly studied by Breus, who desig- nated it as tuberous subchorial hematoma of the decidua (Fig. 500) ; while Berry Hart, and Taussig described the condi- tion as haematoma mole, or tuberous fleshy mole, respectively. Breus believed that the tuberous appearance was the re- sult of haemorrhage into collapsed folds of the amnion, while Gottschalk, "Wal- ther, Hart, and others considered that the haemorrhage was the primary factor. Davidsohn and Taussig take the view that the disproportion between the size of the fcetus 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 .becomes folded upon itself, the blood being effused into its folds. Fig. 501.- -Section through Blood Mole. XL CLINICAL HISTORY 633 In all uterine moles the foetus 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 considerable period has elapsed between the death of the fcetus and the expulsion of the ovum. Not uncommonly, indeed, the fcetus may undergo complete dissolution, or be represented merely by a stub of umbilical cord hanging from the interior of the ovum; while in rare instances all trace of it may disappear, and, after resorption of the amniotic fluid, the ovum may be represented by a solid mass of varying size, composed of chorionic villi embedded in coagulated blood. Dissolution of the dead fcetus 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 fcetus 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 histological stains. In rarer instances the fcetus becomes compressed and takes on a dry, parchment-like appearance—mummification. This is rarely observed in ordinary abortion, but is noted with comparative frequency in twin pregnancies, when one fcetus has died at an early period while the other has gone on to full development—fcetus papyraceus. In very exceptional instances, the fcetus 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 lithopaedion. This phenomenon, though extremely 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.—From a clinical standpoint, it is a matter of consid- erable importance to distinguish the period at which the pregnancy is terminated. When it occurs in the first half it is not unusual for the ovum to be expelled as a whole, while in the second half of pregnancy the course of events is similar to that observed at a full-term labor. The onset of abortion is usually preceded by certain premonitory symp- toms, the most important of which are haemorrhage 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 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 distinctly 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 few weeks of pregnancy begins to lose blood, 634 ABORTION, MISCARRIAGE, PREMATURE LABOR 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 haemorrhage 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 mem- branes and escape of the liquor amnii indicate that abortion is inevitable. When abortion becomes imminent, the haemorrhage is usually quite pro- fuse, though as a rule not sufficient to endanger the life of the woman. At the same time she experiences severe cramp-like 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 fcetus alone is expelled, while the placenta and membranes remain in the uterus—incomplete abortion. In such cases the haemorrhage usually persists until the retained structures 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 haemorrhage and pain cease, and a process of involution begins, identical with that observed after full-term labor. In my experience spontaneous abortion occurs most frequently during the second and third months of pregnancy, and the relative inci- dence of the complete to the incomplete variety is in the ratio of one to three. Treatment.'—Prophylactic treatment is most important, although, as a rule, it is not available in women aborting for the first time. If, how- ever, the patient presents a history of repeated abortion or premature labor, precautionary measures should be instituted before conception has again taken place. The general and local condition should be carefully investigated and any abnormality subjected to appropriate treatment. If the patient has a retroflexed uterus, 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 endome- tritis be present, the patient should be curetted and warned against be- coming pregnant until sufficient time has elapsed to allow the uterus to recover from the morbid condition. If the symptoms reappear, the opera- tion should be repeated. If there is no abnormality in the generative tract, the possibility of syphilis in either parent should be borne in mind. The Wassermann reaction should be tested, and appropriate treatment instituted if it proves positive. The urine should always be carefully examined with a view to determining the presence or absence of renal lesions. If past experience has shown that the patient has an irritable uterus and 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 TREATMENT 635 existence. Occasionally, the only efficient means of leading the process to a successful termination is by keeping the patient in bed throughout preg- nancy. Treatment of Threatened Abortion.—Whenever symptoms of threat- ened abortion appear, the patient should be placed in bed and kept in a recumbent position. If pains occur, a hypodermic injection of y± grain of morphine should be administered at once, to be followed by 1-grain rectal suppositories of extract of opium, repeated at intervals of every four or six hours. Better results are occasionally obtained by combining the opium with the extracts of hyoscyamus and viburnum prunifolium. The following suppository, administered every four or six hours, according to circum- stances, often gives most satisfactory results: B. Codiae sulphat........ Ext. hyoscyami ...... Ext. viburni prunifolii 01. theobromae ....... In many instances the symptoms rapidly subside under such treatment, but the patient should be kept in bed for at least a week after their disap- pearance, in the hope of avoiding any repetition. In other cases, the pain yields to the administration of sedatives, but the haemorrhage persists, and we then have to decide how long we are justi- fied 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 pregnancv, and may be permitted to go on for some time. In view of the part played by developmental abnormalities of the fcetus in the production of abortion, it is my opinion that palliative treatment is frequently continued unnecessarily long. Consequently, if the symptoms do not disappear after a few weeks, I allow the patient to assume her usual avocations, in the hope that the threatened abortion will become inevitable. On the other hand, if the bleeding becomes so profuse that the patient be- gins to show signs of anaemia, the uterus should be emptied by the methods to be described later. In many instances, notwithstanding appropriate treat- ment and rest in bed, slight haemorrhage may persist for weeks, and it then becomes necessary to ascertain whether there is any possibility of the preg- nancy continuing. Unfortunately, this problem usually requires several weeks for its solution. Thus, if bimanual examination shows at the end of two weeks that the uterus has remained stationary in size, one is justified in concluding that the fcetus has perished; while, on the other hand, an increase probably indicates that the fcetus is still alive, but does not neces- sarily 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 treatment sometimes exposes the patient to serious danger. gr. ss. gr-j- gr. v. q.s. 636 ABORTION, MISCARRIAGE, PREMATURE LABOR Treatment of Inevitable Abortion.-—When convinced that abortion is inevitable, particularly in those cases in which the haemorrhage is profuse, the uterus should be emptied in the most conservative manner, the choice of procedure depending upon the degree of dilatation of the cervix. If it be sufficiently patulous to admit a finger, the patient should be anaesthetized, brought to the edge of the bed, and prepared for operation. The carefully sterilized hand, anointed with sterile vaseline, having been introduced into the vagina, 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 the 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 permit 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 recommended above. The introduction into the cervical canal of a laminaria tent is recommended by many authori- ties. While it affords a satisfactory method of dilatation, I strongly deprecate its employment, as I know no way by which it may be rendered absolutely sterile. Except when the haemorrhage is so profuse as seriously to threaten the patient's life, these methods of procedure are preferable to the rapid dilata- tion of the cervix with a Goodell or some similar dilator, followed by the immediate removal of the ovum by means of a curette or polypus forceps. Moreover, the cervix is sometimes so resistant that it is impossible to dilate it sufficiently 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 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 rem- nants of the ovum are still retained in the uterus. On several occasions I have seen patients profoundly exsanguinated from profuse haemorrhage 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 gynaecologist is familiar with cases in which the softened uterus has been perforated by the curette, and knows of rare 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 TREATMENT 637 evacuation of the uterus becomes necessary in the presence of a rigid cer- vix, 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 by means of the curette, as it is usually expelled spontaneously within a few days. At the same time, the physician should always satisfy himself by careful inspec- tion that the entire ovum has come away, and that portions of it are not retained. 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 haemorrhage has passed. It often happens that the physician does not see the patient until some days after the expulsion of the fcetus, when he is summoned on account of the persistent loss of blood. In such cases the cervix is usually found to be retracted to such a degree that it will not admit the finger, but 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, or neglected, abortion infection may occur. Symptoms may develop while the entire ovum is still in the uterus, in the course of an incomplete abortion, or after the completion of the entire process. The latter will be considered in the chapter upon puer- peral infection. The two former conditions are always serious, and are responsible for the greater part of the deaths following abortion. The infection may be due to the streptococcus or to the various so-called putre- factive bacteria, 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 very favorable when they are absent. In either event, the uterus should be promptly emp- tied in the most conservative manner, and afterward washed out with an abundance of sterile salt solution. The complication of a rigid cervix is always a source of anxiety, as the existence of infection contraindicates the employment of vaginal hysterotomy, and renders more serious the lacerations which are usually associated with instrumental dilatation; whereas in cases of infected incomplete abortion 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 28 per cent., and, in view of a similar experience, Winter has raised the question as to whether it would not be better in such cases to defer interference until the acute symptoms have subsided. With the exception of infected cases, the prognosis following abortion is excellent, provided a rigid technique is scrupulously observed. I have never had a death in an uninfected patient, and Young and Williams in a series of 1,331 such cases, with an operative incidence of 87 per cent., record a mortality of only 0.07 per cent. The treatment of abortion in the second half of pregnancy and of pre- 638 ABORTION, MISCARRIAGE, PREMATURE LABOR mature labor is identical with that already described for full-term labor, and does not require further mention. Missed Abortion.—This term was applied by Oldham to the cases in which the fcetus is retained in the uterine cavity for months or years after its death. The condition occurs frequently 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 the frequency of the condition. Retention may exist for a long period without giving rise to symptoms, 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 separated 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 in the seventh or eighth month of pregnancy, and yet on examination the uterus will be found to correspond in size 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 is apparently 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 the occurrence of regressive changes in the breast, when upon examination the uterus will be found to be smaller than it was at the time of the threatened abortion. Not uncommonly the con- dition, after persisting for some time 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 temperature, and occasionally symptoms of mental derangement. According to Yeit 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 expul- sion the ovum frequently presents the characteristic structure of a haenia- toma mole; in other cases there are no manifestations of haemorrhage, and one has to deal with a so-called "dropsical ovum." In one of my cases, which had persisted for more than one year, the foetus was mummified, the amniotic fluid almost entirely resorbed, and the placenta transformed into an infarct-like mass. Whenever the diagnosis is established beyond doubt, the cervix should be dilated by means of a vaginal and cervical pack, and the uterus emptied of its contents. In several instances under my observation the cervix was so resist- ant that its dilatation by means of steel instruments was out of the question. 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 ad- vanced as far as the fourth month, and Koebner has demonstrated its possibility by animal experiments. LITERATURE 639 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. Fkanque. Ueber histologische Veranderungen in der Placenta und ihre Beziehungen zum Tode der Frucht. Zeitschr. f. Geb. u. Gyn., 1897, xxxvii, 277-298. Franz. Zur Lehre des Aborts. Beitrage zur Geb. u. Gyn., 1898, i, 493-514. Gottschalk. Zur Lehre von den Hamatommolen, etc. Archiv f. Gyn., 1899, xviii, 134-169. Graefe. Ueber Retention des menschlichen Eies im Uterus nach dem Fruchttod. Festschrift zu Carl Ruge, Berlin, 1896, 38-79. Granville. Graphic Illustrations of Abortion, etc. London, 1834. Hart. On the Nature of the Tuberous Fleshy Mole. Jour. Obst. and Gyn. Brit. Emp., 1902, i, 479-481. Koebner. Knochenresorption bei intrauterinem Eischwund. Archiv f. Gyn., 1910, xci, 109-142. 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. Merttens. Beitrage zur normalen und path. Anatomie der menschlichen Placenta. Zeitschr. f. Geb. u. Gyn., 1894, xxx, 1-97. Oldham. Missed Labour. Guy's Hosp. Reports, 1847, 105-112. Russell. Contagious Abortion in Cattle. Science, 1911, p. 494. Sentex. Des causes de la mort du produit de la conception pendant la grossesse. These de Paris, 1901. Taussig. Haematom Mole. Am. Jour. Obst., 1904, i. 456-472. Prevention and Treatment of Abortion, St. Louis, 1910. Veit. Vorzeitige Unterbrechung der Schwangerschaft. Muller's Handbuch der Geburtshiilfe, 1889, ii, 23-57. Walther. Ein Fall von tuberosem, subchorialem Hamatom der Decidua. Zentralbl. f. Gyn., 1892, xvi, 707-710. Winter. Zur Prognose und Behandlung des septische Abortes. Zentralbl. f. Gyn., 1911, 569-576. Voung 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 com- plete development. Ectopic gestation, which is sometimes used as a synony- mous term, has a broader meaning, inasmuch as it includes not only the usual forms of extra-uterine pregnancy, but also those in which the ovuni is implanted in the rudimentary horn of a bicornuate uterus. Reference has already been made to this class of cases in Chapter XXVII. 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. The history of its development is treated in detail in the mono- graphs of Campbell, Hecker, Parry, Tait, Werth, and Webster. Prior to 1876, extra-uterine pregnancy was considered so rare an affection that Hennig 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 rec- ognized. Thus, Schrenck, in 1892, collected 610 cases which had been reported in the preceding five years, but since then many operators have placed on record large series of cases, and it is now generally admitted that extra-uterine pregnancy is encountered in several per cent, of all gynecologi- cal laparotomies. 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 extremely doubtful whether the ovum can become implanted upon the peritoneum and a primary abdominal pregnancy follow. etiology.—According to Leopold, ovarian pregnancy results from the fertilization of the ovum before its escape from the Graafian follicle. More- over, he believed, when several follicles mature at the same time, that a deeply lying one may rupture into a more superficial one without the escape of its ovum, in which event the latter may be fertilized by spermatozoa en- tering through the superficial follicle. Such an occurrence would afford a satisfactory explanation for a pregnancy occupying the central portion of 640 .ETIOLOGY 641 the ovary, and the fact that several investigators, following the example of Tussenbroek, have demonstrated corpus luteum cells about the periphery of the ovum would also speak in its favor. Unfortunately, equally concise and definite statements cannot be made concerning the aetiology of tubal pregnancy, although a number of explana- tions, of greater or less plausibility, have been advanced. Broadly speaking, these may be divided into three main groups: (1) Conditions which inter- fere mechanically with the downward passage of the ovum; (2) Inflam- matory diseases of the tubes; (3) Physical and developmental abnormalities which favor decidual formation in the tubes. I. Conditions Which Interfere Mechanically with the Downward Passage of the Ovum.— (a) Fritze, in 1779, first directed attention to the fact that peritoneal adhesions, by compressing the lumen of the tube or by inter- fering with its peristalsis, might cause the arrest of the ovum. (b) Leopold, Breslau, Beck, Wyder, and others believed that polypi pro- jecting into the lumen of the tube might occasionally interfere with the descent of the ovum. It is quite possible, however, that such structures were merely decidual outgrowths, and 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 lumen 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 endo- salpingitis. 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 presupposed that fertilization occurred in the uterine cavity, and was based upon the belief that the ciliary current was directed down- ward in the tubes and from below upward in the uterus, the entry of spermatozoa into the uterine cavity being thereby facilitated, while their access to the tubes was rendered difficult. The work of Hofmeier and Mandl has demonstrated the fallacy of these suppositions. Moreover, it is now generally held that fertilization occurs normally in the tubes, so that 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 pregnant 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 fcetal convolutions of 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 Rheinsiein, and I demonstrated the presence 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. 502). Specimens, in 43 642 EXTRA-UTERINE PREGNANCY which the fcetal sac lay entirely outside of the lumen of the tube, being separated from it by a layer of tissue of varying thickness (see Fig. 508), apparently offered confirmatory evidence of such an occurrence. After further examination of my specimens, however, while not wishing to deny Fig. 502.—Diverticulum from the Lumen of Tube. such a possibility, I am of the opinion that such conditions can usually be more satisfactorily explained by supposing that the fertilized ovum had burrowed beneath the mucosa of the tube, just as it does into the decidua in uterine pregnancy. Now and again, in serial sections through the tube, it is possible to Fig. 503.—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. 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 condi- iETIOLOGY 643 tions which 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 culs-de-sac. That the fertilized ovum may be arrested in such a structure and go on to further development was con- clusively demonstrated by Henrotin, Herzog, and Walthard (Fig. 503). (g) Diihrssen believes that in occasional instances the arrest of the ovum may be due to puerperal atrophy of the tube, whereby its normal peristalsis is markedly impaired. Hoehne attributes a similar result to gen- eral hypoplasia. (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 believes that such a phenomenon may favor the produc- tion of extra-uterine pregnancy, since the fertilized ovum may attain such proportions during its migration as to prevent its passage through the tube. II. Conditions Resulting from Inflammatory Conditions of the Tubes. —As has already been said, Schroeder and Tait pointed out the aetiological importance of such conditions. This view is supported by the fact that many cases of tubal pregnancy have been preceded by pelvic inflammatory trouble. Thus Diihrssen, Mandl and Schmidt, Kiistner, Petersen, Runge, and others were able to elicit a history of gonorrhceal salpingitis or of in- flammatory lesions of the appendages in more than two-thirds of their cases. After it had been demonstrated that the arrest of the ovum was not due to the destruction of the cilia by the inflammatory process, great difficulty was experienced in explaining the connection between the two conditions. In 1902 Opitz found definite histological inflammatory lesions in two-thirds of his specimens, and, even when they were absent, noted that the tips of many 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 very satisfactory explanation for the arrest of the ovum. He assumed that some of the canals inclosed be- tween the adherent folds communicated freely with the main lumen of the tube, but ended blindly at the other extremity, so that if a fertilized ovum were arrested in such a cul-de-sac a tubal pregnancy would develop. After similar observations had been made by Micholitsch and others, this explanation was enthusiastically accepted by Werth, who considered it of almost universal application. I have frequently observed the same condition, and have no doubt that it may be a frequent aetiological factor. III. Physical and Developmental Conditions Which Favor Decidual Formation in the Tubes.—Webster believes that the explanation for the comparatively infrequent occurrence of tubal pregnancy is to be found in the fact that the decidual reaction, which he considers essential to the proper implantation of the fertilized ovum, is usually lacking. Ho holds that tubal pregnancy can come about only when the tubes are capable of this reaction, 644 EXTRA-UTERINE PREGNANCY which he considers represents a reversion to an earlier type, and may be regarded as a sign of degeneracy. 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 aetiology of tubal pregnancv, and the question which we have to consider is which of them is correct, or whether any one is of universal application. Theoretically, it would appear that certain of the mechanical conditions mentioned above must frequently play a part in the production of the affection. On the other hand, it must be admitted that diverticula from the lumen of the tube, and the so-called follicular salpingitis, are frequently noted, while tubal pregnancy occurs but comparatively rarely. Tainturier, and Mandl and Schmidt applied ligatures to various por- tions 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 demonstrated in the tubes 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 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 recent work upon the anatomy of the pregnant tube shows that the decidual formation is never abundant, and is frequently alto- gether absent, would militate strongly against such a view. The only positive experimental work along these lines was. reported by Xuck many years ago, but it is probably open to the objection that he did not distinguish carefully enough between the uterine cornua and the tubes in the lower animals. The idea that the affection 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 perfectly healthy 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 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 somewhat too radical, as Waldeyer has reported an undoubted case in an ape. In view of the considerations just adduced, it is apparent that the aetiology 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 OVARIAN PREGNANCY 645 ovum in a crypt resulting from follicular salpingitis, or in a diverticulum, may afford a satisfactory explanation. 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 then remain as great a problem to us as to our prede- cessors. Ovarian pregnancy was first described in the seventeenth century, by Mercerus and St. Meurice, after which it was generally recognized until Rupture Site of rupture |' * ' ■•' Sagittal section_________ Posterior view_________________ Fig. 504.—Dr. E. K. Cullen's Specimen of Ovarian Pregnancy. XI. 1835, when Yelpeau 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 Pouchet, Allan Thompson, and others. This scepticism was probably quite justifi- able, 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, Webster, and Bland Sutton. Indeed, as far as I can ascertain, only 3 cases were reported in England 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 646 EXTRA-UTERINE PREGNANCY authorities, although Parry admitted its existence and not a few operators have reported doubtful cases; but it was.not until 1902 that Thompson demonstrated a perfectly conclusive specimen. Up to 1878 there existed no definite criteria by which specimens could be judged, and many were described as examples of ovarian pregnancy which had no claim to such a title. In that year, however, Spiegelberg 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 fcetal 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 found 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 admitted, and even so rigorous a critic as Webster has abandoned his scepticism, 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 be- longing in the first, and 17 in the second, category. The former were thoroughly described, and so carefully studied microscopically that their ovarian origin was conclusively demonstrated; namely, the cases of Gott- schalk, 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 Lud- wig had gone to term, but in none of the other 11 had the pregnancy progressed beyond the fourth month. Since 1906 many more positive cases have been described, and important contributions made to the subject by Bryce, Kerr and Teacher, C. C. Norris, Lea, and others. It is interesting to note that in one third of the 30 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 lithopaedia, which had been carried for years before being removed. This would 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, as is shown by the fact that 11 of the 13 positive cases had not progressed beyond the fourth month. It is also important to bear in mind that the pregnancy may be destroyed 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 obser- vations render it probable that a certain proportion of ovarian haematomata may actually represent the remains of an early pregnancy, but such a TUBAL PREGNANCY 647 diagnosis should not be considered unless microscopical examination reveals the presence of chorionic villi. In ovarian pregnancy, the ovum itself and its mode of implantation do not differ eventually from that observed in the uterus, except that a definite decidua is lacking, so that the foetal ectoderm invades the ovarian stroma directly and opens up its blood-vessels. 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 Uterine cavity. Partially separated placenta. • ervix Fig. 505.—Interstitial Pregnancy (Bumm). 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, while Lequeux was able to collect 75 cases up to 1911. Of 57 cases analyzed by Martin and Orthmann, 48 were ampul- lar, 8 isthmic, and only 1 was interstitial. Most recent writers state that the isthmic 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 work of Graf Slice and Peters, however, has demonstrated that even in the uterus this is not necessary, and has shown clearly that the ovum burrows down into the depths of an cedematous endometrium, 648 EXTRA-UTERINE PREGNANCY whose stroma cells have not yet assumed a characteristic decidual appear- ance. This work, which has completely revolutionized our conception of the mode of implantation of the ovum and the development of the placenta in uterine pregnancy, applies equally well to the tube, although certain anatomical peculiarities of the latter usually necessitate a different out- come. The ovum may become arrested in any portion of the tube, and, accord- ing to Werth, may become implanted in either one of two varieties. 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 in a depression between two folds at the peripheral portion of the lumen. In either event, the ovum does not remain upon the surface, but at once burrows through the epi- thelium, and comes to lie in the tissue just beneath it. By that time its periphery is made up of a capsule of rapidly proliferating ectodermal cells —the trophoblast—which soon invade the surrounding tissues. It is gen- erally believed that the arrosive properties of the trophoblastic cells bring about degeneration of the muscle and connective-tissue cells, which event- ually become converted into fibrin. At the same time the blood-vessels are opened up, and the maternal blood is poured out into spaces of varying size lying entirely within the trophoblast, or between it and the adjacent tissue. Young, on the other hand, considers that oedema and necrosis occur before the maternal tissue is reached by the fetal cells, and are probably due to the action of chemical substances secreted by the latter. In the usual, intercolumnar mode of implantation, as soon as the ovum penetrates the epithelium it comes to lie in the muscular wall of the tube, and is separated from the lumen by a layer of tissue of varying thickness— the capsular membrane or pseudo-reflexa (Fig. 508). On the other hand, in the very rare columnar mode of implantation, 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 expan- sion. Every specimen of early tubal pregnancy, which I have studied in recent years, has served to strengthen my belief that the implantation occurs in practically the same manner as in uterine pregnancy. That this view is correct is shown by the fact that it has been endorsed by Fiith, Griffiths, Aschoff, Kiihne, Kreisch, Petersen, Andrews, Couvelaire, Lockyer, Werth, Pfannenstiel, Kromcr, A'oigt, Kermauner, Berkeley and Bonney, Wallgren, and many others. The further development of the pregnancy depends in great part 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, which eventually may become so compressed as to appear as a mere crescentic slit, whose walls are almost in apposition. 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 may be- come obliterated in the immediate vicinity of the ovum. On the other hand, when implantation occurs in the isthmus, and par- TUBAL PREGNANCY 649 ticularly in the portion immediately adjoining the uterus, the small size of the lumen precludes the possibility of such expansion, and as a con- sequence the ovum distends the tube wall peripherally to its lumen, so that the latter may eventually become completely separated from the un- derlying muscularis and be surrounded by fcetal tissue and villi. (b) Decidua.—Bland Sutton in US'il, 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 sceptical of its existence, and contended that the cells, which Fig. 506.—Section Showing Attachment of Chorion to Tube Wall. X90. Dec, decidual cells; L. C, Langhans's cells; Syn., syncytium; V., villi. had formerly been described as decidual, were really of fcetal origin. These contentions have been sustained by most subsequent observers, so that at present no one claims that a distinct continuous decidual membrane is formed. On the other hand, it is equally 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 fcetal 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, care- ful study will occasionally enable one to distinguish decidual cells scattered 650 EXTRA-UTERINE PREGNANCY between the fcetal tissues at the placental site (Fig. 506), 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, Voigt, Both, Couvelaire, Dobbert, Petersen, Lange, Kermauner, Young, myself, and others. Moreover, the possibility of a decidual reaction is demonstrated by the fact that characteristic decidual Fig. 507.—Section Showing Formation of Decidual Cells in Right Tube, While the Pregnancy Was in the Opposite Tube; Conclusively Demonstrating that They Could not Be of Fcetal Origin. m.m., tubal mucosa; muse, muscularis; d., decidua. cells are sometimes observed in the non-pregnant tube (Fig. 507). Observa- tions of this character by Webster, Mandl, Goebel, Janot, Kromer, and my- self are beyond criticism, as in such cases it is impossible to confuse decidual with fcetal 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 fcetal elements. In TUBAL PREGNANCY 651 uterine pregnancy, such an invasion is noted only in the rare instances in which there is an imperfect development of the decidua, and it would therefore appear that one of the main purposes of the latter is to protect the maternal tissues against the invasive and corrosive action of the fcetal cells. (c) Decidua Reflexa.—Since the time of Rokitansky, the question as to the existence of a decidua reflexa in tubal pregnancy has been repeatedly discussed, one set of investigators claiming that it is usually present and the other set holding that it is always absent. The investigations of the past few years have served to reconcile these differences. In view of the general scantiness of the decidual reaction, it is evident that one could not reasonably expect the formation of a structure identical with the decidua reflexa of uterine pregnancy. On the other hand, in all intact early tubal pregnancies, the ovum is separated from the lumen of the tube by a thicker or thinner layer of connective and muscular tissue, with possibly a few isolated decidual cells (Fig. 508). As the pregnancy ad- vances this membrane becomes invaded by fe- tal cells, and later un- dergoes fibrinous de- generation, and, if rup* ture does not occur, eventually becomes fused with the mucosa of the opposite side of the tube. As this struc- ture is only superficial- ly analogous to the de- cidua reflexa, it is bet- ter designated as the pseudo-reflexa or cap- sular membrane. (d) Placenta.—As the early stages of the development of the pla- centa are identical in both tubal and uterine pregnancy, the different outcome in the former is dependent upon the absence or scanty devel- opment of a decidual reaction. As a conse- quence, the tissues of Fig b.c. 508.—Early Tubal Pregnancy, Showing Ovum Em- bedded in Wall of Tube Outside of Lumen. X6. blood-clot; v., chorionic villi; refl., capsular membrane. the tube wall in contact with the ovum offer but slight resistance to the invasive properties of the fetal elements, and soon undergo degenerative changes. The chorionic villi and fetal calls invade this tissue, almost like a malignant growth, and open up maternal blood-vessels. In many cases they penetrate directly through the peritoneal surface or the capsular membrane, as the case may be, and 652 EXTRA-UTERINE PREGNANCY give rise to intra-peritoneal haemorrhage or tubal abortion. In other in- stances, however, early rupture is due to the sudden opening up of a large vessel, when the Aveakened tube walls yield to the increased pressure. Werth has quaintly expressed the condition by stating that the ovum, in making its bed, digs its own grave. The microscopic structure of the fetal portion of the placenta is iden- tical with that observed in uterine pregnancy (Fig. 506). Even more frequently than in that condition masses of Langhans's cells, syncytium, or even fragments of villi become broken off from the placenta, and are car- ried by the veins to various portions of the body. This process of deporta- tion can be demonstrated in almost every case by cutting serial sections through the tube (Fig. 457). Yeit has still further extended this concep- tion 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 necessarily give way. It is stated by Gubb and others that the placenta may continue to grow after the death of the fetus. I, however, agree with Berry Hart, that it is out of the question, except in the rare cases of hydatidiform mole forma- tion; although it must be admitted that in advanced tubal pregnancy haemorrhage occasionally takes place into the placenta, and thus leads to a considerable increase in its size. (e) Structure of the Fetal Sac.—In extra-uterine 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 thick- ened, 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 fetal sac contracted so strongly that he mistook it for a pregnant uterus. In most cases the exterior of the tube gives evidence of peritonitic involvement, and a considerable portion of the thickness of the fetal sac is often due to peritoneal adhesions. In order for complete tubal abortion to occur, the fimbriated extremity must remain patent, but in other cases its condition varies, being some- times closed, sometimes open. As a rule, the lumen of the tube communi- cates directly with either end of the fetal sac. Less commonly, however, this communication is noted only at one end, while still more rarely the fetal sac is completely shut off from the main lumen. A satisfactory explanation of these differences has not yet been adduced. TUBAL PREGNANCY 653 Fig. 509.—Uterine Decidua from a Case of Extra-Uterine Pregnancy (Zweifel). (/) [.ferine Changes.—Jn the first three months the uterus undergoes considerable hypertrophy, and its endometrium becomes converted into a decidua similar to that observed in uterine pregnancy, and differing from it only in a less marked development of the spongy layer and a greater abundance of blood spaces just beneath its free surface. Soon after the death of the fcetus, the decidua is thrown off in small pieces, and occasionally as a triangular cast of the uterine cavity. Its discharge is usually considered of marked diagnostic significance; so much so that in doubtful cases many observers recommend curetting the uterus, and base their diagnosis upon the presence or absence of decidual tissue. Terminations of Tubal Pregnancy. —According to Tait, the universal fate of tubal pregnancy was rupture either into the peritoneal cavity, or between the folds of the broad ligament, oc- curring not later than the twelfth week. More careful study has demonstrated the incorrectness of such a statement, as the great majority of 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 rupture, as in the cases reported by Saxtorph, Spiegelberg, Chiari, Gutzwiller, Emanuel, Freund, and others. My collection also contains a similar specimen. (a) Tubal Abortion (Intra-tubal Rupture.)—After Werth, in 1887, had directed attention to the possibility of tubal abortion, it has gradually been demonstrated that this is by far the most frequent outcome of tubal preg- nancy. The marked change of opinion which has taken place upon this point is readily appreciated by comparing the statements made by Sehrenck and Werth, in 1892 and 1904, respectively. The former found only (i case? of abortion in 610 cases of tubal pregnancy collected from the literature; whereas the latter stated that seven out of eight cases end in that way and only one by rupture. According to Martin, "this termination is the general rule, spontaneous rupture occurring only in those cases in which occlusion of the abdominal end of the tube precludes the possibility of an abortion, or in which the ovum, being inserted in a hernia of mucosa, burrows directly through the tube wall." The frequency of tubal abortion depends in great part upon the site of implantation of the ovum. In ampullar pregnancy, it is the general rule, whereas intra-peritoneal rupture is the usual outcome in isthmic pregnancy. This difference is probably due to the fact that in the former the tubal lumen is sufficiently patulous to permit of a considerable degree of expansion 654 EXTRA-UTERINE PREGNANCY of the fetal 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 capsular membrane or pseudo-reflexa, and therefore does not differ essentially from Fig. 510.—Early Tubal Pregnancy, with Abortion of Ovum into Lumen of Tube. X6. b.c, blood-clot; v., chorionic villi. intra-peritoneal rupture, except in the fact that in the one case the haemor- rhage 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 intra-tubal rupture, as suggested by Berk- eley and Bonney. The immediate consequence of the haemorrhage is the loosening of the connection between the ovum and the tube wall, the former becoming completely or partially separated from its site of implantation. If the separation is complete, the entire ovum is extruded into the lumen of the TUBAL PREGNANCY 655 tube, and gradually forced by the effused blood toward the fimbriated end, through which it may be extruded into the peritoneal cavitv, where- upon the haemorrhage usually ceases. On the other hand, if the separation is only partial, the ovum remains in situ, and the haemorrhage continues. Accordingly, we distinguish between complete and incomplete abortions, the latter occurring far more frequently than the former—10 to 1, accord- ing to Wormser. In a small number of cases the ovum may be observed in the act of abortion (Fig. 511). Thus, among my own specimens are several which Fig. 511.—Tubal Abortion, Ovum Being Extruded through Fimbriated Extremity (Kelly). XI. show the fetus surrounded by its membranes, protruding from the dilated fimbriated extremity of the tube. When the haemorrhage is moderate in amount and the ovum remains in situ, it may become infiltrated with blood and increase markedly in size, being converted into a structure analogous to the blood or fleshy mole observed in uterine abortions (Fig. 512). The haemorrhage usually persists as long as the mole remains in the tube, and the blood slowly trickles from the fimbriated extremity into the peritoneal cavity, where it becomes encapsulated, giving rise to an hematocele. If the fimbriated extremity is occluded, the tube may gradually become distended by blood—hematosal- pinx. 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.—Somewhat less than one eighth of the cases of tubal pregnancy end within the first twelve weeks by intraperitoneal rupture, which usually occurs spontaneously, but occasionally is the result of violence. Generally speaking, when rupture occurs in the first few weeks, the pregnancy is situated in the proximal end of the tube, a short distance from the cornu of the uterus (see Fig. 513). On the 656 EXTRA-UTERINE PREGNANCY other hand, when the ovum is implanted in the interstitial portion of the tube, rupture occurs later than in the other varieties—as a rule, not until after the fourth month, sometimes considerably later. This difference is due to the fact that the inter- stitial portion of the tube is sur- rounded 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 considerable size before rupture occurs. Fig. 513.—Isthmic Pregnancy. Rupture Ten Days after Last Menstrual Pe- riod. XL The prime factor in the causation of rupture is the intra-mural em- bedding of the ovum, and the consequent invasion and weakening of the tube wall by the ectodermal elements and chorionic villi. 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 such circumstances, rupture is brought about either by direct perforation by the growing villi, or by the weakened tube wall yielding to a sudden access of pressure in the inter-villous spaces, following the sudden opening up of a large vessel or the clogging of venous channels by chorionic villi. The evidence at present available seems to indicate that the former is the less usual factor. If rupture occurs in this way in an otherwise normal tube, it is appar- ent that it will be likely to occur at a much earlier period if the ovum be arrested in a diverticulum from its lumen, as under such circumstances it will have only a portion of the tube wall to penetrate, instead of its entire thickness. Occasionally, secondary rupture may occur in a tube the seat of a primary abortion, though this is possible only when the fimbriated end is occluded. Under such circumstances 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. Rupture usually occurs in the neighborhood of the placental site, and either into the peritoneal cavity or between the folds of the broad liga- ment, depending upon the original site of the ovum. The terminations of the two conditions differ so markedly that it will be necessary to con- sider them separately. t.w. _ . ., <% A-»'I" } i-Ov B.C U.T. — Fig. 512.—Section through Tubal Mole. XL B.C., blood-clot; Ov., ovum; T.W., tube wall; U.T., uterine end of tube. TUBAL PREGNANCY 657 Tn the former accident, the entire ovum may be extruded from the tube, but if the rent be small, profuse haemorrhage may occur without its escape. In either event, the patient immediately shows signs of collapse, which may rapidly end in death. If this does not occur, 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 fetus is inevit- able; 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 pos- sible. I do not believe that this can occur, as it is highly improbable that such connections could be established before the ovum had become irrepar- ably damaged, not to speak of the negative evidence afforded by the experi- ments just mentioned. On the other hand, if only the fetus escapes at the time of rupture, the effect upon the pregnancy will vary according to the amount of injury sustained by the placenta. If much damaged, death of the fetus and termination of the pregnancy is inevitable; but if the greater portion of the placenta still retains its attachment to the tube, further development is possible, and the fetus may go on to full term, giving rise to a secondary abdominal pregnancy. In such cases, the tube may close down upon the placenta and form a sac, in which it remains during the rest of the preg- nancy. Or, a portion of the placenta may remain attached to the tube wall, while its growing periphery extends beyond it and establishes con- nection 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. 1 do not believe, however, that the placenta can become 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 con- sider that one has to deal with a broad-ligament pregnancy, in which the 44 658 EXTRA-UTERINE PREGNANCY placenta is situated upon the upper portion of the fetal sac, which had become adherent to the organ in question. When the fetus escapes from the tube 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 observers, notably Roth, have reported cases in which a full-term fetus 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, rupture may occur at the portion of the tube uncovered by peritoneum, so Fig. 515.—Broad-Ligament Pregnancy (Zweifel). 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 development of the pregnancy. The outcome depends largely upon the degree of completeness with which the placenta has been separated. If it remains attached to the tube on the side opposite the point of rupture, it generally becomes dis- placed upward as 'pregnancy advances, and comes to lie above the fetus; but when it is situated near the point of rupture it gradually extends down between the folds of the broad ligament, being implanted partly upon the tube and partly upon the pelvic connective tissue. In either event, the fetal 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 ABDOMINAL PREGNANCY 659 extruded into the peritoneal cavity, while the placenta retains its original position—secondary abdominal 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 only a small proportion of cases of tubal pregnancy end in rupture, it is evident that his statements were based upon imperfect information. The frequency of this mode of rupture has been considerably overestimated, as it was noted in only 4 out of 276 cases collected from the articles of Mandl and Schmidt, Kiistner, and Fehling, and only once in my series of cases. The so-called tubo-ulerine pregnancy results from the gradual extension 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 extended into the peritoneal cavity. In such circumstances, the portion of the fetal sac projecting into the peritoneal cavity forms adhesions with the surrounding organs, which often seriously complicate its removal at operation. Neither of these conditions is very 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 fetal 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 peritoneum, giving rise to a primary abdominal pregnancy, and in Heeler'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 secondary in character, hav- ing resulted from ruptured tubal pregnancy. Gradually doubt began to be cast upon the existence of primary ab- dominal pregnancy, so that at present most authors, while admitting its theoretical possibility, are extremely sceptical as to its actual occurrence. Bland Sutton positively denies its occurrence in women, and contends that it is not observed in the lower animals. Hirst and Knipe in 1908, and Grone in 1909, however, described specimens, which, while not entirely con- vincing, 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, Yoigt, Leopold, and Werth, the fertilized ovum may become implanted upon the fimbria ovarica. Such conditions may closely resemble primary abdominal pregnancy, inas- much as the surface upon which the ovum is primarily implanted is so small that the margins of the placenta soon extend beyond it and become 660 EXTRA-UTERINE PREGNANCY attached to the surrounding organs, thus giving the impression that the peritoneum was the original site of implantation. A careful microscopical examination, however, will usually enable one to differentiate between the two conditions. Fate of Extra-uterine Fcetus.—As has already been pointed out, absorp- tion is the universal fate of small embryos which are extruded into the peritoneal cavity, unless the placenta retains its attachment to the tube wall and still offers conditions suitable for the continuance of the circula- tion. Moreover, the young fetus 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 amphorous 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. On the other hand, when the fcetus has attained a certain size before death it cannot be absorbed in this manner, and must undergo suppuration, mum- mification, calcification, or adipocere transformation. Pyogenic bacteria often gain access to a gestation 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 septicaemia, portions of the fetus 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 account of their proximity to the rectum and the liability to infection by intestinal bacteria. Mummification and lithopedion formation have already been referred to in the chapter on Abortion, and are dealt with fully in Kuchenmeister's article. The latter is generally regarded as the most favorable of the pos- sible eventualities in cases of advanced extra-uterine pregnancy, as in many instances the calcified product of conception may be 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 lithopaedion has been known to remain in the abdomen for fifty years or more, and the literature con- tains numerous cases in which a period of twenty to thirty years elapsed before its removal at operation or autopsy. Much more rarely the fcetus 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 described tubal ova which had become converted into haematoma moles. Hydatidiform moles have been observed by Otto, Recklinghausen, Wenzel, Sykow, and others; and hy- dramnios by Teuffel, Webster, and others. Ahlfeld and Marchand first described a case of chorio-epithelioma following tubal pregnancy, and Risel, in 1905, was able to collect ten additional cases from the literature. It is interesting to note that Spiegelberg and Hoist observed the occurrence SYMPTOMS 661 of eclampsia during the false labor in cases of advanced extra-uterine preg- nancy. Symptoms.—Unfortunately, the manifestations belonging to an unin- terrupted extra-uterine pregnancy are not characteristic, and the patient and her physician are usually entirely unaware of the existence of any abnormality until death of the fetus, rupture, or tubal abortion occurs. Ordinarily the patient considers herself pregnant, presents the usual sub- jective symptoms, and possibly suffers from slight pains in one or other ovarian region, which she regards as the usual concomitants of her condi- tion. 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 con- dition as with normal pregnancy, being noted in only 43 per cent, of the cases observed by Martin and Orth, Mandl, Bouilly, and Wormser. These statements, however, do not carry as much weight as would appear at first sight, for frequently the haemorrhage does not represent a genuine men- strual flow, but is due to endometritis, or to the fact that the dilated vessels in the uterine decidua are not covered by a layer of fetal tissue. More- over, the death of the extra-uterine fetus at an early period, if not accom- panied by rupture or abortion, is usually associated with more or less uter- ine haemorrhage, which is frequently mistaken for the menstrual flow or for an early abortion, the latter belief being still further confirmed by the discharge of decidua. In many eases the first manifestation of the abnormal pregnancy is 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 persistently subnormal, and an examination of the blood shows a marked diminution in the number of red corpuscles and in the a'mount 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 abortion, the patient rallies promptly, the general condition is not so alarming, and gradual recovery ensues. Vaginal examination a few days later frequently reveals the presence of a large 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 hamiatocele, on the other hand, does not require the presence of adhesions for its formation, but results 662 EXTRA-UTERINE PREGNANCY 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 about the more fluid portions. 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 becomes larger and larger until it finally ruptures and its contents are poured out into the peritoneal cavity. Such an accident is speedily followed by collapse. Again, bacteria some- times make their way into the mass from the intestines and cause suppura- tion. If the patient survives the rupture of a tubal pregnancy, a secondary abdominal pregnancy may result, provided the placenta has not been sepa- rated to too great an extent. Under such circumstances the usual symp- toms of pregnancy persist, except that the woman suffers more pain and feels the fetal movements more acutely than usual. The pain is due partly to stretching and possibly to contractions of the fetal sac, but prin- cipally 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 the latter event, the fetus lies within the peritoneal cavity, while the placenta re- mains 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, associated with distinct pains similar to those occurring in the early stages of normal labor. They are due to uterine contractions, since the fetal sac contains 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 $ few hours or several days, and is soon followed by the death of the child, although in a small number of cases the fetal movements have been known to persist for a considerable time after the cessation of the pains. After the death of the fetus, the placental circulation gradually be- comes abolished, the amniotic fluid is absorbed, and the fetal 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, DIAGNOSIS 663 and has been investigated by Browne, Strauss, Zincke, Xeugebauer, and many others. 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 Xeugebauer in 1907 added many more cases. 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 fetus in each tube, both showing the same development. Sanger and Krusen 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, and soon followed by those of Dorland, Weil, Varnier, and Pesta- lozza, the last author having 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. 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 cra- niotomy under similar circumstances. As a rule, however, dystocia is not encountered, Funck-Brentano hav- ing 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, presenting 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 laparotomy is performed for a supposed unruptured, early tubal pregnancy a tumor of some other origin is found. On the other hand, the unruptured pregnant tube may prolapse into Douglas's cul-de-sac and be mistaken for the body of a retroflexed pregnant uterus, in which event an attempt at its reposition may lead to rupture and occasionally to death. When the fetus has died before the occurrence of rupture or abortion, errors in diagnosis are common, and many cases are mistaken for incom- plete uterine abortions or for tubal tumors associated with uterine hem- 664 EXTRA-UTERINE PREGNANCY orrhage. 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 fetus, is a characteristic sign of tubal pregnancy. 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. It is generally believed that the presence of de- cidual tissue in the uterus, in the absence of a fetus, affords conclusive evidence of the existence of tubal pregnancy, especially if a tumor mass can be detected on one side. In doubtful cases curettage is recommended for diagnostic purposes. My own experience has taught me that the pres- ence of decidua in such circumstances usually affords strong presumptive evidence, but that its absence is not an equally convincing negative proof, 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 no 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 hematocele 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 associated with symptoms of abdominal hemorrhage in a woman during the childbearing period as prima facie evidence of a ruptured tubal pregnancy. 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 nterus which is usually mistaken for pelvic inflammatory trouble. In a small number of cases, a fluctuant tumor can be felt pos- terior and lateral to the uterus, and when exploratory 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. If the child has survived the rupture, the diagnosis of secondary ab- dominal pregnancy is rarely made until false labor supervenes, unless 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 much smaller than it should be for the duration of the pregnancy, TREATMENT 665 and more or less displaced by the fetal 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 the persistence of symptoms following the expulsion of the uterine fetus, 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. Examina- tion 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 rup- ture, but in the vast majority of cases the condition escapes recognition until symptoms of collapse point to the probability of rupture or abortion. In advanced cases careful examination will usually disclose the real condi- tion of affairs, and when full term has been passed the history is so charac- teristic that mistakes should scarcely occur. Treatment.—As soon as an unruptured extra-uterine pregnancy is posi- tivclv diagnosed, its immediate removal by laparotomy is urgently indi- cated, since rupture may occur at any time and the patient die.frOm hemor- rhage 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 fetus and thus terminating pregnancy with- out operation are absolutely unjustifiable. This applies not only to the use of electricity, but also to the injection of various poisonous substances into the gestation sac. Even when such procedures are successful, the danger to the mother is by no means at an end, since rupture sometimes takes place after the death of the fetus; and, even if this accident does not occur, the retention of the product of conception renders the tube a useless organ. Although Stephen Rogers, in 1867, seriously suggested the propriety of performing laparotomy for the purpose of checking hemorrhage from a ruptured tubal pregnancy, Lawson Tait, in 1SS3. was the first to undertake such an operation. After he had demonstrated the ease with which it could be performed and the surprisingly good results obtained thereby, the pro- cedure came into general use. Its beneficent results were clearly demon- strated by Schauta, who, after a careful study of the literature, in 1891, 666 EXTRA-UTERINE PREGNANCY found that 123 cases operated upon and 121 cases treated without operation presented a mortality of 5.7 and 86.9 per cent, respectively. For these reasons, whenever we see a possibly pregnant woman in a state of profound collapse, and presenting a deathly pallor of the face, a subnormal temperature, and other symptoms of intra-abdominal haemor- rhage, immediate operation is demanded, unless, indeed, her condition is so desperate that death is imminent. The abdomen should be opened rapidly, under cocaine 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 re- moved 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 fetal sac has been taken away, it is not advisable to attempt to remove all the blood from the peritoneal cavity unless the patient's condition is fairly satisfactory. 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 far better to allow them to remain than to prolong the operation if the patient is in a very bad condition. In desperate cases it is advisable to begin the subcutaneous or intravenous infusion of sterile salt solution while the necessary preparations for the operation are being made. In less severe cases good results follow the in- troduction of several liters of it into the abdomen just before the wound is closed. In certain cases of tubal abortion, Prochownick, Martin, and others advocate attempting to save the tube, if possible, by opening it and remov- ing the product of conception, after which it is closed by sutures. Such a procedure may occasionally be advisable if the patient is in good con- dition, but proof is still lacking that a tube so treated regains its normal functions. A freshly ruptured tubal pregnancy should not be attacked through the vagina, for the reason that the procedure is often 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. Robb, in 1907, advocated deferring operation while the patient was profoundly shocked, and waiting until the general condition had im- proved, as he held that the initial hemorrhage was rarely fatal. The sub- ject was discussed in detail at the meeting of the American Gynecological Society the following year, when the majority of speakers expressed a con- trary opinion. 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 steadily increases in size or presents symptoms TREATMENT 667 indicative of suppuration. This condition, however, rarely presents 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, as has been recommended by Kelly, Segond, and others. Broad-ligament hematomata should be treated in a similar manner. In the later months the treatment of extra-uterine pregnancy differs markedly according as the fetus is alive or dead. In very rare cases a living fetus 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 fetal membranes and newly formed adhesions, the placenta being within the tube or broadly implanted upon the floor of the pelvis. Whatever the anatomical conditions, the mother is constantly exposed to the possibility of sudden and acute hemorrhage so long as pregnancy continues, and accord- ingly 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 carefully explained to the patient and her family and accepted by them. In a small number of cases the operation is comparatively easy and the fetal sac can be removed as readily as a large ovarian cyst. More fre- quently, however, the sac is markedly 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 under such circumstances the entire sac may be removed without great difficulty by ligating the ves- sels 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 com- pleted without markedly endangering the life of the patient, the sac should be incised, the placenta being avoided, if possible, and the fetus extracted. The margins of the sac are then stitched to the abdominal 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 much 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 668 EXTRA-UTERINE PREGNANCY pregnancy with a living child have improved markedly since the introduc- tion of aseptic methods. This was clearly shown by Harris, who 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 the gynecologist is called upon to perform. When the fetus is dead the conditions are much more favorable, as the dangers incident to bleeding from the placental site are markedly dimin- ished. For this reason, the operation should be deferred for six or eight weeks after fetal death in order to permit the obliteration of the maternal blood spaces in the placenta, and thus render possible its removal without hemorrhage. In such cases, however, should dangerous symptoms super- vene, immediate interference is indicated. On the other hand, the opera- tion should not be deferred too long, as there is always a possibility that the fetal 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 opera- tion 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 Eileitersehwangerschaft nebst Bemerkungen zur Entwicke- lung der menschlichen Placenta. Archiv f. Gyn., 1891, xxxix, 393-436. Ueber wiederholte Tubengraviditat bei derselben Frau. Archiv f. Gyn., 1893, xiv, 55-89. Ahlfeld. Ein Fall von Sarcoma uteri deciduo-cellulare bei Tubenschwangerschaft. Monatsschr. f. Geb. u. Gyn., 1895, i, 209-213. Andrews. On the Anatomy of the Pregnant Tube. Jour. Obst. and Gyn. Brit. Emp., 1903, iii, 419-441. Anning and Littlewood. A Case of Primary Ovarian Pregnancy, etc. Trans. Lon- don Obst. Soc, 1901, xliii; Lancet, 1901, i, 100. Aschofp. Anatomie der Extrauterinschwangerschaft. Ziegler 's Beitrage, 1899, xxv, H. 2. Die Beziehungen der tubaren Placenta zum Tubenabort und zur Tubenruptur. Archiv f. Gyn., 1900, Ix, 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. Pcchtsseitige Tubarschwangerschaft. Ruptur 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. Bouilly. Notes sur la grossesse extra-uterine tirees de 1'analyse de cinquante ob- servations personelles. La Gynecologie, 1898, iii, 1-16. Beeslau. Zur Aetiologie und path. Anatomie der Extrauterinschwangerschaft. Mo natsschr. f. Geburtsk., 1863, xxi, Supplement Heft, 119-124. LITERATURE 669 Brossi. Quoted by Sanger. Browne. A Contribution to the History of Combined Intra-uterine and Extra-uter- ine Twin Pregnancy. Trans. Amer. Gyn. Soc, 1882, vi, 444 462. Bryce, Kerr and Teacher. An Early Ovarian Pregnancy. Glasgow, 190s. Campbell. Abhandlung iiber die Schwangerschaft ausserhalb der Gebarmutter. Translated from the English by Dr. Ecker, Karlsruhe and Freiburg, 1841. Cheston. Quoted by Funck-Brentano. Chiari. Beitrage zur Lehre von der Graviditas tubaria. Zeitschr. f. Heilkunde, 1887, viii, 127-146. Couvelaire. Note sur 1 'anatomie de la reflechie dans la grossesse tubaire. Comptes rendus soc. d'obst., de gyn. et de paed. de Paris, 1900, ii, ;"j0-61. Quelques points de 1'anatomie des grossesses tubaires en evolution, etc. Revue de gyn., 1902, vi, 51-84. Croft. An Anomalous Case of Ectopic Pregnancy, probably Ovarian. Trans. Lon- don Obst. Soc, 1900, xiii, 316-323. Dakin. Cast from the Uterus having all the Characters of the Decidual Membrane Found 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. Dibot. Quoted by Sanger. Monatsschr. f. Geb. u. Gyn., 1895, i, 21-28. Dobbert. Sechzig Falle in friihon Entwickelungsstadien unterbrochener Tuben- schwangerschaften. Archiv 1'. Gyn., 1902, Ixvi, 70-123. Dorland. Repeated Extra-uterine Pregnancy. Amer. Jour. Obst., 1898, xxxvii, 478- 491. Dtjhrssen. Ueber operative Behandlung, insbesondere die vaginale Coeliotomie bei Tubarschwangerschaft, nebst Bemerkungen zur Aetiologie der Tubarschwanger- schaft und Beschreibung eines Tubenpolypen. Archiv f. Gyn., 1897, liv, 207- 323. Emanuel. Eine zwanzigjahre getragene Extrauterinschwangerschaft. Zentralbl. f. Gyn., 1894, xviii, 1306. Fehling. Die Bedeutung der Tubenrupter und des Tubaraborts fiir Verlauf, Prog- nose und Therapie der Tubarschwangerschaft. Zeitschr. f. Geb. u. Gyn., 1898, xxxviii, 67-100. Franz. Ueber Einbettung u. Wachstum des Eies im 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. Tliese de Paris, 1898. FtiTH. Ueber die Einbettung des Eies in der Tube. Archiv f. Gyn., 1901, lxiii, 97-158. Ueber Ovarialschwangerschaft. Beitrage zur Geb. u. Gyn., 1902, vi, 314-331.. Glitsch. Zur Aetiologie der Tubenschwangerschaft. Archiv f. Gyn., 1900, lx, 385- 425. Goebel. Beitrag zur Anatomie und Aetiologie der Graviditas tubaria an der Hand eines Priipartes von Tubarmole. Archiv f. Gyn., 1898, lv, 658 713. Gottschalk. Ein praparat von Ovarialschwangerschaft aus der 3.-4. Woche der Gra- viditat. Zentralbl. f. Gyn., 1886, x, 727. Ein Lithokelyphopadion, das gleichzeitig als Fall von reiner Eierstocksschwanger- schaft sehr bemerkenswerth ist. Verhandlungen der deutschen Ges. f. Gyn., 1893, 304-305. 670 EXTRA-UTERIXE PREGNANCY Griffiths. Note on the Importance of a Decidual Cast as Evidence of Extra-uterine Gestation. Trans. London Obst. Soc, 1894, xxxvi, 335-340. Gestation in the Fallopian Tube, and the Structural Changes that take Place in its Walls. Jour, of Pathology and Bacteriology, 1898, v, 443-459. Grone. Ein Fall von primarer Peritoneal-schwangerschaft. Zentralbl. f. Gyn., 1909, 45-56. Gubb. The Placenta in Ectopic Gestation and its Growth after the Death of the Fcetus. Med. Press and Circular, 1894, lvii, 326. Gurgui. Die Ovarialschwangerschaft vom path. anat. Standpunkte. Stuttgart, 1880. Harris. Operation of Primary Laparotomy in Cases of Extra-uterine Pregnancy, with a Tabular Record showing the Results in 27 Women under 26 Operators. Amer. Jour. Obst., 1887, xx, 1154-1167. Weitere Fortschritte der Entbindung ektopischor lebensfahiger Friichte durch Koe- liotomie. 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 Fcetus. Amer. Jour, of Obst., 1892, xxv, 721-735. Hecker. Beitrage zur Lehre von der Schwangerschaft ausserhalb der Gebarmutter- hohle. Monatsschr. f. Geburtsk., 1859, xiii, 81-123. Heinsius. Beitrage zur Lehre von der Tubengraviditat, etc. Zeitschr. f. Geb. u. Gyn., 1901, xlvi, 385-434. Ueber tubare Einbettung des menschlichen 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. Stuttgart, 1876. Henrotin et Herzog. Anomalies du canal de Muller comme cause des grossesses ectopiques. Revue de gyn., 1898, 633-649. Hirst and Knipe. Primary Implantation of an Ovum in 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, Ixiii, 106-123. 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. Janot. De l'oviducte chez la femme; ses modifications pendant la grossesse uterine. These de Lyon, 1898. Janvrin. A Case of Tubal Pregnancy of Unusual Interest. Trans. Amer. Gyn. Soc, 1886, xi, 471-484. Kelly. The Treatment of Extra-uterine Pregnancy ruptured in the Early Months by Vaginal Puncture and Drainage. Trans. Amer. Gyn. Soc, 1896, xxi, 190-209. Kermauner. Beitrage zur Anatomie der Tubenschwangerschaft. Berlin, 1904. Kouwer. Fall von Schwangerschaft im Graaf'schen Follikel. Zentralbl. f. Gyn., 1897, xxi, 1426. Kreisch. Beitrag zur Anatomie und Pathologie der Tubargraviditat. Monatsschr. f. Geb. u. Gyn., 1899, ix, 794-812. Kromer. Untersuchungen iiber die tubare Eieicbettung. Archiv f. Gyn., 1903, Ixviii, 57-108. LITERATURE 671 Kuchenmeister. Ueber Lithopiidion. Archiv f. Gyn., 1881, xvii, 153-359. Kuhne. Beitrag zur Anatomie der Tubenschwangerschaft. Marburg, 1899. Kustner. Ueber Extrauterinschwangerschaft. Volkmann's Sammlung klin. Vort- rage, N. F., 1899, Nr. 244-245. Landau und Rheinstein. Beitrage zur pathologischen Anatomie der Tube. Archiv f. Gyn., 1891, xxxix, 273-290. Lange. Beitrage zur Frage der Deciduabildung in der Tube, etc. Monatsschr. f. Geb. u. Gyn., 1902, xv, 48-71. Lea. A Case of Ovarian Pregnancy. Jour. Obst. and Gyn. Brit. Empire, 1910, xviii, 182-187. Leopold. Zur Lehre von der Graviditas interstitialis. Archiv f. Gyn., 1878, xiii, 355-365. Ovarialschwangerschaft 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. Lockyer. A Case of Incomplete Tubal Abortion showing Intramural Imbedding of the Ovum. Trans. London Obst. Soc, 1903, xiv, 191-196. Ludwig. Eierstocksschwangerschaft neben normaler uteriner Schwangerschaft, 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. Mandl. Ueber den feineren Bau der Eileiter wahrend und ausserhalb der Schwanger- schaft. Monatsschr. f. Geb. u. Gyn., 1897, V. Erganzungsheft, 130-139. Ueber die Richtung der Flimmerbewegung im menschlichen 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. Martin und Orthmann. Eileiterschwangerschaft. Die Krankheiten der Eileiter von A. Martin, Berlin u. Leipzig, 1895, 303-399. Mayer. Kritik der Extrauterinschwangerschaft, etc. Giessen, 1845. Mendes de Leon et Holleman. De la grossesse ovarienne. Revue de gyn., 1902. vi, 337-400. Mikolitsch. Ueber Ovarialgraviditat. Zeitschr. f. Geb. u. Gyn., 1903, xlix, 508-522. Zur Aetiologie der Tubenschwangerschaft. Zeitschr. f. Gob. u. Gun., 1903, xlix, 42-62. Moericke. Zur Aetiologie der Tuben-graviditat. Sammlung zwangloser Abhand- lungen aus dem Gebiete der Fraunheilkunde u. Geb., 1900, Bd. iii, H. 4, u. 5. Neugebauer. Zur Lehre von der Zwillingsschwangcrschaft mit heterotypem Sitz der Friichte. Leipzig, 1907. Noble. Remarks on Ectopic Pregnancy. Amer. Gyn. and Obst. Jour., 1895, vi, 167-171. Norris. Primary Ovarian Pregnancy, etc. Surg. Gyn. and Obst., 1909, ix, 123-131. Oliver. Ovarian Pregnancy. Lancet, 1896, ii, 241. Opitz. Ueber die Uraschen der Ansiedlung des Eies im Eileiter. Zeitschr. f. Geb. u. Gyn., 1902, xlviii, 1-39. Otto. Ueber Tubenschwangerschaft mit Beriicksichtigung eines Falles von Graviditas tubaria molaris hydatidosa. D. I., Greifswald, 1871. 672 EXTRA-UTERINE PREGNANCY Parry. Extra-uterine Pregnancy. London, 1876. Pestalozza. Sulla gravidanza tubarica recidivante. Annala di ost. e gin., 1901, No. 1. Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. Petersen. Beitrage zur path. Anatomie der graviden Tube. Berlin, 1902. Pfannenstiel. Extrauterine Graviditat. Verh. d. deutschen Gesellschaft f. Gyn., 1903, x, 194-199. Pinard. Nouveaux documents pour servir a 1'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. Robb. Ectopic Pregnancy with Especial Reference to the Treatment of Tubal Rup- ture. Trans. Am. Gyn. Soc, 1907, xxxii, 373-397. Robson. Primary Ovarian Gestation. Trans. London Obst. Soc, 1902, xliv, 215-221. Rogers. Extra-uterine Fetation and Gestation, etc. Philadelphia, 1867, pp. 61. 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 Tubargraviditat. Archiv f. Gyn., 1904, lxvi, 652-674. Sanger. Ueber einen Fall von ektopischer Drillingsschwangerschaft. Zentralbl. f. Gyn., 1893, xvii, 148. Ueber solitare Hematocele und deren Organisation. Verh. 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. Saxtorph. Quoted by Spiegelberg. Schauta. Beitrage zur Casuistik, Prognose und Therapie der extrauterinen Schwan- gerschaft. Prag, 1891. Tubarschwangerschaft mit Haematommole. Zentralbl. f. Gyn., 1903, xxvii, 1402- 1403. von Schrenck. Ueber ektopischer Graviditat. D. I., Dorpat, 1893. Segond. Traitement des grossesses extra-uterines. Annales de gyn., et d'obst., 1898, 1, 241-316. Sippel. Ueber aussere Ueberwanderung des Eies. Zentralbl. f. Gyn., 1091, xxv, 289-296. Spiegelberg. Eine ausgetragene Tubenschwangerschaft. Archiv f. Gyn., 1870, i, 406-414. Zur Casuistik 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, Dogs, and Rabbits. Lancet, 1904, ii, 1625. Tubal Pregnancy. Surgical Diseases of the Ovaries and Fallopian Tubes. Phila- delphia, 1891, 313-326. Tainturier. Etiologie de la grossesse ectopique. These de Paris, 1895. LITERATURE 673 Tait. Lectures on Ectopic Pregnancy and Pelvic Hematocele. Birmingkam, 1888, 107. 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 Bockenhamatome. 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, Iii, 537-573. Varnier. Recidive de grossesse ectopique. Comptes rendus soc. d 'obst., de gyn., et cle psed. de Paris, 1900, ii, 296-301. Veit. Die Eileiterschwangerschaft. 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 accouchements. Paris, 1835, t. i, 214. Voigt. Schwangerschaft auf der Fimbria ovarica. Monatsschr. f. Geb. u. Gyn., 1898, viii, 222-232. Zur Bildung der Capsularis bei der Tuberschwangerschaft. Arch. f. Gyn., 1903, Ixviii, 642-660. Zur Bildung der intervillosen Raume, etc. Zeitschr. f. Geb. u. Gyn., 1904, li, 557- 578. Wallgren. Zur mikroseopischen Anat. der Tubenschwangerschaft beim Menschen. Anatomische Hefte, 1905, xxvii, 359-377. 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. Weil. Ueber wiederholte Eileiterschwangerschaft. Prager med. Wochenschr., 1899, Nrs. 1, 2, 3. Wenzel. Blasenmole im Eileiter. Alte Erfahrungen im Lichte der neuen Zeit, Wies- baden, 189.!, 85-89. Werth. Beitrage zur Anatomie und zur operativen Behandlung der Extrauterin- schwangerschaft. Stuttgart, 1887. Die Extrauterinschwangerschaft. Winckel's Handbuch der Geburtshiilfe, 1904, ii, 2, 655-1018. Wertheim. Hsematommole bei Tubenschwangerschaft. Zentralbl. f. Gyn., 1903, xxvii, 1403. Williams. Contribution to the Normal and Pathological Histology of the Fallopian Tubes. Amer. Jour. Med. Sciences, October, 1891. Wormser. Beitrage zur Kenntniss der Extrauteringraviditat. Beitrage z. Geb. u. Gyn., 1899, 280-321. Wyder. Beitrage zur Lehre von der Extrauterinschwangerschaft und dem Orte des Zusammentreffens von Ovulum und Spermatozoen. Archiv f. Gyn., 1886, xxviii, 325-407. 45 674 EXTRA-UTERINE PREGNANCY 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. Zincke. A Case of Extra- and Intrauterine Pregnancy. Amer. Jour. Obst., 1902, xiv, 623-646. Zweifel. Ueber Extrauteringraviditat und retro-uterine Hamatome. Archiv f. Gyn., 1891, xii, 1-61. SECTION VII PATHOLOGY OF LABOR CHAPTER XXXI DYSTOCIA DUE TO ANOMALIES OF THE EXPULSIVE FORCES 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 an insuperable mechanical obstacle to the descent of the presenting part. (3) Those in which the fcetus, on account of faulty presentation or excessive development, cannot be extruded by the vis a tergo. (4) Those cases in which accidental complications, such as eclampsia, haemorrhage, or rupture of the uterus, lead to various irregu- larities 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 gaged. Thus, in many multiparous women a rapid and happy termination of labor may follow a few relatively slight pains, which in 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 abnormal- ities in their frequency and intensity. Prolonged Labor.—Normally, in the early stages of labor, the uterine contractions occur at infrequent intervals, and gradually increase in fre- quency, intensity, and duration as its termination is approached. More- over, a proper alternation between the contraction and relaxation of the uterus is a very important requisite for the successful accomplishment of delivery. 675 676 DYSTOCIA DUE TO ANOMALIES OF EXPULSIVE FORCES Anomalies are often noted in the first stage of labor. In many in- stances the pains recur at long intervals and are so feeble in char- acter 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 interference. For this reason, the obstetrician should not interfere too 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 favorable 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, without any appreciable cause, the pains become less fre- quent and less intense, although giving rise to quite as much or even more suffering than previously. At the same time, the cervix, which was becom- ing obliterated and dilated in a satisfactory manner, ceases to make further progress, and labor apparently comes to a standstill. 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 cramp-like in character, but exert very little influence upon the dilatation of the cervix. As a result, obliteration 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 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 at- tributed to the imperfect dilatation of the cervix, which is supposed to be due to an abnormal rigidity of its tissues. Ordinarily, however, the con- verse is true, as the condition is the direct result of faulty uterine contrac- tions. That this latter view is correct is shown by the fact that the appear- ance 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 primiparae of thirty years of age or over, 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 mem- branes. Both in primiparous and multiparous women this accident may occur before the onset of uterine contractions, and gives rise to 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. This complication is usually not so serious in multiparous as in primi- parous women, since in the former labor, as a rule, sets in within 24 hours PROLONGED LABOR 677 after the discharge of the liquor amnii. Occasionally, however, days, and in rare instances even weeks, may elapse before it occurs, so that it is unwise to make a definite prediction as to when labor will supervene. Not uncommonly obliteration of the cervical canal takes place without difficulty, while the external os alone appears to offer the obstacle to dilata- tion. In such cases 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 cedematous. 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 majority of cases this is only apparent, the delay being really due to an insufficient vis a tergo. /Etiology.—Uterine insufficiency is usually attributed to one of three causes: faulty development or diseased conditions of the uterine muscula- ture, anomalies in its innervation, or mechanical interference with its con- traction. The first factor is the one most frequently concerned in the causation of tardy labor, and is especially likely to be associated with im- perfect general development, being frequently observed in patients pre- senting varieties of the justo-minor pelvis, but only rarely in sufferers from rachitic deformities. It should, however, be remembered that faulty development of the musculature is occasionally noted in apparently nor- mal women, and is relatively common in large, pale, and corpulent indi- viduals. Sometimes the faulty action of the uterine muscle is attributable to a loss of tonicity incident to excessive distention, and is therefore fre- quently met with in women who have passed through a number of preg- nancies in rapid succession, or in whom the uterus has been subjected to acute distention, as in certain cases of multiple pregnancy and hydramnios. Much less commonly the defect is due to general weakness following ex- hausting diseases, but that this is rarely responsible is shown by the com- mon observation that the pains are usually very efficient even in patients suffering from advanced stages of tuberculosis. Although direct proof of the existence of abnormalities in the innerva- tion of the uterine musculature cannot be adduced, clinical observation affords strong presumptive evidence in favor of this view, or at least indicates clearly that extraneous 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 fol- lowed by a temporary 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 adminis- 678 .DYSTOCIA DUE TO ANOMALIES OF EXPULSIVE FORCES tration of a sedative may be followed by a return of satisfactory contrac- tions. That the action of the uterus is occasionally influenced by mechanical conditions is shown by the frequent association of unsatisfactory contrac- tions with the presence of multiple myomata in the uterine wall. Much the same effect is exerted by uterine displacements, especially when the organ sags markedly forward in a pendulous abdomen. Old adhesions about the uterus and appendages and fresh inflammatory areas in the same location may act in a similar manner. Defective abdominal contractions may be due to a number of causes. Sometimes the insufficiency results from faulty development of the muscles themselves, but more frequently 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 ap- parent, and is due to the fact that for fear of 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 often 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 administration of chloroform is attended by most 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 sponta- neous 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 liecome manifest. If the condition lasts for several days it is important that the patient should sleep well at night, and the administration of hyp- notics, or even of morphine hypodermically, is indicated. On the other hand, when the pains are inefficient, cramp-like, and fol- low one another in rapid succession without exerting any appreciable effect upon the dilatation of the cervix, excellent results often follow the admin- istration of a hypodermic injection of morphine (grain \), combined with the sulphate of atropine (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 admin- istration of 15 grams of quinine sulphate, in solution or in freshly prepared capsules, is promptly followed by a marked increase in the frequency 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. PROLONGED LABOR 679 Following the discovery by Dale that the administration of an extract of the infundibular portion of the hypophysis stimulated the uterine con- tractions, Hofbauer, in 1911, advocated its employment in uterine inertia. Since then a considerable literature has accumulated upon the subject, and the contributions of Parisot and Spire, Fischer, and others indicate that the hypodermic injection of 1 to 1.5 cubic centimeters of Parke, Davis & Co.'s "pituitrin," repeated a second time, if necessary, frequently leads to a marked improvement in the activity of the uterus. My own experi- ence has not been so satisfactory, but, in view of the favorable reports of others, its employment is justifiable in appropriate cases. Ergot was formerly used with a free hand in this condition, but the practice cannot be too strongly reprehended. It is true that its administra- tion may be followed by an increase in the intensity of the uterine contrac- tions, but experience has shown that they soon lose their normal charac- teristics and become tetanic. As a result the uterus is liable to remain firmly contracted 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 wdiich it was given. Moreover, if the existence of a mechanical obstacle has been overlooked, the use of ergot may lead to so pronounced an overstretching of the lower uterine segment that rupture occurs. Accordingly, ergot should never be employed for its oxytocic properties, but should be used only as a prophylactic against uterine haemorrhage after the expulsion of the placenta. As has already been pointed out, abnormalities in the contraction 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 tis- sues can sometimes be invoked as its underlying cause. In many cases the administration of a sedative is followed by satisfactory results. The use of an ansesthetic, although it sometimes leads to satisfactory dilatation of the cervix, is generally inadvisable, inasmuch as the patient, having once experi- enced 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 satis- factory results. In other cases, if the objective condition of the patient indicates the necessity for interference, the introduction into the uterus of a small Champetier de Rihes rubber bag acts as an efficient uterine irritant, and brings about complete dilatation. As a rule, however, if the prompt termi- nation of labor is indicated, dilatation of the cervix should be effected by Harris's manual method, provided the internal os and cervical canal are already obliterated. 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. That such a warning is neces- sary is shown by the fact that each year I see in consultation several women who die from haemorrhage or infection following deep cervical tears, which have resulted from unnecessary or too hasty interference. Should it appear 680 DYSTOCIA DUE TO ANOMALIES OF EXPULSIVE FORGES that manual dilatation cannot be safely effected, vaginal hysterotomy may be employed with advantage, as recommended by Seitz. When labor is complicated by premature rupture of the membranes, the patient should be informed concerning its probable effect, and should be encouraged to bear her sufferings as patiently as possible. At the same time she should be most carefully watched, and care should be taken that the child's head is not subjected for too long a time to injurious pressure. Moreover, the premature opening up of the amnion greatly increases the danger of intrapartum infection. This complication may be due to contact infection, or to bacteria making their way up from the external genitalia by means of the capillary layer of fluid extending from the interior of the uterus, and should be guarded against by the strictest observance of asepsis. Infection of the amniotic fluid is not only serious for the mother, but according to the researches of Hellendall may also lead to the death of the child, as the bacteria contained in the amniotic fluid gain access to the mouth and give rise to a general infection or a broncho-pneumonia, which may end fatally a few days after birth. Accordingly, if objective symptoms of exhaustion exist, and it appears that the mother or child will suffer from further delay, interference is indicated, particularly if the temperature becomes elevated, or changes in the fcetal pulse-rate, the passage of meconium, or a markedly cedematous condition of the cervix be noted. In such circumstances dilatation may be effected by means of the rubber bag or manually, or vaginal hysterotomy may be performed, after which delivery should be brought about by the most conservative method available. Forceps, however, should never be applied until the cervix is completely dilated, nor while the head is freely movable above the superior strait. Tardy labor, due to the prolongation of the second stage, is best treated by the application of forceps, except in those cases in which there is some mechanical obstacle. Occasionally when the patient refuses to use her ab- dominal muscles, the necessity for instiumental delivery may be obviated by the judicious administration of chloroform. Precipitate Labor.—In certain multiparous women precipitate labor may result from an abnormally slight degree of resistance offered by the soft parts, or from abnormally strong uterine and abdominal contractions, or very occasionally from the absence of painful sensations during the uterine contractions. Generally speaking, precipitate labor is not attended by serious con- sequences, although the child is sometimes extruded so rapidly that the 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 sometimes falls to the ground and sustains severe or even fatal injuries. Occasionally the cord is torn through and the child may bleed to death before aid is obtain- able. If tempestuous pains come on while the patient is under the observation of a physician, they should be controlled by the administration of chloro- HOUR-GLASS CONTRACTION 681 form, 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 Uterus.—Occasionally in the first, and more frequently in the second stage of labor, the uterus may cease to relax at regular intervals, and remain in a condition of continued or tetanic contrac- tion. 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 imminent, although now and again this accident may occur when everything 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 anaesthetic, after which delivery should be effected as soon as practicable. Contraction of Bandl's Ring.—Closely related to this form of dystocia is that which is sometimes attributed to a stricture resulting from tonic contraction of Bandl's ring. Considerable attention has been directed to this complication within the last few years, and numerous cases have been described by Budin, Demelin, (.heron, Rossa, Dickinson, and others. The French observers believe that, while the portions of the uterus above and below it remain flaccid, Bandl's 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. Oheron 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. Veit is probably correct in denying the existence of such conditions in head presentations, and in believing that the reports are due to faulty obser- vation. That the contraction should be confined to Bandl's ring would appear highly improbable, and it is much more likely that the entire active portion of the uterus may pass into a condition of tetanic rigidity, and that under such circumstances its lower margin would be felt as a contracted ring. In such cases the lower uterine segment would be flabby, while the upper portion of the uterus would be tightly contracted, thereby opposing a serious obstacle to the expulsion of the child and to the introduction of the hand or instruments into the uterus. In cases of this character the administration of an anaesthetic relaxes the spasmodic contraction, and delivery can then be accomplished by the most appropriate procedure. It is likewise probable that, in a certain number of cases in which the dystocia has been attributed to the contraction of Bandl's ring, the condi- tion was really due to more or less rigidity of the internal os, while the cervical canal below it had undergone satisfactory dilatation. Hour-glass Contraction.—As the result of the misuse of ergot, or of 682 DYSTOCIA DUE TO ANOMALIES OF EXPULSIVE FORCES extensive adherence of the placenta, the uterus sometimes undergoes such an extreme degree of retraction during the third stage that the latter be- comes imprisoned in its cavity. In such cases the greater part of the upper segment of the uterus is tightly contracted over the retained placenta, while its lower portion is felt by the examining finger as a tightly contracted ring below the placenta. The lower uterine segment 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 contraction." Its occurrence usu- ally necessitates the manual removal of the placenta, which can sometimes be accomplished only under anaesthesia. 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 mummification or putrefac- tion, 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 re- tained for two hundred and eighty and two hundred and ten days respect- ively 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 fcetus, 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. XTothing is known as to the aetiology 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 associate the phenomenon 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 rudi- mentary horn of the uterus, though a careful examination should preclude the possibility of such a mistake. Labor should be induced as soon as the diagnosis is made, and was readily accomplished by the introduction of a bougie in one of my patients two months after the death of the fcetus. LITERATURE Budin. De la dystoeie causee par I'anneau de Bandl. L'Obstetrique, 1898, iii, 289- 310. Cheron. Des difficultes de la version causees par la retraction de I'anneau de Bandl. These de Paris, 1899. Cuilla. Ueber die fettige Degeneration der Gebarmutter in die Schwangerschaft. Zentralbl. f. Gyn., 1907, 1109-1117. Demelin. De la retraction uterine avant la rupture des membranes. L 'Obstetrique, 1898, iii, 49-59. LITERATURE 683 Dickinson. Caesarean Section for Impassable Contraction Ring. Surg. Gyn. and Obst., 1910, x, 377-391. Fischer. Pituitrinwirkung in 50 geburtshilflichen Fallen. Zentralbl. f. Gyn., 1912, 15-20. Hellendall. 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. Hypophysenextract 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, Ixi, 435-444. Labhardt. Ein Fall von "Missed Labour" bei Carcinoma uteri. Beitrage zur Geb. u. Gyn., 1902, vi, 437-448. 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. Veit. Ueber die Dystocie durch den Contractionsring. Monatsschr. f. Geb. u. Gyn., 1900, xi, 493-501. Winckel. Ueber die Bedeutung pracipitirter Geburten fiir die Aetiologie des Puer- peralfiebers. Munchen, 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 lack- ing, while the upper third communicated with the bladder. Coitus was accomplished per urethram, through which a three months' foetus was sub- sequently 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. Many cases are on record in which an almost imperforate hymen has remained 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. In some women, especially in elderly primiparae, the vulval outlet is very small, rigid, and altogether lacking in elasticity. Again, as the result of pressure or renal lesions, the vulva may become so cedematous that its orifice is almost occluded. The latter condition does not necessarily give rise to dystocia, but in both the brittleness of the soft parts predisposes to perineal laceration. Moreover, when the oedema has been excessive, and 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 haematomata 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 dys- tocia. 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, but more frequently result from accidental complications. Very occasionally the vagina is divided into two halves by a longitudinal septum extending from the vulva to the cervix; more often the structure is 684 VAGINA 685 incomplete, being limited to either the upper or lower portion of the canal. Such conditions are frequently associated with abnormalities in the develop- ment of the generative tract, and their detection should always lead to further careful examination, with a view to determining whether the uterus and appendages are normal. 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 severed by the obstetrician. Occasionally the vagina may be obstructed by ring-like strictures or hands of congenital origin. These, however, rarely offer a serious obstacle to labor, as they usually yield before the oncoming head, though in ex- treme cases incision may be necessary. Sometimes the upper portion of the vagina is separated from the re- mainder of the canal by a diaphragm-like structure with a small central opening. Such a condition is occasionally mistaken by inexperienced ob- servers for the vaginal fornix, and at the time of labor for the undilated 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 fur- ther dilatation; but if this is not effectual crucial incisions may be neces- sary 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 heal- ing occurs its lumen has become almost entirely obliterated. A similar result is sometimes noted after diphtheria, small-pox, 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 induc- ing abortion. That the most frequent cause of atresia is injury or inflam- matory 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 neces- sary; while in very rare cases extreme dystocia may demand Caesarean sec- tion. 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, fibromata, car- 686 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT cinomata, sarcomata, or haematomata, 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 indication for Caesarean sec- tion. Sasonoff observed a case in which a vaginal haematoma developed so rapidly after the birth of one twin as to interfere seriously with the delivery of the second child. Exceptionally tetanic contraction of the levator ani muscle may seriously interfere with the descent of the head. In this condition, which is analo- gous 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 to the administration of sedatives or anaesthetics, though in one of my patients the obstruction persisted in spite of profound anaesthesia, 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 forma- tion. In the majority of cases, however, the atresia is only apparent, and is simulated by a very minute external os. A good illustration is afforded by the so-called conglutinatio orificii externi. In this condition the cervical canal undergoes complete oblitera- tion 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 very thin layer of 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, though in rare instances manual dilatation or crucial incisions may become necessary. Cicatricial stenosis of the cervix frequently follows difficult labor asso- ciated with considerable destruction of tissue. Less frequently it is due to syphilitic ulceration and induration, several instances 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. Ordinarily, owing to the softening and succulence of the tissues incident to pregnancy, the stenosis, whatever its cause, gradually yields to the natu- ral forces; but in other cases dilatation has to be accomplished by manual methods or by the employment of rubber bags. In rare instances, how- ever, the resistance may be too great to be so overcome, and in such cases Caesarean section should be performed early in labor, for, if it be deferred, the lower uterine segment may become stretched to such a degree that rupture becomes imminent. In two of my patients Caesarean section was necessary on account of complete atresia of the external os. As spontaneous labor had occurred UTERINE DISPLACEMENTS 687 previously, and as no history of inflammatory trouble or of attempts at abortion could be elicited, the cause of the condition could not be ascer- tained. Ahlstrom, in 1904, reported a somewhat similar case, and thor- oughly reviewed the literature. Rigidity of Cervix.—Reference has already been made to the unyielding cervix of elderly primiparae. Occasionally still greater rigidity is encoun- tered in patients who have suffered from inflammatory lesions, though such conditions rarely give rise to serious dystocia. On the other hand, in cer- tain extreme cases of hypertrophic elongation of the cervix, spontaneous dilatation does not occur, although, as a rule, one is surprised 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 condi- tion 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 repeated 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 interfered 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 preg- nant uterus is usually incompatible with advanced pregnancy, since, if spon- taneous or artificial reposition does not occur, the patient either aborts or presents symptoms of incarceration before the end of the fourth month. In the very exceptional instances in which pregnancy goes on to term 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 con- ception. In this condition, which is known as sacculation, the head of the child occupies the fundus, wdiile 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. As a rule, the cervix can be dilated manually under anaesthesia, and the child delivered by ver- sion; but in rare instances it is so inaccessible that Caesarean section will afford the most conservative method of delivery. Dystocia Due to Operations for the Relief of Retroflexion of the Uterus. —Unfortunately, several of the operations which have been suggested 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 occur after suspension, even when performed by competent operators with the most approved technique. Thus, it may occasionally happen, as the result of infection or some other unknown condition, that the proposed suspension becomes converted into 688 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT a fixation, and as a consequence the uterus becomes firmly attached to the anterior abdominal wall by a thick adhesion, wdiich will neither break nor stretch during pregnancy. In such an event, serious difficulty may arise at the time of labor in one of three ways: Most frequently, as the result of the adhesion, the 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 hyper- trophied anterior wall is represented by a thick mass of muscle extending from the point of fixation to the cervix, and more or less encroaching upon 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 the promontory of the sacrum, and some- times considerably above it, so that in extreme cases its posterior lip may be opposite the second or third lumbar vertebra. When labor sets in, dila- tation 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 wall of the uterus does not hypertrophy, and in such cases the dystocia will be due entirely to the upward dislocation of the cervix. Very exceptionally, 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 buckles or becomes folded upon itself, instead of forming a thick muscular pad in front of the cervix. In such conditions the lower part of the uterine cavity becomes divided by a crcscen- tic fold, in front of which a sacculation is formed, in which portions of the foetus may lie, and thus be inaccessible to the operating hand. More- over, the dystocia is exaggerated by the upward displacement of the cervix, as well as by the fold itself interfering with the engagement of the pre- senting part. Andrews, in 1905, collected the histories of 395 cases of pregnancy occur- ring in women who had been subjected to ventral fixation or suspension. In the 359 patients who went to full term, delivery was effected by Cesarean section in 20, by forceps in ^1 instances, and once by craniotomy. This, however, does not exhaust the untoward effects of the operation, as the uterus ruptured in 3 other cases, and transverse presentations were noted in 10 instances. In December, 1906, I was able to increase still further the list of complications, and collected from the literature 36 cases of Caesarean 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 one of the definite factors in the production of dystocia. I have delivered a large number of women after ventro-fixation or sus- pension, but in only 4 was serious dystocia observed as the result of the operation. In 2 instances Caesarean section was necessary, in another a most difficult version was performed, while in the fourth case the dead child UTERINE DISPLACEMENTS 689 was delivered after craniotomy. In one of my cases the dystocia followed ventrofixation by an unknown operator, while in the other 3 it had been preceded by a typical suspension performed by thoroughly competent opera- tors. In view of such experiences, the question arises whether the perform- ance of these operations is justifiable in women during the childbearing Fig. 516.—Dystocia Following Ventro-suspension. Sacculation of Anterior Uterine Wall. X %• Ad., adhesion between uterus and anterior abdominal wall; A.W., abdominal wall; U.W. uterine wall; B., bladder; F., folded anterior uterine wall; P., placents. period. Formerly I held that, while ventrofixation was contra-indicated, suspension was practically devoid of danger from an obstetrical point of view. My own experience, however, shows that I was in error, and that the latter operation may occasionally give rise to most serious obstetrical complications. Accordingly, I feel that during the childbearing period neither fixation nor suspension should be employed in the treatment of retroflexion of the 46 690 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT uterus, except when the ovaries are likewise removed. During the past few years I have used Gilliam's operation in a number of cases with great satis- faction as far as the immediate result is concerned, but so small a number of pregnancies have followed that it is as yet impossible to determine its effect upon the course of labor. The vaginofixation, suggested by Diihrssen and Mackenrodt, in which the fundus was firmly stitched to the anterior vaginal wall, has been fol- lowed by such serious dystocia that it has been practically abandoned during the childbearing period. Riihl has collected 9 cases of Caesarean section fol- lowing this operation. Esch reports that similar complications have fol- lowed the Schauta-Wertheim prolapse operation, which should accordingly be restricted to patients who have passed the menopause. Prolapse.—Pregnancy cannot go on to full term when the uterus is completely prolapsed. In the incomplete variety, however, the fundus oc- cupies its usual level, while the protrusion from the vulva is made pos- sible by elongation of the lower uterine segment and the hypertrophied cervix. As a rule, the latter becomes retracted before labor sets in, though in rare cases it may continue to protrude from the vulva and become markedly cedematous and so swollen as to give rise to serious dystocia. Under such circumstances multiple incisions may be necessary in order to effect delivery. Dystocia Due to Tumors of the Generative Tract and Pelvis.—Carcino- ma of the Cervix.—The effect of this condition upon pregnancy and labor and its appropriate treatment has been considered in Chapter XXVII. Fibro-myomata 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 observa- tion that women suffering from this disease are relatively sterile. Thus, 75 per cent, of Schauta's patients were over thirty years of age when pregnancy first occurred. The obstacle to conception is most marked when the tumor is of the submucous or interstitial variety, and much less so when it is subserous in origin. Moreover, when pregnancy occurs, owing to the haemorrhagic changes in the endometrium, which are frequently associated with the pres- ence of submucous myomata, there is an increased tendency toward prema- ture expulsion of the ovum. On the other hand, pregnancy is not without influence upon the tumors themselves, which frequently increase rapidly in size, more as a result of oedema than of actual hypertrophy. Moreover, owing to the pressure to which they are subjected by the growing ovum, the softened tumors undergo changes in shape and become markedly flat- tened. 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. Haemorrhage may occur at intervals as the result of 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 an abortion occurs. On the other hand, a sudden increase in the rapidity of the growth of the uterine tumor should direct attention to the TUMORS OF THE GENERATIVE TRACT AND PELVIS 691 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 observa- tion, being mistaken for the small parts, or sometimes for the head of the fcetus, so that a diagnosis of multiple pregnancy may be made. At the time of labor the effect exerted by the myomata depends entirely upon their size and situation. Generally speaking, subserous tumors are without great significance, except when their large size leads to pressure symptoms, though a pedunculated tumor occasionally prolapses into the pelvic cavity and gives rise to serious dystocia. On the other hand, inter- stitial 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 contractions, a submucous myoma may become par- tially separated from its bed and protrude from the cervix as a polypoid mass. In such circumstances, 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 frequently exerts a deleterious influence upon the position of the child. Thus Olshausen, in tabulating the cases reported in the literature, found only 53 per cent, of vertex presentations, as compared with ^4 and 1!) per cent, of breech and transverse presentations respectively. 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. In not a i'ew cases the condition appears to predispose toward placenta pnevia, as well as to favor the occurrence of post-partum haemorrhage. The latter is due partly to the fact that the myomatous nodules interfere with the nor- mal contraction and retraction of the uterus, and partly because they offer mechanical obstacles to the separation and expulsion of the placenta. In the puerperium, myomata not infrequently 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 become smaller after the birth of the child, and occasionally disappear entirely. Prognosis.—In preantiseptic times the outlook in labors complicated by the presence of myomatous tumors was most serious. Thus, the ma- ternal 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, though at the same time the condition is sometimes one of the most serious with which the obstetrician has to cope. 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.; wdiile Schauta stated that 60 per cent, of his cases ended spontaneously, and in only 4 per cent, was radical operative interference necessary. Treatment.—When extreme distention, serious haemorrhage, or symp- toms of impaction occur before the child has attained the period of via- 692 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT bility, 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. Thumin has collected 62 myomectomies, 40 enucleations, and 98 supravaginal hys- terectomies performed between the years 1885 and 1901, with a mortality of 10, 5, and 11.23) per cent, respectively. 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 deliverv. To my surprise, however, when she returned to the hospital at the end of pregnancy for a Caesarean section, the tumor had risen out of the pelvis, and had become so much smaller that operation was not thought necessary, and a few days later an easy spontaneous de- livery occurred. So fortunate an outcome, however, cannot always be expected, and in any event the patient should lie examined thoroughly under anaesthesia shortly before the expected date of confinement. If the tumor is found to be firmly impacted in the pelvis, Caesarean section should be performed before labor sets in, followed by supravaginal amputation or enucleation, according to the judgment of the operator. On the other hand, if there is apparently no danger of impaction, and spontaneous delivery seems proba- ble, the patient should be allowed to go into labor. But if symptoms of ob- struction occur, Cesarean section should be promptly performed in prefer- ence to attempts at delivery by the more usual obstetrical procedures. 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 delivery at the time of labor. Moreover, even after a spontaneous labor, its presence occasionally gives 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 cystomata, 46 dermoid cysts, 9 malignant tumors, 5 fibromata, and 2 colloid cysts; while Spencer observed TUMORS OF THE GENERATIVE TRACT AND PELVIS 693 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 collected by Remy, spontaneous abortion or premature labor occurred in 17 per cent. If the tumor occupies the pelvic cavity it may give rise to most serious dystocia. 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 lapar- Fig. 517.—Dystocia Due to Ovarian Cyst (Bumm). otomies having been performed, 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 termina- tion. Again, the cyst may rupture and extrude its contents into the peritoneal 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. In other instances rupture of the uterus occurs, or the tumor is forced into the vagina and occasionally even into the rectum. Diagnosis.—Unfortunately, the presence of an ovarian tumor com- 694 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT plicating pregnancy often remains unsuspected, the condition having been recognized in only 18 of McKerron's first series of cases. Nevertheless, more careful observation should certainly eliminate a large proportion of these errors, as any excessive enlargement of the abdomen or the appear- ance of pressure symptoms should always lead one to make a careful exam- ination. Again, failure of the presenting part to engage, when the pelvis is known to be normal, suggests an obstructing mass. On the other hand, if the tumor does not occupy the pelvic cavity, the diagnosis is extremely difficult, and the abdominal enlargement is frequently attributed to the presence of twin pregnancy or hydramnios, and the true condition is not recognized until after labor. Treatment.—If the tumor is detected prior to the last month of preg- nancy, it should be removed at once by laparotomy. Orgler has collected 142 such operations, which Heil, in 1904, increased to 188, 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 the cases collected by Orgler and Heil. It should, however, 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 the last month of 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. At the time of labor, if the tumor is impacted in the pelvis, unanimous opinion favors its immediate removal by laparotomy. Ltand Sutton, Spencer, and most authorities advise that the abdomen should then be closed and the birth of the child left to Nature, or at most assisted by forceps. On the other hand, I am of the opinion that a supple- mentary Caesarean section should immediately follow, believing that the woman should not be submitted to the strain of labor immediately after a severe operation. Formerly it was advised to attempt the reposition of the mass under anaesthesia. This practice, however, is not to be recommended, for the reason that the tumor is very liable to give rise to trouble during the puerperium. 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 be considered as a dangerous and extremely reprehensible prac- tice, inasmuch as we possess no means of preventing the tumor contents from contaminating the peritoneal cavity. If spontaneous labor has occurred, the patient should be carefully watched during the puerperium for the appearance of untoward symptoms. 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. LITERATURE 695 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 XXXVIII reference will be made to dystocia due to tumors arising from the pelvic walls. In rare instances a normal sized or enlarged kidney or spleen may pro- lapse 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 pro- lapsed spleen in the second month of pregnancy, which would have given rise to serious dystocia at the time of labor had it remained in situ, Echinococcus cysts are occasionally implanted in the pelvic cavity. Franta, in 1902, collected 22 cases noted during pregnancy and discussed their effect upon the course of labor. In 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 pregnancv. Enterocele or hernia through the vaginal walls occasionally gives rise to dystocia, though in the majority of cases the prolapsed intestine can be replaced and the obstacle temporarily overcome. Where this is not possible, Ca'sarean section is indicated as a more conservative procedure than forci- bly dragging the child over a large irreducible hernia. In occasional instances tumors of the bladder 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, cases have been re- ported in wdiich it has been necessarv to remove a large calculus from the bladder before deliverv could be elTected. A large rectocele or cystocele, though occasionally offering slight obstacle to labor, can generally be replaced while delivery is being effected. Tumors arising from the lower part of the rectum or pelvic connective tissue may likewise give rise to serious dystocia Holzapfel having collected a. series of cases in which carcinoma of the rectum rendered Ca-sarean section necessary. LITERATURE Ahlstrom. Zwei Kaiserschnitte wegen narbiger Verengerung der weichen Geburts- wege. 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., 190:1, viii, 97-125. Bland Sutton. The Surgery of Pregnancy and Labour complicated with Tumours. Lancet, 1901, i, 382-386; 452-450; 529-532. Brindeau. Do 1 'atresie acquise du vagin au point de vue obstetricale. L 'Obstetrique, 1901, vi, 97-122. Cambell. Rupture of an Incarcerated Retroverted Gravid Uterus. Jour. Obst. and Gyn. Brit. Empire, 1908, xiv, 402 404. Carstens. Fibroid Tumor Complicating Pregnancy. Am. Jour. Obst., 1909, lix, 4-17-lf>2. Coester. Ueber Geburtshindernisse durch hymenale Balken, etc. D. I., Marburg, 1900. 696 DYSTOCIA DUE TO ANOMALIES OF GENERATIVE TRACT 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, Ivii, 165-197; 296-308. GtlDER. Ueber Geschwulste der Vagina als Schwangerschafts- und Geburtskomplika- tionen. D. I., Bern, 1889. Heil. Beitrag zur Ovariotomie in der Schwangerschaft. Miinchener med. Wochen- schr., 1904, li, No. 3. Holzapfel. Kaiserschnitt bei Mastdarmkrebs. Beitrage zur. Geb. u. Gyn., 1899, ii, 59-77. Hue. Quelques recherches sur 1'ampliation du diaphragme pelvien, etc. Paris, 1906. 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 'accouche- ment. These de Paris, 1899. Lefour. Quoted by Olshausen. Lynch. Kaiserschnitt und schwere GeburtsstSrung infolge Ventro-fixation und Suspension. Monatsschr. f. Geb. u. Gyn., 1904, xix, 521-538. McKerron. The Obstruction of Labour by Ovarian Tumours in the Pelvis. Trans. Lond. Obst. Soc, 1897, xxxix, 334-382. Pregnancy with Ovarian Tumour. London, 1906. von Meer. Conception und Abort durch den Ausfiihrungsgang der Blase bei ange- borener Defect der Vagina. Beitrage zur Geb. u. Gyn., 1900, iii, 409-424. Neugebauer. Zur Lehre von den angeborenen und erworbenen Verwachsungen 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, 765-814. Orgler. Zur Prognose und Indikation der Ovariotomie wahrend der Schwanger- schaft. Arch. f. Gyn., 1901, lxv, 126-160. Pinard. Fibromes et grossesse. Annales de gyn. et d'obst., 1901, lv, 165-167. Remy. De la grossesse compliquee de kyste ovarique. Paris, 1886. Rtjhl. Kritische Bemerkungen iiber Geburtsstorungen nach Vaginalfixatio-uteri. Monatsschr. f. Geb. u. Gyn., 1901, xiv, 477-911. Sasonoff. Etude du thrombus de la vulve et du vagin. Annales de gyn. et d 'obst., 1884, xxii, 447-467. Schauta. Myom und Geburt. Compte-rendn XVIe Congres internat. de Medecine, vii, 8-32. Budapest, 1910. Schenk. Hochgradige frische vEtzstenose der Cervix und des Fornix in der Schwan- gerschaft. 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 Pregnancy, with Report of a Successful Case. Bull. Johns Hopkins Hosp., 1898, ix, 56-61. LITERATURE 697 Thumin. Chirurgische Eingriffe bei Myomen der Gebarmutter in Schwangerschaft und Geburt. Archiv f. Gyn., 1901, lxiv, 457-525. Ward. Atresia Vagina? complicating Labour. Obstetrics, 1899, i, 623-625. Williams. Dystocia following Ventral Suspension and Fixation of the Uterus. Trans. Southern Surgical and Gyn. Association, 1906, xix. CHAPTER XXXIII CONTRACTED PELVIS We consider a pelvis contracted Avhen 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 centimeters or less in flat, and 10 centimeters or less in generally contracted pelves. History.—Inasmuch as Vesalius 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 (1530-15S!)), 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 experi- ence 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 knowledge of contracted pelves from an obstetrical standpoint. In his "New Light for Midwives," which appeared in 1701, he described the generally contracted 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 contraction, carefully described the mechanism of labor in such cases, and gave excellent pictures showing the influence exerted by the contracted pelvis upon the fcetal head. Baudelocque (1746-1810) contributed largely toward the development of our knowledge of the subject, as he devoted particular attention to the 698 FREQUENCY 699 diagnosis of the condition in the living woman, and showed that it could be detected by measuring the distance between certain external bony parts 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 some- what similar lines and devised a pelvimeter for the direct mensuration 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 conjugata vera of 10 or 9.5 centi- meters, 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 Naegele, 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 considerably in differ- ent countries, and even in various parts of the same country. Thus, as is shown by 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. Heinsius (Breslau) ...... ' 8.5 ' " 1,641 (< Pfund (Munich) ........ ' ' 9.5 ' 1 " 1,199 11 Fuchs (Erlangen) ...... ' ' 11.43 ' ' " 1,766 l c Michaelis (Kiel) ........ ' ' 13.1 ' ' " 1,000 (I Kottgen (Bonn) ......... ' 13.45 ' ' " 2,000 i I Litzmann (Kiel) ....... ' ' 14.9 < ' " 1,000 i I 16 ' ' " 1,177 i t Weidenmiiller (Marburg).. ' ' 18.7 ' < " 3,224 11 Baisch (Tubingen) ...... ' 24 ' ' " 3,375 I ( Leopold (Dresden) ...... 24.3 < " 2,415 11 700 CONTRACTED PELVIS Winckel states that contracted pelves are observed in from 10 to 15 per cent, of all German women, while Schauta estimates that the condition is met with in one woman out of seven. 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 " Large series of statistics are not available for France. The yearly reports from Pinard's clinic, however, indicate a frequency of about 5 per cent., while Budin gives 8 per cent, in 7,687 cases, and Tarnier 16 per cent. in 715 cases. Fancourt Barnes, in 1897, reported that only 0.5 per cent, of coi cracted pelves were observed in 38,065 cases of labor in London. In view of the fact, however, that every year a considerable number of Caesarean 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 in this country contracted pelves are very rare, 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. Hirst, on the other hand, states that these diseases are not of infrequent occurrence, and that no one who practices obstetrics can fail to meet with occasional examples. We owe to Reynolds the first statistical statement upon the subject in this country. In 1890 he reported that he had observed 1.34 per cent, of contracted pelves in 2,227 women delivered in Boston. His statements, however, must be accepted with reserve and as nnderestimating the fre- quency of the condition; since he measured the pelvis only in those cases which required operative interference, and left out of consideration those in which labor terminated spontaneously. Had he taken these into account 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 con- secutive patients delivered by the Society of the New York Lying-in Hos- pital. 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, and in 1901 recorded an identical percentage in 2,133 women, somewhat over one-half having been delivered by the out-door service. In April, 1911, I analyzed the conditions found in 4,750 patients treated in the lying-in ward, of whom 3,837 were delivered at full term— 2,178 white and 1,659 black. In this series the total incidence of the usual types of contracted pelves was 18.4 per cent., but a pronounced difference METHODS OF DIAGNOSIS 701 was noted in the two races: H.49 per cent, in the white, as compared with 32.61 per cent, in the black women. In the last 2,750 patients—with 2,215 full-term deliveries, 1,313 white and 902 black—I not only made the usual pelvic measurements, but paid particular attention to the dimensions of the inferior strait, and designated as "funnel" all pelves in which the distance between the tubera ischii was reduced to 8 centimeters or less. In this series the usual types of con- tracted pelvis showed an incidence of 18.33 per cent., and the funnel pelvis one of 6.1 per cent.; the former being observed in 7.46 and 34.5 per cent., and the latter in 5.87 and 6.43 per cent., of the white and black women, respectively. Accordingly, it would appear that in my service the usual types of con- tracted pelvis occur four or five times more frequently in black than in white women, while funnel pelves are equally frequent in the two races. In other words, every twelfth to 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 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 clue 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 those of white women, as was demonstrated by my former assist- ant, T. F. Riggs. Methods of Diagnosis.—It is essential that the obstetrician be able to diagnose 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 line of treatment to be instituted in each case. With this in view, accurate pelvic mensuration should constitute an integral part of the pre- liminary 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 treasts diseases of the heart and lungs without the aid of auscultation and percussion. At the preliminary examination, which should be made four to six weeks before the expected 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 perfectly 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 over- looked, as they are frequently of rhachitic origin. The more usual signs 702 CONTRACTED PELVIS of rhachitis—deformities of the extremities, the characteristically 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 possibil- ity 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 may be relatively easy, while each suc- cessive one becomes more difficult. In primiparous women a markedly pen- dulous abdomen, or the absence of engagement of the head in the last month of pregnancy, should always be regarded as evidence of the exist- ence of a marked 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 in suggesting the possibility of pelvic deformity, accurate in- formation 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 importance 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 instruments of this kind have since been devised, but, although most of them give satisfactory results. Fig. 518.—Budin's Fig. 519.—Martin's Pelvimeter. Pelvimeter. Fig. 520.—Method of Holding Pelvimeter. EXTERNAL PELVIMETRY 703 before buying 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 pelvimeter (Fig. 518), which can readily be carried in the pocket, gives satisfactory results in the vast majority of cases; but it cannot be used to measure the external conjugate in stout women, owing to the slight curva- ture of its blades. Personally, I usually employ the instrument devised by E. Martin (Fig. 519). (a) External Pelvimetry.—The ordinary measurements are four in number: the distance between the anterior superior spines of the ilium, Fig 521.—Measuring the Distance between the Anterior Superior Spines. between the crests of the ilium, between the heads of the trochanters, and between the depression beneath the spinous process of the last lumbar verte- bra and the anterior surface of the symphysis pubis. Normally these meas- ure 26, 29, 32, and 21 centimeters respectively. Naegele suggested certain other measurements, wdiich, 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 704 CONTRACTED PELVIS not be exposed. In order to make the first three measurements, the phy- sician should sit on the side of the bed facing the patient. He then grasps the tips of the pelvimeter 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 possible, the distance between them being indicated on the scale of the instrument. In measuring the distance between the iliac crests, the most widely sepa- rated portions are located, and the tips of the pelvimeter applied to their Fig. 522.—Measuring the External Conjugate. outer edges. In taking these measurements, it should be borne in mind that the iliac spines and crests present an outer and inner lip and an inter- mediate ridge, and that the distance between the outer lips is 1.5 to 2.5 centimeters greater than that between the inner lips. In determining the distance between the trochanters, the patient's 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 pelvimeter are then firmly pressed against them, so that they come into the closest possible con- tact with the bones, after which the measurement is read off on the scale. EXTERNAL PELVIMETRY 705 The external conjugate, or Baudelocque's diameter, extends from the depression just beneath the spine of the last lumbar vertebra to the ante- rior and upper margin of the symphysis pubis. For this measurement, the woman should lie on her side with her back toward the physician. As a rule, the spine of the last lumbar vertebra is quite prominent, and is readily found by palpating and counting the spinous processes from above downward. Imme- diately 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 in place, while the other hand seeks the upper margin of the sym- physis pubis, and firmly applies the other tip of the pelvimeter to it. The distance separating them is then read off on the scale. In stout women considerable difficulty may be experienced in locating the posterior extremity of this diameter,. owing to the fact that the spinous process of the last lumbar vertebra cannot be iden- tified. This, difficulty can usually be obviated in the following manner: A line is drawn between the depressions marking the attachment of the fas- cia to the superior posterior spines of the ilium, which are usually clearly visible. A point 2.5 centimeters above the middle of this line will usu- ally correspond to the point required, and will lie at the apex of a four-sided space1—Michaelis's rhomboid—whose upper and lower margins are formed by the transverse and sacro-spinalis and gluteus muscles respectively. The Value of External Pelvimetry.—Baude- locque, 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 observed a difference of more than 1 or 2 lines between the esti- mated 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 deducted varies with the thickness of the sacrum and the symphysis pubis, and also depends, to a great extent, upon the elevation of the promontory of the sacrum and the length of the spinous process of the last lumbar ver- tebra. Unfortunately, these factors cannot be accurately estimated 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 conclusions Fig. 523.—Michaelis's Rhomboid (Stratz). 47 706 CONTRACTED PELVIS after studying 120 dried pelves; and I have in my possession two specimens whose true conjugates 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 never- theless enables us to draw certain important conclusions. Thus, generally speaking, when 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 Fig. 524.—Measuring the Diagonal Conjugate. It was formerly believed that one could form a fairly accurate estimate of the length of the transverse diameter of the superior strait by making certain deductions from the distances between the anterior superior spines and between the crests of the ilium. The incorrectness of this conclusion, however, was first demonstrated by Scheffer, who showed that the trans- verse 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 EXTERNAL PELVIMETRY 707 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 corresponding decrease in the transverse diameters of the pel- vic 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 meas- ured 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 indicates the presence of contracted pelvis in three-quarters of all colored women, as compared with only one-third as shown by internal pelvimetry. Fig. 525.—Measuring the Length of Diagonal Conjugate upon the Fingers. Fig. 526. Fig. 527. Figs. 526, 527.—Diagrams Showing Variations in Length of Diagonal Conjugate De- pendent upon the Height and Inclination of the Symphysis Pubis. Nevertheless, despite many possible inaccuracies, the external measure- ments are of considerable value, in that they serve to indicate with tolerable certainty the variety of pelvis with which one has to deal. Normally 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, 708 CONTRACTED PELVIS this proportion becomes deranged, aiid the two measurements approximate one another in length, the former frequently being equal to, and occasion- ally exceeding the latter. If, however, both measurements are considerably below the normal, but preserve their usual relation 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. In private practice it is my rule to employ external pelvimetry at the preliminary examination four to six weeks before the expected date of confinement. If the measure- ments are approximately normal, the patient being a primipara and the child's head deeply engaged in the pelvic cavity, internal mensuration is not practiced. But if the external conjugate falls below 18 centime- ters, internal pelvimetry should be resorted to, no matter what the po- sition of the head, nor how many children the patient may have borne previously. (b) Internal Pelvimetry. — In the vast majority of abnormal pelves the most marked deformity affects the antero-posterior diameter of the superior strait, and as a consequence we are especially anxious to ascertain the length of the conjugata vera. Un- fortunately, this cannot be measured directly in the living woman, and in practice it is estimated by measuring the diagonal conjugate—the distance from the promontory of the sacrum to the lower margin of the symphysis Fig. 528.—Diagram Showing Effect of Position of Promontory of Sacrum upon the Length of the Diagonal Conjugate. Fig. 529.—Stein's Pelvimeter. pubis—and making a certain deduction from it. This method was intro- duced by Smellie, and still further 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 can- INTERNAL PELVIMETRY 709 not 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 the anterior surface of the sacrum is methodically palpated from below upward, and its vertical and lateral curvature noted. Fig. 530.—Measuring Conjugata Vera with Skutsch's Pelvimeter. At the same time the mobility of the coccyx should be tested by seizing it between the fingers in the vagina and the thumb externally. In normal pelves only the last three sacral vertebra} 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 measure the diagonal conjugate, the elbow must he 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 of the sacrum is soon felt by the tip of the second finger as a projecting bony margin at the base of the sacrum. With the finger 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 dis- tance between it and the tip of the second finger is measured (Figs. 524 and 525). This represents the diagonal conjugate, from which the true conju- gate is estimated by deducting 1.5 to 2 centimeters, according to the height and inclination of the symphysis pubis. In this method the problem consists in estimating the length of one side of a triangle, the conjugata vera; the other two—the diagonal conju- gate 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 conjugate could readily 710 CONTRACTED PELVIS be ascertained by the ordinary rules of trigonometry. Unfortunately, this cannot be done in the living woman, but for practical purposes it suffices to estimate the length of the 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. 526 and 527. 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. 528). Van der Hoeven (1912) has pointed out the fallacies involved in indirect mensuration, 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 the majority of them, while theoretically correct, are prac- tically useless on account of the difficulty of their application. Descrip- tions and illustrations of many of them are to be found in Skutsch's excel- lent monograph. Skutsch, in 1886, devised a pelvimeter by which the conjugata vera could be indirectly, though accurately, measured (Fig. 530). Hirst more Fig. 531.—Hirst's Pelvimeter. recently described a simple device for the same purpose. Both of these instruments give fairly satisfactory results when properly used, but their employment is usually so painful to the patient as to require the adminis- tration of an anaesthetic. Naturally, therefore, they are employed only when accurate information concerning the length of the conjugata vera is urgently called for, and even then they leave a great deal to be desired. Neumann and Ehrenfest, in 1900, described a complicated instrument —the pelvigraph—by means of wdiich the contour of the anterior and pos- terior walls of the pelvis can be graphically outlined, whence the exact length of the various antero-posterior diameters can be readily ascertained. This instrument gives excellent results, but is too complicated for use out- side of a well-regulated hospital. Since 1904 renewed interest has been manifested in the direct mensu- INTERNAL PELVIMETRY 711 ration of the conjugata vera, and Bylicki, Ahlfeld, Zweifel, Gauss, and others have devised more or less simple instruments for the purpose.. In the hands of their inventors such instruments have proven most satisfactory, but others have found that their employment gives no more accurate results than can be obtained by the old manual method; although Van der Hoeven considers that greater accuracy can be obtained by the use of Gauss's in- strument than by any other method. Measuring the Transverse Diameter of the Superior Strait.—This diam- eter cannot be measured directly in the living woman, and, as a rule, for all practical purposes it is nec- essary only to palpate the linea terminalis with the examining fingers, and in this way rough- ly estimate the outlines of the superior strait. If, however, we wish to be more exact, its length can be ascertained ap- proximately by the employ- ment of Skutsch's instrument (Fig. 532). Lohlein attempted to esti- mate the size of this diameter by adding a "constant" to what he designated as the as- cending oblique diameter. This extends from the lower mar- gin of the symphysis pubis to the anterior and upper margin of the sacro-sciatic notch, and can be measured by the finger. As the investigations of Stein- brecher 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 Pelvic Outlet.—As has already been indicated, con- tractions of the pelvic outlet occur in 5 or 6 per cent, of all women, and probably represent the most usual type of abnormality encountered in the white women of this country, and, as they may give rise to serious dystocia, should receive more extended consideration than they are usually accorded. The contraction may be limited to either the transverse or the antero-pos- terior diameter, or may involve the two, and be either symmetrical or irregu- lar in character. Leaving out of consideration 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 Fig. 532.—Measuring Transverse Diameter of Superior Strait with Skutsch's Pelvimeter 712 CONTRACTED PELVIS ischii should be made an integral part of the routine examination of the pelvis. An approximate idea may readily be obtained by Sellheim's method of palpating the pubic arch. For this purpose, the woman having been placed in the dorsal position with the hips protruding beyond the edge of Fig. 533.—Palpation of Pubic Arch. the bed or examining table and the legs drawn up, the buttocks are seized by both hands in such a manner that the web of the thumb comes in con- tact with the ischial tuberosity, while the thumb follows the course of the corresponding ischio-pubic ramus and the other fingers grasp the side of the thigh (Fig. 533). In this way the outlines of the pubic arch are very sat- isfactorily indicated by the position of the thumbs, so that with a little practice one can readily determine whether it is normal or contracted. If the pubic arch appears to be narrowed, the transverse diameter of the outlet should be accurately measured, and, if it be 8 centimeters or less in length, still other measurements should be made. For this purpose the regions about both tubera ischii are carefully palpated with the thumbs, and, when the points corresponding to the ends of the diameter have been MEASURING THE PELVIC OUTLET 713 located, the thumbs are brought into such a position that their nails repre- sent 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. 535). If an assistant is not available, equally Fig. 534.—Palpation of Ischial Tuberosities. satisfactory results may be obtained by using the outlet pelvimeter which I have devised, in wdiich the tips of the blades are attached to the thumbs by adjustable rings (Fig. 536). Direct measurement by means of the palpating fingers is to be preferred to the method described by Schroeder, in wdiich, 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, however, it must fre- quently happen that considerable distortion will occur as soon as the pres- sure of the fingers is removed. The antero-posterior diameter, between the lower margin of the sym- physis and the tip of the sacrum, is readily measured by a modification of Breiskv's method. For this, the woman should be brought so far down upon the table that 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 deduc- 714 CONTRACTED PELVIS tion of 1 centimeter from this measurement will give a tolerably accurate idea of the length of this diameter (Fig. 537). Unfortunately, however, this knowledge is of but slight practical value in the cases in which it is most particularly desired, for the reason that, when the transverse diameter is markedly shortened, the pubic arch be- comes 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 Fig. 535.—Measuring the Distance between the Tubera Ischii. not upon the length of the antero-posterior 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 by Klien as the posterior sagittal of the outlet, and should be measured whenever the trans- verse diameter measures 8 centimeters or less. This, however, requires the use of a special instrument, and will be considered in greater detail under the heading of Funnel Pelves. Use of X-rays.—After the discovery of the Rontgen ray and the dem- onstration of the various uses to which it might be put, it was thought possible that it might also afford a valuable method of investigating the shape and size of the pelvis. Budin and A'arnier, in 1897, reported their experience with it, and showed that, while it often gave an excellent idea of its shape, the ideas as to size obtained by it were erroneous. A compre- hensive review of the literature upon the subject was given by Miillerheim in 1898. Up to 1900 all radiographs of the pelvis gave distorted ideas in regard to its dimensions, owing to the fact that the sacrum lay much nearer the sensitive plate than the symphysis, and consequently the anterior portion of the pelvis was enlarged out of all proportion to the posterior. This defect CLASSIFICATION OF CONTRACTED PELVES 715 made it impossible to attempt to utilize the radiograph for purposes of mensuration. Bouchacourt suggested that it might be obviated by placing a rectangular metal frame about the woman's hips, more or less correspond- ing 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 on 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. A similar method was employed by Fig. 536.—Mensuration of Transverse Diameter of Outlet with Williams's Pel- vimeter. XM> Fabre, of Lyons, and, according to Donnezan, has given most satisfactory results. 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 aetiological factors which lead to its production. This method was adopted by Michaelis, and reached its greatest perfection in Litzmann's hands. The former thor- oughly realized its inherent defects and regretted that other methods of classification could not be employed. Kilian, Busch, and Siebold had pre- viously recognized the necessity of taking into account the aetiological fac- tors 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 satisfac- tory etiological classification, which soon obtained general acceptance, although it was still far from ideal. Tarnier and Budin, in their treatise 716 CONTRACTED PELVIS 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 under- lying 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 Fig. 537.—Diagram Showing Williams's Modification of Breisky's Method of Meas- uring Antero-posterior Diameter of Outlet. X H. aetiological classification can be perfectly satisfactory, though from a prac- tical .point of view the one employed by Tarnier and Budin would seem to approach more nearly to it. For convenience of reference we shall give the classifications of Tarnier and Budin and of Schauta in parallel columns; but although we shall gen- erally follow the former in describing the several varieties, we shall not necessarily adhere to the order in which the different groups are arranged. CLASSIFICATION OF CONTRACTED PELVES 717 Tarnier and Budin's Classification I. Pelvic Anomalies due to Excess of Malleability of Pelvic Bones: (a) Ehachitic pelvis. (6) Flat, non-rhachitic pelvis. (c) Osteomalacic pelvis. IT. Anomalies due to Abnormal Trans- mission of the Body Weight to Pelvis: (a) Lordosis. (b) Scoliosis. (c) Kyphosis. III. Anomalies resulting from Abnormal Articulation of the Vertebral Col- umn with the Sacrum: (a) Spondylolisthesis. (b) Spondylizeme. IV. Anomalies resulting from the Abnor- mal Direction of the Upward and Inward Force exerted by the Fem- ora: (a) Unilateral lameness. (b) Bilateral lameness. V. Anomalies resulting from Primary Defects in the Development of the Pelvic Bones: (a) Generalized and symmetrical: 1. Excess of general development (justo-major pelvis). Schauta 's Classification I. Anomalies resulting from Faulty Development: (a) Generally contracted pelvis. (b) Simple flat, non-rhachitic pelvis. (r) Generally contracted flat pelvis. (d) Narrow, funnel-shaped, foetal or un- developed pelvis. (V) Imperfect development of one sacral ala (Naegele pelvis). (/) Imperfect development of both sacral alae (Robert pelvis). (g) Generally, equally enlarged (justo- major pelvis). IT. Pelvic Anomalies resulting from Diseases of the Pelvic Bones: (a) Rhachitic pelvis. (b) Osteomalacic pelvis. (c) New growths. ( per cent. As abnormal j^resentations occur more frequently in multiparous than in primiparous women even under favorable conditions, as might be ex- pected, they become 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 pe- culiar significance, as their occurrence is nearly always associated with marked 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 Fcetus.—La Torre, Pinard, and others have stated that the chil- dren 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 factors predis- posing to the premature termination of pregnancy. Wilcke and Riggs, after careful study, have concluded that such is not the case, but that the children, under such circumstances, are generally slightly smaller than usual. This is particularly the case with generally contracted rhachitic pelves, as such women are usually under-sized and would naturally give birth to smaller children than would larger and better formed individuals. 744 ANOMALIES DUE TO MALLEABILITY OF PELVIC BONKS MECHANISM OF LABOR IN SIMPLE FLAT AND FLAT RHACHITIC PELVES The possibility of the occurrence of spontaneous labor in flat pelves de- pends primarily upon the degree of contraction, and, when this is not ex- cessive, upon the following additional factors: the size, compressibility, and malleability of the foetal head, and the character of the expulsive forces. The measurements of the pelvis can be estimated with tolerable accuracy, but there are no satisfactory methods of determining in advance the size and other properties of the head, and not until labor is well advanced can one tell at all approximately what the uterus can do. In 701 cases of labor in contracted pelves, occurring in my clinic up to July, 1910, spontaneous delivery occurred in 74.76 per cent., and became less frequent the more marked the 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 deliverv 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 diagnose the presence of a flat pelvis without resorting to pelvimetry. Inasmuch as in the varieties of pelves under consideration the contrac- tion is practically limited to the anterior posterior diameter of the superior strait, while the transverse diameter remains unchanged, or may even be slightly enlarged, it is evident that the obstacle to the passage of the child's head is offered by the shortened conjugata vera; and when this measures less than 9 or 9.5 centimeters it becomes out of the question for the bipari- etal 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 relation with the conjugata vera. As a result the long arm of the head lever becomes dis- placed 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, owing to the fact that the transverse diameter of the superior strait is not shortened, the head tends to accommodate itself to it, 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 as- sumes when the disproportion between it and the pelvis is at all marked, when we may have what is known as an anterior parietal presentation. In MECHANISM OF LABOR IN FLAT PELVES 74") this the presenting part, which is 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 external palpation. According to the explanation gen- erally 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 of which the posterior portion of the head is pressed against the promontory of the sacrum, where it becomes arrested, while its anterior portion is forced into the pelvis. This presentation is simply an exaggeration of the so-called Xaegele's obliquity, and the mechanism of descent is readily understood when we com- pare the passage of the head through the abnormal superior strait to the manceuvre 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 m^A Fig. 565.—Showing Anterior Parietal Presentation. Fig. 566.—Showing the Passage of an An- terior Parietal Presentation through the Superior Strait. stick so as to allow it to enter the ring obliquely, and after it has partially passed through its other end will descend without difficulty. Sellheim sug- gests that this presentation provides a mechanism for effecting a diminu- tion 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 an oval beyond its fellow the greatest transverse diameter will become considerably diminished. In order for descent of the head to occur, the posterior parietal bone is firmly pressed against the promontory of the sacrum, while under the influence of the uterine contractions the anterior portion of the head is slowly forced down into the pelvis along the posterior surface of the sym- physis 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 pos- terior portion of the head must be subjected to considerable pressure, as is demonstrated by the presence of a more or less well-defined curved depres- sion, just behind the coronal suture, upon the side of the head which was in 740 ANOMALIES DUE TO MALLEABILITY OF PELVIC BOXES contact with the promontory. After the posterior parietal bone has passed the superior strait, all resistance has been overcome, and, owing to the fact that the lower portion of the pelvis is often larger than usual, the rest of the labor is promptly accomplished. In about one-fourth of the cases, according to Litzmann, the reverse condition—the posterior parietal presentation—is observed. The sagittal Fig. 567.—Showing Posterior Parietal Presentation. Fig. 568.—Showing the Passage of a Pos- terior Parietal Presentation through Superior Strait. suture now lies almost in contact with the symphysis pubis, while the pos- terior parietal bone occupies the superior strait, and in marked 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 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 order for the head to enter the pelvis its posterior portion must be pushed down past the promontory of the sacrum, after which its ante- rior portion de- scends 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 of this abnormality is not definitely understood, although it is observed most frequently when the grade of contraction is marked, the pelvic inclination considerably increased, and the abdomen Fig. 569.—Engagement of Head in Reniform Superior Strait (Tarnier). MECHAXISM OF LABOR IN FLAT PELVES 747 not pendulous. The presentation is generally considered as very unfavor- able 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 much more frequently than the anterior, and is without ominous prognostic significance. In my experience, however, it has occurred far less frequently than the anterior variety, although in many eases 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 bead to assume its usual transverse position, and the sagittal suture must occupy an oblique diameter (Fig. 56!)). In rare instances the promontory may project so far forward as to make the superior strait resemble the figure 8. Under such circumstances only one side of it is available for the passage of the head, and Breisky has designated the condition as extra- median engagement. Naturally, either of these conditions serves to ex- aggerate the degree of disproportion. When the pelvic contraction is complicated by the existence of a face presentation, the prognosis becomes more dubious, as it is more difficult for the face than for the vertex to pass the contracted superior strait, and accordingly the course of labor is unduly prolonged. Breech presentations likewise complicate matters to some extent, as the imperfect adaptation of the breech to the superior strait frequently facilitates prolapse of the cord or of one or more of the extremities. In such circum- stances, although the prognosis for the mother remains favorable, the child's life is endangered. This is especially true when the contraction is marked, as considerable difficulty may be expe- rienced in extracting the after-coming head, which, in passing through the contracted superior strait, follows a mechanism analogous to that observed in anterior parietal presentations. In other words, its posterior portion is ar- rested at the promontory, while its anterior portion passes down behind th symphysis, after which its posterior portion descends. Fig. 570.—Showing Passage of After- coming Head through Superior Strait; Darker Child Last. MECHANISM OF LABOR IN GENERALLY CONTRACTED FLAT AND GENERALLY EQUALLY CONTRACTED RHA- CHITIC PELVES The mechanism of labor in generally contracted fiat pelves varies ac- cording 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 con- 748 ANOMALIES DUE TO MALLEABILITY OF PELVIC BOXES tracted type. In the former case, provided the contraction be not too marked, the mechanism of labor will be identical with that just described for flat pelves, whereas in the latter the head will become sharply flexed and be born by the mechanism which we shall consider in detail when we study the generally contracted or justo-minor pelvis. In the generally and equally contracted rhachitic pelvis the mechanism corresponds to that observed in the justo-minor pelvis; while in the pseudo- osteomalacic forms the contraction is usually so marked that the child can- not be born per vias naturales. COURSE OF LABOR IN CONTRACTED PELVES When the pelvic deformity is sufficiently marked 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 to so mold and configure the head as to render possible its entrance into the pelvic cavity. Abnormalities in Dilatation of Cervix.—Normally, dilatation of the cer- vix is brought about by the unruptured membranes acting as a hydro- static wedge, and after their rupture by the direct action of the presenting 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 conse- quently, as its force is not broken by the intervening head, as in normal labor, premature rupture frequently results, occurring, according to Litz- mann, 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 long succession of strong pains have molded the head sufficiently to permit its descent, or have led to the for- mation of a caput succedaneum upon its most dependent portion. Even after the cervix is completely dilated considerable 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.—Frequently the course of labor is still further prolonged owing to faulty uterine contractions. This is rarely the case in rhachitic primiparae, in whom the pains are usually very efficient; but in multiparas, in which previous difficult labors have weak- ened the uterine musculature, secondary uterine inertia frequently occurs as the result of exhaustion. Occasionally the uterus, instead of presenting signs of secondary inertia, may become tetanically contracted. This is an extremely serious condition, as it cannot lead to the termination of labor, and at the same time markedly increases the danger of uterine rupture. If this complication does not yield COURSE OF LABOR IN CONTRACTED PELVES 749 promptly to the administration of sedatives, it affords an imperative indica- tion for the termination of labor by one means or another. Danger of Uterine Rupture.—Abnormal thinning of the lower uterine segment frequently constitutes a very serious danger. When the dispropor- tion between the head and the pelvis is so pronounced that engagement does not occur, the lower uterine segment becomes markedly stretched during a prolonged second stage, 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 somewhere between the symphysis and the umbilicus, and occasionally at the level of the latter, 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 manoeuvres give rise to traumatic rupture. Production of Fistulas.—When the presenting part is firmly wedged into the superior strait, but makes no advance for a long time, portions of the generative tract lying between it and the pelvic wall may be subjected to undue pressure. As a result the circulation is interfered with and necrosis follows, which may manifest itself a few days after labor by the appearance of vesico-vaginal, vesico-cervical, or recto-vaginal fistulas, de- pending 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 pro- longed second stage. Intra-partum Infection.—Infection is another serious danger to which the patient is exposed in prolonged labors complicated by contracted pelvis, particularly when examined repeatedly by a physician who does not observe the most stringent aseptic technique. If the amniotic fluid becomes infected, febrile symptoms appear during labor, while in other cases the micro-organisms pass through the fcetal membranes and invade the uterine walls, giving rise to the characteristic manifestations of infection during the puerperium. In other instances gas-producing bacteria may be introduced into the uterus, which soon becomes distended with gas as a result of their activity —tympanites uteri or physometra. This condition usually follows infec- tion 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 fur- ther 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 lower portion, spontaneous rupture of the sym- physis pubis or of one or both sacro-iliac joints has been observed. Such cases have been reported by Ahlfeld, Schauta, Braun-Fernwald, De Lee, Mayer, and others, though in the majority the injury is produced by in- judicious methods of delivery. Effect of Labor upon the Child.—So long as the membranes remain 750 ANOMALIES DUE TO MALLEABILITY OF PELVIC BONES intact the child suffers but little from the prolonged labor; but after their rupture, frequent and prolonged uterine contractions exert a deleterious influence upon it. This is due in great part to interference with the pla- cental circulation, which sooner or later leads to manifestations of asphyxia- tion. Now and again premature separation of the placenta occurs, causing certain death to the child. After the membranes have ruptured, and 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 occurrence 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 between the presenting part and the pelvic Avail, unless prompt delivery can be accomplished. This must be regarded as one of the most frequent causes of foetal death in spontaneous labor in contracted jielves. 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 consider- able proportions, but is without significance so far as the life of the child is concerned, usually disappearing within a few days after birth. When well marked it may lead to serious diagnostic errors, as it may project almost to the pelvic floor while the head is still above the brim, so that an inexperi- enced physician may mistake it for the head and thus be tempted to resort to ill-timed operative measures. 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 ac- commodation, which is usually spoken of as configuration. In exceptional cases the head may descend into the pelvic cavity compara- tively early in pregnancy, and as it cannot readily escape it undergoes further develop- ment 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. 571. 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 bone which is in contact with the promontory, becomes overlapped by that of its fellow and the same occurs with the frontal bones. The occipital bone on the Fig. 571.—Showing Molding of Head in a Generally Con- tracted Rhachitic Pelvis. COURSE OF LABOR IN CONTRACTED PELVES 751 other hand, becomes shoved under the parietal bones, so that the posterior margins of the latter frequently overlap it. These changes are usually accomplished without detriment to the child, though when the distortion is marked they occasionally lead to rupture of the longitudinal sinus, fol- lowed by fatal haemorrhage. Fk '.—Overlapping of Bones of Skull (Tarnier). Fig. 573.—Overlapping of Bones of Skull (Tarnier) At the same time the head also becomes molded, and the parietal bone, which was in contact with the promontory, usually shows signs of having been subjected to marked pressure, sometimes becoming very much flattened. This process 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 property is of marked 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 spontane- ous labor can result; in the other the more resistant head retains its original shape, and a radical oper- ative procedure becomes necessarv for its delivery. Reference has already been made to the pressure marks upon the seal]) covering the portion of the head which passes over the promontory of the sacrum. Tliese are frequently very characteristic in appearance, and from their lo- cation 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 svmphysis pubis. These marks have no influence upon the well- being of the child, and usually disappear a few days after birth, although in Fig. 574.—Child Born Spontaneously through Generally Contracted Rha- chitic Pelvis, Conjugata Vera 7.25 Cen- timeters, Showing Caput Succedaneum and Depression of Skull. 752 ANOMALIES DUE TO MALLEABILITY OF PELVIC BONKS exceptional instances the pressure may have been so severe as to lead to necrosis and sloughing of the scalp. In a small number of cases fractures of the skull are met with. This accident usually follows violent attempts at delivery, though occasionally it may occur spontaneously. These fractures are of two varieties, appearing either as a shallow gutter-like groove or as a spoon-shaped depression just posterior 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 Fig. 575.—Pressure Marks from Fig. 576.—Spoon-Shaped Fracture of Promontory. Skull (Tarnier). per cent, of the cases, since it extends through the entire thickness of the skull and gives rise to projections upon its interior, 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 the occurrence of pressure symp- toms. Prognosis for the Mother.—The prognosis as to the outcome of labor complicated by contracted pelvis depends not only upon the degree of con- traction, 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 centimeters or less, and is very unlikely when it measures 7.5 cm. Above the latter limit it becomes more and more frequent the less marked the pelvic distortion. 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 incidence increased to 81.75 per cent, when the deliveries by low forceps were de- ducted, in which the operation had naturally no connection with the pelvic deformity. These results compare very favorably with those of other in- vestigators, as is shown by the following figures: Valency ............69 per cent. Burger .............77.8 per cent. Peham .............72.4 per cent. Kronig .............78.5 per cent. Bar .................76.5 per cent. Baisch .............80 per cent. The probability of spontaneous labor decreases rapidly with the degree COURSE OF LABOR IN CONTRACTED PELVES 753 of pelvic contraction, as is shown by the following analysis of my cases, in which the third column gives the total incidence, and the fourth column the corrected incidence obtained by deducting all operations not due to pel- vic 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...................... 248 270 111 37 17 15 85.1% 78.5% 61.3% 37.8% 29.4% 13.3% 94. % 84.3% 67.6% 37.8% 29.4% 20. % 9.5-9.1 cm................... 9 -S.6 cm.. . 8.5-8.1 cm................. 8 -7.6 cm..... 7.5 cm. or less................... Furthermore, if we calculate the length of the conjugata vera by de- ducting 2. instead of 1.5, centimeters from the diagonal conjugate, as is done by most other authorities, our results appear still more favorably, 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................ 9.5-8.6 cm................ 89 % 80 Co 54.4% 9.9'0 89 % 80.5% 63.8% 14.8% 94 % 90 % 65 % is % •• % 89.8% 8.5-7.6 cm................ 60.1% 7.5 cm. or less............. 25 % Generally speaking, the probability of spontaneous labor is somewhat less in generally contracted than in flat pelves presenting the same conjugata vera, it being customary to calculate that half a centimeter must be added to the conjugata vera of the former to reduce it to terms of the latter. This, however, is denied by Baisch, and, in my own experience, the expected diffi- culty is usually compensated for by the somewhat smaller size of the children. The danger to the mother depends upon the course of labor, the per- fection with which aseptic technique is observed, and the treatment pur- sued in operative cases. Speaking broadly, the maternal mortality after spontaneous labor should be hardly greater than that observed in nor- mal pelves, if the1 case is conducted properly. On the other hand, if spon- taneous labor does not occur, and the patient is left to herself, she will die undelivered, either from haemorrhage 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 technique. In our 701 cases of labor complicated by contracted pelves there were 50 754 ANOMALIES DUE TO MALLEABILITY OF PELVIC BONKS 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 cultures taken from the uterine cavity at the time of delivery demonstrated the presence of the micro-organisms which caused the fatal infection, leaving a net mortality of 1.0 per cent. Bar had one maternal death in 1GG 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 70(5 cases of spontaneous labor complicated by contracted pelves, as compared with 5.2 per cent. in 591 operative cases. These results were obtained within the last few years—after the perfection of aseptic technique; previously they were im- possible, as Michaelis, and Litzmann reported a mortality of 10 per cent. and 7.-"> per cent., respectively. A very instructive comparison between the conditions existing then and now was furnished by Tarnier, who stated that the maternal mortality was 22 per cent, in 334 cases occurring in the Maternite in Paris between the years LS(i() and 18G9, as compared with 1.91 per cent, in 1,036 cases occurring between 1884 and 1892. In the latter series 7G4 labors were spontaneous, with a mortality of 0.78 per cent., and 272 were operative with a mortality of 5.15 per cent. Prognosis for the Child.—The prognosis for the fcetus 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, it may be said that the fcetal mortality 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: Conjugata vera 9.25—8.5 cm., foetal mortality 5% " " 8.4 —7.5 " " " 16.9% " " 7.4 —7 " " " 52.9% According to Ludwig and Savor, the mortality was 9.4 per cent, in 706 spontaneous, as compared with 46.3 per cent, in 591 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 two similar series of cases. The difference between the results obtained is due to the fact that Ludwig and Savor resorted to craniotomy in the difficult cases, while Bar and Baisch per- formed (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 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 admitted to the hos- pital, having succumbed as the result of operative measures undertaken out- side, 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 IN CONTRACTED PELVES 755 TREATMENT OF LABOR COMPLICATED BY CONTRACTED PELVES The treatment of labor complicated by contracted pelves varies accord- ing to the degree of contraction, the size of the c-hild, and the history of previous labors. Generally speaking, a normally developed full-term child cannot be born spontaneously when the conjugata vera measures 7 centi- meters 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 below and those above the limits just mentioned. In the first group the problem is comparatively 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 differ- entiate between the flat and generally contracted pelvis, and to consider that a conjugata vera of a certain length in the former gives rise to the same degree of dystocia as one a half centimeter longer in the latter. Accord- ingly, a flat pelvis of 7 centimeters is usually considered as equivalent to a generally contracted one of 7.5 centimeters; but as, in my experience, this is usually not the case, I shall group both types together. When the conjugata vera falls below 7.5 centimeters the treatment will vary according as the child is alive or dead, as well as upon the physical condition of the mother and her surroundings. If the deformity be diagnosed during pregnancv, the patient should be sent to a well-regulated hospital for the performance of Cesarean sec- tion 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 nearly all of the mothers should be saved, inasmuch as the maternal mortality following Cesarean section, when performed upon healthy women by competent operators at an ap- pointed time, need hardly exceed that following the removal of ovarian cystomata. On the other hand, if the condition of the pelvis is not diagnosed 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 among suitable surroundings, Cesarean section will offer every prospect for saving both her and the child, pro- vided the latter is in good condition. But if the patient is infected or in poor condition, or the child is dead or dying, the line of treatment to be pursued will be determined by the degree of pelvic contraction. If the conjugata vera be above 5.5 centimeters, craniotomy should be performed; 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 impos- sible, or at least quite as dangerous to the mother as a Cesarean section, 756 ANOMALIES DUE TO MALLEABILITY OF PELVIC BONES done under unsatisfactory conditions. In infected cases the delivery of the child should be followed by a total hysterectomy, whereas the classical conservative operation should be chosen if the patient is in good condition. Pubiotomy should not be thought of here, as its field of usefulness is limited to those cases in which the conjugata vera measures more than 7 centimeters. Conjugata Vera above 7.5 Centimeters.—Here the question as to the proper treatment cannot be so readily disposed of, since definite rules can- not be laid down for the entire group, and each case must be considered upon its own merits. We know in general that spontaneous labor will occur in many of these cases, and that its probability increases markedly with each half centi- meter's increase in length of the conjugata vera. But at the same time it is very 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 tolerable accuracy, unfortunately we can form only a very imperfect estimate concerning the other factors; and until some method is devised by which this becomes possible, the treatment of labor complicated by moderate degrees of contraction will remain a very difficult problem. Methods of Determining the Size of the Head.—Despite the existence of numerous methods devised for accurately 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; and if they were large and firmly ossified, it is extremely probable that the child in question will possess a head showing similar characteris- tics, which may even be somewhat larger, as it is well known that the size is liable to increase with the age of the mother. Again, in some instances, Midler's method of impression may afford material aid. In this procedure, the patient having been anaesthetized, 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 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 the question, as we have no means of foretelling the extent to which molding and con- figuration will occur at the time of labor. Munro Kerr employs the following method, which has the advantage of not requiring the services of an assistant. The obstetrician takes the Pawlik grip of the foetal head with his right hand and presses it 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. TREATMENT OF LABOR IN CONTRACTED PELVES 757 In Pinard's palper mensurateur, the browT 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 down- ward 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 prominent tumor over the symphysis pubis, the probabilities are that engagement will not occur. Ahlfeld believes that the biparietal diameter of the head bears a definite relation to the length of the child, and suggested attempting 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. t i it 49 " " '' " 8.72 '' " " 48 " " " " 8.56 " n << 47 '' '' '' '' 8.44 '' n a 4G " " " " 8..'54 " These figures, however, represent only the average obtained from the meas- urements of a number of children, but do not necessarily hold good for any given case. 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 by means of strips of adhesive plaster. The former estimates the length of the biparietal by subtracting 2.5 centimeters from the measurement so obtained, while the latter contends that the amount to be subtracted averages 2.33 centi- meters, but varies according to the length of the fronto-occipital diameter, as shown by the following table: Fronto-occipital diameter 10.00, subtract 1 centimeter 10.50, < t 1.55 centimeters 10.75, i. 1.81 3.7 per cent. of all pelvic abnormalities in the two races respectively, ^n the colored race it is undoubtedly a sign of degeneration, and is a manifestation of the im- perfect physical development wdiich characterizes negroes 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 1|K "^ ^^3**p ' S but rarely, militates against such M^. «t ^v ^ 4 a view. It is quite possible that not a few so-called justo-minor pelves are really of rhachitic origin, especially in negroes, and that in such cases the other more characteristic changes are lack- fig. ssi.—Chondrodystrophia Fcetalis. ing. The diagnosis is readily made.. The existence of a generally contracted pelvis should always be suspected in small women, and especially in poorly developed working women, although it should not be forgotten that it may occur in large and apparently wedl-formed individuals. Accurate informa- tion can be obtained by means of pelvimetry. All of the external measure- ments are considerably and uniformly shortened. Internal examination shows a shortened conjugata 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 wen- Spines, 23.2^\ crests, '2r>.7; trochanters, -26.3; Baudelocque, 17.9; and diag- onal conjugate, 11.1 centimeters, while in 167 colored women each meas- urement was a few millimeters shorter. The effect of the generally contracted pelvis upon labor is very char- acteristic. Owing to the fact' that all the diameters of the superior strait are shortened, instead of only the conjugata vera, as in flat pelves, the head encounters more or less equal resistance from all sides of the pelvic inlet, and consequently enters it in a sharply flexed position, so that on vaginal examination the small fontanelle is readily felt, whereas the large fontanelle is almost or quite out of reach. Moreover, as the contraction involves all portions of the pelvic canal, labor is not rapidly completed after the head has passed the superior strait, but as a rule is considerably prolonged. This is due partly to the resistance offered by the pelvis, and partly "to the faulty character of the uterine contractions incident to the im- perfect development of the uterus, which frequently characterizes such cases. 51 770 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT As has already been said, it is usually taught that a generally contracted pelvis with a conjugata 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 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 justo-minor variety, though in exceptional instances the relatively great contraction of the inferior strait may give rise to serious dystocia. The Infantile Pelvis.—In rare instances, as the result of disease, which has caused the individual to spend her entire life in bed without attempt- ing to sit up or walk, the pelvis retains the characteristic infantile form to which refer- ence was made in Chapter I. Examples of this abnormality have been described by Naegele, Leisinger, Biittner, and Gurlt, but naturally it possesses no obstetrical significance. The Dwarf Pelvis.—According 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 chondrodystrophia fcetalis (Kauf- mann), achondroplasia (Parrot and Porak), or fcetal rhachitis, as the disease has been vari- ously designated. The affection is not allied to rhachitis, but is characterized by well-marked changes in the epiphyseal cartilages, which lead to imperfect development of the shafts of the. long bones, so that the individual may present a well-formed head and body, while the ex- tremities are short and stumpy. Herrgott has shown that the condition is sometimes heredi- tary, and that persons suffering from it 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 development, which is particu- larly 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 Fig. 582.—Chondrodystrophic Dwarf (Breus and Kolisko). THE DWARF PELVIS 771 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 those who would fall far below the normal height even if the deformities were straightened out and compensated for. In the hypoplastic dwarf the changes are quantitative instead of quali- tative, 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. Fig. 583. Fig. 584. Figs. 583, 584.—Chondrodystrophic Pelvis (Breus and Kolisko). This variety of pelvis is characterized by an extreme antero-posterior 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 development of the portion of the iliac bone entering into the formation of the ilio-pectineal line, owing to which the sacral articulation is brought much nearer the pubic bone than usual. In 6 pelves of this character described by Breus and Kolisko the conjugata vera varied from 4 to 7 centimeters, while the transverse diameter of the superior strait was but slightly shortened, varying from 11 to 12 centi- meters. The True Dwarf Pelvis (Pelvis Nana).—This variety of pelvis is ex- tremely rare, only 4 well-marked specimens being in existence—those de- scribed by Naegeie and Boeckh, Schauta, Paltauf, and Breus and Kolisko, two of which were in females. The pelvis is generally contracted and 772 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT tends toward the infantile type, but its most characteristic feature is the persistence 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 vertebra? were not fused together (Fig. 585). 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 cartilage may be present here and there in young subjects, but it disappears with ■Jljj^^Z'' ^P| Fig. 585. Fig. 586. Figs. 585, 586.—True Dwarf Pelvis (Boeckh). advancing age and is never found in all the epiphyses as in the true dwarf pelvis. The Rhachilic Dwarf Pelvis.—True rhachitic dwarfs are rare, and pos- sess generally contracted, flat rhachitic pelves, which do not differ from those described in the previous chapter except by their extremely small size. The Hypoplastic Dwarf Pelvis.—According to Breus and Kolisko this variety of pelvis is observed in very small individuals, and is simply a 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 speci- mens, one of which had been obtained from an Egyptian mummy. NAEGELE PELVIS 773 The Naegele pelvis presents the following characteristics: The alas of the sacral vertebra' are either lacking or imperfectly developed upon one side, while the corresponding sacral foramina are smaller than those on the normal side. 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, and its crest is at a higher level than that of its fellow. The ilio-pectineal line is less curved than normally, being almost straight when the deformity is marked, while upon the opposite side its curvature is accentuated, particularly in the anterior portion. Cor- responding with the change in position of the innominate bone, the ischial tuberosity and spine are displaced inward, upward, and backward, thereby approaching the outer margin of the sacrum and narrowing the sacro- Fig. 587. Fig. 588. Figs. 587, 588.—Anterior View of Obliquely Contracted Pelvis (Naegele). sciatic 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 ankvlosed 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-iliac joint and its larger end toward the horizontal ramus of the pubis on the well side. Its oblique diameters are of unequal length, the shorter extending from the sacro-iliac synchondrosis of the well side to the ilio-pectineal eminence on the diseased side, while the conjugata vera is usually somewhat lengthened and is directed obliquely. The distances from the promontory of the sacrum to the acetabulum 774 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT and from the tip of the sacrum to the ischial spine are markedly diminished 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 corresponding 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 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. The walls of the pelvis converge below, so that the contraction involves 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 ace- tabulum on the diseased side is directed more anteriorly, while that on the well side looks almost directly outward. Mode of Production.—The genesis of this variety of pelvic deformity has given rise to a great deal of discussion, some writers claiming that Fig. 589.—Posterior View of Obliquely Contracted Pelvis (Naegele). 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 alse. The former view was advocated particularly by Unna, 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 alae might be lacking without a sign of synostosis. Moreover, Thomas and Kundrat, among other observers, have demonstrated that the alse 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: NAEGELE PELVIS 775 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 displace- ment of the corresponding innominate bone. Owing to the increased pressure, the synovial membrane at the sacro-iliac synchondrosis gradually undergoes pressure necrosis, and synostosis eventually results. Frequency.—Thomas, in 1861, was able to collect from the literature 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. Unfor- tunately, 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 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. Naegele suggested five measurements which should be made in such cases: (1) From the tuber ischii of one side to the opposite posterior supe- rior 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 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 information obtained from the second and third is of very considerable value. A differ- ence of more than 1 centimeter between these measurements 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 in- ternal 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 lateral wall of the pelvis, as well as the ischial spine and tuberosity, approaches the sacrum much more closely on the diseased than on the opposite side, while the ilio- pectineal line is markedly flattened. At the same time the distance between the tubera ischii is markedly diminished. Effect upon Labor.—When the deformity is at all pronounced, the side of the pelvis corresponding to the small end of the oval is so contracted as to be useless for the passage of the child, so that engagement, if it is to 776 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT occur at all, must take place on the opposite side. In effect, the pelvic inlet becomes converted into one of the generally contracted variety, 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, labor will progress more favorably when the occiput is directed toward the ilio- pectineal 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 steady increase of the contraction in the lower portion of the pelvis, marked difficulty is experienced when the head attempts to pass between the ischial spines and tuberosities, and the possibility of deliverv depends upon the distance between these points. Prognosis.—If the deformity is at all pronounced the prognosis is bad, unless Ca'sarean section be performed. Litzmann states that 22 out of 28 Fig. 590. Fig. 591. Figs. 590, 591.—Transversely Contracted Robert Pelvis (Robert). 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 8.5 centimeters. When this limit is reached 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 ramus of the pubis and the ascending ramus of the ischium on the diseased side—ischio-pubiotomy. The operation was strongly con- demned by Budin, and its performance is not to be recommended, for the reason that the ankylosis at one sacro-iliac joint may prevent sufficient expansion of the pelvis. ROBERT PELVIS 777 III. LOCALIZED AND SYMMETRICAL ANOMALIES IN DEVELOPMENT These may be of several characters: (a) Imperfect development of both sacral ake; (b) lack of union at the symphysis pubis; (c) lack of develop- ment 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. The Transversely Contracted or Robert Pelvis.—Imperfect development of the sacral ala? on both sides produces a pelvis which is markedly con- Fig. 592. Fig. 593. Figs. 592, 593.—Split Pelvis (Breus and Kolisko). tracted 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. 590). In the pelvis described by Robert, the alae on both sides of the sacrum were lacking, and the innominate bones 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 antero-posterior and 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 ahv on the two sides it can readily be understood how an asymmetrically transversely contracted pelvis may result. 778 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 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 only slightly changed, while it is hardly possible for the marked approach of the ischial spines and tuberosities to one another to escape recognition. 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 Caesarean section is the only rational method of treatment. 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 blad- der and imperfect development of the lower portion of the anterior abdom- inal wall. It has been observed in adults, but naturally is more common in young children. 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 are more or less parallel. External pelvimetry in such cases shows a marked Fig. 594.—Contracted Pelvis Due to Absence of Bodies of Sacral Vertebrae (Litzmann). flaring of the anterior superior spines of the ilium, and were the defective condition of the pubis not clearly evident a rhachitic pelvis might be sus- pected. The distance between the extremities of the pubic bones varies consider- ably, and occasionally is as great as 14 centimeters. This space is usually filled by a fibrinous band. Schickele, in 1901, reported a case of labor in SPLIT PELVIS 779 a pelvis of this character, and stated that 8 others are to be found in the literature. In only 2 of them was labor perfectly spontaneous, but in none was great difficulty experienced; consequently for practical purposes 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. Breus and Kolisko give an excellent description of several hitherto undescribed cases, and discuss fully the mechanical factors concerned in their j^roduction. Imperfect Development of the Vertebral Bodies of the Sacrum.—Litz- mann has described a remarkable pelvis, in which almost the entire sacrum Fig. 597. Figs. 595-597.—High Assimilation Pelvis. was lacking. This defect was associated with considerable transverse con- traction, which increased as the inferior strait was approached, the trans- verse diameter of the superior strait measuring 10.5 centimeters, while the 780 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT distance between the ischial spines and ischial tuberosities was 6.5 and 8.5 centimeters respectivelv (Fig. 594). Assimilation Pelvis.—Quite frequently the transverse processes ot the Fig. 598. Fig. 599. Figs. 598, 599.—Transversely Contracted Assimilation Pelvis (Breus and Kolisko) last lumbar vertebra may be transformed into structures similar to the lateral masses of the sacral vertebrae. Hence the former assumes the func- tions of the first sacral vertebra, the sacrum being now composed of 6 Fig. 600.—Low Assimilation Pelvis (Breus and Kolisko). instead of 5 pieces. In other instances the first sacral vertebra may take on the characteristics of a lumbar vertebra and be assimilated with the lumbar column, so that there are 6 lumbar and only 4 sacral vertebrae. ASSIMILATION PELVIS 7S1 Occasionally the first coccygeal vertebra 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 studv. 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 first sacral vertebra is the twenty-fifth vertebra, as normal, or is the twenty- fourth or twenty-sixth vertebra, as the case may be. 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 cor- responds to the second sacral, the twenty-fifth vertebra not becoming in- volved until later. Accordingly, a sacrum with only four vertebrae may indicate the persistence of a feetal type, while the presence of six vertebra shows that the normal process of articulation has been exaggerated. Fig. 001.—Asymmetrical Assimilation Pelvis (Brous and Kolisko) Assimilation is the most common of all pelvic abnormalities, and is noted in at least every fifth or sixth pelvis. Indeed, it frequently happens that pelves which have been demonstrated for years as typically normal present one or other type of this abnormality. Moreover, the condition may be associated with rhachitis or general imperfect development, so that one frequently has to deal with rhachitic or generally contracted assimila- tion pelves (Fig. 552). 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 (! pieces, important changes in the shape of the pelvis result, which depend in great part upon the 782 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 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 pro- ducing a funnel-shaped pelvis (see Fig. 595). In other cases the condition gives rise to a pelvis with a somewhat transversely contracted superior strait (see Fig. 598). 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 be, while the other side undergoes considerable modifica- tion. Under such circumstances asymmetrical pelves result, which are frequently obliquely contracted (see Fig. 601). Funnel Pelvis.—While the most typical examples of funnel-shaped pel- vis are associated with lumbo-sacral kyphosis, contractions of the pelvic outlet are also noted in spondylolisthetic, osteomalacic, obliquely contracted, and other rare types of abnormal pelves. These, however, occur so rarely that they are of scientific rather than practical importance. On the other hand, moderate degrees of outlet contraction are frequently noted under other conditions. Thus, in every fourth or fifth generally con- tracted or justo-minor pelvis the measurements of the inferior strait may be diminished out of proportion to the rest of the pelvis, and occasionally to such an extent as to give rise to serious dystocia. In such cases, how- ever, the diagnosis 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 frequently occurs in pelves which appear to be perfectly normal, at least as far as the usual external and internal measurements are concerned. Such pelves I have designated as typical funnel, in contradistinction to the generally con- tracted variety to which reference has just been made, and they may pass unnoticed if appropriate measurements are not made, unless serious dystocia arises. In the latter event the physician may find himself in the embarrass- ing position of being obliged to resort to a serious operation in order to save the child, after having assured the patient that her pelvis was per- fectly normal. Whenever the transverse diameter of the outlet measures 8 cm. or less I designate the pelvis as funnel and, as stated in Chapter XXXIII, typical funnel pelves were noted in 6.1 per cent, of a series of 2,750 consecutive patients whom I examined up to April, 1911. Indeed, it is the most fre- quent abnormality observed in wdiite women, making up 44 per cent, of the contracted pelves occurring in that race, and being almost as frequent as all of the other varieties combined. On the other hand, it constitutes only 15 per cent, of the abnormal pelves in black women. Notwithstanding this FUNNEL PELVIS 783 marked difference in the relative ratio, its actual incidence in the two races is practically identical—5.87 and 6.43 per cent., respectively. This fact is of great importance in determining the mode of production of the abnormality, for when it is remembered that the incidence of the usual types of contracted pelvis is five times greater in the black than in the white women of the same series, it becomes evident that outlet contractions must be due to some factor other than rhachitis or imperfect general de- velopment, 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 taught me that such is not the case, and I now believe that the great majority of outlet contractions are associated with Fig. 602.—Diagram Showing the Significance of Anterior and Posterior Sagittal Diam- ExElxvS* /\ ?i Spontaneous labor through a transverse diameter of 5.5 cm Fig. 603.—Diagram of Pelvic Out- let of Same Case, Illustrating Possibility of Spontaneous La- bor, Owing to Long Posterior Sagittal Diameter. Xi- 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 lower portion of the pelvic cavity converge, while the upper portion retains ap- proximately 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 sacral verte- brae can be counted accurately on vaginal or rectal palpation in only a com- paratively small proportion of cases. Accordingly, the demonstration of the existence of high assimilation in a small number of living women justi- fies the assumption that it really occurs much more frequently. Shortening may occur in either the transverse or antero-posterior diam- eter of the pelvic outlet, pj ;n both simultaneously. In the great majority 784 ABNORMAL PEEVES FROM ANOMALIES IX DEVELOPMENT of cases the distance between the tubera ischii is reduced to between 7 and 8 centimeters, but in several instances it was less, and in one instance meas- ured only 5.5 centimeters (Figs. 602 and 603). That contractions of this character may seriously affect the course of labor is shown by the fact that in 135 cases, which went to term, the follow- ing operations were necessary to effect delivery: namely, 17 forceps, 1 Caesarean section, 3 pubiotomies, and 1 craniotomy upon the after-coming head. Moreover, even when the disproportion is not sufficiently great to give rise to marked dystocia, it may play an important part in the produc- tion 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 Fig. 604.—Diagram Showing the Significance Fig. 605.—Diagram of Pelvic of Anterior and Posterior Sagittal Diam- Outlet of Same Case, Illus- eters. Xi trating Necessity for C^esa- Caesarean section in spite of a transverse diameter of 6.5 cm. EEAN Section. Xi ischio-pubic 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. In view of the frequency and practical significance of outlet contractions, 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 transverse and antero-posterior diam- eters of the outlet should be measured, and a shortening of the former to 8 centimeters or less should be regarded as a danger signal. Unfortunately, as Klien pointed out in 1896, the length of either of these diameters does not afford a sufficient basis for the formulation of an intelligent prognosis. And it may happen that serious dystocia may sometimes arise with a transverse diameter of 7.5 centimeters, while on the other hand spontaneous labor may occur when it is reduced to 5.5 centi- meters, as in one of my cases (Figs. 602-605). The decrease in length of the transverse diameter is associated with a FUNNEL PELVIS 7S5 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 antero-posterior diameter, but rather upon the space available between the transverse diam- eter and the tip of the sacrum. Klien has designated this distance as the posterior sagittal diameter of the outlet, and has devised a specially constructed pelvimeter for its men- Fig. 606.—Diagram Showing Mensuration of Anterior and Posterior Sagittal Diameters by Williams's Modification of Klien's Pelvimeter. Xi- suration. Fig. 606 represents my modification of the instrument. In order to use it, the patient is placed upon a table with her buttocks projecting so far beyond its edge that the lower portion of the sacrum becomes readily accessible. The tubera ischii are then palpated and the location of the trans- verse diameter determined. The transverse bar of the pelvimeter is then placed in relation with it, and the distance to the tip of the sacrum is meas- ured—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. This latter varies between 5 and 6 centimeters and is subject to comparatively little change; while the external posterior sagittal may vary greatly, and from it the length 52 786 ABNORMAL PELVES FROM ANOMALIES IN DEVELOPMENT 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 diameter of the outlet is shortened, and my observations show that it is unlikely with measurements less than the following: Transverse diameter 8 cm., posterior sagittal 7.5 cm. " " 6.5 " " " 8.5 " " " 5.5 " " " 10 " It should, however, be understood that these are only approximate estimates and by no means accurately indicate the necessity for radical interference, as spontaneous labor may occur when least expected. In multiparous wo- men with a history of previous se- vere dystocia, they may afford an indication for Caesarean section or pubiotomy; while in primiparous women, if spontaneous labor does not occur, they should lead us to substi- tute pubiotomy for brutal attempts at forceps delivery. In young women pubiotomy is the operation of choice whenever the dys- tocia is serious, as it not only affects delivery at the time, but also offers a reasonable prospect of permanently overcoming the abnormality. In four of my patients the transverse di- ameter became permanently widened following the operation. As the increase varied from 1 to 3 cm., the outlet became normal in two patients, while in the other two its transverse diameter increased from 6 to 7.5 and from 7 to 8 cm., respectively. In moderate degrees of outlet contraction the effect of postural treat- ment should be tested before resorting to operative interference, as I have found that by placing the patient in an exaggerated Sims's position the in- nominate bones rotate upon the sacrum to such an extent that the length of the posterior sagittal undergoes an average increase of 0.75 cm., with extremes of 0 and 4 cm. In minor degrees of contraction, such an in- crease may be sufficient to do away with the necessity for the use of forceps. LITEEATTJKE Betschler. Neue Zeitschr. f. Geb., 1840, ix, 121. Boeckh. Ueber Zwergbecken. Archiv f. Gyn., 1893, xliii, 347-472. Breus und Kolisko. Die path. Beckenformen, 1900, i. Spaltbecken, 107-139. As- similationsbecken, 169-256. Zwergbecken, 259-366. Fig. 607.—Diagram Illustrating Effect of Pubiotomy in a Pronounced Funnel Pelvis. Dotted lines show public arch before operation. X§. LITERATURE 787 Budin. Eecherches experimentales a propos de 1'ischio-pubiotomie. Femmes en couches et nouveau-nes, 1S97, 468-4X52. Buttner. Beschreibung des inneren Wasserkopfs und des ganzen Beinkorpers einer von ihrer Geburt an bis im 31. Jahr krank gewesenen Person weibiichen Gesch- lechts. Konigsberg, 1873. Deventer. Neues Hebammenlicht. IT. Aufl., 1728, 196. Gonner. Zur Statistik der engen Becken. Zeitschr. f. Geb. u. Gyn., 1882, vii, 314- 331. Gurlt. Ueber einige Missgestaltungen des weibiichen Beckens. Berlin, 1854. Herrgott. Du nanisme au point de vue obstetricale. Annales de gyn. et d'obst., 1906, 2me S. iii, 1-18. Hohl. Das schragverengte Becken. Leipzig, 1852. Kaufmann. Untersuchungen iiber die sogenannte fotale Eichitis. Berlin, 1892. Klien. Die geburtshulfliche Bedeutung der Verengcrungen des Beckenausgangs. Volkmann's Samml. klin. Vortrage, 1896, N. F. No. 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, 1817. 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, ls41. 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. Pinard. De l'ischio-pubiotomie ou operation de Farabeuf. Annales de gyn. et d'obst., 1893, xxxix, 139-1415. PoRAK. de l'achondroplasie. Nouv. archives d'obst. et de gyn., decembre, 1889. Eichelet. Du bassin generalement retreci, etc. These de Paris, 1896. Eobert. Beschreibung eines im hochsten Grade querverengten Beckens, etc. Karls- ruhe u. Freiburg, 1842. Schauta. Die Beckenanomalien. Midler's Handbuch der Geb., 1889, ii, 220-496. Schickele. Beitrag zur Lehre des nermalen und gespaltenen Beckens. Beitrage zur Geb. u. Gyn., 1901, iv, 243-272. Stein. Lehre der Geburtshiilfe, etc., 1825, i, 78. Tarnier et Budin. Traite de l'art des accouchements, 1898, iii, 314-318. Thomas, S. Das schragverengte Becken, etc. Leipzig, 1861. Unna. Zur Genese des schragverengten Beckens. Hamburger Zeitschr f. die ges. Med., 1843, xxiii, 281. 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. CHAPTER XXXVII PELVIC ANOMALIES DUE TO DISEASE OF THE VEETEBEAL COLUMN KYPHOTIC PELVIS History.—Kyphosis or humpback, the result of spinal caries, plays an important part in the production of pelvic abnormalities, for when situated in the lower portion of the vertebral column it is usually associated with a characteristically funnel-shaped pelvis. We are indebted to Rokitansky for the first accurate work upon the Fig. 608.—Longitudinal Section through Pelvis and Spinal Column in Dorso-lumbar Kyphosis (Breus and Kolisko). subject, although as early as 1759 Madame Boursicr de Coudray reported a Ca'sarean 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 Breisky (1865), who clearly set forth the mechanical factors by which the alteration in shape was brought about. 788 KYPHOTIC PELVIS 7S0 Later, Chantreuil, Champney^. Barbour, Treub, and particularly Breus and Kolisko 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 junc- tion of the dorsal and lumbar portions of the vertebral column its effect upon the pelvis becomes manifest, and is still further accentuated when the kyphosis is lower down, being most marked when it is at the lumbo- sacral junction. Klien analyzed 85 enses reported in the literature, and found that the kyphosis was dorso-lumbar in 2V lumbar in 17, and lumbo-sacral in 37 Fig. 609.—Kyphotic Pelvis, Showing Elongation of Conjugata Vera. cases, while in 7 other cases the vertebral column so overhung the superior strait as to produce a "pelvis obtecta" (Eig. 610). Characteristics. —The 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 fossa1 become flared outward while the lower portions of the ischial bones are turned in toward the middle line. When the kyphosis is in the dorso-lumbar region, marked lordosis below it indicates an attempt at compensation, but as this is imperfect the body weh>ht is transmitted to the sacrum in such a manner that the latter be- 790 ANOMALIES DUE TO DISEASE OP VERTEBRAL COLUMN comes markedly retroposed and lengthened, its promontory being farther backward and at a higher level than usual. At the same time its anterior surface loses its normal vertical concavity and becomes straight or even con- vex ; while its lateral concavity is obliterated by the projection of the verte- bral bodies beyond their alas. The bodies themselves are considerably nar- rower than usual, and the alas of the first sacral vertebra appear to be drawn out and to extend obliquely upward to the promontory. Owing to its backward displacement the posterior surface of the sa- crum approaches the superior posterior spines, thereby relaxing the ilio- sacral ligaments. At the same time the posterior extremities of the innom- inate bones are pushed apart, and as a conse- quence their upper por- tions rotate outward and the lower portions in- ward, 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 Fig. 610.—Pelvis Obtecta (Fehling). movement of rotation is still further accentuated by the increased tension exerted by the ilio-femoral ligaments resulting from a diminution of the pelvic inclination. The acetabula also are shifted slightly and look more to the front than usual. Coincident with the dis- placement of the sacrum, the ilio-pectineal line becomes longer, particularly 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 strait be- comes round or oval in shape, with the long diameter running antero- posteriorly, while the transverse diameter remains unchanged or may even be somewhat shorter than usual. There is also a gradual diminution of all the antero-posterior diameters of the pelvis below the superior strait, 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 vera varied from 10.7 to 16.5 centimeters in length, the distance between the spines from 5.2 to 8.2 centimeters, and that between the ischial tuber- osities from 6 to 12.1 centimeters. At the same time it should be remem- bered that in not a few cases the entire cavity is smaller than usual, Klien having pointed out that 30 per cent, of all the kyphotic pelves described were also generally contracted, so that a conjugata vera which at first glance appears normal may in reality be relatively increased in length. KYPHOTIC PELVIS 791 When the kyphosis is situated at the junction between the last lumbar and the first sacral vertebras, the pelvic changes are generally more marked than those just described, as the promontory of the sacrum is usually cari- ous and takes part in the formation of the gibbus. In such cases there Fig. 611.—Diagram Showing Forces Concerned in the Production of Kyphotic Pelvis (Tarnier). 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 alas 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 cen- timeters, as in the cases described by Scliroeder and Doktor. The pelvic inclination is always diminished, and in some cases is entirely obliterated. When the kyphosis is very marked, the lumbar vertebras may so over- 702 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN hang the superior strait as effectively to prevent the child's head from entering it. This condition was described by Eehling as pelvis oblecta. 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 Klien, and has been described by Herrgott as spondylizeme. Mode of Production.—A kyphosis in the dorsal region is usuallv 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 down- ward and the other backward. This latter force draws the promontory of the sacrum backward and upward, thus leading to rotation and elongation of the entire bone (Fig. 611). Breus and Kolisko have shown 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 anterior portions of the vertebras become widely sepa- rated, thus leading to marked lordosis beneath the gibbus. This causes an upward drag upon the bodies of the sacral vertebras, which become stretched and elongated. Coincident with these changes, and resulting from the backward displacement of the sacrum, as well as from the in- creased tension exerted by the ilio-femoral ligaments, the innominate bones likewise undergo rotation, which brings about a narrowing of the lower portion 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 whole, it is probable that any one who has an extensive obstetric practice is liable to meet with this abnormality. 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 trochanters, whereas normally the reverse is true. In a patient suffering 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 out- let will be noted, while internal examination will reveal the lengthening of the conjugata vera. In the lumbo-sacral variety the promontory no longer exists, and the bodies of the lower lumbar vertebra overhang the superior strait. Accordingly, particular attention should be devoted to esti- mating the length of the "pseudo-conjugate"—the distance from the upper margin of the symphysis pubis to the nearest portion of the vertebral col- KYPHOTIC PELVIS 793 umn. 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 abdomen, which in consequence becomes markedly pendulous at an early period of pregnancy. These mechanical conditions favor the occurrence of certain abnormal positions of the foetus, and Klien, in 103 cases, found 100 longitudinal and 3 oblique presentations. Of the former 90 were vertex, 1 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, Fig. 612.—Front and Side View of Patient with Lumbo-sacral Kyphosis (Hirst). while the remainder are equally divided between right anterior and pos- terior presentations. It is difficult to give a satisfactory explanation for the unusual frequency of the right anterior position, but the production of posterior positions is due to the pendulous abdomen, as under such circum- stances the concave anterior surface of the child tends to apply itself to the convex anterior surface of the uterus. At the time of labor the presenting part experiences no difficulty in entering the superior strait, 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 passage of the head, further difficulty is encoun- tered when the latter attempts to pass beneath the pubic arch, which, owing 794 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN 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 impossi- ble, according to the degree of contraction of the transverse diameter 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. (See p. 785.) Owing to the narrowing of the pubic arch, occipito-anterior are less favorable than occipito-posterior presentations, as in the former the wide biparietal diam- eter has to accommodate itself to the pubic arch, whereas in the latter its place is taken by the brow. According to Klien, face presentations are still more favorable for the same reason. Prognosis.—If the contraction is at all marked, the prognosis is bad unless Cassarean 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 occurring 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 forceps, can be looked for, provided the posterior sagittal diameter is not too shortened; but when the measurements are be- low this limit operative interference becomes necessary. Cassarean section is usually the operation of choice, unless the child is very small. Pubiot- omy, however, may be considered if the deformity is not too pronounced, as it will give a sufficient increase in the size of the pelvic outlet to permit the passage of the head, provided the distance between the spines or tubera does not fall below 6 centimeters. If the child is already dead, craniotomy is the operation of election. KYPHO-RHACHITIC 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 widen the inferior strait. Thus it may happen that a woman presenting a SCOLIOTIC PELVIS 795 markedly deformed vertebral column of this character 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 are often observed which have no connection with rickets. When the scoliosis involves the upper portion of the vertebral column, it is usually compensated Fig. 613. Fig. 614. Figs. 613, 614.—Obliquely Contracted Non-rhachitic Scoliotic Pelvis (Breus and Kolisko). for by a corresponding curvature in the opposite direction lower down, thus giving rise to a double or S-sbaped 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 anom- alies 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. When due to rhachitis, the scoliosis may be very pronounced, and give rise to marked pelvic deformity, in which the characteristic changes 796 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN due to the anomaly of the vertebral column are superadded to those result- ing from rhachitis. In such cases the scoliotic convexity is usually directed to the right side, as was noted in 7 out of the 9 cases described by Leopold. Under 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 pro- cesses being directed toward the compressed side, a result which indicates the abnormal direction along which the body weight is transmitted to the iliac bone, and thence to the femur. 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 to the coexistence of rhachitic changes, the contraction is in great part limited to the superior strait. Owing to the pressure exerted upon the eomjiressed side of the sacrum, ankylosis at the sacro-iliac articulation often occurs. At the same time the innominate bone on the affected side is displaced upward, inward, and backward, while its acetabulum looks more forward than usual. The sym- physis 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 pro- nounced cases the superior strait assumes an obliquely ovate appearance, and occasionally the acetabulum on the affected side may come almost in con- tact with the promontory. KYPHO-SCOLIO-RHACHITIC PELVIS 797 The location of the contraction can be determined by external examina- tion, as it alwavs 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 becomes 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 portion of the pelvis. KYPHO-SCOLIOTIC PELVIS 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 deformities 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. KYPHO-SCOLIO-RHACHITIC 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 Fig. 017. Fig. 618. Figs. 617, 618.—Kypho-Scoliotic-Ehachitic Pelvis (Leopold). rhachitis is nearlv always complicated by a scoliosis, and the latter usually predominates in the production of the pelvic deformity, for the reason that the kyphosis and the rhachitis tend mutually to counteract one another in their effect upon the pelvis. Accordingly, the resulting pelvis does not 798 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN differ materially from that observed in scolio-rhachitis, except that the ten- dency to antero-posterior 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, however, this class of pelvis is more favor- able from an obstetrical standpoint than that due to scolio-rhachitis alone. SPONDYLOLISTHETIC PELVIS The term spondylolisthesis (from cmovSvloS, vertebra, and GhiffQ^ffiS, slipping or sliding) was introduced by Kilian in 1853, in describing a pelvis in which the last lumbar vertebra bad become displaced downward over the anterior surface of the sacrum. Characteristics.—The degree of displacement may vary greatly. When the deformity is slight the anterior inferior margin of the last lumbar vertebra merely projects a short dis- tance beyond the anterior margin of the promontory of the sacrum; while in pronounced cases the entire body of the vertebra is displaced down- ward 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 that of the second sacral vertebra. As a conse- quence, a greater or lesser portion of the lumbar column comes to oc- cupy the upper portion of the pelvic cavity, the superior strait becoming markedly obstructed and assuming a reniform shape. The lower lumbar vertebras may overhang the pelvic inlet to such an Fig. 619.-Vertical Section through Spon- Cxte.nt that the °°stetrical or pseudo- dylolisthetic Pelvis (Kilian). conjugate 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 extended to the lower margin of the third lumbar vertebra and measured 6.5 centimeters, as compared with 7.6 centimeters to the lower margin of the fourth lumbar. The displace- ment of the last lumbar vertebra is due not to luxation, but to the lengthening and bending of its interarticular 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 ar- ticular processes, together with the rest of the vertebral column become SPONDYLOLISTHETIC PELVIS 799 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 further displacement. In advanced cases the inferior articular processes of the last lumbar and the superior articular processes of the first sacral verte- bra are usually firmly synostosed together, as are also the inferior articular processes of the fourth and the superior articular processes of the fifth lum- bar vertebra. Owing to the collapse of the vertebral column into the pelvic cavity Fig. 621. Fig. 022. Figs. 620-622.—"Williams's Spondylolisthetic Pelvis. the center of gravity falls in front of instead of just behind the acetabula, 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 diminished, 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 ilio-femoral ligaments, 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 800 ANOMALIUS DUE TO DISEASE OF VERTEBRAL COLUMN by characteristic changes in the pelvic inclination was obliterated Fig. 623.—Spondylolisthesis; Verti- cal Section through Last Three Lumbar Vertebrae and Sacrum. Xi Fig. 624.—Fourth and Fifth Lumbar Vertebrae from Author's Case of Spondylolisthesis. X^. A, superior articular process; B, trans- verse process; (', inferior articular pro- cess; D, lamina of fourth lumbar verte- bra; E, superior articular process; F, inferior articular process; G, transverse process; H, I, J, fissures in interarticu- lar portion of last lumbar vertebra. gait of the patient, In my own case the ; but, had it remained normal, the verte- bral column would have formed a right angle with the legs, necessitating the patient's going upon all-fours, whereas, 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 superior 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 ilio- femoral ligaments, causes each innomi- nate bone to rotate about an axis ex- tending from the symphysis to the sa- cro-iliac joint, and tends to give the pelvis a funnel shape, just as in kypho- sis, the inferior strait becoming consid- erably contracted transversely. .ZEtiology.—Kilian considered that the displacement of the last lumbar vertebra was rendered possible by in- flammatory softening of the interverte- bral disk. Later, various hypotheses were advanced as to its mode of pro- duction. Robert, Lambl, and Konig- stein showed that the displacement could not take place so long as the in- ferior 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. 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 discussions and demonstra- tions in which he took part. He showed conclusively that in the vast majority of cases the deformity was rendered possi- SPONDYLOLISTHETIC PELVIS 801 hie by a lengthening and thinning out of the interarticular portions of the last lumbar vertebra, by which its superior and inferior articular processes become separated by a long, thin lamina of bone instead of being almost in the same vertical line (Fig. 624). This condition he attributed to imperfect development of the inter- articular portion (spondylolysis) or to its fracture, with subsequent stretch- ing of the callus. He considered that the former was the more frequent cause, as he was able to demonstrate it in many vertebras which presented no signs of spondylolisthesis. When the displacement is marked the inter- articular portion is not only lengthened and thinned out, but also becomes Fig. 625.—Front and Back Views of Woman with Spondylolisthesis (Ahlfeld). bent over the promontory of the sacrum, thus forming a dolicho-kyrto- platy-spondylus. In opposition to Neugebauer's statement that the deformity always re- sults from changes in the interarticular portion, Chiari definitely showed that it can occasionally follow fracture of the articular processes without the characteristic changes in the vertebra. At the same time, he holds that spondylolysis is the usual cause. Arbuthnot Lane stated that the disease is more common than is gener- ally supposed, as he observed several examples of it in coal-heavers. He considers that in such cases, at least, the changes in the interarticular por- tion are due not to abnormalities in development but to excessive pressure, which results from carrying heavy burdens. Complete literature upon 53 802 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN the subject will be 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 spon- dylolisthesis, most of which were clinical observations. In 1899 I collected 123 cases, which Chiari, in 1911, increased to 147, including 12 cases oc- curring in males—8.1 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. 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, al- though it should be remembered that it is likewise associated with considera- ble contraction of the inferior strait. When the deformity is pronounced and the lower lumbar vertebras overhang the superior strait, the degree of con- traction, from an obstetrical point of view, is to be reckoned not by the dis- tance between the symphysis pubis and the anterior portion of the last lum- bar vertebra, but by the length of the pseudo-conjugate, whose posterior ex- tremity 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 en- tering the pelvis. Diagnosis.—In typical cases mere inspection of the patient should lead one to suspect the existence of this de- formity, inasmuch as there 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 ap- Fig. 626.—Side View of Author's Spon- pear unusually redundant. Such r»a- dylolisthetic patient, Showing Pro- l■ -„ i -.. , . ,.. ,, jecting Spine of Last Lumbar tients have a Pillar duck-like walk or Vertebra. waddling gait, to which Neugebauer first directed attention. Since the pos- terior portion of the last lumbar vertebra retains its normal position while the rest of the vertebral column sinks forward, its spine will sometimes form a marked prominence just above the sacrum. The condition, how- ever, should not be mistaken for a deep-seated kyphosis. On internal examination the diagnosis, 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 SPONDYLOLISTHETIC PELVIS 803 the sacrum. At the same time the ilio-pectineal 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 condi- tion, the bodies of the lower lumbar vertebras can readily be palpated and counted, and the bifurcation of the aorta, or at least the common iliac arteries, are frequently readily accessible to the examining finger. Occasionally pronounced rhachitic changes in the sacrum may simulate spondylolisthesis, but a correct diagnosis can usually be arrived at. If such patients be anassthetized, careful palpation will show that the ilio-pectineal 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 marked cases of lumbo- sacral kyphosis, particularly in the pelvis obtecta. Under such circum- stances the promontory of the sacrum is destroyed, but a correct diagnosis can usually be made by carefully palpating the anterior surface of the sacrum and tracing the alas to the body of the first vertebra, which, of course, is impossible in spondylolisthesis. Prognosis.—(Jenerally 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 operative meas- ures be undertaken. Other things being equal, a spondylolisthetic pelvis offers a worse prognosis than a rhachitic one with the same antero-posterior measurements, for the reason that in the former the inferior strait is con- tracted, while in the latter it is usually enlarged. In considering the probable outcome of labor, one should measure the pseudo-conjugate- with particular care, inasmuch as it, rather than the antero-posterior 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 deformity frequently increases with age, as was clearly demonstrated in my own case. Treatment.—With a pseudo-conjugate of 8 centimeters or more, the possibility of spontaneous labor should be borne in mind; but when it falls below that limit Cesarean section should be done at the onset of labor. 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. In my case the operation was clearly contraindicated, but was performed in my absence by an assistant, after the patient had refused to submit to Cassarean sec- tion. LITERATURE Barbour. Spinal Deformity in Relation to Obstetrics. Edinburgh, 1883. Boursier de Coudray. Abrege de l'art des accouchements. Paris, 1759. Breisky. Ueber den Einfluss der Kyphose auf die Beckengestalt. Zeitschr. der Ge- sellsch. der Aerzte in Wien, i, 1865. Breus und Kolisko. Die path. Beckenformen. 1900. Bd. iii, I. Theil, Spondylolia- 804 ANOMALIES DUE TO DISEASE OF VERTEBRAL COLUMN' thesis, 17-159. Kyphosen-Becken, 163-307. Skoliosen-Becken, 311-352. Ky- phoskoliosen Becken, 355-359. Champneys. The Obstetrics of the Kyphotic Pelvis. Trans. Lond. Obst. Soc, 1883, xxv, 166-194. Chantreuil. Etude sur les deformations du bassin chez les cyphotiques. These de Paris, 1869. Chiari. Die Aetiologie und Genese der sogenannten Spondylolisthesis lumbo-sacralis. Zeitschr. f. Heilkunde, 1892. Spondylolisthesis. Bull. Johns Hopkins Hospital, 1911, xxii, 41-46. Doktor. Ein Fall von conservativen Kaiserschnitt. Zentralbl. f. Gyn., 1893, xvii, 630-633. Fehling. Pelvis obtecta. Archiv f. Gyn., 1872, iv, 1-33. Herrgott. Du spondylizeme. Archives de toeologie, 1877 (Few-Mars). Kilian. De spondylolisthesi gravissimae pelvangustiae causa nuper detecta. Bonn, 1853. Klien. Die Geburt beim kyphotischen Becken. Archiv f. Gyn., 1896, 1, 1-128. Konigstein. Entstehungsweise spondylolisthetischer Becken. D. I., Marburg, 1871. Lambl. Das Wesen und die Entstehung der Spondylolisthesis. Scanzoni's Beitrage, 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. Lond. Path. Soc, 1885, xxxvi, 364-378. Leopold. Das skoliotische und kypho-skol. rachitische Becken. 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 Entwickelunsgeschichte des spondylolisthetischen Beckens und seiner Diagnose. Halle u. Dorpat, 1S82. Spondylolisthesis et spondylizeme. Paris, 1892. Die heutige Statistik der Geburten bei Beckenverengerung infolge von Riickgrats- kyphose. Monatsschr. f. Geb. u. Gyn., 1895, 1, 317-347. Robert. Eine eigenthiimliche angeborene Lordose, etc Monatsschr. f. Geburtsk., 1855, v, 81-94. Rokitansky. Anomalien der Gestalt des Ruckgrats und seiner Theile. Lehrbuch der path. Anat., III. Aufl., 1856, ii, 162-172. Schroeder-Olshausen-Veit. Lehrbuch der Geb., XIII. Aufl., 1899, 649. Treub. Recherches sur le bassin cyphotique. Leyden, 1889. Williams, J. Whitridge. A Case of Spondylolisthesis, with Description of the Pelvis. Amer. Jour. Obst., 1899, xl, 145-171. CHAPTEK XXXVIII PELVIC ANOMALIES RESULTING FROM THE ABNORMAL DIRECTION 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 accompany 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 Fig 627.—Diagram Showing Coxalgic Pelvis, A, before and, B, after the Individual Has Walked. shortening of one leg from various causes, while the most common causes of the latter are luxation of both femora and double club-foot. These con- ditions 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. 806 ANOMALIES FROM DIRECTION OF FORCE OF FEMORA PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS iEtiology— Coxitis occurring in early life nearly always gives rise to an obliquely contracted pelvis. If the disease makes its appearance before the patient learns to walk, or if the child is obliged to keep to its bed for a prolonged period, definite changes occur in the pelvis as a direct result of the disease. These are in great part atrophic, and are manifested by im- Fig. 630. Figs. 628-630.—Coxalgic Pelvis with Ankylosed Femur. perfect development of the diseased side of the pelvis, the innominate bone being smaller than its fellow and the ilio-pectineal line represented by 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. G'27, A and B). 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 body weight is transmitted in great part to the well leg. As a result the pelvis becomes obliquely tilted, being higher on the well side, and a compensatory scoliosis appears. At the same time the upward and inward force exerted PELVIC DEFORMITIES DUE TO UNILATERAL LAMENESS 807 by the femur tends to push the well side of the pelvis upward, inward, and backward, whereby the ilio-pectineal 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 supe- rior strait, but involves the lower portion of the pelvis as well, the spine and tuberosity of the ischium being displaced toward the middle line. Not uncommonly these changes are accompanied by irritative processes at the sacro-iliac articulations, which eventually lead to ankylosis. As a Fig. 632. Fig. 633. Figs. 631-633.—Obliquely Contracted Pelvis, Due to Unilateral Luxation of Femur general rule, the oblique contraction is to be found on the well side of the pelvis, but, according to Tarnier. the reverse is the case when the affected leg is ankylosed in a position of adduction and internal rotation (Fig. 628). b Usually as the result of gonorrhceal coxitis, the base of one or both acetabula may yield to the pressure exerted by the head of the femur, and project into the pelvic cavity, thus leading to a uni- or bi-lateral transverse contraction, which when pronounced may give rise to serious dystocia. Eppinger, who studied the condition exhaustively in 1903, designated such 808 ANOMALIES FROM DIRECTION OF FORCE OF FEMORA pelves as coxartbrolisthetic, and attributed their production to deficient and delayed ossification of the base of the acetabulum. Breus and Kolisko, on the other hand, have shown that the deformity was known to A. W. Otto in 1824, and have demonstrated that it results from a coxitis, which is usually gonorrhceal in origin. The condition is rare, only 11 cases being recorded up to 1912. Oblique contraction of the pelvis may also develop when unilateral luxation of the femur occurs in early life, although they are usually 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 accordingly 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. In unilateral infantile paralysis, and in those cases in which disease at the knee- or ankle-joint or amputation has caused shortening of one leg, unless the patient has had the benefit of proper orthopaedic treatment, similar changes occur in the pelvis, though it rarely assumes the extreme degree of obliquity which characterizes the coxitic variety. Diagnosis.—A limping gait at once suggests an obliquely contracted pelvis, and when, upon questioning the patient, it is found that the condi- tion has been present since early childhood, the existence of pelvic deform- ity 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 imperfect development of the sacral alas. An accurate conception concerning the degree of con- traction, however, can be obtained only by careful exploration of the interior of the pelvis, preferably with the patient under the influence of an anaesthetic, although in many coxalgic patients this may be extremely difficult on account of the ankylosis of one leg. Effect upon Labor.—The effect of this class 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 contracted, Prouvost reporting that 40 out of the 50 cases of labor complicated by them ended spontaneously. Treatment.—As the pelvic contraction is usually not very pronounced, Caesarean section is rarely indicated, unless the fcetug is large, or the PELVIC DEFORMITY DUE TO BILATERAL LAMENESS 809 history of previous labors has shown that the 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 the asymmetry of the pubic arch may make its proper application practically impossible. Pubiotomy is not a justifiable operation in these cases, particularly in those due to coxitis, as we have no means of determining in advance whether the sacro-iliac synchondroses are synostosed; and if such be the case the operation cannot lead to a satisfactory increase in the capacity of the pelvic canal. 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 acetabula are entirely absent, but more frequently they are present in a rudiment- ary condition, new but imperfect substitutes be- ing formed higher up. Strange to say, the con- dition does not usually seriously interfere with the individual in the mat- ter of learning to walk at the usual age, though the gait is more or less wab- bly. The pelvic changes resulting from this con- dition have been studied particularly by Klein- wachter, Schauta, and Sassmann, the latter writer having collected 27 cases from the liter- ature. Owing to the fact that the upward and in- ward 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 antero-posteriorly. The transverse widening is particularly marked at the inferior strait, while the flattening, as a rule, is not very pronounced. Thus, the conjugata vera usually measures between 9 and 10 *<4£^ Fig. 634.—Side and Rear View of Patient with Bilateral Luxation of Femora. 810 ANOMALIES FROM DIRECTION OF FORCE OF FEMORA centimeters, and Delmas, after studying 17 cases, concludes that the vari- ous diameters are usually enlarged unless the condition is complicated by some other abnormality. Hence, this pelvis rarely offers any serious obstacle to labor. The patient presents a characteristic appearance, which is suggestive of that observed 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 appear- ing considerably shortened and presenting a marked saddle-shaped depres- sion 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. Accord- ingly, with each step a distinct shock was imparted to the acetabula, instead of the more gentle force which is exerted under ordinary circumstances. ATYPICAL DEFORMITIES OF THE PELVIS In rare instances the pelvis may be more or less deformed by the pres- ence of bony outgrowths at various points, and less frequently by tumor formations. Exostoses are most frequently observed upon the pos- terior surface of the symphysis, in front of the sacro-iliac joints, or upon the anterior surface of the sacrum, though in occasional cases they may be formed along the course of the ilio-pectineal line. Kilian, in 1854, directed atten- tion to the fact that such struc- tures may form sharp, more or less knife-like projections. He desig- nated the condition as acanlhope- lys or pelvis spinosa. Such forma- tions are rarely sufficiently large to offer any obstacle to labor, but ow- ing to their peculiar structure may do considerable injury to the ma- ternal soft parts. In fact, in sev- eral of the cases reported, they have cut through the lower portion of the uterus. In rare instances callus forma- tion, resulting from inflammatory processes within the pelvis, may attain such proportions as to lead to serious pelvic obstruction, as in a case reported by Ahlfeld. Fig. 635.—Obstruction of Pelvic Canal by Cystic Enchondroma (Zweifel). ATYPICAL DEFORMITIES OF THE PELVIS 811 Tumor formations of various kinds may spring from the walls of the of Fig. 636.—Fractured Pelvis (Mars). false or true pelvis and so obstruct its cavity as to lender labor impossible Fibromata, osteomata, enchondromata, carcinomata, and osteosarcomata oi the pelvis have been de- scribed, and sometimes assume very considerable proportions, and occa- sionally become cystic. Stadfeld was able to col- lect 49 such cases in 1879, and Coder 81 cases in 1895. Enchondro- mata occur more fre- quently than other va- rieties of tumor forma- tion, 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 necessary in his series of cases. 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 eases 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 insuperable 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 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 be- come pregnant. The effect upon labor depends upon the location of the fracture and its manner of healing. Fig. 636 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 sec- ond 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. LITERATURE Ahlfeld. Das durch Knochenauswiichse verengte Becken. Lehrbuch der Geburts- hiilfe, II. Aufl., 1898, 336. Breus und Kolisko. Coxitis-Becken. Die path. Beckenformen. Leipzig u. Wien, 1912, iii, 474-593. 812 ANOMALIES FROM DIRECTION OF FORCE OF FEMORA Delmas. Sur Uanatomie obst. du bassin a, luxation caxo-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. Von dem Becken ausgehende Tumoren als Geburtshinderniss. D. I., Halle, 1895. Kilian. Das Stachelbecken (Akanthopelys) ; Schilderungen neuer Beckenformen. Mannheim, 1854, 59-114. Kleinwachter. Das Luxationsbecken, etc. Prager Vierteljahrsschr. f. Heilkunde, cxviii, cxix. Mars. Schragverengtes Becken infolge einer Fractur. Archiv f. Gyn., 1889, xxxvi, 289-300. Meurers. Beitrag zur geb. Bedeutung der Frakturbecken. D. I., Heidelberg, 1904. Prouvost. Etudes sur les bassins vicies par boiterie. These de Paris, 1891. Sassmann. Das Becken bei angeborener doppelseitiger Hiiftgelenksluxation. Archiv f. Gyn., 1873, v, 241-267. Schauta. Muller's Handbuch d. Geb., 1889, ii. Die Beckenformen bei doppelseitiger Luxation der Schenkelpkopfe, 466-472. Die Beckenform bei Klumpfuss, 472-473. Schopping. Das Becken-enchondrom, besonders als Geburtshinderniss. Monatsschr. 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 accouchements. Paris, 1898, iii. Malformations du bassin dans la claudication, 229-278. Deformations atypiques du bassin, 338-352. CHAPTER XXXIX DYSTOCIA DUE TO ABNORMALITIES IN DEVELOPMENT OR PRESENTATION OF THE FG3TUS 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 in- fants are to be found in the literature. Provided the pelvis is not contracted, it is very exceptional for a nor- mally 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 increasing 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 un- usually large shoulders either at the pelvic brim or outlet. Excessive development of the fcetus can usually 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 Oyamada states that possible prolongation of pregnancv was noted in 11 per cent. of the {X\2 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, it is only apparent, and merely means that fertiliza- tion took place just before the first period missed, instead of shortly after the last menstrual flow. On the other hand, actual prolongation is oc- casionally observed, and may exert a serious influence upon the course of labor, inasmuch as the child increases in size for every additional day 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 at frequent intervals, so that labor may be induced as soon as there is any sign of disproportion between the size of the head and the pelvis. 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 fcetal head in many instances resembles that of its father, large-headed men usually producing children with similar characteristics. The age of the mother has likewise an important influ- ence upon the fatal development. Thus, the children of elderly primiparae 813 814 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS frequently exceed the ordinary average, and in multipara1 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 en- gagement, but predisposes to certain injuries, such as spoon-shaped de- pressions 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 difference between an easy and a difficult labor. At the same time, it must be remembered that in multiparous women the dystocia is often due in great part to the loss of tone of the uterine musculature incident to repeated childbearing. 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 Midler's method of impression are employed, should ordinarily enable the trained obstetrician to arrive at fairly accurate con- clusions and prepare him to meet this complication. If the pelvis is nor- mal the failure of engagement in the last weeks of pregnancy in a primi- para or the existence of a face, brow, or transverse presentation should suggest the probable existence of pronounced disproportion. Treatment.—If the patient has apparently gone several weeks beyond term, and examination shows that the size of the child is beyond the aver- age, there should be no hesitancy in the immediate induction of labor as a prophylactic measure, such a procedure being particularly indicated in multiparous women whose history shows that excessive foetal development was the cause of the previous difficult labors. On the other hand, if the pregnancy is not prolonged, the condition is rarely suspected by the ordi- nary practitioner before the outset of labor, and the diagnosis is made only after Nature has shown that she is unable to effect delivery. In such cases it is often difficult to determine upon the best method of dealing with the complication. If careful examination shows that the head is not en- gaged and is excessively large and well ossified, the advisability of (Cesarean section or pubiotomy should be considered, provided the patient has not been subjected to unavailing attempts at delivery; as radical interference is quite as justifiable in such circumstances as when dystocia is due to the failure of a normal-sized head to pass through a contracted pelvis. On the other hand, if physicians with questionable technique have failed to effect delivery by forceps or version, radical surgical interference is contra-indi- cated, and craniotomy becomes our sole resource. When the obstacle to delivery is due to excessive size of the shoulders rather than to the head, labor can often readily be terminated after dimin- ishing the size of the shoulder girdle by cutting through the clavicles with a pair of heavy scissors—cleidotomy. MALFORMATION OF THE F(ETUS 815 MALFORMATION OF THE FCETUS Double Monsters.—For practical purposes 3 groups of double monsters 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 (thora- copagus and dicepbalus). The diagnosis of any one of these conditions is not made until the seri- ous difficulty experienced in attempting delivery has led to careful explora- tion under ana'sthesia with the entire hand, although in many cases the existence of a multiple pregnancy may have been suspected. As such mon- strosities frequently present minor deformities as well, the detection of a club-foot, hare-lip, etc., should always 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 connection be- tween the two halves is often of such a character as to permit of sufficient motility between the component parts as to make their successive delivery possible. On the other hand, in the first group the large size of the doubled por- tion 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 pri- marily. In the second group a craniopagus presenting by the head usually causes only a moderate amount of difficulty; whereas, on the other hand, isch.iopa.gi and pygopagi, as a rule, call for complicated and difficult manoeu- vres 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 presentations 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 bead 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 ampu- tate 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 chil- dren to present in a different manner. When possible, it is advisable 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 816 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS 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 FCETUS 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 pregnancies as the result of inequalities in the communicating placental circulation. One twin is well developed and normal, while the other is imperfectly formed, and either possesses a rudimentary heart or no heart at all, being designated according to Kehrer as hemiacardius or holoacardius, respec- tively. The way in which this is brought about 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 fcetus. 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 um- bilical cord may be attached to any portion of its surface. The interior of the monstrosity contains a rudimentary intestinal tract, cystic cavities, ver- tebras, etc., but no trace of a heart. The rarest variety of acardiacus is the acornus or trunkless monster, which con- sists of an imperfectly developed head and a rudimentary body, the umbilical cord being attached to the cervical re- gion. As a rule such monsters do not attain any notable size, although exceptionally, as the result of obstruction in the umbili- cal vein, they may become cedematous and give rise to dystocia. The aneuceplialus 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 shoul- ders 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 examining finger, so that the sella turcica can be distinguished. Owing to the ex- posed 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 experiments of the physiologists. Fig. 637.—Anencephalus {Schroeder). HYDROCEPHALUS 817 In view of the abnormal shape of the head face presentations are fre- quently 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 eye being noted in the former, and the absence of the cranial vault and the presence of the sella turcica in the latter presentation. Delivery, as a rule, occurs much more readily wdien 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 spon- taneous delivery is observed. Even when the enlarged shoulders give rise to dystocia, delivery can usually be accomplished by means of version with- out any great difficulty. HYDROCEPHALUS In this not very rare condition, the cerebral ventricles are distended by an excessive amount of eerebro-spinal fluid (Fig. 638). As a result the skull becomes much increased in size, frequently attaining several times its normal dimensions, while the brain sub- stance forms a layer only a few milli- meters thick beneath it. At the same time the cranial bones are imperfectly de- veloped, the sutures and fontanelles be- ing much wider than usual. Fig. 638.—Dystocia Due to Hydrocephalus (Bumm). If the enlarged head is not tensely filled with fluid, under the influence of the uterine contractions, it may undergo such changes in shape that its spontaneous expulsion becomes possible. This, however, is so rare a pos- sibility 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 eerebro-spinal fluid can es- cape, after which the head collapses and spontaneous delivery becomes pos- 54 818 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS sible. 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 haemorrhage. 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 ob- stacle to delivery. On the other hand, careful examination should ordi- narily lead to a correct diagnosis in 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 iso- lated above the superior strait or in the fundus of the uterus. Furthermore, the examiner should always be on the lookout for the presence of fluctua- tion, 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 examination. 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 manoeuvres. Of course this does not hold good when the child presents by the breech, but 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 XTature 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 eerebro-spinal fluid can escape and the skull collapse, after which de- livery can be effected by the unaided efforts of Nature, or may be acceler- ated by the employment of the cranioclast. In breech presentations^ after 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 con- sider 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 always synonymous with fcetal 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 FCETUS 819 ENLARGEMENT OF THE BODY OF THE FCETUS Enlargement of the abdomen sufficient to cause grave dystocia is usuallv the result of ascites, a very much distended bladder, or of tumors of the kidneys or liver. Whenever the abdominal distention is marked spontaneous labor is out of the question; but unfortunately the condition usually escapes detec- tion until fruitless attempts at delivery have demonstrated the existence of some obstruction and have led the obstetrician to intro- duce his entire hand into the uterus in the hope of discover- ing its nature. Occasionally a fcetus af- fected with general dropsy may attain such immense propor- tions that spontaneous deliv- ery is impossible. A number of such cases are recorded in Ballantyne's valuable mono- graph. In very rare instances the ascites associated with fac- ial peritonitis may have a sim- ilar result, and exceptionally a child suffering from chondro- dystrophia foztalis may become so cedematous as to give rise to dystocia. As the result of the dilata- tion of the superficial lym- phatics associated with oedema of the subcutaneous tissues, the fcetus may assume im- mense proportions and take on a bizarre shape. This condi- tion, which is designated as elephantiasis congenita cystica, has been studied in detail by Ballantyne, and is a very rare cause of difficult labor (Fig. 639). Defective development of the lower portion of the urinary tract may lead to the retention of urine accompanied by distention of the abdomen sufficient to render normal delivery impossible (Fig. 640). Examples of this condition have been reported by Walther, Schwyzer, and others, who also give details as to its aetiology. A much more frequent cause of abdominal enlargement is the presence of congenital cystic kidneys. The growth, which is histologically an adeno- cystoma, may involve one or both organs, and give rise to tumors of im- mense size. The condition is frequently associated with dilatation of the rfc*..*^ Fig. 639.—Elephantiasis Congenita Cys- tica (Ballantyne). 820 DYSTOCIA DUE TO ABNORMALITIES OF THE FCETUS ureters, and with dropsical effusions into the various body cavities. Fig. 641 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 ab- dominal enlargement may be due to tumors of the liver, Porak and Couvelaire having re- ported a case of congeni- tal cystic liver associated with a similar condition of the kidneys. More- over, large tumors, aris- ing from any of the ab- Fig. 640.—Fcetus with Immensely Distended Bladder dominal organs, may give _________^!!^_____________ rise to dystocia. Thus, Rogers has described an immense fibro-cystic tes- ticle, and Phaenomenow an aortic aneurysm so large as to interfere with delivery. In rare in- stances fcetal inclusions, such as the so-called fcetus in fcetu, may be responsible. Occasionally the invasion by Bacillus aerogenes capsulatus may be followed by such an extensive production of gas that the size of the foetus becomes more than doubled, when spontane- ous delivery is impossi- ble. In all of these condi- tions, if the dystocia is marked, delivery can be accomplished only after opening the body of the foetus and allowing the fluid to escape, or remov- Fig. 641.—Fcetus with Congenital Cystic Kidneys. mg a portion, at least, of /rx/- DYSTOCIA DUE TO TRANSVERSE PRESENTATIONS 821 the offending tumor formation. The latter operation is not always easv. 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 arising from various portions of the body of the fcetus may seriously interfere with delivery. Cases are on record in which lipomata, carcinomata, angiomata, and various other tumors have given rise to such an enlargement that spontaneous delivery became out of the question. Exceptionally, dermoid cysts and teratomatous tumors about the perineum and sacrum may offer a serious obstacle. Fig. 27"> represents a fcetus in which an adenoma of the thyroid gland necessitated a destructive operation. In rare instances parasitic fcetal tumors, 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 Fig. 642.—Diagram Showing Left Acro- Fig. 643.—Diagram Showing Right Acro- mion DORSO-POSTERIOR PRESENTATION. MION DoRSO-ANTERIOR PRESENTATION. angle we speak of an oblique presentation. The latter, however, is usually only transitory, becoming converted into a longitudinal or transverse pre- sentation 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 (Figs. 642 and 643). 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 acro- mion 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 shoulder is directed. Moreover, as, in either position, the back may be directed either anteriorly or posteriorly, it is customary to dis- tinguish between the dorso-anterior and dorso-postcrior varieties. The rec- ognition of the position of the back is of very considerable importance in connection with the proper performance of version—the treatment par ex- cellence in this condition. 822 DYSTOCIA DUE TO ABNORMAL PRESENTATIONS According to Scliroeder, the shoulder is directed toward the left side of the mother L\6 times more frequently than toward the right, while the back looks anteriorly 2.f> times more frequently than posteriorly. /Etiology.—The existence of a transverse presentation in a primiparous woman is prima 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 multipara, on the other hand, the most frequent aetiological factor is an abnormal relaxation of the abdominal and uterine walls, the result of repeated childbearing. which may be still further complicated by any of the causes already enumerated. Accordingly, transverse presentations arc much more frequently observed in women who have borne a number of children, and in them, as a rule, the condition is less serious, for the reason that spontaneous reposition some- ' times ensues after the onset of labor pains, the child assuming a longi- tudinal presentation, whereas such an occurrence is very exceptional in primiparae. Spontaneous version is very improbable after rupture of the membranes, and is rendered very difficult by any condition which interferes with the descent or engagement of the head; as, for example, a contracted pelvis, placenta praevia, 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 dispro- portion 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 frequently does not extend above the um- bilicus. On palpation the first manoeuvre reveals the absence of the head or the breech from the fundus. On the second manceuvre a ballottable head will be found in one and the breech in the other iliac fossa, while the third and fourth manoeuvres 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 diagnosed. 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 XV). 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 be- comes tightly wedged in the pelvic canal, and a hand and arm frequently prolapse into the vagina; whether it is the right or left can be readily de- termined by ascertaining to which one of the obstetrician's it corresponds, just as in shaking hands. PLATE XV. L-. lTl__ ' >- PALPATION IN RIGHT ACliOMIO, DOIISO-ANTERIOR PRESENTATION. DYSTOCIA DUE TO TRANSVERSE PRESENTATIONS 823 Course of Labor.—With very rare exceptions the spontaneous birth of a fully developed child is impossible in persistent transverse presentations, since expulsion cannot be effected unless both the head and trunk of the child enter the pelvis at the same time, which is manifestly impossible. Accordingly, both the fcetus and mother must almost inevitably perish if appropriate measures are not instituted. On the other hand, small prema- ture, and particularly macerated, children are frequently born spontane- ously. After rupture of the membranes, if the patient is left to herself an arm usually prolapses and the shoulder becomes forced down into the pelvic cavity, but can descend for only a certain distance, being arrested by the head and trunk at the superior strait. 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 intraperitoneal haemorrhage, 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 contract before the membranes rupture, and the child, being retained within the uterus, may eventually become mummified or converted into a lithopaedion. 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 circum- stances bacteria would gain access to the uterus and give rise to infection, which, if not terminating in the death of the patient, would lead to the gradual casting 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 en- sues. Bartholin, in the seventeenth century, pointed out that a child which has lain transversely during the later months of pregnancy may spontane- ously assume a longitudinal presentation at the time of labor. This so- called spontaneous version is a not infrequent occurrence. Its mode of production has already been referred to. A century later Roederer pointed out that in rare instances, if the child was very small and the pelvis large, spontaneous delivery might occasionally be accomplished in spite of the persistence of the abnormal presentation. 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 corpore. Manifestly, such a mechanism is possible only in the case of very small children, and is occasionally observed when the second child in twin pregnancv is prematurely born. In very rare instances, a dead child of moderate or average size may be expelled spontaneously by another mechanism, which is designated as 824 DYSTOCIA DUE TO ABNORMAL PRESENTATIONS 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, a 2,700-gram child being born 8 hours after the onset of labor in the only case of the kind occurring in my experience. This mode of delivery occurs once in every several hundred transverse presentations, and its mechanism has recently been studied by Payer, Zangemeister, and Franz. It is possible only after the cervix has become completely dilated, and the shoulder impacted into the superior strait, in women with vigorous uterine contractions. It may be effected by either one Fig. 644.—Frozen Section through Woman Dying in Labor with a Neglected Trans- verse Presentation (Chiara). of two mechanisms, which are designated as those of Douglas and of Den- man, after the observers who first described them. In the more frequent mechanism of Douglas, one arm is always prolapsed and the strong con- tractions force the shoulder to the vulva. While this is being effected the child rotates in such a manner as to bring the head to the front, where it is arrested at the pelvic brim. If the neck is sufficiently long or elastic, the shoulder is partially forced out under the pubic arch and is followed by the trunk, buttocks, legs, and finally the head (Fig. 645). Delivery by this mechanism would probably have been effected in Chiara's case had the patient survived. (Fig. 644.) On the other hand, in the less frequent mechanism of Denman, the conditions are less favorable, as the buttocks are obliged to pass through the pelvic cavity while it is still occupied by the thorax, with the result that both the shoulders and breech emerge from the vulva simultaneously. (Fig. 646.) Prognosis.—If spontaneous version does not occur within the first few hours after the onset of labor, and operative procedures are not instituted DYSTOCIA DUE TO TRANSVERSE PRESENTATIONS 825 spontaneous evolution offers the only possibility for spontaneous 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 haemorrhage 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 fcetal death. Treatment.—If the diagnosis has been made in the last month of preg- nancy 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 not advisable, as Caesarean sec- tion 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, per- form internal podalic version, followed by prompt extraction. On the other hand, if the patient be not seen until she is well advanced in labor and the membranes have ruptured, the treatment will vary accord- ing to the degree of dilatation of the cervix, the condition of the patient, as well as that of the foetus and uterus. 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 826 DYSTOCIA DIE TO ABNORMAL PRESENTATIONS , be allowed to dilate still further before extraction is completed. On the other hand, if the condition is complicated by prolapse of the cord, the cervix should be dilated manually, and the child rapidly 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 pro- cedure appears synonymous with rupture. Even in such cases anaesthesia sometimes so relaxes the organ that version may be safely effected, although at first glance it had appeared to be out of the question. undertaken except at the express wish of the patient and her family, and then only after they have been made fully conversant with its inherent dan- ger in the case of a patient who in all probability is already infected. Compound Presentations. —P,v 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. 647). As a rule, a hand or an arm comes down with the head; much less com- monly 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 DYSTOCIA DUE TO COMPOUND PRESENTATIONS 827 legs, so that the scrotum and head were felt upon vaginal examination (Fig. 648). Some idea of the relative frequency of the different com- binations may be gained y^S^^S^^^^^^i^^t HP^^" from the following table, jfiimd ^s!PKii taken from Pernice: /ZmEIK** «mc**& NSSiS Jr~om "^ Fig. 647.—Frozen Section through Woman Dying at End of Pregnancy. Compound Presentation (Braune). 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 re- sult one or more of the extremities have prolapsed before the present- ing 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 $WfMh^>ii it will usually not interfere with lHpi//if labor. On the other hand, if the entire arm is prolapsed alongside of the head, an energetic effort Fig. 64S.—Compound Presentation (Hahl). 828 DYSTOCIA DUE TO ABNORMAL PRESENTATIONS should be made to replace it. If this is not possible, version should be performed, since if the arm retains its position it may give rise to serious dystocia, more especially if it extends around the child's neck, constituting the so-called nuchal position. When, as happens only rarely, the foot prolapses, attempts should be made to replace it; if these fail version should be resorted to. LITERATURE Ballantyne. General Foetal Cystic Elephantiasis. The Diseases of the Fcetus, Edin- burgh, 1892, i, 182-219. Bartholin. Quoted by Payer. Franz. Zur Lehre von der Geburt mit gedoppelten Korper. Gyn. Rundschau, 1910, iv, 399-408. Hahl. Strictur des os internum als Geburtshinderniss. Archiv f. Gyn., 1901, lxiii, 684-694. 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. Payer. Zur Lehre von der Selbstentwickelung. Volkmann's Sammlung klin. Vor- trage, N. F., 1901, Nr. 314. Pernice. Die Geburt mit Vorfall der Extremitaten neben dem Kopfe. Leipzig, 1858. Phaenomenow. Beitrag zur Casuistik der durch die Frucht bedingten Geburtshinder- nisse. Archiv f. Gyn., 1881, xvii, 133-139. Porak et Couvelaire. Foie polykystique cause de dystocie. Comptes rendus soc. d 'obst., de gyn. ct de paed. de Paris, 1901, iii, 26-37. Roederer. Quoted by Payer. Schroeder, Olshausen, und Veit. Lehrbuch der Geburtshiilfe, XIII. Aufl., 1899, 737. Schwyzer. Ueber einen Fall von Geburtshinderniss, bedingt durch hochgradige Erweiterung der fotalen Harnblase. Archiv f. Gyn., 1893, xliii, 333-346. Walther. Dystokie infolge iibermassiger Ausdehnung der fotalen Harnblase. Zeit- schr. f. Geb. u. Gyn., 1893, xxvii, 333-347. Zangemeister. Mechanik und Therapie der in der Austreibungsperiode befindlichen Querlagen. Leipzig, 1908. CHAPTER XL HEMORRHAGE A profuse haemorrhage occurring prior to or shortly after the birth of the child is always a dangerous and sometimes a fatal complication. Practically all varieties of ante-partum haemorrhage, with the exception of those originating from lacerations of the genital canal, are due to a partial 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—placenta praevia, but occasionally occurs when the organ occupies its normal site in the upper portion of the uterus. PREMATURE SEPARATION OF THE NORMALLY IMPLANTED PLACENTA From the time of Hippocrates it had been customary to ascribe all cases of ante-partum haemorrhage to this accident, but, with the recognition of the nature of placenta prawia and the knowledge that its separation is un- avoidably associated with haemorrhage, the earlier view was abandoned and the former accident came to be regarded as of rare incidence. Goodell, in 1870, collected 106 instances from the literature, while Holmes, in 1901. was able to find 200 additional cases. The latter, how- ever, believes that these figures give a very inadequate idea of the fre- quency of the accident, and considers that it occurs about once In every 500 labors. His contention is confirmed by Erie's statistics, which show that 40 cases were observed in the Rotunda Hospital of Dublin during the ten years ending with 1899. On the other hand, Lobenstine and Harrar noted the complication less frequently, having reported 47 cases in 42,000 labors at the New York Lying-in Hospital, an incidence of 1 to 894. My own experience leads me to believe that Holmes's estimate is approximately correct. etiology.—Unfortunately, the primary cause of the premature sepa- ration of the placenta is imperfectly understood, although a number of theories have been advanced concerning it. In 67 of Holmes's cases there was a historv of a preceding traumatism which, according to Coe, is the most common aetiological factor. On the other hand, this was noted in only ten per cent, of the series of cases reported by Lobenstine and Harrar, and was lacking in all of my own cases. Most German authorities attribute the accident to inflammatory changes in the decidua, which were present in 829 830 HEMORRHAGE every one of the 8 cases examined by Weiss, although in 2 of them the predominant lesion was a suppurative metritis. Schickele, on the other hand, found no signs of endometritis, but described a pronounced degenera- tion of the decidua in the cases which he studied. Winter believes that a close relationship exists between nephritis and premature separation of the placenta, and many authors have subscribed to this opinion. Lobenstine and Harrar, however, were able to demonstrate albuminuria in only 30 per cent, of their cases, and it would appear prob- able that in many instances, at least, such a combination is purely acci- dental ; for, if renal lesions played anything like the prominent part assigned to them by Winter and his followers, premature separation of the placenta Figs. 649, 650.—Premature Separation of Placenta with External Haemorrhage (Winter). would be frequently observed, since nephritis complicating pregnancy is by no means uncommon. Multiparity would appear to be a predisposing cause, only 19.2 per cent. of the cases collected by Holmes having been noted in primiparae. More- over, the frequency of the accident increases directly with the number of pregnancies, and the advocates of the endometritis theory believe that these facts add to the force of their argument. Any of these conditions may come into play during pregnancy or at the time of labor. On the other hand, certain aetiological factors cannot become operative until labor has set in. Among these may be mentioned traction exerted by an abnormally short 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 hydramnios. Pathology.—As the result of the separation of the placenta the vessels PREMATURE SEPARATION OF THE PLACENTA 831 traversing the decidua serotina are torn through and, since the uterus, which is still distended by the product of conception, is unable to retract in the usual manner and compress them, haemorrhage must inevitably result. The blood may make its way to the exterior or be retained within the uterus. According to Goodell, the latter condition, which constitutes what is termed concealed hemorrhage, is liable to occur (1) when there is an effusion of blood behind the placenta, its margins still remaining ad- herent; (2) when the placenta is completely separated, while the mem- branes 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 about two thirds of the cases, however, the membranes are dissected off and the blood eventually escapes from the cervix. Thus, in the series of 306 cases collected by Goodell and Holmes, the haemorrhage was external in 193 and concealed in 113. Rigby, in 1780, directed particular attention to this condition, and des- ignated the haemorrhage resulting from it as accidental, as contrasted with the unavoidable haemorrhage following the partial separation of a placenta praevia. In many instances the prematurely separated organ may be seri- ously damaged by the haemorrhage; and especially in the cases complicated by albuminuria a large part of its bulk is often found occupied by fresh red infarcts or placental apoplexies. In other cases, however, the only anatomical indication of the condition visible in the placenta will be a few large blood-clots adhering to its maternal surface or to one of its margins. 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 haemorrhage 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 anaemia, 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 that of actual haemorrhage, and may pass off under appropriate medicinal treatment. In concealed haemorrhage the uterus gradually becomes of a size con- siderably larger than would normally correspond to the duration of the pregnancy, and assumes an almost ligneous consistency, so that the results of palpation become very indefinite. At the same time the patient com- plains of intense pain. On the other hand, when the haemorrhage is ex- ternal, 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 conditions, and the patient is sometimes left to die undelivered. 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 hy- dramnios, external haemorrhage generally occurs, and the fcetal heart sounds become imperceptible. In very exceptional instances the placenta may become separated from 55 832 HEMORRHAGE 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 praevia, although now and again, as in the case reported by Miinchmeyer, such an accident may occur even when the pla- centa is inserted normally—prolapse of the placenta. Diagnosis.—The appearance of acute anaemia, with manifestations of shock, in a patient in the later months of pregnancy should always suggest the possibility of concealed intra-uterine haemorrhage, though similar symp- toms may follow the rupture of an advanced extra-uterine pregnancy, or the very exceptional cases of spontaneous rupture of the uterus. In many instances the diagnosis is placed beyond doubt by the large size of the uterus and its ligneous consistence, though usually it is arrived at mainly by exclusion. When, however, the haemorrhage is external, the diagnosis is rendered practically positive by the failure to demonstrate the presence of a placenta praevia, though, of course, it is impossible 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 are suggestive of those following rupture of the uterus, though the latter accident rarely occurs except after a prolonged second stage, while premature separation may occur at any period. In the exceptional instances in which the haemorrhage is entirely retro- placental a localized elevation of the corresponding portion of the uterine wall can occasionally be detected on palpation. Prognosis.—Accidental haemorrhage, whether external or concealed, is one of the most serious complications of pregnancy and labor, practically all of the children and many of the mothers perishing. Thus, Goodell, Holmes, and Lobenstine and Harrar reported a maternal and fcetal mor- tality of 50.9 and 94.4 per cent., of 32.2 and 85.8 per cent., and of 17 and 77 per cent., respectively. Treatment.—In the more marked forms the life of the mother can be saved only by prompt evacuation of the uterus. 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 expectant 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 haemorrhage, whether of the concealed or external variety, the uterus should be emptied with the least possible delay, in order that it may retract and thus compress the bleeding vessels. If labor has not yet set in, and the symptoms are urgent, the treatment will depend upon whether the patient is in a hospital or not. In the former event abdominal or vaginal Cesarean section should be performed; while in the latter event the cervix should be dilated instrumentally to a sufficient extent to permit the introduction of a Champetier de Ribes balloon, and, as soon as the internal os has become obliterated, further dilatation should be effected by Harris's method. If, however, labor is already in progress and PLACENTA PREVIA 833 the cervical canal has become in great part obliterated, manual dilatation should be employed from the outset and the child promptly delivered by version or forceps, as appears most advisable. It of course goes without saying that the various measures appropriate for combating shock should be employed as adjuvants to the purely obstetrical treatment. In some instances the tonicity of the uterus has been so impaired by the loss of blood and the distention to which it has been subjected that it fails to contract and retract during the third stage of labor, and as a result profuse post-partum haemorrhage may follow. This possibility should always be borne in mind, and the operator should have in readiness the necessary materials for packing the uterus at a moment's notice. PLACENTA PRAEVIA The most common cause of ante-partum haemorrhage is the partial separation of a placenta implanted in the neighborhood of the internal os— placenta praevia. Our knowledge concerning this abnormality may be said to date from Figs. 651, 652.—Showing Different Modes of Placental Insertion. (Modified from American Text-Book.) the end of the seventeenth and the beginning of the eighteenth centuries, Portal, in 1685, and Schacber, in 1709. having accurately described the condition from a clinical and an anatomical point of view. Notwithstand- ing the fact that Smellie, William Hunter, and Eigby were well acquainted with placenta praevia and its dangers, very little advance was made in our knowledge concerning it until Barnes promulgated his views as to its mode of production and the methods of controlling the haemorrhage arising from 834 HEMORRHAGE / it. Since then many investigators have busied themselves in searching for its mode of origin 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 exam- ining finger. Ordinarily, three varieties are distinguished: Placenta praevia centralis, lateralis or partialis, and marginalis. In the first the internal os is completely ^covered by placental tis- tllf sue, which is adherent to its margins; in the sec- ond the placenta en- croaches 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. 651 and 652). Strictly speaking, the dif- ferentiation between the several varieties should not be made until the cervix has become fully dilated, for the reason that the marginal variety cannot be felt until this has occurred; while what may ap- pear to be a complete placenta praevia during pregnancy and the first part of labor may prove to be only partial, and to encroach only a little beyond the mar- gin of the internal os when dilatation is complete. In both the central and par- tial varieties, partial separation of the placenta is an inevitable consequence of FM 6f--PLA<™ PB^VIA IN WHICH ^ formation Qf the J t j No Attempt at Delivery Had Been ^i^^^ dv.& Made (Ahlfeld) ment and the dilatation of the cervix. This is always associated with haemor- rhage, which was therefore designated by Rigby as unavoidable. In pla- centa praevia marginalis, on the other hand, haemorrhage does not always occur, and, as the placental tissue can be felt only after dilatation has proceeded to a certain extent, the existence of the condition is frequently unrecognized. Such cases are closely related to the so-called vicious inser- tion of the placenta described by Pinard and his pupils, which is of frequent occurrence. Frequency.—Placenta praevia is fortunately a comparatively rare compli- cation, although the statements as to its frequency vary considerably. Thus, W. Muller, whose statistics were based upon 876,432 labors, stated that it PLACENTA PREVIA 835 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 correct 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 pnevia 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 measure- ment 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 above reproach. iEtiology.—Concerning the a'tiology of placenta pnevia comparatively little is known. Two factors, however, appear to favor its occurrence— multiparity and endometritis. The abnormality occurs comparatively rarely in primipara>, and increases 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 Ohrobak's clinic. He noted placenta praevia in 0.17, 0.48, 1.37, 1.28, and 3.39 per cent, of the patients, according as they had given birth to 1, 2, 3, 4. 5, or 6 children respectively; whereas, when the number of children varied between 7 and 10, the per- centage was 5.51. The occurrence of placenta praevia. 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. 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 inflammatory or atrophic changes, the latter being favored by repeated and closely following pregnancies. Such conditions, 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 par- tially overlapping it as the case may be. Plausibility is lent to such a view bv the fact that the placenta in this abnormality is spread over a greater area of the uterus than usual, while at the same time it is often consider- ably thinner. Thus, in one of my cases which came to autopsy, the placenta 836 HEMORRHAGE was almost membranous, and its site occupied four-fifths of the interior of the uterus. Mode of Formation.—The older authorities believed that placenta prae- via was due to the separation from its attachment of a normally implanted ovum, which, falling to the lower portion of the uterus, contracted new connections just before escaping through the cervix. Later it was urged that such a view failed to explain the production of the central variety, as it was inconceivable that the minute ovum could be prevented from escaping from the uterus sufficiently long to permit the formation of attachments between it and the margins of the internal os. The fallacy of this view becomes apparent when one re- calls the fact that, with the uterus in its normal anteflexed position, the region of the internal os is frequently at a higher level than the fundus, and consequently the force of gravity would not neces- sarily aid in carrying the ovum through the cervix. Furthermore, Bumm, in 1905, con- Serotina tended that, in view of the congested condi- tion of its margins, the internal os is smaller than the fer- tilized ovum, and that therefore no funda- Reflexa mental reason exists why it should not be- come implanted in that locality. The former view was gener- ally accepted until 1888, when Hofmeier and Kaltenbach ad- vanced the theory that a part of the placenta 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 with the decidua vera, after which vascular connections with the uterine wall became established (Fig. 054). 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 meeting of the German Gynecological Congress, he was careful to state that it was not the only manner in which a placenta praevia 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 extend beyond the serotina, Should such a process extend Fig. 654.—Diagram Illustrating Hofmeier's Theory of the Formation of Placenta Previa. PLACENTA PREVIA 837 downward, it was readily conceivable that the placenta might grow on either side of the internal os, and, as the latter became obliterated, com- pletely cover it. At that time our present views concerning the mode of implantation of the ovum and of the growth of the placenta were not held, so that Hofmeier was not aware that an analogous process occurs in every normal pregnancy. Ahlfeld and Aschoff, in 1904, admitted the correctness of this explanation, and stated that the cleavage might extend so far as to give the impression that a part of the placenta, at least, had developed in the wall of the cervix. In view, therefore, of our present knowledge concerning the normal im- plantation of the ovum, as well as of Strassmann's theoretical deductions, it appears probable that placenta praevia results either from the primary im- plantation of the ovum in the lower portion of the uterus, associated with an extensive cleavage of the decidua vera, by which the extension of the placenta to the region of the internal os is facilitated, or to its partial de- velopment over the decidua reflexa or capsularis. 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 the condition 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 pri- marily implanted above it. Symptoms.—The most characteristic symptom of placenta praevia is haemorrhage, which usually does not appear until after the seventh month of pregnancy. At the same time it is probable that many abortions are due to this condition, although the true state of affairs usually escapes observa- tion. I have seen several abortions in the third month which were clearly due to this abnormality. The haemorrhage 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 in rare instances the first haemorrhage may be so profuse as to prove fatal. In other cases the bleeding does not cease entirely, there being a continuous discbarge of small quantities of a blood-stained fluid, which eventually so weakens the woman that a comparatively slight acute haemorrhage may be sufficient to cause death. In a certain proportion of cases, particularly when the inser- tion 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 haemorrhage. As a rule, it is less copious in this than in the other varieties. The mode of production of the haemorrhage 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 it is evident that as the formation of the lower uterine segment and the dilatation of the 838 HEMORRHAGE internal os progress its attachments must inevitably be torn through, the rupture being necessarily followed by haemorrhage from the intervillous spaces and from the vessels of the decidua. Moreover, as the lower uterine segment becomes developed, it is impossible for the ovum to follow its re- traction, and consequently the connection between it and the placenta must of necessity be more or less completely severed and haemorrhage result. At the same time, 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 placenta becomes separated during the third stage of a normal labor. Furthermore, when the placenta has developed in the capsularis, it is apparent the latter is deprived of all support where it bridges over the region of the internal os, and consequently a slight trauma would open up the intervillous space. As the placenta praevia occupies the lower portion of the uterus, 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; but in placenta praevia, as a result of abnormal adhesions or an excessively large area of attachment, the process of separation is sometimes interfered with, while in other cases there is a pronounced tend- ency to atony of the uterus. As a result, profuse haemorrhage frequently occurs after the birth of the child, and exceptionally continues even after the manual removal of the placenta. Diagnosis.—Placenta praevia should always be suspected in patients suf- fering from uterine haemorrhage in the second half of pregnancy, and its possibility should be borne in mind until a careful examination has revealed some other satisfactory explanation for its origin. In the great majority of cases the cervix is softer and more succulent than usual, and its canal is more or less patulous, so that but little difficulty is experienced in carry- ing the finger through the internal os and feeling the characteristic sponge- like 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 anaesthesia if necessary, suffi- ciently 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 is true that such a procedure occasionally re- sults in the induction of premature labor; but the risk is nevertheless quite 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 condition 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 are born alive perishing within the first ten days following deliverv. The danger to the mother arises primarily from haemorrhage, which is usually the direct result of the condition, though frequently it may be in- PLACENTA PREVIA 839 creased by deep cervical tears resulting from too hasty artificial dilatation, or to the extraction of the child through an imperfectly 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 many of the children are born some weeks or months prematurely. In many instances they perish from asphyxiation, the result of placental haemorrhage, while occasionally they succumb during attempts at extraction through an im- perfectly dilated cervix. Nowadays the maternal mortality depends upon the variety of the placenta prawia, 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 mor- tality was 4.5 per cent., whereas 93 cases in the hands of the three operators above mentioned showed a mortality of only 1 per cent. Kob- lanck reports a death-rate of 3.8 per cent, in 107 cases treated in the Frauenklinik in Berlin, Jellett one of 3.69 per cent, in 138 cases treated at the Ifotunda in Dublin, and Pinard one of l\18 per cent, in 18.", cases treated in his service. Of the 20 deaths reported by Eiirgor and Graf in 190,*), 7 were due primarily to haemorrhage, 4 to lacerations of the cervix and lower uterine segment, 1 to pulmonary embolism, and 8 to in- fection. According to their figures the progno- sis is from 3 to 8 times more serious in central placenta praevia titan in the other varieties. Knrthermore, the mortality depends upon the condition of the patient when first seen, it be- ing 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 haemorrhage. Unfortunately, the fo>lal mortality has shown comparatively little decrease in recent years, Kiistner, Biirgcr and Graf, and Strass- mann giving percentages of 35, 55, and 01.2. respectively. A very great improvement in this respect is hardly to be anticipated on account of the large number of premature children with which one has to deal. Treatment.—On account of the danger of profuse and unexpected haem- orrhage, pregnancy or labor, as the case may be, should be terminated in the most conservative manner as soon as possible after a placenta praevia has Fig. 655.—Fostus Partially Extracted from a Patient Dying of Placenta Pre- via, Showing how It Acts as a Tampon (Leopold). 840 HEMORRHAGE been positively diagnosed. There is no single method of treatment applicable to all classes, and the obstetrician who understands how to differentiate his cases will obtain the best results. If the diagnosis is made during pregnancy, the cervix should be dilated sufficiently to permit the introduction of two fingers. This having been at- tained, further treatment will 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 Ribes balloon after rupture of the membranes or per- foration 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 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 and ex- traction. On the other hand, if the child is not viable, equally good ma- ternal results are more readily obtained by bringing down a foot by Braxton Hicks's manceuvre and using the breech of the child as a tampon to control further bleeding. If the haemorrhage 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 be made upon the leg so as to compress the placenta with the child's buttocks. Whichever method is employed, extrac- tion 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 profuse haemor- rhage and requiring the application of sutures, while in other instances serious difficulty may be encountered in delivering the child. Generally speaking, better results will be obtained in private practice by the employment of Braxton Hicks's bipolar version, no matter what may be the condition of the child, for the reason that the average practi- tioner will rarely be equipped with a suitable balloon and the necessary paraphernalia for its introduction. In hospital practice, however, its em- ployment has undoubtedly aided materially in diminishing the fcetal mor- tality. In very exceptional instances in primiparous women the cervix may be so rigid that it is impossible to dilate it sufficiently to permit the employ- ment of either of the above-mentioned procedures. Under such circum- stances, in the hands of an expert, abdominal or vaginal Caesarean section may be indicated, but in general practice a tight cervical and vaginal 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 employment of whatever manoeuvres 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 dilata- tion and the condition of the patient. If the cervix is obliterated, imme- diate delivery by version or forceps is indicated. On the other hand, if the dilatation is only partial, the haemorrhage slight, and the placenta inserted marginally, good results frequently follow rupture of the membranes, since PLACENTA PREVIA 841 the placenta is then able to follow the retracting uterine wall. In all other cases, provided the child is alive, 1 prefer to complete the dilata- tion by means of a large Champetier de Ribes balloon. For this purpose it should be introduced into the amniotic cavity after rupturing the mem- branes or perforating the placenta, as the case may be, and gentle traction exerted by the hand or a weight attached to the end of the tube. After dilatation has been completed, delivery is usually best effected by version and extraction. If, however, the child is dead, or a balloon is not available, equally satisfactory 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. In this class of cases the cervix is particularly prone to laceration, and no matter how gradually and care- fully 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 haematoma following a tear through the lower uterine segment, which I thought had been satisfactorily repaired, as well as several con- sultation cases in which laparotomy and amputation of the uterus were necessary to check haemorrhage following complete uterine rupture. 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 haemorrhage, expression should not be attempted until the placenta has been expelled into the vagina; but if bleeding is at all profuse, Crede's method of expression should be imme- diately resorted to, and, if not effective, the placenta should be removed manually. Occasionally the loss of blood continues after the completion of the third stage. In such cases the cervix should be inspected, and imme- diately 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 haemorrhage has been profuse, and the patient presents the subjective symptoms of an acute anaemia, it becomes necessary to resort to the constitutional measures outlined under the treatment of post-partum haemorrhage. Occasionally, when the patient is markedly exsanguinated when first seen, but is losing little or no blood at the time, it is better to devote one's attention to improving her general condition rather than to attempt immediate delivery. In view of the danger to the mother, but particularly because many chil- dren are sacrificed by extraction through an imperfectly dilated cervix, after version by Braxton Hicks's method, Tait, Palmer, Dudley, and others recommended the performance of Caesarean 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 praevia patients die from haemorrhage, and held that our methods of treatment were in urgent need of improvement. Furthermore, as they believed that 842 HEMORRHAGE any method associated with natural or artificial dilatation of the lower uterine segment still further accentuated the danger, they advocated that all cases of partial or central pnvvia should be treated by classical or extra- peritoneal Caesarean 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 con- servative obstetricians and has given rise to a voluminous literature. When we remember that Jellett, and Pinard in 1910, reported a ma- ternal mortality from all causes of 3.69 and 2.18 per cent., respectively, 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 Cesarean section will come into very general use, particularly as it is applicable only to hospital patients, or to the rich, who can be surrounded by every convenience and safeguard. If such treatment were generally adopted among the poorer classes in their own homes, the death-rate, I am sure, would be much greater than that obtained by the usual methods. Moreover, as has been said, the fcetal mortality in any case is not susceptible of any material reduction, for the reason that the pregnancy is generally terminated before term, when the chances of extra-uterine life are relatively unfavorable. Ehrenfest and Holmes, after carefully considering the sub- ject, have arrived at the same conclusion. Nevertheless, I am prepared to admit that Caesarean section may occasionally be the operation of choice, as, for instance, when a primipara with a rigid cervix and a living child is overtaken by profuse haemorrhage. Bumm, in 1905, strongly recommended vaginal Caesarean section in appropriate cases, and since then many oper- ators have employed it. That its results have not been as satisfactory as were anticipated is shown by the fact that his assistant, Jolly, strongly deprecated its employment in 1911. The mode of production and significance of slight ante-partum haemor- rhage, which sometimes follows intra-uterine rupture of the cord or the tearing of the vessels of the velamentously inserted umbilical cord, have already been considered in Chapter XXVIII. POST-PARTUM HAEMORRHAGE 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 retention of the partially separated placenta or of individual cotyledons; less often it is due to deep tears involving the tissues of the birth canal, and in very rare instances to defective functioning of the uterine musculature—atony. etiology.—As long as the placenta remains firmly attached to the uter- ine wall the possibility of haemorrhage is slight, but when it has become partially separated, the normal action of the uterine musculature is inter- fered with. As a result the torn vessels at the partially denuded placental site are not constricted, and more or less profuse haemorrhage occurs. Imperfect separation of the placenta can usually be attributed to POSTPARTUM HEMORRHAGK 843 improper management of the third stage of labor, particularly the too early and energetic employment of Crede's manceuvre. Kxceptionallv, it may result from an abnormally intimate attachment of the placenta, due to a decidual endometritis or some other morbid condition. The retention of isolated cotyledons or of a small succenturiate lobe interferes with the normal contraction and retraction of the uterus in preciselv the same manner as the partially separated placenta. The part played by deep tears of the generative tract is perfectly obvi- ous, and will be considered in detail in the following chapter. In very rare instances serious haemorrhage 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, atony of the puerperal uterus was considered the most fre- quent cause of post-partum haemorrhage, but more careful observation has shown that such a condition is seldom primary; for, with the exception of the rare instances in which it follows excessive distention of the uterus incident to twin pregnancy or hydramnios, serious abnormalities in the contractile function of the uterine musculature are usually 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 asso- ciated with degeneration of the muscle fibers resulting from an abnormal invasion of fetal elements, as described by Kworostansky, Martin, and others. It is probable, however, that Veit goes too far in denying in toto the possibility of a primary atony, although Hofstlitter did not observe a single example in the 13 fatal cases of post-partum haemorrhage occurring in a series of 32,180 labors in Rosthorn's clinic. The rare cases of haemorrhage 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; while the occasional instances in which patients bleed profusely after each labor without demonstrable cause likewise afford corroborative evidence. At the same time the possible existence of haemophilia should always be borne in mind in such women, as in a case reported by Wehle. Clinical History.—Severe haemorrhage is observed once in every few 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. For- tunately, haemorrhage dependent upon the latter cause is usually not seri- ous, for the reason that the condition is only transitory, complete separation occurring spontaneously as the result of uterine contraction, when satisfac- tory retraction checks the loss of blood. Exceptionally the bleeding may persist even after the placenta has become completely separated and lies free in the uterine cavity. In such cases it is due either to tears or to im- perfect functioning of the uterus. Generally speaking, partial separation occurring during the course of 844 HEMORRHAGE placental expulsion by the Schultze mechanism is not accompanied by external haemorrhage 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 haemorrhage 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 con- tractions, 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 instances the haemorrhage may be concealed, several liters of blood sometimes accumulating in the uterine cavity. The amount of blood lost during a post-partum haemorrhage may vary from 500 to 3,500 cubic centimeters, the latter extreme, however, being invariably incompatible with life. 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 at- tributed by Zuntz to the fact that a marked increase in the amount of blood occurs during pregnancy. He estimates that it constitutes 5.3 per cent, of the body weight before conception, and increases to 8.4 per cent, at the end of pregnancy. On the other hand, Fries holds that there is no such in- crease. However this may be, the effect of haemorrhage will depend more upon the general condition 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. As a rule, the loss of a small amount of blood is not attended by serious symptoms; but when the haemorrhage is profuse 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 pa- tient usually passes into unconsciousness before the fatal termination. Diagnosis.—The diagnosis offers no difficulty, except in the rare in- stances in which the haemorrhage has taken place into the uterine cavity and does not appear externally. It must, however, be distinctly stated that concealed haemorrhage 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 markedly increased in size, 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 generally depends upon the recognition of the source of the haemorrhage, a differential POST-PARTUM HEMORRHAGE 845 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 haemorrhage 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 haemorrhage persisting after the uterus has been emptied, while abdominal palpation shows that the organ itself is firmly contracted, sug- gests 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 care- fully 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 examined by the fingers in the vagina. If a cervical lesion cannot be detected, the vaginal walls should be spread apart by means of a speculum and thoroughly inspected. A haemorrhage 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 haemorrhage must be sought for either in the retention of a placental cotyledon or in atony. Certainty with regard to the former point is usually obtained by careful inspection of the after- birth, a large defect upon its maternal surface indicating the retention of a cotvledon, 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 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, luemorrhage during and imme- diately 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 manceu- vre until the rising up of the fundus indicates that the placenta has become completely detached. Premature attempts at expression are a frequent cause of imperfect separation. Again, owing to the tendency toward re- laxation following the birth of twins, as well as in hydramnios, concealed haemorrhage, and placenta prawia, the condition of the uterus in such cases should be most carefully watched for the few minutes immediately follow- ing the birth of the child, and energetic kneading through the abdominal walls promptly resorted to upon the first sign of failing contraction. The placenta should be carefully examined immediately after its ex- pulsion, for the purpose of ascertaining whether it is intact. If it shows any serious defect, immediate preparations should be made for the removal of the jetained portion in case symptoms supervene. 846 HEMORRHAGE In the presence of actual haemorrhage, 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 abdom- inal wall and firmly kneaded. If firm contractions come on, all is well, but if the haemorrhage 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 XXIV should be most conscientiously followed. If the haemorrhage 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 haemorrhage 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 circum- stances 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 haemorrhage is due to atony the uterus should be vigorously kneaded, and 60 minims of the fluid extract of ergot or of ergotol adminis- tered 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. The experiments of Kurdinowsky indicate that adrenalin has an even more potent effect, and the clinical observations of Xeu show that the injection of 0.0001 gram of suprarenin directly into the uterine mus- culature brings about intense contractions. Furthermore, Foges and Hof- statter state that the hypodermic employment of 2 cubic centimeters of "pituitrin" is likewise more efficient than ergot. I have had no personal experience with the use of either drug. 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 haemostatic, effectively irritating the uterus and causing it to contract forcibly and permanently. If the haemorrhage 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 XXIV (see Fig. 441). Before resorting to the use of the pack it is always advis- able to palpate the interior of the uterus, as occasionally a portion of the placenta may have been retained, even though immediately after expulsion the organ may have apparently been entire. Should the loss of blood continue after the employment of these meas- ures the aorta should 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, and its value was critically consid- ered by Gueniot in 1911. Formerly it was customary to recommend the introduction into the INVERSION OF THE UTERUS 847 uterus of ice or solutions containing vinegar, the perchloride of iron, or other astringent substances. Their employment, however, is not advisable, 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 act as promptly or efficiently as the pack, the employment of which, although comparatively rarely indicated, in exceptional cases offers the only 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 technique in every intra-uterine manipulation under- taken for the purpose of checking post-partum haemorrhage. 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 attended by most serious consequences, the patient being saved from death from haemorrhage 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 disinfecting his hands before beginning any manipulations. In fact, the only exception is offered by the very rare cases of atonic haemorrhage in which it appears probable that a delay even of a few minutes means inevitable death. After the actual haemorrhage has been checked, attention must be di- rected 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 strychnine hypodermically, 3 doses being given in prompt succession, if necessary, is attended by excellent results, which may be supplemented by hypodermic injections of whisky or ether. Hot rectal enemata of equal parts of black coffee and salt solution are also valuable. When the patient is profoundly 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 the best re- storative, and even more striking results may be obtained by administering it intravenously. Occasionally, when the loss of blood has been very great, these measures may be supplemented by actual transfusion by means of arterio-venous anastomosis. INVERSION OF THE UTERUS This condition is a very rare, but important, cause of post-partum haem- orrhage. 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 con- dition. On the other hand, it is much more frequently noted in the prac- tice of ignorant midwives. The historical and statistical aspects of the 56 848 HEMORRHAGE subject are fully dealt with in the articles of Beckmann, Browne, Holmes, and Vogel. Now 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 (Fig. 656). 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 Fig. GoO.—Complete Inversion of Uterus (Bunini). 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 the too vigor- ous employment of Crede's manoeuvre 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 patient, Fritsch having observed it in three successive pregnancies. Beckmann, who has carefully analyzed 100 cases reported in the litera- LITERATURE 849 ture, believes that in the majority of instances the accident occurs spon- taneously, while Vogel, in a similar review, holds that most cases are due to violence. His contention appears to be confirmed by Beckmanns statis- tics, as only 3 of the 100 cases occurred in hospital practice. 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 con- ditions existing in private practice, particularly as conducted by midwives. The complication usually follows a full-term labor, although a number of cases are recorded in which it was noted after abortion. It is also an interesting fact that more than 50 per cent, of the cases recorded by both Beckmann and Vogel were in primiparous women. Symptoms.—As a rule, inversion of the uterus is promptly followed by alarming symptoms, the patient presenting marked evidences of shock, with a rapid pulse and a tendency to syncope. In other cases convulsions occur and profuse haemorrhage is 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 re- placed immediately, the prognosis is fair, Beckmann reporting a mortality 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, anaesthesia 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 eon- tractile function of the inverted uterus being in abeyance, there is always the risk of profuse haemorrhage. 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 gynaecology. * LITERATURE Ahlfeld. Ueber Placenta pnvvia. Verh. d. deutschen Resell, f. Gyn., 1897, 268-277. Ahlfeld u. Aschoff. Neue Beitrage z. Genese der 1 lacenta praevia. Zeitschr. f. Geb. u. Gyn., 1904, li, 544:1:1(3. Barnes. The Physiology and Treatment of Placenta Prama. London, 1S.1S. Placenta Previa. Lectures on Obstetric Operations, 4th ed. London, ISSfi, 398-422. Beckmann. Zur .Wiologie der Inversio uteri post partum. Zeitschr. f. Geb. u. Gyn. 1895, xxxi, 371-401. 850 HEMORRHAGE Behm. Die combinirte Wendung bei Placenta praovia. Zeitschr. f. Geb. u. Gyn., 1883, ix, 373 419. Braun, Chiari, und Spaeth. Paralyse des Uterus. Klinik der Geb. u. Gyn., Erlan gen, 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. Ueber die Methoden der kiinstlichen Eiweiterung des schwangeren u. kreissenden Uterus. Verh. d. deutschen Gesell. f. Gyn., 1906, xi, 54-6S. Burger u. Graf. Zur Statistik der Placenta praevia. Monatsschr. f. Geb. u. Gyn., 1907, xxv, 49-76. Coe. Accidental Haemorrhage during the First Stage of Full-term Labour. Trans. Amer. Gyn. Soc, 1891, xvi, 35-50. Didry. De la dilatation manuelle du col uterin dans les accouchements avec hemorrha- gies placentaires graves. These de Nancy, 1899. Doranth. Statistisches iiber Placenta praevia. Chrobak's Berichte aus der 2ten geb. gyn. Klinik in Wien, 1897, i, 77-119. Dudley. The Modern Caesarean Section an Ideal Method of Treatment for Placenta Praevia. New York Med. Jour., 1900, lxxii, 754-760. Ehrenfest. The Impropriety of Caesarean Section in Placenta Praevia, etc. Amer. Med., 1902, iii, 64-68. Foges u. Hofstatter. Ueber Pituitrinwirkung bei post-partum Blutungen. Zen- tralbl. f. Gyn., 1910, 1500-1504. Fries. Ueber Veranderungen der Blutmenge in der Schwangerschaft. Zeitschr. f. Geb. u. Gyn., 1911, Ixix, 340-350. Fritsch. Zur Aetiologie der puerperalen Uterusinversion. Zentralbl. f. Gyn., 1907, xxxi, 427-429. Goodell. Concealed Accidental Haemorrhage of the Gravid Uterus. Amer. Jour. Obst., 1870, ii, 281-346. Gueniot. L'hemostase par la procede de Momburg. L'Obst., 1911, iv, 56-70. 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. Hofmeier. Zur Behandlung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1882, viii, 89-101. Ueber Placenta praevia. Verh. d. deutschen Gesell. f. Gyn., 1888, 159 163. Zur Entstehung der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1S94, xxxix, 1.-17. Ueber Placenta praevia. Verh. d. deutschen Gesell. f. Gyn., 1897, 204-225. Storungen der Schwangerschaft durch fchlerhaften Sitz der Placenta. Winckel's Handbuch der Geb., 1904, ii, 1198-1259. Hofstatter. Die Behandlung der post-partum Blutungen. Monatsschr. f. Geb. u. Gyn., 1910, xxxii, 470-484. Holmes. Inversio Uteri complicating Placenta Praevia. Obstetrics, 1899, i, 297-311. Ablatio Placentas. Amer. Jour. Obst., 1901, xliv, 753-784. Caesarean Section for Placenta Praevia, an Improper Procedure. Jour Amer. Med. . Ass., 1905, xliv, 1594-1602. Hunter. Anatomical Description of the Human Gravid Uterus. Birmingham, 1774. Jellett. The Place of Caesarean Section in the Treatment of Placenta Praevia. Lan- cet, 1910, i, 1271. LITERATURE 851 Kaltenbach. Zur Pathogenese der Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1890, xviii, 1-7. Kermauner. Placenta praevia cervicalis. Beitrage z. Geb. u. Gyn., 1906, x, 241. Koblanck. Placenta praevia. Sanger-Herff, Encyklopadie der Geb. u. Gyn., 1900 ii 189-191. Kronig. Zur Behandlung der Placenta praevia. Zentralbl. f. Gyn., 1908. Kurdinowsky. Adrenalin als ein Gebarmuttermittel. Archiv f. Gyn., 1904, Ixxiii, 425 437. Kustner. Ueber Placenta praevia. Verh. d. deutschen (Jesell. f. Gyn., 1897, 277-283. 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. Lobenstein and Harrar. A Study of Forty-seven Cases of Premature Separation of the Placenta. Bull. Lying-in Hospital, N. Y., 1907, iv, 53-59. Lomer. On Combined Turning in the Treatment of Placenta Praevia. Amer. Jour. Obst., 1884, xvii, 1233-1260. Lyle. The Treatment of Accidental Haemorrhage. The Physician and Surgeon, London, April 12, 1900. Madden. (Quoted by Browne. Martin. Zur iEtiologie lethaler Atonien post partum. Monatsschr. f. Geb. u. Gyn., 1906, xxiii, 207 217. Momberg. Blutleere der unteren Korperhalfte. Zentralbl. f. Gyn., 1909, 716. Muller, W. Placenta praevia. Stuttgart, 1877. Munchmeyer. Ueber den Vorfall der Nachgeburt bei regelmassigem Sitze derselben. Archiv f. Gyn., 1888, xxxiii, 486 497. Neu. Die Bedeutung der Suprarenins fiir die Geburtshilfe. Archiv f. Gyn., 1908, Ixxxv, 617-711. Olshausen. Paralyse der Placentar-insertionsstelle. Schroeder's Lehrbuch der Geb., XTII. Aufl., 1899, 775. Peters. Ueber die Einbettung des menschlichen Eies. Wien, 1899. Pinard. De la rupture prematuree, dite spontanee, des membranes, etc. Annales d'obst. et de gyn., 1886, xxv, 171-179; 321-345. Ponfick. Zur Anatomie der Placenta pnevia. Archiv f. Gyn., 1900, lx, 147-173. Portal. La pratique des accouchements, etc. Paris, 1685. Rigby. An Essay on the Uterine Haemorrhage which Precedes the Delivery of the Full-grown Foetus. London, 1776. Schacher. De placentae uterinae morbis. Lipsiae, 1709. Schickele. Die vorzeitige Losung der normal sitzenden Placenta. Beitrage zur Geb. u. Gyn., 1904, viii, 357-364. 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. Strassman. Ueber Placenta praevia. Zeitschr. f. Geb. u. Gyn., 1901, xliv, 529-546. Placenta praevia. Archiv f. Gyn., 1902, xxvii, 112-275. Tait. On the Treatment of Unavoidable Hemorrhage by Removal of the Uterus. Med. Record, 1899, lv, No. 9. Tarnier et Budin. Hemorrhagic par insertion vieieuse du placenta. Traite de l'art des accouchements, .isj»8, iii, 571-659. Veit. Ueber die Behandlung der Blutungen unmittelbar nach der Geburt. Zeitschr. f. Geb. u. Gyn., 1895, xxxi, 214-225. 852 HEMORRHAGE Vogel. Beitrag zur Lehre von der Inversio uteri. Zeitschr. f. Geb. u. Gyn., 1900, xiii, 490-525. Wehle. Ueber Hamophilie bei einer Gebarenden. Zentralbl. f. Gyn., 1893, xvii, 672-675. Weiss. Ueber vorzeitige Losung der normal sitzenden Placenta. Archiv f. Gyn., 1897, xlvi, 256-291. Zur Kasuistik der Placenta prawia centralis. Zentralbl. f. Gyn., 1897, xxi, 641-649. Williams. Decidual Formation throughout the Uterine Muscularis. 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. 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 INJURIES TO THE BIRTH 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 and 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 haemorrhage; while following pubiotomy, such tears may commu- nicate 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 distance up one or both vaginal sulci, being almost always sufficiently deep to involve some filters 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 (Eig. 315). 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 sustained during a forceps operation, though now and again they follow spontaneous delivery. They frequently extend deeply into the underlying tissues, and may give rise to a copious haemorrhage, which, however, is readily con- 854 INJURIES TO THE BIRTH (ANAL trolled 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, as they are not associated with tears through the vaginal mucosa, usually escape immediate detection. As the result of overdistcntion of the birth canal, there may occur a submucous separation of certain fibers of the mus- cle, or at least so great a diminution in its tonicity that it can no longer properly fulfil its function as the pelvic diaphragm. In these 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, indications for prophylactic measures are not always at hand, since 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 retrac- tion 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 possible only in those cases in which the lips of the cer- vix are not compressed between the presenting part and the pelvic wall, but are free to follow the retracting uterus. It sometimes occurs spontane- ously, but more frequently follows ill-chosen operative procedures. 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 Ross. 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. LESIONS OF THE CERVIX 855 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 determining whether a woman has borne children or not. In other cases the tears are deeper, implicating one or both sides of the cervix and extending up to or beyond the vaginal junction. In 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 usually associated with profuse haemorrhage. Deep cervical tears occasionally occur during the course of spontaneous labor, and under such circumstances their genesis is not always readily explainable. More usually, however, they follow rapid manual or instru- mental dilatation, especially in eclampsia, placenta praevia, or in women suffering from general oedema. Moreover, they are apt to result from attempts at delivery through an imperfectly dilated cervix, no matter whether forceps or version be employed. Occasionally, even in spontaneous labors, the anterior lip of the cervix may be caught between the head and the symphysis pubis and be com- pressed 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 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 haemorrhage may be profuse. In many cases, however, the bleeding is so slight that the con- dition would pass unrecognized were it not detected upon vaginal examina- tion. When one lip of the vaginal portion of the cervix is torn off, there is usually very little haemorrhage, 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 folloAved by bleeding. Slight cervical tears heal spontaneously, provided the patient remains uninfected; but extensive lacerations afford to any pathogenic micro-organ- isms which may be present a ready port 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 haemorrhage 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 vaginal examination is necessary, while the extent of the injury can be fully appreciated only after drawing the cervix down to the vulva and subjecting it to direct inspection. 856 INJURIES TO THE BIRTH CANAL In all cases of accouchement force, the cervix should be inspected at the conclusion of the third stage, even if there be no bleeding; since in the great majority of cases deep tears will be discovered, which should be united by sutures as a prophylactic measure. Annular detachment of the vaginal portion of the cervix should be diagnosed whenever an irregular mass of tissue having a circular opening is cast off before or after the birth of the child. Treatment.—Deep cervical tears accompanied by haemorrhage should be immediately repaired, the introduction of a few sutures readily check- Fig. 657.—Lacerated Cervix Drawn down to Vulva, Preparatory to Repair (Bumm). ing the flow of blood. On the other hand, if there be no haemorrhage, the condition usually escapes detection unless specifically looked for. I have already indicated the advisability of inspecting the cervix after accouche- ment force; but I consider its routine employment unnecessary, as I hold that the benefits following the repair of all tears will be more than counter- balanced by the increased incidence of infection resulting from unnecessary manipulations. Moreover, the majority of such tears heal spontaneously, and in the exceptional cases in which this does not occur better results are usually obtained by a secondary operation performed in the latter part of the puerperium. RUPTURE OF THE UTERUS 857 The treatment of cervical tears associated with haemorrhage 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, most 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 down- ward pressure upon the uterus, while at the same time the operator exerts strong traction by means of a bullet forceps inserted into either lip of the cervix, the vaginal walls, if necessary, being held apart by means of suitable retractors (Fig. 657). As the haemorrhage usually comes from the upper angle of the wound, it is advisable to apply the first suture in that situa- tion, 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 haemorrhage 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. Many authorities recommend a tight vaginal pack in this class of cases. No doubt it will usually check the hemorrhage and may be employed 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 with 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 following 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 labors, although instances of spontaneous rupture during pregnancy have been reported. 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 occurring during pregnancy collected by Baisch were observed in the first five months. 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 infan- tile 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 occasionally occurs after Caesarean section, or in women whose uteri had been previously perforated or other- wise injured during curettage or some other operative procedure. In other cases the accident may be attributed to faulty 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, 858 INJURIES TO THE BIRTH CANAL 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 pre- vious pregnancies. In other instances, as in the two cases occurring in my service, no satisfactory cause can be discovered. In spontaneous rupture occurring during pregnancy, the lesion is al- most 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 aetiological factors must be concerned. Contrary to the statement of Blind that the rupture nearly always occurs in the neighbor- hood of the fundus, Baisch found that it was situated upon the anterior or posterior wall in 32 out of 56 cases in which the location of the rupture had been accurately described. The symptoms, diagnosis, prognosis, and treatment of this condition are identical with those following rupture of the uterus occurring at the time of labor. It should be noted, however, that in a number of the cases reported in the literature the haemorrhage 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 by Leopold and Henrotin, the placenta remained in the uterus, while the fcetus, surrounded by its membranes, escaped into the peritoneal cavity, where it went on to further development—utero-abdominal pregnancy. Such an occurrence is usually synonymous with fcetal death. /Etiology.—Rupture 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. Practically we are indebted to Bandl for the first clear explanation as to its mode of production, its aetiology 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 dif- ferentiated into two portions, separated by a circular ridge of tissue, to which the term contraction ring is usually applied. The upper, by its con- tractions, 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 forced. 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 re- tracted, 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 portion 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 RUPTURE OF THE UTERUS 859 thicker and more prominent, so that it can readily be distinguished 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 subjected to an abnormal strain and remain tense even in the intervals be- tween the uterine contractions. As the process goes on the lower segment becomes extremely sensitive to pressure, the uterine contractions increase progressively in frequency and intensity, and cause the patient greater suffering. The pulse becomes more rapid, the patient presents a worn and haggard appearance, and the contraction ring becomes more prominent on palpation. 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 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 threatens 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 dan- ger of rupture, is favored by any factor which interferes with the birth of the child, and more particularly with the entrance of the presenting part into the pelvis. Such conditions are most frequently afforded by con- tracted pelves, neglected transverse presentations, hydrocephalus, excessive size of the child, and, in fact, by any obstacle to labor. The following analysis by Merz shows the aetiological factors concerned in the production of 160 cases of rupture of the uterus: Contracted pelvis ..................................... 70 Neglected transverse presentation...............,....... 26 Hydrocephalus ........................................ IS 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 uterine seg- ment 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 rup- ture of the uterus. In the former the accident occurs spontaneously, while in the latter it is usually 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 extension of cervical tears, following rapid manual or instrumental dilatation of the cervix. 860 INJURIES TO THE BIRTH CANAL Traumatic rupture occurs relatively frequently when version is at- tempted in neglected transverse presentations. The proper treatment of this class of cases requires the utmost nicety of judgment, as it is ofttimes 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 anaesthesia 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 followed 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 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 Fie. i VS. Longitudinal Section through Woman Dying from Rupture of the Uterus (Zweifel). 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. It is quite likely that in such circumstances the second rupture occurs in tissues already weakened by the previous accident. Pathology.—Rupture of the uterus occurring at the time of labor is limited almost entirely to the lower uterine segment, the rent usually pur* suing an oblique direction; although when it is in the immediate vicinity of the cervix it frequently extends transversely. On the other hand, it ia usually longitudinal when it occurs in the portion of the uterus adjacent to the broad ligament, and, according to Freund, when it occurs spontane- ously in neglected transverse presentations. It is customary to distinguish between complete and incomplete rupture, according as the laceration communicates directly with the abdominal cav* RUPTURE OF THE UTERUS 861 ity or is separated from it by the peritoneal covering of the uterus or broad ligament. The former is apparently the more common, Merz having col- lected 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 haemorrhage often occurs less rapidly than in the com- plete variety, the blood slowly accumulating between the leaflets and lead- ing to the separation of the peritoneum from the surrounding viscera, with the consequent formation of a large subperitoneal hematoma. Occasionally, an effusion of blood sufficiently copious to cause the death of the patient may be inclosed between the structures. More frequently, however, the fatal issue does not occur until rupture of the haematoma 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 downward through the cervix into the vagina. The tear itself usually presents jagged, irregular margins which are stained with blood. Following complete rupture, the uterine contents may escape into the peritoneal cavity, while in the incomplete variety they usually remain within the uterus, but exceptionally they may come to lie beneath the serous cov- ering of the uterus or between the leaflets of the broad ligament. When the presenting part is firmly engaged at the time of rupture, only a portion of the fcetus escapes, the rest remaining in the uterine cavity. Symptoms.—The symptoms of actual rupture vary considerably. If it occurs spontaneously, or as the result of traumatism during the later months of pregnancy, the patient usually experiences sharp abdominal pain. In some cases marked symptoms of collapse immediately 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. In the earlier months, on the other hand, profuse haemorrhage is the rule, and the patient rapidly succumbs to acute anaemia if not operated upon. If the accident occurs at the time of labor, the patient, after presenting 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. Im- mediately following these symptoms there is an absolute cessation of the uterine contractions, and the patient, who had previously been in intense agony, suddenly experiences marked relief. At the same time there is usually some external haemorrhage, 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 be 862 INJURIES TO THE BIRTH CANAL 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 markedly in rapidity, loses tone, and takes on a filiform character, the face becomes pallid, assumes a drawn appearance, and is often covered with beads of sweat. If the haemorrhage has been copious, she may complain of chilliness, disturb- ances 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 incom- plete rupture, on the other hand, the immediate symptoms are sometimes very slight, but increase in severity as the subperitoneal haematoma becomes larger, while actual symptoms of collapse frequently do not appear until secondary rupture into the peritoneal 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 char- acter having been collected by Dischler. It is probably usually due to the invasion of the subperitoneal connective tissue by Bacillus aerogenes cap- sulatus. It is true that bacteriological proof has not been adduced in sup- port 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 accompanied by profuse haemorrhage, the profound collapse should at once lead to a provisional diagnosis, but in other cases the condition usually escapes 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 fcetus, 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 super- vision during its course. If she is not seen until later the characteristic history and the collapse are almost pathognomonic, the only other condi- tions 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 examina- tion frequently 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. 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 RUPTURE OF THE UTERUS 863 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 separation of the placenta, being otherwise inevitable. If left to themselves, the vast majority of the mothers die from haemorrhage or infection, although spon- taneous recovery has been noted in exceptional cases. In the 23 cases re- ported by Scipiades, which came to autopsy, death was due to infection in 52 per cent., to haemorrhage in 39 per cent., and to haemorrhage and shock in 44 per cent. Death from haemorrhage usually occurs within the first few hours, though occasionally 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 concerned, 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 frequently 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 ex- istence of an obstacle to the birth of the child, the obstetrician should al- ways 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 sus- picion, and if the contraction ring rises up labor should be promptly ter- minated by the most conservative procedure. In neglected cases decapita- tion in transverse and craniotomy in bead presentations often promise the best results. Such procedures are the more justifiable in the circumstances, as the children are usually cither 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 uterus, or if it has already escaped into the abdominal cavity, no attempt should be made to extract it per vagi nam, 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, de- livery may be effected by the natural passages by the most feasible and con- servative procedure, after which, as well as in those cases which are not seen until after delivery per vaginam and in which the uterine rupture was not recognized until afterwards, various procedures have been suggested by different authorities. Personally, I believe that in hospital practice the best results will fol- 57' 864 INJURIES TO THE BIRTH CANAL low laparotomy, no matter what the character of the tear, or the extent of the ha'inorrbage; for the reason that it is often difficult to determine the extent of the laceration, and furthermore that it is absolutely impossible to foretell whether the haemorrhage can be controlled by simple procedures; and, even if these succeed, whether the result will be permanent. I there- fore agree with Fritsch, Varnier, Zweifel, and Munro Kerr, who hold that it is only by opening the abdomen that one can be assured against all further risk of haemorrhage. On the other hand, in outside practice, and particularly in cases of incomplete rupture, radical surgical treatment is usually inadvisable, so that, after delivering the child and placenta, one must be content with the employment of palliative measures. Many authorities, however, agree that, inasmuch as the danger to be apprehended in cases of incomplete rupture is haemorrhage, 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. Schmit, Klien, Scipiades, and others have collected large series of cases which apparently bear out this contention. My own experience leads me to believe that it is usually 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, while radical surgical measures are practically limited to the desperate cases, which would naturally lead one to overestimate the dangers of radical intervention. INSTRUMENTAL PERFORATION OF THE UTERUS Reference has already been made to perforation of the uterus following attempts at criminal abortion or in the effort to remove placental tissue by means of the 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 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. Under 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 LITERATURE 865 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 vesico-vaginal .fistula. Less fre- quently the anterior lip of the cervix is compressed against the symphysis pubis, and an abnormal communication is eventually established between the cervical canal and the bladder—cervico-vesical fistula. If the patient is not infected the fistulous tract frequently heals with- out 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 results, and a connection is established with Douglas's cul-de-sac. If infection occurs the accident is usually followed by septic peritonitis. Fortunately, recovery usually follows without further complications, inasmuch as a local- ized 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. LITERATURE 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 Ruptur 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 I'accouchement. These de Toulouse, 1902. Dischler. Ueber subperitoneales Emphysem nach Ruptura uteri. Archiv f. Gyn., 1S98, lvi, 199-217. Freund. Neuere Arbeiten iiber die Zerreissung der Gebarmutter. Zeitschr. f. Geb. u. Gyn., 1910, lxv, 735-759. Fritsch. Ueber die Behandlung der Uterusruptur. Verh. d. deutschen Gesell. f. Gyn., IS!)"), 1-19. Goldner. Dehnung des unteren Uterinsegmeiits bei stehender Blase. Monatsschr. f. Geb. u. Gyn., 1903, xviii, 491-512. IIenrotin. Utoro-nbdominal Gestation. The Practice of Obstetrics by American Authors, 1899, .".SO. HccKXBERGER. Ueber Kolpaponhexis in der Geburt. Petersburger med. Zeitschr., is75, v, Heft 5. Jellinoi-iaus. Ueber Uterusrupturen wahrend der Schwangerschaft. Archiv f. Gyn., 1897, liv, 103-116. Kaufmann. Ueber die Zerreissung des Scheidengewblbes wahrend der Geburt. Mo- natsschr. f. Geb. u. Gyn., 1901, xiii, 464-170. 866 INJURIES TO THE BIRTH CANAL Kerr. Rupture of the Uterus and Its Treatment. Jour. Obst. and Gyn. Brit. Em- pire, 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, Iii, 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, xiv, 181-271. Mikhine. Un cas de recidive de rupture uterine. Annales de gyn. et d 'obst., 1902, Ivii, 403-410. Peham. Ueber Uterusrupturen in Narben. Zentralbl. f. Gyn., 1902, xvi, 87-94. Poroschin. Zur jiEtiologie 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. Sanger. Ruptura uteri. Verh. der deutschen Gesell. f. Gyn., 1895, 19-86. Schick. Zerreissung des Scheidengewolbes wahrend der Geburt. Prager med. Woch- enschr., 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, lvi, 249-279. Zweifel. Ueber die Behandlung der Uterusruptur. Beitrage z. Geb. u. Gyn., 1903, vii, 1-27. CHAPTER XLII PROLAPSE OF THE UMBILICAL CORD—ASPHYXIA NEONATORUM— SUDDEN DEATH DURING LABOR 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 presenta- tions. On the other hand, it is rarely observed when the child presents by the head, unless accommodation is interfered with as a result of a con- tracted pelvis, excessive development of the fcetus, hydramnios, or abnormal flaccidity 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 most frequent causes of fcetal 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 funis is diagnosed when on palpation a soft, pul- sating, cord-like body can be felt through the membranes. In many in- stances, 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 the structure may protrude from the vulva. Mistakes are hardly possible if the foetus is alive, as distinct pulsations are felt, although in their absence the condition is sometimes overlooked on super- ficial examination. The possibility of prolapse of the cord should be particularly borne in 867 868 PROLAPSE OF THE UMBILICAL CORD mind in multiparous women in whom the membranes rupture while the bead is still freely movable above the superior strait. In such cases the sudden cessation of the fcetal heart-beat renders the diagnosis almost cer- tain, 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 ex- tent upon the presentation of the child. In cases of presentation of the funis there is no immediate danger of compression so long as the mem- branes remain intact, and for this reason every precaution should be taken to avoid their premature rupture, vaginal examinations being made with the utmost gentleness. At the same time the obstetrician should hold him- self in readiness to effect delivery as soon as the cervix is sufficiently dilated. In prolapse of the cord, provided dilatation is complete, the life of the child can often be saved by prompt delivery. In cephalic presentations this can usually be effected more rapidly by version than by forceps, unless the head is already deep down in the pelvic canal. In breech presentations a foot should be brought down and followed immediately by extraction. In transverse presentations version is indicated. On the other hand, when the cervix is only partially dilated, the chances of a favorable outcome for the child are markedly diminished. If the head is not deeply engaged 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 portion of the child's body. If the cord remains in the uterus the patient should be made to lie upon the side toward which the child's back is directed in the hope of avoiding compression. 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. Occasionally the tendency to prolapse may be overcome by placing the patient in the knee-chest position until engagement of the presenting part occurs, when the cord cannot get past it. In most cases, however, these manoeuvres prove ineffectual, and, unless the resistance offered by the cervix can be promptly overcome, the death of the child becomes almost inevitable in vertex, and only somewhat less so in breech and transverse presentations. In exceptional cases, if the child is in good condition, excellent results may be obtained by manual dilatation of the cervix, or by vaginal hyster- otomy, followed by prompt version and extraction. On the other hand, if the pulsations in the cord are weak or have ceased altogether, such a pro- ASPHYXIA 869 cedure should not be adopted, 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. ASPHYXIA Normally the foetus while it remains in the uterus is in a condition of apnoea, being satisfactorily supplied with oxygen by means of the placental circulation. As soon as delivery occurs, owing to the separation 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 establishment of this function, al- though numerous accessory causes come into play during the act of de- livery and just after birth. Exceptionally, as the result of compression of the prolapsed cord, pre- mature separation of the placenta, or much less commonly of tetanic con- traction 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 consequent diminution in the area of placental attachment. As a result of the action of any of these factors the child may take its 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 in- creased respiratory efforts, which are nevertheless of no avail. Gradually the accumulation of carbon dioxide and other excrementitious materials in the fcetal organism leads to such a pronounced decrease in the irritability of the medulla that eventually the attempts at respiration cease, the inter- vals 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 operative 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 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, and intra-cranial haemorrhage. When limited to the cerebral hemispheres a very consider- 870 ASPHYXIA able effusion of blood may occur without exerting a 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 delivery, without which the life of the child is inevitably lost. The most characteristic symptom is afforded by changes in the fcetal 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 be- tween 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. Exceptionally, 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. In vertex presentations another characteristic sign of impending as- phyxia is the escape of meconium. This is due to relaxation of the sphinc- ter ani muscle induced by faulty aeration of the blood. In breech presen- tations, of course, this symptom is without significance, and is to be regarded as a purely mechanical result of pressure applied to the abdomen of the foetus. Accordingly, whenever the amniotic fluid in a vertex presen- tation presents a yellowish-green appearance and contains flakes of mecon- ium, we may conclude that the child is in danger, and that the only hope for its safety lies in prompt delivery. 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 cir- cumstances the finger in the child's mouth can readily appreciate the fact that vigorous inspiratory movements are being made. A similar phenom- enon 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 utero—vagitus uterinus. For the pro- duction 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 phenom- enon has been recorded by Bucura, who has collated the literature bearing upon the subject up to 190-1. After delivery the asphyxiated child may present one of two appear- ances—asphyxia pallida or asphyxia Uvula. In both respiration is in abey- ance or occurs only in gasps, while the heart beat-s slowly and feebly. In ASPHYXIA 871 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. Prognosis.—Asphyxia neonatorum 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 intra-cranial haemorrhage, fractures, or de- pressions of the skull. Treatment.—Normally, the child should make its first inspiratory move- ment a few moments after it emerges from the vulva. If this does not occur, the feet being grasped by the fingers of one hand and the child sus- pended with its head downward, its body should be slapped vigorously with the other. If this manceuvre does not prove immediately successful, and particularly if attempts at respiration are associated with a gurgling sound, a finger 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 asphyx- iated, these measures will bring about the desired results; but if they fail artificial respiration should at once be instituted, the child's thorax being compressed 5 or 6 times to the minute. In some instances, however, more radical measures will be found neces- sary. In such cases the cord should be ligated and cut through, and the child immersed in hot and cold water alternately, with only its head pro- truding, and rubbed vigorously. If there is any reason to believe that the trachea and larger bronchi contain mucus or amniotic fluid, a small, soft- rubber catheter should be introduced into the larynx and the offending ma- terial removed by suction exerted by the obstetrician, or by the employment of a Ribemont-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 manceuvre being repeated at regular intervals 10 or 12 times to the minute. After the first few tractions an inspiratory movement usu- ally follows, after which respiration goes on regularly. This procedure, known as Laborde's method of resuscitation, is based upon the principle that traction upon the tongue irritates the fibers of the superior laryngeal, glosso- pharyngeal, and lingual nerves, which in turn give rise to a reflex stimu- lation of the phrenic nerves with consequent contraction of the diaphragm and the intercostal muscles. Generally speaking, it is the most effective measure at our disposal, and the prognosis becomes extremely gloomy if its employment is not attended by satisfactory results within a few minutes. Occasionally its efficiency may be heightened by practicing it with the child immersed in a hot bath. 872 ASPHYXIA had to tfchullze's method. 659. Before, however, despairing of saving the child's life recourse may be In this manceuvre, as shown in Figs, 6.">9 and 6(>0, the child is seized by both hands in such a manner that the index fingers of the opera- tor lie under its axillae, the thumbs over the thorax, while the palmar surfaces of the re- maining 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 allows the fcetus to hang down between them, he then slowly car- ries 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 manoeuvre is repeated 4 or 5 times a minute. The rationale of the method is readily ap- preciated : the thorax is markedly compressed when the child is elevated, and expanded when it is lowered, the two positions favoring ex- piration 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 contends that it is the most efficient method at our disposal. The procedure, however, is not without disadvan- tages; for, if too violently employed, it some- times give 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 manceuvre is contra-indicated when the clavicle or hu- merus 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 1871, and Dew, in 1893. sug- gested a convenient substitute for Sehultze's method. The latter recommended that the child be grasped with the left hand, allowing the neck to rest between the thumb and fore- finger so that the head falls far backward; while the right hand grasps the legs in such Figs. 059-660.-SchultzfAs a wa>' that the riSnt knee rests between the Method of Resuscitation, thumb and forefinger, and the left between Fig. 660. SUDDEN DEATH DUIMXG OR SHORTLY AFTER LABOR 873 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 con- tents and causes expiration. Dew claims that this method is quite as efficient as that of Schultze, and has the additional advantages that it is less likely to cause injury to the child, and is much less fatiguing to the operator. In hospital practice satisfactory results may be obtained by the use of the so-called "pulmotor." This is a patented device, by means of which a regulated quantity of pure oxygen gas, under suitable pressure, can be forced into and withdrawn from the lungs, thus effectually stimulating res- piration. 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 Lr> cubic centimeters of blood. In obstinate eases some authorities recommend the injection of a few drops of whisky 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 persevered in as long as the heart continues to beat, one method after another being given a trial. The neces- sity for persistence is shown by the fact that successful results are oc- casionally 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 im- mediately following it, is the result of some one of the abnormalities tc which allusion has already been made, particularly pulmonary embolism, acute (edema of the lungs, apoplexy complicating eclampsia, or acute anae- mia the result of post-partum haemorrhage, placenta prawia, 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 bibliography. 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 haematoma 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 sud- denly from the effects of any condition which would give rise to a similar outcome under other circumstances. Thus, cases have been reported in which the fatal termination was due to rupture of an aortic or cardiac aneurism, haemorrhage from a gastric ulcer, or other accidents. Van der 874 SUDDEN DEATH DURING OR SHORTLY AFTER LABOR Velde has reported a case of a fatal retro-peritoneal haemorrhage compli- cating an acute pancreatitis, while Node and Hines observed sudden death during labor following the rupture of an aneurysm 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 myo- cardium. 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 in certain individuals after prolonged and very painful labors, the incidental loss of rest, imperfect nutrition, and mental excitement being looked upon as predisposing 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 condition sufficiently serious to account for the unfavorable outcome, the most com- mon being haemorrhage following some severe injury to the genital tract. Syncope.—Faintness is not an uncommon result of exhaustion following prolonged labor, and in neuropathic individuals may occur even after an easy and rapid delivery. In rare instances it may be clue to cerebral anaemia resulting from lack of blood in the nervous centers 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 occasionally 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 possible anxiety, and who was in imminent danger for more than twelve hours. Haig Ferguson reports 3 cases of serious exhaustion following labor in which he was inclined to attribute the condition to reflex irritation resulting from pressure upon the ovaries incident to the improper employ- ment of Crede's method of expressing the placenta, the organ being grasped laterally instead of antero-posteriorly. Profound Mental Depression.—In rare instances the only apparent ex- planation for death, or for a profound collapse which eventuates in recov- ery, 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, who was unhappily married, had already passed through two very 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 myself to witness her will, as she said she felt sure she would not recover. The labor was rapid and uneventful, the placenta coming away spon- taneously, and everything appearing to be most satisfactory. On approach- SUDDEN DEATH DURING OR SHORTLY AFTER LABOR 875 mg the bed to take leave of the patient an hour later, I was struck with her haggard appearance. Fearing the possibility of haemorrhage I at once applied my hand over the uterus and found it tightly contracted, while the pulse was of excellent quality. Without any apparent reason, and in spite of energetic stimulation and the subcutaneous administration of salt solu- tion, 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 Hip- pocratic expression. The most carefm 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 mor- bid forebodings, and acting upon this supposition I administered a large dose of morphine hypodermically, which was promptly followed by sound sleep, a marked improvement in the character of the pulse, and a rapid change for the better in the general appearance. Upon awaking 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. It is usually associated with infective or thrombotic processes elsewhere in the body, though it may occur in women who were apparently perfectly 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 appearance, and presents symptoms of profound dyspncea and eventually of air hunger. These embolisms, however, are not always fatal, a small proportion of the patients recovering. The treatment is purely palliative. The woman should be placed in the recumbent position, stimulants by the mouth and salt solution subcutane- ously should be administered. Inhalations of oxygen, if obtainable, are also indicated. Entrance of Air into the Uterine Sinuses.—Certain cases of death fol- lowing intra-uterine manipulations in women suffering from placenta praevia or rupture of the uterus are attributed by many authorities 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, Lesse, Perkins, Roger, and others. That such a condition occasionally occurs is clear from the fact that several cases have been reported in which sudden death followed the pump- 876 SUDDEN DEATH DURING OR SHORTLY AFTER LABOR ing 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 reason- able explanation. Thus, G. W. Dobbin was able to demonstrate the pres- ence of Bacillus aerogcnes capsulatus in the tissues from one of Perkins's cases, in which the presence of air bubbles in the blood-vessels bad been regarded as satisfactory evidence as to the cause of death. Wendeler bad a similar experience, and it would therefore seem permissible to regard with scepticism all cases of supposed air embolism in which death did not occur almost instantaneously, or in which careful bacteriological investiga- tion demonstrated the presence of gas bacilli. Acute Dilatation of the Stomach.-—Aery exceptionally following an op- erative and sometimes a spontaneous labor, the patient may pass into a condition of profound shock, associated with symptoms of acute dilatation of the stomach—great distention of that organ and the expulsion of im- mense quantities of dark fluid vomitus—and death may follow, or recovery ensue, just as in the similar condition, which is so well known to sur- geons. I have encountered the complication upon one occasion. In this instance an apparently perfectly 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 21 hours. The first manifestation was a marked change in the character and rate of the pulse, but the true condition 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 chloroform. In my case, as the patient received only a minimal amount of the drug, 1 sought the aetiological factor in an arterio-duodenal 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 mav be, the condi- tion is most serious, and now that attention has been called to its possi- bility it should be recognized as one of the causes for sudden death follow- ing 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 Reimann, 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 multi- parous women in whom the vaginal outlet is markedly relaxed, and is sup- posed to be due to a marked increase in the intra-abdominal pressure pro- LITERATURE 877 duced by putrefactive changes, though certain authorities are inclined to attribute isolated cases to rigor mortis of the uterine musculature. LITERATURE Audebert. La dilatation aigue de l'estomac chez les accouchees. Annales de gyn. et d'obst., 1912, ix, 92-104. Avelixg. On Post-mortem Parturition, with References to Foity-four Cases. Trans. London Obst. Soc, 1873, xiv, 240-258. Bccura. Vagitus uterinus. Zentralbl. f. Gyn., 1904, xxviii, 129-136. Byrd. A Speedy Method in Asphyxia. The Obst. Jour, of Great Britain and Ire- land, LS74, i, 65-69, Amer. Supplement. Davis. Sudden Death during or immediately after the Termination of Pregnancy. Trans. Am. Gyn. Soc., 1905, xxx, 345-366. Dew. Establishing a New Method of Artificial Respiration in Asphyxia Neonatorum. Medical Record, Mar. 11, 1893. Dobbin. Bemerkungen zu den Arbeiten von Schnell, Wendeler, und Goebel: Ueber einen Fail von Gasblasen im Blute einer nach Tympania uteri gestorbenen Puer- pera. Monatsschr. f. Geb. u. Gyn., 1897, vi, 375-379. Fkrguson. On a Variety of Postpartum Shock, its Nature, Cause, and Prevention. Edinburgh Med. Jour., 1899, xxxv, 32-41. Laborde. Les tractions rhythmees de la langue, moyen rationnel et puissant de rani- mer la fonction respiratoire et la vie. Paris, 1894. Lesse. Ein weitcrer Fall von Luftembolie bei Placenta pravia. Zeitschr. f. Geb. u. (!yn., 1896, xxxv, 184-191. Nodes and 11 ines. Fatal Rupture of an Aneurysm of the Splenic Artery immedi- ately after Labour. Trans. London Obst. Soc, 1900, xiii, 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. Etude clinique sur la phenomene de 1'entree de l'air par les sinus uterins dans l'etat puerperal. These de Paris, 1899. Schultze. Ueber die beste Methode der Wiederbelebung scheintodt geborener 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, Ixviii, 51)1-596. Van der Velde. Ein Fall von todtlicher Pancreasblutung. etc Ref. Frommel's Jahresbericht, 1898, 764. Wendeler. Ueber einen Fall von Gasblasen im Blute einer nach Tympania uteri gestorbenen Puerpera. Monatsschr. f. Geb. u. Gyn.. 1896, iv, 581-583. 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 micro-organisms 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 aetiological factors which may be concerned. Moreover, it emphasizes the febrile phenomena of the affection, instead of laying stress upon its infectious nature and the consequent responsibility of the obstetrician and his assistants. Again, "puerperal septicaemia" and "puerperal 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 essen* tially a metritis, and was followed in the next century by Puzos with his milk metastasis theory. From the time of Plater, until Semmelweiss proved its identity with wound infection, and Lister demonstrated the value of antiseptic methods, all sorts of theories were suggested concern- ing 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 878 BACTERIOLOGY 879 many other British observers had vague ideas upon the subject, it was not until the middle of the nineteenth century that such views were strongly urged. In 1843 Oliver Wendell Holmes read a paper before the Boston Society for Medical Improvement, entitled "The Contagiousness of Puer- peral Fever," in which he clearly urged 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 A'ienna Lying-in Hospital, began a careful inquiry into the causes of the frightful mortality attending labor in that institution, as compared with the comparatively small number of women succumbing to puerperal infection when delivered in their own homes. As a result of his observations 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 physicians, students, and midwives should disinfect their hands with chlorine water before examining parturient women. In spite of almost immediate 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 un- appreciated until the influence of Lister's teachings and the development 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 micro-organisms concerned are the fol- lowing : (a) Streptococcus.—As early as 1865 this organism was observed in the tissues of women who had died during the puerperium by Mayrhofer, whose findings were confirmed by Coze and Feltz, Recklinghausen, Waldeyer, Klebs, Orth, and Heiberg. Pasteur, in 1880, however, was the first to culti- vate streptococci from cases of puerperal infection, and be called them "chapelets en grains." He was assisted by Doleris, who carried the work still further, and showed that the streptococcus was generally the infectious agent, but that other bacteria were sometimes concerned. These researches were soon confirmed by Lomer, Bumm, Doderlein, Winter, Widal, and by all subsequent observers, so that it is now believed to be the usual cause of the epidemic and fatal forms of puerperal infection. In 1903, Scbottmiiller showed when streptococci, obtained from seri- ously ill patients, were grown upon blood-agar that each colony became sur- rounded by an area of haemolysis, which was lacking in the saprophytic varieties of the organism. As his findings were confirmed by Fromme, Gonnet, and others, 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 was always haemolytic, was concerned in the production of virulent infections, while the other two varieties were lacking in haemolytic properties, and were either saprophytic or only slightly pathogenic in character. The work of Natwig, Lea and Sidebotham, and others has shown that these conclusions are too sweeping, and that while haemolytic streptococci 58 880 PUERPERAL INFECTION are usually virulent, they are not always so. Furthermore, the non-haemo- lytic variety is occasionally highly pathogenic; and, as the haemolytic prop- erties may either be lost or accentuated by various cultural methods, it would appear inadvisable to consider the existence of such properties as characteristic of an absolutely distinct species of streptococcus. Although Kronig, myself, and others had previously isolated an anaero- bic streptococcus, it was not until 1910 that Schottmuller demonstrated its practical importance. By the use of suitable anaerobic culture media he was able to isolate it in many cases, and even concluded that it was more frequently concerned in the production of puerperal infection than the ordinary aerobic variety. As the organism produced large amounts of sulphuretted hydrogen he designated it as the streptococcus putridus. Bondy and others have made similar observations, but much more extensive investigation will be required before it will be possible to accept Schott- mtiller's conclusions without question. (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 188b, reported that he had demonstrated Staphylo- coccus 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 observa- tions of other investigators. Occasionally mixed infections are observed; association with the streptococcus being reported by Doderlein, and Bar and Tissier, and with the colon bacillus by Marquis. It appears that Staphy- lococcus aureus is the variety observed in puerperal infection, the albus and citreus playing little or no part in its production. (c) Gonococcus.—Although clinicians had long suspected that gonor- rhoea 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 all of which he was able to obtain pure cultures of gonococci from the uterine lochia. In a later communication he stated that he had been able to cultivate the same organ- ism from the discharges of 50 out of 179 patients presenting febrile puer- peria, and that most of them recovered spontaneously. Kronig's experience has been confirmed by all subsequent investigators, and Taussig, and Stone and McDonald state respectively that probably one sixth to one tenth of all rises of temperature in the puerperium are the result of gonorrhceal infection. As far as I am aware Foulerton and Bonney are the only recent writers who have not had a similar experience. I have repeatedly been able to demonstrate the gonococcus in the tissues of cases of decidual endometritis, and others have made similar observa- tions. As a rule, gonorrhceal infection in the puerperium pursues a favora- BACTERIOLOGY 881 bio course, but occasionally fatal septicemia may result, as in two of my cases reported by Harris and Dabney, and J. T. Smith. (d) Bacillus Coll Communis.—In my first article upon puerperal infec- tion (1893), it was stated that von Franque had cultivated the colon bacil- lus 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 cases due to this organism. A priori, this is what would be expected when one takes into consideration the proximity of the genital tract to the rectum, and the ease with which contamination can occur when the obstetrician fails to observe the strictest asepsis. Some idea of the enormous numbers of colon bacilli present in the body may be gained from the figures of Yignal, which show that 1 deci- gram of leces contains about 20,000,000. It is therefore evident that the examining finger can hardly avoid contamination with these organisms if it comes in contact with a non-disinfected perineum. Gebhard demonstrated their presence in 7 cases of tympania uteri, either alone or in combination with other organisms, and Galtier states that it is the organism most frequently concerned in the production of this con- dition. Ordinarily pure colon infections are very benign in character, but oc- casionally, as shown by Lenhartz and others, fatal septicemia may ensue. In most serious infections the colon bacillus is associated with the strep- tococcus, as in eases reported by Marmorek, Charpentier, Bar and Tissier, and myself, and it appears that such a combination tends to augment the virulence of both organisms. (c) Bacillus Diphtheria.—Formerly it was believed that the diphther- itic 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 culti- vated the Klebs-Loeffler bacillus from the diphtheritic membrane in the vagina, the affection yielding promptly to the use of the anti-diphtheritic serum. Gide, in 1911, was able to collect VI such cases. (/) Bacillus Acrogenes Capsulatus (Gas Bacillus).—The gas bacillus of Welch is occasionally concerned in puerperal infection. In 1896 I ob- served an instance of this kind, which was reported by Dobbin. Briefly stated, the case was as follows: An outdoor patient, with a generally con- tracted pelvis, had been in labor for three to four days under the care of a midwife. When she came into our hands she was profoundly infected and the head of a macerated child was found firmly engaged in the superior strait, the uterus being in a state of tetanic contraction. A foetid, dark- colored discharge, which contained many gas bubbles, was escaping from the vagina with a crackling sound. Delivery was effected by means of Tarnier's basiotribe. The mother died the next day, and within a few hours her body had nearly doubled its original size, as the result of the develop- ment of gas in the subcutaneous tissues. Similar changes were observed in the foetus and in the placenta, and in both we were able to demonstrate 882 PUERPERAL INFECTION the presence of the gas bacillus, as well as in the uterine lochia. Unfor- tunately no autopsy was allowed upon the mother, and we were therefore unable to say to what extent the organisms 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, reported ten cases in which it had been isolated in the Obstetrical Department of the Johns Hop- kins Hospital, and pointed out that in all probability it was identical with the "vibrion septique" of Pasteur, as well as with the bacillus perfringens described by various writers. In only one of our cases did the bacillus occur in pure culture, while in all the others it was associated with other bacteria —particularly the streptococcus. As a rule, the gas bacillus exists merely as saphrophyte 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 septicaemia. Accordingly, the prognosis is usually favorable when it occurs in pure cul- ture, but becomes very serious when it is associated with the streptococcus, as it would seem that such an association tends to augment the virulence of the latter organism. According to Welch, its presence in the puerperal uterus may give rise to emphysema of the fcetus, endometritis, physometra, emphvsema 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. Therefore such a diagnosis is not justifiable unless careful bacteriological examination has demonstrated the absence of the gas bacillus. (g) Bacillus Typhosus.—In 1898 Dobbin and I isolated Bacillus typhosus, Streptococcus, Staphylococcus aureus, and an unidentified anae- robic 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 characteristic 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 introduced 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. A somewhat similar case has been reported by Blumer, in which the autopsy revealed an unsuspected typhoid fever. (h) Pneumococcus.—In rare instances this organism when introduced into the birth canal may give rise to puerperal infection, which is par- ticularly liable to eventuate in peritonitis. Foulerton and Bonney, and Natwig have reported cases in which it was found in pure culture or as- sociated with other bacteria. Occasionally the presence of pneumococci in the uterine lochia is merely a manifestation of a general septicaemia originating from a focus outside of the generative tract, as in cases reported by Czemetschka, Burch- hardt and others. BACTERIOLOGY 883 Still more occasionally the pneumo-bacillus of Friedlander may be iso- lated, as was shown by the observations of Howard, Fromme, Chirie, and others. (i) Bacillary Infections.—Perkins, Charrin, and others have reported cases in which they believed that the bacillus pyocyaneus was the infectious" agent. Moreover, isolated cases reported by Fraenkel, Doleris, Widal, Mixius, Goldscheider, Bumm, and others tend to show that certain cases of fatal infection may be due to bacilli with whose properties we are as yet unacquainted. But the bacteriological work upon which these statements are based is not of a character to enable us to identify the organisms in question, much less to classify them. At the same time, bacteriological ex- amination of the uterine lochia in all cases of fever in the puerperium, as carried out by Kronig and myself, clearly show that many bacteria with which we are as yet unfamiliar may take part in the process. I have seen a case of phlegmasia alba dolens in which the infectious agent was appar- ently a short, thick, anaerobic bacillus. (j) Sapramia.—Besides the cases in which the infection is due to the growth and extension of micro-organisms within the body, there is a large group in which the symptoms are due to the absorption of toxins produced within the uterus by bacteria which do not invade the tissues nor make their way into the blood current. To this form of infection Matthews Dun- can applied the term "sapramia." It is usually thought to be due to putre- factive organisms with whose properties we are as yet almost totally un- familiar. No doubt the term has been greatly abused, and many cases have been included under it which were really due to infection with the ordinary pyogenic organisms. This statement has been borne out by the obser- vations of Bumm, who found streptococci in 8 out of 11 cases which were thought to present the clinical picture of sapraemia. Von Franque has obtained similar results, and concluded that sapraemic fever should be diag- nosed only after an accurate bacteriological examination of the uterine lochia has demonstrated the absence of pathogenic and the presence of saprophytic organisms. The causative organisms 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 which is so characteristic of these cases. Undoubtedly various bacteria may be concerned in its produc- tion, though only a few have as yet been isolated. Thus, Sackenreiter, 1912, studied 50 cases of so-called putrid endometritis with especial reference to the bacteria concerned in producing the odor associated with it. He was able to isolate the causative factor in 88 per cent, of his cases, and found the colon bacillus, an anaerobic staphylococcus—staphylococcus parvulus, the streptococcus putridus, an influenza-like 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, dur- ing the first ten days of the puerperium, gave the following results: 884 PUERPERAL INFECTION Streptococcus alone .................................... 60 cases '' and bacillus coli ......................... 9 " " unidentified bacilli ................... ? " " bacillus aerogenes capsulatus .......... ° " " gonococcus ........................... 4 " " bacillus aerogenes capsulatus and bacillus coli ............................... 3 Streptococcus, anaerobic variety ......................... 3 " staphylococcus, gas and typhoid bacillus.... 1 case << " n a colon bacillus ..... 1 " Staphylococcus aureus .................................. 3 cases " " and gas bacillus .................. 1 case " " " albus and gas bacillus........ 1 " " albus.................................... 5 cases Bacillus coli communis .................................. 18 " ". and gas bacillus ........................... 2 " " " gonococcus ........................... lease Gonococcus ............................................ -9 eases '' 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 diphtherias ..................................... 1 <':*se '' typhosus ...................................... 1 " Bacteria on cover slip, cultures negative .................. 63 cases Sterile ................................................ 68 " Contaminated .......................................... 2 " 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, gonococcus, and pneumococcus) and the various putrefactive varieties. Pathological Anatomy.—The lesions may vary widely even in cases clin- ically 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 inflammatory process involv- ing the entire generative tract, or extending beyond it to the parametrium or peritoneum, and sometimes resulting in a systematic infection. In other cases the infectious elements pass through the portal of entry Avith 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 morbid process is limited to the endometrium, resulting in a septic or putrid endometritis, according as it has resulted from infection by pyogenic or putrefactive organisms respectively. In other cases the lesions may be situated in any part of the generative PATHOLOGICAL ANATOMY 885 tract, more than one region being frequently implicated. Thus, at differ- ent times we have to deal with a puerperal vaginitis, endometritis, metritis, parametritis, metrolymphangitis, metrophlebitis, salpingitis, 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 meth- ods its frequency has become markedly diminished. These ulcers appear on the surface of tears about the vulva and peri- neum, soon take on a dirty, greenish-yellow appearance which is due to necrosis, and are bathed in a foul-smelling secretion. In some cases they are covered by a grayish-white membrane, and on this account were for- merly designated as "diphtheritic ulcers," but usually, 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 frequently pass unnoticed were it not for ocular inspection. Puerperal Vaginitis.—Of this there are two forms, the one being char- acterized 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 pseudo-diphtheritic 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 strep- tococcus, it was believed for a time that none of the so-called cases of diph- theria of the vagina were due to invasion by the Klebs-Loeffler bacillus; but the observations of Bumm, Xisot, myself, and others show that in a few cases the latter organism is undoubtedly the etiological factor. Endometritis.—The most common lesion in puerperal infection is an inflammation of the endometrium. When one recalls the condition of 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 into its walls. Again, when one considers the mechanism by which the decidua is normally removed, one can readily see that an ideal culture medium is prepared by Nature for their reception and propagation. In puerperal endometritis the infection may be limited to the placental site, or may extend over the entire mucosa. When the former alone is implicated the organisms are usually found growing into the thrombi and producing comparatively little local reaction. On the other hand, when the entire internal surface of the uterus is affected, the endometrium may become converted into a stinking, sloughing area made up of necrotic mate- rial and decidual debris, and bathed with a bloody, purulent discharge. The necrotic material soon takes on a dirty yellowish-green appearance, and in many instances ulcerated surfaces appear, coated with fibrin and presenting the clinical picture of diphtheria. This was formerly designated as diph- theritic endometritis, but, just as in the case of the vagina, the condition. as a rule, simply represents a fibrinous exudation, the result of an intense necrosis following the invasion of the usual pyogenic organisms. Infections due to the streptococcus or staphylococcus are usually associated with very 886 PUERPERAL INFECTION little odor; whereas in those excited by bacillus coli or any of the various putrefactive organisms the interior of the uterus is bathed with a profuse foul-smelling discharge which frequently contains gas bubbles. The amount of necrotic material produced is often enormous, and may recur with great rapidity after curetting. Fig. 661 represents the uterus from a case of Fig. 661.—Uterus from Woman Dying Ten Days after Labor from a Mixed Infec- tion with Streptococcus and Bacillus Coli. X f. puerperal infection due to streptococcus and bacillus coli. The woman suc- cumbed 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 ma- terial, which in all probability had been reproduced in the interval elapsing between the curettage and the time of death. Although the infection generally remains limited to the endometrium, in not a few cases it may progress beyond it, giving rise to a metritis, a lymphangitis, a phlebitis, or a peritonitis, as the case may be. This exten- sion usually occurs through the lymphatics, and in such cases areas of inflammation can be traced along their course extending to the peritoneal surface of the uterus. At other times, especially when the infection has been limited to the placental site, the thrombi may be invaded by the micro- organisms, and there results a phlebilis which may remain limited to the PATHOLOGICAL ANATOMY 887 uterine wall, or may rapidly extend beyond it and give rise to the various thrombotic forms of puerperal infection. The lesions produced in the endometrium vary considerably according to the micro-organisms concerned, and still more according to their viru- lence. When the infection is due to a virulent streptococcus or staphy- lococcus, the local changes are comparatively slight, the process rapidly spreading through the lymphatics or veins past the uterus, and giving rise to a peritonitis or a general systemic infection. On the other hand, in the cases due to putrefactive organisms, to the colon bacillus, and to the or- dinary pus-organisms of lesser virulence, the process remains more or less Fig. 662.__Uterus from Woman Dying Ten Days after Labor from Streptococcus Infection. X §■ limited to the endometrium and causes marked local lesions. Fig. 662 represents the uterus from a woman dying of a virulent streptococcic in- fection. The walls of its cavity are seen to be almost perfectly smooth, and nothing is present which could have been removed by means of the curette. In this" respect the case stands in marked contrast to the one represented in 888 PUERPERAL INFECTION Fig. 661, in which the infectious agents were streptococcus and bacillus coli. Moreover, upon studying the microscopical features of puerperal endo- metritis, one finds these differences still further accentuated. Our original knowledge on this point we owe to the researches of Bumm and Doderlein, both of whom have shown that there are marked histological differences between the putrid and septic forms. According to Bumm, in sections through the wall of a uterus the seat of a putrid endometritis, a thick layer of necrotic material is found lining the uterine cavity, embedded in which are large numbers of the offending micro-organisms. Beneath this is a thick layer of leukocytic infiltration—the zone of reaction—and, under this again, more or less normal tissue. Careful study shows that the micro- organisms are limited almost entirely to the superficial necrotic layer; and although a few may be present in the reaction zone, none can be made out in the tissues beneath it, thus showing Nature's mode of preventing the in- vasion of the body (Figs. 663 and 665). Fig. 663.—Puerperal Endometritis Due Fig. 664.—Puerperal Endometritis Due to Colon Infection, Showing Marked to Streptococcus Infection, Show- Development of Leukocytic Wall. ing Slight Development of Leuko- cytic Wall. Similar pictures are also observed in the cases due to infection with 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 laver of necrotic material containing organisms is likewise found adjoining the PLATE XVI. * * •»,. ••.-.■ s % ^.-, -a -v. \ # «*. ., * - 1... / \ ■•. ' •it;;."'. ,„.;. .. -•f. \ £. # ' '*', i.... 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Less frequently, detached particles of thrombi may be arrested in one of the larger vessels of the lungs and give rise to pulmonary 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 Ricbter 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 a serious thrombotic process. Most cases of pyaemia present very little uterine involvement, and death, when it occurs, is due to general exhaustion following a prolonged suppurative process, rather than to peritonitis, which is the usual cause of death in the other forms of infection. Phlegmasia Alba Dolcns.—A* was pointed out when the question of parametritis was considered, this affection is sometimes due to the extension through the lymphatics of a parametritic process to the tissues surrounding the great vessels of the thigh. As a rule, however, it results from the exten- sion of a thrombotic process from the pelvic veins; and in several of my appear on various por- tions of the body, and in 892 PUERPERAL INFECTION autopsy cases the thrombo-phlcbitis could be traced from the uterus to the internal and common iliac veins, whence it extended upward to the vena cava and downward through the external iliac to the vessels of the foot. Occasionally, in cases which recover, the phlegmasia appears to be an isolated process, though it is probably only a part of a much more exten- sive thrombosis. Moreover, it should be borne in mind that even wide- spread thrombosis may give rise to but slight clinical manifestations, as in one of my cases, in which at autopsy the femoral vein and all its branches were completely occluded, though careful mensuration was necessary to detect any difference in the size of the legs. Clinically phlegmasia alba dolens should always be regarded as a mani- festation of infection; although it may possibly be of other origin. Thus, my assistant, F. C. Goldsborough, described a case of complete occlusion of the common iliac, external iliac, and femoral veins, which was clearly the result of pressure. Such an inference, however, is not permissible .unless the case comes to autopsy, and careful bacteriological examination demonstrates the absence of bacteria. An excellent idea of the frequency of the various lesions in fatal cases of puerperal infection may be gained from the statement of Kneise, who studied the autopsy reports from 89 cases in Halle, with the following results: Peritonitis ............................................ 43 cases Thrombophlebitis ...................................... 20 " Pyapmia .............................................. P7 " 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 wound infection, it must follow that puerperal infection is a wound infection resulting from the introduction of pyogenic organ- isms into the generative tract either before, during, or immediately after labor. In other words, it is usually a direct infection from without, the offending bacteria being brought to the woman by the bands, 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 exuda- tions are the result of this change. The decomposed animal-organic ma- terial, which, when resorbed, causes childbed fever, is brought to the indi- vidual from without in the great majority of cases, and this is infection from without. These are the cases which represent the epidemics of child- bed 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 appar- ently originated with Thomas Kirkland, of Ashby, in 1774, but was first yETIOLOGY 893 clearly enunciated in 179o by Gordon, of Aberdeen, in his treatise "On the Epidemic of Puerperal Fever, as it prevailed in Aberdeen from Decem- ber, 178!), to March, 17!>"2." 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 iniroducing 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 pre- ventable, and owed its origin cither to the accoucheur or midwife. His teachings, however, did not exert the influence which might have been ex- 'poctcd, mainly because they were opposed by the leading obstetricians 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 1861; although in 186-1, 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 bichloride of mercury in obstetrics, that the great mass of the profession began to understand that puerperal fever was due to contact infection, and could be prevented to a very great degree. The bacteriological work of Pasteur and bis successors, and the almost constant presence of streptococci in fatal cases, decided the question, and at present no one doubts the in- fectious 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 of dirty bands, 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 fin- gering her o-enitalia or even making internal examinations and copulation during the latter days of pregnancy. Liepmann states that bacteriological examination of the prepuce of the penis reveals the presence of streptococci in 7o per cent, of all cases; while I have seen two out-patients die, who bad not been examined internally; but upon seeking an explanation for the in- fection, I found that they had copulated during the first stage of labor. Contact with secretions from wounds of any kind also plays an important part, and whether the purulent material be from an external wound or else- where within the body, the result will be the same. It is only nec-essary to recall in this connection the case of Dr. Eutter, of Philadelphia, who was 894 PUERPERAL INFECTION followed wherever he went by an epidemic of puerperal fever, while his brother practitioners were practically free from it. It appeared later that the source of infection was an ozaena from which he was constantly con- taminating his hands. Wounds on the hands of the physician or nurse, bone felons, and other affections of the fingers, and not infrequently 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 and most serious cases of puer- peral infection are 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 erysipelatos of Fehleisen and the or- dinary streptococcus pyogenes. Puerperal fever has also been frequently observed to occur in the prac- tice of those attending diphtheria, scarlet fever, and occasionally typhoid patients. Although no essential relationship between these affections has ever been proven, it is well known that in both diphtheria and scarlet fever complications due to the streptococcus are frequently met with, and these organisms may be conveyed to the woman in labor. Air infection is supposed by some to play an important aetiological part, and many authors advise covering the external genitalia with an occlusive pad to prevent the entry of air into the vagina, and thus eliminate this source of infection. This, however, occurs very rarely, if, indeed, it 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 prominent part in its production. But I believe that the danger of infection from such sources has been greatly exaggerated, and will be spoken of less and less frequently as medical men become better versed in vigorous aseptic technique. To show how accurate a conception Semmelweiss possessed of the vari- ous modes of contact infection, it may be interesting to quote what he says concerning it: "The bearer of the decomposed animal-organic mate- rial is the examining finger, the operating hand, instruments, bedclothes, atmospheric air, sponges, the hands of midwives or nurses which come in contact with the excrement of women sick with puerperal fever, and after- wards 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,—Every one at the present time believes that the vast majority of serious cases of puerperal infection are the result of the intro- duction from without of pathogenic micro-organisms into the genital canal of the pregnant or parturient woman. Nevertheless, many authorities teach that in a certain number of cases the infection does not result in this man- ner, but owes its origin to micro-organisms which were already within the genital tract before the onset of labor. To infection arising in this way the term "auto-infection" is applied. The conception originated with Semmel- AETIOLOGY 895 weiss, who stated: "In rare cases the decomposed animal-organic material, which causes childbed fever when absorbed, is produced within the patient herself. These are the eases of auto-infection, and cannot be prevented." With the enthusiasm which attended the introduction of antiseptic methods of midwifery, the possibility of auto-infection Avas lost sight of for a time, and it was only after the statistics of well-conducted lying-in estab- lishments showed that a certain number of cases of infection still occurred, despite the rigorous application of antiseptic principles, that the idea was rehabilitated by Ahlfeld and Kaltenbach (1883-1889). Of course, with the recognition of the fact that puerperal fever was a bacterial disease, the definition introduced by Semmelweiss fell to the ground, since the micro-organisms could not originate spontaneously within the body of the woman. Kaltenbach then advanced the view that pathogenic bacteria are normally present in the vagina1 of a considerable number of healthy pregnant women, and that these might make their way into the uterus, or be introduced into it, by the sterile examining finger. Most observers now hold that auto-infection, even in this modified sense, is not possible, and that all cases of puerperal infection are clue to the intro- duction from without of pathogenic micro-organisms at the time of labor. Apparent proof of the possibility of the occurrence of auto-infection is afforded by the rare instances of serious puerperal infection in women who had not been examined vaginally, and whose labors had been conducted in a thoroughly aseptic manner. Such cases undoubtedly sometimes occur, but even in them the proof is not absolute; as it is impossible to prove that the women may not have infected themselves by handling the genitalia, or that the bacteria were not derived from a suppuration focus within the body, or were not brought to the uterus by means of the blood current. Winter, in 1911, admitted the justice of these contentions, and held that one is justified in speaking of auto-infection only when careful bacteriologi- cal examination can demonstrate that the bacteria found in the puerperal uterus had existed in the vagina at the onset of labor. He considers that he has been able to adduce such proof, and therefore holds that auto-infec- tion undoubtedly occurs. Accordingly, the question can be finally decided only by the results of the bacteriological examination of the generative tract in the pregnant condition. Unfortunately, the investigations which have been undertaken in the hope of settling the question have not given uniform results, and consequently Ave are nearly as far from a scientific solution of the problem as when it was first broached ; although in actual practice a con- stantly increasing number of obstetricians act as if the possibility of auto- infection had been definitely disproved. Practically all investigators are united in claiming that the cavity of the normal uterus is free from micro-organisms both in the pregnant and non-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 free from bacteria, and that their presence afforded indubitable evidence of infection. In that year, however, Franz stated 59 896 PUERPERAL INFECTION that bacteria could frequently be found after the first feAV days of the puer- perium in women Avho had presented no clinical signs of infection. His results were soon confirmed by Burckhardt, and promptly denied by Doder- lein and Winternitz. At first it was believed that the bacteria in question were merely saprophytes, but other investigators, such as Stolz, Schenk, and Scheib, found streptococci in from 30 to 38 per cent, of their cases. On the other hand, Foulerton and Bouncy. Brownlee, and others stated that strep- tococci were never present in the normal puerperal uterus. In vieAv of these contradictory statements, my former assistant, H. M. Little, investigated the question. For this purpose he studied the uterine lochia obtained from 50 consecutive women delivered in my clinic in 1904. In each case cultures were taken immediately after the expulsion of the placenta, and again on the third and ninth days of the puerperium. Not 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. These observations, therefore, clearly indicate that the normal puer- peral uterus at no time contains the usual pyogenic bacteria; but, on the other hand, it cannot be regarded as sterile except immediately after deliv- ery, and becomes progressively more and more contaminated as the puer- perium advances. The bacteria present are usually saprophytic in charac- ter, and while they may give rise to slight febrile disturbances they cannot be held responsible for the production of the grave forms of infection. As our investigations, contrary to those of many German authorities, show that the normal puerperal uterus does not contain streptococci, the question as to the possibility of auto-infection must stand or fall with the demonstration of such bacteria 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; Avbereas if they cannot be demonstrated, such a contention must be dismissed as unfounded. The vaginal secretion during pregnancy always contains large numbers of bacteria, mostly bacillary in character, although cocci are frequently seen. Unfortunately, the bacteriological investigations which have been undertaken to determine the nature of the latter have served rather to complicate than to settle the question; 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 studies of Doderlein, published in 1892, promised for a time to reconcile the conflicting results, but as they 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 desig- nated as normal and pathological. The former was a thick, dry, cheese-like material of a whitish color and a distinctly acid reaction. Microscopically it showed epithelial cells, a pure culture of tolerably long, thin bacilli, and occasionally 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 AETIOLOGY 897 normal secretion, occasionally neutral, and very rarely even alkaline. In it were found large numbers of leukocytes and many micro-organisms of various kinds, both bacilli and cocci. Fifty-five per cent, of his patients presented a normal and 45 per cent, a pathological secretion. As pyo- genic bacteria were never present in the former, while streptococci were noted in 10 per cent, of the latter, he held that auto-infection was out of the question when the secretion was normal, but might occasionally occur when it Avas pathological. The folloAving table gives an idea of the frequency with which strep- tococci have been demonstrated in the vaginal secretion by certain inves- tigators: Burckhardt .......... 4% Winter .............. 15% Steffeck ............. 4% Williams (1,893) ..... 20% Doderlein ............ 4.1% Vahle ............... 25% Burguburu ........... 8.5% Walthard ............ 27% Koblanck ............ 9.5% Stolz ................ 30% Vahle ............... 10% Bumm and Sigwart . . 74% Witte .......'......... 12.5% Natwig ..............100% Kottmann ........... 13% This great disparity would seem to indicate that some of the investi- gators, at least, were in error, as it is scarcely conceivable that streptococci could occur 25 times more frequently in one set of women than in another. Moreover, if they occur as frequently as some observers state, it would ap- pear remarkable that relatively so few patients suffer from streptococcic infection. To overcome this objection it was assumed by some that the vaginal streptococci were of a different strain from those which give rise to severe infections, or at least possessed only a very slight degree of viru- lence. The comparison of the biological characteristics of such streptococci with those derived from infectious processes, boAvever, failed to sustain such a contention. Accordingly, Walthard and Reber attempted to escape from the dilemma by assuming that the women became immune to the action of their oAvn streptococci, and therefore could be infected only by those coming from an extraneous source. This appears to me to be a red actio ad absur- dum, and it Avould seem far more probable that the explanation for the high percentage of streptococci is to be sought in some error of technique. On the other hand, Kronig, in 1897, stated that in the vaginal secretion of 167 pregnant Avomen he had been unable to demonstrate the presence of typical streptococci or any other pyogenic bacteria, Avith the exception of the gonococcus. Moreover, he shoAved that the secretion was decidedly antagonistic to streptococci introduced from without, all trace of them usually disappearing in the course of twelve hours. He therefore concluded that it should be considered as practically sterile, and that there was not the slightest evidence in the support of the doctrine of auto-infection. In 1898 I confirmed Kronig's findings, when I reported to the Ameri- can Gynaecological Society that I had been unable to demonstrate the pres- ence of the streptococcus or staphylococcus aureus in the vaginal secretion of 92 pregnant women. In vieAv of this fact I concluded that auto-infec- tion from these micro-organisms was impossible, and when they were dem- 898 PUERPERAL INFECTION onstrated in the puerperal uterus, that they had been introduced from with- out. At the same time I admitted that certain cases of puerperal endo- metritis might occasionally be due to auto-infection by other bacteria. These conclusions were absolutely contradictory to those at Avhich I had arrived five years previously, when I found streptococcci in 20 per cent. of my cases. In the two series of observations the work was conducted under identically the same conditions, except that in the first the secretion was obtained by means of a sterile glass speculum, whereas in the second Menge's tube was employed, which could be introduced without coming in contact with the margins of the hymen. The conclusion, therefore, appeared in- evitable that in the first series bacteria from the margins of the hymen or the inner surfaces of the labia minora had been carried into the vagina by the speculum; Avhereas, such contact having been avoided in the second series, the secretion obtained Avas absolutely free from contamination. The correctness of this explanation was placed beyond all reasonable doubt by the examination of 25 additional cases, 3 sets of cultures being made from each. The first was taken from the inner surface of the labia minora, the second from the vaginal secretion obtained by means of a Menge tube, and the third from the vaginal secretion obtained through a sterilized speculum. Pyogenic cocci or colon bacilli were demonstrated in 80 per cent, of the first, in none of the second, and in 48 per cent, of the third set of cultures, thereby indicating that the vaginal secretion of healthy women is free from pyogenic cocci, when obtained without contamination, but that since bacteria are usually present upon the hymen and labia minora, it is impossible to introduce a speculum into the vagina without carrying them along Avith it, in at least one half of such cases. This explanation apparently settled the matter for a few years, but in 1904 Bumm and Sigwart stated that it Avas not satisfactory, and that my negative results were to be attributed to the employment of unsuitable culture media, so that streptococci escaped detection. They then reported the results obtained in the examination of the vaginal secretion of 103 pregnant women. Menge's tube was not employed, but instead a speculum was introduced and the secretion obtained from a portion of the vaginal wall, Avhich presumably had not come in contact with it, and then inocu- lated into bouillon. Streptococci were demonstrated in from 38 to 74 per cent, of their cases, according as cultures were taken upon one or several occasions. These results were at such variance with my own that my assistant, John M. Bergland, in 1906, repeated Bumm's experiments, employing ex- actly the same technique and culture media. For this purpose cultures were taken from 50 consecutive normal pregnant women, as follows: 1. From the vulva before disinfection. 2. From the vagina by means of Menge's tube. 3. From the vagina by means of a speculum, following Bumm's tech- nique. In each group cultures Avere made in sugar bouillon, following Bumm's recommendation, as Avell as upon solid media. In group 1 the cultures were nearly always positive, in group 2 always negative, as far as pyogenic cocci were concerned, while in group 3 positive ETIOLOGY 899 results Avere obtained in more than one half of the cases in which bacteria had been demonstrated upon the vulva. These observations confirmed in toto my previous Avork, and demon- strated conclusively to my mind that the vaginal secretion, Avhen properly obtained, is sterile so far as pyogenic bacteria are concerned, and also that a speculum cannot be introduced into the vagina except at a considerable risk of carrying up bacteria from the vulva. It is important to note that even when Bergland obtained positive results streptococci were found but rarely, their place being taken by staphylococci and colon bacilli. It would, therefore, be interesting to find an explanation for this difference, as it is impossible to believe that so competent bacteri- ologists as Bumm and SigAvart could have confounded other bacteria with streptococci; while at the same time it is hardly probable that the bacterial flora of the vulva could vary so greatly in Baltimore from that observed in Berlin and Halle. Unfortunately for our peace of mind, Kronig and PankoAV, in 1908, again took up the subject, and in a series of 52 examinations found no streptococci in the vaginal secretion when agar plates Avere used, but demon- strated them in 17.3 per cent, of the cases when Aveak alkaline grape-sugar bouillon was employed. I have not repeated this work, but expect to do so in the near future. In the meantime, however, as a result of our own Avork, I hold that pyogenic cocci are not normally present in the vaginal secretion of pregnant women. Consequently, whenever they are demonstrated in the uterine lochia of puerperal women, they should be regarded as distinct evidence of external infection. At the same time it is possible in rare instances that auto-infection may occur from other organisms, which are found in the vaginal secretion, and plausibility is lent to such a supposition by the increasing frequency Avith which bacteria are found in the uterus with the advance of the puerperium; but satisfactory evidence cannot be adduced in support of such an occurrence 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 frequently the cause of an elevation of temperature durino- the puerperium. Such cases, however, should not be considered as supporting the doctrine of auto-infection, for the reason that the Avomen Avere infected before conception or in the first few months of pregnancy, after which the gonococci persist in the crypts of the cervical canal, where they live as parasites, and simply find more suitable conditions for devel- opment in the first few days of the puerperium, when they make their way up into the uterine cavity and manifest their presence by the produc- tion 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 900 ITERPERAL INFECTION which the process results from some pre-existing affection of the generative tract, such as an old pyosalpinx. An interesting fact in connection Avith the question of auto-infection is that those who believe most firmly in its possibility, and Avho are in the habit of employing a prophylactic vaginal douche for the destruction of the vaginal bacteria, have thus far been able to present less favorable statistics than their opponents. Thus, Ahlfeld found that after its use 38 per cent, of his patients had a rise of temperature during the puerperium. Again, Kaltenbach, Avhile chief of the Lying-in Clinic at Halle, always resorted to its routine employment, but the statistics showed a very mate- rial improvement after his successor, Fehling, discontinued the prac- tice. Furthermore, the results of Leopold and Mermann, who did not use the douche at all, shoAved a constant improvement corresponding with the increasing precision with which objective asepsis Avas carried out. Frequency. — It is very difficult to make accurate statements as to the frequency of puerperal infection, especially when it occurs outside of hos- pital practice. Concerning this condition the vital statistics of the health offices of the various American cities are of no value, inasmuch as the vast majority of deaths from this disease are returned as being due to malaria, typhoid fever, pneumonia, or other causes. Since the introduction of antiseptic methods into midAvifery 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 Yienna, it varied from 10 to 15 per cent., so that finally it at- tracted the attention of the public at large, and steps Avere being taken to abolish such institutions as a menace to public health. With the introduc- tion 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,(533 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 morbidity 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 Avhether the results are materially better to-day than they were before the introduction 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 very large proportion of obstetrical cas. s. Though, at the same time, it must be admitted that we rarely hear of out- breaks of puerperal infection such as are mentioned in the historical work of Hirsch, who gives the particulars of 216 epidemics occurring betAvcen the years 1652 and 1862. Boehr stated in 1875 that 363,324 women had died from puerperal infec- tion in Prussia during the preceding 60 years, and calculated that every thirtieth married Avoman eventually perished from it; Avhile Ehlers con- tended that outside of the well-regulated hospitals the results were equally SYMPTOMS 901 bad in 1900. Furthermore, Fromme stated, in 1916. that at least 5,000 women succumb each year in Prussia to this preventable malady. Bacon, in an article based upon the records of the health department of Chicago, shoAved that for the forty years prior to 1S!)6 puerperal infec- tion Avas assigned as the cause of death in 12.75 per cent, of the Avomen dying between the ages of twenty and fifty years, varying between 20 per cent, in 1873 and 7.3 per cent, in 1895. Similar results Avere reported by Ingerslev, who stated that, even at the present time in Denmark, Avith the single exception of tuberculosis, puerperal infection is the most frequent cause of death in women during the childbearing period. The investigations of Boxall, Bvers, and Lea sIioav a similar condition in England, where it may be said that outside of the lying-in hospitals this preventable scourge claims as many and perhaps more victims than it did twenty or even forty years ago. Moreover, in trying to determine the frequency of puerperal infection, one cannot be guided altogether by the mortality statistics, inasmuch as the largest proportion of these eases do not end fatally. On the other hand, any one who deals much with gynaecological patients cannot fail to be im- pressed with the very large proportion Avhose troubles have originated from febrile affections during the puerperium, which in many instances were clearly due to the neglect of aseptic precautions on the part of the obstetrician or midwife. Symptoms.—As was stated Avhen considering the pathological anatomy of puerperal infection, the common lesion is an endometritis. This may be either of the septic or putrid variety, each type presenting 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 tem- perature remains constantly elevated. At the same time there is some ten- derness in the lower part of the abdomen, the uterus is larger and more doughy in consistency than it should be, and is sensitive on pressure. The lochial discharge is sometimes increased in quantity, and is partly bloody, partly purulent in character, although in the purely septic forms it is practically devoid of odor. If the temperature is very high the secretion is frequently 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 puerperal infec- tion with profuse and foul-smelling lochia; whereas, in reality in the more virulent cases of streptococcus infection, 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 micro-organisms make their way through the muscular 902 PUERPERAL INFECTION walls of the uterus by means of the lymphatics, and when the organ is markedly relaxed these channels are more patent and offer far 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 pro- cess remains limited to the cavity of the uterus or extends beyond it. In the former case the temperature gradually falls, the secretion becomes less and less, and the patient is slowly restored to health. The mucosa, how- ever, is not restored to its normal condition at once, but for a long 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 pyae- mia, as the case may be, are superadded. In putrid endometritis Ave 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, hoAvever, 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 appearance. These cases usually eventuate in recovery, and only rarely terminate fatally. Between these two Avell-marked classes of cases, however, there exist all gradations, and not uncommonly Ave have to deal with a mixed infection due to pyogenic as avcII as putrefactive organisms. As has already been said, the chill and rise of temperature are occasion- ally associated with localized ulceration about the vulva or somewhere in the vagina. In the vast majority of cases, however, the puerperal ulcer or vaginitis does not occur alone, but is accompanied by an endometritis. The extension of the process from the uterine cavity or from ulcers about the cervix to the parametrium produces an array of more or less characteristic manifestations. In many cases the initial rise of tempera- ture lasts only for a short time, and we are congratulating ourselves that our patient has escaped so easily when suddenly another chill occurs, the fever rises again, to pursue a more or less irregular course, usually marked by evening exacerbations. Within a few days vaginal examination or ab- dominal 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 the broad ligament itself, or may extend along the connective tissue upon the anterior portion of the pelvis up to the neigh- borhood of Poupart's ligament; in other cases, again, it extends backAvard 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 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 certain instances the infection extends from the uterine cavity to the Fallopian tubes, and there gives rise to a salpingitis with its accom- SYMPTOMS 903 panying symptoms. A large proportion of the cases of pyosalpinx, particu- larly those folloAving abortions, which come to operation months or years later, have originated in this manner. Unfortunately, it frequently happens that the 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. Somewhat rarely the peritoneal implication is limited to the portion lining the pelvic cavity—pelvic peritonitis. If the process does not spread the chances are that the patient will recover, but if the peritonitis becomes generalized death is almost inevitable. The characteristic symptoms of peritonitis usually make their appearance during the first week of the puer- perium, 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 endometritic implication is usually very slight, and practically the first sign of infection appears from the side of the peritoneum. A marked rigor occurs, the tem- perature 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, Avhich is at first limited to the loAver portion but gradually extends over the entire abdomen. At the same time there is marked tympanites, and the abdominal Avails are rendered tense by the dis- tended intestines. If a fatal issue ensues death usually occurs within the first ten days of the puerperium, the patient gradually sinking, although she may remain conscious to the last. In many cases, hoAvever, the tem- perature is but little elevated, the pain slight, and the abdominal symptoms slightly marked, or even absent, the serious character 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 elevated, but instead Ave 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 dislodgment of a single thrombus or of the constant entry into the blood of small infected particles. In the first instance a metastasis develops at some one point, the symptoms depending upon the organ involved. On the other hand;if thrombi are being constantly dislodged Ave may have symptoms referable to various organs. One of the most constant manifestations of pyaemia is an infectious broncho-pneumonia, which contributes to the fatal termination. In other cases sAvellings 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 904 PUERPERAL INFECTION eye. The course of pyaemia varies very materially according to the organs attacked and the resisting poAvers of the patient, but it is nothing like so uniformly fatal as the peritonitic form of infection. 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 toxines are found in abundance in the circulating blood, Avith very slight implication of the uterus. This happens in cases of so-called acute septice- mia—the sepsis foudroyante of the French writers—which represents the most rapidly fatal form of infection, the patients occasionally dying on the second or third day of the puerperium in a condition of shock, and without the development of local symptoms. A case of streptococcus septicaemia, observed in my out-patient department, ended fatally Avithin eighteen hours after the initial rise of temperature. In a small number of cases the thrombotic process involving the pelvic veins may extend to the femoral vein on one or both sides, giving rise to phlegmasia alba dolens. This accident, as a rule, does not make its appear- ance until some time in the second or third Avcek of the puerperium, or even later, the first symptom being pain along the course of the femoral vessels, which, in thin individuals, may be felt as hard, sensitive cords. At the same time oedema appears in the feet and soon extends upward, though oc- casionally it may appear first in the thigh. This SAvelling is associated with severe pain, and usually lasts for a considerable time, months sometimes elapsing before the patient can Avalk Avith comfort. At the same time 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 Pinard and Wallich to the arrest of minute emboli in the smaller vessels of the lung, Avith 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 intra-partum infection, and usually occurs 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 ahvays think of this complication, and at once institute procedures to hasten the evacuation of the uterus. Diagnosis.—The diagnosis of puerperal infection is usually made with- out difficulty, as the clinical history is very significant. If a patient, Avho has been doing well after delivery, has a chill and a rise of temperature on the third or fourth day, Ave may be practically sure that we have to deal Avith an infection, unless the symptoms can be accounted for by some other satisfactory explanation. In many cases the initial chill does not occur, and the first indication of the condition is a rise of tem- perature. In general, a temperature exceeding 100.4° F. (38° C), and persisting for more than twenty-four hours, should be regarded as a prima facie evidence of infection. In the old times it Avas believed that the onset of the lacteal secretion was accompanied by fever, and the older observers were always ready to DIAGNOSIS 905 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 abso- lutely afebrile. After the infection has become well established, either as an endome- tritis, peritonitis, or one of the other forms, the diagnosis is generally easy. In uncomplicated cases of puerperal endometritis usually very little pain is complained of, and it sometimes becomes a difficult matter to decide posi- tively Avhetber the temperature is due to a uterine infection or some other cause. Occasionally a febrile moA'ement may occur late in the first week, Avhich may justifiably be ascribed to emotional causes, such as excitement, fright, or grief. The temperature may rise suddenly, and after reaching a con- siderable height promptly fall to normal Avithin a few hours. At first we should always suspect a beginning infection, and it is only after the rapid subsidence of the symptoms that such a diagnosis is permissible. Noav and again a somoAvhat similar rise is caused by auto-intoxication from the in- testinal tract. Budin and Galtier state that in some instances such a con- dition may closely simulate puerperal infection. The diagnosis, hoAvever, is readily arrived at by the administration of a purgative, for after a copious movement of the boAvels the temperature falls rapidly and remains normal. Again, fever occurring in the early part of the puerperium is not uncommonly due to inflammatory troubles about the breasts, but the sub- sequent history of the case readily clears up the question of diagnosis. In addition to the more usual causes of fever during the puerperium not due to infection, many intercurrent diseases may be accompanied by a chill and high temperature which for a short time may make one suspect puerperal infection, although the subsequent history shoAvs that one's fears have been groundless. This is frequently so in angina and acute pulmonary affections Avhich may occur at any time during the puerperium. Occasion- ally prolonged suppurative processes in the pelvis, or other parts of the body, may be accompanied by symptoms which may readily be confounded with puerperal infection, but in the present state of our knowledge there is no reason why Ave should long remain in doubt as to the cause and origin of the fever in a given case. There are two diseases, however—malaria and typhoid fever—which are frequently confounded Avith puerperal infection, and which are often made the scapegoat to shield the practitioner Avho has neglected aseptic precau- tions in the conduct of his case. While there is no doubt that either of these affections 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 posi- tive finding one is not justified in making such a diagnosis. Indeed, it Avould be far better to go still further and to hold that one should never exclude puerperal infection as a probable causative factor unless cultural methods have 'demonstrated that the uterine cavity is free from pyogenic organisms; for it is possible in exceptional cases that a puerperal infection 906 PUERPERAL INFECTION may be associated Avith malarial poisoning, and, Avithout the bacteriological examination of the uterine lochia, after finding the specific plasmodia in the blood, one might be satisfied of the exclusive malarial origin of the symp- toms, whereas, in reality, they are partially due to infection. If these criteria were applied a malarial fever complicating the puerperium would appear in health statistics far less frequently than at present. On the other hand, there is no doubt that occasionally a latent malarial infection may suddenly burst out again during the puerperium. Thus, in several of our cases the women had chills followed by fever, and we Avere able to demonstrate the presence of tertian malarial organisms in the blood, and at the same time to make sure of the absolute sterility of the uterine lochia. The diagnosis of typhoid fever is very 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 oc- casionally occurs, but any one who will make a point of inquiring fully into the many instances of which he hears will soon be convinced that only a small proportion of the cases so designated are really typhoid in origin, but that most of them depend upon an infection of the genital tract. In the present state of our knowledge we are not justified in making a diagnosis of typhoid feATer 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 this mistake was made, the true nature of the malady not being discovered until autopsy, and I haATe had a similar experience. Like- wise, 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. In one of my patients, with a typical pyaemia following a brutal delivery, streptococci were demonstrated, both in the blood and uterine lochia, and seA7eral superficial abscesses developed. Later pulmonary symptoms appeared, and for a time it was thought that we had to deal with a metastatic process, until the demonstration of tubercle bacilli in the sputum cleared up all doubt. To sum up, it may be safely said that every rise of temperature ob- served in a puerperal woman should be regarded 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 affection complicating the puerperium, an accurate and complete physical examina- tion of the patient is necessary, and at the same time all the aids which the recent advances in microscopy and bacteriology have placed at our com- mand should be utilized. Batteriological 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 or putrid variety; but although in many cases the clinical symptoms will give tolerably definite indications, a positive conclusion can be arrived at only after a bacte- riological examination of the uterine lochia. In gonorrhceal infections the development of a purulent ophthalmia on the part of the child affords an DIAGNOSIS 907 almost 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 Avith compara- tively little difficulty by means of a simple device first introduced by Doderlein and modified by H. M. Little. This consists of a glass tube 20 to 25 centimeters in length and 3 to 4 millimeters in internal diameter, with a slight bend at one end so as to conform to the anteflexed condition of the uterus. It is then threaded with a piece of strong silk, to one Fig. 668.—Little's Tube for obtaining Uterine Lochia. When cultures are to be made the 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's or dorsal position and the cervix exposed by a suitable speculum. It is then seized with a volsellum forceps and, its vaginal portion having been care- fully 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 ex- ternal genitalia with it during the manipulation. On making traction upon the thread protruding from the free end of the tube, a partial vacuum is created and a certain amount of uterine lochia is draAvn up. The tube is then removed from the uterus and its ends hermetically closed with sealing Avax. After being taken to the laboratory it is broken in its middle portion and cultures are made from the contents (Fig. 668). This method, although it may appear to be someAvbat complicated, can be readily carried out by any practitioner who is conversant with the ordinary rules of surgical technique, and if the tube be sent to a competent bacteriologist for examination, it can be determined Avithin twenty-four hours Avhether the infection is due to pyogenic or putrefactive bacteria, and Avhether one has to deal with a dangerous or a comparatively harmless condition. Furthermore, this knowledge frequently gives important indi- cations as to treatment. In my practice such a procedure forms a part of the routine exami- nation in every ease presenting a rise of temperature above 101° F., and gives most reliable information if employed during the week following de- livery. After that period, however, the results are not so decisive, as the uterine lochia in the latter port of the puerperium practically always con- tain putrefactive bacteria. I consider that this technique is far preferable 908 PUERPERAL INFECTION to the examination of the vaginal lochia obtained by means of diphtheria sAvabs, as recommended by Yeit, Fromme, and other German authorities. The former method gives precise information concerning the bacterial con- tents of the uterus, Avhile in the latter one simply infers that the uterine and vaginal flora are identical, which is by no means ahvays the case. As has already been indicated, it Avas for a time believed that the dem- onstration of the presence of haemolytic streptococci ahvays indicated the existence of a virulent infection. The work of SigAvart, Lea, and others, hoAvever, has shoAvn that this is incorrect, as we now know that such bac- teria are occasionally present in the lochia of Avomen who are but slightly ill. At the same time, their presence is always highly suggestive, and should always lead to strict isolation of the patient. 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 during the first ten days of the puerperium, but after that period, and especially in certain prolonged cases of pyaemia, his contention may be correct. On the other hand, if reliance were placed solely upon blood cultures, practically all of the mild and some of the severe cases of infection would escape differentiation. 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 examination 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, as the demonstration of streptococci adds to the gravity of the prognosis. At the same time, it does not necessarily indicate a fatal termination, as I have repeatedly seen such patients recover, and in many instances they appeared to be but slightly sick. After removing the lochia for bacteriological examination, provided the cervix is sufficiently patulous, it is well to introduce the sterile finger into the uterus and feel its interior, after which a douche of several liters of normal salt solution should be given. Palpation of the cavity of the uterus enables us in many cases to predict in advance the result of the bacterio- logical examination, and, Avhat is of more practical value, it gives us im- portant information as to the line of treatment to be pursued. Thus, in putrid endometritis we usually find the interior of the uterine cavity rough and covered with shreds of broken-doAvn tissue; Avhile in the septic forms it is often perfectly smooth. 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 empha- sized, since the first question which the practitioner usually asks in the presence of fever during the puerperium is whether the lochia are foul- smelling or not, 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 PROPHYLACTIC TREATMENT 909 reverse is almost constantly true, and, as a rule, the foulness of the odor is in inverse proportion to the danger to Avhich the patient is exposed. When the process has extended beyond the uterus the diagnosis is much more readily made, and, provided that malarial or typhoid fever and acute miliary tuberculosis have been positively excluded, it is hardly possible to mistake the symptoms produced by a peritonitis or by a pyaunia. In the cases of parametritis and suppurative affections of the tubes and ovaries, bimanual 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. Prophylactic Treatment.—In considering the treatment of puerperal fever, prophylaxis should occupy the most important place. As has been repeatedly insisted, puerperal infection is Avound-infection, and is due to the introduction of pyogenic micro-organisms by the hands or instruments of the doctor or nurse. Hence, it folloAvs that the most scrupulous asepsis immediately before and during labor is the means upon which Ave have mainly to rely to limit its occurrence. Every physician who conducts a labor case cannot feel too strongly his personal responsibility in this con- nection, 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 operation. This question in all its various phases has been fully dealt with in the appropriate chapters. 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 forbidden to make vaginal examinations or give douches except at the direct request of the physician in charge. 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 they occasionally give rise to infection. For this reason vaginal examinations should be dispensed with as far as possible, and with this end in view the accoucheur should never lose an opportunity of perfecting himself in the methods of rectal and external examination. Tn view of what has already been said concerning practical sterility of the normal vaginal secretion, as avcII as the results of the investigations of Leopold and others, which have been confirmed by my own experience, I strongly advise against the employment of the prophylactic douche as a routine procedure, believing that it should be resorted to only when the vaginal secretion presents marked evidences of abnormality. During the second stage of labor it is well to have the vulva covered with an aseptic pad in the form of a toAvel soaked in bichloride solution. This is done not so much for fear of infection from the air as to prevent the possibility of contamination from the patient's hands. The third stage of labor likewise oilers many facilities for infection, and too much stress 910 PUERPERAL INFECTION 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 tangere, unless an emergency, such as haemorrhage or an adherent placenta, ne- cessitates the introduction of the hand. The recommendation that a routine vaginal examination is called for at the conclusion of the third stage of labor, in order to detect cervical tears with a view to their immediate repair, cannot be too strongly deprecated, and those who follow it will inevitably encounter a much larger puerperal morbidity than when vaginal 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 Avounds, unless the procedure is contra-indicated by profound exhaustion on the part of the patient, or by a very cedematous condition of the tissues implicated. To save time, it is my practice to introduce the sutures immediately after the birth of the child, and while waiting for the expulsion of the placenta. To recapitulate, the liability to puerperal infection will be materially lessened by the strict observance of the folloAving: (1) The maintenance of strict asepsis by the obstetrician and nurse before, during, and after delivery; (2) the restriction of vaginal examinations within the narrowest limits possible; (3) the omission of vaginal douches except in certain rare cases; (4) the immediate repair of perineal lacerations which might other- wise offer foci for infection; and (5) regarding the genital canal of the puerperal Avoman as a noli me tangere, into which neither finger nor instru- ment should be introduced except in emergencies. Curative Treatment.—The curative treatment of puerperal infection is a question concerning which there is a great deal of dispute, and it is prob- able that Avhat 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 iodine, and the parts kept as clean as possible. If the repaired perineum breaks doAvn and suppurates, the stitches should be removed in order that free drainage may be provided. As has been said, puerperal endometritis is the form of infection most frequently encountered, and unfortunately the directions for its treatment differ widely and are often contradictory. As soon as the patient's temperature reaches 102° F., unless a uterine infection can be excluded with a fair amount of certainty, the uterine lochia should be examined bacteriologically. When feasible, immediately after having withdrawn the tube, the interior of the uterus should be carefully explored by the sterile index finger, after which, by means of careful bimanual examination, the condition of the appendages and the broad ligaments is determined. If the uterine cavity is perfectly smooth, local treatment should be limited to a douche of several liters of boiled water or normal salt solution. On the other hand, if its interior is rough and jagged and contains more or less debris, it should be thoroughly cleaned out with the finger, after which an abundant saline douche should be employed. CURATIVE TREATMENT 911 Curettage as a routine measure in all cases of puerperal endometritis cannot be condemned too strongly, for the reason that in the most severe cases there usually is nothing in the uterine cavity Avhich 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 muc'h debris, its removal is quite as readily, and much more safely, effected by means of the finger. This teaching is directly contrary to that of many American, British, and French writers, who enthusiastically recommend the use of the curette in all cases of puerperal infection, although Pinard, since 1905, has prac- tically abandoned its use. Fritsch, whose views represent the conservative (ierman doctrines on the subject, would reserve its use for exceptional cases, and certainly my experience has convinced me of the advisability of this restriction. The routine use of intrauterine douches containing bichloride, carbolic acid, or other disinfectants in the treatment of these cases is contra- indicated on several grounds. In virulent streptococcus infection, histo- logical examination shows that the organisms have penetrated deep down into the tissues by the time the initial chill and rise of temperature occur. Under these circumstances the employment of an antiseptic douche is not rational, inasmuch as the germicidal fluid cannot possibly penetrate the uterine Avail sufficiently deep to reach the bacteria which are giving rise to the symptoms and upon which the further spread of the disease is dependent. Moreover, it has been shown experimentally by Bumm that bichloride injections penetrate the tissues only to a very slight extent. He took the liver of an animal dead of anthrax, and after soaking it for thirty minutes in a l-to-1,000 bichloride solution placed it upon a freezing microtome and cut thick sections from it. After cutting off about 1/10 of a millimeter, he inoculated the next section into another animal, which succumbed to anthrax, thus showing that the germicidal action of the bichloride had been exerted only upon the surface. If this be the case in the laboratory, Avhere the tissues can be immersed in the antiseptic solution, what effect can we expect upon organisms embedded in the muscular wall of the uterus from the transitory application to the surface of a few liters of a weak bichloride solution? Bumm likewise showed that the streptococci make their way through the uterus with great rapidity, traveling 2 centimeters or more in the space of six hours. What has been said concerning bichloride applies equally well to the other disinfectants. On the other hand, their employment in putrid endometritis is even less rational, as in such cases simply cleaning out the uterus with the fin- ger, folloAved by a douche of sterile salt solution, will lead to a rapid fall of temperature and the amelioration of untoward symptoms. The object in giving a douche in these cases is simply to wash away the debris Avhich has been left behind by the finger, and for this purpose sterile salt solution is superior to any antiseptic fluid. In addition to these somewhat theoretical objections, there is this very 60 912 PUERPERAL INFECTION practical one: that the employment of antiseptics may do an immense amount of harm. Not a feAV cases of sudden collapse folloAving the use of carbolic-acid douches are on record, while in some instances intra-uterine injections of bichloride have been proved to have been the direct cause of death. Several years ago, at the autopsy upon a woman who was supposed to have died from puerperal sepsis, I found all the anatomical lesions of bichloride 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 at that time, I collected some 46 cases in which death had followed the employment of bichloride douches during the puerperium. In many instances, to be sure, excessive 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 poisoning. When these facts are taken into consideration, along Avith the theoretical objections to the employment of antiseptics under these circumstances, it Avould appear that the benefit to be expected from their employment is at least very prob- lematical, Avhile the dangers are very real. The same considerations likeAvise apply to the various other antiseptic agents Avhich have been recommended from time to time. Nor am I inclined to place great confidence in the disinfectant properties of injec- tions of alcohol, as recommended by Wctberill, 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; although the absence of bacteriological data someAvbat Aveakens his case. The results folloAving the method of treatment just outlined are quite as good as those obtained with the various antiseptic douches, and this contention is sustained by the experience of Bumm and Kronig. By this means I have had a mortality of less than 10 per cent, in my cases of streptococcic endometritis, which would be still further reduced were we to exclude the patients who were suffering from general peritonitis or severe pyaemia at the time of admission^ At the same time it is not desired to give the impression that pure streptococcic infections are devoid of dan- ger, as they are always serious and often fatal, and I believe that our favor- able results are probably attributable to the fact that many mild cases are included in our series, which would have escaped detection except for the bacteriological examination of the lochia in all febrile cases. Nevertheless, our results would appear to indicate that too energetic treatment may be harmful, and that an equally good or better outcome can be obtained by safer and more conservative measures. To recapitulate, in dealing Avith a case of puerperal endometritis after having removed some of the uterine lochia for cultures, the cavity should be explored by the sterile finger and cleaned out or not according to its condition. The uterus should then be douched with several liters of sterile salt solution. If the bacteriological examination shows the presence of streptococci all local treatment should at once be omitted. If, on the other hand, one has to deal Avith a putrid endometritis, and the symptoms do not yield to the first injection, additional douches may be given. When CURATIVE TREATMENT 913 the infection has extended beyond the uterus local treatment should not be persisted in, as it will do more harm than good. Bumm redirected attention to the observation made by Guerin in 1858 that in many instances involution had taken place very incompletely, and he therefore recommended the employment of ergot to secure better con- traction, thereby occluding to some extent the lymphatics in the uterine wall. My OAvn experience is in accord Avith this vieAV/and in cases in Avhich the uterus is larger than it should be at a given period of the puerperium the employment of the drug would certainly appear to be indicated. In gonorrhceal endometritis active treatment is not required at the time, since in the vast majority of cases the slight 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 diseases of the appendages, which can be treated much more advantageously at a later period. In all severe cases general tonic measures that Avill serve to keep up the strength of the patient and increase her resistance to the infective virus are most valuable. The most reliable drugs are strychnine and alcohol, and it is a matter of experience that these patients can bear much larger quantities of the latter than when in health. High fever should not be combated with antipyretics, the external application of cold, cither in the form of spongings or cold baths, being preferable. Hydrotherapeutic measures have been enthusiastically advocated by Runge and others, and in their hands have given very satisfactory results. If the process has extended beyond the uterus, and Ave 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. Occasionally, surprisingly good results are obtained in profoundly septic conditions by repeated subcutaneous injections of sterile salt solution. Attention was first directed to this method of treatment by Bosc, and subsequent experience has in great part justified his predictions. Of late a great deal has been written on the operative treatment of puerperal infection, nearly every prominent obstetrician and gynaecologist having made some contribution to the subject. Every one is agreed as to the advisability of opening parametritic abscesses as soon as fluctuation appears rather than allowing them to rupture spontaneously. Not un- commonly, in cases of parametritis, on palpation a semi-fluctuant sensation is conveyed to the examining finger which may lead one to imagine that one has to deal with pus, Avhereas upon opening the supposed abscess through the vagina or abdominal wall, as the case may be, the tumor turns out to be a mass of inflammatory exudate without pus formation, and only a small amount of serous fluid escapes when it is cut into. For- tunately, incision into these masses frequently gives as good results as if a considerable quantity of pus had been evacuated, just as happens in cases of cellulitis in other portions of the body. When pus tubes or ovarian abscesses can be made out by bimanual pal- pation, their removal is indicated, for as long as they remain the patient 914 PUERPERAL INFECTION will continue in a septic condition. At the same time it should be re- membered 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 attempted only when urgently indicated. Whether such conditions 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 at an early period. Here the various surgeons take quite opposite views, the more radical advocating its prompt removal, while the more conservative do not regard this step with favor. For two reasons it would appear that hysterectomy is usually contra- indicated in puerperal infection. In the first place, if one operates at a period sufficiently early to prevent the extension of the process to other organs, a large number of uteri will undoubtedly be removed unnecessarily; on the other hand, if one waits until a later period, when other organs have become implicated, the operation will also be useless. Nevertheless, there is a restricted field for hysterectomy in those cases in which the process has not extended materially beyond the uterus but has given rise to abscess formation within its walls. Again, in a putrid endometritis, when all other attempts to check the disease have proved futile, the operation Avould appear to be justifiable. Lusk suggested that hysterectomy may sometimes be useful in the cases of pyaemia in which infected thrombi are carried from the uterus to various portions of the body, giving rise to a hectic condition. As a rule, however, the thrombotic process has extended far beyond the uterus by the time symptoms appear, and consequently the removal of the uterus would be useless. Much more practical is the suggestion 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 five such operations with four recoveries and reviewed the literature up to that time. In appropriate cases I regard the operation as most valuable. Until very recently the development of general peritonitis was con- sidered almost necessarily fatal, and in such cases the treatment was usu- ally perfunctory. But in the past few years Sourdille, Kownatski, Leopold, Boquel, and others have shoAvn that recovery may occasionally follow after freely opening and draining the abdominal cavity. Cragin, on the other hand, reports that his results were not encouraging, and my experience has been the same. In view, however, of the almost certainly fatal out- come of expectant treatment, such interference would seem justifiable in appropriate cases. CURATIVE TREATMENT 915 In certain cases of infection following criminal abortion Pryor, Robb, Sourdille, and others have reported encouraging results following wide incision of the posterior fornix and packing Douglas's cul-de-sac with iodoform gauze. In many such cases serous or purulent fluid escapes from the incision, so that it would appear that such a procedure may be of value in preventing a pelvic peritonitis from becoming generalized. In my lim- ited 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, up to the present time the results of serum therapy have not proved more satisfactory than other methods of treatment. In May, 1899, a committee of the American Gynaecological Society, of which I Avas chairman, made an exhaustive re- port upon the subject, giving the complete literature and collecting all the cases treated by serum reported np to that time. It was found that 352 cases of puerperal infection had been so treated, with 73 deaths—a mortality of 20.74 per cent. In a large number of cases the lochia were not examined bacteriologically, and there was therefore considerable doubt as to whether the infections were due to the streptococcus; but in 101 cases in which its presence was demonstrated there Avere 33 deaths—a mor- tality of 32.69 per cent. This was a very discouraging shoAving, especially when compared to the results obtained by Kronig and myself without serum therapy. The ques- tion therefore arises, Was the high mortality attending the use of the anti- streptococcic serum due to its employment or to other causes? Our investigations having indicated that the serum was practically harmless, the poor results following its use can probably be explained in one of two ways: first, that only exceptionally severe cases had been treated; and, secondly, that a large number of the cases so treated had already been curetted—a procedure which is often followed by untoAvard results. In view of these facts the committee reported that while there was no evidence in favor of the therapeutic value of the serum, it apparently did not exert a deleterious effect upon the patient, and therefore might be employed if the physician so desired. FoiloAving the report of our committee the general consensus of opin- ion has been that Marmorek's serum had failed to substantiate its value, and is practically useless as a therapeutic agent. More recently the work of Aronsohn, Tavel, Menzer, Meyer, and others has directed renewed attention to the subject. As the result of their investigations, it has been shown that in order to produce an effective serum for use in human beings the strep- tococcus should not be passed through lower animals, but that as many strains as possible of virulent bacteria, 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 anti-diphtheritic and anti-tetanic serum, nor act directly upon 916 PUERPERAL INFECTION the bacteria, but merely gave rise to conditions Avhich favored phagocytosis —in other words, increased the opsonic poAver of the blood. Moreover, ex- perimental Avork has demonstrated that while the serum might possess marked prophylactic value and be able to protect an animal against inocu- lation Avith many times the ordinarily fatal dose of streptococci, it was lacking in curative properties, and at most was of value only in the initial stages of infection, being without apparent effect Avhen the process had become fully established. At the same time it Avas found to exert no deleterious effect upon the patient and might be administered with impunity. Therefore, it may be said that the prospect of cure is very slight when the serum is administered to very sick patients, though, if given prior to the onset of serious symptoms to those v/ho have been exposed to the possibility of infection, it may have some prophylactic value. Modern antistreptococcic serum has been employed in large series of cases by Bumm, Walthard, Peham, RaAV, Pinard, and others, but does not appear to have exerted an appreciable effect upon the course of the disease. The subject was exhaustively considered by Freund in 1910 in the Handbuch der Serumtherapie of Wolff and Eisner. It is'always difficult to arrive at correct conclusions as to the value of any given therapeutic agent, unless large numbers of cases are used as a basis, and this is particularly true in the affection under consideration, for the reason that its clinical course is so very variable. Thus, it is not at all rare in cases of streptococcic infection to see the temperature rise rapidly to 103°-105° F., remain there for a day or so, and then fall as rapidly as it had risen. This may occur Avithout the use of any treatment, and had the specific serum been employed in such cases it is probable that the rapid amelioration of symptoms would have been attributed to its use. Some hope has been 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 infections, although improvement might be expected in certain chronic cases due to the staphylococcus or gonococcus. A collective investigation by a com- mittee of the American Gynaecological Society in 1910, of which I Avas chairman, has served only to confirm his conclusions. At the same time it should be mentioned that Polak is more optimistic and believes the use of vaccines is sometimes followed by surprising results. That we as yet possess no satisfactory treatment for all cases of puer- peral infection is indicated by the vast number of methods advocated. Only a few of the more recent need here be mentioned. • . Hofbauer, in 1896, reported several cases of puerperal sepsis in which an artificial leukocytosis was produced by the employment of nuclein. In some of his cases the temperature fell by a lysis and in others by crisis, and he believed that the treatment played a marked part in their cure. He made a second communication in 1903, and claims that extended obser- vation has confirmed his original statements. Reference need scarcely be made to the employment of intravenous injections of formalin, as advocated by Barrows, in 1903, as subsequent LITERATURE 917 investigation has shown that they are not only of no value, but are abso- lutely 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, hoAvever, clearly sIioavs that they are of but slight value, and act only by promoting phagocytosis. LITERATURE Ahfeld. Beitrage sur Lehre vom Resorptionsfieber im Wochenbett und von der Selbstinfektion. Berichte und Arbeiten, 1883, 165. Beitrag sur Lehre der Selbstinfektion. Zentralbl. f. Gyn., 1SS7, xi, 729. Beitrage sur Lehre vom Resorptionsfieber in der Geburt und im Wochenbette und von der Selbstinfektion. Zeitschr. f. Geb. u. Gyn., 1893, xxvii, 466-519. Aroxsohn. Untersuchungen iiber Streptokokken u. Antistreptokokkenserum. Berl. klin. Wochenschr., 1902, ii, 979-982, and 1903, 1006-1010. Bacon. The Mortality from Puerperal Infection in Chicago. Amer. Gyn. and Obst. Jour., 1896, viii, 429-446. Bar et Tissier. La Semaine med., 1896, 155. Kt'rotherapie dans I'infection puerperale. L'Obstetrique, 1896, 97-128, 204-217. Bardeleben. Streptococcus u. Thrombose. Archiv f. Gyn., 1907, Ixxxiii, 1-82. Barker. The Puerperal Diseases. 3d ed., 1874. Barroavs. 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 iiber die Haufigkeit des Todes im Wochenbett in Preussen. Zeitschr. f. Geb. u. Gyn., 1878, iii, 16. Bondy. Ueber puerperale Infektion durch anaerobe Streptokokken. Monatsschr. f. Geb. u. Gyn., 1911, xxxiv, 536-549. Boquel. Sur le traitement des peritonites aigut's au cours de la puerperalite. Archives mens, d'obst. et de gyn., 1912, i, 37-58. Bosc. Injections de serum artificiel dans les maladies infectieuses et les intoxica- tions. Presse med., 1896, No. 49, 2S7-290. Boxalu. 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 Puerperal- fieber. Charite-Annalen, 1888, xiii, 198. Budin. La Semaine med., 1896, 155. Bumm. Die puerperale Wundinfektion. Zentralbl. f. Bakteriol., 18S7, ii, 343. Ueber die Aufgaben weiterer Forschungen auf dem Gebiete der puerperalen Wund- infektion. Archiv f. Gyn., 1889, xxxiv, 325. Histologische Untersuchungen iiber die puerperale Endometritis. Archiv f. Gyn., 1891, xl, 398. Ueber die verschiedenen Virulenzgrade der puerperalen Infektion^und die lokale Behandlung bei Puerperalfieber. Zentralbl. f. Gyn., 1893, xvii, 975. Ueber Uiphtherie und Kindbettfieber. Zeitschr. f. Geb. u. Gyn., 1895, xxxiii, 126- 136. 918 PUERPERAL INFECTION Bumm. Ueber die chirurgische Behandlung des Kindbettfiebers. Sammlung zwan- gloser Abhandlungen aus dem Gebiete der Frauenheilkunde und Geb., 1902, iv, Heft 4. Ueber Serumbehandlung bei Puerperalfieber. Berl. klin. Wochenschr., 1904, No. 44. Bumm u. Sigwart. Untersuchungen iiber die Bezeihungen der Streptococcen zum Puerperalfieber. Beitrage z. Geb. u. Gyn., 1904, viii, 329-336. Burckhardt. Ueber den Einfluss der Scheidenbakterien auf den Verlauf des Woch- enbettes. 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. Burguburu. Zur Bakteriologie des Vaginalsekretes Schwangerer. Archiv f. exper. Path, und Pharmak., 1892, xxx. Burtenshaw. 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. Chirie. 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. Cragin. The Treatment of Puerperal Infection. Amer. Jour. Obst., 1906, liii, 775- 791. Czemetschka. Prager med. Wochenschr., 1894, xix, 233. Czerniewski. Zur Frage von den puerperalen Erkrankungen. Eine bakteriologische Studie. Archiv f. Gyn., 1888, xxxiii, 73. Denzler. Die Bakterienflora des gesunden Genitalkanals des Rindes, etc. D. I., Zurich, 1904. Dobbin. Puerperal Sepsis Due to Infection with the Bacillus Aerogenes Capsulatus. 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 dea Uterus und der Vagina gesunder und kranker Wochnerinnen. Archiv f. Gyn., 1887, xxxi, 412. Klinisches und Bakteriologisches iiber eine Puerperalfieberepidemie. Archiv f. Gyn., 1891, xi, 99. Das Scheidensekret und seine Bedeutung fiir das Puerperalfieber. Leipzig, 1892. Vorlaufige Mittheilung iiber weitere bakteriologische Untersuchungen des Scheiden- sekretes. 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 pathogenie et la therapeutique des accidents infectieux dea Buites de couches. These de Paris, 1880. Inflammation puerperale. Nouv. archives d'obst. et de gyn., 1894, ix, 97-122, 142- 161. Ehlers. Die Sterblichkeit im Kindbett in Berlin und in Preussen. Stuttgart, 1900. Eisenmann. Wund- und Kindbettfieber. Erlangen, 1837. Fehling. Ueber Selbstinfektion. Verh. d. deutschen Gesellsch. f. Gyn., Freiburg, 1889. Ueber die Erkrankungsziffern Entbindungshauser. Deutsche med. Wochenschr., 1896, 426. LITERATURE 919 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, vrii, 403-471. v. Franque. Bakteriologische Untersuchungen bei normalem und fieberhaftem Woch- enbett. Zeitschr. f. Geb. u. Gyn., 1893, xxv, 277. Franz. Bakteriologische und klinische Untersuchungen iiber leichte Fiebersteigerung- en 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. Fritsch. Ueber Auskratzung des Uterus nach reifen Geburten. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 456. Fromme. Klin. u. bakt. Studien zum Puerperalfieber. Archiv f. Gyn., 1908, lxxxv, 154-196. Physiologie u. Pathologie des Wochenbettes. Berlin, 1910. Galtier. De I'infection primitive du liquide amniotique apres rupture prematuree des membranes de l'oeuf humain. These de Paris, 1895. Gebhard. Bacterium coli commune aus Fallen von Tympania uteri geziichtet. Verh. d. deutschen Gesellsch. f. Gyn., 1893, 305. Gide. De I'infection puerperale par le bacille de Loeffler. These de Lyon, 1911. Goldsborough. Thrombosis of the Internal Iliac Vein during Pregnancy. Bulletin of the Johns Hopkins Hospital, 1904, xv, 193-196. Goldscheider. Klinische und bakteriologische Mittheilungen iiber Sepsis puerperalis. Charite-Annalen, 1893, xviii, 164-242. Gonner. Ueber Mikroorganismen im Sekrete der weibiichen Genitalien wahrend der Schwangerschaft und bei puerperalen Erkrankungen. Zentralbl. f. Gyn., 1887, 444. Gonnet. Streptocoques pyogenes et infection puerperale. L'obst., 1907, xii, 38-56. Gordon. A Treatise on the Epidemic Puerperal Fever, London, 1795. Guerin. Sur la fievre puerperale. Bull, de 1 'acad. de med., Paris, 1858, xxiii, 766-82. Haegler. Quoted by Fehling. Physiologie und Path, des Wochenbetts. Stuttgart, 1890. Harris and Dabney. Report of a Case of Gonorrhceal Endocarditis in a Patient Dying in the Puerperium. Bull. Johns Hopkins Hosp., 1901, xii, 68-76. Heiberg. Die puerperalen und pyamischen Processe, 1873. Heinricus. Exp. Untersuch. iiber die Einwirkung des Bacillus aerogenes capsulatus. Archiv f. Gyn., 1908, lxxxv, 216-250. Heynemann. Der E. Fraenkel'sche Gasbacillus, etc. Zeitschr. f. Geb. u. Gyn., 1911, Ixviii, 425-443. Hirsch. Historisch-pathologische Untersuchungen iiber Puerperalfieber. Erlangen, 1864. Hirst. Modern Methods of Treatment of Puerperal Infection, and their Compara- tive Worth. Amer. Jour. Obst., 1896, xxxiv, 180-184. Some Problems in the Diagnosis and Treatment of Puerperal Infection. Amer. Medicine, 1906, xl, 121-123. Hofbauer. Zur Verwerthung einer kiinstlichen Leukocytose bei der Behandlung septischer Puerperalprocesse. Zentralbl. f. Gyn., 1896, xx, 441-449. Die Nuclein-Kochsalz Behandlung der puerperalen Sepsis. Archiv f. Gyn., 1903, lxxviii, 359-375. Holmes. Puerperal Fever as a Private Pestilence. Boston, 1855. Howard. Importance of Bacillus Mucosus Capsulatus (B. Friedlander) as the Cause of Acute and Chronic Infections. Philadelphia Med. Jour., 1898, i, 336-338. 920 PUERPERAL INFECTION Ingerslev. Die Sterblichkeit an Wochenbettfieber in Danemark und die Bedeutung der Antiseptik fiir dasselbe. Zeitschr. f. Geb. u. Gyn., 1893, xxvi, 443. Kaltenbach. Zur Antisepsis in der Geburtshiilfe. 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 Septikamie. Archiv f. Gyn., 1904, Ixxiii, 333-350. Koblanck. Zur puerperalen Infektion. Zeitschr. f. Geb. u. Gyn., 1899, xi, 85-92. Kottmann. Beitrag zur Bakteriologie der Vagina. Archiv f. Gyn., 1898, lv, 615. Kownatski. Zur Behandlung der freien puerperalen Peritonitis mit Laparotomie u. Drainage. Berliner klin. Wochenschr., 1905, No. 20. Kronig. Vorlaufige Mittheilung fiber Gonorrhoe im Wochenbett. Zentralbl. f. Gyn., 1893, xv, 157. Scheidensekretuntersuchungen bei ein Hundert Schwangeren. Aseptik in der Ge- burtshiilfe. Zentralbl. f. Gyn., 1894, xviii, 3-10. Ueber Fiebor intra-partum. Zentralbl. f. Gyn., 1894, 749. Discussion iiber Endometritis. Vehr. d. deutschen Gesellsch. f. Gyn., 1895, 498- 502. Klinische Versuche fiber den Einfluss der Scheidenspulungen wahrend der Geburt auf den Wochenbettsverlauf. Miinchener med. Wochenschr., 1900, Nr. 1. Kronig und Menge. Bakteriologie des Genitalkanales der schwangeren, kreissenden 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 Sidebotham. 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. Ueber die Wochenbetten von nicht untersuchten und nicht ausgespulten Gebarenden. Verh. d. deutschen Gesellsch. f. Gyn., Freiburg, 1889. Dritter Beitrag zur Verhiitung des Kindbettfiebers. Archiv f. Gyn., 1889, xxxv, 149-162. Ueber die Entbehrlichkeit der Scheidenausspfilungen und Auswaschungen bei regel- massigen Geburten und fiber die grosstmogliche Verwerthung der ausseren Un- tersuchung in der Geburtshiilfe. Archiv f. Gyn., 1891, xl, 349. Vergleichende Untersuchungen fiber die Entbehrlichkeit der Scheidenausspulungen bei ganz normalen Geburten und fiber die sogenannte Selbstinfektion. Archiv f. Gyn., 1894, xlvii, 580-635. Zur operativen Behandlung der puerperalen Peritonitis u. Pyaemie. Archiv f. Gyn., 1906, Ixxvii, 1-33. Leopold und Orb. Die Leitung ganz normaler Geburten nur durch aussere Unter- suchung. Archiv f. Gyn., 1895, xlviii, 304-323. Leopold und Sporling. Die Leitung der regelmassigen Geburten nur durch aussere Untersuchungen. Archiv f. Gyn., xiv, 339-371. Liepmann. Das geburtschilfliche Seminar. Berlin, 1910, 292. Little. A Simple Method of Obtaining Uterine Lochia for Bacteriological Exami- nation. Bull. Johns Hopkins Hospital, 1904, xv, 250-251. The Bacillus Aerogenes Capsulatus in Puerperal Infection. Bull. Johns Hopkins Hospital, 1905, xvi, 136-146. The Bacteriology of the Puerperal Uterus. American Jour. Obst., 1905, Hi, 815- 847. LITERATURE 921 Lomer. Ueber den heutigen Stand der Lehre von den Infektionstragern bei Puer- peralfieber. Zeitschr. f. deb. u. Gyn., 1SS4, x, 366. LUSK. Recent Bacteriological Investigations concerning the Nature of Puerperal Fever, Amer. Jour. Obst,, 1S96, xxxiii, 337-347. Mahler. Thrombose, Lungenembolie u. plotzlicher Tod. Arbeiten aus der Frauen- klinik 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. Marquis. Staphylococcies et coli-bacilloses puerperales. Annales de gyn. et d 'obst., 190S, v, 207-221. Mayrhofer. Zur Frage nach Aetiologie der Puerperalprocesse. Monatsschr. f. Geburtskunde, ISIi.j, xxv, 112-134. Meigs. On Childbed Fever. Philadelphia, 1854. Menzer. Das Antistreptokokkenserum und seine Anwendung beim Menschen. Miinchener med. Wochenschr., 1903, 1057-1061 and 1125-1129. Mermann. Zur Antisepsis in der Geburtshiilfe. Zentralbl. f. Gyn., LSS7, xi, 439. Die Entbehrlichkeit und Gefahren innerer Desinfektion bei normalen Geburten. Verh. d. deutschen Gesellsch. f. Gyn., Freiburg, 1XS9. Fiinfter Bericht filler zwei Hundert Geburten ohne innere Desinfektion. Zentralbl. f. Gyn., 1894, xviii, 786/ Meyer. Ueber Antistreptokokkenserum. Zeitschr. f. klin. Med., 1903, i, 145-152. Mixius. Bakteriologische Untersuchungen einiger Falle puerperaler Sepsis. D. I., Berlin, 1S92. 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. Diphtheric vagino-uterine puerperale. Serotherapie, guerison. Annales de gyn. et d'obst,, 1896, xiv, 259. Orth. Virchow's Archiv, lviii, 441. Osterloh. Beitrag zur Behandlung des Puerperalfiebers mit intravenosen. Collargoleinspritzungen. Deutsches Archiv f. klin. Med., 1905, lxxxv, 227-233. Pasteur. Septicemic puerperale. Bull, de I'acad. de med., 1879, 2(50-271. Peham. Ueber Serumbehandlung beim Puerperalfieber. Archiv f. Gyn., 1905, lxxiv, 47-69. Perkins. Report of Nine Cases of Infection with Bacillus Pyocyaneus. Jour. Med. Research, 1901, vi, 281-297. Pinard. Discussion sur les indications du curettage pendant les suites de couches pathologiques. Comptes rend, de la soc. d'obst., de gyn. et de paed. de Paris, 1905, vii, 124-131. Pinard et Wallich. Traitement de 1 'infection puerperale. Paris, 1896. 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. Raw. Puerperal Septicaemia with Special Reference to the Value of Antistreptococcic Serum. Jour. Obst. and Gyn. Brit. Emp., 1904, v, 525-526. Recklinghausen. Zentralbl. f. med. Wissenschaften, 1871, 713. Richter. Thrombose u. Embolie im Wochenbett. Archiv f. Gyn., 1905, lxxcv, 122-142. 922 PUERPERAL INFECTION Robb. The Vaginal Incision in Sepsis following Abortion. Amer. Gyn., 1903, ii, 524-530. Runge. Die Allgemeinbehandlung der puerperalen Sepsis. Archiv f. Gyn., 1888, xxxiii, 39-52. Sackenreiter. Die Erreger der putriden Endometritis. Beitrage z. Geb. u. Gyn., 1912, xvii, 246-276. Schenk and Scheib. Die Stellung u. Bedeutung des Streptococcus pyogenes in der Bakteriologie der Uteruslochien normaler Wochenerinnen. Zeitschr. f. Geb. u. Gyn., 1905, lvi, 325-350. Schmidlechner. Gangraena uteri puerperalis (Metritis dessicans). Archiv f. Gyn., 1906, Ixxviii, 525-358. 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 Kindbettfiebera. Pest, Wien u. Leipzig, 1861. Sigwart. Die Streptokokken-forschung, etc. Monatsschr. f. Geb. u. Gyn., 1910, xxxi, 486-496. Silberschmidt. Historisch-kritische Darstellung der Pathologie des Kindbettfiebers, Gekronte Preisschrift. Erlangen, 1859. Sitsinsky. Die Behandlung des septischen Wochenbetterkrankungen. Monatsschr. f. Geb. u. Gyn., 1904, xx, Ergiinzunsheft, 640-677. Smith. Severe Puerperal Sepsis Due to Gonococcus Infection. Cleveland Med. Jour., 1911, x, 810-818. Sourdille. Traitement de I'infection puerperale grave par la laparotomie ou par la colpotomie sans hysterectomie. Revue de gyn., 1905, ix, 857-890. Steffeck. Bakteriologische Begriindung der Selbstinfektion. Zeitschr. f. Geb. u. Gyn., 1890, xx, 339. 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. Septicemic puerperale experimentale. Nouv. archives d'obst. et de gyn., 1889, cv, 277-295. Strother. Critical Essay on Fevers. London, 1718. Taussig. Gonorrhceal Puerperal Infection. Amer. Gyn., 1903, ii, 334-345. Tavel. Exp. u. klinisches fiber das Antistreptokokkenserum. Deutsche med. Wochen- schr., 1903, No. 50. Trendelenburg. A Review of Surgical Progress. Jour. Am. Med. Assn., 1906, xlvii, 81-83. Vahle. Ueber das Vorkommen von Streptococcen in der Scheide Gebarender. Zeit- schr. f. Geb. u. Gyn., 1896, xxxv, 192-215. 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 Vorkommen von Bakterien bei der diphtheritischen Form dea Puerperalfiebers. Archiv f. Gyn., 1872, iii, 293. Walthard. Bakteriologische Untersuchungen des weibiichen Genitalsekretes in der Graviditat und in Puerperium. Archiv f. Gyn., 1895, xlviii, 201-269. Grundlagen zur Serotherapie des Streptokokkenpuerperalfiebers. Zeitschr. f. Geb. u. Gyn., 1904, li, 400-538. Walthard u. Reber. Beitrage zur Kenntniss der Natur u. klin. Bedeutung der Vaginalstreptokokken. Zeitschr. f. Geb. u. Gyn., 1905, liv, 304-442. LITERATURE 923 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. fitude sur 1 'infection puerperale. These de Paris, 1889. Infection puerperale et phlegmasia alba dolens. Gaz. des Hop., 1889, 565. Williams, J. W. 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 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 Bac teriological 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 Fall von puerperaler Infektion, bei dem sich Typhusbacillen in den Lochien fanden. Zentralbl. f. Gyn., 1898, xxii, Nr. 34. Puerperal Diphtheria. Amer. Jour. Obst., August, 1898. 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. Die Mikroorganismen im Genitalkanal der gesunden Frauen. Zeitschr. f. Geb. u. Gyn., 1888, xiv, 443. Ueber Selbstinfektion. Zentralbl. f. Gyn., 1911, 1495-1505. Witte. Bakteriologische Untersuchungsbefunde bei path. Zustanden im weibl. Geni- talapparat, mit besonderer Beriicksichtigung der Eitererreger. Zeitschr. f. Geb. u. Gyn., 1892, xxv, 1-30. CHAPTER XLIV DISEASES AND ABNORMALITIES OF THE PUERPERIUM We have already discussed in detail the more typical instances of puer- peral 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 encountered 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 patho- logical conditions in the breasts, disorders of the intestinal tract, and in very rare instances may be due to emotional causes. Moreover, it must be remembered that Xature 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 puerpe- rium, although a very rare occurrence, has been fully established by the researches of Chantemesse and Widal, Heyse, Rubeska, Schotmtiller, and others, who have isolated the characteristic bacilli from the uterine lochia. The infection usually follows gross errors in aseptic technique, 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. Occasionallv, however, such an explanation cannot be adduced, as in an epidemic in the Prague Lying-in Hospital, the disease, in one in- stance, at least, occurred in a woman who had not even been examined in- ternally. 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 instances 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 Rubeska 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, and thus far the results obtained from the employment of anti-tetanic serum have not been encouraging, although its prophylactic employment has been attended by excellent results. In view of the hopelessness of other lines of treatment, Pawlik and Eubeska removed the uterus in several of their cases, but without avail. 924 TIIROMLOSIS OF VESSELS OF LOWER EXTREMITIES 925 Thrombosis of the Vessels of the Lower Extremities.—Thrombosis oc- curring in the crural, popliteal, or saphenous veins—phlegmasia alba dolens —is usually a manifestation of puerperal infection, and follows the direct extension of a thrombotic process from the pelvic, veins, occasionally it results from a localized phlebitis or periphlebitis, and in very rare in- stances may be due to purely mechanical factors. The lumina of the large veins rarely undergo complete obliteration, so that the circulation, 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 oedema, 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 cord-like structure can often be palpated just beneath Poupart's ligament and can be followed for a certain distance down the thigh. Tbe 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 pyaemia, incident to a more or less generalized thrombo-phlebitis. The pain, swelling, and temperature continue for several weeks, and then gradually subside, though occasionally months elapse before the patient regains the full use of tbe 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 generalised process, or when the thrombus undergoes suppuration and softening, so that infected particles are carried to other parts, giving rise to metastatic abscesses and occasionally 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 absorbent cotton and protected from the weight of the bedclothes by a suitable con- trivance. If the pain is severe morphine may be required, though or- dinarily 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 ichtbyol. On account of the danger of detaching portions qJ the thrombus, the leg should never be massaged. The patient.;should be kept in a horizontal position for at least a week after the pain has disappeared and the tempera- ture subsided, and after being allowed to get up she sliould be cautioned against making sudden movements, 926 DISEASES AND ABNORMALITIES OF PUERPERIUM Small varicose veins of the lower extremities sometimes undergo spon- taneous thrombosis during pregnancy, but more often during the first weeks of the puerperium. In pregnancy this occurrence is favored by the inter- ference with the circulation due to the pressure exerted by the uterus upon the vessels returning from the extremities. During the puerperium its development is occasionally favored by pressure exerted upon the intra- pelvic veins by inflammatory exudates. In small veins the thrombosis is usually unattended by symptoms, although now and again the development of a localized phlebitis or periphlebitis may cause pain, and exceptionally 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 par- ticularly by Wormser and Burckhard, is a most serious complication, and usually ends fatally. Wormser, in 1904, collected 80 cases from the liter- ature, 6 of which were apparently examples of Raynaud's disease, while of the remaining 72 cases 66 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 occur- rence 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 view of the constant presence of bacteria in the normal urethra, and of the impossibility of thoroughly disinfecting the vulva and urethral ori- fice, cystitis will occasionally occur, despite the most rigid precautions. For this reason catheterization should be restricted to the greatest possible extent, and employed only when the patient is unable to evacuate the blad- der after being placed in a sitting position. In rare instances the affection results from the direct extension of areas of inflammation about the urethral orifice and vulva. 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 contains a large proportion of blood. The acid reaction is usually retained, although, more especially when the process is prolonged, the secretion may become alkaline, and very offensive in odor. Xow and again cases are encountered in which the in- HEMORRHAGES DURING THE PUERPERIUM 927 fection is so severe that larger or smaller portions of the mucosa become exfoliated and are cast off with the urine, their expulsion being associated with cramp-like pains. In these virulent types, and also in the milder but obstinate processes, 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 pyelo-nepliritis or a pyelo-nephrosis. Thus, it sometimes happens that a patient, who had apparently recovered from a cystitis, may suddenly expe- rience 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. Tbe condition frequently apparently passes off, to recur again when least expected. In mild cases of cystitis tbe treatment consists in the ingestion of large quantities of fluid, particularly milk and tbe carbonated and alkaline waters. Tbe vesical irritability is often satisfactorily allayed by tbe admin- istration of 5-grain capsules of salol or urotropin repeated every four to six hours. Ordinarily, simple treatment leads to recovery in a compara- tively short time, but if the process drags on, daily irrigation of the bladder with a 2-pcr-cent. solution of boric acid or a l-to-20,000 or 30,000 solution of bichloride should be practiced. Most cases of pyelo-nephrosis recover spontaneously after rest in bed and the administration of large quantities of fluids and the usual renal antiseptics; but whenever a pyelo-nephritis is accompanied by prolonged febrile manifestations, drainage and occasionally extirpation of tbe organ becomes necessary. Retention of Urine.—In Chapter XVI, upon tbe care of tbe patient dur- ing 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, for tbe first few days of the puerperium, coughing, sneezing, or other factors leading to a sudden increase in the intra-abdominal pressure often produce an involuntary dis- cbarge of a small quantity of urine. The condition usually passes off spon- taneously, but cure is sometimes hastened by the administration of 1/30 grain of strychnia every six hours. 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 the end of tbe first week it is usually tbe first sign of tbe development of a vesico-vaginal fistula. In the majority of such cases scrupulous attention to cleanliness will be fol- lowed by spontaneous recovery; but when the fistulous opening is extensive, a cure can be effected only by operative procedures at a later period. Haemorrhages during the Puerperium.—Ordinarily, if there lias been no serious loss of blood during the first hour or hour and a half following delivery, it may be assumed that the danger of post-partum haemorrhage has practically passed. Occasionally, however, in the latter part of the first week, and more often still later in the puerperium, more or less severe uterine haemorrhages are encountered. They are nearly always due to the retention of portions of a placental cotyledon or of a succenturiate lobule 61 928 DISEASES AND ABNORMALITIES OF PUERPERIUM which may have been overlooked at the time of labor; although the reten- tion of large portions of placenta indicates gross negligence on the part of the obstetrician. If the retained tissue is not cast off spontaneously or re- moved 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 in- volution of the adjacent portion of the uterus that bleeding continues so long as it remains in utero. The retention of large portions of the fcetal membranes rarely gives rise to serious haemorrhage, 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 post-partum or post-abortion, according as it follows full-term labor or abortion. It usu- ally interferes with the process of involution, and leads to more or less haemorrhage. 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, whenever a patient suffers from an acute loss of blood during the puerperium, tbe 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 haemorrhage following retroflexion and sub- involution of the uterus has been referred to under those headings. The loss of blood associated with an endometritis post partum also demands curettage. If the patient bleeds excessively after tbe expulsion of an hydatidiform mole, similar treatment is indicated. And, on account of the possibility of the existence of a chorio-epithelioma, the tissue removed should be carefully examined microscopically. Puerperal Hematoma.-—A tumefaction resulting from the escape of blood into the connective tissue beneath the vaginal mucosa or the skin covering the external genitalia is known as a vaginal or vulval hematoma. This condition, first studied in detail by Deneux, in 1830, is a rare com- plication 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. Less fre- quently fatal haemorrhage 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. Xow 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 prolonged pressure. The site at which the haematoma develops varies according as the torn vessel lies beneath or above the pelvic fascia. In the former case the tumefaction involves the lower part of the vagina or the vulva and perineal region; while in the latter it protrudes into the upper portion of the vaginal canal, and as it increases in size separates the peritoneum from the ad- jacent tissues, so that at times the effused blood makes its way into the SUBINVOLUTION OF THE UTERUS 929 iliac fossae, gradually invades the renal region and eventually reaches the lower margin of the diaphragm. Vulval haematomata of moderate size are usually absorbed spontane- ously. In other cases the tissues covering the tumor may undergo pressure necrosis and give way, profuse haemorrhage resulting, or the contents may be discharged in the form of large clots. In either event the interior of the haematoma is very prone to become infected, the condition sometimes ending fatally. If the tumor is large it not only causes discomfort 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 tbe subperitoneal variety such immense quantities of blood may be effused beneath the peritoneum that the patient rapidly succumbs to acute anaemia. In other cases a fatal issue follows secondary rupture into the peritoneal cavity, and many patients perish from infection. In 33 cases of this character which I collected in 11)01 the mortality was 5<; 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 haemorrhage came from a vessel at the base of tbe bladder, which had be- come torn through during the course of a spontaneous labor. A vulval haematoma is readily diagnosed by the sudden appearance at the vulva 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 symptoms soon leads to a vaginal examination, when a round, fluctuant tumor is found, which encroaches upon the lumen. On the other hand, when the haematoma extends upward between the folds of tbe broad ligament, it is liable to escape detection, unless symptoms of anaemia or infection appear. In my case tbe uterus was markedly displaced upward by tbe effused blood, and on bimanual examination a fluctuant tumor 15 centimeters in diameter could be palpated beneath it; although had tbe patient not been seen until after the infection had occurred, the differential diagnosis between such a condition and an extensive pelvic inflammatory mass would have been very difficult. The prognosis is usually favorable, though very large haematomata occa- sionally lead to death from haemorrhage, whereas in rare cases the fatal termination is the result of infection. Treatment.—Small haematomata should be left alone, as spontaneous resorption usually takes place, provided the parts be kept clean and infec- tion avoided. On the other band, a steady increase in size indicates a con- tinuance of haemorrhage, and in such cases the tumor should be laid widely open and packed with gauze. The strictest antiseptic precautions are im- perative, inasmuch as infection is a frequent complication. In large sub- peritoneal haematomata, accompanied by acute anaemia, laparotomy should be promptly performed, the blood clots removed, and the haemorrhage con- trolled by ligature or by packing the cavity with gauze. Diseases and Abnormalities of the Uterus.—Subinvolution.—This term is used to describe an arrest or, retardation of the process of involution, by 930 DISEASES AND ABNORMALITIES OF PUERPERIUM 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 after- birth, inflammatory lesions of the endometrium, the presence of myomatous nodules in the uterine wall, abnormalities of circulation which frequently accompany displacements of the uterus, the existence of pelvic inflamma- tory lesions, and insufficient rest during the puerperium. In other words, subinvolution is practically always the result of local conditions and not of constitutional disorders, and accordingly careful investigation will reveal the underlying cause, and appropriate treatment, if undertaken sufficiently 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 leucorrhoea 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 tbe condition is not properly treated it may lead to permanent changes in the uterus, which are sometimes associ- ated with such serious haemorrhage as eventually to necessitate the removal of the organ. According to R. F. Smith, the uterus in such cases is ab- normally large, contains much more fibrous and less muscular tissue than normally, while tbe 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. Xormally the fundus should have descended to the level of the upper margin of the symphysis by the tenth day, although the organ does not regain its original size for six weeks after delivery. Inasmuch as subinvolution is dependent mainly upon local conditions, very little can be expected from medicinal treatment, although the admin- istration of a half dram of the fluid extract of ergot every three or four hours for several days is sometimes followed by improvement. Local meas- ures afford much better results. If the uterus is displaced it should be put in proper position by bimanual manipulation and held in position by a suitably fitting pessary, and copious hot saline vaginal douches given twice a day. 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 subinvolution may become permanent. Lactation Atrophy of the Uterus.—Ordinarily, in women who suckle their children, the uterus may undergo excessive involution, becoming DISPLACEMENTS OF THE UTERUS 931 smaller than in the virginal state. This condition, which usually becomes most marked during the third or fourth month after delivery, 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 lactation, should be partly attributed to this form of atrophy. The condition 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 Vineberg. In rare instances the atrophy may persist after weaning and become permanent, the uterine cavity sometimes measuring only a few centimeters in length. This abnormality, first described by Chiari, Braun, and Spaeth, in 1855, was later designated by Simpson as superin volution. It is prob- able that it may occasionally be the causative factor in the unusually early appearance 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. 322). In these circumstances a comparatively trivial cause, such as a slight increase in the intra-abdominal pressure or distention of the rec- tum, may lead to an excessive bending forward of the body of the uterus— ante flexion. The condition is usually without significance, but occasionally tbe 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 lochial discharge—lochiometra. As a rule tbe retention, when it occurs, is only transitory, but if it be prolonged the lochia may undergo putrefactive changes which are accompanied by the formation of toxins, the absorp- tion of which may give rise to constitutional symptoms. The complication is readily overcome by allowing the retained discbarge to drain away through a douche-tube, after which the uterine cavity should be irrigated with sterile salt solution. So long as tbe body of the uterus lies above the superior strait, retro- displacement cannot occur, as the failing backward of the enlarged fundus is prevented by the promontory of tbe sacrum. But as soon as the organ has descended into the pelvic cavity a retroflexion or retroversion becomes possible. The development of such displacements, which are rarely ob- served before tbe third week of the puerperium, is probably connected with excessive relaxation of some of the structures about the base of the broad ligaments. This apparently results from overdistention by the presenting part, and is by no means always due to traumata incident to operative pro- cedures, as in mv experience retroflexion frequently follows normal spon- taneous labors during which no apparent injury was sustained. It is pos- siblv favored by the use of an abdominal binder which may cause the ab- dominal contents to exert pressure upon the fundus of the uterus, forcing it downward and backward. In other cases the retroflexion merely repre- 932 DISEASES AND ABNORMALITIES OF PUERPERIUM sents a recurrence of a similar condition existing prior to pregnancy, while occasionally it may be the result of extreme distention of the bladder. Backward displacements 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 most characteristic manifestation is a marked increase in the amount of lochial discharge or the reappearance of the flow if it 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. A positive diagnosis can alwavs be made upon vaginal examina- tion, when the displaced uterus will be found to be larger and softer than normal—in other words, the condition is usually associated with subinvo- lution. The restoration of the uterus to its normal position by bimanual manip- ulations, and the introduction of a properly fitting pessary, as a rule will afford prompt relief, and on removal of the pessary some 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 puer- perium, much less favorable results are obtained, 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 discharg- ing the puerperal patient. When the patient has suffered from retroflexion before pregnancy, an examination made at the end of the second week of the puerperium will usually show that the uterus has returned to its abnormal position. In such cases it should be replaced and a pessary at once intro- duced, although 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 time of labor and the consequent relaxation of the vaginal out- let which follows neglect to repair them. Moreover, the changes following childbearing predispose to the occur- rence 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 results, and to prevent serious disability, an early operation is imperative, since the diffi- culty 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 investigations of Rowland and Richards, and Whipple upon preg- nant dogs show 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 approxi- OBSTETRICAL PARALYSES 933 mately normal cells is preserved at the periphery. Associated with these changes is a pronounced perversion of metabolism. I have encountered the complication upon one occasion. In a primi- parous woman dilatation of the cervix was completed manually and forceps applied on account of threatened foetal asphyxia, after which several lacera- tions were repaired. The anaesthetic was taken badly and was given for a little longer than 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 presented an appearance similar to that observed in the early stages of acute yellow atrophy of the liver, and identi- cal with that produced experimentally in dogs. Xo doubt such cases were occasionally observed in the past, when death was attributed to some obscure toxaemia. In view of our present knowledge it behooves us to inquire whether we are justified in continuing to use chloroform as an anaesthetic. I believe that it may be safely employed for ordinary obstetrical anaesthesia, but that it should be replaced 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 cramp-like 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 deliverv, and is accompanied by the development of paraly- sis 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 Hiinermann, H. 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 the sacral plexus pass over the brim of the pelvis, where they are exposed to danger from com- pression, whereas the lower roots which lie upon the pyriformis muscle are more protected. Hiinermann considers that the chances of injurious pressure are great- est where the pelvis is generally contracted, and less so in the rhachitic varieties, inasmuch as the projecting promontory in the latter tends to pre- vent 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 on record in which both legs" were affected. The paralytic 934 DISEASES AND ABNORMALITIES OF PUERPERIUM symptoms usually appear immediately after delivery, and may become per- manent 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 tbe 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 laparotomy and the separation of the adherent appendages from the posterior and lateral portions of the pelvic wall. Winschcid has directed particular attention to the rare cases of neuritis which follow delivery. The inflammation may be general or localized. 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, though they are supposed to be due to toxaemic influences. Tbe prognosis is fair for the localized but poor for the generalized variety. 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 disturbances 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 instances these result from various varieties of apoplexy, and occasionally from areas of cerebral degeneration incident to eclampsia and the other toxaemias. 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 com- monly known as Duchennes paralysis. In this form, paralysis of the del- toid, 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 tbe 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 muscles in- volved. He considered that the paralysis frequently follows compression of the plexus by the clavicle in the Prague method of extraction, more par- ticularly when the arms have become extended over the head. In other ABNORMALITIES ANI) DISEASES OE THE BREASTS 935 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 manoeuvres is at once evident from a consideration of the anatomical relations. On the other hand, tbe experiments of Stolper show that the plexus cannot possibly be compressed by the tips of the for- ceps so long as the child presents by the vertex, although it may occur in face or brow presentations. Carter, in ltt!)3, 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 employed in order to effect delivery of the shoulders in vertex presentations, it is readily seen that Duchenne's paralysis might 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 extractions the Prague manoeuvre should be employed only when absolutely necessary, and particular attention should be devoted to preventing tbe extension of the arms over tbe head, as it not only materially complicates delivery, but adds considerably to the danger of infantile paralysis. The prognosis is usually fair, tbe majority of tbe children recovering. Occasionally, however, a case may resist all treatment and the child may remain hopelessly paralyzed. All of the instances which I have personally observed ended in recovery, but in some of them prolonged treatment was necessary. In this form of paralysis the children should be promptly put under the care of a competent neurologist, as the intelligent use of the electrical current is frequently the only means by which degenerative changes in the nerves and muscles can be obviated, and neglect in this regard may result in the condition becoming permanent. 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 is nevertheless an infrequent occurrence. In a large proportion of the recorded cases the condition developed rapidly in young unmarried women, both breasts being implicated and occasionally attaining such immense proportions that am- putation became necessary. Cases have been reported in which a single breast weighed more than 50 pounds. The hypertrophy sometimes recedes during lactation, so that tbe abnormality does not always afford an absolute contra-indication to suckling the child. Overdevelopment of the mammae is sometimes observed in men, a number of cases having been collected by Laurent. Supernumerary Breasts.—Probably one in every few hundred women 936 DISEASES ANI) ABNORMALITIES OF PUERPERIUM has one or more accessory breasts—polymastia. Reference to 262 such cases are to be found in Goldberger's article. The supernumerary breasts rarely attain any considerable size, and oc- casionally are so minute as to be mistaken for small pigmented moles. They are often provided with distinct nipples. They are most commonly situ- ated upon the anterior thoracic or abdominal walls, usually near the mam- mary line; less frequently they are found in tbe axillae, and occasionally upon other portions of the body—the shoulder, flank, or groin, and in rare instances the thigh. They vary greatly in number, Xeugebauer having described a patient with 10 breasts. 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. Xot all observers, however, accept this view, Ahlfeld holding that the distribu- tion 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 occasionally the en- largement of supernumerary breasts occupying the axillae may result in considerable discomfort to tbe patient. Abnormalities of the Nipples.—Tbe 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 pronounced as to inter- fere 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 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 injuries 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- ABNORMALITIES AND DISEASES OF THE BREASTS 937 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, secretes only a small (piantity; while, on tbe other hand, one is often surprised at tbe abundant supply produced by another whose mammae are small and flat. It is a matter of common observation that stout women with well-formed but re- dundant breasts usually have a very deficient secretion, the bulk of the organ being made up of fatty tissue while the glandular elements are poorly devel- oped. 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 secretion— 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, rela- tive deficiency is frequently observed, a large number of women secreting an amount of milk quite insufficient for the nutrition of the child. In Chapter XVII reference was made to the variations in the quantity of the milk as well as the various factors which may be concerned in their pro- duction. Occasionally the mammary secretion is excessive—polygalacin—and may even be so abundant that milk is constantly escaping from the nipples. This latter condition, which is known as galactorrhea, sometimes continues for years after the birth of the child, and is extremely intractable to treat- ment. Nothing is known as to its cause. Although 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. Galactorrhcea is best treated by not attempting to empty the breast, but rather by allowing it to become engorged, when the intramammary pressure becomes so great as to compress the vessels and thus check secretion. At tbe same time the breasts should be supported by a bandage, and fairly laro-e doses of potassium iodide should be administered. 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 improvement 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 tbe employment of electricity. Diseases of the Nipples.—The mode of production and treatment of fis- sures 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 tbe hreasts 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 fre- 938 DISEASES AND ABNORMALITIES OF PUERPERIUM quently 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 development of a mammary abscess. It is probable that the excessive distention of the glandular por- tion of the breast leads to slight tissue changes, thereby offering a locus minoris resistant ice 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, and if necessary giving 1/4 grain of codia, which may be re- peated 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 proper massage. The nurse having anointed the palmar surfaces of her hands 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 ac- customed to them more force may be employed, which will soon cause the milk to exude from the nipple. After the breast has 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 "dry- ing up the milk," as it is usually designated. Formerly this was accom- plished by the use of the binder, the application of belladonna ointment, and tbe employment of the breast-pump and massage when 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 such treat- ment was unnecessary, and 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 treat- MASTITIS 939 ment. 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 tbe course of twenty-four hours they become more or less engorged, and sometimes very painful. If the pain is severe, y± grain of codia is administered, and repeated if necessarv, 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. Since I have employed this method I have entirely abandoned the use of belladonna ointment, the breast-pump, and massage, as well as the tight breast binder, though when the breasts are large and pendulous they may be held in position by a loose bandage. II. J. Storrs, in U»09, published a report of the cases so treated in my clinic, and stated that not a single breast abscess had developed, and that less than one woman in ten com- plained of sufficient pain to necessitate the administration of a sedative. Inflammation of the Breasts—Mastitis.—Parenchymatous inflammation of the mammary glands is a not infrequent complication of the puerperium. The symptoms rarely appear before the end of the first week, and as a rule not until considerably later. Marked engorgement usually precedes tbe inflammatory trouble, the first sign of which is afforded by chilly sen- sations or an actual rigor, which is soon followed by a considerable rise in temperature and an increase in the rate of the pulse. Tbe breast becomes bard, 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 nfluenced by the application of a tightly fitting bandage. But if the symptoms persist for longer than forty-eight hours, suppuration is to be expected. Tbe 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 marked, and sometimes lead to a fatal termination, whereas 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 bacteria. On the other hand, a certain number of cases pursue a subacute or almost chronic course, the breast being some- what harder than usual and more or less painful, but constitutional symp- toms 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 940 DISEASES AND ABNORMALITIES OF PUERPERIUM 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. Tbe researches of Bumm, Honigmann, Koesllin, and others have demonstrated that Staphylococcus albus is present in 80 to 94 per cent, of all breasts. Ordinarily this micro-organism lives in the milk as a harm- less parasite, but when the tissues are seriously altered as tbe result of en- gorgement, 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 .......................... 9 '' Staphylococcus albus ..................................... 3 " Streptococcus ........................................... 1 case Exceptionally, other bacteria are causative agents, Sarfert having demon- strated the gonococcus, Chassot the bacillus pyocyaneus, 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, the infec- tion may be limited to the areola, beneath which small abscesses, rarely exceeding 1.5 centimeters in diameter, may develop—subareolar mastitis. In rare instances tbe affection may be erysipelatous in character, 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 Rubeska show a frequency of 0.54 to 1.1 per cent, in the various German clinics. Generally speaking, it may be said that the frequent occurrence of mastitis is indicative cf 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 preventing tbe development of fissured nipples or treating them properly after they have appeared. Tbe most suitable measures for hardening the nipples during pregnancy, 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 prac- tically valueless unless the nipple can be placed at comparative rest which is best afforded by the use of a suitable nipple-shield. If the con- dition becomes worse after some days' trial of this treatment it is ad- PUERPERAL PSYCHOSES 941 visable 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. 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 reports excellent results following the use of his method of artificial hyperaemia, but in my service the procedure has been of little value. As soon as the slightest 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. Tbe incision should be made radially, extending from near the areolar margin toward the periphery of the 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 suffi- cient, but when multiple abscesses are present several incisions may be re- quired. The operation should always be done under anaesthesia, and should not be considered as completed until the obstetrician has introduced a finger through the incision and carefully explored the interior of the breast, break- ing down the partition walls between tbe 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, which is removed at the end of twenty-four hours and the cavity washed out with sterile salt solution or a 2-per-cent. boric- acid solution, after which another pack is inserted. If the pus has been thoroughly evacuated, the abscess cavity becomes obliterated with a rapidity which is sometimes surprising. (Salaclocclc.—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, while in others the structure may attain such a size that puncture becomes 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 fortu- nately the latter is of relatively rare occurrence. The insanity of pregnancy is usually a manifestation of auto-intoxica- tion, and may be accompanied by melancholic or maniacal symptoms. It usually persists throughout the remainder of gestation, but disappears 942 DISEASES AND ABNORMALITIES OF PUERPERIUM l shortly after labor, unless the patient has an hereditary tendency to mental derangement. Puerperal insanity, on the other hand, is much more common, and according to the statistics compiled by Berkley and Jones is noted once in every 616 and 1,100 labors, respectively, though my experience would lead me to believe it less frequent. In former times it was a comparatively com- mon complication, and it would seem that tbe introduction of aseptic methods into midwifery is responsible for a reduction by one half in its incidence. The affection usually makes its appearance within the first two weeks following delivery. When it occurs at a later period it is designated 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 recognized, but it is only of late that the bacteria concerned have been identified, and then only in a small proportion of the eases. In 2 of the 3 instances which have come under my observation the infection was due to streptococcus, and in the third to the streptococcus and colon bacillus. Berkley likewise reports a case due to the organism first mentioned. Auto-intoxication is also a frequent aetiological factor, and is prob- ably usually concerned in the production of the mental derangements fol- lowing eclampsia. Ordinarily, insanity is regarded as a rare complication of eclampsia, though Olshausen observed it in 6 per cent, of his 515 cases. According to Hansen and Pieque, infection and auto-intoxication are re- sponsible for more than 80 per cent, of all cases, while the remainder are to be attributed to other causes, occurring particularly in women afflicted with hereditary tendencies, tbe exciting cause of the insanity being shock, ex- treme mental depression, or the rapid loss of a large quantity of blood. The puerperal psychoses are usually characterized by great excitement during tbe 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 tbe eases following eclampsia, tbe majority of these 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 infec- tion 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 rigor- ously followed. The acute maniacal symptoms should be met by the admin- istration of sedatives, and the patient should be watched most carefully throughout her entire illness, more particularly during the periods of de- pression, during which she should never be left alone for fear that she may do an injury to herself. If prompt improvement does not follow the dis- ACUTE INFECTIOUS DISEASES 943 appearance 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 influenced by tbe fact that the patient is already debilitated by the strain incident to labor. The diagnosis should never be made unless a definite Widal reac- tion can be demonstrated, inasmuch as all the other symptoms of the dis- ease may be associated with a prolonged puerperal infection, especially when the endocardium is involved. Furthermore, the so-called typhoid condi- tion is often encountered in various forms of pyamiia. Malarial Fever.—In certain districts the puerperium is sometimes com- plicated 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 disorder, in women who have already suffered from it, the typical phenomena often appearing during the first few days of the puerperium. Too many sins of omission and commission on the part of the obstetri- cian have undoubtedly been cloaked under the diagnosis of "malaria." At the present day, whenever a patient presents a temperature characterized by marked remissions and possibly by chills, puerperal infection should be suspected, and the existence of malarial fever should never 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, quinine should be given in sufficiently large doses to break up the attack, as it exerts no appre- ciable influence upon the mammary secretion or the well-being of the child. Pneumonia.—Croupous pneumonia is a rare complication of the puer- peral state, unless the disease has existed before the onset of labor. The outlook is always serious. Tbe lobular variety, or broncho-pneumonia, 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 discussion and a very considerable literature. The interest manifested in the disease is largely to be accounted for by the fact that a scarlatiniform rash is occa- sionally observed during the course of a puerperal infection, so that in many cases a differential diagnosis becomes very difficult. Epidemics of scarlet fever in the puerperium have been reported by Boxall, Meyer, Ahlfeld, and others. Xevertheless, it would appear that the puerperal woman is to a certain extent immune from the disease, inas- much 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 bis patients. It is generally stated that infection may occur in the usual manner, as 62 944 DISEASES AND ABNORMALITIES OF PUERPERIUM well as by the entrance of the specific poison through wounds about the geni- talia. Tbe belief in the possibility of the latter eventuality is based upon tbe fact that the rash occasionally appears first in the neighborhood of the vulva, and thence spreads to other portions of the body. Moreover, the fre- quent association of pelvic inflammatory troubles, and the occasional locali- zation of diphtheritic patches in the vulva or vagina, instead of in the throat, are advanced in support of the view. Modern bacteriological in- vestigation, however, has destroyed the force of this last argument, since it has shown that the so-called diphtheritic deposits occurring in the throat in scarlet fever are clue to a coincident streptococcic 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 during the course of puerperal infection. It is also urged that the appearance 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 pseudo-diphtheritic 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 the other band, in the absence of characteristic manifestations, the diagnosis cannot be made, it being often impossible to differentiate between scarlet fever and puerperal infection, even when a distinct history of exposure to conta- gion 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 haemorrhagic 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 small-pox 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 ba- cillus can be demonstrated, occasionally occur upon denuded portions of the vulva and vagina. They may be due to a primary genital infection, or be merely part of a process primarily localized in the throat. Inasmuch as pseudo-diphtheritic patches in the genital tract during the course of puerperal infection are of frequent occurrence, the presence of fibrinous exudates about the vagina or vulva should lead to a diagnosis of diphtheria only in those cases in which 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 the anti-diphtheritic serum. LITERATURE 945 LITERATURE Ahlfeld. Spaltnng der Anlage der Brustdriise, Polymastie. Die Missbildungen des Menschen. Leipzig, lsso, 110-113. Ueber Exantheme im Wochenbette, etc. Zeitschr. f. Geb. u. Gyn., 1N93, xxv, 31- 44. Berkley. The Insanities of the Puerperal Period. A Treatise on Mental Diseases, 1900, 307-328. Boxall. Scarlatina during Pregnancy and in the Puerperal State. Trans. Lond. Obst. Soc, 1SS9, xxx, 11-77; 126-154. Bumm. Zur Aetiologie der puerperalen Mastitis. Archiv f. Gyn., 1886, xxvii, 460- 48 1. Burckhard. Gangran der unteren Extremitaten im Wochenbette. Zentralbl. f. Gyn., 1900, xxiv, 1:581-1384. Carter. Obstetrical Paralysis, etc. Boston Med. and Surg. Jour., May 4, 1893. Chantemesse et Widal. Recherches sur I'etiologie du tetanus. Le bull, med., 1889, No. 74. Chiari, Braun, und Spaeth. Acquirirte Volumsabnahme des Uteruskorpers. Klinik der Geb., 1854, 371-372. Deneux. Memoire sur les tumeurs sanguines de la vulve et du vagin. Paris, 1830. Doderlein. Die Atrophia uteri. Veit's Handbuch der Gyn., 1897, ii, 391-402. Duchenne. Paralysies obstetricales infantiles du membre superieur. De 1'electrisa- tion 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 selteaer 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. Wochenschr., 1893, Nr. 14, 318. Honigmann. Bakteriologische Untersuchungen iiber Frauenmilch. D. I., Breslau, 1893. Hosslin. Ueber periphere Schwangerschaftslahmungen. Miinchener med. Wochen- schr., 1905, Nr. 14. Howland and Richards. An Experimental Study of the Metabolism and Pathology of Delayed Chloroform Poisoning. Jour. Exp. Med.., 1909, xi, 344-72. Hunermann. Ueber Nervenlahmung im Gebiete des Nervus ischiadicus infolge von Entbindungen. Archiv f. Gyn., 1900, xiii, 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. KiixziG. Ueber das Haematom der Vulva und der Vagina. D. I., Tubingen, 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. Meyer. Ueber Scharlach bei Wochnerinnen. 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. 946 DISEASES AND ABNORMALITIES OF PUERPERIUM Olshausen. Beitrag zu den puerperalen Psychosen, speciell den nach Eklampsie auftretenden. Zeitschr. f. Geb. u. Gyn., 1891, xxi, 371-585. Picque. Considerations sur les psychoses post partum. Bull, de la soc. d 'obst. de Paris, 1905, viii, 19-38. Rubeska. Beitrage zum Tetanus puerperalis. Archiv f. Gyn., 1897, liv, 1-12. Zur Behandlung von wunden Warzen und Mastitiden im Wochenbett. Archiv f. Gyn., 1899, lviii, 177-184. Sarfert. Diplokokken im Eiter bei Mastitis. Deutsche med. Wochenschr., 1894, Nr. 8. Schumaker. Ueber die Aetiologie der Entbindungslahmungen, etc. Zeitschr. f. Geb. u. Gyn., 1899, xii, 33-53. Smith. The Subinvoluted Uterus. Surg. Gyn. and Obst., 1910, x, 17-27. 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. Beitrag sur Lehre von der Atrophia uteri. Zeitschr. f. Geb. u. Gyn., 1889, xvi, 57-105. Die Laktationsatrophie des Uterus, etc. Volkmann's Sammlung klin. Vortrage, 1910, Nr. 602 and 603. Vinay. Du tetanus puerperal. Archives de tocologie, 1892, xix, 179. Vineberg. A Further Contribution to the Study and Practical Significance of Lac- tation Atrophy of the Uterus. Amer. Gyn., 1902, i, No. 2. Whipple. Pregnancy and Chloroform Anaesthesia. Jour. Exp. Med., 1912, xv, 246- 258. Whipple and Sperry. Chloroform Poisoning. Bull. Johns Hopkins Hospital, 1909, xx, 278-289. Williams. Subperitoneal Haematoma following Labour, not associated with Lesions of the Uterus. Trans. Am. Gyn. Soc, 1904, xxix, 186-205. Winckel. Entziindung des Brustdriisenparenchyms, etc. Die Pathologie u. Therapie des Wochenbetts. III. Aufl., 1878, 428-439. Winscheid. Neuritis gravidarum und Neuritis puerperalis. Graefe's Sammlung zwangloser Abhandlungen auf dem Gebiete der Frauenheilkunde und Geb., 1898, iii, Heft 8. Wormser. Nochmals zur puerperalen Gangran der unteren Extremitaten. Zentralbl. f. Gyn., 1901, xxv, 110-112. Ueber puerp. Gangran der Extremitaten. Wiener klin. Rundschau, 1904, Nr. 5 u. 6. INDEX Abdomen, discoloration of, in pregnancy, 174. enlargement of, during pregnancy, 191. foetal, enlarged, cause of dystocia, 819. pendulous, 192. striae of, in pregnancy, 174. Abdominal binder, 348. pedicle, 115, 117. pregnancy, 659. wall, changes in, during pregnancy, 174. during puerperium, 342. emphysema of, 862. function of, during labor, 230. Abortion, 627. aetiology of, 628. changes in fcetus in, 632. clinical history of, 633. complete, 634. criminal, 382. curettage in, 483, 636. epidemic, 629. exciting causes of, 630. frequency of, 627. in cholera, 490. in retroflexed pregnant uterus, 573. in typhoid fever, 491. incomplete, 634. induction of, for contracted pelves, 383. for diseases of ovum, 382. for malignant growths, 383. for missed abortion, 383. for ovarian tumors, 383. for pernicious vomiting of pregnancy, 528. for renal insufficiency, 382. for retroflexed pregnant uterus, 382. for tuberculosis, 383. for uterine haemorrhage, 382. for uterine myomata, 383. for vomiting of pregnancy, 382. methods of, 383. inevitable, 634. lithopaedion in, 633. membranes, retention of, in, 637. miscarriage, 627. missed, Ci38. mole, formation of, in, 631. neglected, 637. pathology of, 631. predisposing causes of, 630. prognosis of, 385. Abortion, prophylaxis of, 634. repeated, 630. rupture of uterus in, 864. threatened, 634. treatment of, 634. tubal, 653. Abscess, in puerperal fever, 891. of Bartholin's gland, 567. of breast, 939. metastatic, 891. pelvic, 890, 913. retro-mammary, 940. Absolute indication for Caesarean section; 451. Acanthopelys, 810. Acardiacus, 372, 816. Accessory fontanelle, 154. Accessory ostium of tube, 58. Accessory ovaries, 63. Accessory tubes, 59. Accidental haemorrhage, 831. Accidents during pregnancy, 511. Accommodation theory as to production of presentations, 219. Accouchement force, 391. for haemorrhage due to premature separa- tion of placenta, 832. in eclampsia, 556. in placenta praevia, 840. in pre-eclamptic toxaemia, 535. versus post-mortem Caesarean section, 460. Acephalicus, 816. Acetonuria during pregnancy, 183. during puerperium, 346. Achondroplasia, 735, 770. Acormus, 816. Acromio-iliac presentations. (See Trans- verse Presentations.) Active movements of foetus, 191. Acute infectious diseases in pregnancy, 489. oedema of cervix, 578. yellow atrophy of liver, 528. Adherent placenta, 611. Adhesions, amniotic, 601. Adipocere, 660. Afterbirth, 136. After-coming head, forceps to, 427. in contracted pelves, 428. perforation of, 474. After-pains, 345, 348. Agalacia, 937. 947 [DEX 948 IN Age of foetus, calculation of, 149. Air, entrance of, into veins, 875. entrance of, into uterine sinuses, 875. infection, 894. Albuginea, 62. Albuminometer, Esbach's, 533. Albuminuria, changes in placenta in, 608. during pregnancy, 179, 533. during puerperium, 346. in eclampsia, 542. in labor, 346. relation to premature separation of pla- centa, 830. Albuminuric retinitis, 542. Alimentation, rectal, in hyperemesis, 519. Allantoic vesicle, 141. Allantois, 109, 115. Amaurosis during pregnancy, 508, 542. Amenorrhcea, conception during, 196, 204. Ammonia co-efficient, 521. Amnion, 105, 107. adhesions of, 601. cysts of, 602. dermoids of, 602. diseases of, 596. dropsy of, 596. fluid of, 122. formation of, in bat, 109. in chicken, 105. in guinea pig, 105. in man, 113. in monkey, 110. inflammation of, 602. structure, 121. Amniotic adhesions, 601. caruncles, 122, 602. fluid, functions of, 161. infection of, 482. origin of, 161, 596. Amorphus, 816. Ampulla of tube, 55. Ampullar pregnancy, 647. of leg, effect upon pelvis, 809. Amputation, intra-uterine, 601. Anaemia, pernicious, 509. Anaerobic bacteria in puerperal infection, 883. Anaesthesia, 329. cocaine, 330. in eclampsia, 558. in heart disease, 498. in irregular pains of first stage, 679. in normal labor, 329. in painful labor, 680. in precipitate labor, 680. lumbar, 330. scopolamine, 331. Anencephalus, 816. Aneurysm of foetus, 820. Annular detachment of cervix, 856. Anteflexion, in contracted pelves, 742. of pregnant uterus, 572. of puerperal uterus, 931. Ante-partum eclampsia, 540. haemorrhage, 829. Anteversion of pregnant uterus, 572. Anthrax during pregnancy, 492. Antistreptococcic serum, 915. Antitetanus serum, 924. Anus, laceration of sphincter of, 333. lesions of, during labor, 259. Apoplexy during pregnancy, 508'. in eclampsia, 547. of placenta, 606. Appendicitis during pregnancy, 512. Apron, Hottentot, 28. Arbor vitae uterina, 41. Area, embryonic, 101. germinativa, 101. opaca, 101. pellucida, 101. Areola, glands of Montgomery in, 176. of pregnancy, 176. secondary, 176. Arteries. (See Blood vessels.) arterial pressure, 233. Artificial feeding, 365. respiration. (See Asphyxia Neonatorum.) Ascites, of foetus, obstructing labor, 819. simulating pregnancy, 200. Asphyxia, from rupture of vasa praevia, 612. intra-uterine, 869. livida, 870. neonatorum, 871. pallida, 870. resuscitation from, 871. trepanation for, 873. Assimilation pelvis, 780. Asthma during pregnancy, 499, 561. Astringents in post-partum haemorrhage, 846. Atony of uterus, 377, 842. Atresia of cervix, 686. follicular, 77, 174. of vagina, 684. of vulva, 684. Attitude of fcetus, 213. Auscultation, obstetrical, 190, 224. errors in, 224. foetal heart, 189. foetal heart murmurs, 190. funic souffle, 190. gas in maternal intestines, 191. in multiple pregnancy, 374. movements of fcetal diaphragm, 190. placental souffle, 190. uterine souffle, 190. Auto-infection, 894. Auto-intoxication, intestinal, 560, 905. of pregnancy, 518, 560. relation of, to eclampsia, 550. to insanity, 942. Autolysis of uterus, 346. Axis of pelvis, 10. Axis traction forceps, 423. Bacillus aerogenes capsulatus, cause of em- physema of abdominal walls, 862. infection with, cause of fcetal dystocia, 820. infection with, simulating air embolism, 876, 882. INDEX 949 Bacillus aerogenes capsulatus, in puerperal infection, 886. Bacillus coli communis, in puerperal infec- tion, 881. in tympanites uteri, 881. Bacillus diphtheriae in puerperal infection, 881. Bacillus typhosus in puerperal infection, 882. Bacterial origin of eclampsia, 549. Bacteriology of lochia, 345, 883. of puerperal infection, 883. of vaginal secretion, 897. Bag of waters, 234, 253, 315, 676. Ballottement, 191. Bandl's ring. (See Contraction Ring.) Barnes's fiddle-bag, 390. Bartholin's glands, 30. inflammation of, during pregnancy, 567. Basal plate of decidua, 133. Basilyst-tractor, 476. Basiotribe, 476. Bath, cold, in puerperal fever, 913. during labor, 315. of new-born child, 356. sweat, in eclampsia, 558. Battledore placenta, 611. Bauchstiel, 115, 141. Baudelocque's cephalotribe, 475. diameter, 705. pelvimeter, 699. Bed, preparation of, 320. Bichloride poisoning from intra-uterine douche, 483, 912. Bicornuate uterus, cause of dystocia, 571. hernia of, 579. pregnancy in, 571. rupture of, 570. Binder, use of, during puerperium, 348. Bipolar version, 442. Bladder, changes in, during pregnancy, 179. calculus of, 695. ectopia of, 778. gangrene of, 575. rupture of, 575. tumor of, complicating labor, 695. Blastodermic vesicle, 99. Blecard's sign of maturity of foetus, 150. Bleeding in eclampsia, 558. Blood, changes in, during menstruation, 82. during pregnancy, 177. during puerperium, 344. freezing point of, 159. moles, 631. pressure in pregnancy, 177. serum, changes in, during pregnancy, 198. toxicity of, in eclampsia, 549. Blood-vessels of clitoris, 29. of ovaries, 62. of placenta, 135. of uterus, 49. of vagina, 37. pudic, 257. umbilical, 139, 356, 612. vestibular bulbs, 29. Blot's perforator, 473. Blunt hook, 440, 478. Bossi's dilator, 393. Bougie, for induction of premature labor, 389 ; Bossi's dilator, 393. Bowels in pregnancy, 2'iS Bradycardia during puerperium, 344. Brain, changes in, in eclampsia, 547. Braun's blunt hook, 478. cranioclast, 475. sign of pregnancy, 193. trepan, 473. Braxton Hick's cephalotribe, 475. method of version, 442, 839. sign of pregnancy, 195. Breasts, absence of, 935. anatomy of, 359. areola of, 176. caked, 937. care of, during nursing, 350, 363. in pregnancy, 209. changes in, during pregnancy, 176, 196. drying up secretion of, 364, 938. engorgement of, 937. hypertrophy of, 935. inflammation of, 939. supernumerary, 935. Breech presentations, 215, 292. aetiology of, 294. asphyxia in, 297. blunt hook in, 440. bringing down foot in frank, 298. causation of, 294. cephalic version in, 297, 441. complicated by contracted pelves, 760. diagnosis of, 292. extraction of, 430. fillet in, 440. forceps in, 427, 438, 440. frequency of, 292. in hydrocephalus, 817. liberation of arms in, 432. mechanism of, 294. prognosis in, 296. prolapse of cord in, 867. treatment of, during labor, 297. during pregnancy, 297. Bright's disease. (See Nephritis.) Brim of pelvis. (See Pelvis.) Broad ligament, 47. haematoma of, 929. pregnancy, 658. Broncho-pneumonia in puerperal infection, 903. Brow presentations, 290. causation of, 290. configuration of head in, 291. conversion of, into face or vertex, 292. diagnosis of, 290. frequency of, 290. mechanism of, 291. prognosis in, 291. symphyseotomy in, 292. treatment of, 292. version in, 292. Bruit, uterine, 190. Bryce and Teacher's ovum, 110. 950 INDEX Budin's pelvimeter, 703. Bulb, vestibular, 30. Bylicki's pelvimeter, 711. Byrd's method of resuscitation, 872. Caesarean section, checking haemorrhage in, 454. choice of operation, 457. conservative, 450, 453. contra-indications for, 452. extraperitoneal, 456. following vagino-fixation, 690. ventro-fixation, 688. for carcinoma of cervix, 452, 568. of rectum, 695. for contracted pelves, 451, 755. for malignant tumors of rectum, 452. for myoma of uterus, 452, 692. for old extra-uterine pregnancy, 663. for ovarian tumor, 694. for placenta praevia, 452, 840. history of, 449. hysterectomy after, 450, 456. in brow presentation, 292. indications for, 451. in eclampsia, 452, 556. instead of induction of premature labor, 762. in transverse presentations, 826. Porro's operation, 450, 455. post-mortem, 460. prognosis of, 458. repeated, 459. sterilizing patients after, 457. supra-symphyseal, 456. technique of, 453. vaginal, 394. Calcification of foetus, 660. of placenta, 610. Callus formation, effect upon pelvis, 810. Canal, cervical, 41, 243, 249. of Nuck, 28. Canalized fibrin, 133, 607. Cancer. (See Carcinoma.) Capsular membrane, 648. Caput succedaneum, 222, 280, 748. Carbamic acid, relation to eclampsia, 540. Carbolic-acid poisoning from intra-uterine douche, 483. Carbon dioxide, increase of, in blood, cause of labor, 227. Carcinoma of cervix, Caesarean section for, 452. complicating pregnancy, 568. of rectum, cause of dystocia, 695. Carcinoma syncytiale, 591. Cardiac lesions in pregnancy, 496. Carneous moles, 632. Carunculae myrtiformes, 33, 342. Caruncles of amnion, 602. of placenta, 602. Catheterization during puerperium, 350. Caul, 252. Causation of labor, 226. Cell layer of chorion, 119. mass, internal, 100. Cell nodes, 131, 132. Cellulitis in puerperal infection, 889. Central placenta praevia, 834. tear of perineum, 334. Centrosome, 90. Cephalalgia, during pregnancy, 506. in threatened eclampsia, 532. Cephalic version, 297, 441. indications for, 441. methods of, 442. Cephalometer, 757. Cephalotribe, 475. Cervical endometritis, 568. Cervical ganglion, 53, 169. Cervico-vesical fistula, 865. Cervix, 38, 40. acute oedema of, 578. anatomy of, 40. annular detachment of, 856. apparent shortening of, in pregnancy, 243 arbor vitae uterina, 41. atresia of, 68'6. carcinoma of, 568. changes in, during labor, 243. during pregnancy, 195. during puerperium, 341. circular detachment of, 855. condition of, in latter part of pregnancy, 243. dilatation of, during labor, 250. manual, 392. with balloon. 393. with Bossi's dilator, 393. with forceps, 405. diseases of, during pregnancy, 568. ectropion of, 42. external os, 40. ganglion of, 53. glands of, 41. hypertrophy of supravaginal portion dur- ing pregnancy, 578. incision of, 394. infravaginal portion of, 40. in normal labor, 234, 248. internal os, 41. lesions of, during labor, 855. mucosa of, 41. myoma of, 690. rigidity of, 687. stenosis of, 686. stricture of, 686. supravaginal portion, 40. tears of, 855. vaginal portion, 40. Chadwick's sign of pregnancy, 197. Chamberlen forceps, 403. Champetier de Ribes's balloon, 389, 393. Changes in uterus during contractions, 248. Child. (See New-born Child.) Chill, during puerperium, 343. following normal labor, 343. in puerperal infection, 904. Chloroform in labor, 329. Chloroform poisoning, in puerperium, 932. Cholera complicating pregnancy, 490. Chondrodystrophia foetalis, 735, 770, 819. INDEX 951 Chondrodystrophic dwarf pelvis, 770. Chorea, 387. during pregnancy, 507. Chorio-angioma of placenta, 610. Chorio-epithelioma, 591, 660. Chorion, 105, 107. abortion, from disease of, 628. angioma of, 609. canalized fibrin of, 133, 607. cell layer of, 119. cilia of, 120. cystic degeneration of, 586. decidual islands of, 117, 132. diffuse myxoma of, 596. diseases of, 586. epithelioma of, 591. epithelium o£, 117, 119, 134. fastening villi of, 119. formation of, in chicken, 105. in man, 107. frondosum, 118, 132. giant cells of, 117. laeve, 118', 131. Langhans's layer of, 119, 134. membrane of, 117. myxoma fibrosum of, 596. myxoma of, 586. Plasmodium of, 119. stroma of, 101-102. structure of, 116. syncytium of, 119, 134. trophoblast of, 112, 135. villi of, 117, 134. Zellschicht of, 119, 134. Chorionic villi. (See Villi, Chorionic.) membrane, 117. epithelium, 116. epithelioma, 591. Chromosomes, number of, 96; reduction of, 94. Chronic infectious diseases in pregnancy, 492. Cilia of ovaries, 67. of tubes, 58. of uterus, 44. Circular sinus of placenta, 139. detachment of cervix, 855. Circulation in fa-tus, 156. in new-born child, 354. Circumcision, girl, 29. Circumvallate placenta, 605. Cleidotomy, 480, 814. Clitoridectomy, 29. Clitoris, 29. amputation of, 29. anatomy of, 29. prepuce of, 28. Cloasma, 181, 511. Closing plate of decidua, 133. Clothing during pregnancy, 208. Club-foot, effect upon pelvis, 810. Cocaine anaesthesia in labor, 330. Coccygeus muscle, 255. Coccyx, 2. Coelome, 103. Coffee ground vomit, 524. Coffin birth, 876. Cohn's method of inducing labor, 390. Coiling of cord, 140, 326, 613. Coitus during pregnancy, 208. Collapse during labor, 874. Collargol in puerperal infection, Colles's law, 496, 614. Collision of twins, 376. Colostrum, 176, 359. corpuscles, 359. Colpaporrhexis, 854. Colpeurynter in induction of premature labor, 389. Colpo-hyperplasia cystica, 567. Columns of vagina, 36. Coma in puerperium, 561. Combined pregnancy, 662. examination, 223. Complete abortion, 634. Compound presentation, 826. Concealed haemorrhage, 831, 844. Conception, date of, 90, 203. during amenorrncea, 196, 204. Conduct of normal labor, 311. Conduplicato corpore, 823. Confinement, estimation of date of, 203. Congenital cystic kidneys, 819. ectropion, 42. Conglomerate glandular body, 78. Conglutinatio orificii externi, 686. Conjugata diagonalis, 6. externa, 699. vera, 5. Conjugate, anatomical, 6. Baudelocque's, 698, 705. diagonal, 708. external, 699. Meyer's, 9. normal, 9. oblique, 6, 699. obstetrical,- 6. of outlet, 713. true, 709. Conservative Caesarean section, 450, 453. Constipation during pregnancy, 178, 208, 502. during puerperium, 346. Constrictor vaginae, 257. Contracted pelves, Caesarean section in, 451, 755. cause of difficult labor, 698. classification of, 715. congenital, 723, 735. course of labor in, 748. craniotomy in, 759. diagnosis of, 701. due to abnormal malleability of bones, 721. to bilateral lameness, 809. to diseases of the vertebral column, 788. to generalized and symmetrical anoma- lies in development, 767. to localized and asymmetrical anoma- lies in development, 772. to localized and symmetrical anoma- lies in development, 777. 952 INDEX Contracted pelves, due to tumors, etc., 811. to unilateral lameness, 808. effect of, upon course of pregnancy, 742. frequency of, 699. history of, 698'. in new-born child, 723, 735. induction of abortion in, 383, 762. of premature labor for, 385, 762. mechanism of labor in, 744. pelvimetry in, 702. position of uterus in, 742. prognosis of labor in, 752. pubiotomy in, 468, 760. size of foetus in, 743. treatment of labor complicated by, 755. X-rays in diagnosis of, 714. Contraction, center for uterine, 230. hour-glass, of uterus, 682. of Bandl's ring, 681. painless, 195, 231. ring, 221, 246, 858. cause of dystocia, 682. in dystocia, due to contracted pelves, 748. in threatened rupture of uterus, 749, ' 826. uterine, 231, 248. Conversion in brow presentations, 292. in face presentations, 289. Convulsions. (See Eclampsia.) Cord. (See Umbilical Cord.) Cornua of uterus, 38, 571. Corona radiata, 72. Coronal suture, 153. Corpulence simulating pregnancy, 200. Corpus albicans, 76. fibrosum, 75. luteum, 73, 173. cystic, 78. cysts in chorio-epithelioma, 594. cysts in hydatidiform mole, 588. evidence of pregnancy, 78'. false, 78. internal secretion of, 63, 78. of menstruation, 78. of pregnancy, 78. structure of, 74. true, 78. Corpus uteri, 42. Corrosive sublimate. (See Bichloride of Mercury.) Cortex of ovary, 61. Cotyledons of placenta, 138'. Coxarthrolisthetic pelvis, 808. Coxitis, 805. Cranioclast, 475. Craniopagus, 815. Craniotomy, 472. dangers of, 477. for old extra-uterine pregnancy, 663. in collision of twins, 376. in contracted pelves, 759. in face presentations, chin posterior, 289. in hydrocephalus, 817. in rupture of uterus, 863. indications for, 472. Craniotomy, prognosis of, 477. recovery from, 477. technique of, 473. upon aftercoming head, 474. Cranium. (See Head, Fcetal.) Cravings in pregnancy, 197. Crede's method of expressing placenta, 306. ointment, 917. Cretin dwarf pelvis, 770. Criminal abortion, 382. Crotchet, 440. Culbute, 217. Cul-de-sac, incision in puerperal infection, 915. of Douglas, 35. Cumulus oophorus, 70. Curettage, 483. dangers of, 484. in abortion, 636. indications for, 483. in puerperal infection, 911. Cystic degeneration of chorion, 586. Cystitis, during pregnancy, 506. during puerperium, 350, 926. Cystocele, complicating labor, 695. Cysts of umbilical cord, 614. of vaginal walls obstructing labor, 68'6. Cytolysis, 551. amnion, 602. of corpus luteum, 78, 588. of ovary, complicating diagnosis of preg- nancy, 199. of placenta, 608. Date of confinement, estimation of, 203. Death of foetus during pregnancy, 201. of mother during labor, 873. during pregnancy, 460. Decapitation, 478. in locked twins, 377. in transverse presentations, 826. Decapsulation of kidneys, 559. Decidua, 122. bacteria in, 582. basal plate of, 133. basalis, 124, 129. capsularis, 124, 127. cells of, 124. cervical, 123, 837. changes in, cause of labor, 227. in abortion, 629. closing plate of, 133. compact layer of, 124. development of, outside of uterus, 127. diffuse formation of, 127. thickening of, 580. diseases of, 580. fatty degeneration of, 227. giant cells of, 129. glandular hyperplasia of, 581. layer of, 124. gonococci in, 582. hyperplasia of, 581. in bicornuate uterus, 571. in extra-uterine pregnancy, 643, 649. UND EX 953 Decidua in non-pregnant tube in intra- uterine pregnancy, 174. in ovaries, 127. in peritoneum, 127. inflammation of, 582. islands of, 117. menstrual, 85. origin of, 127. polyposa, 580, 629. pseudo-reflexa, 651. reflexa, 123, 127. reparation of, in puerperium, 340, 341. serotina, 123, 129. spongy layer of, 124. syphilis of, 619. tuberous subchorial haematoma of, 632. vera, 123, 124. Decidual cast in extra-uterine pregnancy, 653. cells, 124. endometritis. (See Endometritis.) islands, 117, 132. reaction in tubes, 643, 649. sarcoma, 593. Deciduoma malignum, 591. in extra-uterine pregnancy, 660. Deformed pelves. (See Contracted Pelves.) Delivery, normal, 322. post-mortem, 876. Dental caries during pregnancy, 502. Deportation of chorionic villi in eclampsia, 551. Dermatitis herpetiformis, 510. Dermoid cysts of ovary, 692. Descent of foetus, causes of, 253. in breech presentations, 294. in brow presentations, 291. in face presentations, 286. in vertex presentations, 266. Deutoplasm, 72. Development of allantois, 115. of amnion, 107. of chorion, 107. of clitoris, 29. of cord, 140. of fcetus, 146. of hymen, 31. of ovaries, 64. of ovum, 99. of pelvis, 17. of placenta, 129. of tubes, 53. of uterus, 53. of vagina, 37. of vulva, 31. Diabetes during pregnancy, 388, 503. during puerperium, 346. phloridzin, 162. Diagnosis, differential, of pregnancy. (See Pregnancy.) of life or death of foetus, 201. of pregnancy. (See Pregnancy.) of presentation of fretus, 219. of sex during pregnancy, 189. Diameters of head, 154. of pelvis, 4. Diastasis of recti muscles in pregnancy, 175, 579. in puerperium, 343. Dicephalus, 815. Dickinson's sign of pregnancy, 193. Diet during pregnancy, 208. during puerperium, 349. Differential diagnosis of pregnancy, 198. Dilatation of cervix, artificial, 392. in normal labor, 250. Dilatation, acute, of stomach, 876. Dipagus, 815. Diphtheria, during puerperium, 944. puerperal, 881, 885. Diphtheritic ulcer of vulva, 885. Diprosopus, 815. Directions for obstetrical nurse, 312. for patients during pregnancy, 210. Disappearance of pregnancy, 638. Discus proligerus, 70, 72. Diseases complicating pregnancy, 489. complicating puerperium, 924. Disinfection of hands, 316. of vulva, 318. Displacements. (See Uterus.) Distinction between first and subsequent pregnancies, 200. Diverticula from tubes, 59. uterine cavity, 572. Dolicho-cephalic head, cause of face presen- tation, 28'4. Dolicho-kyrto-platy-spondylus, 801. Doremus's ureometer, 534. Double Naegele pelvis, 777. uterus, 571. Douche, intra-uterine, 482. prophylactic, 481. vaginal, 481. Douglas's cul-de-sac, 35. perforation of, 865. Dropsy of amnion. (See Hydramnios.) of fcetus, 620, 819. of ovum, 638. Dry labor, 235, 676. Drying up breasts, 938. Duchenne's paralysis, 934. Ducts, Gartner's, 47. lactiferous, 359. Mullerian, 53. para-urethral, 30. Skene's, 30. Wolffian, 30, 62, 65. Ductus arteriosus, 157. venosus, 157. Diihrssen's cervical incisions, 394. Duncan's mechanism in extrusion of pla- centa, 302. Duration of labor, 240. pregnancy, 201. Duverney's glands, 30. Dwarf, 770. pelvis, 770. Dyspnoea during pregnancy, 499. Dystocia due to abnormalities of cervix, 686. due to abnormalities of the expulsive forces, 675. 954 INDEX Dystocia due to abnormalities of foetus, 813. to abnormalities of vagina, 684. to abnormalities of vulva, 684. to contracted pelves, 742. to contraction of Bandl's ring, 681. to levator ani muscle, 686. to old extra-uterine pregnancy, 663. to size of child, 813. to tumors of birth canal, 690. to uterine displacements, 687. following vaginofixation, 687. following ventrofixation, 688'. Dysuria from incarcerated pregnant uterus, 575. Echinococcus cysts complicating labor, 695. Eclampsia, accouchement force in, 391, 556. aetiology of, 548. albuminuria in, 542. bacterial origin of, 549. bleeding in, 558. blindness accompanying, 542. Caesarean section in, 452, 556. clinical history of, 538. diagnosis of, 554. frequency of, 537. haemoglobinuria in, 542. hydatidifoFm mole in, 542, 551. immunity to, 533. in extra-uterine pregnancy, 542, 661. in new-born child, 550. mammary origin of, 554. mania following, 541, 941. pathology of, 544. prognosis of, 554. treatment of, 555. urine in, 542. venesection in, 558. without convulsions, 539. Ectoderm, 103. Ectopic pregnancy. (See Extra-uterine Pregnancy.) Ectoplacenta, 108. Ectropion, congenital, 42. Egg nests, 65. Elastic ligatures in Caesarean section, 454. Elderly primiparae, 240. Electricity in extra-uterine pregnancy, 665. Elephantiasis congenita cystica, 819. Embolism, air, 875. during pregnancy, 499. pulmonary, during labor, 875. Embryo, 146. anatomy of, 146. development of, 99. nourishment of, 155. Embryonic area, 101. shield, 101. Embryotomy, 478. Emesis in pregnancy, 196, 519. Emphysema complicating pregnancy, 499. fcetal, causing dystocia, 820. of abdominal walls following rupture of uterus, 862. Encephalocele, 601. Enchondroma of pelvis, 811. Endarteritis, compensatory, during puer- perium, 341. Endocarditis during pregnancy, 499. gonorrhoeal, 492, 880. Endocervicitis, 568. Endometritis, acute decidual, 582. atrophic decidual, 582. cause of abortion, 629. cause of placenta praevia, 835. cause of premature separation of placenta, 829. cervical, 568. decidua cystica, 582. glandularis, 581. diphtheritic, 885. in pregnancy, 580. post-abortum, 928. post-partum, 928. puerperal, 885. putrid, 888. septic, 888. treatment of, 583. Endometrium, 43. in old age, 45. in young child, 45. lymphoid nodules of, 46. regeneration of, after curettage, 43. during puerperium, 340. reticulum of, 46. structure of, 43. Engagement, extra-median, 747. in breech presentations, 294. in brow presentations, 291. in face presentations, 286. in vertex presentations, 264. Enterocele, complicating labor, 695. complicating pregnancy, 578. Enteroptosis during pregnancy, 502. Entoderm, 103. Entrance of air into uterine sinuses, 875. Epilepsy during pregnancy, 507. during puerperium, 507. Epiphyses in syphilis, 617. separation of, during extraction, 437. Episiotomy, 326. Epoophoron, 47. Erb's paralysis, 934. Ergot in post-partum haemorrhage, 846. use of, in labor, 332, 679. Erysipelas in pregnancy, 491. relation of, to puerperal infection, 894. transmission to foetus, 492. Esbach's albuminometer, 533. Escutcheon, 26. Estimation of date of confinement, 203. Ether, 329. Eustachian valve, 157. Evisceration, 478. Evolution, spontaneous, 824. Examination, combined, 223. final, 351. preliminary, during pregnancy, 210, 311. vaginal, during labor, 319. pregnancy, 212. Exanthemata in pregnancy, 489. Exercise during pregnancy, 207. INDEX 955 Exostosis, producing pelvic deformities, 810. Expression of placenta, 306. Expression, Ritgen's method of, 325. Expulsion in breech presentations, 294. in face presentations, 286. in vertex presentations, 274. Extension in face presentations, 286. in vertex presentations, 273. External generative organs, 26. External os, 39. External rotation in breech presentations, 295. in face presentations, 287. in vertex presentations, 238, 274. External version, 297, 440. Extraction, 430. in breech presentations, 430. indications for, 430. in frank breech presentations, 438. Mauriceau's manoeuvre for, 434. Prag manoeuvre for, 436. Extra-uterine pregnancy, 640. abdominal, 659. abortion of, 655. aetiology of, 640. anatomy of, 647. associated with intra-uterine, 662. attachment of ovum in, 648. broad ligament, 658. cause of dystocia, 663. chorio-epithelioma in, 660. classification of, 640. decidual reaction in, 643, 649. diagnosis of, 6C3. eclampsia in, 542, 661. effects upon subsequent childbearing, 663. fate of fcetus in, 660. formation of decidua in, 649. of placenta in, 651. frequency of, 640. haematoma mole in, 660. haematocele in, 661. hydatidiform mole in, 660. hydramnios in, 660. interstitial, 647. lithopaedion formation in, 660. migration of ovum in, 643. multiple, 662. mummification in, 660. ovarian, 645. placenta in, 651. repeated, 603. rupture of, 655. symptoms of, 661. terminations of, 653. treatment of, 665. tubal, 647. uterine decidua in, 653. Eyes of child, 357. Face presentations, 214, 282. abnormal mechanism in, 287. causation of, 283. complicated by contracted pelves, 760. conversion of, into vertex, 289. craniotomy in, 289. Face presentations, diagnosis of, 282. forceps in, 289, 426. frequency of, 282. mechanism of, 285. mistaken for breech, 287. perforation in, 289. prognosis of, 288. prolapse of cord in, 867. pubiotomy in, 290, 468. symphyseotomy in, 289. treatment of, 288. version in, 290. Facial paralysis following forceps, 428. Faeces of infant, &58. Fallopian tubes, 55. accessory, 59. lumina of, 59. ostium of, 58, 642. anatomy of, 55. changes in, during pregnancy, 173. ciliary current in, 58'. decidua in, 127. diverticula of, 59, 641. glands of, 58. in pregnancy, 173. False labor, 662. False promontory, 729, 783. Fascia, pelvic, 257. perineal, 257. Fastening villi, 132. Fat in abdominal walls simulating preg- nancy, 200. Fatty degeneration of placenta, 606. Fecundation, 89, 96. Feeding, artificial, 365. Female pronucleus, 96. Fertilization of ovum, 96. Fever in eclampsia, 555. in labor, 680, 749, 904. in puerperium, 349. Fibro-myomata of uterus, complicating la- bor, 690. Fillet, 440. Fimbria ovarica, 56, 88. Fimbriated extremity of tube, 56. Fissure of nipple, 364, 936. Fistulae, production of, 749. Flat, non-rhachitic pelvis, 721. rhachitic pelvis, 727. Fleshy mole, 632. Flexion in breech presentations, 295. in brow presentations, 291. in face presentations, 287. in vertex presentations, 267. Floating kidney during pregnancy, 505. spleen, 506. Foetal circulation, 156. diseases, 614. dropsy, 819. dystocia, 813. heart-beat, 189. leukaemia, 509. membranes, 94, 139. monstrosities, 815. peritonitis, 819. syphilis, 614. 956 Foetus, abnormalities of, obstructing labor, 816. active movements of, 190, 191. aneurysm of, 820. ascites of, 819. at full term, 136. attitude of, 213. bladder, distention of, 820. calcification of, 633, 660. cardiac lesions in, 189. circulation of, 156. compressus, 373. congenital hydrocephalus of, 817. cranium of, 153. cystic kidneys of, 819. death of, 201. deformities of, 816. due to amniotic adhesions, 601. due to oligo-hydramnios, 601. development of, 146. diameters of head of, 154. diet, effect upon size of, 208. digestive functions of, 163. diseases of, 614. dissolution of, 633. distention of bladder of, 820. emphysema of, 820. enlargement of abdomen of, 819. estimation of age of, 149. excessive development of, 813. excessively large, 151, 813. extraction of, 430. general dropsy of, 620, 819. habitual death of, 388. habitus of, 213. head of, 153. headless, 816. heart-beat of, 189. heart sounds of, in asphyxia, 870. in pregnancy, 189. hydrocephalus of, 817. infection of, with Bacillus aerogenes cap- sulatus, 820. in fcetu, 820. lanugo of, 149. length of, 149. lesions of, in eclampsia, 550. maceration of, 615, 633. malformations of, 815. meconium of, 358. metabolism of, 155. movements of, in pregnancy, 190. mummification of, 373, 633. negro, 150. nutrition of, 155. over-development of, 151, 813. papyraceus, 373, 633. passive movements of, 191. peritonitis of, 819. physiology of, 155. position of, 215. presentation of, 213. pressure marks on head of, 751. respiration of, 163. sanguinolentus, 632. signs of maturity of, 150. Foetus, size of, in contracted pelves, 743. in various months, 149. syphilis of, 614. tumors of body of, 821. tumor of testicle of, 820. of liver of, 820. urine of, 161, 358. vernix caseosa of, 150. warmth of, 163. weight of, 149. Follicle, Graafian. (See Graafian Follicle.) Follicular atresia, 77, 174. epithelium, 67. Fontanelles, 154. Footling presentation, 215. Foramen ovale, 157. Forceps, 400. application of, 408. as dilator of cervix, 406. axis traction, 423. cephalic application of, 409. Chamberlen's, 403. choice of, 404. conditions necessary for application of, 406. contrasted with version, 761. delivery in oblique occipito-posterior posi- tion, 417. with head at vulva, 411. with high, 422. with mid, 414. with occiput in hollow of sacrum, 414. description of, 400. facial paralysis following, 428. functions of, 405. high, 408. history of, 401. in breech presentations, 427. in brow presentations, 292. in collision of twins, 376. in contracted pelves, 760, 761. in eclampsia, 556. in face presentations, 289, 426. in frank breech presentations, 427. in heart disease, 405, 498. in occipito-posterior presentations, 417. in prolapse of cord, 868. in protracted second stage of labor, 679. in rupture of uterus, 863. indications for, 405. Levret's, 404. long, 404. low, 408. mid, 408, 414. ovum, 635. Pajot's manoeuvre, 425. Palfyn's, 403. pelvic application of, 409. perineal tears due to, 428. preparations for operation, 407 prognosis of, 427. Saxtorph's manoeuvre, 424. Scanzoni's manoeuvre, 420. short, 404. Simpson's, 400. Smellie's, 404. INI INDEX 957 Forceps, Tarnier's, 425. to aftercoming head, 427. upon floating head, 408. Forces concerned in labor, 243, 253. Formalin injections in puerperal infection, 916. Fornix, vaginal, 35. rupture of, during labor, 854. Fossa navicularis, 30. ovarica, 60. Fourchette, 28'. Fractures of pelvis, 811. of skull. (See Skull.) Freezing point of blood, 159. Frenulum clitoridis, 28. Frontal suture, 153. Fundal incision in Caesarean section, 453. Fundus uteri, 38. Funic souffle, 190. Funis. (See Umbilical Cord.) Funnel-shaped pelvis, 721, 782. Galactocele, 941. Galactogogues, 361. Galactorrhoea, 937. Gall stones in pregnancy, 501. Ganglion, cervical, 53. Gangrene of lower extremities during puer- perium, 926. of puerperal uterus, 890. Gas bacillus. (See Bacillus Aerogenes Capsulatus.) Gasserian fontanelle, 154. General metabolism in pregnancy, 181. Generally contracted, flat, rhachitic pelvis, 731. contracted pelvis, 767. enlarged pelvis, 767. equally contracted rhachitic pelvis, 732. Germ layers, 101. inversion of, 107. Germinal epithelium, 64. spot, 72, 73. vesicle, 72, 73. Giant cells of decidua, 129. of placenta in lungs, 548. placental, 135. Gingivitis in pregnancy, 502. Giraldes, organ of, 47. Glands, Bartholin's, 30. cervical, 41. decidual, 125. Duverney's, 30. interstitial, of ovary, 62. mammary, 176, 359, 935. Montgomery's, 176. salivary, changes of, in pregnancy, 502. thyroid, cause of face presentation, 284. changes of, in eclampsia, 553. in pregnancy, 179. foetal, cause of dystocia, 819. tubal, 58. uterine, 45. vaginal, 36. vestibular, 30. vulval, 30. Globulin, increase of, in eclampsia, 542. Gloves, rubber, use of, 317. Glycerine, use of, in inducing labor, 390. Glycosuria during pregnancy, 503. during puerperium, 346. Goitre in pregnancy, 508. Gonococcus in Bartholin's glands, 567. in endometritis decidua, 582. in mammary abscess, 940. in ophthalmia neonatorum, 357. in puerperal infection, 880. Gonorrhoea in pregnancy, 492. in puerperium, 880. Gonorrhoea! endometritis, 913. ophthalmia, 357. Goodell's cervical dilator, 383, 38'4. Graafian follicle, 68, 70. atresia of, 174. degeneration of, 77. rupture of, 73. Gravitation theory as to production of pres- entation, 218. Greater fontanelle, 154. Guerin's line, 617. Gumma of placenta, 620. Gut, primitive, 104. Gynecomastia. 935. Habitual death of foetus, 388. Haemato-kolpos, 42. Haematocele, diffuse, 655, 661. pelvic, 661. solitary, 661. treatment of, 666. Haematoma mole, 632, 660. of abdominal walls, 511. of broad ligament, 658, 929. of decidua, 632. of liver, in eclampsia, 547. of placenta, 607. of sterno-cleido-mastoid muscles, 437. of umbilical cord, 614. of vagina, 928. of vulva, 929. puerperal, 928. subperitoneal, 861, 873, 929. Haematosalpinx, 655. Haematuria during pregnancy, 504. Hemoglobinuria in eclampsia, 542. Haemophilia during pregnancy, 509. Haemorrhage, accidental, 831. adrenalin in, 846. ante-partum, 829. concealed, 831. curettage in, 636, 928, 930. due to atony of uterus, 842. to haemophilia, 509. to inversion of uterus, 847. to paralysis of the placental site, 8'43. to placenta praevia, 833. to premature separation of normally implanted placenta, 829. to retention of placenta, 842. to rupture of umbilical cord, 842. during normal labor, 239. puerperium, 927. 958 INDEX Haemorrhage, ergot in, 846. from velamentous insertion of cord, 612. in abortion, 633. in cholera, 491. in influenza, 491. in multiple pregnancy, 377. intraperitoneal, 655, 661, 861. intra-uterine douche in, 482, 846. pack in, 486, 846. manual removal of placenta for, 486, 841, 848. pituitrin in, 846. post-partum, 842. suprarenin in, 846. unavoidable, 831. use of salt solution in, 846. Haemorrhagic hepatitis, 546. Hair of pubis, 26. Halisteresis, 736. Hand disinfection, 316. Harris's method of dilating the cervix, 392. Head, faetal, changes in shape of, in brow presentations, 291. in face presentations, 287. in vertex presentations, 279. circumferences of, 154. diameters of, 154. estimation of size of, 756. fontanelles of, 154. of new-born child, 153. scalp tumor on. (See Caput Succeda- neum.) sutures of, 153. Headache in eclampsia, 532. in pregnancy, 506. Head folds, 102. lever in face presentations, 286. in vertex presentations, 267. Heart, diseases of, in pregnancy, 387, 496. foetal, 189. means of diagnosing sex, 189. palpation of, 189. hypertrophy of, in pregnancy, 177. Hebosteotomy, 464. Hebotomy, 464. Hegar's sign of pregnancy, 193. Heine and Hofbauer's ovum, 113. Hemianopsia following eclampsia, 542. Hemicephalus, 816. Hepatization of placenta, 606. Hepato-toxaemia, 518, 550. Heredity, explanation of, 98. Hermann's foiceps, 425. Hermaphroditism, 30. Hernia, congenital, of foetus, 612. inguinal, 578. of pregnant uterus, 578. umbilical, 579. vaginal, 695. Herpes gestationes, 510. Hicks's sign of pregnancy, 195. High forceps, dangers of, 428, 761. Hilum of ovary, 60. Hirst's pelvimeter, 710. Hirudin in eclampsia, 559. Hodge's inclined plane of pelvis, 3. Hodge's parallel planes, 8. Hook, blunt, 478. Hour-glass contraction of uterus, 682. Hubert's forceps, 425. Hyalin in ovary, 75. Hydatidiform mole, 388', 58G. benign, 588. destructive, 590. in eclampsia, 542, 551. in extra-uterine pregnancy, 660. malignant, 588. ovaries in, 588. pathology of, 587. relation of, to deciduoma malignum, 591, treatment of, 591. Hydraemia of pregnancy, 177. Hydramnios, 388, 596. acute, 596. eclampsia in, 538. in double-ovum twins, 372, 598. in extra-uterine pregnancy, 660. Hydrocephalus, 817. craniotomy in, 473. version in, 444. Hydrorrhoea gravidarum, 581. Hydrosalpinx, 58. Hygiene of pregnancy. (See Pregnancy, Management of.) Hymen, 31. atsence of injury at childbearing, 33. annularis, 31. atresia of, 42, 684. carunculae myrtiformes, 33. consistency of, 31. cribriform, 31. denticulate, 31. development of, 31. fimbriated, 31. imperforate, 31, 42. cause of difficult labor, 684. injuries at coitus, 32. injuries following childbearing, 33. operations upon, 32. semilunaris, 31. septate, 31. structure of, 31. Hyperemesis gravidarum, 519. Hyperplasia of chorionic villi, 596, 609. Hypertrophic elongation of cervix during pregnancy, 578\ Hypertrophy of uterus during pregnancy, 168. Hypnotism in lanor, 332. Hypophysis cerebri, 181. Hypoplastic dwarf pelvis, 772. Hysterectomy during pregnancy, 692. for chorio-epithelioma, 596. for myomata, 692. for puerperal infection, 914. supravaginal, after Caesarean section, 456. total, after Caesarean section, 456. Hysteria, cause of nausea of pregnancy, 521. in pregnancy, 508. Hysterotomy, vaginal, 394. Ice, use of, in haemorrhage, 847. INDEX 959 Icterus of child, 358. during pregnancy, 501, 528. gravis, 528. Ileus due to retroflexed pregnant uterus, 575. Ilio-pectineal line. (See Linea Terminalis.) Ilium, 3. Imaginary pregnancy, 200. Impetigo herpetiformis, 510. Implantation of ovum, 105, 129, 647. Impregnation, 90, 94. Incarceration of prolapsed pregnant uterus, 577. of retroflexed pregnant uterus, 575. Incisions of cervix, deep, 394. Inclination of pelvis, 8. Incomplete abortion, 634. Indigestion during pregnancy, 501. Induction of abortion. (See Abortion, In- duction of.) of premature labor. (See Premature La- bor, Induction of.) Inertia uteri, 676. Inevitable abortion, 634. Infant. (See New-born Child.) Infantile paralysis, effect upon pelvis, 808. pelvis, 17, 770. Infarcts of placenta, 606. Infectious diseases complicating pregnancy, 489. Inferior strait, 6, 711. contractions of, 711. Infibulation, 28. Influenza during pregnancy, 491. Infundibulo-pelvic ligament, 61. Infundibulum, 55. Injuries to birth canal, 853. Inlet, pelvic, 5. Innervation of uterus, 53. Innominate bone, 21. Insanity in pregnancy, 941. lactational, 942. puerperal, 942. Insertio velamentosa, 611. Insufflation of lungs in asphyxia neonato- rum, 871. Interglandular tissue of uterus, 45. Intermittent contractions of uterus, 195. Internal cell mass, 100. Internal os, 39. Internal rotation, 268. causation of, 269. in breech presentations, 295. in brow presentations, 291. in face presentations, 287. in vertex presentations, 268, 275. Internal secretion of ovaries, 63. Internal version, 441, 446. Interstitial gland of ovary, 62. Interstitial pregnancy, 647. Intervillous blood spaces, 131, 132. Intestinal obstruction, 513. Intra-partum eclampsia, 540. infection, 680, 749, 904. Intra-tubal rupture, 653. Intra-uterine douche, 482, 911. 63 Intra-uterine douche, indications for, 482. in post-partum haemorrhage, 482, 846. in puerperal infection, 482, 911. pack, 486. pressure, 232. Inversion of germ layers, 101, 107. of uterus, 847. Involution of uterus, 339. Ischio-cavernosus, 258. Ischiopagus, 815. Ischio-pubiotomy, 776. Ischio-rectal fossa, 257. Ischium, 3. spines of, 3. Isthmic pregnancy, 647. Isthmus of tube, 55. Isthmus uteri, 40. Jaundice of child, 358. of mother, 501, 528. Joints, mobility of, during pregnancy, 11. pelvic, 10. pubic, 10. relaxation of, during pregnancy, 511. rupture of, during labor, 749. sacro-iliac, 11. Justo-major pelvis, 767. Justo-minor pelvis, 767. Kidney, changes in, during pregnancy, 179. in eclampsia, 545. cystic, of foetus, 819. dislocation of, during pregnancy, 506. dislocated, complicating labor, 695. floating, during pregnancy, 505. of pregnancy, 180, 531. removal of, 506. tumor of, complicating labor, 506. Klien's pelvimeter, 714, 786. Knee presentation, 215, 292. Knots of umbilical cord, 613. Krause's method of inducing labor, 389. Kypho-rhachitic pelvis, 794. Kypho-scolio-rhachitic pelvis, 797. Kypho-scoliotic pelvis, 797. Kyphosis, 788. Kyphotic pelvis, 788. Labium majus, 27. commissures of, 27. development of, 28'. hernia into, 28. oedema of, 500. Labium minus, 28. fossa navicularis, 30. fourchette, 28. frenulum clitoridis, 28. laborium, 28. infibulation, 28. nymphae, 28. praeputium clitoris, 28. Labor, abdominal contractions during, 254. action of expellent forces in, 253. acute dilatation of stomach in, 876. albuminuria in, 346. anaesthesia during, 329. DEX 960 in: Labor, arterial pressure in, 233. asepsis in, 222, 316. bed, preparation of, for, 320. caput succedaneum, 280. cause of onset of, 226. changes in arterial tension during, 177, 233. *. in perineum during, 260. in pulse during, 233. in rectum during, 260. in respiration during, 230, 233. in shape of head in, 279. in temperature during, 233. in uterus during first stage of, 248. in uterus during second stage of, 251. in vagina and pelvic floor during, 255. chill after, 343. clinical course of, 233. cocaine anaesthesia during, 330. collapse after, 8'74. complicated by bony tumors of pelvis, 811. by compound presentation of foetus, 826. by concealed haemorrhage, 831. by coxalgic pelvis, 806. by deformities of fcetus, 816. by eclampsia, 555. by enlargement of abdomen of foetus, 819. by excessive size of child, 813. by foetal monstrosities, 815. by flat pelvis, 721, 747. by funnel pelvis, 782. by generally contracted pelvis, 767. by generally contracted, flat, rhachitic pelves, 731. by generally enlarged pelvis, 767. by hydrocephalus, 8J.7. by injuries to cervix, 855. by injuries to vagina, 853. by intra-uterine asphyxia, 869. by inversion of uterus, 847. by kyphotic pelvis, 788. by myoma of uterus, 690. by Naegele pelvis, 772. by osteomalacic pelves, 736. by ovarian tumor, 692. by paraplegia, 232. by pelvis spinosa, 810. by placenta praevia, 838. by post-partum haemorrhage, 842. by premature separation of placenta, 829. by prolapse of placenta, 832. by prolapse of umbilical cord, 867. by rhachitic pelvis, 724. by Robert pelvis, 777. by rupture of the uterus, 858. by split pelvis, 778. by spondylolisthetic pelvis, 798. by transverse presentation of foetus, 821. by tumors of fcetus, 821. by tumors of pelvis, 811. conduct of, 822. first stage of, 315. conduct of second stage of, 320. Labor, third stage of, 333. contraction of uterine ligaments during, 48, 221. course of, in contracted pelves, 748. death during, 873. delivery of shoulders, 327. dilatation of cervix, 250. dry, 235, 676. duration of, 240. entrance of air into uterine sinuses dur- ing, 875. episiotomy in, 326. ergot during, 332, 679. examination in, 321. false, 662. first stage of, 234. force exerted during, 231. forces concerned in, 243, 253. formation of contraction ring during, 246, 253, 826, 858. of lower uterine segment, 245. haemorrhage during, 239. hand disinfection in, 316. hypnotism in, 332. in elderly primiparae, 240. in young primiparae, 240. intra-uterine pressure during, 232. laceration of perineum during, 322, 428. mechanism of, in breech presentations, 294. in brow presentations, 291. in face presentations, 285. in vertex presentations, 262. missed, 68'2. molding of head in, 279. metabolism in, 229. nervous influences during, 230. normal, 234, 311. obstructed. (See Dystocia.) painful, 675. painless, 231. pains of, 230. palpation in, 262, 274. perineal tears in, 324. phenomena, clinical, of, 233. physical changes during uterine contrac- tions, 232. physiology of, 226. pituitrin in, 679. precipitate, 680. prediction of date of, 203. premature, 627. preparations for, on part of patient and nurse, 311. on part of physician, 314. profound mental depression during, 874. prolonged, 675. protection of the perineum in, 324. pulmonary embolism during, 875. repair of perineal tears, 333. respiratory exchange, 230. rubber gloves, use of, during, 317. rupture of membranes in, 235, 321. second stage of, 236. shock during, 874. stages of, 234. INDEX 961 Labor, syncope during, 874. tardy, 675. temperature in, 680, 749, 904. third stage of, 239, 300. time of, 241. tying of cord in, 327. vaginal examination during,_ 319. Laborde's method of resuscitation, 871. Lactation, 359. atrophy of uterus, 930. Lactational insanity, 942. Lactiferous ducts, 359. Lactosuria during pregnancy, 503. during puerperium, 346. Lambdoid suture, 153. Langhans's layer of chorion, 119, 134. Lanugo, 149. Laparo-elytrotomy, 456. Laparotomy, for colpaporrhexis, 854. for deep cervical tears, 857. for puerperal infection,. 914. for rupture of uterus, 863. in extra-uterine pregnancy, 665. in treatment of retroflexed pregnant uterus, 576. Lateral curvature of spine, 795. displacement of pregnant uterus, 576. flexion in breech presentations, 295. placenta praevia, 834. plane presentations. (See Transverse Presentations.) Laxatives in puerperium, 350. Lead poisoning during pregnancy, 509. Leg-holder, 407. Leopold's ovum, 114. Lesser fontanelle, 154. Leukocytosis in puerperium, 178, 344, 916. Leukaemia during pregnancy, 509. Levator ani muscle, 255. dystocia due to, 686. injuries to, during labor, 854. Levret's forceps, 404. Life, 197. perception of, 197. Ligaments, broad, 47. cardinal, of Kocks, 48 ilio-sacral, 21. infundibulo-pelvic, 47, 60. of uterus, 47. ovarian, 60. pubic, 10. recto-uterine, 48. round, 48. sacro-sciatic, 6. suspensory, of ovary, 47, 61. utero-sacral, 48'. Ligamentum arcuatum pubis, 11. latum, 47. ovarii, 61. teres, 48. transversale colli, 48. Linea terminalis, 3. Liquor amnii. 122. folliculi, 70. Lithopaedion, 633, 660. Little's lochial tube, 907. Liver, acute yellow atrophy of, during preg- nancy, 528. changes in, in eclampsia, 546. in pernicious vomiting, 521. cystic, in foetus, 820. syphilitic cirrhosis of, 616. Lochia, 345. bacteria in, 345. bacteriological examination of, 883, 906. in puerperal infection, 906. retention of, 902. Lochia-metra, 931. Locked twins, 377. Longings in pregnancy, 197. Loops in umbilical cord, 613. Lott's dilator, 394. Lower uterine segment, 244. during puerperium, 342. history of, 244. nature of, 245, 246. palpation of, 221. Lumbar anaesthesia, 330. puncture in eclampsia, 559. Lungs, changes in, during pregnancy, 178. lesions of, in eclampsia, 548. Lutein cells, 71, 74, 76. Luxation of femur, effect upon pelvis, 808. Lymphatics of ovaries, 62. of tube, 58. of uterus, 46, 52. of vagina, 36. Lymphoid nodules in endometrium, 46. Maceration of foetus, 615, 633. Macula embryonalis, 100. Malacosteon disease, 736. Malaria during pregnancy, 494. in puerperium, 906, 943. transmission of, to child, 494. Male pronucleus, 98. Mammae. (See Breasts.) Management of pregnancy, 207. Mania. (See Insanity.) Manual removal of placenta, 309, 486, 841, 846. Marginal insertion of cord, 611. placenta praevia, 834. Margo placentae, 606. Markstrange, 62. Martin's pelvimeter, 703. Masculine pelvis, 770. Mastitis, 939. Maturation of ovum, 94. Maturity of foetus, signs of, 150. Mauriceau's manoeuvre, 434. Measles during pregnancy, 490. during puerperium, 944. urinary, 30. Meatus, urinary, 30. Mechanism of labor, complicated by foetal monstrosities, 815. in breech presentations, 294. in brow presentations, 291. in contracted pelves, 744. in face presentations, 285. in occipito-posterior presentations, 275. 962 INDEX Mechanism of labor, in transverse presenta- tions, 823. in vertex presentations, 262. Meckel's diverticulum, 142. Meconium, 358. Medulla of ovary, 62. Medullary cords, 62. groove, 101. ridges, 102. Membrana granulosa, 70, 72. Membranes, foetal, 92, 139. method of rupturing, 321. rupture of, 252. premature, 235. in contracted pelves, 748. Membranous placenta, 604. Memory, loss of, in eclampsia, 541. Menopause, 82. Menses, cessation of, in pregnancy, 196. persistence of, in pregnancy, 196. Menstrual cycle, 84. decidua, 85. nerve, 87. wave, 87. Menstruation, 82. after ovariotomy, 87. after puerperium, 351. amount of blood lost in, 83. anatomical changes in, 83. causation of, 85. cessation of, in pregnancy, 196. in infants, 82. participation in, by tube, 87. persistent, 82. precocious, 82. relation of, to ovulation, 84. Mental and emotional changes during preg- nancy, 197. depression during labor, 874. derangement following eclampsia, 541. in pregnancy, 532. Mento-iliac presentation. (See Face Pres- entations.) Mercurial poisoning from intra-uterine douche, 483, 912. Mesoblastic somites, 103. Mesoderm, 102. Mesodermic area, 101. Mesosalpinx, 47, 60. Mesovarium, 60. Metabolism at time of labor, 229. general, in pregnancy, 181. in puerperium, 346. Metritis dessicans, 890. in pregnancy, 583. Metritis, puerperal, 890. Meyer's conjugate, 9. Michaelis's rhomboid, 705. Migration of ovum, 87, 643. Milk, anatomy of, 360. corpuscles of, 360. cow's, 365. drying up, 365. fever, 343, 905. human, 360. leg. (See Phlegmasia Alba Dolens.) Milk, modified, 366. Miscarriage, 627. Missed abortion, 638. labor, 682. Modified milk, 366. Mole, 631. blood, 632. carneous, 632. destructive, 590. fleshy, 632. haematoma, 632, 660. hydatidiform, 586. tubal, 655. uterine, 633. Molecular concentration of blood, 159. Mollifies ossium, 736. Monsters, 815. Mons veneris, 26. Montgomery's glands, 176. Morales's forceps,-425. Morning sickness, 196, 519. Morula, 99. Movements of foetus during pregnancy, 190. Mulberry mass, 99. Mullerian ducts, 53 Muller's method of impression of head, 756. Muller's ring, 243. Multiple placenta in single pregnancy, 603. Multiple pregnancy, 368. acardia in, 372, 816. aetiology of, 368. course of labor in, 375. diagnosis of, 374. eclampsia in, 538. foetus papyraceus in, 373. frequency of, 368'. haemorrhage in, 377. hydramnios in, 372. in tubes, 662. mummification of foetus" in, 373. relation of placenta and membranes in, 370. size of children in, 372. treatment of, 375. Muscle fibers of pregnant uterus, 170. rhomboids of uterus, 171. Muscular contractures in osteomalacia, 739. palsies in osteomalacia, 739. Musculature of non-pregnant uterus, 46. of pregnant uterus, 170. of tube, 56. Myocarditis during pregnancy, 498. Myoma of uterus, Caesarean section in, 452, 690. complicating labor, 690. in pregnancy, 199, 388. Myomectomy during pregnancy, 692. Myxoma chorii, 586. fibrosum of placenta, 609. Nabothian follicles, 42. Naegele's obliquity, 266, 745. Naegele pelvis, 772. Nausea and vomiting in pregnancy, 196, 519, Negro foetus, characteristics of, 150. Nephrectomy and pregnancy, 506, 512. INDEX 9G3 Nephritis, chronic, during pregnancy, 179 503, 530. in acute yellow atrophy, 529. in eclampsia, 545. in toxaemic vomiting, 523. Nerves of clitoris, 29. of ovaries, 62. of uterus, 53. Nervous system in pregnancy, 181. Neuralgia during pregnancy, 507. Neurenteric canal, 116. Neuritis during pregnancy, 387, 507, 560. puerperal, 934. Neurotic vomiting of pregnancy, 520. New-born child, artificial feeding of, 365. asphyxia of, 871. care of, 354. eyes of, 357. circulatory changes in, 354. ductus arteriosus of, 354. feeding cf, 362. foramen ovale of, 157, 354. head of, 153. icterus of, 358. jaundice of, 358. length of, 150. loss of weight of, 359. nursing of, 362. ophthalmia of, 357. sex of, 163. stools of, 358. umbilical cord of, 355. urine of, 358. weight of, 150. Nipples, abnormalities of, 936. care of, during pregnancy, 209. during puerperium, 350. cracked, 364, 936. depressed, 936. fissures of, 364, 936. Nipple shield, 209, 364. Nitrogenous partition of urine, 533, 543, 553. Nomenclature of presentation, 215. Notochord, 104. Nuchal presentation, 828. Nuck, canal of, 28. Nuclein, use of, in puerperal infection, 916. Nucleus, segmentation, 98. Nursing, 362. Nymphae, 28'. Obliquely contracted pelvis, 772. Obstetrical outfit, 314. paralysis. (See Paralysis, Obstetrical.) Obstetrical surgery. (See Operations, Ob- stetrical.) Obstructed labor. (See Dystocia.) Occipito-anterior presentations. (See Ver- tex Presentation.) Occipito-posterior presentations. (See Ver- tex Presentation.) CEdema of cervix, acute, 578. In pregnancy, 175, 500. Oligo-hydramnios, 600. Omphalo-mesenteric vessels, 132. Oocyte, 66, 69. Oogenesis, 66. Oogonia, 66. Oophoritis, puerperal, 890. Operations, obstetrical, 379. accouchement force, 390. Caesarean section, 449. cervical incisions, 394. cleidotomy, 480, 814. craniotomy, 472. curettage, 483. decapitation, 478. douche, 481. embryotomy, 478. evisceration, 478. extraction in breech presentations, 430 forceps, 400. hebotomy, 464. induction of abortion, 381. premature labor, 385. Intra-uterine pack, 486. Iaparo-elytrotomy, 456. manual removal of placenta, 486. preparations for, 379. pubiotomy, 464. surgical, in pregnancy, 512. symphyseotomy, 460. tampon, 484. vaginal Caesarean section, 394. Ophthalmia, 357. neonatorum, 357. Organ of Giraldes, 47. of Rosenmiiller, 47. Os externum, 39. innominatum, 2. internum, 39. Os tincae, 40. Ossification of pelvis, 17. Osteo-chondritis syphilitica, 617. Osteomalacia, clinical history of, 736. pathology of, 737. pelvis in, 739. Osteomalacic pelvis, 736. Osteophyte, 180. Outlet of pelvis, 6. contractions of, 711, Ova, early human, 110, 112. Ovarian abscess, 913. artery, 49. epithelium, 64. fimbria, 56, 88. pregnancy, 645. tumors, Caesarean section in, 452. complicating pregnancy, 196, 383, 388. 692. Ovaries, 60. accessory, 63. anatomy of, 60. changes in, in pregnancy, 173. corpus luteum of, 73. cortex of, 61. cysts of, 588, 594. decidual cells in, 127. development of, 64. epithelium of, 61. erectility of, 61. 964 INDEX Ovaries, ganglion of, 62. Graafian follicle, 68, 70. hilum of, 60. in osteomalacia, 737. internal secretion of, 63. interstitial glands of, 62. in young child, 69. ligament of, 60. medullary cords of, 62. microscopic structure of, 68. nerves of, 62. peritoneum, relations of, to, 61. position of, in pregnancy, 173. relation of, to Wolffian body, 64. removal of, pregnancy after, 87. rete of, 62. transplantation of, 63. Ovariotomy during pregnancy, 694. Ovate pelvis, 772. Over-rotation in breech presentation, 295. Ovula Nabothi, 42. Ovulation, 84. during pregnancy, 173. relation of to menstruation, 84. Ovum, 72. abdominal pedicle, 115. allantoic vesicle, 116. allantois of, 109, 115. amnion of, 105, 107. area opaca of, 101. area pellucida of, 101. Bauchstiel of, 115. blastodermic vesicle, 99. Bryce and Teacher's, 100, 110. centrosome of, 99. chorion of, 105, 107. chromosomes of, 94. cleavage of, 99. coelome of, 103. corona radiata of, 72, 73. deutoplasm of, 73. development of, 99. discharge of, from ovary, 73, 84. diseases and abnormalities of, 383, 586. dropsical, 638. ectoderm of, 104. ectoplacenta of, 108. embryonic area of, 101. embryonic shield of, 101. entoderm of, 104. female pronucleus of, 96. fertilization of, 96. germinal spot, 72, 73. germinal vesicle, 72, 73. head folds of, 102. Heine and Hofbauer's, 113. Hyrtl's, 100. • implantation of, 105, 129. impregnation of, 90. internal cell mass of, 100. in transit through tube, 100- Inversion of germ layers of, 107. Leopold's, 114. macula embryonalis of, 100. male pronucleus of, 98'. maturation of, 73, 94. Ovum, mature, 73. medullary groove of, 101. medullary ridges of, 102. mesoblastic somites of, 103. mesodermic area of, 101. mesoderm of, 102. migration of, 87, 643. external, 88. internal, 89. morula of, 99. neurenteric canal of, 116. notochord, 104. parietal zone of, 103. parthenogenesis of, 98. perivitelline space of, 73. Peters's, 112. physiology of, 84, 94. place of meeting with spermatozoa, 89. polar bodies of, 96. premature expulsion of. (See Abortion.) primary segments of, 103. primitive folds of, 101. primitive streak of, 101. primordial, 64. pronucleus, 96. protovertebrae of, 103. segmental layer of, 103. segmentation nucleus of, 98. segmentation of, 98, 99. sex of, 164, size of, 72. somatopleure of, 103. Spee's, 114. splanchnopleure of, 103. trophoblast of, 112. tuberculosum, 632. umbilical vesicle of, 115, 141. vitelline membrane of, 72. with double nuclei, 69, 369. yolk of, 73. yolk-sac of, 115, 141. zona pellucida of, 70, 73. Oxytocics; indications for use of, 679. Pack. (See Tampon.) Painless labor, 231. Pajot's manoeuvre, 425. Palfyn's forceps, 403. Palpation, 219. in anterior occipito presentations, 262. in breech presentations, 292. in brow presentations, 290. In face presentations, 282. in posterior occipito presentations, 274. of cephalic prominence, 221. of contraction ring, 221. of foetal heart-beat, 189. of lower uterine segment, 221. of outlines of fcetus, 191. of round ligaments. 221. of shoulder, 221. through perineum, 322. Palper mensurateur, 757. Pampiniform plexus, 52. Paradoxical incontinence, 575. Paralysis, Duchenne's, 934. INDEX 965 Paralysis during pregnancy, 506. during puerperium, 933. facial, following forceps, 428. obstetrical, 437, 933. of placental site, 843. Parametritis, 889. Parametrium, 48. Paraplegia complicating labor, 232. during pregnancy, 506. Parathyroids in eclampsia, 553, 559. Para-urethral ducts, 30. Parietal layer, 103. Parietal presentation, 744. Paroophoron, 47. Parovarium, 47. Parthenogenesis, 98. Partial placenta praevia, 834. Parturition. (See Labor.) Passive movements of foetus, 191. Pathology of labor, 675. of pregnancy, 489. of puerperium, 878. Pelvic abscess, 890, 913. axis, 10. cavity, 3. cellulitis following puerperal infection, 889. fascia, 257. floor, 255. anatomy of, 255. changes in, during labor, 255. haematocele, 661. joints, relaxation of, in pregnancy, 174, 511. peritonitis followiBg puerperal infection, 903. Pelvigraph, 710. Pelvimetry, by use of X-ray, 714. external, 703. in pregnancy, 211, 702. internal, 708. of outlet, 711. Pelvis, 1. acanthopelys, 810. anatomical conjugate, 6. anatomy of, 1. articulations of, 10. assimilation, 780. axis of, 10. bilateral luxation of femora in, 809. cavity of, 3. changes in size of, 11. chondrodystrophic dwarf, 770. coccyx, 2. comparison of, 12. conjugata diagonalis, 6, 70S. conjugata vera, 5, 709. contracted. (See Contracted Pelvis.) coxalgic, 806. coxarthrolisthetic, 808. cretin dwarf, 770. development of, 17. diameters of, 4. dolichopellic, 16. double luxation of femora, 809. double Naegele, 777. Pelvis, dwarf, 770. enchondroma of, 811. exostosis of, 810. external conjugate of, 705. false, 3. fibroma of, 811. flat non-rhachitic, 721. flat rhachitic, 727. fractures of, 811. funnel-shaped, 721, 782. generally contracted, 767. flat rhachitic, 731. generally enlarged, 767. generally equally contracted rhachitic, 732. history of, 1. hypoplastic dwarf, 772. inclination of, 8. inclined planes of, 3, 270. infantile, 17, 770. paralysis, 808. inferior strait, 6, 711. inlet of, 5. innominate line, 3. ischial spines, 3. ischium, 3. joints of, 10. justo-major, 767. justo-minor, 767. kypho-rhachitic, 794. kypho-scolio-rhachitic, 797. kypho-scoliotic, 797. kyphotic, 788. ligaments of, 11. linea terminalis, 3. male, 13. masculine, 770. mesatipellic, 16. middle flat rhachitic, 729. movements of, in joints, 11, 511. muscles of, 255. Naegele, 772. nana, 771. nimis parva, 767. normal conjugate of, 9. oblique conjugate of, 6. obliquely contracted, 772. obstetrical conjugate of, 6. obtecta, 789. of new-born child, 17. ossification of, 17. osteomalacic, 736. outlet of, 6, 711. ovate, 772. plana Deventeri, 722. plana osteomalacica, 736. plane of greatest pelvic dimension, 7. plane of least pelvic dimension, 8. planes of, 4. platypellic, 16. pseudo-osteomalacic, 732. pubis, 4. racial differences in, 16. rhachitic, 724. dwarf, 772. Robert, 777. 966 INDEX Pelvis, sacro-cotyloid diameter of, 5. sacro-iliac synchondrosis, 11. sacrum, 3. scolio-rhachitic, 795. scoliotic, 795. second parallel of, 8. separation of, during labor, 1. sexual differences in, 13. simple flat, 722. , soft parts of, 255. spinosa, 731, 810. split, 778. spondylizeme, 792. spondylolisthetic, 798. straits of, 4. superior strait of, 4. symphysis, absence of, 778. symphysis of, relaxation in, 511. symphysis pubis, 11. terminal, length of, 20, 730, 734. transformation of foetal into adult, 19. transversely contracted, 777. true, 3. conjugate of, 5. dwarf, 770. walls of, 3. tumors of, 811. unilateral luxation of femur, 808. variations in, 12. Veit's main plane of, 8. with imperfect development of sacrum, 779. Pendulous abdomen, 702, 742. Perforation. (See Craniotomy.) of Douglas's cul-de-sac, 865. of uterus, 864. Perineal fascia, 257. gutter, 259. muscles, 258. tears, after-treatment of, 336. central, 334. frequency of, 324. mode of production of, 324, 784. prevention of, 325. repair of, 333. Perineum, anatomy of, 255. changes in, during labor, 260. lacerations of, 324, 428. protection of, 324, 325. rigid, 679. Peritonitis, foetal, 819. puerperal, 890, 903. Peri-uterine inflammation in pregnancy, 583. Perivitelline space, 72. Pernicious anaemia during pregnancy, 388, 509. vomiting of pregnancy, 519. Pessary in treatment of retroflexed preg- nant uterus, 576. Peters's ovum, 112. Pfluger's ducts, 65. Phantom tumors in diagnosis of pregnancy, 200. Phlebitis, femoral, 891. uterine, 886. Phleb "my in eclampsia, 558. Phlegmasia alba dolens, 499, 891, 904, 925. Phloridzin diabetes, 162. Phthisis of placenta, 606. complicating pregnancy, 492. Physiology of labor, 226. Physometra, 749. Pigmentation, changes in, during pregnancy, 181, 197, 511. in negro baby, 150. in pregnancy, 197. Pinard's manoeuvre, 439. Pituitrin in post-partum haemorrhage, 846. use of, in labor, 679. Placenta, 129. abnormalities in size of, 602. abnormalities in weight of, 602. adherent, 309, 611. anatomy of, 133. angioma of, 609. annular, 602. apoplexy of, 606. artificial separation of, 486. at full term, 136. atrophy of, 606. basal plate of, 133. battledore, 611. bipartita, 603. bruit of, 190. calcification of, 610. canalized fibrin of, 133. cell nodes of, 131, 132. centuriata, 604. changes in, in eclampsia, 548. chorio-angioma of, 610. circular sinus of, 139. circumvallata, 605. closing plate of, 133. cotyledons of, 138. cysts of, 608. decidual islands of, 132. development of, 129. diagnosis of position of, by palpation of round ligaments, 221. dimidiata, 603. diseases of, 602, 606. duplex, 603. epithelium of, 134. expression of, 306. by author's method, 308. by Crede's method, 306. expulsion of, by Duncan's method, 302, by Sehultze's method, 302. fatty degeneration of, 606. fenestrata, 603. fibroma of, 609. functions of, 135, 158. giant cells of, 135. gumma of, 620. hepatization of, 606. in albuminuria, 606. in eclampsia, 552. in extra-uterine pregnancy, 651. in latter half of pregnancy, 133. in multiple pregnancy, 370. in placenta, 610. in syphilis, 618. INDEX 967 Placenta, infarcts of, 606. inflammation of, 610. intervillous blood spaces of, 131, 134. manual removal of, 309, 486, 841, 846. marginata, 605, 606. margo, 606. mechanism of separation of, 300. membranacea, 604. membranes of, 139. mode of delivery of, 301. mode of extrusion of, 300. multiple, in single pregnancy, 603. myxoma fibrosum of, 609. new growths in, 609. oedema of, 603. osmotic pressure in, 158. phthisis of, 606. polyp of, 928. praevia, 452, 606, 833. accouchement force in, 840. aetiology of, 835. Caesarean section in, 840. developed from reflexa placenta, 836. diagnosis of, 838. frequency of, 834. induction of premature labor, 840. podalic version in, 840. prognosis of, 838. symptoms of, 837. treatment of, 839. vaginal pack in, 484, 840. premature separation of, 297, 829. prolapse of, 832. red infarcts of, 607. reflexa, 837. retention of, cause of haemorrhage, 309, 842. sarcoma of, 610. schirrus of, 606. secretion of, 82. senility of, 607. septuplex, 604. site of, post-partum, 341. situation of, in utero, 300. spuria, 605. succenturiata, 604. syncytium of, 134. syphilis of, 618. transmission of substances through, 158. triplex, 603. trophoblast of, 135. truffe, 607. tuberculosis of, 610. tumors of. 609. velamentous, 611 vessels of, 136. vicious insertion of, 834. villi of, fastening, 131. weight of, 132, 136. Placental forceps, 384. transmission, 158. period, 239. amount of blood lost during, 306. clinical picture of, 304. haemorrhage during. 309. management of. 300, 306. 63* Placental period, mechanism of separation of placenta, 300. mode of extrusion of placenta, 300. normal situation of placenta in utero, 300. souffle, 190. space, 135. Placentitis, 606, 610. Planes of pelvis, 4. Plasmodium, chorionic, 119. Pleurisy in puerperal infection, 904. Plexus, hypogastric, 53. pampiniform, 52. Plicae palmatae 41. Pneumococcus in puerperal infection, 88'2. Pneumonia alba, 616. during pregnancy, 491. during puerperium, 943. Podalic version, 443. in brow presentations, 443. in face presentations, 443. in occipito-posterior presentations, 443. indications for, 443. technique of, 445. Polar body, 96. Polygalacia, 937. Polymastia, 936. Polypus, fibrinous, causing haemorrhage, 923 Porro Caesarean section, 450, 455. Portio vaginalis of cervix, 40. Position of foetus, 215. of uterus, 49. Positive signs of pregnancy, 188. Post-mortem Caesarean section, 460. delivery, 876. Post-partum eclampsia, 540. haemorrhage, 842. aetiology of, 842. clinical history of, 843. treatment of, 845. Posture, in first stage of labor, 234, 320. in second stage of labor, 236, 322. Praeputium clitoridis, 28. Prague manoeuvre, 436. Precipitate labor, 680. Pre-eclamptic toxaemia, 532. Pregnancy, 168. abdominal, 659. enlargement during, 191. abnormalities of pigmentation in, 511. acardia in multiple, 372, 816. accidents during, 511. acute endometritis during, 582. acute infectious diseases in, 387, 489. acute oedema of cervix during, 57S. acute yellow atrophy of liver in, 523. after removal of kidney, 506. after removal of ovaries, 85. albuminuria during, 532, 542. albuminuric retinitis, 542. amaurosis in, 508. amenorrhoea during, 82, 196. ampullar, 647. anaemia, pernicious, in, 505. anomalies and diseases of ovum, 586, anteflexion of uterus during, 572. 968 INDEX Pregnancy, anteversion of uterus during, 572. anthrax in, 492. apoplexy in, 508. appendicitis in, 512. areola in, 176, 196. asthma in, 499. atrophic endometritis decidua during, 582. auto-intoxication in, 518. ballottement in, 191. bladder and rectum, changes in, 179. blood changes in, 177. blood pressure in, 177. bowels in, 208. Braxton Hicks's sign of, 195. breasts, care of, during, 209. broad ligament, 658. changes in, during, 173. carcinoma of cervix during, 568. cardiac lesions in, 387, 496. cephalalgia in, 506, 532. cervix in, 243. Chadwick's sign of, 197. changes in abdominal wall during, 174. bladder during, 179. blood during, 177. blood serum during, 198. breasts during, 176, 196. cervix during, 195, 243. digestive tract during, 178. ductless glands during, 179. general metabolism, 181. heart during, 177. kidneys during, 179. liver during, 179. lungs during, 178. maternal organism during, 168. nervous system during, 181. ovaries during, 173. pigmentation during, 197, 511. respiratory tract during, 178. size, shape, and consistency of uterus during, 171, 193. skeleton during, 180. skin during, 181. teeth during, 180. thyroid during, 179, 553, 559. tubes during, 173. urinary tract during, 179. uterus during, 168. vagina during, 174. weight during, 182. cholera in, 490. chorea in, 387, 507. chronic infectious diseases in, 492. chronic nephritis in, 503. cloasma in, 181, 511. clothing during, 208. coitus in, 208. colpo-hyperplasia cystica during, 567. combined, 662. constipation during, 208, 502. contracted pelves during, 383. corpus luteum of, 78. cravings during, 197. cystitis in, 506. cytolysis, 551. Pregnancy, death of foetus during, 201. decidua polyposa during, 580. dental caries in, 502. depressed nipples in, 209. dermatitis herpetiformis in, 510. diabetes in, 388, 503. diagnosis of, 188. differential, 198. of death of fcetus in, 201. diagnosis of multiple, 374. diastasis of recti muscles during, 579. diet during, 208. diffuse thickening of decidua during, 580. directions for patients during, 210. disappearance of, 638. discoloration of mucous membrane in, 197. diseases of alimentary tract and liver in, 501. of blood in, 509. of cervix during, 568. of circulatory and respiratory systems in, 496. of decidua during, 580. of kidneys and urinary tract in, 503. of nervous system in, 506. of ovum during, 382. of skin in, 510. of vulva and vagina during, 567. dislocation of kidney in, 506. displacements of uterus during, 572. distinction between first and subsequent, 200. disturbances of vision in, 210, 508. duration of, 201. dyspnoea in, 499. eclampsia in, 537. ectopic. (See Extra-uterine Pregnancy.) emesis in, 196, 382, 519. emphysema during, 499. endocarditis in, 499. endometritis decidua cystica during, 581. endometritis during, 580. enteroptosis in, 502. epilepsy in, 507. erysipelas in, 491. estimation of date of confinement, 203. estimation of duration of, 203. examination, preliminary, during, 210. exanthemata during, 489. exercise during, 207. extra-peritoneal, 658. extra-uterine. (See Extra-uterine Preg- nancy.) floating spleen in, 506. kidney in, 505. fcetal heart in, 189. formation of lower uterine segment, 244. funic souffle in, 190. gall stones in, 501. gingivitis in, 502. glandular hyperplasia of decidua during, 581. glycosuria in, 503. goitre in, 508. gonorrhoea in, 492, 582. haematoma of abdominal walls in, 511. INDEX 969 Pregnancy, haematuria in, 504. haemoglobin during, 177. haemophilia in, 509. heart, hypertrophy of, in, 177. Hegar's sign of, 193. hepato-toxaemia in, 518, 550. hernia during, 578. herpes gestationis in, 310. hydatidiform mole in, 388, 586. hydraemia in, 177. hydramnios in, 388, 596. hydroplasmia in, 178. hydrorrhoea gravidarum during, 581. hymen in, 31, 684. hyperemesis in, 519. hypertrophic elongation of cervix during, 578. hypertrophy of cervix in, 195. hypophysis cerebri in, 180. hysteria in, 508. icterus in, 501, 528. imaginary, 200. impetigo herpetiformis in, 510. incarceration of uterus during, 575. incontinence of urine in, 575. indigestion in, 501. induction of abortion in, 381. in diverticula from uterine cavity, 572. infection of uterine contents during, 680, 749, 904. inflammation of Bartholin's glands dur- ing, 567. influenza in, 491. inguinal hernia during, 578. in rudimentary horn of double uterus, 569. insanity during, 541, 941. intermittent contractions of uterus dur- ing, 195. interstitial, 647. intestinal obstruction in, 513. in uterus bicornis, 571. in uterus unicornis, 571. isthmic, 647. kidney of, 180, 531. lactosuria in, 503. laparotomy during, 576, 665, 863. lead poisoning in, 509. leukaemia in, 388, 509. localized thickening of decidua during, 580. lower uterine segment in, 244. malaria in, 494. mammae in, 176, 196, 209. management of, 207. mapping out foetus in, 191. marital relations in, 208. maternal pulse in, 190. measles in, 490. menses, cessation of, during, 196. persistence of, during, 196. mental and emotional changes in, 197. mental derangements in, 532, 541. metabolism in, 181. metritis dessicans, 503. during, 583. milk in, 196, 360. Pregnancy, missed abortion in, 383, 637. morning sickness in, 196, 519. movements of foetus during, 190, 191. multiple. (See Multiple Pregnancy.) myocarditis in, 498. nausea and vomiting during, 196, 519. nephrectomy after, 506. nephritic toxaemia in, 530. nephritis in, 388, 503. nervous irritability in, 181. neuralgia in, 507. neuritis in, 507. neurotic vomiting in, 520. oedema in, 500. operations during, 512. osteophyte, 180. ovarian, 645. cyst complicating, 199, 383, 388. ovulation during, 173. palpation during, 211, 219. of fcetal heart in, 189. paradoxical incontinence of urine during, 575. paralysis in, 506. paraplegia in, 506. pathology of, 489. pelvimetry during, 211. pendulous abdomen in, 192, 702, 742. peri-uterine inflammation during, 583. pernicious anaemia in, 388, 509. vomiting of, 519. pessary in, 576. phlegmasia in, 499. phthisis in, 492. physiology of, 168. pigmentation in, 197. placenta praevia in, 388. placental souffle in, 190. placentitis in, 606, 610. pneumonia in, 491. positive signs of, 188. pre-eclamptic toxaemia In, 532. presumptive signs of, 195. presumable toxaemias, 560. probable signs of, 191. prolapse of uterus during, 577. prolonged, 202, 813. pruritus in, 510. pseudocyesis, 199. psychoses during, 560. pulmonary embolism in, 499. pulse in, 343. pyelo-nephritis in, 388, 505. quickening in, 197. relapsing fever in, 160. relaxation of pelvic joints during, 511. of vaginal outlet during, 567. renal insufficiency during, 382. respiration in, 183. rest, effect of, on, 202. retroflexion of uterus during, 382, 573. retroversion of uterus during, 573. rupture of uterus during, 857. sacculation of uterus in, 199, 574. salivation in, 502. scarlet fever in, 490. 970 INDEX Pregnancy, sepsis in, 491. sexual intercourse during, 208. signs of, 188. signs of previous, 201. size of uterus in, 168, 204. small-pox in, 489. souffle, funic, in, 190. "* spurious, 199. striae of, 174, 197. suppression of menses in, 196. surgical operations during, 512. symptoms of, 188. syphilis in, 495. tachycardia in, 498. taste, perversions of, in, 181. teeth, 180. termination of, 201. tetanus in, 492. tetany in, 508. thyroid in, 179, 553. toothache in, 502. torsion of cord in, 613. toxaemias of, 387, 518. transmission of bacteria from mother to fcetus, 160. tubal, 647. tuberculosis in, 383, 387, 492. tubes and ovaries in, 173. tubo-abdominal, 647, 659. tubo-ovarian, 659. tubo-uterine, 659. tumors complicating, 583. 'typhoid fever in, 491. umbilical hernia during, 579. umbilicus in, 198, 204, 579. urea, amount of, during, 182. urinary disturbances during, 197. urination during, 182 urine, examination of, during, 209. urine in, 182. uterine displacements in, 573, 687. haemorrhage during, 382. myomata during, 383, 388. souffle in, 190. utero-abdominal, 858. uterus in, 168, 193, 231, 243. vaccination in, 490. vagina in, 174, 255, 684. vaginal enterocele during, 578. examination during, 212, 221. vaginitis during, 567. valvular lesions of heart in, 496. varices in, 499, 567. varicose veins in, 499, 567. variola in, 489. vomiting of, 382, 519. weight in, 182. Preliminary examination during pregnancy, 210. Premature labor, 627. in chronic nephritis, 503, 530. in heart disease, 498. in infectious diseases, 387. in lead poisoning, 509. in leukaemia, 509. in malaria, 494. Premature labor in ovarian tumors, 692. in pneumonia, 491. in syphilis, 495, 614. treatment of, 634. Premature labor, induction of, 385. for acute nephritis, 387. for cardiac lesions, 387. for chorea, 387, 507. for contracted pelves, 385, 762. for diabetes, 388. for excessive size of child, 387, 813. for habitual death of foetus, 388. for heart disease, 498. for hydatidiform mole, 388. for hydramnios, 388. for neuritis, 387. for old extra-uterine pregnancy, 663. for ovarian tumors, 388, 692. for pernicious anaemia, 388, 509. for placenta praevia, 388', 840. for pyelo-nephritis, 388, 505. for toxaemia of pregnancy, 387, 535. for tuberculosis, 387, 492. for uterine myomata, 388, 690. methods of, 389. prognosis of, 388. Premature separation of normally im- planted placenta, 297, 829. Preparations for labor, 311. Prepuce of clitoris, 29. Presentation, 213. acromio-iliac. (See Transverse Presenta- tion.) anterior parietal, 744. breech, 213, 215, 292. brow, 214, 290. causation of, 217. cephalic, 213. compound, 826. diagnosis of, 219. ear, 746. face, 214, 282. foot, 215. frank breech, 215. frequency of the several varieties of, 217. funic, 867. head, 213. knee, 215. lateral plane, 821. longitudinal, 213. mento-iliac. (See Face Presentation.) nomenclature of, 215. nuchal, 828. oblique, 821. occipito-iliac. (See Vertex Presentation.) pelvic, 215, 292. posterior parietal, 746. reasons for predominance of head, 217. sacro-iliac. (See Breech Presentation.) shoulder, 213, 821. sincipital, 214. transverse, 213. 821. vertex, 214, 262. Presentation and position, 213. diagnosis of, 219. frequency of, 217. INDEX 971 Presentation and position, in contracted pelves, 743. nomenclature of, 215. Presenting part, 213. Presumable toxaemias, 560. Presumptive signs of pregnancy, 195. Primary segments, 103. Primiparae, elderly, 239. young, 240. Primitive folds, 101. groove, 101. streak, 101. Primordial follicle, 65, 66. ova, 65. Probable signs of pregnancy, 191. Prolapse of placenta, 832. of pregnant uterus, 577. of puerperal uterus, 932. of umbilical cord, 405, 750, 867. Prolonged labor, 675. pregnancy, 202. Promontory, sacral, 3. Pronucleus, female, 96. male, 98. Prophylactic douche, 481, 900, 909. version, 762. Protovertebrae, 103. Pruritus during pregnancy, 510. vulvae, 510. Pseudocyesis, 199. Pseudo-osteomalacic rhachitic pelvis, 732. Pseudo-reflexa, 648. Psychoses during pregnancy, 560. puerperal, 941. Pubiotomy, 464. history of, 464. in brow presentations, 292. in contracted pelves, 468, 760. in face presentations, 290, 468. indications for, 468. prognosis of, 467. technique of, 464. Pubis, 4. arch of, 4. palpation of, 712. symphysis, 2. Pudendum, 26. Puerperal infection, 878. aetiology of, 892. antistreptococcic serum in, 915. auto-infection, cause of, 894. bacteriological examination of lochia in, 906. bacteriology of, 878'. curettage in, 484, 911. diagnosis of, 904. frequency of, 900. hysterectomy for, 914. intra-uterine douche in, 911. operative treatment of, 913. pathological anatomy of, 884. pyaemia in, 891, 903. sapraemia in, 883. septicaemia in, 884. sewer gas in, 894. symptoms of, 901. Puerperal treatment of, 909. infection, ulcer, 885. Puerperium, 339. abdominal wall during, 342. acetonuria during, 346. after-pains in, 345, 348. albuminuria during, 346. anatomical changes in, 339. anteflexion of uterus during, 931. atrophia acutissima during, 340. atrophy of uterus during, 339, 930. binder in, 348. bradycardia in, 344. breasts, diseases of, during, 935. care of patient during, 347. catheterization during, 350. cervix during, 341. changes in blood during, 344. in lower uterine segment during. 342. in uterine vessels during, 341. chill during, 343. chloroform poisoning in, delayed, 932. clinical aspects of, 343. constipation during 346. cystitis during, 926. death during, 873. diabetes during, 346. diet during, 349. diphtheria during, 944. embolism in, 873, 875. endarteritis in, 341, 928'. ergot in, 332, 679, 846. examination during, 351. gangrene of lower extremities during; 926. general functions during, 345. glycosuria during, 346. haematoma during, 928. haemorrhage during, 927. incontinence of urine during, 927. infection during, 878. insanity during, 942. involution of uterus during, 339. lactosuria during, 346. laxatives in, 350. leukocytosis during, 178, 344, 916. lochia during, 345. lochiometra during, 931. loss of weight during, 347. malarial fever during, 906, 943. management of, 347. mastitis during, 939. measles during, 944. menstruation in, reappearance of, 351. metabolism during, • 346. milk fever in, 343, 905. neuritis during, 934. nursing in, 362. ovarian tumors in, 692. paralysis during, 933. peritoneum during, 342. pessary during, 932. phlegmasia alba dolens during, 925. pneumonia during, 943. prolapse of uterus during, 932. psychoses during, 941. 972 IN Puerperium, pulse during, 343. pyelo-nephrosis during, 927. regeneration of endometrium during, 340. rest and quiet during, 349. retention of urine during, 347, 927. ' retroflexion of uterus during, 931. scarlet fever during, 943. small-pox during, 944. subinvolution of uterus during, 929. sweating in, 345. syncope in, 874. temperature during, 343, 349. tetanus during, 924. thrombosis during, 925. time for getting up, 350. typhoid fever during, 906, 943. urination .during, 349. urine in, 346. uterine myomata in, 692. vagina during, 342. vulval toilet during, 348. weight, loss of, during, 347. Pulmonary embolism. (See Embolism, Pul- monary.) Pulmotor in asphyxia, 8'73. Pulse during puerperium, 343. Pyaemia, 891, 903. Pyelitis, 179, 505. Pyelo-nephritis, 388, 927. during pregnancy, 179, 505. puerperium, 927. Pygopagus, 815. Pyriformis muscle, 255. Quadruplet pregnancy. (See Multiple Preg- nancy.) Quickening, 197. Quinine as an oxytocic, 678. Quintuplet pregnancy. (See Multiple Preg- nancy.) "Rapport azoturique," 553. Receptaculum seminis, 90. Rectocele complicating labor, 695. Recto-vaginal fistula, 749. septum, 35. Rectum, carcinoma of, complicating preg- nancy, 695. in labor, 260. Red infarcts of placenta, 607. Reduction of retroflexed pregnant uterus, 576. Reflex vomiting of pregnancy, 520. Relapsing fever in pregnancy, 160. Relative indications for Caesarean section, 451. Relaxation of pelvic joints in pregnancy, 174, 180, 511. of vaginal outlet after labor, 853. of vaginal outlet during pregnancy, 567. Renal decapsulation, 559. insufficiency, 382. Repeated Caesarean section, 459. tubal pregnancy, 663. Repositor for prolapsed umbilical cord, 8'68. Respiration, artificial, 871. Respiration, in pregnancy, 183. intra-uterine, 869. Rest cure, 525. effect of, upon pregnancy, 202. Restitution. (See External Rotation.) Retained placenta, 308, 486, 842. Rete ovarii, 62. Retention of urine, 347. in foetus, 819. Reticulum of endometrium, 46. Retinitis, albuminuric, 542. Retraction ring. (See Contraction Ring.) Retractores uteri, 48. Retroflexion, cause of abortion, 630. due to contracted pelvis, 742. of bicornuate uterus, 573. of pregnant uterus, 382, 573. of puerperal uterus, 931. Retro-mammary abscess, 940. Retro-peritoneal phlegmon, 890. Rhachitic dwarf pelvis, 772. Rhachitic rosary, 732. Rhachitis, diagnosis of, 732. foetal, 735, 770. mode of production of pelvic deformity in, 734. pathology of, 724. pelvis in, 726. Rhomboid of Michaelis, 705. Rima pudendi, 26. Ring of Bandl. (See Contraction Ring.) of Muller, 243. Ritgen's method of expression, 325. Robert pelvis, 777. Roentgen ray in determining size of pelvis, 714. Rosenmiiller, organ of, 47. Rotation with forceps, 419. Round ligaments, 48. function of, during labor, 233. palpation of, 221. Rubber gloves, use of, 317. Rudimentary horn, 569. Rugae, vaginal, 36. Rupture of Graafian follicle, 73. of pelvic joints, 749. of tubal pregnancy, 655. of umbilical cord, 613. of uterus, 857. aetiology of, 858. at time of labor, 858. during pregnancy, 857. in contracted pelves, 748. in neglected transverse presentations, 823, 859. in pregnancy in bicornuate uterus, 570. in scar following Caesarean section, 459. repeated, 860. symptoms of, 861. treatment of, 863. Sacculation of uterus, 199, 574. Sacro-iliac synchondrosis, 11. rupture of, in labor, 749. synostosis of, 773. Sacro-sciatic notch, 3. INDEX 973 Sacrum, 3. assimilation of, to vertebral column, 780. imperfect development of, 779. not a keystone, 4. promontory of, 3. Sagittal fontanelle, 154. suture, 153. Salivation in pregnancy, 502. Salpingitis, follicular, cause of tubal preg- nancy, 643. puerperal, 890. Salt solution in eclampsia, 558. in haemorrhage, 847. Sapraemia, 883. Sarcolactic acid in eclampsia, 553. Sarcoma uteri decidua-cellulare, 592. Saxtorph's manoeuvre, 424. Scanzoni's manoeuvre, 420. Scarlet fever in pregnancy, 490. in puerperium, 943. intra-uterine, 490. relation of, to puerperal infection, 943. Schatz method of conversion, 289. Scheele's method of inducing labor, 389. Schirrus of placenta, 606. Sehultze's mechanism of extrusion of pla- centa, 302. method of resuscitation, 872. Scolio-rhachitic pelvis, 795. Scoliosis, 795. Scoliotic pelvis, 795. Scopolamine anaesthesia, 331. Seat-worms, 511. Segmental layer, 103. cavity, 99. Segmentation nucleus, 98. of ovum, 98. Semen, 96. Sepsis foudroyante, 884. in pregnancy, 491. Septicaemia, puerperal, 878, 904. Sewer gas in puerperal infection, 894. Sex, determination of, 163, 189. diagnosis by heart-beat, 189. Sexual intercourse in pregnancy, 208. organs, abnormalities of, 567, 684. Shock during labor, 874. Shortening of cervix, apparent, in preg- nancy, 243. Shoulder presentation. (See Transverse Presentation.) delivery of, 327. Show, 234. Signs of pregnancy, 188. Simple flat pelvis, 722. Simpson's basilyst, 477. cranioclast, 475. forceps, 400. Sincipital presentation, 214. Skene's ducts, 30. Skull, configuration of, 750. depression of, 752. fracture of, 438, 752. pressure marks on, 751. Skutsch's pelvimeter, 710. Slow pulse during puerperium, 343. Small-pox during pregnancy, 489. during puerperium, 944. intra-uterine, 160, 489. Smellie's forceps, 404. scissors, 473. Somatopleure, 103. Souffle, funic, 190. placental, 190. uterine, 190. Spee's ovum, 114. Spermatid, 97. Spermatocyte, 97. Spermatogenesis, 97. Spermatozoa, 89, 96. entrance into ovum, 96. influence upon sex, 164. mode of entry into uterus, 90. number of, 90. Sphincter vaginae, 37. Spirochaete, 496, 619. Splanchnopleure, 103. Spleen, enlarged, complicating labor, 695. Split pelvis, 778. Spondylizeme, 792. Spondylolisthesis, 798 Spondylolysis, 801. Spontaneous amputation by amniotic adhe- sions, 601. evolution, 824. version, 823. Spurious pregnancy, 199. Stages of labor, 234. Staphylococcus in puerperal infection, 880. Stein's pelvimeter, 699. Stenosis of umbilical vessels, 597. Sterilization of patient after Caesarean sec- tion, 457. Sterno-cleido-mastoid muscles, haematoma of, 437. Stigma folliculi, 71. Stomach, acute dilatation of, 876. Straits of pelvis, 4. Streptococcus in mammary abscess, 940. in puerperal infection, 879. in puerperal insanity, 942. Striae of pregnancy, 174, 197. Subareolar mastitis, 940. Subinvolution of uterus, 929. curettage in, 484, 930. Subperitoneal haematoma, 929. Succenturiate placenta, 604. Sudden death during labor, 873. Sugar in urine, 346, 388, 503. Superfecundation, 373. Superfcetation, 373. Superinvolution of uterus, 931. Superior strait, 4. Supra-symphyseal Caesarean section, 456. Surgical operations during pregnancy, 512. Sutures of head, 153. for perineal repair, 335. Symphyseotomy, effect of, upon size of pel- vis, 461. history of, 460. in brow presentations, 292. in face presentations, 289. 974 INDEX Symphyseotomy, in Naegele pelvis, 776. in spondylolisthetic pelvis, 803. indications for, 462. prognosis of, 463. technique of, 462. Symphysis pubis, 2, 10. absence of, 778. relaxation of, 511. rupture of, in labor, 749. separation of, during labor, 1. Synchondrosis, sacro-iliac, 10. Synclitism, 267. Syncope during labor, 874. Syncytioma malignum, 591. Syncytium, 119. in eclampsia, 551. in lungs, in eclampsia, 548. Syncytolysin, 551. Syphilis, bone lesions in, 617. during pregnancy, 495. foetal, 614. pathology of, 614. placental lesions in, 618. post-conceptional, 495. transmission of, to foetus, 495. Syphilitic osteochondritis, 617. Tabes dorsalis, 507. Tachycardia in pregnancy, 498. Tampon, 484. in abortion, 485. in placenta praevia, 485, 840. in post-partum haemorrhage, 486, 846. in rupture of uterus, 864. Tardy labor, 675. Tarnier's basiotribe, 476. cephalotribe, 475. excitateur uterin, 390. forceps, 425. Temperature during labor, 343, 680, 749, 904. during puerperium, 343, 349. Temporal fontanelle, 154. suture, 153. Teratoma of testicle, 595. production of, 96. Terminal length of pelvis, 20. Tetanic contraction of uterus, 681. Tetanus during pregnancy, 492. in puerperium, 924. of newly born child, 355. uteri, 681. Tetany in pregnancy, 508. Theca folliculi, 71. Third stage of labor. (See Placental Pe- riod.) Thoracopagus, 815. Threatened abortion, 634. Thrill in uterine artery during pregnancy, 190. Thrombosis of uterine vessels, 341. of vessels of lower extremities, 925. Thyroid, cause of dystocia, 821. cause of face presentations, 283. toxaemia of pregnancy, 179. changes in, during pregnancy, 179. Thyroid, in eclampsia, 553, 559. Toothache in pregnancy, 502. Torsion of cord, 613. of uterus, 173. Touch, vaginal, during labor, 319. in pregnancy, 222. Toxaemia of pregnancy, 387, 518, 532. relation of, to eclampsia, 533, 536. treatment of, 533. urine in, 534. Toxaemic vomiting of pregnancy, 520. Trachelorhekter, 479. Transfusion of salt solution in eclampsia, 558. in extra-uterine pregnancy, 666. in post-partum haemorrhage, 847. Transit of ovum, 100. Transplantation of ovaries, 63. Transportation of chorionic villi, 551, 590, 652. Transverse presentations, 821. cephalic version in, 441, 825. course of labor in, 823. decapitation in, 478', 826. diagnosis of, 822. podalic version in, 443, 826. Transversely contracted pelvis, 777. Transversus perinei, 258. Trepanation for asphyxia neonatorum, 873. Triplet pregnancy. (See Multiple Preg- nancy.) Trophoblast, 112, 648. True dwarf pelvis, 776. Tubal abortion, 653. pregnancy, 647. Tuberculosis during pregnancy, 383, 387, 492. puerperium, 906. of placenta, 493, 610. transmission of, to fcetus, 160, 493. Tuberous subchorial haematoma of decidua, 632. Tubes, Fallopian. (See Fallopian Tubes.) Tumors, abdominal, diagnosis of, in preg- nancy, 198. complicating pregnancy, 583. fibroid, of uterus, 690. of foetus, 821. of pelvis, 811. of placenta, 609. of umbilical cord, 614. osseous, deforming pelvis, 810. ovarian, 199, 692. phantom, differentiation of, from preg- nancy, 200. scalp, 222, 280, 750. vaginal, 685. Tunica externa of Graafian follicle, 71. interna, 71. Turning. (See Version.) Twin pregnancy. (See Multiple Pregnancy.) Twins, collision of, 376. locked, 377. Tympania uteri, 881. Tympanites uteri, 749, 881. Typhoid bacilli, transmission to foetus, 160. INDEX 975 Typhoid fever during pregnancy, 491. in puerperium, 906, 943. Typhoid icterus, 528. Ulcer, puerperal, 885. Umbilical arteries, 140, 157. hernia, 579. infection, 357. vesicle, 141. relation to velamentous insertion of cord, 612. Umbilical cord, 139. abnormalities of, 611. battledore insertion of, 611. care of, 355. coils of, about neck of child, 326. compression of, in breech presentation, 297. cysts of, 614. dermoid of, 614. development of, 140. formation of, 140. haematoma of, 614. hernia of, 612. infection of, 355. inflammation of, 613. knots of, 613. laceration of, 612. ligation of, 328, 357. loops of, 613. marginal insertion of, 611. myxoma of, 614. oedema of, 615. prolapse of, 405, 750, 867. reposition of, 868. rupture of, 613. sarcoma of, 614. shortening of, 613. souffle in, 190. stalk, 140, 141. stenosis of vessels of, 597. strangulation of, by amniotic adhesions, 601. syphilis of, 619. tetanus of, 355. torsion of, 613. tumors of, 614. tying of, 327, 356. variations in length of, 612. varices of, 614. velamentous insertion of, 611. vesicle, 141. Unavoidable haemorrhage, 831. Uraemia, 530. in retroflexion of pregnant uterus, 575. Urea in eclampsia, 543. in pregnancy, 182. Ureometer, Doremus's, 534. Ureter, compression of, cause of eclampsia, 545. Urethra, 30. Urethral opening, 30. Urinary disturbances in pregnancy, 197. Urine, ammonia co-efficient of, 526. examination of, during pregnancy, 209. incontinence of, 927. in acute yellow atrophy, 530. Urine, in eclampsia, 542. in pregnancy, 182. in puerperium, 346. in toxaemia of pregnancy, 532. in vomiting of pregnancy, 524. nitrogenous partition of, 533. of foetus, 161, 597, 819. . retention of, during puerperium, 347, 927, Uterine atony, 377, 842. bruit, 190. glands, 45. inertia, 676. insufficiency, 676. milk, 136. paralysis, 843. souffle, 190. Utero-sacral ligaments, 48. Uterus, non-pregnant, 38. anatomy of, 38. blood-vessels of, 49. cervix of, 38, 40. cornua of, 38. corpus of, 38, 42. development of, 53. fundus of, 38. isthmus of, 40. ligaments of, 47. lymphatics of, 52. mucosa of, 43. musculature of, 46. nerves of, 53. position of, 49. weight of, 39, 168. Uterus, parturient, action of, in labor, 248. anteflexion of, 687. contractions of, 230. faulty contraction of, 748. hour-glass contraction of, 682. inertia of, 676. myoma of, 690. nerve supply of, 230. perforation of, 864. retroflexion of, 687. rupture of, 748, 857. sacculation of, 574, 687. tetanus of, 681, 748. Uterus, pregnant, abnormalities of, 686. anteflexion of, 572, 687. anteversion of, 572. atrophy of decidua causing abortion, 629. atrophy of decidua causing placenta prae- via, 835. bicornis, 571. carcinoma of, 690. changes in cervix, 243. changes in, during contractions, 248. changes in size and shape of, 171, 193. consistency of, 193. contractions of, 195. developmental abnormalities of, 569. diverticula of, 572. double, with rudimentary horn, 569. duplex, 571. hypertrophy of, 168. incarceration of retroflexed, 575 involution of, 339. 976 INDEX Uterus, pregnant, laceration of cervix of, 234, 393, 842, 855. lateral displacements of, 576. lower uterine segment of, 244. malformations of, 569. muscle layers of, 170. myoma of, 690. nerve supply of, 230. perforation of, 864. prolapse of, 690. pseudo-didelphys, 569. retroflexion of, 382, 573, 687. retroversion of, 573. sacculation of, 574, 687. shape of, 168. sinking of, 204. suspension of, cause of dystocia, 687. torsion of, 173. tumors of, complicating pregnancy, 690. unicornis, 571. weight of, 168. Uterus, puerperal, anteflexion of, 931. atrophy of, 339. endarteritis of, 341. gangrene of, 890. hour-glass contraction of, 682. inversion of, 847. involution of, 339, 930. lactation atrophy of, 930. paralysis of, 843. prolapse of, 932. regeneration of, 341. removal of, after Caesarean section, 456. after rupture, 863. for infection, 914. retroflexion of, 931. subinvolution of, 484, 929. superinvolution of, 931. weight of, 340. Vaccinia, 490. Vagina, 33. atresia of, 684. changes of, in labor, 255. in pregnancy, 174. in puerperium, 342. closer of, 37. color of, in pregnancy, 197. development of, 37. diphtheria of, 885. double, 572, 684. fornix of, 35. functions of, 35. glands of, 36. haematoma of, 686, 928. injuries of, during labor, 853. laceration of, during labor, 853. lymphatics of, 36. mucosa of, 36. neoplasms of, 685. prolapse of, in pregnancy, 567. relations of, 33. rugae of, 36. secretion of, 37. septa in, 684. sphincter of, 37. Vagina, stenosis of, 685. thrombus of, 928. tumors of, 685. ulcer of, 885. vascular supply of, 37. Vaginal Caesarean section, 394. douche, 481, 911. enterocele, 578, 695. examination during pregnancy, 212, 221, in eclampsia, 556. in placenta praevia, 840. in pre-eclamptic toxaemia, 535. in premature separation of placenta, 832. opening, 31. outlet, relaxation of, during pregnancy, 567, 853. secretion, 37, 175. in pregnancy, 175, 896. in puerperium, 394. tampon, 484. touch during labor, 319. in pregnancy, 222. Vaginismus, 686. Vaginitis, 567. puerperal, 885. Vagino-flxation, cause of dystocia, 687. Vagitus uterinus, 870. Varicose veins in pregnancy, 499, 567. Variety of presentation, 215. Vasa praevia, 612. Veins. (See Blood-vessels.) Veit's main plane, 8. Velamentous insertion of cord, 611. Venesection in eclampsia, 558. in heart disease, 498. Ventro-flxation, cause of dystocia, 687. Veratrum viride in eclampsia, 559. Vernix caseosa, 150. Version, 441. bipolar. (See Bipolar Version.) cephalic. (See Cephalic Version.) combined, 447. external. (See External Version.) in contracted pelves, 761. in transverse presentations, 825. podalic. (See Podalic Version.) prophylactic, 762. spontaneous, 823. Vertebrae, primitive, 103. Vertex presentations, 214, 262. causation of, 217. diagnosis of, 262. frequency of, 262. mechanism of, 264. occiput posterior, 274. Vesical calculus complicating labor, 695. Vesicle, blastodermic, 99. umbilical, 141. Vesico-cervical fistula, 749, 865. Vesico-vaginal fistula, 749, 927. septum, 35. Vesicular mole, 586. Vestibular bulbs, 30. Vestibule, 30. glandulae vestibulares majores, 30. minores, 30. INDEX Vibrion septiquc, 882. Villi, chorionic, 116, 134. hyperplasia of, 596, 609. metastases from, 590. syphilitic changes in, 618. transportation of, 551, 590, 652. Visceral arches, 147. clefts, 147. Vision, disturbances of, during pregnancy, 508. in eclampsia, 542. Vitelline membrane, 72. Volvulus, 513. Vomiting of pregnancy, 196, 382. Vulva, 26. atresia of, 684. clitoris, 29. commissure of, 27. diphtheria of, 885. diphtheritic ulcer of, 885. fourchette of, 28. frenulum of, 28. haematoma of, 684, 929. hymen, 31. injuries of, during labor, 853. labia majora, 27. minora, 28. oedema of, 500. pruritus of, 50. toilet of, during puerperium, 348'. urethral opening, 30. Vulva, vaginal opening, 31. varices of, 567. vestibular bulbs, 30. vestibular glands, 30. vestibule, 30. Walcher's posture, 11. in contracted pelves, 758. Wegner's bone disease, 617. Weight, changes in, during pregnancy, 182. loss of, during the puerperium, 347. of foetus at various months, 149. of newly born child, 150. Wharton's jelly, 140. White infarcts of placenta, 606. line, 255. Williams's outlet pelvimeter, 713. Wolffian body, 62, 64. • ducts, 30, 65. X-ray in determining size of pelvis, 714. Yolk, 73. Yolk-sac, 141. Young primiparae, labor in, 240. Zellschicht of chorion, 119. Zweifel's pelvimeter, 711. trachelorhekter, 479. Zona pellucida, 70, 72. (12) LIBRARY OF MEDICINE NLM D17D5t.lfi 5 NLM017056185 999999�