NATIONS!. LiBRSRv OF MEDICINE" NLM 00580110 M ^m/i 3NOIQ3W jo Aavaan ivnouvn 3NOia3w jo Aavaan ivnouvn 3NIDIQ3W jo Aa^ ! A/ \ W\ J /W NLM005809404 NATIONAL LIBRARY OF MEDICI 3NI3IQ3W jo Aavaan ivnouvn 3noiq3w jo Aavaan tvnouvn 3Ni3ia3w jo Aavaan ivno /\^lwv f/WiW\ I /w A / TEXT-BOOK OBSTETRICS BARTON COOKE JHIRST, M.D. PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA (~ "Library I SURGtON GENERAL'S OFFICE 0 EC.-G-1898 KcjICtr-, Wftb 653 Illustrations PHILADELPHIA W. B. SAUNDERS 925 walnut street 1898 Copyright, 1898, by \Y. B. Saunders. t TO RICHARD A. F. PENROSE, M.D., LL.D. EMERITUS PROFESSOR OF OBSTETRICS AND OF THE DISEASES OF WOMEN AND CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA Cbis ;©ooft is (SratefullE DeMcateD BY HIS FORMER PUPIL, THE AUTHOR / PREFACE. This work is the result of a practice devoted for the past twelve years exclusively to gynecology in both its branches— obstetrics and gynecic surgery. The author has served during this period as consulting and attendant gynecologist and obstet- rician in eight of the principal hospitals of Philadelphia. His experience in obstetrical complications and operations has con- sequently been exceptionally large. He has been engaged, moreover, during the whole of his professional career, in teaching medical students in clinics, hospitals, laboratories, and in the lecture-room. He ventures to entertain the hope, there- fore, that his training has fitted him for the preparation of a book which shall serve as a guide to undergraduate students and to physicians in active practice. It has been his constant aim to condense the text as far as is consistent with a comprehensive treatment of the subject. Illustrations have been extensively employed, the majority of them from original photographs and drawings. The task, impossible within a single volume, of presenting a complete bibliography of each subject has not been attempted. The student who desires such information is referred to the " Catalogue of the Surgeon-General's Library," the ten volumes of the " Jahresbericht iiber die Fortschritte auf dem Gebiete der Geburtshilfe und der Gynakologie,'; and to the " In- dex Medicus." References are given to articles and books which have been most helpful to the author or which have been epoch-making in the history of obstetrics. 1821 Spruce Street, Philadelphia, November, 1898. II CONTENTS. PART I.—PREGNANCY..................... 17 Chapter I.—Anatomy.................... 17 Anatomy of the Pelvis.................. 17 The Female Sexual Organs................ 39 Chapter II.—Menstruation, Ovulation, Fertilization, etc. . 56 Menstruation...................... 56 Ovulation ....................... 59 The Corpus Luteum................... 62 The Connection between Ovulation and Menstruation..... 63 Insemination...................... 64 Changes in the Ovum following Impregnation........ 72 Chapter III.—The Development of the Embryo and Fetus . 74 Development during the Months of Pregnancy........ 74 The Mature Fetus.................... 85 Chapter IV.—The Fetal Appendages............ 91 The Amnion . . . •................... 92 The Chorion.....................103 The Placenta......................112 The Umbilical Cord...................132 The Deciduae......................139 Chapter V.—The Diseases of the Fetus...........151 Chapter VI.—The Physiology of Pregnancy........181 Changes in the Uterus..................181 Changes in the Several Systems of the Body.........186 The Diagnosis of Pregnancy...............189 Chapter VII.—Pathology of the Pregnant Woman.....210 Diseases of the Genitalia................. 210 Diseases of the Uterine Muscle..............215 Diseases of the Alimentary Canal.............221 Diseases of the Urinary Apparatus ............226 Diseases of the Nervous System..............232 Diseases of the Circulatory Apparatus............236 Diseases of the Respiratory Apparatus...........238 Diseases of the Osseous System..............240 Infectious Diseases....................240 Skin Diseases.....................241 Abortion, Miscarriage, and Premature Labor.........243 Extra-uterine Pregnancy.................259 13 H CONTENTS. PAGE PART II.—THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM.........285 Chapter I.—Labor...... ..............2 5 Chapter II.—The Puerperal State.............3r9 PART III.—THE MECHANISM OF LABOR..........35° Forces Involved in the Mechanism of Labor.........354 Mechanism of the Several Presentations and Positions.....357 Abnormalities in Mechanism and their Management......364 Mechanism of the Third Stage of Labor..........395 PART IV.—THE PATHOLOGY OF LABOR..........4°i Chapter I.—Dystocia....................4DI Abnormalities in the Forces of Labor............4QI Labor Complicated by Accidents and Diseases........525 Dystocia Due to Disease.................57° PART V.—PATHOLOGY OF THE PUERPERIUM.......584 Chapter I. Abnormalities in the Involution of the Uterus after Child-birth . 584 Puerperal Hemorrhages..................59° Non-infectious Fevers..................607 Acute Intercurrent Affections...............615 The Exanthemata....................617 Puerperal Malaria....................626 Rheumatism and Arthritis.................629 Gonorrhea.......................631 Skin Diseases......................632 Tympanites......................632 Diseases of the Urinary System..............634 Diseases of the Nervous System..............640 Developmental Anomalies of the Breast...........641 Anomalies in Milk Secretion...............644 Diseases of the Mammary Glands.............652 Relaxation of the Pelvic Joints..............658 Chapter II.—Puerperal Sepsis...............659 PART VI.—OBSTETRIC OPERATIONS............7t9 Induction of Abortion..................yjo Induction of Labor...................*2I Forceps........................722 Extraction of the Breech.................*.r Artificial Dilatation of the Cervical Canal..........«4g Version ........................yr. CONTENTS. 15 PAGE Embryotomy......................7^7 Symphyseotomy....................774 Cesarean Section ....................779 PART VII.—THE NEW-BORN INFANT............789 Chapter I.—Physiology of the New-born Infant......789 Chapter II.—Pathology of the New-born Infant......799 Injuries to the Infant during Labor.............799 Diseases of the New-born Infant..............808 A TEXT-BOOK OP OBSTETRICS. PART I. PREGNANCY. CHAPTER I. Anatomy of the Pelvis; Development and Anatomy of the Female Generative Organs. THE ANATOMY OF THE PELVIS. The hip-bones together with the sacrum, including the coccyx, compose the pelvis, which forms the basin-like lower portion of the trunk. In the erect position of the body the pelvis is bent obliquely backward from the vertebral column above, so that the crest of the pubis descends nearly to a level with the end of the sacrum. The pelvis is divided into two parts by a prominent rim, named the brim of the pelvis, which is formed on each side by the iliopectineal line continued behind the crest of the pubis and by the curved ridge and promontory of the sacrum. The upper part is formed by the ilia, and includes the widest space of the pelvis which pertains to the abdominal cavity. The lower part is distinguished as the true pelvis, and incloses the cavity of the pelvis. It is a complete bony girdle, formed by the sacrum and coccyx, the ischium and pubis, and a small portion of the ilium. The upper extremity of the pelvic cavity, corresponding with the brim, is the inlet, or superior strait; the lower extremity is the outlet, or inferior strait. In consequence of the curvature of the sacrum and 2 17 18 PREGNANCY. coccyx the pelvic cavity appears as a curved cylinder, slightly narrowed toward the outlet. It is deepest behind and shallowest at the pubic symphysis. Its lateral wall is deep and vertical It extends from the iliopectineal line to the end of the ischial tuberosity, and is mainly formed by the body of the ischium with small portions of the ilium and pubis. The anterior depth of the pelvis (height of the symphysis) is 4 cm. The lateral depth is 9 cm. The posterior depth is 13 cm. The pelvic inlet is cordiform, with the notched base con- forming with the base of the sacrum and the rounded apex with the pubes. The outlet, rather smaller than the inlet, when completed by the great sacrosciatic ligaments has the same shape, with the notched base formed by the coccyx and the apex Fig. 1.—Female pelvis (one-third natural size). by the pubic symphysis. Its fore part is the pubic arch, the base of which extends between the ischial tuberosities ; and the sides are formed by the conjoined rami of the pubes and ischia. On each side of the outlet is the deep sacrosciatic notch, formed in front by the ischium, above by the ilium, and behind by the sacrum and coccyx. It is converted into the great and small sciatic foramina by the sacrosciatic ligaments, which also sepa- rate them from the pelvic outlet. The pelvis of the female not only differs from that of the male in accordance with the usual difference in other parts of the skeleton, but also exhibits impor- tant modifications which relate to the sexual function. The female pelvis is proportionately larger, but of more delicate con- THE ANATOMY OF THE PELVIS. 19 struction. It is proportionately, and often absolutely, of greater breadth, and is of less depth. The ilia spread more laterally, so as to produce greater breadth or prominence of the hips than in the male. The true pelvis has greater horizontal capacity, less depth, and is commonly less curved and less contracted at the outlet. The inlet is larger, less intruded upon by the sacral promontory, and is more circular or transversely oval. The outlet is likewise larger, with the ischial tuberosities less conver- gent, and with the pubic arch wider, lower, more truly arched, and with the sides more everted. Fig. 2.—The funnel-shaped false pelvis. In the female the sides of the pubic arch are narrower, more flattened, and less ridged than in the male.x The hip or innominate bones—in the adult a single piece— are composed, in fetal life and in childhood, of three separate bones,—the ilium, the ischium, and the pubis. The three bones are united by a triradiate cartilage in the acetabulum, which begins to ossify at puberty, the ankylosis being complete in the eighteenth year. The descending ramus of the pubis and the 1 This brief anatomical description of the pelvis is taken, modified, from Leidy's " Anatomy." 20 PREGNANCY. ramus of the ischium are also originally united by a cartilage which ossifies at about the eighth year. The Anatomy of the Pelvis Obstetrically Considered.— jo the obstetrician the pelvis is a canal and not a basin, and is to be studied mainly in its relation to the fetal body which must pass through it. The false pelvis is of minor importance, acting simply as a funnel-shaped structure to direct the presenting part toward and into the superior strait of the true pelvis. The obstetrical study of pelvic anatomy may be confined to the shape, size, position, and direction of the true pelvis. Pelvic Shape___If one were forced to define the shape of the pelvis he might describe it as a truncated cylinder, but the Fig. 3.—The shape of the superior strait. description would not be exactly accurate. As a matter of fact, the pelvic canal is of different shape at different levels, and it is necessary to study certain typical planes of the pelvis in order to understand fully the relationship of fetal to pelvic shape in labor. The first of these imaginary planes is laid at the entrance to the pelvic cavity or canal, the pelvic inlet or superior strait, and is bounded by the promontory of the sacrum, the iliopectineal lines, the crests of the pubis, and the upper edge of the symphysis. The shape of the pelvic inlet is cordi- form. In the bays on either side of the promontory rest the important nerve-trunks and blood-vessels of the pelvis, where they are guarded from the pressure of the fetal head. It was THE ANATOMY OF THE PELVIS. 21 thought formerly that the shape of the pelvic inlet was elliptical, but this is only exceptionally the case, as in certain justominor pelves, in which the nerve-trunks and vessels may be subjected to such excessive pressure that disease and disability result. In studying the pelvic canal from above downward it appears that the canal expands below the pelvic inlet and then contracts again as it approaches the outlet. It is convenient, therefore, to lay off a plane at the level of greatest expansion and another at the level of greatest contraction, which are called, respectively, the plane of pelvic expansion and the plane of pelvic contraction. The shape of the pelvic canal at the plane of pelvic expansion, passing through the middle of the sym- Fig. 4.—The diameters of the superior strait. physis, the top of the acetabula, and the sacrum, between the second and third vertebrae, is almost exactly circular, being only a trifle larger in its anteroposterior than in its transverse diameter. The shape of the pelvic canal at the plane of pelvic contraction, passing through the tip of the sacrum, the spines of the ischia, and the lower surface of the symphysis, is distinctly elliptical, being a centimeter longer anteroposteriorly than it is transversely. Finally, the shape of the pelvic outlet, or inferior strait, is cordiform, from the projection forward of the tip of the sacrum and the coccyx. 22 PREGNANCY. Pelvic Size___In determining the size of an irregularly shaped canal like that of the pelvis it is necessary again to resort to certain typical planes at different levels, and to measure typical diameters in these planes. Beginning with the cordiform pubic inlet it is obvious that its dimensions may best be expressed by the following diameters : An anteroposterior diameter measured from the middle of the promontory of the sacrum to the sym- physis pubis, about ^ of an inch below its upper edge ; this measurement averages, in the well-developed Caucasian woman, 11 cm. A transverse diameter, the longest distance from side to side of the pelvic inlet, measuring on the average 13^ cm-> and oblique diameters from the top of a sacro-iliac junction to the opposite iliopectineal eminence, measuring 12^4 cm. At the plane of pelvic expansion it is possible to measure but two diameters, an anteroposterior and a transverse ; the former is 12^ cm., the latter 12^ cm. At the plane of pelvic contraction the anteroposterior diam- eter is n}4 cm., the transverse 10*/2 cm. At the inferior strait the anteroposterior diameter, measured from the tip of the coccyx to the lower edge of the symphysis pubis, is 9^ cm.; but this is not a fixed measurement, as the coccyx is normally movable and is displaced backward in labor ; the obstetrical anteropos- terior diameter, therefore, is measured from the tip of the sacrum to the lower edge of the symphysis pubis ; it is 11 cm. The transverse diameter, measured from one to the other tuberosity of the ischium, is 11 cm. Pelvic Position.—By pelvic position is meant the angle or inclination of the pelvis to the trunk and to the horizon. The inclination of the plane of the superior strait to the horizon, as the individual stands erect, is fifty-five degrees, and of the inferior strait, ten degrees. The inclination of the pelvis, however, changes with changes of posture. It disappears in a squatting or sitting posture, and is increased if the individual leans backward. The greater the inclination of the pelvis, the more the axis of the superior strait diverges from the long axis of the uterine cavity, and con- sequently the greater must be the divergence in direction of the presenting part from that of the rest of the fetal body when the former engages in the superior strait. Much stress was once laid upon this fact, but, by placing a woman upon her side and flexing the thighs upon the trunk, the inclination of the pelvis is made practically to disappear. The obliquity of the pelvis, therefore, need not be seriously considered, as a rule, in labor but the habitual inclination of the pelvis as the woman stands erect must be taken into account if one would understand the THE ANATOMY OF THE PELVIS. 23 Fig. 5.—The inclination of the pelvis. pelvic deformities of rachitis, lordosis, kyphosis, spondylolis- thesis, and osteomalacia ; some of the anomalies of labor in these pelvic deformities ; and the abnormal relations of the ex- Fig. 6.—Variation in sacral curves : P, Promontory of sacrum ; C, coccyx. 24 PREGNANCY. ternal genitalia to the pelvis, whenever the latter shows an excessive or deficient inclination. Pelvic Direction.—By this term is meant the direction of the pelvic canal. It was the custom in a former generation to express pelvic direction by an exceedingly complicated mathe- matical formula, yielding what was called the "curve of Cams." Not only is this formula unnecessarily complicated, but it is also incorrect. The direction of the pelvic canal depends entirely upon the curve of the sacrum, and this differs in every pelvis. Taking, at random, any half-dozen or so of sacra from my col- lection, the utmost diversity of curvature is seen. The direction of the pelvis may be described with approximate accuracy as a line parallel with the sacral curve, and equally distant at all points from the pelvic walls. The Development of the Pelvis.—It may be easier to understand the peculiarities of the adult pelvis if one considers the forces imposed upon it and their influence upon the individual bones and upon the pelvis as a whole. The pelvis is subjected to the weight of the trunk imposed upon it from above, the counter- pressure of the limbs below, and the pull of powerful ligaments, muscles, and joints. The weight of the trunk, transmitted from above downward and from behind forward, tilts the sacrum forward by a rotary movement on its transverse axis and confers upon it the characteristic position or inclination. This force, however, is resisted by the pull of the muscular and ligamentous con- nections between the trochanters of the femora and the tuber- osities of the ischia and by the pressure of the heads of the femora on the acetabula. By the former force the tuberosities of the ischia are pulled apart and the normal width oi the pelvic outlet is secured. The sacrum bears the greatest weight of the trunk, and in consequence its top is forced downward and for- ward. The natural consequence would be to tilt the lower end of the sacrum and the coccyx backward, but they are subjected to the powerful pull forward of the ligaments and muscles attached to them and to the lateral and anterior pelvic walls. Hence the sacrum, subjected to these two opposing forces, is bent like a bow between them, and thus acquires its perpendicular curve. As the upper portion of the sacrum moves downward and forward, it drags with it the posterior superior portions of the iliac bones, to which it is attached by the sacro-iliac junctions and by the strong sacro-iliac ligaments. The natural result of the movement of the posterior portions of the innominate bones inward, downward, and forward, would be to throw outward the anterior extremities of these bones, and this would happen were not the bones joined firmly at the symphysis. Subjected to the THE ANATOMY OF THE PELVIS. 25 force behind and restrained by its junction in front, the innominate bones are bent upon themselves, and thus acquire their lateral curve. These few illustrations by no means exhaust the dynamics of the pelvis. The subject will be referred to again in the study of some of the pelvic deformities. The Bony Pelvis in Life Filled with Soft Tissues.—Besides the generative organs, the obstetrical anatomy of the pelvis must Fig. 7.—The pull of the ligaments and the pressure of the femora upon the pelvis (Schroeder). take into account the muscles, ligaments, connective tissue, blood-vessels, lymphatics, and nerves. The Muscles.—The iliopsoas, the obturator internus, and the pyriformis clothe the pelvic walls, modifying the diameters of the pelvic cavity and acting as buffers or cushions to protect the child's body in its passage through the birth-canal. The bulky iliopsoas muscles diminish the transverse diameter of the pelvic inlet by five centimeters, thus making the oblique diameters of the 26 PREGNANCY. pelvic inlet the longest and insuring ordinarily an oblique position of the presenting part, but these muscles are subject to compres- sion and to some displacement under pressure in labor and, it the pressure is excessive, the transverse diameter again becomes the longest; hence the transverse position of the head m ob- structed labors. The coccygeus, the levator am, the retractor am, the sphincter ani, the constrictor vaginae, and the transversus perinei are the muscles of the pelvic floor giving the direction to Fig. 8.—The pelvis with soft parts, bladder, rectum, uterus, and its appendages having been removed (from a model in the University of Pennsylvania). the lower part of the parturient tract in labor and directing the presenting part forward, outward, and upward under the pubic arch. The levator ani is by far the most important muscle in the pelvic floor. It is a strong, horseshoe-shaped band of muscle, consisting of two symmetrical halves slung back from the anterior pelvic wall and surrounding the vagina and rectum. It is the chief factor in pushing the presenting part forward away from the THE ANATOMY OF THE PELVIS. 27 perineum and out through the vulvar orifice. It is thus the chief conservator of the integrity of the pelvic floor in labor. Its injury robs the rectum and posterior vaginal wall of their strongest sup- port, allowing them to drop downward, outward, and forward in the rectocele, with which the gynecologist has to deal in second- ary operations upon so-called lacerations of the perineum. Fig. 9.—The pelvic canal encroached upon by the soft structures (Veit). The ligamentous structures of the pelvis of greatest interest to the obstetrician are the obturator membranes and the sacrosciatic ligaments, which close the pelvic walls, help to impart to the canal its shape and direction, and, by their situation at either end of the oblique diameters, receive upon their yielding surfaces the greatest pressure from the extremities of the long diameters of the fetal head,—an arrangement much more favorable for the child 28 PREGNANCY. than would be the compression of the longest diameters of the head between bony pelvic walls. The Connective Tissue of the Pelvis.—An intimate knowledge of the complex arrangement of the pelvic fascia is not essential Fig. 10.—Female pelvis, showing the form and attachments of the levatores ani muscles (Dickinson). to the obstetrician. For his purpose it suffices to remember that the arrangement of the pelvic connective tissue may be compared, roughly speaking, to a six-pointed star centering at the uterus, the three arms on each side being disposed as follows : A lateral Fig. ii.—Female pelvis, showing the levatores ani muscles from before and below (Dickinson). arm running out from the uterus between the layers of the broad ligament and becoming continuous with the subperitoneal connect- ive tissue of the lateral pelvic wall ; an anterior arm skirting- the bladder; a posterior arm skirting the rectum and continuing in THE ANATOMY OF THE PELVIS. 29 Fig. 12.—Schematic representation of the superior strait: a, Promontory; l>, symphysis; I, I, iliopsoas muscles; 2, 2, rectus abdominis; dotted line, the pelvic inlet (Veit). Fig 17 — The plane of pelvic expansion: a, Sacrum; b, pubis; ^lateral pelvic wall; 1,1, pyriformis; 2, 2, obturator internus; m, m, obturator membrane; i, i, sciatic nerve. 30 PREGNANCY. Fig. 14.—Plane of pelvic contraction : a, Tip of sacrum ; b, b, ascending ramus of pubis; c, c, ischium; 1, 1. obturator internus. Fig. 15.—Female pelvis, viewed from above, with ligaments (one-third natural size) THE ANATOMY OF THE PEL J IS. 31 Fig. 16.—Sacrosciatic ligaments. Fi', ovarian hydatid; U, uterus formed by fusion of the posterior ends of the ducts of Miiller; S, urogenital sinus; O (answering to D in I), ovary; P, parovarium, or remnant of Wolffian body and duct. 3, Modifications in the male : H, Testis (corresponding to D in I) ; E, epididymis; h, hydatid of Morgagni ; a, vas aberrans; V, vas deferens, or Wolffian duct; u, uterus masculinus, the remnant of the lower ends of the fused ducts of Miiller ; S, urogenital sinus (from Landois and Stirling). The testicle is distinguishable from the fetal ovary about the eighth week. The cells which in the female form ova, in the male subdivide and give origin to the spermatozoa, while the cells which correspond to the lining cells of the female egg-tubes develop the lining cells of the seminiferous tubules. These canals may be detected in the human embryo of ten weeks ; they branch, and during the third month are collected into groups, indicating the lobular subdivision of the adult testis. The genital cord is a cylindrical mass in which, in both sexes, the ducts of Miiller and Wolff become imbedded near the uro- genital sinus. The four ducts (two from each side) are at first THE FEMALE SEXUAL ORGANS. 41 separate. The Miillerian ducts coalesce at their lower ends and in the female enlarge to form the vagina and the posterior por- tion of the uterus ; in the male the lower fused portions of Miil- lerian ducts remain as the prostatic vesicle, or uterus masculinus. Fig. 32.—Diagrammatic outline of the Wolffian bodies and their relation to the ducts of Miiller and the reproductive glands : ot, Seat of origin of ovary or testes ; w, Wolffian body; w, Wolffian duct; m, m, duct of Miiller; gc, genital cord ; ug, urogenital sinus; i, rectum; cl, cloaca (from Allen Thompson). Fimbria. Labium Labium Bartholin's major. minor. gland. Fig. 33.—Diagram illustrating changes taking place in development of female generative organs (modified from Allen Thompson). In the female the anterior portions of the ducts of Miiller form the upper part of the body of the womb and the Fallopian tubes. In the female the Wolffian ducts almost entirely disap- pear, but traces of them may be found as the canals of Gartner. 42 PREGNANCY. Pathological development and distention of these ducts some- times give rise to vaginal cysts, which may obstruct labor. Meanwhile most of the Wolffian body (mesonephros) disap- pears on each side, but remnants of it may be found in adults. In the female they constitute the parovarium (epoophoron, or body of Rosenmuller). The Development of the External Genitals.—The forma- tion of the cloaca is common to both sexes, as is also its separa- tion into an anal and a urogenital portion. The urogenital sinus is at first narrow and deep, but soon becomes shallow, and meanwhile the perineal tissues separate it more and more from the anus. Before the subdivision of the cloaca a genital emi- nence appears at its ventral or anterior end about the sixth week. On each side of the cloacal slit outgrowths of skin and Fig. 34.—To illustrate the development of the human external genitals: 1. h, Genital eminence; r, cloacal aperture; s, tail or coccyx of embryo. 2. h, Genital eminence; r, cloacal opening; w, commencement of labia majora or scrotum, accord- ing to sex ; s, embryonic tail. 3. Next stage, practically permanent in the female ; c, Genital eminence (clitoris); /, nymphse ; L, labia majora; a, anus. 4. Later or male condition : P, Penis; R, edges of embryonic folds enfolding to inclose the penial urethra; S, scrotum ; a, anus. 5 and 6 illustrate the descent of the testicle (from Landois and Stirling). subcutaneous tissue (Fig. 34, 1) become prominent. At the eighth or ninth week there is a groove in the under (posterior) side of the genital eminence, with well-marked side-walls leading back to open into the cloaca. The development of the perineum divides this groove (during the third month) transversely into a smaller anal opening and a larger urogenital. This condition is but slightly modified in the female. The genital eminence in that sex remains small and constitutes the clitoris. The side walls remain separate and form the labia minora, while the cuta- neous folds enlarge and become the labia majora (Fig. 34, 3). The urogenital sinus is, therefore, permanent in woman, and forms the vestibule, which has in front of it the clitoris, and, opening THE FEMALE SEXUAL ORGANS. 43 into it, the urethra and vagina. The skinfolds remain separate in the female to form the labia majora.1 The genital organs and structures of woman are divided into the external and the internal genitalia. The former, described often as the genitalia, pudendum, or vulva, comprise the mons veneris, the labia majora, the labia minora, the vestibule, with »Eirf|uri I ANUS DIAGRAM Fig. 35.—Diagram of the genitalia (Dickinson). the urethral orifice, and the clitoris ; the latter, the hymen, the vagina, the uterus, the Fallopian tubes, and the ovaries. The Mons Veneris and the Labia Majora.—The mons veneris is a flat protuberance over the symphysis pubis, consisting of fat and connective tissue covered with a tough skin clothed with coarse hair. In females the upper border of the hairy region 1 The description of the development of the sexual organs is taken, with modifi- cations, from Newell Martin's article in "The American System of Obstetrics," edited by the author. 44 PREGNANCY. is a horizontal line ; in males the hair rises in a triangular shape to a point upon the median line of the abdominal wail. The labia majora are folds of skin containing fat, connective tissue, and involuntary muscle-fibers, continuous with the mons veneris and uniting belowr an inch in front of the anus. They surround the urogenital fissure. Their points of junction above and below are called the anterior and posterior commissures. Just within the latter there is a crescentic transverse fold of skin, called the fourchet. The region between the fourchet and the posterior commissure is the fossa navicularis. The Labia Minora, or Nymphas.—Just below the anterior com- missure of the labia majora the nymphae begin on each side as two leaflets of delicate skin ; one, the upper, with its fellow of the other Fig. 36.—Hypertrophied nymphae (author's case). side, constituting the prepuce of the clitoris ; the lower leaflet, with its other half, forming the frenum of the prepuce. Uniting below and to the outer side of the clitoris, the nymphae run downward to merge into the labia majora at about their middle or lower third. The labia minora are often asymmetrical. They lie apposed to each other in the middle line, completely covered by the labia majora. They vary much in size. In Hottentots they are uniformly enormous, projecting far beyond the labia majora. As an exception this condition is sometimes seen in the Caucasian race. The skin of the nymphae is in a transition stage between mucous membrane and skin. It merges on its outer side into the delicate skin of the inner surface of the labia majora, and on its inner side into the mucous membrane of the THE FEMALE SEXUAL ORGANS. 45 vestibule. The venous spaces and the unstriped muscular fibers in the nymphae resemble the structure of erectile tissue. The vestibule is the space between the clitoris, nymphae, and vaginal entrance. It is pierced in its mid-line by the urethral orifice,—the external meatus. The bulbs of the vestibule are two masses of venous plexuses about an inch long, lying along the sides of the vestibule below the clitoris and within the nymphae. They are the homologues of the corpora spongiosa in the male. In sexual excitement, by muscular compression of their efferent vessels, they become turgid and erect. The clitoris has the structure and anatomical features of the penis, but in miniature, and modified by the cleft below, the absence of the urethra, and the separation of the spongy bodies into the bulbs of the vestibule. The cavernous bodies of the clitoris are erectile. The glans of the clitoris is surrounded at its base by sebaceous follicles secreting a smegma, which may be confined by preputial adhesions, and is likely to cause irritation by its decomposition. Bartholin's glands, or the vulvovaginal glands, are muco- serous, racemose glands about a third of an inch in diameter, lying under the mucous membrane of the lateral vaginal walls and emptying by long, slender ducts in the vestibule just outside the vaginal entrance. The Hymen.—The crescentic septum, occluding usually the posterior portion of the vaginal entrance, with the concavity of its opening directed upward, but presenting often an annular, cribriform, cordiform, crenelated, or cleft appearance, is a fold of mucous membrane reinforced by fibrous tissue, usually ruptured with ease, but occasionally so firm and unelastic that it even resists the impact of the descending head in labor. The hymen is torn at the first coitus, sometimes by gynecological examina- tion, or by masturbation. It is partially destroyed in labor, the remnants persisting as isolated protuberances around the vaginal orifice,—the carunculae myrtiformes. The Vagina.—The vagina is a musculomembranous canal extending from the hymen to the base of the vaginal portion of the cervix uteri. The posterior wall of the canal is about three and one-half inches (9 cm.) long, the anterior two and one-half inches (6.5 cm.). The axis of the canal is slightly sigmoid in shape, but corresponds quite closely to the axis of the pelvic canal. The upper portion of the canal is expanded into the vaginal vault, the recesses being particularly well marked ante- riorly and posteriorly, constituting the anterior and posterior for- nices. The vagina, therefore, is flask-shaped. The vaginal walls are composed of three structures,—the mucous membrane, 46 PREGNANCY. the muscular coat in two layers (the inner circular and the outer longitudinal), and a fibrous sheath. The anterior and posterior walls should be in contact, while the lateral walls are thrown into folds which give a transverse section of the vagina the shape of the letter H. The mucous membrane is covered with squa- mous epithelium, and with numerous papillae, but has no glands except a few tubular structures in the upper part of the canal. The mucous membrane is thrown into numerous transverse folds or rugae, most marked upon the anterior wall and in nulliparous women. There is an anterior and a posterior cord-like process in the median line, the anterior and posterior columns of the vagina, indicating the lines of junction of the ducts of Miiller. The Uterus.—The uterus is a hollow, muscular organ, in the adult virgin measuring 7.5 cm. in length, 4 cm. in breadth, and 2]/2 cm. in its anteroposterior diameter. In shape the uterus is a flattened, pyriform body, the anterior wall being almost perfectly flat, the posterior more convex. It is divided into the body, the isthmus, and the neck, or cervix. The first occupies about three-fifths of its length, the last, two-fifths. In structure the uterus consists of a muscular wall with a mucous lining and a peritoneal covering. The muscle is unstriated and is arranged, roughly speaking, in three layers,—an external, a middle, and an internal. The middle layer constitutes the bulk of the wall; its fibers are arranged in a somewhat spiral form, though no very definite arrangement is to be distinguished. The fibers of the inner and outer layers are arranged in longitudinal and circular bands. The mucous membrane of the body of the uterus is composed of columnar, ciliated, epithelial cells, resting upon a delicate basement membrane. The cilia of the uterine epithelium lash in the same direction as those of the tubes, namely, from within outward, or from above downward.1 As there is no submucous tissue, the mucosa of the uterus rests di- rectly upon the muscle. The uterine mucous membrane is richly supplied with tubular glands, divided in their lower ends usually into two branches or forks. In the cervix the mucous membrane is thrown into longitudinal folds with lateral branches, —the arbor vitae of the uterus. The epithelial cells in the upper two-thirds of the cervical canal are columnar, ciliated, in the lower third stratified, squamous cells. In addition to the tubu- lar glands of the uterine body the cervical mucous membrane contains wide mucous crypts, the orifices of which easily become obstructed, so that they are converted into retention cysts, which commonly stud the cervix in cases of old inflammation or in- jury,—the glands or follicles of Naboth. 1 This has long been a disputed point. See Mandl. " Ueber die Richtung der Flimmerbewegung im menschlichem Uterus," " Centralbl. f. Gyn.," No. !-• 1808 THE FEMALE SEXUAL ORGANS. 47 The uterine cavity is normally fusiform, widened in its upper part into a triangular space, most contracted below at the level of the internal os uteri. It has three openings, the internal os communicating with the cervical canal and the two uterine orifices of the Fallopian tubes. The cervical canal in the nul- liparous woman is a slender ovoid in shape, contracted at its upper and lower boundaries,—the internal and the external os uteri. In a woman who has borne children the cervical canal is often funnel-shaped, the external os, or the cavity just above it, being the most expanded portion. The cervix itself is divided into two portions, the vaginal and the supravaginal. The former projects into the vaginal vault; Fig- 37-—Section of human uterus, including mucosa [a) and adjacent muscular tissue (b) ; c, epithelium of free surface and tubular uterine glands (d) ; f deepest layer of mucosa, containing fundi of glands; h, strands of non-striped muscle pene- trating within the mucosa (Piersol). the latter is attached to the vaginal walls and extends a short distance above their attachments. The anatomist commonly speaks of the supravaginal portion as being entirely above the vaginal attachments and extending to the isthmus. This view, however, is erroneous, as it assumes that the lower uterine seg- ment is a part of the cervix. It is usual to describe an anterior, shorter lip of the cervix and a longer posterior one. This description is more accurate in the parous woman with a bilateral tear of the cervix. As may be seen in figure 38, the supravaginal portion of the cervix is longer anteriorly than posteriorly. The normal position of the uterus 48 PREGNANCY. is almost horizontal as the woman stands erect. It is slung between the layers of the broad ligament, supported by lateral, anterior, and posterior musculofibrous bands and folds of pen- ^, V/\C,INM. <^Jn> Portion ^ PoRTiofl; VflCINAL FottioiJ Fig. 38.—Diagram illustrating the relations of the uterus to the vagina, bladder, and peritoneum (Dickinson). Fig. 39.—Uterus didelphys : a, Right segment; b, left segment; c, d, right ovary and round ligament; f e, left ovary and round ligament; g, j, left cervix and va- gina ; k, vaginal septum ; h, i, right cervix and vagina. toneum. It is so freely mobile that it rises and falls with every breath the woman draws. The uterus is formed by the junction and fusion of the two ducts of Miiller. An arrest of development in embryonal life THE FEMALE SEXUAL ORGANS. 49 results in a partial junction or a complete failure to unite on the part of the Miillerian ducts. The consequent deformities of the uterus may occasion abnormalities in pregnancy or complications in labor and after-delivery. If there is complete disjunction of the two ducts, the deformity is known as uterus didelphys (Fig. 39). If there is an outward junction but a complete disassociation of the two tubes except for their superficial union externally, the condi- tion is called uterus bicornis duplex (Fig. 40). If there is a junction Fig. 40.—Uterus bicornis duplex: a, a, Double entrance to vagina; b, meatus urinarius ; c, clitoris ; d, urethra ; e, e, double vagina ; f f external orifices of uterus ; g, g, double cervix; h, h, bodies and horns of uterus; i, i, ovaries; k, k, tubes; /, /, round ligaments ; m, ?n, broad ligaments. at the cervix but separation of the ducts above, there is a uterus bicornis unicollis (Fig. 41). There may be complete junction of the two Miillerian ducts, but the fusion of the two canals is incom- plete ; a uterus subseptus or semipartitus is the result. Finally, one may see in the form of the uterus an indication of its double origin : there may be a uterus cordiformis (Fig. 42) or a uterus incudiformis (Fig. 43). Occasionally one duct of Miiller de- 5o PREGNANCY. velops normally while the other is present as a mere rudiment. There is, in consequence, a uterus unicornis (Fig. 45)- The vagina is double in uterus didelphys and often in uterus bicornis duplex. The duplicity of the birth-canal may be con- Fig. 41.—Uterus bicornis unicollis: a, Vagina; b, single neck; c, c, horns; d, d, tubes ; c, e, ovaries ; /, /, round ligaments. Fig. 42.—Uterus cordiformis : a, Indented fundus ; b, b, tubes; c, c, round liga- ments ; d, central longitudinal ridge on posterior wall of uterine cavity; e, e, lateral ridges of same ; f, internal os ; g, g, cervix. fined to the vagina (double vagina) or it may affect the cervix without involving the rest of the uterus,—uterus biforis (Fig. 44). The Oviducts, or Fallopian Tubes.—These are tubular structures about 10 or 12 cm. long, running from the cornua THE FEMALE SEXUAL ORGANS. Fig. 43.—Uterus incudiformis. Fig. 44.—Schematic drawing of double vagina and single uterus : A, Left vagina ; B, right vagina ; C, cervical septum. Fig. 45.—Uterus unicornis : LH, Left horn ; Z T, left tube ; Lo, left ovary ; Z Lr, left round ligament; RH, right horn ; RT, right tube; Ro, right ovary; R Lr, right round ligament. 52 PREGNANCY. Fig 46 -Ill-developed uterus unicornis : a, Cervix ; b, fundus ; c, d, longitudinal axis ofguferine body; e, cornu; /, tube; g, ovary; h, ovarian ligament; ,, round ligament; /^parovarium. Fig. 47.—Ill development of right side of uterus ; congenital lateral flexion. Plications. Fjtr 48 —Longitudinal section of Fallopian tube, exposing the complicated longitu- ° dinal plications of the mucosa which expand into the fimbriae (Sappey). THE FEMALE SEXUAL ORGANS. 53 of the uterus at the upper edge and between the layers of the broad ligament outward, upward, and at their outer extremi- ties downward and backward to the free surface of the ovary. The canal of the tube begins in the uterine wall as a fine opening (ostium internum) ; it expands to about 2 mm. in diameter, becomes wider as it runs outward, again contracts when it passes the ovary, widens again to a distinct opening 4 mm. in diameter (ostium abdominale) into the apex of the pavilion, or infundibulum, a funnel-shaped expansion at its outer extremity surrounded by fringed processes,—the fimbriae. Fig. 49.—Transverse section of Fallopian tube, showing the complicated arrangement of the longitudinal plications which are here cut across (Ahlfeld). The fimbriated extremity is connected with the ovary by the tubo-ovarian ligament. The tube has three coats,—a mucous, muscular, and serous. The mucous membrane of the tube consists of a single layer of columnar, ciliated, epithelial cells, the cilia lashing toward the uterine cavity. The membrane is thrown into deep longitudinal folds, becoming more complex as the fimbriated extremity is approached. There are no glands in the mucous membrane. The muscular coat consists of circular fibers of unstriped muscle, 54 PREGNANCY. with an outer, ill-developed layer of longitudinal fibers. The serous covering is continuous with the serous covering of the broad ligament. The Ovaries.—These are almond-shaped bodies varying in size in different individuals and under different circumstances, but having average diameters of 3.5 cm. in length, 2 cm. in Fig. 50.—Section through part of ovary of adult bitch : a, Germinal epithelium; b, b, ingrowths (egg-tubes) from the germinal epithelium, seen in cross-section ; c, c, young Graafian follicles in the cortical layer; d, a more mature follicle, containing two ova (this is rare); e and/", ova surrounded by cells of discus proligerus; g, h, outer and inner capsules of the follicle; /, membrana granulosa; /, blood-vessels; pi, m, parovarium ; g, germinal epithelium commencing to grow in and form an eg^- tube ; z, transition from peritoneal to germinal epithelium (from Waldeyer). width, and 1.5 cm. in thickness. They are attached to the pos- terior layer of the broad ligament by the hilum. The ovary is a gland secreting eggs. It has, therefore, a gland-structure, stroma, parenchyma, and gland-spaces. There are, however certain distinctive peculiarities about this gland. Its peritoneal covering exhibits a modified form of cells,—the germinal epi- THE FEMALE SEXUAL ORGANS. 55 thelium. The gland-spaces have no ducts, but excrete their contents by a rupture of their walls. The body of the ovary is divided into a cortex and a me- dulla. The former contains the gland-spaces called Graafian follicles (after their discoverer, Regnier de Graaf), set in a stroma of spindle-shaped con- nective-tissue cells. The lat- ter contain blood-vessels, nerves, a few muscle-fibers, and irregular groups of poly- hedral cells (the interstitial cells), representing atrophic remains of the Wolffian bodies. Besides its connection with the posterior layer of the broad ligament by the hilum, the ovary is attached to the uterus by the utero-ovarian ligament, to the tube by the tubo-ovarian ligament, and to the pelvic wall by the sus- pensory ligament of the ovary (ovariopelvic, infundibulopel- vic ligament). Fig. 51.—Section of human ovary, in- cluding cortex : a, Germinal epithelium of free surface ; b, tunica albuginea; c, peri- pheral stroma containing immature Graafian follicles, d ; e, well-advanced follicle from whose wall the membrana granulosa has partially separated; f cavity of liquor folliculi; g, ovum surrounded by cell-mass constituting discus proligerus (Piersol). f„$.W v-S m 4,' Fig. 52.—Section of well-developed Graafian follicle from human embryo; the inclosed ovum contains two nuclei (von Herff). 56 PREGNANCY. CHAPTER II. Menstruation, Ovulation, Insemination, and Fertilization; The Changes in the Ovum After Fertilization. MENSTRUATION. Menstruation is the periodic discharge of a sanguineous fluid from the uterus and the Fallopian tubes occurring during the time of a woman's sexual activity, from puberty until the meno- pause. From the earliest ages of medical literature many theories have been advanced to account for menstruation. The oldest explanation entertained until comparatively recent times was founded upon woman's supposed uncleanliness. Menstruation was thought to be an effort on the part of nature to rid the woman's body of noxious humors.x Again, it was explained that woman was plethoric and that nature provided a periodic vent for the superfluous blood. In modern times Pfliiger has advanced the theory that menstruation occurs in consequence of a conges- tion brought about as follows : A Graafian follicle by its growth finally produces so great a reflex irritation as to determine a local congestion, which manifests itself in a bloody discharge from the uterine mucous membrane. Sigismund, Lowenhardt, and Rei- chert propounded the doctrine that menstruation occurs because the ovum discharged prior to the menstrual period is not impreg- nated ; consequently, failing this stimulus to further growth and development, a retrograde change with bleeding occurs in the uterine mucous membrane. As a matter of fact, the cause of menstruation is one of the many life-phenomena at present beyond human comprehension. All that can be said is that a nervous influence proceeds periodically from the sympathetic nerve-glands in the lower abdomen and pelvis, leading to a stimu- lation and congestion of the sexual organs. We can no more account for this nervous action than we can explain the nervous force which continues respiration from the moment of birth until death. Certain facts from comparative physiology, however, throw a glimmer of light upon the subject. For instance, it is 1 Many popular superstitions are founded upon this idea; for example, that a drop of menstrual blood will wither a flower, and that a menstruating woman in a dairy will turn the milk sour. The modern physician is still influenced by this old super- stition, if the author may judge from grave discussions he has heard as to the pro- priety of allowing a menstruating nurse to be present during the performance of an abdominal section. MENSTRUA TION 57 asserted that if sheep fall into heat and are not gratified, the rut returns in a month. Menstruation in the female is obviously what rut is in the lower animals, and the bloody discharges from human females are probably the result of their erect posture and the pelvic congestion which is a consequence of it. The mechanism of menstruation is better understood than its causes. It is a diapedesis of blood through delicate, new-formed capillaries in a thickened and congested endometrium, the provi- sion for carrying blood to the membrane being better than that for bearing it away by the efferent vessels. Leopold has given the following description of the uterine mucous membrane dur- ing menstruation : The mucous membrane is 8 mm. thick, swollen, dark brownish red, soft almost to liquefaction, but perfectly intact and separated by a sharply defined boundary-line from the paler muscular tissue of the uterus. The uterine glands, ^ to ^ of a mm. wide, are considerably lengthened and can be seen by the naked eye. In the superficial portion of the mucous membrane, which is very well preserved and only in certain spots lacks its epithelium and subjacent cells, may be seen an immense and enormously hypertrophied capillary network, the vessels of which have irregular outlines and lie in the uppermost layer of the mucous membrane. From this observation of Leopold's, and from other studies of mucous membrane removed by the curet during menstrua- tion, it appears that the theory of hemorrhage in consequence of degeneration of the mucous membrane is untenable. There are certain clinical phenomena of menstruation which must often be taken into account by the obstetrician. Time of First Occurrence and of Cessation.—The onset of menstruation is influenced by race, climate, mode of life, heredity, and genital sense. In temperate climates and in the home of the Teutonic and Anglo-Saxon races, menstruation occurs oftener in the fifteenth than in any other year. In these same races transplanted to the eastern middle sea-board of the United States, menstruation appears a year or two earlier. In Hungary the three races, Slavonic, Magyar, and Jew- ish, living side by side in the same climate, begin to menstru- ate, respectively, at sixteen, fifteen, and thirteen years of age. Hindu girls of Calcutta and negresses of Jamaica, living in similar climatic conditions, begin to menstruate at the eleventh and at the fifteenth year. Climate, however, does influence the onset of menstruation. It appears at eighteen years in the girls of Lapland and at ten years in Fgypt and Sierra Leone. The social conditions of a girl determine, to a certain extent, 58 PREGNANCY. the age at which menstruation begins. If she lives in a city, subjected, perhaps, to indiscriminate association with the other sex and to sexual temptations, the function appears earlier than it does in the country, or in a girl carefully brought up in com- parative seclusion. The same rule applies to lower animals. If a bull is admitted to the pasture of a herd of heifers, heat appears earlier in the latter than it would if they were segre- gated. It is a matter of common observation that peculiarities of menstruation run in certain families. Thus, through several gen- erations of females menstruation appears late and ends early, or vice versa. By genital sense is meant the strength of sexual feeling. In women of strong sexual passion the function of menstruation is commonly instituted earlier and lasts to a greater age than common. Precocious menstruation is not uncommonly associated with nymphomania. Menstrual Molimina.—By this term is meant the local and reflex subjective symptoms of menstruation. There is a feeling of weight and heaviness in the pelvic organs, due to their con- gestion and increase of size. There is a general nervous excita- tion, so that women disposed to hysteria and epilepsy will exhibit outbreaks at this and perhaps at no other time. The breasts swell and may secrete milk. The thyroid gland is enlarged and the tonsils are swollen, so that singers may lose their voice. There is increased vascular tension, increased activity of the heart, shown by sphygmographic tracings, and the pulse is accelerated. The temperature is elevated by o. 5° C. The skin is more vascular and shows unusual pigmentation, especially in the dark rings under the eyes. The Character of the Flow.—The discharge consists, in great part, of blood. It is alkaline in reaction. It contains, besides blood, mucous secretion from the glands along the genital canal and epithelial cells. It is dark in color, and should not clot. It has a peculiar odor from the secretions of the sebaceous glands at the vaginal outlet, excited, as are all the structures of the genital canal, to unusual activity. The Duration of the Flow.—Menstruation rarely lasts less than three days ; a continuance of four, five, or seven days if the natural and invariable habit of the individual may indicate nothing pathological. In the first two or three days the greatest amount of blood is lost. After that the discharge grows less until it ceases. A leukorrhea or mucous discharge for a day or two after the cessation of the bloody flow is common. The Quantity of the Flow.—The actual quantity of dis- charge during menstruation has been estimated at four to six 0 VULA TION. 59 ounces. It is not practicable for the physician, however, accurately to measure the amount of flow. He must estimate it by the number of napkins worn in twenty-four hours. If a woman is obliged to change her napkins during the height of the flow more than three times a day, the quantity of the flow is excessive. The Cessation of the Flow—The menstrual flow ceases usu- ally in the forty-fifth year, becoming infrequent and more scanty over a period of six, nine, or twelve months, until it stops alto- gether. There are many exceptions, however, to this rule. A woman who begins to menstruate much later than the fifteenth year wall often have the menopause before forty. Or, if she begins to menstruate early, she will often continue beyond the forty-fifth year. As a rule, therefore, it may be stated that a woman menstru- ates from about the fourteenth to the forty-fifth year of her age. Precocious menstruation, however, has been recorded in the infant of one or two years old, and has continued to the sixty- fifth and even to the eightieth year. OVULATION. By ovulation is meant the discharge of a mature ovum from its Graafian follicle. The study of the process involves a con- sideration of the development of the Graafian follicle and its rupture ; the maturation of the ovum ; the transmigration of the ovum from the surface of the ovary to the uterine cavity. The Development of the Graafian Follicle and its Rup= ture.—The germinal epithelium on the surface of the ovary sends down into the ovarian stroma columnar prolongations called egg-cords. These cords become constricted at intervals, so that they are converted into a number of spherical gland- spaces unconnected with one another and without efferent ducts. The gland-space is surrounded by a containing membrane (the theca folliculi) divided into two layers,—the tunica fibrosa and the tunica propria. The interior of the gland-space is lined with a layer of epithelial cells,—the membrana granulosa. One of these cells, more highly specialized than the rest (the ovum), is surrounded by an aggregation of the cells of the membrana granulosa,—the proligerous disc. The cavity of the gland-spaces is distended with fluid (the liquor folliculi) containing paralbumin. As the Graafian follicle develops, it retires deeper into the interior of the ovum. Finally, however, the most mature follicle, under the influence of premenstrual congestion, rapidly secretes liquor folliculi, swrells to the size of a pea or a cherry, so that it stands out plainly from the surface of the ovary. On the most promi- 60 PREGNANCY. nent portion of its free periphery the tunica propria fails at one spot (the stigma), so that the integrity of the follicle is preserved only by the tunica fibrosa ; this, too, soon gives way under the pressure imposed upon it from within, and the follicle ruptures. The ovum and surrounding discus proligerus, attached to the follicle-wall just under the stigma, are washed out into the free peritoneal cavity by the escaping liquor folliculi. The Maturation of the Ovum---The primordial ovum in the immature Graafian follicle is an epithelial cell without a cell-wall, but with cell-con- tents called the yolk, a nu- cleus called the germinal vesi- cle, and a nucleolus called the germinal spot. As the ovum matures, it acquires a cell-wrall with three coats or layers,— the zona pellucida, the vitelline membrane, and the internal cell-membrane. The human ovum is holoblastic,—that is, it completely segments,—and contains much more proto- plasm, or germ-yolk, than deutoplasm, or food-yolk. In its maturation, or preparation for impregnation, the ovum shows a curious movement of its nucleus (karyokinesis, a moving of the nucleus), which approaches the cell-periphery, arranges itself in two star- shaped figures (the amphiaster stage), and extrudes portions of its substance as little glob- Fig- 53-—Section through part of a mammalian ovary : KE, Germinal epitheli- um ; PS, an egg-cord ; U, U, primitive ova ; G, investing cells; K, germinal vesicle; S, follicular cavity arising in one of the older follicles; If, follicular cavity, more enlarged; Ei, nearly mature ovum, which has developed around it the zona pellu- cida, Mp ; Mg, membrana granulosa; D, Discus proligerus; So, ovarian stroma; Tf capsule of follicle ; g,g, blood-vessels; u, immature Graafian follicle (after Wie- dersheim). ules (polar globules) upon the ovular surface. These globules then disappear and are lost. It is supposed that they contain, perhaps, the male substances, which might unite with the female portions of the ovum to produce an imperfect being, as is done in certain hermaphroditic animals. Nature, it is presumed, takes this measure to prevent partheno- genesis, or the closest kind of inbreeding. A similar action may be observed in the spermatozoon during its development. After the extrusion of the polar globules the nucleus retreats into the interior of the ovum and becomes the female pronucleus. The ovum is now ready for fertilization. OVULATION. 61 The Discharge of the Ovum from the Ovary and its Migra- tion to the Uterine Cavity.—Ova are discharged from the ovary from puberty until the menopause,—that is to say, on the average, from the fourteenth to the forty-fifth year. Ovulation, however, Fig. 54.—Formation of polar bodies in ova of Asterias glacialis: ps, Polar spinale ; pb'', first polar body; pb'', second polar body; n, nucleus returning to condition of rest (Hertwig). may begin before menstruation, may cease before the menopause, or possibly may continue after it. A young girl has been im- pregnated as early as the ninth year. In the child-marriages of A « B Fig. 55.—A, Mature ovum of echinus: n, female pronucleus; B, immature ovarian ovum of echinus (Hertwig). India impregnation has occurred before menstruation had begun ; but usually premature maternity is preceded by precocious men- struation. Ovulation has continued, as proved by impregnation, until the fifty-second, fifty-fourth, fifty-eighth, and even to the fifty- 62 PREGNANCY. ninth year ! A case is recorded of delivery at the age of fifty-nine years and five months. An obstetrician investigating the nature of an abdominal tumor should remember, therefore, that pregnancy is possible from the ninth to the fifty-ninth year. After the ovum is discharged from the ovary it is caught in a current of fluid moistening the surface of the ovary, and is carried to the interior of the corresponding tube. The existence of this current of fluid is explained by the movement of the ciliated epithelium in the tubes. In some animals there is a development of ciliated epi- thelium on the peritoneum at the time of ovulation. Arrived in the tube, the ovum is transported to the uterine cavity by the movement of the cilia on the epithelium and by the vermiform movements of the tubal walls. In certain cases of extra-uterine pregnancy an anomalous transmigration of the ovum has been demonstrated. Thus it is possible for the ovum, after its dis- charge from the ovary, to be taken up by the fimbriated extremity of the opposite tube,—an external transmigration of the ovum. It is also possible for the ovum to traverse one tube and the uterine cavity and to enter the uterine ostium of the opposite tube,—an internal transmigration of the ovum. It has been calculated that the human ovary at birth contains 70,000 ova. As it is unlikely that any woman discharges many more than 360 ova, even if she ovulates uninterruptedly for thirty years, an enormous number of ova must atrophy, disintegrate, and disappear within the ovary. THE CORPUS LUTEUM. The changes which occur in the Graafian follicle after its rup- ture and the discharge of the ovum, discus proligerus, and liquor folliculi lead to a formation within the Graafian follicle called the corpus luteum. There is an effusion of blood into the cavity of the follicle and an enormous development of the membrana granulosa. Leopold thus describes the development of the typical corpus luteum : It appears on the first day as a follicle just broken open, the inte- rior filled with blood. From the eighth day on there appears a fine capsule around the blood-extravasation, while the inner por- tion becomes lighter and clearer. From the twelfth day the capsule grows thicker and is thrown into folds ; from the six- teenth day this becomes a pale red, merging into a yellow. About the twentieth day the central matter of the broken follicle has become much shrunken, while the capsule, more decidedly a pale yellow, projects toward the center of the follicle in rays and narrow folds. The corpus luteum of menstruation, or the so- OVULATION AND MENSTRUATION. 63 called false corpus luteum, reaches its highest development in ten to thirty days. Nine days later it is merely a lamina of fibrous tissue beneath a little pit or depression of the ovarian surface. The true corpus luteum of pregnancy, so called, is simply an exaggeration of the corpus luteum of menstruation, the longer growth and greater size being due to the stimulation and congestion of gestation. It grows for thirty or forty days after conception, occupying a third, perhaps, of the ovarian area. It then remains stationary until after the fourth month, when it begins to atrophy ; at term it is only two-thirds its largest size ; one month later it is reduced to a small mass of fibrous tissue. The true corpus luteum is of value as an indication of the ovary from which the impregnated ovule came. It should be remembered, however, that the ovaries of virgins have exhibited corpora lutea like those of pregnancy in consequence of intense and prolonged congestion. THE CONNECTION BETWEEN OVULATION AND MENSTRUATION. Neither one of these functions is dependent upon the other, but they both depend upon a common cause,—the periodic nervous excitation and congestion due to an impulse from the sympathetic nervous system. Dependent as they are upon the same cause, their occurrence is usually synchronous,—that is, the ovule is discharged at the height of menstrual congestion. But this is by no means the invariable rule. Leopold,1 in an examination of twenty-nine pairs of ovaries removed on suc- cessive days up to the thirty-fifth after a menstrual period, found a Graafian follicle bursting on the eighth, twelfth, fifteenth, sixteenth, eighteenth, twentieth, and thirty-fifth day after the menstrual period. In other words, ovulation may occur without menstruation at any time in the intermenstrual interval. In five cases there was no ovulation at the menstrual period, or men- struation occurred without ovulation. Many examples might be given, from clinical observation, of the mutual independence of these two functions. The common occurrence of impregnation during lactation is a good instance of ovulation without men- struation.2 Menstruation after oophorectomy and during the 1 "Archiv f. Gyn.," Bd. xxix, S. 347. 2 Remfry (" Revue internationale de Medicine et de la Chirurgie," 1896, No. 5) has found by an investigation among 900 nursing women that in 57 per cent, only did there occur an absolute amenorrhea. Menstruation was regular in 20 per cent. and irregular in 43 per cent. It was also common for conception to occur during lactation, 60 per cent, of the menstruating women conceiving. Among the non- menstruating women but 6 per cent, conceived during lactation. 64 PREGNANCY. first three months of pregnancy occurs without ovulation. I attended, in her first childbirth, a young woman twenty-two years old, who had never menstruated. She had obviously, however, ovulated. Repeated ovulation without menstruation is seen also in those curious cases of postmarital amenorrhea, lasting for years. The wife of a physician among my acquaintances menstruated once after marriage ; in the following fifteen years she bore ten children without ever menstruating. Three years after the birth of the last child, or eighteen years since its cessa- tion, menstruation returned copiously and regularly, but more frequently than normal, for twelve years. The menopause then began, at the age of forty-eight.x Finally, I was once obliged to remove the ovaries in a case of ill-developed, infantile womb, associated with well-developed ovaries, in which there was a violent exaggeration of the men- strual molimina every month without a discharge of blood and the consequent relief of menstrual congestion. The ovaries were found, after their removal, to be filled with well-developed Graafian follicles and numerous depressions representing corpora lutea. In one of these ovaries there was a corpus luteum that would have answered for an illustration of the yellow body of pregnancy. INSEMINATION. By the term insemination is meant the ejaculation of seminal fluid from the male organ and its deposition within the genital canal of the female. The study of insemination involves a con- sideration of the seminal fluid, the development and life-history of its active constituent (the spermatozoa), the mechanism of its ejaculation from the penis, and of its reception within the vagina and womb. The seminal fluid is yellowish white in color, thick and sticky in consistency, varying in quantity at each emission from one-quarter to two drams. It possesses a peculiar odor and is neutral or alkaline in its reaction. The constituent parts, on chemical examination, are found to be water, eighty-two per cent. ; salts, mainly phosphates ; protein matter, fats, and spermatin. On microscopical examination there are seen seminal cells, crys- tals of phosphates, and spermatozoa, discovered by Hammen in 1677 and demonstrated to be the active principle in fertilization by the filtration experiments of Spallanzani and others. A sper- matozoon is g-l-g- of an inch in length and possesses a power of 1 Similar cases are reported in "Amer. Jour, of Obstetrics" i p -ik.2 and " N. Y. Med. Record," 1893, p. 717. -->*".» » INSEMINA TION. 65 motion by which it can travel its own length in a second, one inch in seven and one-half minutes (Henle), or from the hymen to the neck of the womb in three hours (Marion Sims). The progressive force of these bodies is sufficient to overcome obstacles that appear insuperable ; they may be seen, under the microscope, to push aside epithelial cells ten times their size. Their vitality under favorable circumstances is remarkable. They have been found alive in the testicles of criminals who had been executed three days, and of bulls which had been killed six days before. In the cow they have been found six days after insemination, in a rabbit, eight days ; a * in the female bat they may be found alive for months, and in the queen-bee for three years. In the human female living spermatic particles have been found in the cervical canal eight days after copulation. On the contrary, they are extremely susceptible to certain unfavor- able surroundings. They are destroyed by heat, cold, acid solutions, lack of water, and the mineral poisons. A solution of bichlorid of mercury, 1 : 10,000, is fatal to them. As a consequence of chronic disease in the man, of alcoholic or sexual excess, or of catarrh of the seminal vesicles, the spermatozoa may be dead when emitted. As a result of inflam- mation and obliteration of the seminal ducts or of anatomical defects the seminal particles may be absent from the seminal fluid. The indifferent constituent parts of the seminal fluid are derived from Cowper's glands, the prostate, and the vesiculae seminales. The spermatozoa are developed from mother-cells, or spermatoblasts, specialized from the epithe- lium of the testicle. In the course of their development a portion of the cell is extruded (seminal granule or accessory corpuscle) just as in the maturation of the ovum the polar globules are cast off In the fully developed spermatozoon the head represents the nucleus of an epithelial cell, and the tail cell-contents specialized in the form of a cilium, with much larger size and greater power, however, than the cilia of ordinary ciliated epithelium possess. Spermatic particles first appear in the seminal fluid at about the fifteenth or sixteenth year. There is often, in boys of twelve or thirteen, a seminal discharge, but it contains, as a rule, no spermatic particles. I have had charge, however, of a girl four- 5 Fig. 56. — Hu- man spermatozoa: A, Spermatozoon seen en face; h, head; m, middle-piece; t, tail; e, end-piece; B, C, seen from the side (after Retzius). 66 PREGNANCY. teen years of age impregnated by her brother, aged thirteen, who had stimulated his sexual development by masturbation. Sper- matozoa often disappear from the sexual discharge of old men, but the age at which this disappearance occurs varies greatly. As a general rule it might be put down as sixty-five, but it will be remembered that the French engineer, de Lesseps, was a father at eighty-two, and that old Thomas Parr illegitimately impregnated a woman after he had passed his hundredth birth- . day. Fig. 57.—a-h, Isolated sperm-cells of the rat, showing the development of the spermatozoon and the gradual transformation of the nucleus into the spermatozoon head. In g, the seminal granule is being cast off (after H. H. Brown), i—1/1, Sperm-cells of an elasmobranch; the nucleus of each cell divides into a large number of daughter-nuclei, each of which becomes converted into the rod-shaped head of a spermatozoon (after Semper), n, Transverse section of a ripe cell, showing the bundle of spermatozoa and the passive nucleus (/, n, after Semper), o—s, Sperma- togenesis in the earthworm; o, young sperm cell; p, the same divided into four; q, spermatophore with the central sperm-blastophore ; ;-, a later stage ; s, nearly mature spermatozoa (after Blomfield) (from Haddon). The Mechanism of the Ejaculation of Seminal Fluid and of its Reception within the Genital Canal of the Female. —The mechanism of ejaculation is only understood by a study of the anatomy of the penis, which need not be considered here. It is sufficient to state that at the height of the orgasm in the male the seminal fluid is emitted by the action of the circular and longitudinal muscle-fibers of the vesiculse seminales and of INSEMINA TION. 67 the urethra. The mechanism of the reception of the fluid within the genital canal of the female is a much more important matter to the obstetrician, for on a knowledge of this subject depends the comprehension of many a case of conception and of sterility. It has been found, in studying the sexual congress of animals, especially in horses, that during the emission of semen and for a short time afterward the uterus exerted an intermittent suction, or aspiration action, upon the seminal fluid, drawing it into the uterus. In the observation of sexual excitement in bitches it has been noticed that the uterus is drawn down into the small pelvis. In experimenting with the electrical stimulation of the sexual organs in female animals, it was observed that the uterus grew7 shorter, but broader; that it descended toward the vaginal outlet; that the cervix projected farther than normal into the vaginal canal, at the same time becoming softer and shorter, but broader, by which action the os uteri was opened. The stimulus being removed, the uterus returned to its normal condition and the os closed. These interesting experiments upon animals have been con- firmed by observations which gynecologists occasionally have the opportunity of making upon erotic females during a specular examination. It is justifiable, therefore, to state that in the orgasm a woman's uterus becomes broader and shorter ; that it descends into the small pelvis ; that the cervix projects into the vagina, becomes broader, shorter, and softer, and that the os opens ; these actions being intermittent, the uterus might be likened to an animal gasping for breath. It would appear that the intention of this action is to suck the seminal fluid directly into the uterine cavity. The postmortem examination of two women murdered at the conclusion of a copulation in whom the uterine cavity was found full of seminal fluid does not, therefore, seem necessarily apocryphal, though the reports date from an unscientific age, and have been used as the foundation of absurd theories.1 A perfectly normal and typical mechanism of the reception of seminal fluid may be thus briefly described : The orgasm of male and female should be synchronous ; as the seminal fluid is ejacu- lated from the penis it is sucked in part into the uterine cavity. An absolutely normal mechanism, however, is not always neces- sary to impregnation, though a lack of it explains some cases of sterility. One of my patients bore a child within a year after marriage and then remained sterile for six years. During the whole of this time she did not once experience sexual excite- 1 See Janke, " Hervorbringung des Geschlechts," Berlin and Leipsic, 1887. 68 PREGNANCY. ment during intercourse. Finally, for the first time in six years there was an orgasm, and it was synchronous with the husband's. This coitus proved fruitful. The resultant pregnancy, curiously enough, was tubal. There are many women who have abso- lutely no sexual feeling and who never experience an orgasm, but who, nevertheless, become pregnant repeatedly. Insemination has occurred also when the woman was asleep, drunk, asphyx- iated, or unconscious from some other cause. These cases are explained by the deposition of semen in the vault of the vagina, in what is called the seminal lake, into which the cervix projects. The spermatozoa, attracted by the alkalinity of the cervical mucus and repelled by the acidity of the vaginal secretions, make their way through the cervical canal into the uterus. This explanation presupposes a normal position of the uterus, but a retroverted uterus, with the cervix tilted so far forward that it is not bathed in the seminal lake, is not necessarily a bar to con- ception. The motility of the spermatozoa enables them to pene- trate the canal, although it may be difficult of access. Retro- version, however, is sometimes a cause of sterility. One of my patients bore a child and was sterile for five years afterward. On examining her to learn the possible cause of her sterility, which she had desired to remedy if possible, I found a complete retroversion. The malposition was corrected and the uterus was supported with a pessary. In the next six years that woman bore five children. The motility of the spermatozoa accounts, too, for the cases of conception without insemination at all,— that is, after a mere deposition of seminal fluid upon the external genitals. I have attended in confinement two married women with unruptured hymens, and on one occasion examined a young, unmarried girl with a perfectly intact, though delicate hymen, who had been impregnated, during an embrace by her lover in the erect posture, from the deposition of semen upon the labia majora. The Meeting Place of Ovule and Spermatic Particle.—It is generally assumed that the spermatozoa meet the ovule in the ampulla of the tube. That this may be the meeting place is proved by cases of tubal pregnancy. There are strong argu- ments, however, in favor of the fundus uteri as the normal meeting place of spermatic particle and ovule. If ovulation occurs at the height of menstrual congestion, the ovule has probably reached the uterine cavity before the fruitful coitus occurs. Hyrtl 1 found the ovule in the uterine extremity of the tube in a girl who had died on the fourth day of menstruation. 1 Miiller's " Handbuch," vol. i, p. 151. Plate i. Segmentation : I, 2, 3, Diagrams illustrating the segmentation of the mammalian ovum (Allen Thompson, after von Beneden) ; 4, diagram illustrating the relation of the primary layers of the blastoderm (Bonnet). INSEMINA TION. 69 In Jewesses, who are proverbially prolific, copulation is not allowed until a week after the cessation of menstruation. It is almost inconceivable that the ovum has not reached the uterine cavity by this time. The question, however, is not yet decided, and the student is at liberty to adopt the view most acceptable to his reason. The Fertilization of the Ovum.—From what has been seen in the lower animals and in the vegetable kingdom, it is probable that the ovum, during its passage through the tube or on its arrival in the uterine cavity, excretes some material which attracts the spermatic particles, as the female elements of some plants attract the male elements by an excretion of malic acid. From the swarm of spermatozoa around it a number may penetrate the cell-wall of the ovum, but only one penetrates the cell-contents. Fig. 58.—Portions of the ova of Asterias glacialis, showing the approach and fusion of the spermatozoon with the ovum : a, Fertilizing male element; b, elevation of protoplasm of egg; bf', b", stages of fusion of the head of the spermatozoon with the ovum (Hertwig). The head of this spermatozoon fuses with a projection from the protoplasm of the ovum ; the tail disappears. The head then penetrates the cell-contents and becomes the male pronucleus,— a small, oval body with a striated arrangement of cell-contents about it. Finally, the male pronucleus unites with the female pronucleus. Conception occurs at the moment of this union, and from this instant dates the life-beginning of the future embryo, fetus, and infant. The Time when Coitus is Most Likely to Result in Con- ception.—Statistical studies show that impregnation is most likely to occur after copulation during the first eight days suc- ceeding the cessation of menstruation. There is a period, begin- ning fourteen days after the cessation of menstruation and lasting for a week, during which coitus is least likely to be followed by 7° PREGNANCY. conception. Some regular women among my patients avoid impregnation or become pregnant at will, by following or disre- garding this rule. As any woman, however, may ovulate at any time during the intermenstrual period, this method of preventing conception is by no means invariably reliable. A B Fig. 59.—A, Fertilized ova of echinus : The male a. and the female pronucleus, b, are approaching; in B, they have almost fused ; C, ovum of echinus after com- pletion of fertilization ; s.n., segmentation-nucleus (Hertwig). The Average Date of Conception after Marriage—Nor- mally, impregnation should succeed the first menstruation following marriage, but marriages are only called sterile after eighteen months have elapsed without conception. Pregnancy is possible, however, after years of sterility. I have had under my care women who conceived for the first time nine, thirteen, and twenty-four years after marriage. INSEMINA TION. 71 1 ! i 1 's ' 1 1 , 1 - ■ 45 T^ ^___ _________ __ 40 _____ ________________ 26 - -it--------------- ---------- ITL 7 4V jf \-l 5 H TT 7 1 K l / 15 lie j:---- it "T7 T \l | 1 6 +t-, ^t—T~ I^Kl""---X~~ / ' V ">/i /\ i \ . I \ 1 \ As,. l>\ 0 S 10 -la 20 25 »0 40 j_ ...... 2r\ ,., ,, ... 7 \ 1 t_i_±________________ io-----^ j^ it -.-h- ^ A > /\ 6 \ ' l| 1 1 III I ^-/l iV' 1 1 Figs. 60 and 61.—Curves showing relative frequency of conception following coitus at different times in relation to menstruation. In both diagrams the divisions on the abscissa line correspond to days: in the first, to days after the onset of menstruation ; in the second, to days after the cessation of men.struation. The curves indicate the proportion of conceptions to copulations on each day of the menstrual month (Hensen). 72 PREGNANCY. Fig. 62.—Diagrammatic section of a mammalian blastoderm after the cover-cells have completely closed in the blastoderm, and the embryo proper has become two-layered: ep', Non-em- bryonic epiblast; ep, embryonic epi- blast ; hy, hypoblast; ys, yolk-sac (from Haddon). CHANGES IN THE OVUM FOLLOWING IMPREGNATION.1 Directly after the formation of the nucleus of segmentation by the fusion of male and female pronucleus the ovum begins to segment. The original mass di- vides itself into two cells (blasto- meres), these into four, and so on until the whole ovum is sur- rounded by a layer of cells inclos- ing a group of somewhat larger cells (morula, or mulberry mass), and a hollow cavity containing albuminous fluid. This stage of development is called the blastula, or blastodermic vesicle. The cells of the ovum next arrange them- selves into a thinned-out, lami- nated layer around the periphery of the ovum, and another layer just within this, the offspring of the central mass of cells (the ectoderm), and the proliferating central mass itself, — the entoderm. Regarding the surface of the ovum, an oval, opaque region may be observed (the embryonal area), and in the middle of this area a streak of greater opacity appears,—the prim- itive streak. At the site of this streak a depression next appears,—the prim- itive groove. A microscopic examination of a section through this region now shows the development of a median layer of cells (the mesoderm), made up of cells derived in part from a Fig. 63. —Embryonic area of rabbit em- layer furnished by the ectO- br>?: Pr»™tive streak beginning in cell- , , J , proliferation, known as the " node of Hensen derm and by another fur- (e. v. Beneden). Head- process. Primitive streak. 1 It is not intended to give more than a mere sketch of the development of the embryo. The student interested in the subject is referred to special works, such as Minot's "Embryology." CHANGES IN OVUM FOLLOWING IMPREGNATION. 73 nished by the entoderm. In the course of its development the mesoderm develops lateral reduplications and parts into two layers (the parietal and visceral layers) inclosing spaces,—the body- cavity, or celom (Fig. 64). The parietal or somatic layer unites with the ectoderm to form the somatopleure. The visceral or splanchnic layer joins the entoderm to form the splanch- rrimitive groove. Beginning amnion fold. Parietal r. . . dayer of Ectoderm. \.„'j,r, Visceral layer 0/ mesoderm. Entoderm. Fig. 64.—Transverse section of the embryonic area of a fourteen-and-a-half-day ovum of sheep (Bonnet). Axial zone. , Neural canal. Somite Lateral zone Cavity within somite. Lateral plates for body-walls. Lateral plates for____Jj§£»,?J'^* gut-tract. $2lii Parietal mesoderm. Pleu roperitoneal cavity. Vitelline vein. Fig. 65.—Transverse section of a seventeen-and-a-half-day sheep embryo (Bonnet). nopleure. At the end of the second week the development of the embryo proper begins, by the formation of the neural folds, the neural canal, the chorda dorsalis, or notochord, and the somites, or provertebrae. The normal development of the em- bryonal body now depends, in its gross features, upon an arch- ing-over process of cells which inclose the spinal canal, the 74 PREGNANCY. abdominal and thoracic cavities, and the cranial cavity. An arrest in these developmental processes results in such deformi- ties as spina bifida, exomphalos, celosoma, hydrencephalocele, and anencephalia. CHAPTER III. The Development of the Embryo and Fetus* The changes in the developing embryo and fetus1 that mark its growth from month to month have practical value for the ob- stetrician when he would determine the probable date of im- pregnation from the appearance of the cast-off ovum. The intelligent explanation of many congenital deformities and intra- uterine accidents and diseases also depends upon a knowledge of intra-uterine development. First Month.—The life-history of the human ovum during the early part of the first month is involved in considerable doubt. The place in which the spermatic particle and ovule meet, the length of time required for the passage of the latter from the ovary to the uterine cavity, the part that the lining membrane of the oviduct and its secretion plays in the nourish- ment of the ovule and in the production of certain modifications in the external coat are all matters yet in dispute ; and as direct observation of the human ovum during and shortly after impreg- nation fails us, we must base our theories as to the site in which this phenomenon occurs, as to the changes that immediately suc- ceed it, upon what has been actually seen to occur in the lower animals, and upon the clinical history of those pregnancies in which the ovum is developed in an unnatural situation. Thus it is argued that the spermatic particle must penetrate the ovule shortly after its escape from the Graafian follicle, for the occa- sional occurrence of abdominal and tubal pregnancies proves that the so-called spermatozoa can make their way far into the tube and even on to the surface of the ovary ; and what is seen in animals, makes it probable at least that the outer coating of the ovule, during its passage through the tube, receives an addi- tional thickness from an albuminous deposit upon it, or that the original cell-wall becomes denser and more tough by a process of coagulation ; either of which conditions would render the penetration of the ovule by the spermatic particle unlikely, if not 1 The usual plan of calling the p.oduct of conception " embryo " for the first three months, and afterward "fetus," is the one adopted here. A. Second and Third Weeks. 3 4 B. Fourth Week. J3 14 15 i5 17 Fig. 66.—Early human embryos, all enlarged about two and a half times : 1-4, From twelfth to fifteenth day • 5, 6. from eighteenth to twenty-first day; 7, 8, from twenty-third to twenty-fiftli day; 9-12, from twenty-seventh to thirtieth day; 13-17, from thirty-first to thirty-fourth day. am, Amnion ; uv, umbilical or vitelline vesicle- ah allantoic or abdominal stalk; c, c', brain vesicles; //.heart; va, visceral arches; o, optic vesicle ; ot, otic vesicle ; ol olfactory pit; /, I', upper and lower extremities; s, somites; at, caudal process; u, primitive umbilical'cord (.His) bo >o ^3 Vl 76 PREGNANCY. impossible. On the other hand, it is claimed1 that if the ovule escapes from the ovary at the beginning of the menstrual flow, and if the fruitful coition occurs only some days after menstruation has ceased, as is common at least among civilized people, the time that intervenes between the rupture of the Graafian follicle and the deposition of semen in the female genital tract has been too great to lend probability to the idea that the ovule still remains in the ovarian extremity of the oviduct, but, on the contrary, would insure its presence in the uterine cavity. It is asserted that the rhythmical contraction of the muscles in the tubal walls which tend to drive the exuded menstrual blood, as well as the ovule, toward the uterus would offer an additional barrier to the ascent of the spermatozoids. This argument is invalidated, however, by the occasional occurrence of extra-uterine preg- nancy. There has been great difference of opinion in the past as to the manner in which the ovule travelled from the Graafian follicle, after its rupture, to the orifice of the oviduct, the usual explana- tion having been that the fimbriated extremity of the latter became "erected" at the time the ovule escaped, and grasped with its fimbriae the surface of the ovary, thus displaying a sort of independent intelligence. As, however, the anatomical impos- sibility of the fimbriae being closely and accurately applied to the surface of the ovary has been demonstrated,2 and as the tube contains no true erectile tissue, this theory has long been ex- ploded. The fact that the fimbriae are provided with ciliated epi- thelial cells which work actively toward the uterus, and create a stream in the moisture which is always present upon the peritoneal surface, is now held sufficient to account for the transference of the ovule from the ovary to the oviduct. The ovule, being dis- charged from the Graafian follicle, is either brought directly in contact with the cilia of a fimbria, or else, dropping upon the peritoneum, it is caught in the gentle current of a minute quan- tity of fluid that always bathes that membrane, and is so conveyed to the wide opening of the abdominal end of the oviduct. This explanation will also account for the so-called " external migra- tion " of the ovule, which, discharged from an ovary and failing for some reason to be taken up by the corresponding tube, finds its way to the opposite tube,— an occurrence that has been observed in certain cases of tubal pregnancy.3 1 See Wyder: " Beitr. zur Lehre v. d. Extrauterinschwangerschaft u. dem Orte des Zusammentreffens von Ovulum u. Spermatozoen," "Archiv f. Gyn " Bd xxviii «■ 325- 2 Henle, " Handb. d. Anat. d. Menschen," 1864, Bd. ii, S. 470 ; and Bischoff, " Entwickelungsgeschicte," S. 28. 3 Wyder, loc. cit. DEVELOPMENT OF THE EMBRYO AND FETUS. J "J The changes in the ovum immediately before impregnation are described in the preceding chapter. The changes in the uterine mucous membrane preparatory to and after the lodgment of the ovum in one of the depressions formed by the folds into which the hypertrophied mucous membrane is thrown will be described fur- ther on. It only remains to notice the successive changes in size and development that would enable one to determine the length of time that had elapsed since impregnation occurred, and to comprehend more fully intra-uterine deformities and diseases. The youngest human ova seen and described have been eight to thirteen days old.1 The embryo is 2 mm. long, the chorion is furnished with thin and simple villi, the allantois is not to be detected, and almost the whole ovum is occupied by the yolk-sac. Waldeyer has described an ovum, twenty-eight to thirty days old, that measured 19 mm. in length, 16.5 mm. in breadth (about the size of a pigeon's egg), and weighed 2.3 gm. The length of the embryo, in a straight line from cephalic to caudal extremity, was 8 mm., while the actual length of the dorsal line was 20 mm. During the first month the human embryo is indistinguish- able from that of other mammals. The ovum at this early period may be described as a double-walled, flattened vesicle, filled with fluid. The outer wTall bears the branched villi; the inner one is smooth. The connection of the villi with the decidua reflexa, and even with the decidua serotina, is a super- ficial one, and the ovum is easily separated from its uterine attachments.2 The yolk-sac, at first occupying nearly the whole ovum, even at the end of the first month is larger than the cephalic extremity of the embryo. The visceral arches are distinct; the limbs are merely rudimentary ; the cord is straight, thick, and short; and the amnion is still quite close to the embryo, and is separated from the chorion by a clear space. As to the embryo itself, during the first month the heart ap- pears as a cylindrical body, which soon becomes S-shaped, and by the fourth week displays four distinct cavities and is covered by its pericardium. It is probably functionally active by the third week.3 The brain and spinal columns are inclosed ; the 1 " Edinb. Med. Jour.," vol. Hi; " Verhandl. d. Ak. d. W. Amsterdam," iii. 3 ; "Historie du Develop.," pi. iii; "Arch. f. Gyn.," Bd. v, S. 170; "Abhandl. d. Konigl. Ak. d. W. zu Berlin"; " Wien. med. Wochen.," 1877,8. 502; "Arch. f. Gyn.," Bd. xii, S. 421 ; ibid., Bd. xii, S. 482 ; Leopold, " Centralbl. f. Gyn.," 1896, p. 1057; also " Uterus u. Kind." 2 See Br. Hicks, " Obst. Tr.," xiv, p. 149; Langhans, "Archiv f. An. u. Phys.," 1877, ii u. iii, S. 231 ; Ahlfeld, "Arch. f. Gyn.,"Bd. xiii, S. 231. 3 Preyer, " Specielle Physiologie des Embryos." 78 PREGNANCY. intestinal tract is also closed over, but the connection with the umbilical vesicle is still a wide one ; the first traces of a liver appear ; the primitive kidneys may be seen ; and toward the end of this period the eyes may be distinguished at the sides of the head and the rudimentary extremities become visible as four bud- like processes. The oral and anal orifices of the intestinal tract are formed by depressions in the integuments, which open into the extremities of the tract after the absorption and disappearance of the intervening tissues. Second Month.—At the beginning of the second month the ovum is the size of a pigeon's egg, and the embryo measures 8 mm. (0.3 inch) in a straight line from head to tail. During this month the embryo grows to 2 j4 cm. in length and the ovum reaches the size of a hen's egg. The visce- ral clefts close, with the exception of the first, which eventually forms the external auditory meatus, the cavity of the tympanum, and the Eu- stachian tube. The first visceral arch, dividing into two branches, forms the superior and inferior maxillary processes. The latter, one from each side, approach each other and finally unite to form the lower jaw. The superior maxil- lary processes, while ap- proaching each other, are kept from uniting by the interven- tion of the frontal process. At the point of junction of this last process with the two superior maxillary processes there occurs occasionally the deformity known as harelip, from the failure of the processes to unite ; but as union is always perfect before the end of the second month, the arrest of development that results in this deformity must have taken place at some period prior to the third month. During the second month, from the growth of the viscera, the body becomes somewhat straightened out, and from the development of the brain the Fig. 67.- -Human embryo of about six weeks, enlarged five times (His). DEVELOPMENT OF THE EMBRYO AND FETUS. head increases in size. The umbilical vesicle atrophies, and may be found attached to the body by a slender pedicle. The umbilical ring is somewhat contracted, but still contains a few loops of intestine ; so that if at this time an arrest in the devel- opment of the abdominal walls should occur, a bad umbilical hernia or exomphalos might be the result. The umbilical cord runs straight to the periphery of the ovum. The eyes occupy a position on the side of the head ; behind them may be seen the ears, and in front arises the external nose. The limbs are sepa- rated into their three divisions, and the first suggestions of hands and feet appear, with the fingers and toes webbed. The Wolffian bodies are much lessened in size, but the kidneys and suprarenal capsules are now developed. The external genitals make their appearance, but neither internally nor externally is the sex to be distinguished, for the elements of both sexes are present in equal degree. Toward the end of the second month or at the begin- ning of the third the eyelids appear. There are points of ossifi- cation to be seen in the lower jaw and clavicle. The villi of the chorion have taken on a more luxurious growth at the point where the future placenta is to be developed, and the fetus is drawing its nourishment from the maternal blood. Third Month.—During this month the ovum attains the size of a goose's egg (9.5 to 11 cm. long), and the embryo grows to a length of 7 to 9 cm. (2.75 to 3.5 inches) and weighs about 30 gm. (460 grs.). The umbilical cord increases in length to 7 cm. (2.7 inches) and becomes twisted. The umbilical ring is smaller and the intestines are retracted within the abdomen. The fingers and toes lose their webbed appearance, and the nails appear as fine membranes. The eyes approach nearer to each other and become protected by the lids. Points of ossifica- tion may be found in most of the bones, and the neck now separates the head from the trunk. The ribs divide the trunk plainly into chest and abdomen ; the oral and nasal cavities are separated by the palate ; the lips close over the mouth and teeth begin to form in the jaws. The sex may be distinguished by the presence or absence of a uterus ; cutaneous folds form a scrotum or the labia majora, but the clitoris and penis are still of equal length. The chorion loses its villi, except at the point where the placenta is developing. The latter, though small, can plainly be distinguished. Fourth Month.—In the fourth month the fetus attains a length of 10 to 17 cm. (4 to 6.75 inches) and a weight of 55 gm. (850 grs.).1 The umbilical cord is more twisted than in 1 Given by Spiegelberg as Hecker's weights and measurements. Spiegelberg, " Lehrbuch," tr. by Syd. Soc, p. 118. 80 PREGNANCY. the preceding month, and the placenta is increased in size. The head of the fetus now amounts to a quarter of the whole length of the body, and the cranial bones are in part ossified, although the fontanels and sutures gape widely. The sex is plainly to be distinguished, the genital fissure, in the case of a male, hav- ing united to form the scrotum, leaving in the median line a distinct raphe. The future prostate is indicated by a thickening at the point of meeting of the genital cord and the urethra. A fine growth of down appears upon the fetal skin (lanugo), and a few hairs are seen on the scalp. The intestines contain meco- nium ; the limbs may be feebly moved ; and the fetus may live, if born, as long as four hours (Cazeaux). Fifth Month.—During this month the fetus is about 18 to 27 cm. (7 to 10.5 inches) long and weighs about 273 gm. (8 ounces). The umbilical cord is about 31 cm. (12 inches) long. The liquor amnii exceeds the fetus in weight. The head is relatively very large; the face has a senile look and is wrinkled, and the eyelids begin to open. The skin is richer in fat, is covered with lanugo, and in places with vernix case- osa, a sebaceous material containing also epithelial scales and downy hairs. Some time during the fifth month the mother usually experiences " quickening,"—that is, the movements of the fetus,—and the fetal heart-sounds may be heard on auscultation. If the fetus should be born at this time, it may make efforts to cry, but it dies in a few minutes or, at the most, hours. Sixth Month.—The fetus toward the end of the sixth month is from 28 to 34 cm. (11 to 13.5 inches) long and weighs 676 gm. (23^ ounces). The skin is better supplied with fat; the hairs of the scalp grow longer; eyebrows and eyelashes are distinct. The umbilical cord is inserted in the middle third, between the pubic symphysis and the xiphoid cartilage. The head is still relatively large. The testicles in boys approach the inguinal rings. If a fetus at this stage should be born, it might live from one to fifteen days, but would, in all probability, eventually die from insufficient assimilation of food, from rapid loss of heat, and from imperfect respiration, owing to the undeveloped state of the finer ramifications of the air-passages. Seventh Month.—At the end of this month the fetus measures in length 35 to 38 cm. (13.75 to 15 inches) and weighs 1170 gm. (41 % ounces). The whole body is covered with lanugo except the palms of the hands and the soles of the feet. The large intestine contains a considerable quantity of meconium. The pupillary membrane, which had hitherto obscured the pupil, DEVELOPMENT OF THE EMBRYO AND FETUS. 8 I now disappears. A child born between the twenty-fourth and twenty-eighth weeks will usually die.1 Eighth Month.—The fetus measures now in length 39 to 41 cm. (15.25 to 16 inches) and weighs 1571 gm. (3^ pounds). The hair on the scalp is more abundant; the down on the face is disappearing. One of the testicles, usually the left, has de- scended into the scrotum. The nails are firmer, but do not yet project beyond the finger-tips. At the end of the eighth month ossification begins in the lower epiphysis of the femur. The cord is inserted a little below (0.6 to 1.2 inches) the middle point, between the xiphoid appendix and the pubic symphysis. A child born at this period will, with proper care, survive. Ninth Month.—The length of the fetus measures 42 to 44 cm. (16.5 to 17.25 inches) and the weight is 1942 gm. (4^ pounds). There is a decided increase in subcutaneous fat. The nails are not yet perfectly developed. Toward the end of this month, near the thirty-sixth week, the weight will be about 5 *4 pounds, and the diameters of the skull about 1 to 1.5 cm. less than in a normal fetus at term.2 At this period also the bones of the skull are compressible and easily molded to the shape of the pelvic cavity; and if at this time, about the thirty-sixth week, the infant should be born, with ordinary care it will certainly live. Tenth Month.—During the tenth month (thirty-sixth to for- tieth week) the fetus is developing from the condition just de- scribed—that is, characteristic of the thirty-sixth week—into the infant at term, distinguished by all the features that indicate the arrival of the fetus at maturity. It is during the last month of pregnancy that the physiology of the fetus can be studied to the best advantage. It has now reached a large size and requires a considerable quantity of oxygen3 for its blood and nourishment 1 There persists, even yet, in the minds of some general practitioners, as well as among the laity, as the writer can testify, the idea that children born in the seventh month will be more likely to survive than those born at the eighth month. Professor Parvin (" Science and Art of Obstetrics ") shows how this superstition has descended, through more than two thousand years, from Hippocrates, who explained that the fetus is placed with its head uppermost in the uterine cavity until the seventh month, when the increasing weight of the head causes it to fall down to the 05 uteri. As soon as this occurs, the fetus attempts to make its escape, and if it is strong it suc- ceeds, but if the attempt fails, it is repeated at the eighth month, and if the infant now succeeds in escaping from the womb, being exhausted by its previous effort, it is likely to die. 2 Schroeder, from the measurements of 68 premature infants, gives the average biparietal diameter of the head as 8.83 cm. from the thirty-sixth to the fortieth week; 8.69 cm. from the thirty-second to the thirty-sixth week; 8.16 cm. from the twenty- eighth to the thirty-second week, showing that this diameter, a most important one, is relatively very large even early in fetal life. 3 That the fetus obtains oxygen from the maternal blood has been proved by (i) cutting off the blood-supply to the uterus, when the fetus will die of asphyxia fVesal, Seyl) ; (2) by the discovery, by means of spectral analysis, of oxyhemoglobin in the umbilical vein of the cord (Zweifel). 6 82 PREGNANCY. for its tissues, both of which it obtains from the maternal blood through the medium of the epithelial cells that form the outer- most fetal layer of the placenta (the syncytium). From the fact that the fetus undoubtedly swallows considerable quantities of liquor amnii during the latter months, at least, of pregnancy,1 and because that liquor contains a small proportion of albumin,2 some writers would have it that the fetus derives its whole nourishment from the amniotic fluid, while the func- tion of the placenta is confined to the oxygenation of the fetal blood,—a theory that has not yet found general acceptance, nor is it likely that it ever will. Another fact, however, in its favor is the secretion of the stomachic glands which is going on during the latter period of intra-uterine life.3 The urine, which is secreted in considerable quantity, and which is, as a rule, albuminous,4 is voided freely into the amniotic cavity. The fetus, from time to time, moves its limbs vigorously, and its heart beats from one hundred and twenty to one hundred and sixty times a minute. The circulation of the fetal blood has certain peculiarities that deserve consideration. Beginning at first by a very simple arrangement in a tubular heart and four vessels (two arteries and two veins), which carry the blood to and from the umbilical vesicle, it soon assumes the characteristics that are most plainly to be seen in the stage of pregnancy under consideration. The blood that has been oxygenated in the terminal villi of the placental tufts is returned by veins of increasing size to the large branches of the umbilical vein, which may be seen directly under the amnion on the fetal surface of the placenta. These branches, converging, unite in the umbilical vein, which is carried by the cord to the fetal body, which it enters at the umbilicus. Thence it runs along the anterior surface of the abdominal cavity to the under surface of the liver, where, giving off branches to the lobus quadratus, lobus Spigelii, and to the left lobe, it divides into two main trunks at the transverse fissure, the larger of which enters the portal vein, while the other empties into the ascending cava and is called the ductus venosus. Thus by far the greatest quantity of oxygenated blood that is returned to the fetus from the placenta must first pass through the liver before entering the general circulation. The ascending cava conveys 1 Zweifel, " Untersuchungen iiber das Meconium," "Arch. f. Gyn.," Bd. vii, 1875, P 474- 2 Anderson, "Am. Jour. Obstetrics," Aug., 1884. 3 Krukenberg, " Magensecretion des Fotus," " Centralbl. f. Gyn.," No. 22, 1884. 4 Ribbert, " Ueber Albuminuric des Neugeboren u. des Fotus," Virchow's Archiv," Bd. xcviii, S. 527. DEVELOPMENT OF THE EMBRYO AND FETUS. 83 t:h then to the right auricle a large proportion of arterial blood, but mixed with it is the venous blood from the lower extremities and the blood returned from the liver. But this great volume of blood having arrived at the right auricle, instead of descending into the right ventricle and being carried thence to the lungs, which in their unex- panded condition could not contain it, is guided across the right auricle by the Eus- tachian valve, and enters the left auricle by means of an opening in the interauricular septum,—the foramen ovale. From the left auricle the blood from the ascending cava enters the left ventricle and is driven thence into the aorta, by which it is conveyed pri- marily to the upper extremity of the fetus by the ascending branches of the arch of the aorta. Here may be seen an arrangement peculiar to fetal life, by which the blood is di- verted from the unused lungs and conveyed instead to the aorta. Just beyond the point at which these branches are given off there opens into the aorta a large branch from the pulmonary artery (the ductus arteriosus), which conveys the blood that enters the right auricle, and then the right ventricle, from the descending vena cava, only a small quan- tity of blood, sufficient for their nutrition, going to the lungs. Thus it will be seen Fig. 68.—Diagram of the fetal circu- lation: a, a, Aorta; b, innominate artery; c, left carotid; d, left subclavian; e, iliacs ; f internal iliac arteries; g, hypogastric arteries; h, pulmonary artery; i, right ventricle ; j, left ventricle; k, ductus ar- teriosus; /, left auricle; m, left auriculo- ventricular opening ; n, foramen ovale ; o, right auricle ; p, Eustachian valve; q, right auriculoventricular opening; r, vena cava ascendens ; s, liver; t, hepatic vein; u, branches of the umbilical vein to the liver ; v, umbilical vein ; w, umbilical cord; x, bladder; y, vena cava descendens; z, ductus venosus (Flint). that the aorta conveys a mixed blood, still further devitalized from the infusion of the venous blood from the head, neck, and upper extremities, to the trunk and lower extremities. It is by this arrangement that a greater quantity of arterial blood is conveyed to the brain, which develops so 84 PREGNANCY. rapidly during intra-uterine life. Following the blood-current down the aorta to the iliac arteries, and then to their internal branches, two arteries, one from each branch, may be seen springing upward toward the umbilicus whence they pass out of the body to form the two arteries of the umbilical cord. Within the body they are known as the hypogastric arteries. The two arteries of the cord carry to the placenta what is usually called venous blood, which, in the terminal placental villi, discharges into the maternal blood the effete products of the life-processes in the fetus and receives in return a fresh supply of oxygen and nutriment, and probably a fair share of the soluble salts of the blood, as well as any other substance, medicinal 1 or otherwise, that the maternal blood may contain in solution or possibly even in suspension. While the passage of matter from the maternal into the fetal blood seems to occur so frequently, it would appear to be more difficult for substances, aside from the effete products of tissue-activity, to pass from fetus to mother. There is reason to believe, however, that the poison of syphilis may take this course. It has also been demonstrated that certain drugs, as strychnin, may pass from fetus to mother.2 The ease with which medicinal substances will pass from mother to fetus has given rise to anxiety lest in the administration of powerful drugs to the mother the fetus might be injuriously affected.3 It is possible, of course, to harm the fetus by administering poisonous substances to the mother, but it is extremely unlikely that the fetus will be much affected unless the dose to the mother much exceeds the usual therapeutic limit. But, like the adult, the fetus may become accustomed to a drug, and be able finally to endure large quantities of it in the maternal blood.4 The temperature of the fetus in utero is slightly higher than that of its mother. Priestley,5 in experiments on rabbits and cats, found the temperature of the fetus about i° F. higher than that of its mother, which seems natural enough 1 Chloroform, carbonic oxid gas, salicylate of sodium, benzoate of sodium, atropin, strychnin, morphin, quinin, corrosive sublimate, iodid of potassium, ether, urea, the bile-salts, soluble salts of lead, tobacco, sulphindigolate of soda, the germs of many diseases, have all been known to pass from mother to fetus. 2 Schroeder, " Geburtshiilfe," 8th ed., p. 63. 3 Parvin's "Obstetrics," 148. 4 I was obliged on one occasion to administer excessively large doses of morphin daily for a period of some weeks to a patient who was suffering from general septi- cemia in the seventh month of pregnancy. The fetus continued to move actively in utero, and I could detect no change in the fetal heart-sounds. The woman finally gave birth to a living infant. 5 " Lumleian Lectures on the Pathology of Intra-uterine Death," rep. for "Brit. Med. Jour.," 1887, p. 16. THE MATURE FETUS. 85 if one considers the very great functional activity in the organs of the rapidly growing fetus, and the fact that the liquor amnii, although abstracting heat to some extent from the fetal body, remains itself at a constant temperature equal at least to that of the maternal body. That the human fetus also pos- sesses a temperature higher than the maternal body-heat has been proved by taking the temperature /// ano of a fetus coming down during labor by the breech, and comparing it with the tempera- ture of the vagina,1 or by taking the temperature of infants immediately after birth.2 In these cases the fetal body is found warmer by o. 5 ° C. than the maternal body. Of all the organs in the fetal body, the liver seems the most active. Almost all the arterial blood from the placenta goes first to the liver. The great quantity of meconium in the fetal intestines—a substance composed mainly of bile-salts— attests the active secretory work of this organ, and to it, too, may be attributed the source of the large quantity of glycogen 3 found in fetal tissues, especially the muscles, where this sub- stance has work to perform the nature of which is not yet understood. THE MATURE FETUS. There is no single sign, perhaps, that would enable one to declare a given fetus to be fully mature ; but the weight, measure- ments, and stage of development, taken together, will indicate with tolerable accuracy the length of time that the fetus has remained in ntero. By the two hundred and eightieth day a healthy fetus should weigh about 71^ to 7^ pounds, according to the statis- tics of Lusk and Parvin ; but in Europe the weight of the mature fetus would seem to be somewhat less, for the statistics of Scan- zoni, Ingerslev, Hecker, Fesser, and Bailly, including a very large number of observations, give a wreight of less than 7 pounds. Variations in weight at term between 6 and 9 pounds 4 are by no means rare, and the range of possibility in the weight of a 1 Wurster, " Berlin, klin. Wochens.," 1869, No. 37, and " Beitr. z. Tocother- mometrie," D. i, Zurich, 1870. 2 See Barensprung, Midler's " Archiv," 1851 ; Schafer, D. i, Greifswald; Andral, " Gaz. Hebd.," July, 1870; Schroeder, Virchow's "Archiv," Bd. xxxv, S. 261 ; and the " Lehrbuch," 8th ed., 1894, p. 65 ; also, Alexeeff, "Archiv f. Gyn.," Bd. x, S. 141. 3 Marchand, " Ueber das Glykogen in einigen fotalen Geweben," Virchow's " Archiv," Bd. c, S. 42. 4 An infant of over nine pounds is not common, while heavier weights are pro- gressively rare. Out of 1000 infants, Dr. Parvin saw but one that weighed 11 pounds (Parvin's "Obstetrics," p. 138). Of 1156 infants born in my service in the Mater- nity Hospital, the heaviest weighed 12 pounds. 86 PREGNANCY. mature fetus is a very wide one. Thus Harris1 tells of one infant that weighed but a pound, and of another, the child of the Nova Scotia giantess, that weighed 28 ^ pounds at term. A decided departure, however, from the normal average would indicate, on the one hand, prematurity or a weak development; on the other, the prolongation of pregnancy, race peculiarities, the vigor or excessive size of the parents, especially the mother, or the preoc- currence of several pregnancies. Sex also influences the size of the infant, males being, on an average, larger than females. The length of a mature fetus is 20 to 21 inches (51 to 53 cm.). The width across the shoulders (binacromial diameter) is about 12 cm. (4.75 inches) ; the dorsosternal diameter is 9 to 9.5 cm. (3.5 inches) ; the biniliac, 9.5 to 10 cm. (4 inches). The length of the foot is about 8 cm.2 The dimensions of the head are im- portant as a sign of the development of the fetus. The following dimensions of the fetal head may be consid- ered characteristic of the normally developed infant directly after its expulsion from the uterus : Bitemporal (B. T.) diameter,........... 8 cm. Biparietal (B. P.) diameter, ........... 9^ cm. Occipitofrontal (O. F.) diameter,......... i\=£ cm. Occipitomental (O. M.) diameter,......... 13 cm. Maximum (M. M.) diameter, .......... l3% cm- Suboccipitobregmatic (S. O. B.) diameter,..... 9^ cm. Trachelobregmatic (T. B.) diameter,.......9^ to 10 cm. Circumferences: O. F., 34^ cm.; S. O. B., 30; O. M., 37. These dimensions are subject, however, to considerable modifications. Any of the causes that tend to increase the size of the infant as a whole will likewise influence the size of the head ; but even with a normal body-weight and length the head may be disproportionately large, without being diseased. Another valuable sign of maturity in the fetus is the appear- ance and extent of certain centers of ossification.3 In the center of the lower epiphysis of the femur may be found at birth a spot of ossification measuring five millimeters in diameter, while a similar but smaller spot is just appearing in the upper epiphysis of the tibia. The center of ossification in the astrag- alus is to be found without difficulty, for it first appears at the seventh month of intra-uterine life. The center of ossification in the cuboid bone is at birth beginning to make its appearance. 1 Note to Playfair's " Midwifery." 2 Negri says ("Aran, di Ostet," May to June, 1885) that when the foot measures eight centimeters the fetus is well developed and weighs about 3500 gm. 3 See Rossie, " Amer. Jour, of Obstetrics," 1886, p. 18. THE MATURE FETUS. 87 The ossified spot in the lower epiphysis of the humerus only appears some months after birth. The general appearance of a new-born infant is of value as indicating whether or not the fetus had reached maturity before its expulsion from the uterus. A healthy infant at term looks stout and well-nourished. The face is plump and is free from lanugo ; miliaria are to be seen about the tip of the nose, but are not nearly so evident as they were in the ninth month of intra-uterine existence. The eyes are usually opened, the limbs move vigorously, and the child will seize with its lips the nipple when presented to it, and will suck with energy. The vernix caseosa is abundant only on the back of the child and on the flexor surface of the limbs. The nails project beyond the finger- tips ; the cartilage of the ears and nose feels firm ; eyebrows and eyelashes are well developed ; the hairs of the scalp are about an inch long ; the bones of the head are hard and lie close together. The breasts in both sexes are large, and usually a thin fluid can be squeezed out of them. In boys the testicles are usually to be felt in the scrotum, although the tunica vaginalis is not yet closed. In girls the labia majora are usually approxi- mated, although occasionally the nymphae project between them. The Determination of Sex.—In all countries the number of male children born exceeds the number of females, the average proportion being 106 to 100 ; but, as more boys die than girls, by the time puberty is reached the sexes are about equal in num- ber. This normal proportion is, however, in modern times much disturbed by the migratory tendencies affecting chiefly the male populations of old and long-settled countries. The law that governs the production of sex has long been a subject of dis- cussion and speculation. The Hippocratic doctrine that the right ovary produced boys and the left girls was for centuries accepted by the majority as the truth, and upon this belief was founded the precept that women who desired male offspring should lie during coition upon the right side, while those who desired daughters must lie upon the left side. By experiments upon animals, by the observation of women in whom one ovary was destroyed by disease, and by a more complete knowledge of the mechanism of impregnation, the long-accepted teaching of Hippocrates was disproved, although not until comparatively recent times. At present it is yet undecided whether the ques- tion of sex is determined before impregnation occurs,—that is, whether certain spermatic particles or ovules are predestined to produce males, while others will produce females ; whether the sex is impressed upon the ovule at the moment of conception, or whether the embryo is possessed of the elements of both 88 PREGNANCY. sexes until one or the other acquires a preponderating influence owing to causes which may be operative during the early part of pregnancy. The first theory receives its chief support from the fact that unioval twins are invariably of the same sex, which looks as though the ovule was predestined in the ovary to the formation of one or the other sex. The last theory is based upon the study of plants and lower animals, in which the sex is only determined at some time after conception by the influence of nourishment; overfeeding being found to produce females, underfeeding to produce males. It is even possible in the case of certain animals to alter the sex, or at least to produce her- maphrodites, even after the sexual organs have begun to be dif- ferentiated.1 This theory is further supported by the fact that in the human embryo the elements of both sexes are always present apparently in equal force during the early part of em- bryonal life. The belief that the sex of a human embryo is impressed upon it at the moment of conception rests upon the fact that in certain conditions of nourishment or sexual vigor in one or the other parent one sex will preponderate, while under opposite circumstances the other sex will most frequently be produced.2 Disregarding the time at which the sex is determined, the most diverse conditions have been called upon to explain ap- parent departures from the normal numerical relation of the sexes at birth. Illegitimacy,3 age of parents,4 conception at certain periods after menstruation,5 deformities in the female pelvis,6 the nutrition or sexual vigor of the parents,7 the ten- dency of each sex to produce the opposite of the reverse,8 the 1 In the case of the larvae of bees from impregnated eggs, when the female gen- ital organs have begun to appear, if the nourishment is very insufficient, instead of becoming female workers these animals will actually develop into true hermaphro- dites, with the organs of both sexes (Fiirst). 2 Thury ("Zeitsch. f. w. Zoologie," 1863, Bd. xiii, S. 541) found in 29 experi- ments upon cattle that in every case, if connection occurred at the beginning of heat, females were produced ; if at the end, males. 3 Fiirst ("Archiv f. Gyn.," Bd. xxviii, S. 19) says that in illegitimate births the males fall below the average (based upon 807,332 cases). This coincides with my experience in the Maternity Hospital in more than 1000 cases of illegitimate births. 4 See Hofacker, " Ueber die Eigensch. welche sich von den Eltern auf die Nachk. vererben," 1828; Sadler, "Law of Population," London, 1830; Hecker, "Archiv f. Gyn.," Bd. vii, S. 448; Bidder, "Zeitsch. f. Geburtsh.," Bd. ii, S, 358; Ahlfeld, " Archiv f. Gyn.," Bd. ix, S. 448; Wall, " The Causation of Sex," London " Lancet," 1887, i, pp. 261, 307. 5 Thury, loc. cit. ; Coste, " Comptes Rendus," 1865 ; Schroeder, " Lehrbuch," 8te Aufl., 1884, S. 33 ; Fiirst, " Kneben Ueberschuss nach Conception zur Zeit der postmenstruellen Anamie," " Archiv f. Gyn.," Bd. xxviii, S. 18. 6 Olshausen, "Klinische Beitrage," Halle, 1884; Linden, "Hat das enge Becken einen Einfluss auf die Entstehung des Geschlechts ?" Dis. Inaug., Mar- burg, 1884; R. Dohm, "Zeitsch. f. Geburtsh. u. Gyn.," Bd. xiv, S. 80. 7 See Fiirst, loc. cit., and Schroeder, op. cit., S. 33. 8 See Fiirst, loc. cit. THE MATURE FETUS. 89 tendency to produce that sex which is most needed to per- petuate the species,1 the season of the year,2 climate and alti- tude,3 and the degeneration of a race, as during the decadence of imperial Rome,4—have all been advanced as reasons for ap- parent excess in the number of male or female births as the case might have been. All these theories, however, have been found either false or inadequate upon further investigation. An ex- planation that appeals to the author's reason is that the indi- vidual stronger in mental, physical, and sexual attributes will impress upon the ovule at the moment of impregnation that individual's sex. A perfectly satisfactory explanation of the de- termination of sex, however, will be difficult to obtain, while the production of the sexes at will has hitherto been an impossibility. Multiple Fetation.—It is the rule that but one fetus at a time is developed within the uterus of a human female. Once in about 120 pregnancies,5 however, two fetuses will be developed simultaneously in the same uterus, so that twins are not of un- common occurrence. Triplets will be found once out of 7900, quadruplets once out of 371,126 births. Quintuplets are ex- tremely rare. There is one case of sextuplets on record.6 Multiple fetation maybe the result: (1) Of the impregnation of a single ovum that contains two or more germinal vesicles, or in which the formative material of the area germinativa divides ;7 (2) of the impregnation of two or more ova which were contained either in one Graafian follicle or in separate follicles, the latter being situated either in one or both ovaries. There may be a hereditary disposition to multiple fetation. Boer reported, in 1808, an extraordinary example : 8 A woman aged forty had in 11 pregnancies during twenty years given birth to 32 children, to wit: quadruplets twice, triplets six times, twins thrice. The woman herself was one of quadruplets and her mother had had 38 children. Her husband was one of twins, and there was a history of other plural births in his family. 1 Diising, " Die Regulirung des Geschlechtsverhaltnisses bei der Vermehrung der Menschen, Thiere, u. Pflanzen," Jena, 1884. 2 According to Diising {loc. cit.), women impregnated in summer give birth to fewer boys than those impregnated in winter (conclusions based on more than 10,500,000 births). 3 Ploss found, in Saxony, that up to 2000 feet, the greater the altitude, the larger was the number of male births (at 2000 feet, 107.8 to 100). 4 Darwin's Collected Works. 5 According to statistics collected by Veit, based on more than 13,000,000 births, twins occur once in 89 pregnancies; in New York and Philadelphia the pro- portion is about I to 120. 6 Vassali, " Gaz. Med. Ital. Lombardia," Milano, 1888, No. 38. 7 Ahlfeld, "Archiv f. Gyn.," Bd. ix, S. 196. 8 "Wien. med. Wochens.," No. 3, 1897. 9o PREGNANCY. If the multiple fetation is the result of the impregnation of a single ovum, there will be but one chorion and one decidua reflexa, although each fetus will be inclosed in its own amnion.1 In these cases the sex of the fetuses will be the same. The placentae will usually be found intimately united when expelled at term, presenting extensive arterial and venous anastomoses— a condition that may give rise to the deformity of one of the twins, known as acardia. But in the early stages of development each placenta, even in unioval twins, is separate. When the em- bryos are derived each from a separate ovum, there should be separate deciduae reflexae, chorions, and pla- centae. Occasionally, how- ever, when the ova are im- planted close together, the placentae may be joined, there may be but one decidua reflexa, and it may be difficult to detect the double layer of chorion that should separate the two ova. Although twins are not infrequently born, the con- dition should be regarded as pathological in its influence, at least, upon the fetus. From statistics collected by Schatz,2 it appears that in twins from different ova one would be born dead in every twenty-three cases, while from the same ovum the death-rate would be one in six. One fetus will, perhaps, outstrip its fellow in growth, and divert the greater part of the nourishment from the mother to itself, thus growing rapidly and encroaching so upon the room that should belong to the weaker fetus that the Fig. 69.—Fetus papyraceus (author's specimen). 1 Occasionally two fetuses are found in a single amniotic cavity, which is to be explained (1) by the atrophy and absorption of the contiguous amniotic walls; (2) by rupture of the amnion in the latter months from the vigorous movements of the fetus; or (3) by the development of but a single amnion from the very beginning (Myschkin, Virchow's "Archiv," Bd. cviii, S. 133, 146). 2 "Archiv f. Gyn.," Bd. xxix, S. 438. THE FETAL APPENDAGES. 91 latter is killed and finally pressed flat against the uterine wall (fetus papyraceus). Hydramnios is also very common in twin pregnancies, and occasionally one fetus is converted into an acardiac monster. If the fetuses of a twin pregnancy escape the dangers of intra-uterine life, there are many complications awaiting them in labor. Should one fetus die during pregnancy, it is usually retained until term, when the living and dead children are cast off together, widely different in appearance and develop- ment ; x or else one ovum may be aborted at an early period of pregnancy, while the other goes on developing until term.2 Even though both children have been retained in utero an equal length of time, there is usually a marked difference in their length and weight, especially if they have resided in one ovum.3 In cases of uterus duplex, fetuses of different ages have been found developing in the two divisions of the uterus. Fordyce Baker reports a case of delivery of two mature children from a woman with a double uterus, one male, the other female, at an interval of two months.4 Upon such cases, and also upon the fact that of twins in negresses rarely one is light and the other dark, showing probably different paternity, has been based the theory of superfetation ; but as there is no clear proof, as yet, of the occurrence of ovulation during pregnancy, the possibility of the impregnation of ovules which escaped from their Graafian follicles at rather wide intervals of time, say weeks or months, is doubtful.5 CHAPTER IV. The Development, the Anomalies, and the Diseases of the Fetal Appendages: the Membranes, the Placenta, and the Umbilical Cord. The study of the development, anomalies, and diseases of the fetal appendages is necessary to a clear understanding of fetal pathology. First will be considered the development and diseases of the fetal appendages springing directly from the 1 Schultze, " Volkm. Samml. klin. Vortrage," No. 34. 2 Sirois, "L'Union medicale du Canada,." July, 1887; and Warren, "Am. Jour. Obstetrics," 1887. 3 Schatz, loc. cit. 4 See Lusk, op. cit., p. 233, ed. 1886. 5 For some interesting observations which would seem to indicate the possibility, at least, of ovulation during pregnancy, see "Ovulation During Pregnancy," Chris- topher, "Am. Jour. Obstetrics," 1886, p. 457. 92 PREGNANCY. embryo—namely, the amnion, the chorion, the allantois, and the placenta; lastly, the deciduae, the maternal envelope of the fetus. THE AMNION. After segmentation has occurred, and after the interior of the ovum has become reduced to a granular mass, around which is a membrane composed of a single layer of cells, at a certain point—the embryonal area—in this membrane there appears a thickening, by a heaping up of the cells. Finally this mass of cells resolves itself into two layers (ecto- and entoderm), and between these two appears another layer of cells (mesoderm). The outer layer, the ectoderm, sends a prolongation around the whole interior surface of the ovum, and this layer receives a Fig, 70.—e, Embryo ; ec, cephalic Fig. 71.—e, Embryo; a, amnion; extremity; eg, caudal extremity; ca, oa, amniotic umbilicus; cac, amnio- ca, amniotic hood ; pp, pp, pleuroperi- chorional cavity ; pp, pp, pleuroperito- toneal cavity ; y, umbilical vesicle. neal cavity; ch, chorion ; mv, vitel- line membrane ; vo, umbilical vesicle. reinforcement from the middle layer of cells, or the mesoderm. As now the embryo begins to assume a definite shape, and the lateral walls begin to fold in toward one another, and the caudal extremity approaches a little to the cephalic end of the embryo, giving it the arched back characteristic of the young embryo, the outer layer of cells, forming a membrane continuous with the outer covering of the embryo, instead of being simply car- ried forward to meet in the median line in front, sends reduplica- tions backward over the dorsal aspect of the embryo, which shortly meet and join one another. There are consequently two cavities formed,—one within the membrane doubled back upon itself; the other between the inner (the true amnion) of the two layers of membrane and the outer covering of the embryo. The THE AMNION. 93 latter is the true amniotic cavity, which is gradually more and more distended by the accumulation of fluid until the membrane which contains it is pushed out on all sides, uniting in front around the umbilical cord, and coming in contact throughout the whole extent of the ovum with the outer membrane (true chorion), to which it becomes loosely united by a gelatinous sub- stance,—the tunica media of Bischoff The Fully=developed Amnion. — The amnion forms the innermost of the membranes that surround the fetus at term. It is continuous with the fetal epidermis at the umbilicus, and forms a complete sheath for the umbilical cord, and also covers the fetal surface of the placenta. In its structure it consists of a single layer of flat endothelial cells turned toward the cavity of the amnion, and externally of a layer of young connective tissue, in which may be seen long spin- dle- or star-shaped cells with long nuclei imbedded in a fibrous substance (Schroeder). The reg- ular disposition of the inner layer of endothelial cells, how- ever, is disturbed at certain points of the amnion lying over the placenta, where there may be seen numbers of cells heaped together, forming a little villus- like projection. There are, nor- mally, no blood-vessels in the amnion,—at least, in its later stages of development; their possible occurrence, however, in hydramnios will be referred to later. The Liquor Amnii.—It is the physiological function of the amniotic membrane to furnish a fluid medium (the liquor amnii), which distends the uterine walls and allows the fetus some free- dom of movement, and, by its density, approaching the specific gravity of the fetus, robs these movements of much muscular effort. It acts as an additional protection to the fetus from ex- ternal violence, pressure, and changes of temperature ; it receives the urine secreted in the latter part of fetal life ; and, perhaps, has some little part in the nourishment of the fetus, or at least in supplying the fetal tissues with that excess of water which they have been shown to possess during intra-uterine life.1 That the fetus actually swallows considerable quantities of Fig. 72-—Completion of the am- nion : n, Umbilical vesicle; p, pedicle of the allantois ; a, amniotic cavity. 1 Preyer, " Physiologie des Embryos." 94 PREGNANCY. liquor amnii admits of no doubt, for not only have lanugo and epidermis-scales been found in the meconium,1 but also particles of colored matter which had entered the amniotic fluid from the maternal structures (Zuntz). It is not likely, however, that the liquor amnii plays an important part in the nutrition of the fetus, as claimed by von Ott and others ; for if it did, the birth of well-nourished children with a breach of continuity in the upper part of the alimentary tract from the mouth to the small intes- tine would be inexplicable. The Composition of the Liquor Amnii.—The amniotic fluid is usually clear; occasionally, however, opaque, whitish, greenish, or a dark brown from the presence of meconium, or of a reddish color when the fetus is macerated. The specific gravity varies from 1002 to 1028 (Schroeder), being usually, however, about 1007 to 1011. Its reaction is slightly alkaline. It contains salts, urea, carbonate of ammonia, kreatinin, albumin, lanugo, sebaceous matter, epidermis, scales from the fetal skin, and epithelium from the bladder and kidneys. The quantity of the liquor amnii differs at different periods of pregnancy : in the early stages it develops with great rapidity, and at the middle of pregnancy has reached its maximum of about 1 to 1.5 kilograms (Landois). From this time it diminishes in amount, until at the end of pregnancy its average quantity is 680 grams.2 The Origin of the Liquor Amnii---The origin of the liquor amnii has been attributed to a maternal source, to the fetus, or to both mother and fetus. The last view is doubtless correct. The maternal origin 3 of the amniotic fluid has been demonstrated by Zuntz, who injected sodium sulphindigolate into the veins of pregnant rabbits, and found a blue coloration of the amniotic fluid, although there was no coloring matter in the kidneys of the fetus. As further evidence might be cited the fact that there are cases in which the embryo is destroyed very early, but in which an amount of amniotic fluid may be found corresponding not to the age of the embryo, but to that of the ovum. And, moreover, it is not unusual to find hydramnios associated with some other serous effusion in the mother.4 1 Zweifel, " Untersuchungen iiber das Meconium," "Archiv f. Gyn.," Bd. vii,474. 2 Fehling, " Archiv f. Gyn.," Bd. xiv, S. 221. 3Ahlfeld ("Ueber die Genese des Fruchtwassers," "Archiv f. Gyn.," Bd. xiii, pp. 160—241) gives an ingenious explanation of the manner in which the maternal structures take part in the formation of the liquor amnii : As the uterus develops by an eccentric hypertrophy, the pressure within the uterine cavity becomes less than that of the abdominal cavity, and consequently there is a disposition for the serum of the maternal blood to exude into the amniotic cavity. As Phillips (" Edin. Med. Jour.," March, 1887, p. 811) remarks, however, the case of hydramnios in extra-uterine pregnancy ("Archiv f. Gyn.," Bd. xxii, p. 57), reported by Teuffel, would seem to invalidate this theory. 4 Pfliiger's " Archiv," Bd. xvi, S. 548 ; and Wiener, " Archivf. Gyn.," Bd. xvii, S. 24. THE AMNION. 95 That the fetus also contributes to the formation of liquor amnii is demonstrated by the fact that the excretion of urine during the latter part of fetal life reaches a considerable amount. Thus, more than three pints of urine have been found retained in the fetal bladder.1 Gusserow 2 has injected benzoic acid into the mother, and recovered it as hippuric acid in the liquor amnii,—a proof that it had passed through the kidneys of the fetus ; and Wiener has found sodium sulphindigolate in the fetal kidneys and bladder after it had been injected into the maternal tissues. The constant presence of urea 3 in the amniotic fluid, at least after the sixth week, is an additional proof, if one were needed, of the renal activity of the fetus. It is probable also that the vasa propria, discovered by Jungbluth,4 in the early life of the embryo lying close under the amnion, have something to do with the produc- tion of the amniotic fluid in the earlier periods of pregnancy. Prochownik 5 claimed that it was the skin of the fetus that se- creted the amniotic fluid during the early months of gestation; and there has since appeared corroborative evidence of this view. There have been cases of hydramnios associated with morbid con- ditions of the skin, notably one instance observed by Budin,6 in which the skin of the fetus was the seat of extensive nevi. Thus it appears that the amniotic fluid is derived from a fetal as well as a maternal source, but the relative importance of the fetal and maternal supply of liquor amnii at different periods of preg- nancy is still undetermined. Abnormalities of the Amnion.—There is a striking simi- larity between the pathology of the amnion and that of other serous membranes. There is the same liability to changes of secretion, to inflammation with a plastic exudate, and to the for- mation of bands of adhesion. The function of the amnion, how- ever, and its close relation to the embryo and fetus, give rise, in case of disease, to symptoms and results peculiar to itself. Abnormalities of Secretion: Oligohydramnios.—The quantity of liquor amnii varies, at term, between one and two pints. Occasionally, however, the quantity of fluid is very much below the normal—so much so in some cases as to seriously interfere with the growth of the fetus and to determine its premature 1 Lefour, " Archives de Tocol.," June 30, 1887. 2 " Archiv f. Gyn.," Bd. xiii, S. 56. 3 Prochownik, "Archiv f. Gyn.," Bd. xi, S. 304-561. 4 " Beitr. zur Lehre v. Fruchtwasser," Inaug. Dissert., Bonn, 1869; Virchow's "Archiv," Bd. xlviii, S. 523 ; " Archiv f. Gyn.," Bd. iv, S. 554. 5 Loc. cit. 6 Tarnier et Budin, loc. cit., p. 279. 96 PREGNANCY. expulsion.1 Schatz 2 reports a case in which there were ulcers on the inner surface of the knees and malleoli of a fetus from constant friction due to a deficient quantity of liquor amnii, and many curious deformities of the fetus may be traced to the same cause.3 This condition is called oligohydramnios. More fre- quently the quantity of the liquor amnii becomes abnormally increased—a condition known as polyhydramnios hydroamnion, dropsy of the amnion, or, more commonly, hydramnios. Hydramnios.—It has been already stated that the normal quantity of liquor amnii at the end of pregnancy is from one to two pints. Should this quantity be much exceeded, the condition of hydramnios exists. A slight excess is, no doubt, frequent, but would usually pass unnoticed, while an accumulation of fluid amounting to two quarts or more, which might perhaps inconvenience a woman, is not very common. It is difficult, therefore, to express the relative frequency of hydramnios. Charpentier states that it occurs in I in ioo or I in 150 pregnan- cies,—an estimate probably too low for the minor grades of the affection, but far too high for those more decided cases in which the accumulation of fluid is large enough to give rise to well- marked symptoms. In the majority of cases the fluid collects gradually, but steadily, until at the end of the pregnancy it may reach the enormous quantity of six gallons or more.4 Occa- sionally, however, the fluid accumulates very rapidly, giving rise, from the sudden distention of the uterus, to symptoms of a grave character. This rapid accumulation is known as acute hydramnios. The Etiology of Hydramnios.—The theories that at present prevail in regard to the formation of an excessive quantity of amniotic fluid may be thus classified : It may be due to (A) an oversecretion of liquor amnii or to (i?) a deficient absorption of the liquor amnii. A. The excessive collection of fluid may be derived from (I) a maternal source, (II) a fetal source, or (III) both fetus and mother may contribute to its production. I. The Hydramnios May Have a Maternal Origin.—That the serum of the maternal blood contributes to the formation of the liquor amnii has already been demonstrated ; that it occasionally exudes in abnormally large quantities into the amniotic cavity is extremely probable. Thus, in cases of hydramnios associated with serous effusions elsewhere in the mother's body the excess 1 " London Lancet," 1886, ii, p. 383. 2 " Archiv f. Gyn.," Bd. xix, S. 329. 3 See "Tarnier et Budin," p. 294. 4 Wilson, " Am. Jour. Obstetrics," Jan., 1887, p. 22. THE AMNION. 97 of liquor amnii is derived probably from a maternal source. Fehlingx asserts that " the thinner the maternal blood, the greater is the quantity of liquor amnii." It would be well, therefore, to examine the blood of a patient who was affected with hydramnios, in order to detect a possible exaggeration of the usual hydremia of pregnancy. A lymphagogue has been found in the liquor amnii of hydramnios, which is not present in the normal liquid. It has been claimed, therefore, that this sub- stance stimulates a serous exudate from the maternal blood.2 II. The Hydramnios May Originate Entirely from Fetal Structures.—This supposition will explain by far the larger number of cases that admit of an explanation at all, for hydram- nios often occurs (forty-four per cent, of all cases (Bar) ) without a demonstrable cause in either mother or fetus. The production of hydramnios, traced to the fetus, may be due : (a) To abnormal pressure in the blood-vessels of the cord, or of those directly under the amnion, where it covers the placenta (persistence of the vasa propria of Jungbluth); (b) to an excessive urinary secretion ; (c) to an abnormally profuse excretion from the fetal skin. (a) The vasa propria of Jungbluth, normally present in the early stage of embryonal development, have been found at term in cases of hydramnios,3 and the production of an excessive quantity of liquor amnii has been attributed to their persistence. It is more probable, however, that the existence of these vessels is purely secondary, and that, although the serum of the fetal blood does exude from them into the amniotic cavity, their presence is due to an increased blood-pressure in the umbilical vein.4 Increased internal pressure within the umbilical vein will give rise to a transudation through the amnion as has been abundantly proved by Salinger,5 who found that the amount of fluid which would transude depended upon the strength of the pressure and the size of the cord. Any condition of the fetus, therefore, which will raise the blood-pressure in the umbilical vein, thus increasing the blood-pressure in the placenta, may give rise to hydramnios. This happens, for example, in cirrhotic livers common in syphilitic children. There are many other conditions having the same effect—a cord abnormally twisted, 1 "Archiv f. Gyn.," Bd. xxviii, S. 454. 2 E. Opitz, "Centralbl. f. Gyn.," No. 21, 1898. 3 Levison, "Archiv f. Gyn." Bd. ix, S. 517; Lebedjew, " Traite prat, des Ace," Charpentier, 1883, pp. 886, 890. 4 Winckler denies the existence of a capillary system of blood-vessels under the amnion, and attributes hydramnios to the presence of a capillary lymphatic system in the cell-layer of the chorion. 5 " Ueber Hydramn. in Zusamm. mit der Entstehung des Fruchtw.," D. i. Zurich, 1875. 7 98 PREGNANCY. velamentous insertion of the cord (exposing the vein to external pressure), stenosis of the umbilical vein, obstruction of the ductus Botalli,x tumors of the placenta, tumors of the fetus (interfering with its circulation), valvular defects of the heart,2 etc. {p) Excessive excretion of urine is a cause of hydramnios. The action of the fetal kidneys in the production of hydramnios can best be demonstrated in cases of unioval twins,3 in one of which it is common to find a dropsical amnion, while the other one presents usually the opposite condition, oligohydramnios. The history of these cases is that one fetus outstrips the other in growth, and thus, acquiring a preponderating influence in the placenta which is common to both, its heart takes on a hyper- trophy to enable it to carry on the greater part of the placental circulation. The hypertrophied heart produces in its turn hyper- trophy of the kidneys and determines their increased secretion. The increased blood-pressure also determines an increased activ- ity of the excretion from the skin, and thus in a twofold manner helps to increase the quantity of liquor amnii. if) The fetal skin is a source of hydramnios. It can readily be understood how an increased blood-supply from a hyper- trophied heart can stimulate the fetal skin to overaction. There are, however, more direct proofs of the part that the skin may play in the production of hydramnios. Budin 4 has described a case of hydramnios associated with extensive nevi, and another in which the skin was thickened and thrown into folds. Stein- wirker 5 has recorded a case of hydramnios with "elephantiasis congenita cystica." Finally, it is not improbable that the amnion itself may take an active part in the overproduction of liquor amnii; that, in other words, the amnion may be affected by acute inflammation (amnio- titis), followed by an increased serous exudation. This supposi- tion would explain those cases in which a blow or kick 6 on the abdomen of a pregnant woman is followed by the development of hydramnios and the formation of adhesions between the fetus and the amnion. To amniotitis has been attributed the development of acute hydramnios. Werth's 7 theory also de- serves some consideration before leaving the study of the fetal origin of hydramnios. This author believes that a hypertro- 1Nieberding, "Zur Genese des Hydramnios," "Archiv f. Gvn. " Bd. xx, S. 275. 2Cordell, " Tr. Med. and Chirurg. Fac. Maryland," 1888, p. 218. 3 Schatz, "Archiv f. Gyn.," Bd. xix, S. 329; Werth, ibid., xx, 353; Sallinger, loc. cit. 4 Loc. cit. 5 x^oc. cit. 6 " Tr. Obstet. Soc. of Baltimore," meeting Feb. 9, 1887. 7 Werth, loc. cit. THE AMNION. 99 phied placenta can absorb more fluid from the maternal blood than is required for the fetal economy; that the struggle to get rid of this excess of fluid brings about the hypertrophy of the heart and kidneys to which reference has already been made as occurring especially in one of unioval twins. III. Both Fetus and Mother May Contribute to the Production of an Excess of Liquor Amnii.—This proposition has already been demonstrated in showing the possible derivation of the liquor amnii from both mother and fetus. The cause of the hydramnios, however, will most frequently be found in the fetus, while the combined action of both mother and fetus in a single case will be rare, but may occur, as in certain cases of syphilis, in which have been found combined dropsy of the mother and fetus associated with hydramnios.1 B. Hydramnios may be due to a deficient absorption of liquor amnii. Tarnier believes that the production of liquor amnii being normal, but its absorption deficient, hydramnios will result. Thus he would explain the cases of hydramnios asso- ciated with nephritis and serous effusions in the mother. It has been proved that the fetus swallows the liquor amnii in considerable quantities, and it is possible that the skin absorbs some of it. Whether the cessation of these two functions would result in hydramnios is uncertain. Symptoms and Diagnosis.—The symptoms of hydramnios are very like those of other abdominal cystic tumors. There is, however, the history of pregnancy ; the tumor can usually be defined as the uterus, very much larger than usual for the date that pregnancy may have reached; and, except in extreme cases, it is possible to detect the fetal heart-sounds, or to practice ballottement. As the uterus becomes more and more distended it gives rise, by its increased size, to pressure symp- toms in the abdomen and thorax, although it is astonishing to what size the uterus may attain, while the patient remains toler- ably comfortable. This is not the case, however, when the liquid is rapidly effused, as in cases of acute hydramnios. The woman suffers intense pain from the sudden distention of the uterus. Her breathing becomes labored, and complete or- thopnea is developed; her face is cyanosed and bears an anxious expression ; constant and distressing vomiting appears, and there is fever.2 The detection of hydramnios is not always easy, and may be practically impossible. It may be confused with pregnancy associated with ascites, or with a cystic tumor 1 Meissnerand Hufeland, quoted by Wilson, '-Am. Jour. Obstetrics," 1887, p. 13. 2 See Charpentier, " Traite Pratique des Accouchements." IOO PREGNANCY. of the ovary or broad ligament, or with an ordinary twin preg- nancy ; or the fact that the woman is pregnant may be entirely overlooked,—a not uncommon mistake that has frequently led to the tapping of the pregnant womb ;l this procedure, however, appears to be harmless. Finally, it might be possible to mis- take the enlarged bladder associated with a retroflexed gravid uterus for a case of hydramnios (Tarnier). When the dropsy of the amnion has not reached an excessive de- gree, the distinction be- tween it and ascites with pregnancy may be made by mapping out the uter- ine wall and detecting resonance along the flanks in the dorsal de- cubitus ; and an ovarian cyst in pregnancy may be excluded by the ab- sence of two tumors of different consistency and shape. A twin preg- nancy without hydram- nios will present, on ex- ternal palpation, an en- larged uterus, offering firm but irregular re- sistance from its solid contents. In extreme distention of the uterus, which in some cases seems only limited by the utmost capacity of the abdomen, a definite diagnosis becomes im- possible ; in such cases it may be justifiable to resort to an exploratory abdominal section.2 Treatment.—If the fluid should accumulate in such quantity or so rapidly as to produce alarming symptoms in the woman, its evacuation is indicated. This is best accomplished by the natural passage ; that is, by rupturing the membranes through 1 Cases reported by Scarpa, Camper, Noel, Desmarais, Schatz, Tillaud, Chiara, Kidd, etc., not followed by the slightest bad results. 2 Successfully performed in a case of extreme distention of the abdomen from hydnmnios by Wilson, loc. cit. F'g- 73-—Abdominal distention due to hy- dramnios. Woman pregnant six months with twins ; one sac contained 2^ gals. ; the other, one pint (author's case). THE AMNION. IOI the cervix and allowing the liquor amnii to escape. By this method, unfortunately, labor is induced, and if the child has not become viable, its destruction is a necessary consequence. And, moreover, the sudden gush of liquor amnii from the uterus may induce syncope by the rapid removal of the intra-abdominal pres- sure, or may result in excessive tympany from the sudden relief of pressure on the intestines. It has, therefore, been proposed (Guillemet, Schatz) that the uterus be tapped through the ab- dominal walls, and a moderate quantity of liquor amnii be re- moved from time to time, thus preserving the life of the fetus. As, however, the fetus in cases of hydramnios is often deformed or diseased, and usually dies shortly after birth, its life deserves little consideration in comparison with the additional risk that is undoubtedly entailed upon the mother by puncturing the ab- dominal and uterine walls. It is especially in acute hydramnios that puncture of the membranes will be called for, irrespective of the age or condition of the fetus. Special instruments have been devised for the perforation of the membranes, and it has been suggested that the puncture be made at a point far within the uterine cavity, and thus removed from the external os, so that the liquor amnii ma)' trickle slowly down between the membranes and the uterine walls, and the disadvantages of a sudden escape of the fluid be thus avoided. No better or more convenient appliance can be found than the tip of the forefinger. The hand that is introduced into the vagina to dilate the cervix and to rupture the membranes may be clinched so as to form a quite efficient plug, by means of which the operator may regulate at will the escape of the liquor amnii. Abnormalities of the Liquor Amnii in Color, Consistency, and Chemical Constitution—The liquor amnii, which is nor- mally somewhat opaque and whitish in color in the last months of pregnancy, may be green or brown from the presence of meconium, or it may be tinged with red if the fetus is macerated. The consistency of the fluid in extreme cases of oligohydramnios is that of thick syrup or of mucus. It may contain sugar if the mother has diabetes mellitus.1 Putrefaction of the Liquor Amnii---Decomposition of the liquor amnii is most likely to be associated with death and putre- faction of the fetus, but an intensely putrid odor of the fluid, with physometra, has been noted, and yet the child was born alive. Adhesive Inflammation and the Formation of Amniotic Bands.—Early in embryonal life, in case the amnion is not 1 Ludwig, " Centralbl. f. Gyn.," No. II, 1895. 102 PREGNANCY. lifted away from the newly-forming skin of the embryo, owing to an insufficient secretion of amniotic fluid or as a consequence of inflammation, adhesions may form between the skin and amnion, and as the amniotic cavity becomes distended, the adhesive material is stretched, so that it finally forms bands of greater or less length or thickness, either connecting the fetus with the amnion or with one or other or both ends detached, floating more or less free in the liquor amnii. The composition of these bands closely resembles that of the plastic material thrown out in inflammations of the serous membranes generally. They are not provided with blood-vessels. The exudation of this plastic material from the amnion has, as a result, the for- mation occasionally of extensive adhesions between the fetus and the amnion, resulting often in grave deformities, as eventration or anencephalus, by preventing the proper arching over of the walls of the body-cavities. The formation of adhesive bands is sometimes followed by intra- uterine amputations. A de- veloping limb may be caught between two of these bands, and as it grows may be so con- stricted that the distal portion of the limb is entirely cut off from its blood-supply. Adhe- sions may also be formed be- tween various portions of the body and the amniotic covering of the placenta, or the umbilical cord may be artificially shortened by the adhesions of coils one to another and to the fetal skin.1 In the latter part of pregnancy the amnion may burst, the integrity of the ovum being preserved by the chorion.2 The fetus then, by its active movements, can roll the amnion up into cords, which may become so entangled with the umbilical cord as to constrict it sufficiently to shut off its blood-supply. Cysts of the Amnion.—Cases of cystic formations in the substance of the amnion have been reported by Ahlfeld, Winc- 1 Leopold, " Ein Fotus mit Verklebungen der Nabelschnur," etc., " Archiv f. Gyn.," Bd. xi, 383. 2 Schroeder, "Lehrbuch," 8th ed., p. 455. Fig- 74- hesive bands and anus. -Amniotic bands : h, Ad- d, e, feet; f g, genitalia THE CHORION. IO3 kel, and Budin.1 They are small and have no clinical signifi- cance. After the death of the fetus the amnion undergoes certain changes, resulting in a loss of its glistening surface and in a considerable thickening. The histology of this change is not known. THE CHORION. When the ovule first drops into the uterine cavity and be- comes imbedded in folds of the thickened uterine mucous mem- brane, the protoplasmic cell-wall of the ovum sends out numerous prolongations, which serve to fix the egg in its position, and Fig. 75.—A young ovum: a, Natural size; b, magnified, showing chorionic villi (author's specimen). perhaps to draw nourishment for the whole ovum from the blood- vessels of the uterine mucous membrane. This cell-wall, with its villus-like projections, constitutes the false chorion, which soon disappears and is replaced by the single layer of cells springing from the outer layer of the blastodermic membrane and surrounding the whole ovum. This membrane, in its turn, sends out branch-like processes (the villi of the chorion), which, at first non-vascular but hollow, soon receive into the interior of each branch of the villi loops of the blood-vessels that have been carried from the fetus to the periphery of the egg by the allantois. 1 Tarnier et Budin, loc. cit., p. 274. 104 PREGNANCY. These vascular villi absorb nutriment from the whole ex- tent of the decidua reflexa until the third month, when they atrophy and finally disappear, except at that portion of the periphery of the ovum which is in direct contact with the decidua vera (decidua serotina), where the chorion villi develop still further to form the placenta. The Fully=developed Chorion.—Restricting the term chorion to that portion of the original membrane which undergoes atrophy at the third month of pregnancy, it is found to consist of a thin, transparent membrane made up of connective-tissue elements which are continuous with the substance of the umbili- cal cord and very delicate, atrophied villi connecting it with the decidua reflexa. This portion of the chorion is called chorion laeve to distinguish it from the chorion frondosum that forms the placenta. The fibrous mem- brane, constituting wrhat is usu- ally called chorion at term, is derived from the endochorion, so called to distinguish it from the outer epithelial layer (the exochorion), which is to be found persisting in the epithelial cover- ing of the placental villi. Diseases of the Chorion.— An abnormal condition of the chorion is the persistence of the chorionic villi around the whole periphery of the ovum, thus com- pletely enveloping the fetus by the placenta (placenta membran- acea).1 The degenerations, aside from the normal process of atrophy, that can affect the chorion villi are of two kinds,— cystic and fibromyxomatous. Cystic Degeneration of the Chorion Villi.—This disease is char- acterized by the hypertrophy of the chorion villi, by their conver- sion into cysts varying in size from that of a millet-seed to a grape or even to a hen's egg, connected with one another and with the base of the chorion by pedicles of greater or less breadth. It is further distinguished by the rapid growth of the ovum and the consequent expansion of the uterus, usually at the third to the fourth month ; by the escape of blood from the uterine cavity into the vagina, and by the premature expul- m^^ Fig. 76.—Human embryo at the third week, showing villi covering the entire chorion (Haeckel). 1 See " Amer. Jour. Obstetrics," 1886, p. 851. THE CHORION. 105 sion of the ovum, which is covered over a greater or less part of its surface with numbers of small, transparent cysts. Within the cavity of the ovum may or may not be found an embryo. This affection of the chorion, from the peculiar and striking appearance that it gives to the ovum, has attracted much atten- tion, and, from the mystery that formerly surrounded its origin and the difference of opinion that existed as to its etiology and minute anatomy, cystic degeneration of the chorion villi, otherwise known as hydatidiform mole, or dropsy of the chorion villi, has been the subject of much discussion. First definitely described bySchenk,1 the most extraordinary theories have been advanced to account for its occurrence. Regnier de Graaf (1678) believed that each vesicle or little cyst was an unfecundated ovule. But much earlier than this the belief had prevailed that each vesicle was a living embryo.2 The opinion of Ruysch (1691) and Albinus (1754), that the existence of innumerable little cysts in the uterus and their final expulsion were dependent upon some disease or alteration of the ovule, became at last generally adopted. A more definite explanation, however, was not attempted until, in the early part of this century, it was claimed by Percy,3 Cloquet,4 and Mme. Boivin 5 that the vesicular disease depended upon the presence of echinococci. Velpeau 6 was the first to indicate that the cysts were nothing but the dis- tended chorion villi,—a fact that was soon acknowledged to be indisput- able. Since Velpeau's announcement, cystic degeneration of the villi has been attributed to hypertrophy and edema (Meckel, Gierse); to disease of the blood-vessels (Bartolin, Miller, Cruveilhier); to disease of the lymphatics (Bid- los, Sommerring) ; to degeneration of the mucous substance within the villi, continuous with the substance of the cord (Virchow) ; to a degeneration of the epithelial cells derived from the decidua, Fig. 77-—Cystic disease (myxoma) of the chorion ; hy- datidiform mole. 1 See " Tarnier et Budin," p. 299. 2 See the interesting quotation by Priestley {loc. cit., p. 36) from Ambroise Pare, that "the Countess Margaret brought forth at one birth 365 infants, whereof 182 were said to be males, as many females, and the odd one a hermaphrodite " (1276 A. D.). 3 " Jour, de Med.," t. xxii, p. 171, 1811. 4 No. 1, " De la Faune des Med.." Priestley. 5 " Nouvelles Recherches sur le Mole vesiculate," broch., Paris, 1827. 6 " De l'Art des Accouchements." io6 PREGNANCY. which replace the epithelial covering (exochorion) of the chorion (Ercolani); and, finally, to a pathological hyperplasia of the syncytium. Virchow's x explanation is that the change resulting in the cystic degeneration of the chorion villi takes place altogether in the endochorion, which forms the inner of the two layers that compose the chorion and is continuous with the Wharton jelly of the umbilical cord ; this change consists of the overproduction of true mucous tissue within the villi, into which the mucous tis- sue extends at first alone, but afterward accompanied by blood- vessels. The process usually begins at a time when the villi are almost equally developed over the whole ovum,—that is, Fig. 78.—Cystic degeneration of the chorion (from a photograph). before the third month,—and, therefore, when the vesicular, chorion is expelled the disease is usually found equally distributed over the whole surface, showing no evidence of special develop- ment at any one point that might indicate where the placenta should have been situated. The general involvement of the whole chorion is the rule, but exceptionally the placenta alone is affected, the disease having doubtless, in such cases, begun after the atrophy of the villi had taken place over the extra- placental portion of the chorion. Still more rarely will the 1 " Die Krankhaften Geschwiilste," Bd. i, S. 405. THE CHORION. IO7 disease be found in isolated spots upon the chorion laeve.1 There are recorded cases in which one chorion of a twin concep- tion was vesicular while the other remained normal. According to the foregoing explanation, the disease is a true myxoma of the chorion, and the epithelial cells (exochorion) covering the villi do not necessarily take part in the morbid process. Priest- ley's 2 investigations, undertaken as long ago as 1858, gave results in accord with Virchow's theory. Pathological Anatomy.—The appearance of a vesicular mole is striking and peculiar. The mass may be as large as a man's head, covered more or less completely with decidua, which, upon incision, or in spots where the decidual covering is absent, reveals innumerable small cysts, some as large as grapes, or even as hens' eggs, connected one with the other or with the base of Fig. 79.—A, Extremity of a villus in early stage of cystic degeneration : a, Shows the first stage of enlargement in the cells of the villus trunk ; b, a somewhat more advanced stage, showing hyaline cells escaping from the ruptured capsule of a young cyst (Priestley). B, Terminal villus of cystic chorion : a, Stellate connective tissue ; b, c, inner and outer layers of wall; d, early stage of b (Braxton Hicks). the chorion by pedicles of varying thickness. The liquid in the cysts is usually clear and translucent. A microscopic examination of a section through a villus in the early stages of cystic degeneration will show the distended cells of which Priest- ley speaks, or else there may be seen the outer cellular and inner fibrous wall of a villus, while within the interior will be stellate connective-tissue cells, in the interstices between which may be found mucous tissue. The fluid contained in the cysts gives evidence, on chemical examination, of the presence of mucin and albumin in consider- able quantities. 1 Winogradow, Virchow's "Archiv," 1870, Bd. li, S. 146. 2 Loc. cit., p. 37. io8 PREGNANCY. Within the center of the vesicular mass is usually to be found a shriveled or distorted fetus surrounded by its amnion, which occasionally contains an abnormal quantity of fluid (hydramnios). Occasionally, however, no trace of the embryo is to be discov- ered, or at most there may be seen only the remnants of an umbilical cord. More rarely the fetus, although dead, is appar- ently well developed for the date of pregnancy,1 and if the de- generation of the chorion has not been too extensive, a living, healthy infant may be born along with a vesicular chorion.2 It has been already noted that between amnion and chorion may be found a thin layer of jelly-like substance continuous with the Wharton's jelly of the umbilical cord. There is a case on rec- ord 3 in which this substance formed a layer four to five milli- meters thick, originating from a mucous degeneration of the Fig. 80. Fig. 81. Microphotographs of myxoma of the chorion (prepared for the author by Dr. H. L. Williams). connective-tissue layer of the chorion, without involvement of the villi of either the chorion laeve or frondosum, thus consti- tuting a peculiar and, up to the present time, unique variety of myxoma of the chorion. The relation of the cystic chorion to the two deciduae is often peculiar and complicated. Occasionally the membranes retain their normal relative position of external deciduae, median 1 Priestley, loc. cit., p. 42. 2 Schroeder, " Lehrbuch d. Geb.," 8th ed., p. 442; and Sym, " Edin. Med. Jour.," Aug., 1887, p. 102. 3 "Wiener med. Presse," 1867, Bd. i; and Virchow's "Archiv," Bd. xxxix, S. 1. THE CHORION. IO9 chorion, and internal amnion ; but frequently the enlarged villi of the chorion perforate either one or both deciduae over surfaces of varying extent. Thus, specimens have been described x in which the cystic mass was inclosed between the decidua vera and the reflexa, or in which the villi have perforated not only both deciduae, but also the muscular wall of the uterus, and even its peritoneal covering.2 The relation of myxoma of the chorion to syncytial cancers is quite intimate. In a large pro- portion of the latter growths there is associated a cystic disease of the chorion villi. The cases formerly reported of malignant degeneration of the chorion were unquestionably of this charac- ter. There may be a metastasis of whole chorion villi, without a malignant degeneration of the epithelial cells.3 Clinical History and Diagnosis.—There are three prominent symptoms associated with the cystic degeneration of the chorion : (1) Rapid increase in the size of the uterus; (2) discharge of blood or bloody serum, and (3) the escape of vesicles. The last symptom is of rare occurrence, and the first two do not always manifest themselves in a typical manner, so that the clinical phenomena in a case of vesicular mole do not always Fig. 82.—Cystic chorion perforating the uterine walls (Spiegelberg). permit of a definite diagnosis. Should there be an escape of blood at intervals during the early part of pregnancy, if the uterus rapidly enlarges toward the third month, and if careful palpa- tion elicits no sign of the presence of a fetus within the uterine cavity, the existence of a cystic chorion may be suspected. If, as rarely happens, characteristic cysts are expelled, there can be no doubt as to the nature of the case. The sudden distention of the uterus usually causes excessive nausea and vomiting. Occasionally, after the development of the chorion villi, the dis- ease is arrested and the ovum is retained for many months, so that in such cases there may be all the symptoms of pregnancy, with a previous history of bleeding, but the womb at the time of examination is much smaller than it should be at the date which the pregnancy has apparently reached. Vesicular mole is most apt to occur in women who have already borne children 1 Priestley, loc. cit., p. 40. 2 Cory, quoted by Priestley, p. 41. Volkmann, Waldeyer, Jarotzky, Krieger, Wilton, quoted by Schroeder, op. cit., p. 444. 3 Gaylord, " Tr. of the Gyn. Section, College of Physicians of Phila.," 1898. I IO PREGNANCY. or who have reached middle age. Hirtzmann1 found that, of 35 cases, 25 occurred in women over twenty-five years of age. As an exception to this rule, Strieker2 reports a case of pre- cocious menstruation in a child who in her ninth year gave birth to a true vesicular mole. In 100 cases collected by Dorland,3 68 occurred between the twentieth and fortieth year. It is hardly necessary to state that cystic degeneration of the cho- rion villi is necessarily a result of impregnation, and can not occur in a virgin uterus. Cystic degeneration of the chorion will often occur in women who have previously given birth to healthy children, but it will not infrequently recur in the same individual. Depaul 4 mentions a woman who had this affection three times, and Mayer 5 has observed the disease in eleven successive pregnancies. The degenerated chorion usually determines the expulsion of the ovum at some period between the third and sixth months of gestation.6 If, however, the disease does not begin until after the villi of the chorion laeve have atrophied, or if the degeneration is confined to a comparatively limited area, the pregnancy will usually go on to term. On the other hand, if the embryo is absorbed and the chorion becomes adherent to the uterine wall, the pregnancy may be abnormally prolonged to twelve or thirteen months (Schroeder). The adhesion of the cystic villi to the uterine wall has more serious results, however, than the mere prolongation of pregnancy. It is often due to the perforation of the uterine wall by a proliferation of the syncytial cells of the chorion villi, and consequently when the mass is ex- pelled there may be fatal hemorrhage from the uterine sinuses (Volkmann, Waldeyer), or, as in Wilton's case,7 the peritoneal covering may be torn and fatal hemorrhage may ensue into the peritoneal cavity. The retention of a portion of the chorion may be followed by its decomposition within the uterine cavity, giving rise to general septicemia ; or fragments of cystic chorion retained in utero may be expelled at a date remote from the original preg- nancy. With these accidents, of not infrequent occurrence in the course of the disease, it is not surprising that the maternal mor- tality is eighteen per cent.8 Etiology and Frequency.—The occurrence of vesicular disease 1 " These de Paris," 1874. 2 Virchow's "Archiv," Bd. Ixxvii, S. 193. 3 "Am. Journ. of Obst.," 1896, p. 905. 4 " Lecons de Clin. Obstet.," 1872. 5 " Tarnier et Budin," p. 306. 6 In Dorland's loo cases the mass was expelled in 63 per cent, between the third and fifth months. 7 "Lancet," Feb., 1840. 8 Dorland, loc. cit. THE CHORION. Ill of the chorion can not be attributed to any single cause. The connection between disease of the endometrium (Virchow) or of the uterine walls (fibroid tumor (Schroeder) ) and vesicular mole is clearly established in a large proportion of the cases, especially in those in which there is a frequent recurrence of the disease ; but this explanation will not suffice for the occurrence of the disease in the chorion of one fetus while that of its twin remains healthy. In this case the disease is of fetal origin,—per- haps the result of the death of the fetus. Indeed, it has been claimed that the death of the embryo necessarily precedes the cystic degeneration of the chorion. That this view is incorrect, however, is demonstrated by the birth of living children in certain cases of not too extensive degeneration of the chorion. It has been claimed also that vesicular mole is the result of an absence of the allantois (Hecker), or that possibly the allantois may, in certain cases, contain no blood-vessels (Schroeder), thus depriving the villi of their circulation. Stenosis of the umbilical vein has been found associated with cystic chorion, and, therefore, it has been asserted that the cystic degeneration may have been due to dropsy of the chorion villi (Maslowski, Robin). As to the frequency of this affection, there are no reliable statistics. Mme. Boivin x saw the disease only twice in 20,375 pregnancies, while in the Charity Hospital in Berlin it occurred four times in 2130 pregnancies. Two cases have been under my care in ten years. Every obstetrician of large practice has seen at least one case. Perhaps once in two or three thousand cases would be the true expression of the frequency of this disease. Treatment.—The treatment of a pregnant woman affected with cystic degeneration of the chorion will be mainly directed toward the symptoms. Should there be an excessive hemor- rhage, it might be necessary to tampon the vagina until the os is sufficiently dilated to permit the expulsion of the cystic mass. If the diagnosis of cystic disease of the chorion should be made during pregnancy, and if abdominal or combined palpation gives no sign of the presence of a fetus, the immediate induction of abortion would be advisable in order that the chorion might not have an opportunity to grow to inordinate size and to push its way, perhaps, into the uterine wall, giving rise to hemorrhage or possibly to perforation of the uterus. A prolonged retention of the mass would also predispose to the malignant degenera- tion of its epithelium. After the expulsion of the diseased ovum, if there should be symptoms pointing to the retention and decom- ^'Clin. Mem.," 1863. 112 PREGNANCY. position of fragments of the chorion within the uterine cavity, the natural impulse would be to remove the retained substances; but it must be borne in mind that the attenuation of the uterine wall in circumscribed areas may be so great that the slightest interference, the introduction of a curet, or the injection of an antiseptic solution, may cause its rupture with a fatal result.x Fibromyxomatous Degeneration of the Chorion.—If, instead of being thin and watery, the mucous tissue in the intercellular spaces of the degenerated villi should contain more fibrous ele- ments, the resulting mass, instead of being cystic, is solid. Virchow 2 first called attention to this condition in the placenta, and gave it the name of myxoma fibrosum placentae. In this case, the first one described, in the midst of healthy cotyledons one was discovered affected by this fibromucous degeneration. A similar structure may be found in the peripheral layers of the umbilical cord. To complete the study of diseases of the chorion it is necessary to mention a chronic inflammation of the membrane.3 In the case, already referred to, in which the amnion was rup- tured during pregnancy, the irritating effect of the liquor amnii upon the chorion produced a thickened and hyperplastic con- dition of that membrane. THE PLACENTA. The placenta, as a separate organ, dates from the third month of pregnancy. At this time the chorion villi atrophy over the whole periphery of the ovum, except at the point where it comes in direct relation with the true mucous membrane of the uterus— the decidua serotina. Here the villi take on an extraordinary growth, forming buds of epithelial cells (syncytium) upon their surface, which rapidly take on the shape of new villi, thus send- ing out branches in every direction, into each of which a loop of blood-vessels is projected. Separating the villi from one another, and dipping down to the base of the chorion between the parent stems of the villous projections, are processes of the decidua, carrying capillary loops of maternal blood-vessels. Very early in the history of the ovum 4 the arterioles of this sys- tem open directly into the intervillous spaces of the placenta, 1 For a case resulting fatally after the injection of perchlorid of iron, see Priestley, loc. cit., p. 41. 2 Op. cit.,S. 414. 3 Lebedeff, quoted by Tarnier, op. cit., p. 313. 4 In Leopold's ovum of 7 to 8 days their arrangement was already visible. " Uterus u. Kind," Leipsic, 1897. THE PLACENTA. H3 so that the placental villi are bathed directly in maternal blood. So far almost all authorities are agreed, but as to the relation of the terminal villi to the uterine mucous membranes, the action of the chorional and decidual epithelium, the changes that convert the uterine capillaries at first surrounding the villi into the large blood-sinuses that are later found in the placenta, Fig. 83.—The fetal surface of the placenta (Minot). many conflicting theories have been advanced. In regard to the relation between the placental villi and the uterine mucous mem- brane, it has been variously stated that the former enter the mouths of the uterine glands (Bischoff); that they sink into crypts in the uterine mucous membrane, which are new forma- tions especially adapted for their reception (Turner); that the 8 U4 PREGNANCY. villi do not sink into glands or crypts, but are intimately invested with a layer of decidual epithelium, or with an endothelial cover- ing derived from the maternal blood-vessels (Ercolani); and that this cell-covering acts as a glandular structure, secreting from the maternal blood a peculiar substance, the so-called " uterine milk," which acts as nutriment for the fetal blood (Ercolani, Hoffman). It is now well established, however, that the placental villi imbed themselves in the soft interglandular substance of the decidua serotina, and that the connective-tissue cells multiply and hypertrophy around them (decidual cells). The epithelium of the uterine mucous membrane disappears, except in the glands. The chorion villi are at first covered with two distinct layers of cells ; an inner layer composed of single large nucleated cells arranged side by side with distinct cell walls (Langhans' layer), and an outer layer or band of protoplasm in which are imbedded nuclei at irregular intervals (the syncytium). Both of these layers are de- rived from the chorion and not from the uterine epithelium. Early in embryonal life (the third month) the Langhans' layer disappears and the syncytium remains as the sole epithelial covering of the villi. The uterine mucous membrane at first is richly supplied with capillary blood-vessels, from which loops are thrown around the villi in such fashion as to form a complex but very distinct network throughout the placental mass. Later these capillaries disappear, and in their place are seen the large sinuses or lacunae, to which blood is conveyed from the maternal circulation by little curling arteries that wind their way up through the decidual cells and empty directly into the placental sinuses. These arteries are provided with only a deli- cate endothelial wall. From Leopold's x observations it appears that the arterioles of the decidua become more and more dis- tended as they approach the placental villi, so that their terminal -The capillary system of (from Minot). placental villus 1 Loc. cit. THE PLACENTA. H5 Fig. 85.—A, Placenta in its most generalized form ; B, structure of placenta of pig; C, structure of placenta of cow ; D, structure of placenta of fox; E, structure of placenta of cat; F, structure of placenta of sloth ; on the right side of the figure the flat maternal epithelial cells are shown in situ ; on the left side they are removed, and the dilated maternal vessel with its blood-corpuscles is exposed ; G, structure of human placenta; F, fetal, and M, maternal placenta; e, epithelium of chorion; e', epithelium of maternal placenta; d, fetal blood-vessels; d', maternal blood- vessels ; v, villus. The succeeding references apply to G only : ds, Decidua serotina of placenta; t, trabeculae of serotina passing to fetal villi; ca, curling artery; up, uteroplacental vein (from Balfour, after Turner). n6 PREGNANCY. expansions may be compared to a sea into which project Pe"m_ sulas and capes of decidual masses and placental villi. The syncytial cells of the latter have the power to penetrate the endothelium of the decidual arterioles and thus open a direct Fig. 86.—Microphotograph of a section of an injected placenta (prepared for the author by Dr. H. L. Williams). Fig. 87.—Section of a placenta (microphotograph). communication between the placental villi and the maternal blood. By this anatomical arrangement the fetal and maternal blood is, of course, kept separate. The former circulates within THE PLACENTA. 117 the capillary system of the villi; the latter bathes the exterior of the villi. The Fully=developed Placenta.—The placenta at term is a circular mass, measuring about seven inches in diameter, about two-thirds of an inch to an inch in thickness at the point of insertion of the cord, and weighing about sixteen ounces. Upon Fig. 88.—Section of placental villi of a normal placenta at term: M, Fetal mesoderm ; S, syncytial masses; V, V, fetal vessels; L, maternal lacunae, con- taining maternal blood (Durante). Fig. 89.—Surface of villus at three weeks, showing syncytial band, A, and Langhans' cells, B (500 enlargement) ; C, stroma of villus. the surface of the placenta into which the cord enters is seen a smooth, shining membrane, continuous with the sheath of the cord,—the amnion. The fetal side of the placenta contrasts strongly with the maternal surface. The latter is of a dark-red hue, divided by deep sulci into lobules of irregular outline and n8 PREGNANCY. extent,—the cotyledons. Over the maternal surface of the pla- centa is stretched a delicate, grayish, transparent membrane, which is made up of the cells that compose the upper layer of the decidua serotina. This constitutes the maternal portion of the placenta. In separating from the uterine wall, therefore, the line of separation does not divide the fetal from the maternal struc- tures, but is found in the mucous membrane of the uterus, in the lower portion of the cellular layer of the decidua. Around the periphery of the placenta may be seen a large vein, the circular vein of the placenta, which returns a part of the maternal blood from the organ, the remainder returning to the maternal circula- tion by means of the continuity between the placental lacunae and the uterine sinuses. The situation of the placerita within the Fig. 90.—Diagram of uterus and placenta in the fifth month: Ch, Chorion ; am, amnion ; V, V, villi; L, L, lacunae; s, serotina; v, small arteries; /, glandu- lar layer; m, uterine muscle (Leopold). uterus may with equal frequency be found either upon the poste- rior or the anterior wall occasionally, however, upon one of the lateral walls, more frequently the right (Schroeder). A perpendicular section through the middle of a placenta that is still attached to the uterine wall will reveal an intimate connection between the two. The delicate terminal villi, and even branches a millimeter in thickness, are imbedded in the upper portion of the decidua, and held in place by their extremities bulging out into club-shaped masses, so that the exercise of considerable force will not extract them from the uterine mucous membrane, but will, instead, always lacerate the maternal structures. The functions of the placenta are manifold. Not only does it THE PLACENTA. II9 act as a lung, or, rather, gill, in oxygenating the fetal blood, but it may be said to take the place of the alimentary tract in ab- sorbing nutritive material from the maternal circulation. It is probable, moreover, that it plays the part of an excretory organ, getting rid not only of the surplus carbonic oxid gas in the fetal blood, but also of the other waste-products of a tissue-activity that in the rapidly growing fetus must be great. Bernard has shown that in the earlier months of pregnancy the placenta has a glycogenic function. The epithelial cells of the chorion villi take something more than a passive part in the passage of substances to and fro between the fetal and the maternal blood. They have a certain power of selection or resistance. Some pathogenic micro-organisms—as, for instance, those of variola— pass easily from mother to fetus, while the bacilli of tuberculosis, a disease often present in pregnant women, are almost never found in the fetus. Certain drugs, also (iodid of potassium, benzoic acid, bichlorid of mercury), enter the fetal from the maternal blood, while it is asserted that others, as woorara, will not pass to the fetus from the mother. Again, while nutritive material must pass from mother to fetus, the escape of the same material from the fetal into the maternal blood would prove destructive to the fetus. Anomalies of the Placenta.—The placenta may present de- viations from the normal in size, position, shape, weight, or num- ber. Its structure may present anomalies the result of diseases or accidents, and there may be anomalies of function. Anomalies of Position, Size, and Weight.—The position of the placenta is normally near the fundus uteri. A low insertion will give rise to the condition known as placentaprcevia, which will be more fully described in its appropriate place. The size of the placenta may vary considerably. The thickness of the organ is in inverse ratio to its extent, and the younger the ovum, the greater is the relative size of the placenta. The placenta, instead of being confined to that portion of the ovum which is in contact with the decidua serotina, has been known in rare cases to extend around its whole periphery. This condition is known as placenta membranacea, and is to be explained, of course, by the equal development of all the chorional villi. On the other hand, the placenta may be abnormally thick and enlarged in all directions, owing to an irritation from a chronically inflamed endometrium, which results in a hyperplastic condition of both the maternal and fetal portions of the organ. An abnormally small placenta may be associated with an ill-developed child, may depend upon an interstitial overgrowth with subsequent retraction, or may be due to atrophy of the decidua. Anomalies of Shape and Number.—The placenta, usually round 120 PREGNANCY. or oval, may have a horseshoe or crescentic shape, especially if it is inserted near the internal os, which in these cases is sur- rounded by the two arms of the crescent. In multiple preg- nancies each child has its own placenta (Fig. 91). A single child may have two (placenta duplex), three (placenta tripartita), or more placentae (placenta multiloba), or a single placenta may be reinforced by one or more small accessory placental develop- ments (placentae succenturiatae), which are in direct communication with the blood-sinuses of the decidua vera. Should the villi of these accessory growths not communicate with the maternal blood, the growths are called placentae spuriae. Taurin l has reported a case of annular placenta, extending almost completely Fig. 91.—Placentae of triplets. around the ovum as it does in some animals, but separated indis- tinctly into three lobes. Edema of the Placenta.—A serous infiltration of the whole placenta is often observed with a dead and macerated fetus.2 The same condition is often associated with general anasarca of the fetus, with some obstruction of the umbilical vein or of the venous system of the fetus, or with a greatly hypertrophied pla- centa which absorbs more fluid than the fetal economy can dispose of (Werth). The minute anatomy of the placenta may remain 1 " Nouv. Arch. d'Obstet," 1893, p. 486. 2 Tarnier et Budin, op. cit., p. 329. Plate 2. Anomalies of the Placenta: i, Placenta with irregular lobes (Auvard); 2, placenta in two unequal lobes (Auvard) ; 3, irregular placenta (Auvard) ; 4, small accessory placenta (Ribemont-Lepage); 5, placenta succentunata (Ribemont-Lepage); 6, "battledore" placenta, oval (Auvard) ; 7, placenta with velamentous attachment of cord (Ribemont- Lepage) ; 8, placenta with two equal lobes (Ribemont-Lepage). THE PLACENTA. 121 normal in this disease and the placenta may continue to perform its physiological functions. Degeneration of the Placental Villi.—The morbid processes that result in such grave alteration in the structure of the placental villi as to abrogate their physiological activity are, hypertrophy, fibrous and fatty, caseous (phthisical placenta), calcareous, and myxoma- tous degenerations. Placental hemorrhages, placental syphilis, and solid tumors of the placenta have, as a result, the destruction of all or of a part of the placental villi as factors in the nutrition and aeration of the fetal blood, but these conditions will be con- sidered separately. Cellular Hypertrophy.—Ercolani x has described, under the name of " cellular hyperplasia and hypertrophy of the paren- chyma of the placental villi," a disease that is characterized by the extensive multiplication of the cellular elements in the villi to such an extent as often to obliterate the blood-vessels and to give the placenta a hard, dense appearance and feel that has been called by other writers sclerosis of the placenta, and has been attributed to the overproduction of fibrous tissue. Cellular hypertrophy may also be seen in syphilitic disease of the villi. Fibrous and Fatty Degeneration of the Placenta.—A fibrous and fatty change in the placental villi is extremely common, and isolated examples of it may be found in almost every placenta, especially toward the periphery of the organ. It is necessary to consider the two together, for they are always found in common, except when the degeneration of the placenta follows the death of the fetus. In this case there is a simple fatty change without other pathological process (Barnes). It has been claimed by some observers, as Barnes2 and Kilian,3 that fatty degeneration of the placenta may be the primary pathological process, and may originate independently of other degenerative changes ; and it has also been asserted that this degeneration is only an exag- geration of the condition that normally obtains in the placenta toward the end of pregnancy ; but most modern investigators will agree with Robin and Ercolani that the fatty change is sub- sequent to other degenerative processes, most frequently an abnormal development of fibrous tissue,—a condition that might be termed interstitial placentitis. This development of fibrous tissue must be distinguished, however, from the fibrous change that occurs in blood-clots due to effusion from the maternal capillary loops in early pregnancy, or to thrombosis in the pla- cental lacunae later on. The fact that an inflammation of the 1 " Delle Malattie della Placenta," Bologna, 1871. 2 " Med.-Chir. Trans.," 1851. 3 " Neue Zeitschr. f. Geburts.," 1850. 122 PREGNANCY. placenta can occur has been denied. There are, however, the same multiplication of connective-tissue cells and a subsequent contraction that one sees everywhere in the body in a chronic inflammation. The fibrous change may originate either in the decidua sero- tina, the placental villi, or the intervillous spaces. If the disease affects the decidua serotina, it is associated with chronic inflammation of the remainder of the endometrium, and it would be better, perhaps, with Braun, Schroeder, and Spiegelberg, to regard it not as a disease of the placenta, but as an endometritis. As the disease progresses, however, the placenta becomes secondarily involved, either by the encroach- ment of the hypertrophied decidua upon the intervillous spaces, and the consequent compression of the villi, or by the agglutina- tion of the different layers of the membrane one to another, which may result in a firm adhesion of the placenta to the uterine wall. Hegar and Maier and many others have de- scribed this disease as interstitial endometritis.1 The same microscopic appearance may be seen in a hyper- trophied decidua throughout its extent, and is not confined to the placental site. It is, however, possible to find an endome- trium in an advanced stage of hyperplastic inflammation, while the upper layer of the decidua serotina remains unchanged, even although the placental site itself is immensely thickened by new- formed connective tissue and enlarged blood-sinuses. In such a case the placenta remains unaffected. The fibrous degeneration may have its seat in the placental villi alone. The process that transforms a healthy villus contain- ing blood-vessels into a bundle of connective tissue can well be studied in the extraplacental villi of the chorion, which normally undergoes a fibrous degeneration, as they begin to atrophy at the third month of pregnancy. The mucous tissue in the interior of the villi is converted into fibrous tissue, the blood-vessels are obliterated, and the villi shrink, atrophy, and become more or less infiltrated with fat. This same process may be seen in isolated villi of almost every placenta. If the process becomes more extended, the functions of the placenta are naturally abro- gated. According to Neumann,2 the interchange between fetal and maternal blood may be prevented by the great hypertrophy of the placental villi and their consequent encroachment upon the maternal blood-spaces. The development of connective tissue may take place in the 1 Virchow's "Archiv," 1871. 2 See Priestley, loc. cit., p. 54. THE PLACENTA. 123 intervillous spaces,—a condition to be distinguished from the fibrous mass that results from the effusion of blood or the occurrence of thrombosis in the same situation. The develop- ment of the fibrous tissue has been ascribed by Simpson, Rokitansky, Scanzoni, Priestley, and others to an inflammation followed by a cellular exudate which organizes into connective tissue. Priestley has described, under the name of placental phthisis, a pathological condition of the placenta brought about in this way : The first stage of the disease consists of an exuda- tion or deposit thrown out among the villi, probably due to some modification of a low inflammatory process, the result of which is a sort of " hepatization " of the part affected. The mass thus formed either remained dense and firm throughout, or else in the center might be found a crumbled and disintegrated substance resembling the result of cheesy degeneration of tuberculous masses in the lung. As a result of this disintegration there may be found evidences of old hemorrhages in blood-clots at different stages of organization. The result of fibrous degeneration of the placenta, wherever the disease originates, is to prevent the performance of its most important vital functions, and if the pathological condition in- volves a large area of the organ, it must prove destructive to the fetus. The deprivation of their blood-supply determines the fatty degeneration, or in some cases amyloid degeneration,1 of the placental villi. This fatty infiltration is the more marked, as a rule, the older the original lesion. Thus, Bustamente's 2 de- scription of a " sclerotic " placenta as presenting a reddish, spotted, lobulated, or smooth mass resembling the thymus, would be applicable to a fibrous placenta, in which fatty degeneration had not advanced very far. In the latter case the organ would pre- sent a paler, yellowish hue. The diagnosis of fibrofatty degen- eration of the placenta is impossible during pregnancy. Such a condition may be inferred if there is a history of the previous repeated occurrence of the disease. Myxomatous Degeneration.—The myxomatous degeneration that has already been studied in the chorion villi may be confined to the placenta, while the extraplacental chorion remains healthy. Myxoma fibrosum placentae has already been described. This affection has been observed by Virchow,3 Storch (two cases),4 Hildebrandt,5 and Sinclair.6 1 Green, "Am. Jour. Obstet," 1880, p. 279. 2 " These de Paris," 1868. 3 Loc. cit., p. 414. 4 Virchow's "Archiv," 1878 ; and Breus' " Wien. med.Wochens.," 1SS1, No. 40. 5 '• Monat. f. Geb.," Bd. xxxi, S. 346. 6 "Jour. Obstet. Soc," Boston, 1871. 124 PREGNANCY. Calcareous Degeneration.—Depositions of small quantities of lime in the placenta are not at all uncommon. They are usually to be found in that portion of the maternal placenta lying nearest the villi, or they may originate in the villi themselves. Cham- bord x has found as many as five hundred concretions in one placenta. It has been said that extensive calcification of the pla- centa is more apt to occur after the death of the fetus, but Tar- nier asserts that there is no relation of cause and effect between the two, and that the occurrence of large calcareous deposits in the placenta with still-born children is a mere coincidence, as it is also in those cases in which calcareous degeneration had been associated with syphilis.2 Placental Syphilis.—From the end of the last century, when Astruc first called attention to the fact that syphilis of either parent was apt to result in the birth of still-born and macerated children, until the appearance of D'Outrepont's paper 3 in 1830, the opinion prevailed that the cause of the repeated fetal deaths must be sought for in syphilitic disease of the viscera. It was this last-named author who first called attention to the influence of the diseases of the placenta upon the nourishment and the life of the fetus. Shortly afterward followed Simpson's well-known work,4 and ever since all pathological conditions of the placenta have been investigated with increasing care, and the changes asso- ciated with syphilis have received special attention. Virchow was the first to divide the study of placental syphilis into the in- vestigation of the lesions in the maternal and in the fetal portions of the organ and to consider apart the changes in the decidua serotina (endometritis placentaris gummosa) and those in the extraplacental decidua (endometritis decidualis). No consider- able advance was then made in the knowledge of placental syphilis, although the subject was investigated by many ob- servers, until Slavjansky and Kleinwachter 5 called attention to the development of fibrous nodes " of a syphilitic nature " in the fetal portion of the placenta and to the degeneration of the epithe- lium in the placenta materna. In 1873 appeared Frankel's paper in which he claimed to be the first to demonstrate that the "deforming granular hyperplasia and hypertrophy of the placental villi," already described by Ercolani,—without, how- 1 " Lyon Medicale," 1873, p. 431- 2 See also Frankel, "Archiv f. Gyn.," Bd. ii, S. 373; Winckler, "Archiv f. Gyn.," Bd. iv, S. 260; Langhans, "Archiv f. Gyn.," Bd. iii, S. 150. 3 " Ueber die Krankheiten u. Abnorm. der Placenta," " Gem. Deutsche Zeitschr. f. Geburtsh.," Bd. v, 518. 4"Edin. Monthly Jour, of Med. Sci.," Feb., 1845; "Obstet. Works " vol ii, P- 445- 5 See Frankel, " Ueber Placentar Syphilis," " Archiv f. Gyn.," Bd v S 6 THE PLACENTA. 125 ever, reference to its connection with syphilis,—was the most frequent form of placental syphilis. According to Frankel, this infiltration of the villi with granu- lation-cells, and their consequent increase in size and distorted shapes, are characteristic of syphilis and make certain the diag- nosis of the disease. As to the seat and extent of the lesion, they vary with the manner and time of the fetal infection. If the ovule is infected by the impregnating spermatic particle, the placenta, if diseased at all, will constantly present the granulation- cell infiltration of the villi and the degeneration of their epithelial covering. If the mother is infected during the fruitful coitus, there may be endometritis placentaris characterized by the enormous Fig. 92.—Section of villi, showing small-cell infiltration and the deformed shapes of villi: A,A, Luxuriant cell-development in the interior; V, V, lumen of blood-vessels with hypertrophied walls ; B, villus in which only a trace of blood-vessels can be seen at S; C,C, villi without trace of vascular canal; D,D,D, epithelial covering (Frankel). overgrowth of the decidual cells or the overgrowth of connective tissue as well as syphilitic disease of the villi. If the mother is syphilitic before conception, the disease of the placenta takes the form of endometritis placentaris gummosa. If the mother is infected during the latter months of pregnancy, the placenta usu- ally remains unaffected. Frankel bases these conclusions upon the examination of more than one hundred specimens, and his views have been confirmed by Hennig1 and MacDonald.2 Specimens of syphilitic placentae in my possession show the 1 "Archiv f. Gyn.," Bd. vi, S. 141. 2 " Br. Med. Jour.," Aug., 1875, p. 234. 126 PREGNANCY. condition of the villi described by Frankel, and also an endome- tritis placentaris gummosa, in which the decidual cells are enor- mously increased and overgrown, encroaching deeply upon the intervillous spaces and undergoing degeneration in places. In one case, in which the mother was infected at about the fifth month of pregnancy, the placenta materna at birth was greatly thickened, and showed under the microscope an extraordinary development of connective tissue. The fetal placenta and the child itself were perfectly healthy. In their macroscopic appearances syphilitic placentae may differ considerably. If the child has been dead some time, the placenta may be almost white in appearance and soft and greasy in feel.1 If the child is expelled alive at term, the placenta is often unusually large and of a pinkish color, due to the thickened decidua, which pre- vents the true color of the organ from ap- pearing. Very often there are organized clots, showing a pre- vious hemorrhageinto the placenta or the occurrence of throm- bosis in the lacunae ; Fig. 93.—Syphilitic disease of the placenta, showing or Frankel's disease. found nodes2 of a greater or less extent, lamellated in structure and undergoing degenerative changes in the central portions. Often, too, there is extensive calcareous degeneration. The consequence of syphilitic disease of the placenta is usually disastrous to the fetus and often dangerous to the mother. The cellular infiltration of the villi obliterates the blood-vessels within them, and consequently abrogates their functions. The same effect may be produced by the hyperplasia of the decidua serotina and the consequent encroachment of the decidual tissue upon the intervillous blood-spaces, or the destruction of the villi may be brought about by the formation of the nodular masses that have been noticed. All these processes, if, as is the rule, 1 Charpentier, " Syph. hereditaire," 1870, " Presse Med. Beige," No. 8. 2 Ziller, " Studien iiber Erkrankungen der Placenta," etc., Tubingen, 1885. THE PLACENTA. 127 they invade the whole area of the placenta, must, of necessity, be fatal to the fetus. The endometritis placentaris that is often a prominent feature of placental syphilis may prove dangerous to the mother by so matting the layers of the decidua serotina together as to occasion a close adherence of the placenta to the uterine wall, thus subjecting the woman to the perils of hemor- rhage, septicemia, or inversion of the uterus that are incidental to adherent placentae. The accurate diagnosis of placental syphilis is impossible during pregnancy. The condition may be inferred with con- siderable certainty, however, should a history of syphilitic infec- tion be obtained from either parent. The treatment will be referred to later under the head of Fetal Syphilis. Placental Hemorrhages.—The term placental hemorrhage is used to indicate circumscribed collections of blood that have undergone more or less change, frequently found in the placenta. The blood may be found in the shape of a fresh clot, sometimes occupying a very large area, especially in those cases in which abortion occurs as a result of the premature detachment of the placenta ; or the extravasated blood may be encapsulated, sur- rounded by a fibrous wall of varying thickness, within which may be found a reddish or a brownish fluid ; or the cyst may contain nothing but clear serum, while the coloring-matter of the blood is deposited upon the cyst-wall or upon the surround- ing villi.1 The encysted hematocele, on the other hand, may contain large numbers of white blood-corpuscles undergoing fatty degeneration, giving rise to a liquid resembling pus. It is such cases, according to Tarnier, that have been described as abscesses of the placenta by Brachet, Cruveilhier, O'Farrell, and Simpson. Again, the fibrin may predominate, especially in those cases of thrombosis in the placental sinuses described by Bustamente2 and Slavjansky,3 when, if the clot is slowly formed, the resulting mass will consist of laminated fibrin, such as one sees in aneur- ysms undergoing obliteration. In other cases the serum is rapidly absorbed, and there is left a mass of red globules con- taining white corpuscles, either heaped together or scattered through the mass. Finally, the clot may organize through the process described by Weber and confirmed by Virchow, and 1 Ercolani has described a case of " placental melanosis " in which there was no trace of blood-extravasation, but the villi were infiltrated with pigment-granules (" Archiv de Toe," 1896, p. 193). 2 Loc. cit. 3 " Archiv f. Gyn.," 1873, Bd. v, 360. 128 PREGNANCY. thus form a distinct neoplasm in the placenta. The placental villi surrounding the extravasated blood usually undergo a fibro- fatty change. The causes of placental hemorrhage are manifold. The pre- disposing causes may be stated to be those that lead to apoplexies elsewhere in the maternal system, as congestions (Simpson) or albuminuria (Winter, Fehling) ; the slow-moving blood-current in the placental sinuses and the excess of fibrin in the blood of pregnant women, predisposing to thrombosis (Bustamente) ; and diseased conditions of the placental villi (Charpentier and others). The determining cause may be a sudden, powerful action of the heart, producing at the same time, perhaps, apoplexy of the placenta and of the brain ; or syncope, favoring the formation of a thrombus ; or external violence. In the early months of preg- nancy it is more frequently a true apoplexy that gives rise to the hemorrhage, from rupture of the delicate capillary loops of maternal origin that surround the villi. Later, it is more fre- quently thrombosis in the sinuses, or the laceration of the deli- cate blood-vessels that perforate the upper layer of the decidua serotina to enter the placental sinuses.1 The consequence of placental hemorrhage to the fetus de- pends upon the amount of blood extravasated. Should the quantity be large, either the number of villi strangulated by the clot is so great that the fetus is at once asphyxiated, or else the escaping blood is able, especially in the earlier months, to strip the placenta off from the uterine wall, with the same result. The effect of placental hemorrhage upon the mother is usually unno- ticeable, except in case the fetus is killed, when the whole ovum will be prematurely expelled. In some instances, however, the blood will force itself between the placenta and uterus, and, bur- rowing its way downward through the layers of the deciduae, will make its appearance externally as a hemorrhage from the uterus. Or else the blood, unable to escape, will collect at the placental site, or possibly over a larger area, sometimes in such quantities as to form distinctly an additional tumor of the uterus appreciable through the abdominal walls, and also to give rise to all the symptoms of internal hemorrhage. Placentitis—An interstitial placentitis has already been de- scribed. Older authors paid particular attention to inflammations of the placenta, and Simpson described three stages of the dis- 1 My friend, Dr. Robert H. Hamill, of Philadelphia, has shown me a specimen exhibiting an interesting variety of placental hemorrhage. Immediately beneath the amnion there was a large clot occupying more than half the area of the placenta, and evidently containing all the blood of the fetal body. The fetus, corresponding in development to the fourth month, had bled to death into its own placenta from the rupture of a large branch of the umbilical vein. THE PLACENTA. 129 ease—the first characterized by congestion, the second by plastic exudation, the third by suppuration. Numerous instances have been recorded in which " pus " was found in the placenta, but the majority of the cases reported will not bear modern investiga- tion. There are, however, authentic instances of such an occur- rence. x Cysts of the Placenta---Cystic formations may be found not very infrequently in the placenta. In the majority of cases they are the result of changes in extravasated blood. They are sometimes, however, to be ascribed to a circumscribed, un- usually fluid myxoma.2 Jacquet 3 has described small cysts springing from the blood-vessel walls. Tumors of the Placenta---The tumors of the placenta formed in the fibromyxomatous degeneration of the villi have already been noticed. Organized blood-clots have also been described as tumors of the placenta. Hecker 4 speaks of a fleshy sub- stance expelled from the uterus post-partum, although the pla- centa had come away entire as possibly a placental tumor. This may, however, have been nothing but a uterine polypus or a piece of hypertrophied and angiomatous serotina.5 Malignant growths at the placental site have long been recog- nized as malignant placental polypi. In 1888 Sanger described a sarcoma of the decidua serotina. His article attracted great attention and was immediately recognized as most important both in the nature of the tumor described and in its histology. The attention of physicians all the world over being directed to the matter, malignant tumors of the placental site were found to be not so excessively uncommon. The author saw two in three years. It was soon realized, however, that the majority of the growths observed were carcinomata and not sarcomata, and a close study of their histology soon demonstrated the fact that the cancer has its origin in the syncytial cells of the chorion villi. Even in the metastases the syncytium of the placenta is every- where reproduced. From recent sections of the original tumor studied by Sanger, it appears that it really was a sarcoma. It is now admitted that both sarcomata and carcinomata may develop at the placental site, the former from the decidual cells (deciduo- sarcoma, deciduoma malignum), the latter from the syncytium (carcinoma syncytiale, syncytial cancer). Cancer of the placental site, however, is much more common than sarcoma. Gaylord 1 See Schroeder, " Lehrbuch," ed. of 1884, p. 450. 2 " Archiv f. Gyn.," Bd. xi, S. 397. 3 " Gaz. med. de Paris," Oct. 14, 1871. 4 " Klinik der Geburtsh.," 1864. 6 See paper by the writer in " Am. Jour. Obstetrics," Dec, 1887. 9 130 PREGNANCY. has collected fifty-five reported cases.1 Both of these malignant growths have a rapid course, ending fatally in from three to six months. Metastases are numerous and occur early. A metastatic growth of syncytial cancer is possible without a trace of the original tumor. Schmorl 2 reports a syncytial cancer of the vagina with numerous metastases, the uterus being healthy. It is supposed that the original growth was removed with the exfoliation of the decidua serotina. Other tumors of the placenta are myxomata fibrosa, localized hypertrophies, angiomata,3 and organized throm- Fig- 94-—Syncytial cancer: Masses of fibrin, A, containing islands of proliferated syncytial cells. boses. Bode and Schmorl 4 report as a tumor of the placenta (fibroma) a fibrous degeneration of a placenta succenturiata. They have collected the reports of thirty placental tumors. Albert (loc. cit.) adds six cases to their list. Placental polypi developing on the placental site after labor are due to a sort of stalactitic disposition of blood-fibrin on a mass of decidua or a fragment of placenta. 1 "Tr. of the Section on Gyn.," College of Physicians of Philadelphia, 1898. 2 " Centralbl. f. Gyn.," 1896. 3 Albert, "Archiv f. Gyn.," Bd. lvi, H. 1, p. 144. i " Archiv f. Gyn." Bd. lvi, H. 1, p. 73. THE PLACENTA. *3i Fig- 95-—Syncytial cancer (Gottschalk). Localized tumors in the placenta are rare. Leopold in more than 7000 specimens found such a tumor only once.x Fig. 96.—Metastasis of syncytial cancer in liver, showing cells from Langhans' layer and true syncytial cells. 1 V. Mars, " Monatschr. f. Geburtsh. u. Gyn.," Bd. iv, H. 3, p. 229. 132 PREGNANCY. THE UMBILICAL CORD. The early development of the umbilical cord, or the formation of the allantois, has been studied upon the lower animals, as in all the human embryos observed the connection between the embryo and the chorion was already established. Indeed, accord- ing to His, the human embryo is from the first in connection with the periphery of the ovum. Very early, therefore, in embryonal life there may be observed a sac-like projection from the posterior end of the intestinal tract, which, at first solid, but later contain- ing a canal, grows outward and backward, owing to the presence of the large umbilical vesicle anteriorly, until it comes in contact with the periphery of the ovum. Within this sausage-shaped x Fig. 97-—A, Umbilical arteries forming spirals (z, i) around the vein ; con- strictions indicating the presence of folds (d, e); circular folds (d, e); lateral openings showing the arterial walls ; B, vein opened upon the side showing a con- striction {b) corresponding to an interior valve {e); semilunar valves {c, d, e); C, section of vein and arteries showing valve of vein {a), a semilunar arterial valve {b), and a circular arterial valve {c) (Tarnier et Chantreuil). projection are blood-vessels, which are carried with its growth to the periphery of the ovum, where they enter the villi of the chorion in the manner already described. Becoming reduced to two arteries and a vein within the allantois itself, they con- stitute the vessels of the umbilical cord, which are destined to carry the blood of the fetus to the placenta for aeration and nourishment, the two arteries conveying dark, venous blood ; the vein returning bright, oxygenated blood, resembling in this respect the pulmonary arteries and vein. Surrounding the blood- vessels of the cord is a peculiar gelatinous substance, furnishing the vessels the most perfect protection possible under the cir- cumstances (the so-called gelatin of Wharton), derived from the outer layers of the amnion and the allantois, both in their 1 'A7.7.a<;, a sausage. THE UMBILICAL CORD. nz turn being derived from the median layer of the blastodermic membrane. As the amniotic cavity becomes distended the amnion is pushed out on all sides until it meets in front of the em- bryo, and surrounds the cord like the finger of a glove, at the same time inclosing the already atrophied umbilical vesicle, the Fig. 98.—A, Section of the navel: C, Outer covering with blood-vessels ; v.u., umbilical vein; a.u., a.u., umbilical artery; v.o., omphalic duct; u., remnant of the urachus. B, Section of the cord : N.S., Sheath of the cord. Other lettering as in A. ductus omphalicus, and the pedicle of the allantois. That por- tion of the allantois that remains within the abdominal cavity of the fetus forms the bladder and urachus. The umbilical cord at term measures about twenty inches in length and about % to x/2 of an inch or more in diame- ter, the latter measurement being irregular, from the fact that the arteries are coiled around the vein, usually from right to left, giving a twisted appearance to the cord, and also because the gelatin of Wharton is deposited irregularly, being in some places quite thick, and forming thus the so-called false knots of the cord. Both the arteries and the veins of the cord have walls of almost the same thickness, and both are provided with semi- lunar and circular valves. The caliber of the vein is greater than that of the arteries. Accord- ing to Leopold,1 it measures normally 2 to 4 mm. in diameter, but at a point about 8 to 10 cm. from the placental insertion there occurs a physiological narrowing. Fig- 99-—Cross-section of an um- bilical cord at term, magnified about twelve diameters: Y, Remnant of the allantois; V, umbilical vein; A,A, umbilical arteries (from Minot). '"Archiv f. Gyn.," Bd. viii, S. 221. 134 PREGNANCY. Anomalies of the Cord.—The cord maybe abnormally long, measuring rarely as much as 70 inches,x or it may be naturally or artificially too short; and it may be absent altogether. The cord is artificially shortened in those adhesive inflammations of the amnion which result in the gluing together of the coils or in their attachment to the fetal skin or amnion. Exaggerated Torsion.—The cord may be so twisted upon its longitudinal axis that the vessels are nearly or quite obliterated, Fig. 100.—Excessive torsion of the cord. Fig. 101.—Distention of the umbilical vessels. Varices of the cord. and the cord itself, especially near the umbilicus, is reduced to a very small diameter. Formerly the torsion was regarded as a cause of fetal death, but Martin, Ruge, Schauta, and most modern observers regard the exaggerated torsion of the umbilical cord as a postmortem occurrence, resulting from the great movability within the uterine cavity of a fetus that has died from the fifth to the seventh month of pregnancy. The number of twists in 1 Chantreuil, " Disposition de Cordon," Paris, 1875. I have seen one cord 48 and another 56 inches long. The latter was coiled twice around the neck and once around the trunk. THE UMBILICAL CORD. 135 the cord may be surprisingly great. In Schauta's x case it reached 380. Torsion occurs more frequently in male than in female children. Edema and cystic degeneration of the cord may often be found in connection with exaggerated torsion. Stenosis of the Umbilical Vessels.—The umbilical vein may be narrowed by the development in the intima of new connective tissue 2 to such an extent as to seriously impede the flow of blood from the placenta,—a condition resulting in edema of the latter organ (hydramnios), or an immense dilatation (to 15 mm.) of the undiseased portion of the vein, ending occasionally in its rupture (Leopold) and the extravasation of blood into the substance of the cord. This disease of the vein is usually attributed to syphilis. A periphlebitis may also occur, and may diminish somewhat, but not seriously, the caliber of the vein. The umbilical arteries are occasionally obstructed by atheroma and thrombosis. The section of an umbilical cord taken from a syphilitic infant will sometimes show an enormous development of connective tissue throughout the entire wall of the arteries, so that it is impossible to distinguish the different coats ; the lumen of the vessels is often obliterated, not only by the thickened walls, but by the infiltration of the whole substance of the cord with granu- lation-cells. Pinard3 has seen the vessels of the cord obstructed by an overdevelopment of the valves that are found in both arteries and veins. Varices and Rupture of the Vessels in the Cord—Figure 101 represents a varicose condition of the vein of the cord which predisposes to rupture. Five cases of this accident have been collected by Albert.4 True Knots of the Umbilical Cord.—Rarely the fetus slips through a loop of the cord, and, the two ends of the loop being then put upon the stretch, a true knot is tied. This process may be repeated either during pregnancy or while the child is descend- ing in labor, and thus a double knot is tied. In the cord of an infant born under my care there was a true figure-of-8 knot tied in utero (Fig. 102). In the case of twins in a common amniotic cavity the most complicated knotting of the two cords may occur. The effect of these knots in the cord upon the cir- culation of the fetus is usually not serious. Carl Braun 5 says 1 Leopold, "Archiv f. Gyn.," Bd. xvii, S. 20; see also Winckel, " Berichte u. Studien." 2 " Neue Zeitschr. f. Geb.," Bd. iv, S. 62; and Leopold, loc. cit. 3 " Diet, encycloped. des Sc. med.," art. "Fetus." 4 "Archiv f. Gyn.," Bd. lvi, H. 1, p. 136. 5 " Lehrbuch der Ges. Gynak.," p. 552. 136 PREGNANCY. that he has never seen the slightest disadvantage to the fetus from this cause ; but the knots can be drawn so tight as to completely shut off the placental blood-supply, especially in the case of twins in a single amniotic cavity, where one cord may be drawn in a tight knot about the other, obliterating the latter's blood- vessels. The gelatin of the cord is often displaced at the seat of the knot, so that when the latter is untied its situation is marked by deep depressions. " False knots" of the cord are localized collections of the mucous tissue in it. A loop of the cord may adhere by its proximal edges, giving rise to a lateral projection such as is shown in figure 102, in which there is a loop of the three blood-vessels. Coiling of the Cord Around the Fetus.—Loops of the cord may be wound about different portions of the fetal body. The Fig. 102.—A false and a true knot in the cord (author's cases). neck may be encircled once or twice, more rarely from four to nine times (Braun), or loops may be thrown around the limbs. The encircled part may be so compressed that it is strangulated and the distal portion is destroyed, but it is doubtful whether a constricting cord can ever determine the amputation of a part; for when it sinks through the soft tissues to the bones it there experiences a pressure greater than it itself can exert, and is, therefore, in its turn, destroyed (Braun). Thus the neck has been severed to the spinal column, and limbs have been cut through to the bone, but there the process will usually stop. Marginal and Velamentous Insertion of the Cord.—The cord is usually inserted somewhere near the center of the pla- centa. As the insertion approaches the edge of that organ, the THE UMBILICAL CORD. 137 condition receives the name of marginal insertion, or battledore placenta. If the cord should first enter the membranes at some little distance from the placenta, to and from which the vessels, unprotected and more or less separated from one another, pursue their course between the amnion and chorion, a condition known as insertio velamentosa exists. The explanation of such an oc- currence is obvious : The allantois is conveyed at first indiffer- ently to any portion of the periphery of the ovum, but as the placenta begins to be differentiated the embryo, by a movement of rotation, enables the umbilical vessels to pursue a straight course toward their insertion in the placenta. Should the rota- tion of the fetus be in any way interfered with, or should the newly-formed umbilical cord contract adhesions with the amnion Fig. 103.—Entanglement of Fig. 104.—Velamentous insertion of cords in twins (Winckel). cord. or chorion that would prevent the vessels following or comply- ing with the rotation of the embryo, they would naturally enter the membranes opposite the abdominal face of the embryo, or at that point where adhesions arrested their movements. The blood- vessels thus exposed are liable to laceration during labor, usu- ally with a fatal result to the fetus unless delivery is quickly effected. Umbilical Hernia.—Occasionally children are born with a greater or less portion of the abdominal contents protruding into the umbilical cord and covered by nothing but the distended and attenuated amnion. There has been an arrest of development in 138 PREGNANCY. the abdominal walls, preventing the completion of the arching- over process by which the abdominal cavity is closed. Cysts of the Cord.—Cystic formations in the cord are due either to an abnormally fluid condition of the mucous tissue or else to a collection of serum in the pedicle of the allantois, which in horses, swine, and cows is found persisting as a vesicle up to the time of birth. Calcareous Degeneration.—This condition of the cord is occasionally found and is usually associated with syphilis. The lime may be deposited in the walls of blood-vessels or in the substance of the cord. Fig. 105.—Tumor of the cord: c, c, c, Cord; T, tumor (Budin). Tumors of the Cord.—Tumors of the cord may be cysts, localized hypertrophies, or accumulations of the mucous tissue, hematomata, a small fetus amorphus, as in Budin's case (Fig. 105), and telangiectatic myxosarcomata. The last named should be excised immediately after birth, with, perhaps, the umbilical ring.1 1 V. Winckel, " Centralbl. f. Gyn.," 1894, p. 397, reported one case and col- lected four others. THE DEC ID USE. 139 THE DECIDUAE. The explanation which John Hunter gave of the plates pub- lished by his brother William x was, for a long time, accepted as the true history of the development of the uterine membrane which envelops the fetus at term. According to the Hunterian theory, the uterus throws out upon its inner surface an inflammatory exudate forming a closed sac whose walls stretched across the openings of the tubes and the os internum cervicis. As the im- pregnated ovule enters the uterus from one of the tubes it pushes the sac-wall in front of it, but leaves behind it a bare surface, Fig. 106.—Uterus, decidua, and ovum, on the eighth day of pregnancy (Leopold). which is soon, however, covered by an exudate similar to the one at first thrown out. That portion of the original membrane which remained attached to the uterine wall Hunter called the membrana decidua vera ; that portion pushed out in front of the ovule, the membrana reflexa ; and that membrane last formed be- hind the ovule, the membrana serotina. These names have sur- vived until the present day, although modern investigation has robbed them of their original significance. Costi 2 was the first to expose the fallacy of the Hunterian doctrine, and since his time the investigations of Robin, Friedlander, Kundrat, Leopold, En- 1 " Anatomia ut. hum. grav. tab. illustr.," Birm., 1774, table 34. 2 " Origine de la Caduque," "Acad, des Sciences," Paris, 4 et 25 Juillet, 1842. 140 PREGNANCY. gelmann, and others have enabled us to follow the changes that occur in the uterine mucous membrane from the entrance of the impregnated ovule into the uterine cavity until the fetus, with its enveloping membranes, is expelled at term. By the time the fer- tilized ovum arrives within the uterine cavity the lining mucous membrane of the uterus has become very much thickened,x owing to a great increase in the interglandular connective tissue, which consists of enormously enlarged young connective-tissue cells, either closely pressed together or separated from one another by the cellular amorphous substance characteristic of newly forming connective tissue. As a consequence of this thickening the mucous membrane is thrown into folds, and it is in a depression between two of these folds of membrane that the ovule falls and lodges when it first enters the uter- ine cavity. The ovule, being thus imbedded in the uterine mucosa, is gradually inclosed by the arching over of the folds of the membrane, or, as Leopold 2 claims, by their simple approximation owing to the increasing thickness of the mucous membrane. That portion of the uterine mucous membrane upon which the ovule rests, formerly called membrana decidua serotina, might be more properly termed, as it is by the French, the placental decidua, for it is upon this spot that the placenta will be developed ; that portion of the membrane which arches over the ovule, called by is better named the ovular or epi- chorial decidua ; and that portion of the mucous membrane that remains as at first, attached to the uterine wall, the decidua vera of Hunter, is more appropriately spoken of as the uterine decidua. The changes that occur in this last division of the uterine mucous membrane as pregnancy advances are, up to a certain point, only a continuation of the change already noted. The large cells already referred to, the decidual cells of Friedlander, multiply with great rapidity and constitute a thick layer,—the upper portion, or com- pact layer, of the uterine decidua. The glands which at first send their ducts up through the cellular layer of decidua are at last Fig. 107.—Decidua serotina, decidua vera, decidua reflexa, and the ovum: d.s., Decidua serotina ; d.v., d.v., decidua vera; d.r., de- cidua reflexa; 0, ovum (Schroeder). Hunter the decidua reflexa. 1 Tenfold, according to Engelmann (" Am. Jour. Obstetrics," May. 1875). 2 " Archiv f. Gyn.," Bd. xi, S. 455. the decidua;. 141 -old ovum imbedded in the decidua (Leopold). Fig. 109.—The decidua vera and the chorion. .dua serotina. (placentaJT~ Fig. no.—Diagram illustrating relations of structures of the human uterus at the end of the seventh week of pregnancy (modified from Allen Thompson). Fig. III.—Decidua vera, decidua reflexa, the chorion and amnion. 142 THE DECIDUsE. H3 confined entirely to the deeper portions of the membrane, consti- tuting, finally, what is known as the glandular or spongy layer. In its early stage of development the uterine decidua is richly supplied with blood ; the capillary loops spring up luxuriously into the interglandular spaces ; while deeper down, between the glandular layer and the uterine muscle, may be found numerous and extensive blood-sinuses. As, however, the ovular decidua comes in contact with the uterine decidua, the blood-vessels are subjected to pressure and the stage of atrophy begins in the endo- metrium. The blood-vessels disappear ; a fatty degeneration may be seen in the cellular layer ; no trace of epithelium remains in the superficial layer of the membrane, although epithelial cells persist in the glandular layer; and, finally, as labor begins, the uterine decidua separates into two parts, the line of division running Fig. 112.—Decidua vera and decidua reflexa. through the glandular layer, or between the compact and glan- dular layers, the latter remaining behind in the uterus to furnish the nucleus of a new mucous membrane, which soon after labor takes the place of that which has been partly cast off. The history of the ovular decidua is one of atrophy almost from the beginning. As the growing ovum pushes out this portion of the uterine mucous membrane upon the pole of the sphere directly opposite the placental decidua, the epithelium of the membrane begins to disappear and the blood-vessels are soon obliterated, so that at the end of the third month, when the ovular comes in contact with the uterine decidua, the former consists of not much more than a single layer of flattened and elongated cells. The development of the placental decidua has been described with that of the placenta. 144 PREGNANCY. Diseases of the Deciduae.—The decidual mucous membrane of the pregnant uterus may be the seat of many of the diseases that attack the endometrium of the non-gravid uterus. In the former state, however, diseased conditions often manifest them- selves in exaggerated forms, owing to the enormous hypertrophy that the mucous membrane of a pregnant uterus uniformly ex- hibits. In consequence of its relation to the fetus, too, a disease of the decidual endometrium can have more serious consequences than a similar affection of the non-gravid uterus. Diffuse Hyperplastic Inflammation of the Decidual Endometrium.— The atrophy of the deciduae, which normally occurs during the latter part of pregnancy, may not take place, but in its stead the mucous membrane may go on to an increase of that hyperplasia which is a constant phenomenon in the earlier stages of its de- velopment. The cause of this overdevelopment will usually be found in a preexisting endo- metritis, which predisposes the membrane to respond with inor- dinate vigor to the stimulus which an impregnated ovule always furnishes the uterine mu- cosa to rapid growth and devel- opment. It may be possible, however, that the death of the embryo or some disease of the ovum may prove irritating enough to incite the mucous membrane of the uterus, previ- ously healthy, to overgrowth. As the constituent parts of the mucous membrane are more or less affected, so will the manifestations of the disease vary. Diffuse Hyperplasia of the Decidual Endometrium.—This condi- tion of the mucous membrane consists of a progression of the hyperplasia that occurs normally in the early months of pregnancy, but which in these cases is, from the beginning, exaggerated. The steady increase in all the elements of the decidua with greater or less rapidity results in the production of a membrane of varying thickness and density, but always far in excess of the size of the normal deciduae at term. Should the disease advance with great rapidity, an abortion will usually result, either on account of the hemorrhages into the mucous membrane, separating it from the Fig. 113.—Diagrammatic repre- sentation of a section through the membranes : a, Amnion ; b, chorion ; c, decidua; f compact layer; e, line of separation, which Friedlander incor- rectly put in the compact layer; it is really in the glandular layer ; g, spongy or glandular layer ; d, muscularis (Friedlander). THE DECIDHE. 145 uterine wall, or owing to the death of the embryo, from which all nutrition has been diverted to supply the greater needs of the rapidly growing decidua. In such cases the embryo may be absorbed and the deciduae afterward cast off as an empty sac with greatly thickened walls, forming one variety of the so-called fleshy moles.1 Or, the embryo may be destroyed in conse- quence of the hemorrhages into the hypertrophied decidua, the blood bursting its way through all the membranes and occupying the cavity of the ovum, as well as surrounding it exteriorly, so that only with a microscope can one detect the true nature of the mass expelled.2 On the other hand, if the development of the decidua goes on slowly and evenly, the fetus may not be expelled before it becomes viable, or even until the normal end of pregnancy.3 The structure of the hypertrophied decidua is usually only an exaggeration of what may be seen in the decidua of early preg- nancy. There is a great multiplication of the decidual cells, some of which are elongated and seem to be transforming them- selves into connective tissue ; the blood-sinuses are much en- larged in the deeper portions of the membrane, and there is usually an abundance of connective tissue. Madam Kasche- warowa4 has described new-formed muscular fibers in a hyper- trophied decidua, and occasionally either the cellular or the fibrous element has been found greatly to predominate. The cause of hyperplastic decidual endometritis has been already referred to. The determining cause of the hemorrhages, or "apoplexies of the ovum," so often destructive of the embryo and provocative of abortion in this affection, may be anything that would produce congestion of the pelvic viscera, such as physical exertion, plethora, coitus, or the recurrence of the time for a menstrual period. The effect of hyperplastic endometritis is usually disastrous to the embryo and injurious to the mother. The hemorrhages into the decidua may grow excessive in amount, but more frequently the maternal health is endangered by the retention of portions of decidua, owing to adhesions between the diseased membrane and the uterine wall,5 after the remainder of the ovum is cast off. Espe- 1 Schroeder, " Lehrbuch." 2 Priestley, loc. cit., p. 28, who quotes Gendrin, Hegar, and Westmacott. 3 I have seen a living fetus, delivered at the sixth month, from a woman who three days afterward expelled a piece of decidua I cm. thick and measuring 6 cm. in diameter. * Virchow's "Archiv," 1868, Bd. xliv, p. 103. 5 This is particularly true of syphilitic endometritis. See Kaltenbach, " Zeits. f. Geburtsh.," Bd. ii, p. 225. 10 146 PREGNANCY. daily is the placental decidua apt to surpass in its hyperplastic growth the remainder of the decidual membrane and to be retained in utero, to give rise to hemorrhages or, by its decomposition, to septicemia. This is the condition often described as placental polyp and as polypoid hematomata of the uterus. Polypoid Endometritis.—Instead of being evenly and generally thickened, the decidua may display at certain points a less pro- nounced hypertrophy, or, on the other hand, upon the uterine surface may be seen projections or excrescences where the hyper- plastic process seems to have been exaggerated over a limited area. Such cases have been described by Hofe x and Schroeder.2 It is, however, to the most advanced type of this polypoid condi- tion of the uterine mucous membrane that Virchow 3 first gave the name of endometritis decidua polyposa or tuberosa. Fig. 114.—Polypoid endometritis : a, Fine apertures of the glands ; b,b, larger aper- tures of the glands; c,c, protuberances or polypi. In these cases the internal surface of the decidua presents a most peculiar appearance. Villus-like projections stand out from the degenerated mucous membrane to the height of half an inch or more, smooth of surface and very vascular. In the intervals between the projections may be seen the openings of the uterine glands, which are not to be found on the polypoid elevations. The whole membrane is greatly thickened, which, as a micro- scopic examination shows, is due to the great hypertrophy of the connective-tissue elements and to a great increase in the decidual 1 D. I., Marburg, 1869 : "Ueber Hyperplasie der Decidua." 2 Op. cit., p. 402. » " Die Krankh. Geschw.," Bd. ii, S. 478. THE DECIDUAE. 147 cells, which contain nuclei of enormous size. The connective tissue forms fibrous bands constricting the openings of the uterine glands, as well as the blood-vessels in the diseased membrane ; and yet the whole decidua is exceedingly vascular. In Virchow's case there was a syphilitic history, and, therefore, he ascribes the disease to syphilis ; in other instances no cause whatever could be discovered, but often this disease, as well as other affections of the decidual endometrium, depends upon a pre- existing chronic endometritis. It is a disease of young ova, and frequently the chorion villi implanted in the diseased mucous Tuberous projec- - tions. ,s Uterine wall. Decidua. Fig. 115.—Tuberous subchorial hematomata of the decidua (Walther). membrane are in a condition of myxomatous degeneration.1 In all the cases hitherto described the ovum has been expelled at the end of the second to the fourth month of pregnancy (Schroe- der). Polypoid endometritis is closely simulated by blood extravasations between the decidua and the chorion, as shown in figure 114.2 Catarrhal Endometritis.—A chronic inflammation of the de- cidual endometrium will occasionally affect chiefly the glandular 1 Miiller, "'Bau der Molen," 1867. 2 Walther, " Centralbl. f. Gyn.," 1892, p. 707. 148 PREGNANCY. elements of the membrane, with the result of a hypersecretion of a thin, watery mucus, which, collecting between the chorion and deciduae, may be suddenly expelled, after a rupture of the ovular decidua, in the later months of pregnancy. This oc- currence gives rise to sudden gushes of fluid from the vagina, which may reach a pint in quantity. Afterward the fluid may dribble away for a considerable length of time without affecting seriously the course of pregnancy, or else, collecting again in considerable quantities, it may excite the uterus to muscular Fig. 116.—Tuberous subchorial hematomata of the decidua (author's case). action. This affection occurs more frequently in multiparas than in primiparae, and seems to depend in some cases upon a watery condition of the woman's blood. This mucous discharge is one of the forms of hydrorrhea gravidarum. Cystic Endometritis.—If there should be a hypersecretion of the uterine glands, and the escape of the fluid contained in the glandular spaces should be hindered, a condition results, only found in very young ova, known as cystic endometritis. ' It is not improbable that this condition might be found quite con- THE DECIDUM. I49 stantly in the earlier stages of the chronic hyperplastic decidual endometritis already described, the glands being destroyed and obliterated as the disease advances. A section of mucous mem- brane affected with cystic disease presents a somewhat cavernous appearance, numerous small cysts being scattered throughout its thickness. Their connection with the uterine glands can be demonstrated by the relation between the cysts and the ducts of the glands.x About the cysts the decidua is hypertrophied, pre- senting the overdevelopment of connective tissue, increase of decidual cells, and embryonal tissue that has already been re- ferred to.2 As to the prognosis of all these chronic affections of the decidual endometrium, it is, as may be inferred, decidedly un- favorable for the fetus and by no means entirely favorable for the mother. The danger to the fetus from hemorrhages, which bring about separation of the membranes, or which, bursting through all the fetal envelopes, overwhelm the embryo with blood, has been mentioned, as wrell as the diversion of nutriment from the embryo to the overgrown decidua, and the excitation of muscular action upon the part of the uterus, which ends in the expulsion of the ovum. But the possible loss of blood during pregnancy, and the retention of fragments of decidua owing to adhesive inflammation after the ovum is expelled, can not be regarded with indifference as to their effect upon the mother. The treatment of this condition during pregnancy is impos- sible. Its prevention may be attempted, however, by a curet- ment before impregnation occurs again. Acute Inflammation of the Deciduae.—It is in the course of cholera and other infectious, but especially the exanthematous, diseases, or in consequence of unsuccessful attempts to bring on abortion, or perhaps as a result of external injuries, that acute inflamma- tion of the decidual membrane may develop. Hemorrhagic Decidual Endometritis.—This is the name given to the condition of the mucous membrane found in two cases of cholera,3 and, no doubt, present in other grave infectious diseases. In these instances the decidua was thickened, of a dark, purplish hue, and presented throughout its substance numerous extravasa- tions of blood. Exanthematous Decidual Endometritis.—Klotz,4 in a study of the effect of measles upon pregnancy, in eleven cases noted in 1 Leopold, "Gesellsch. f. Geburtsh.," Leipsic, Feb , 1878. 2 See Breus, "Ueber cystose Degeneration der Decidua Vera," "Archiv f. Gyn.," Bd. xix, S. 483. 3 Slayjansky, " Archiv f. Gyn.," Bd. iv, S. 285. 4 "Archiv f. Gyn.," Bd. xxix, S. 448. 150 PREGNANCY. nine a premature expulsion of the fetus, the time at which the expulsive efforts began seeming to bear a relation to the outbreaks of the eruption upon the skin. In these cases, according to Klotz, the uterine action is excited by the occurrence of an exanthema upon the uterine mucous membrane, highly irritating in its action, just as the photophobia, the coryza, the bronchitis, and the vesical tenesmus of measles indicate an irritated condition of the mucous membranes of the eyes, nose, lungs, and bladder. It is quite probable that the same condition of the uterine mucous membrane might account for the abortions or premature labors that often occur when pregnant women are attacked by any of the eruptive fevers. Purulent and Microbic Decidual Endometritis.—Donat x has de- scribed a case of purulent endometritis in pregnancy. A woman expelled at term a placenta about the periphery of which could be seen masses of decidua infil- trated with pus. The amnion and chorion were both thickened and opaque, and between them was an accumulation of purulent fluid. It was suspected that the suppur- ation of the decidua was the re- sult of unsuccessful attempts on the part of the woman to bring on a miscarriage. Atrophy of the Deciduae.—The Fig. 117.—Atrophy of the decidua, ex- deciduae, instead of undergoing ternal surface of the vera (Duncan). inflammatory and hyperplastic changes, may, on the contrary, atrophy, although such an occurrence is doubtless rare. This change in the decidual membranes has been described by Hegar 2 and Matthews Duncan,3 and, among more recent writers, by Spiegelberg 4 and Priestley.5 The uterine, ovular, or placental deciduae may singly or conjointly be the seat of atrophy, resulting either in the ovum being attached by a mere pedicle of slender proportions to the uterine wall, or else, in the case of atrophy of the ovular decidua, the embryo lacks the outermost of its protec- tive membranes, and, consequently, the ovum may rupture and its contents be discharged from the uterus. As a result of the stretching of the pedicle in cases of placental atrophy, the ovum 1 " Archiv f. Gyn.," Bd. xxiv. 2" Monatsh. f. Geburtsh. u. Fr.," Bd. xxi; Supplem., pp. 11, 19, 1863. 3 " Researches in Obstetrics," p. 295, 1868. 4"Lehrbuch," p. 328. * Op. cit. THE DISEASES OF THE FETUS. 151 may be pushed downward by the uterine contractions until it rests in great part within the cervical canal. This condition con- stitutes the cervical pregnancy of Rokitansky. CHAPTER V. The Diseases of the Fetus. Fetal mortality exceeds that of any other period of life. It has been estimated that for every four or five labors there has occurred one abortion, and if to this number be added the still- births in which the death of the fetus was not due to an accident in labor, the proportion of fetal deaths to living births becomes very large. In addition to the diseases having a fatal termination, there are others affecting the fetus in utero running their course wholly or in part during intra-uterine life and ending in recovery ; so that the list of fetal diseases is an extensive one. The present chapter treats of the diseases of the fetal or- ganism itself, of weakness dependent upon defects in the paternal elements entering into the composition of the embryo, and of maternal conditions which are incompatible with the healthy development or with the continued existence of the product of conception. Fetal Syphilis.—First in importance of all the diseases of intra-uterine life, fetal syphilis deserves a somewhat extended notice. According to Ruge,1 eighty-three per cent, of repeated premature and still-births have their cause in syphilis of one or both of the parents. Of 657 pregnancies in syphilitic women col- lected by Charpentier,2 thirty-five per cent, ended in abortion, and of the children that went to term a large number were still- born. Of 100 conceptions in syphilitic 3 women, only seven children were alive a year later. The Syphilitic Infection of the Fetus.—If the woman be syph- ilitic, the ovule is diseased before its impregnation ; or the sper- matic particle from a syphilitic man carries the infection to the ovary of a healthy woman. Modern investigation shows, more- over, the possibility of infecting the healthy fetus at any time during intra-uterine life should the mother acquire syphilis during pregnancy. 1 See Lomer, " Zeitschr. f. Geburtsh.," Bd. x, p. 189. 2 " Traite pratique des Accouchements." 3 Pileur, " Bull, de la Soc. d'Obst. et de Gyn.," Paris, Dec. 13, 1888. 152 PREGNANCY. Syphilis may be transmitted from a syphilitic father direct to. the embryo without the previous infection of the mother. As the fetus grows, however, and the syphilitic poison develops with its growth, the mother becomes infected in her turn directly from the fetus through the uteroplacental circulation. x The longer the time since the acquisition of the disease by either parent, the less likelihood will there be of the production of syphilis in the embryo ; but the limit of safety has not yet been discovered. According to Fournier,2 four years is the maximum of time that syphilis can remain latent, but Lomer 3 tells of the production of a syphilitic infant ten years after the first infection of the father, and Kassowitz 4 records a latent syphilis of twelve years' dura- tion. Lusk said that " the syphilitic poison will not traverse the septa intervening between the fetal and the maternal vascular systems " ; but Vajda 5 and Hutchinson 6 describe cases in which pregnant women were infected near term and gave birth to syph- ilitic children. Neumann 7 also has published observations of 20 women who were infected with syphilis during pregnancy; 5 of this number gave birth to syphilitic children, and of these 5 2 were infected at the fourth and 1 each at the third, seventh, and eighth months. Hirigoyen 8 has reported 12 cases in which the mother contracted syphilis during the first four months of pregnancy ; all the children were still-born ; in cases of infection from the fourth to the sixth month, about half the children were still-born ; and in 7 cases of infection during the last three months of pregnancy there were 4 still-births.9 Manifestations of Fetal Syphilis.—Syphilis acquired by the embryo at the moment of conception from preexisting syphilis of the ovule, or of the spermatic particle, or of both, or trans- mitted to the fetus from the mother at any time during pregnancy, manifests great variety in the tissues attacked and the lesions produced. Thus there are bullous eruptions of the skin, condy- lomata, and inflammations of the mucous membranes, inflamma- tions of the serous membranes, gummatous and miliary deposits, 1 See Tarnier et Budin, op. cit. ; Priestley, loc. cit. ; J. Hutchinson, "British Med. Jour.," Feb., 1886, p. 239; Harvey, "Fetus in Utero," 1886; G. S. West, "Am. Jour. Obstetrics," 1885, p. 182. 2 " Syphilis et Mariage." 3 " Zeitschr. f. Geburtsh.," Bd. x, 94. * Strieker's "Jahrb.," 1875, p. 476. 5"Centralbl. f. Gyn.," 1880, p. 360. e ''British Med. Jour.," 1886, i, 239. 7 " Wien. med. Presse," 29, 30, 1885. 8 Abstract in " N. Y. Med. Record," April 12, 1887. 9 The author has seen a woman impregnated by a healthy man, but infected with syphilis in the third month of pregnancy, give birth to a child with a pemphigoid eruption upon it and a liver twice the normal size. PLATE 3. Head of femur removed from a fetus expelled, dead and macerated, at the seventh month. The liver weighed one-tenth of the body-weight; the spleen, one forty-eighth. The mother was infected with syphilis one year before. THE DISEASES OF THE FETUS. 153 and morbid growth of connective tissue in the brain, lungs, pan- creas, kidneys, liver, and spleen, the muscular system, and the coats of the intestines and walls of the blood-vessels, and a char- acteristic osteitis and osteochondritis. Prognosis.—The influence of syphilis upon intra-uterine life is most unfavorable. If the fetus is not destroyed before it has be- come viable, it is often born with signs of retarded development, performing in an imperfect manner its vital functions, or else ex- hibiting well-marked signs of disease in an enlarged abdomen, due to ascites, to enlarged liver or spleen ; nodes in the lungs or in the bronchial glands ; hydrocephalus ; separation of the epiphy- ses of the long bones from the diaphyses ; extensive pemphigoid eruptions on the skin, or, perhaps, presenting a deformed or monstrous appearance. There are cases, however, in which the course of intra-uterine life does not seem to be influenced in the slightest degree by syphilis. The children are born apparently healthy and well developed, but exhibit unmistakable signs of their hereditary taint within the first few weeks after birth. Diagnosis of Fetal Syphilis.—The infection of the fetus may be inferred with reasonable certainty if either parent had acquired syphilis at a date not too remote from the procreation. If a woman should acquire a chancre during pregnancy, the possi- bility of the disease attacking the fetus must not be overlooked. A trustworthy sign of syphilis in the fetus is occasionally found in those cases in which the ovum is infected by the spermatic particle. The woman may remain perfectly healthy until toward the middle of pregnancy, when signs of secondary syphilis may appear, without the slightest trace anywhere of a primary sore. In such cases the poison of the disease has been transmitted from fetus to mother. Very often the signs of fetal syphilis can be looked for only in the fetus itself, after its expulsion from the uterus, and much may depend upon a correct diagnosis. This is, however, not always easy to reach. The parents' history, from ignorance or design, may be entirely negative. The child may be born with no distinctive sign upon its body. If it is living, however, the coryza and characteristic eruptions during the first few weeks usually point clearly to the hereditary taint. If the child is dead, the diagnosis can easily be made. If the practitioner is a trained pathologist, the detection of syphilis should give little trouble. The bullous eruption on the skin, the condylomata and inflammations of the mucous mem- branes, the inflammations of the serous membranes, the gumma- tous deposits and the morbid growth of connective tissue in the brain, lungs, pancreas, kidney, liver, and spleen, and in the coats 154 PREGNANCY. of the intestines and walls of the blood-vessels, along with a characteristic osteochondritis, should demonstrate the character of the disease. It often falls to the lot of the general practitioner, however, to observe cases of repeated fetal death the cause of which is obscure, although suspicion naturally rests upon syph- ilis. Thanks to the investigations of Wegner,x Ruge,2 Lomer,3 and others, it is now well established that syphilis can be recog- nized in the fetus by a few signs easily found, perfectly reliable, and requiring for their detection no special training in the methods of pathological research. Wegner was the first to call attention to a curious condition of the dividing line between dia- physis and epiphysis of the long bones of a syphilitic infant. Instead of a sharp, regular, delicate line, formed by the immedi- ate apposition of cartilaginous to bony tissue, as in a healthy fetus, there may be seen in syphilitic cases a jagged broad line, of a yellow color, separating bone from cartilage4 (Plate 3). A microscopic study of this portion of the bone shows that there has been a premature attempt at ossification, which has ended in necrosis, fatty degeneration, and suppuration. For more than a year I carefully looked for this sign in every case of unmistakable fetal syphilis that occurred in the Philadel- phia and Maternity Hospitals, and never failed to find it, while in doubtful cases it proved a valuable aid to a correct diagnosis. In the Frauenklinik, at Berlin,5 this sign was also carefully inves- tigated, with a result wholly favorable to its distinctive character.6 According to Ruge,7 the liver of a healthy infant should constitute about -g1-^ part of the body-weight. In syphilitic infants, however, this proportion is much exceeded, the liver forming, in extreme cases, \ of the total body-weight. The spleen, too, is much enlarged in syphilis. This organ, which in a normal fetus at term should be in weight 3-^- part of the whole body, often much exceeds its due proportion. Upon these three signs,—the yellow line between epiphysis and diaphysis, the increased weight of liver, and increased weight 1 Virchow's " Archiv," Bd. i, S. 305. 2 "Zeit. f. Geburtsh.," Bd. i. 3 j^^ }^. x. 4 To discover Wegner's sign, an incision should be made over the trochanter, as though for excision of the head of the femur. The end of the thigh-bone is turned out after cutting its ligaments, and a median section of the epiphysis and diaphysis of the bone is made with a strong cartilage-knife. 5 Lomer, loc. cit. 6 Zweifel thus describes the progress of the disease : " There is formed, in a cer- tain region of the cartilage, granulation-tissue insufficiently supplied with blood- vessels and ill-nourished. There results necrosis of this tissue, with an attempt at exfoliation and accompanying suppuration." 1 Loc. cit. Plate 4. v rr^<^-. V Syphilis of the fetus. THE DISEASES OF THE FETUS. 155 of spleen,—all easily discovered, the diagnosis of syphilis may rest with reasonable certainty. If one would push the investiga- tion further, perhaps the next surest indication of syphilis might be found in the lungs.1 These organs will manifest a syphilitic infection in three ways : By an interstitial overgrowth ; by the presence of gummata ; by a peculiar catarrhal inflammation, resulting in what is called white pneumonia. The interstitial overgrowth is the most common. The connective-tissue overgrowth about the blood-vessels and the alveoli gives the lungs greater weight and more solidity than they should possess ; their color is often dark red ; if the infant has breathed, as it commonly does—although imperfectly—for a short time after birth, the lungs will not float buoyantly, although they do not usually sink outright. Microscopically, it may be seen that the alveoli are much encroached upon by the interstitial thick- ening, and that lung-expansion and adequate respiration are im- possible. The catarrhal pneumonia in utero due to syphilis is rare. The lungs in this form of the disease are large and heavy ; they quite fill out the thoracic cavity and bear upon their external surface the imprint of the ribs ; in color they are yellowish white, the whole organ having undergone a more or less complete fatty degeneration. This condition is incompatible with extra-uterine life : the infant never breathes. Treatment.—The treatment of fetal syphilis during pregnancy consists of a thorough course of antisyphilitic treatment in the mother. Should it be clear that the fetus derives its syphilis from one parent alone, while the other remains healthy, then, of course, treatment of the healthy individual before impregnation occurs would be superfluous ; but in case of doubt it would be wise, in the preventive treatment of fetal syphilis, to administer to both man and woman the appropriate remedies. Should a pregnant woman come under the observation of a physician with the history that she had had syphilis, that she was with child by a syphilitic man, although healthy herself, or that she had acquired a chancre subsequent to conception, she should receive mercury and iodid of potassium. I prefer mercurial oint- ment inunctions daily, and about fifteen grains of iodid of potas- sium three times a day, after meals, in milk, during the whole duration of pregnancy. Under this treatment I have seen women who had given birth to a succession of still-born syphilitic fetuses bear living children perfect in health and development, without a trace in after life of their hereditary taint. 1 For an exceedingly interesting paper on this subject see Heller, " Die Lung- enerkrankungenbei angeborener syphilis," '• Deutsch. Archiv f. klin. Med.," Bd. xlii, S. 159- 156 PREGNANCY. Other Infectious Diseases of the Fetus.—As the infectious diseases are dependent upon the entrance of bacteria into the system for their characteristic symptoms, it is impossible that they should directly affect the fetus in utero, unless pathogenic micro- organisms are able to pass from the maternal blood through the uteroplacental septum into the fetal portion of the placenta. Brauell x and Davaine,2 experimenting with the bacillus of anthrax, saw large colonies of micro-organisms heaped up on the maternal side of the uteroplacental septum, but failed absolutely to find a trace of them in the placenta or fetus. Straus and Chamberland 3 failed to infect animals by injecting the blood of a fetus taken from an animal that had died of anthrax. Runge, of Dorpat, inoculated a number of rabbits with tuberculosis, but was never able to detect a characteristic bacillus in the fetus. Chambrelent4 quotes Budin, Tarnier, Charpentier, Hoffman, Jassinsky, and Fehling as denying the possibility of the passage of microbes from mother to fetus. V. Ott 5 expresses his dis- belief in the passage of solid particles into the placenta, and supports his statement by describing experiments of his own which altered the constitution of the maternal blood without affecting that of the fetus. Wolff6 infected a number of preg- nant rabbits and guinea-pigs with anthrax, and failed entirely to find a trace of the disease in their young. Curt Jani,7 an assistant of Prof. Weigert, of Leipsic, having an opportunity to examine the body of a woman who had died in the fifth month of pregnancy from general miliary tuberculosis, found not a trace of the bacilli of tuberculosis in the placenta or fetus, although every maternal organ was markedly affected. Urvitch 8 inocu- lated seven pregnant mice with the microbes of mouse-septice- mia, and found the specific microorganisms in great quantities through the maternal tissues, but they were entirely absent in the placenta and fetus. Inoculations with the blood of the mother-animals were invariably fatal to other mice, while the fetal blood was entirely inert. Finally Bompiani 9 delivered a woman who was suffering from anthrax, but whose fetus showed no sign of the disease. 1 Virchow's "Archiv," xiv, 1858, p. 459. 2 "Bulletin de l'Academie de Med.," 1867. 3 " Comptes rendus de la Societe de Biologie," 1882, p. 689. 4 " Recherches sur le Passage des Elements figures a travers le Placenta," Paris, 1883. 5 "Archiv f. Gyn.," Bd. xxvii. 6 Virchow's "Archiv," cv, p. 192. 7 Ibid., ciii, p. 522. 8 " Inaug. Diss.," St. Petersburg, 1885, p. 77. 9 " Annali di Ostet.," May, June, 1887. THE DISEASES OF THE FETUS. 157 But, on the other hand, not only microbes, but even small particles of colored substances, like ultramarine blue and cinna- bar, have been found in the placental and fetal structures after they have been injected into the maternal tissues. In 1882, Arloing, Cornevin, and Thomas 1 showed the possibility of the passage of anthrax bacilli from mother to fetus ; and in the same year Straus and Chambeiiand, although they at first supported the views of Davaine and Brauell, finally changed their opinions and announced their belief in the transmissibility of contagious diseases to the fetus in utero.'1 Chambrelent 3 also was able to cultivate the microbes of chicken-cholera from the fetal blood, and to reproduce the dis- ease by inoculating an animal with the cultures. Mars,4 of Cra- cow, found, after injecting putrid solutions into pregnant rabbits, not only in the maternal but also in the fetal blood, a great number of bacilli; and Dr. Pyle,6 working in the pathological laboratory of the University of Pennsylvania, under the superin- tendence of Dr. Formad, obtained practically the same results, not only in the lower animals, but also in a human fetus removed from its mother by Cesarean section on account of her approaching death from septicemia, he found vast numbers of micro-organisms in its blood. Koubassoff,6 after experimenting under the super- vision of Pasteur in his laboratory in Paris, claims never to have failed to find the anthrax bacillus in the fetus when the mother had been thoroughly infected with the disease, except in one instance, where of two fetuses one was partially macerated and its pla- centa the seat of hemorrhagic extravasations, while the other was well developed. In the former no bacilli were found, but in the latter they were present in large numbers. Upon this obser- vation Koubassoff bases the conclusion that the placenta can only offer effective opposition to the passage of microbes when its condition is pathological. It appears from these conflicting statements that micro-organisms may pass from mother to fetus, but will not always do so. Moreover, the list of diseases which depend for their existence upon the presence of specific micro- organisms, and which have in certain well-authenticated cases undoubtedly attacked the fetus in utero, is a long one ; so that the possibility of fetal infection from the maternal blood can not be denied. 1 " Comptes rendus des Seances de l'Academie des Sciences," 1882, xcii, p. 739. 2 See Koubassoff, ibid., vol. c, p. 373. 3 " Recherches sur le Passage des Elements figures a travers la Placenta," Paris, 1883. 4 Abstract by Chambrelent, " Archives de Tocol.," 1883, p. 381. 5 " Medical News," Aug. 30, 1884. 6 Loc. cit. i58 PREGNANCY. Variola.—The occurrence of variola during intra-uterine life has long been a fact beyond dispute, admitted even by the most zealous advocates of the theory that the placenta can not be invaded by the germs of infectious diseases. Many cases are recorded in which a child marked with pustules was born of a mother who had been attacked with variola during pregnancy. But the susceptibility of the fetus to the disease varies. In the majority of cases the fetus is not infected. On the contrary, the mother may have only varioloid and yet the child be born with the marks of small-pox on it; x or the mother, having been exposed to the contagion of small-pox, but having shown no sign of the disease, may give birth to a child covered with pus- tules.2 Again, it has been noted that, of twins, one or both of the children may be affected.3 The fact that small-pox can attack the fetus has led many observers to test the possibility of an intra-uterine vaccination. Behm 4 vaccinated 33 women, and of their children 25 were successfully vaccinated after birth. Wolff 5 says that he has repeatedly vaccinated pregnant women, and has never failed to successfully vaccinate their offspring. Ridgen 6 tells of 8 cases of small-pox occurring in pregnant women, in whose children, born alive, a subsequent vaccination "took." On the other hand, Desnos7 and Chambrelent8 each relate a case in which vaccination was several times unsuccess- fully performed upon children whose mothers had shortly before their delivery recovered from an attack of small-pox. Chambre- lent, moreover, vaccinated 7 pregnant women, but of their chil- dren he was able to successfully vaccinate only 3. Precisely, therefore, as small-pox can affect the fetus in utero, but does not, as a rule, so can the fetus in utero in exceptional cases only ac- quire immunity from small-pox by the vaccination of its mother. Measles.—The transmission of measles from mother to fetus is rare, but there are certain well-authenticated cases on record of children born with a rubeolous rash upon them. Thomas 9 was able to collect 6 such cases from medical literature. There 1 Charcot, " Comptes rendus de la Societe de Biologie," 1851, p. 39, and 1853, p. 88 ; Chaigneau, " These de Paris," 1847 ; Chantreuil, " Gaz. des HSpitaux," 1870. 2 Laurent, " Lyon Medicale," June 15, 1884. 3 "Obstet. Trans.," London, vol. iii, p. 173. 4 " Zeitschr. f. Geburt.," Bd. vii, p. 1. 5 Virchow's "Archiv," Bd. cv, p. 192. 6 " British Med. Jour.," 1877, '> P- 229- 7 Societe med. des Hopitaux, 1871 (see Tarnier et Budin, op. cit., p. 13). 8 Loc. cit., p. 385. 9 Ziemssen's "Handbook," vol. ii, p. 50 (see also Underhill, " Obstet. Jour., Great Britain and Ireland," 1880, p. 285, and MacDonald, " Edin. Med. Tour.," 1884-85, 699). THE DISEASES OF THE FETUS. 159 are also cases recorded of measles appearing in the first few days of extra-uterine life, making it probable, from the short period of incubation, that infection had occurred /;/ utero. Scarlatina.—More than one eminent authority has expressed a doubt as to the occurrence of scarlet fever in utero, but the evidence, although scanty, is conclusive that on rare occasions children have been born with a well-marked scarlatinous rash upon them. Dr. Leale,1 of New York, described a case in his own practice in which a boy was born at the beginning of a well- marked attack of scarlet fever in the mother, which she had con- tracted from an older child. The new-born infant presented a dark, congested, red hue and a characteristic raspberry tongue. The eruption lasted seven days and desquamation began on the tenth day, at which time the albuminuria and general anasarca pointed to a desquamative nephritis. This child recovered. Dr. Leale was, moreover, able to collect a number of cases re- corded by Hiiter, Meynet, Asmus, Baillou, Tourtual, Gregory, and Stichel. Dr. Wilson Saffin,2 of Carthage, Ohio, has also reported a very interesting case of scarlet fever in utero: A lady, who had had scarlet fever in childhood, was nursing her child through the disease, while she herself was in the last month of pregnancy. She was apparently not infected, but complained of a bad sore throat. Two weeks afterward she was delivered of a male child with a typical scarlet rash upon it; the disease ran a course of nine days, with desquamation in large and small flakes, beginning on the fifth day. The infant's temperature ranged from ioo° to 1040 F., and the attack ended in recovery.3 Erysipelas.—Kaltenbach,4 in 1884, observed a child, born of a woman who had had erysipelas in the last month of pregnancy, that a few days after birth shed its skin as if it had had an attack of erysipelas in utero. Runge 5 and Stratz 6 have described similar cases, but Tarnier 7 calls attention to the fact that des- quamation in the healthy new-born infant is not so uncommon an occurrence. Lebedeff,8 however, has presented convincing evidence as to the possibility of intra-uterine erysipelas in the following case : The child of a woman delivered at the seventh month in the midst of an attack of erysipelas presented alternate 1 "Medical News," 1884, p. 636. 2 " New York Med. Record," April 24, 1886. 3 For full bibliography see Ballantyne and Milligan, " Edinb. Med. Jour.," July, 1893. 4 " Centralblatt f. Gyn.," No. 44, 1884. 5 "Centralblatt f. Gyn.," No. 48, 1884. 6 " Centralblatt f. Gyn.," ix, 213. 7 Loc. cit. 8 " Zeitschr. f. Geburt.," xii, 2, p. 321. i6o PREGNANCY. patches of red and white on its skin at birth ; it lived ten minutes ; after death streptococci were found in subcutaneous adipose tissue, were cultivated, and rabbits inoculated with the cultures acquired the disease. No microbes, however, were found in the placenta or cord. Lebedeff believes that the specific microbes entered the placenta through a villus deprived of epithelium. Malaria.—Among others, Burdel x expressed his disbelief in the existence of congenital malaria, and Tarnier quotes Leroux as saying that " as yet it is impossible to say positively that con- genital malaria exists " ; 2 but the testimony as to the occurrence of symptoms of disturbance in the unborn fetus at regular inter- vals, corresponding or not to the attacks in the mother, and the manifestations of periodical seizures, beginning immediately after birth, is quite voluminous and of a credible character. Behr- mann relates 3 two cases of intra-uterine infection in which the disease manifested itself directly after birth. Dr. W. T. Taylor, of Philadelphia, presented to the Philadelphia Obstetrical Society the history of a lady who, having lived during the last months of her pregnancy in a malarial locality, moved to a healthy situa- tion to be delivered. The nurse noticed that the new-born child was seized with attacks of restlessness during the first week of extra-uterine life, and evident discomfort at a certain period during the day. As a malarial origin of the attacks wras sus- pected, quinin was administered to the mother, and in a short time the infant became healthy. Dr. Harris at the same time described a similar case yielding to the same treatment. Aside, however, from the direct action of the malarial poison upon the fetus in utero, the existence of malaria in the mother seems to have a deleterious influence on its growth and develop- ment. Thus, Bompiani 4 says that the children born of malarial mothers very rarely reach 3250 gm. in weight or 50 cm. in length, and Negri 5 observed 34 cases in pregnant women, of which 18 per cent, terminated by premature expulsion of the fetus. The administration of quinin in large doses to the mother affected with malaria would, therefore, be called for, and one need not be deterred from using the drug by the fear that once prevailed of so bringing on an abortion, for, as Tarnier says, " quinin in this condition is the best prophylactic treatment against abortion or premature labor." Tuberculosis.—Considering the very large number of tuber- culous women who become pregnant, it is an extraordinary fact. 1 " Annales de Gyn.," viii, p. 31. 2 Op. cit., p. 24. 3 "Berlin, klin. Wochens.," 1885, Aug. 24, Sept. 7. 4 " Annal. di Obstet.," vi, 42,46, 1884. 5 "Annal. di Obstet.," viii, p. 277. THE DISEASES OF THE FETUS. 161 that the direct transmission of the disease from the mother to the fetus is an extremely rare occurrence. Runge x infected a number of pregnant guinea-pigs with tuberculosis, but invariably failed to find the characteristic bacilli in the fetal tissues or pla- centa. Ballinger, Davaine, Brauell, and Wolff have all expressed a decided disbelief in the existence of congenital tuberculosis, and Jani's observations have already been referred to. But Demme once found the tubercle bacillus in the macerated fetus of a tuberculous woman, and on one occasion Johne 2 discovered tubercles in a still-born calf, in wiiich he found the bacillus tuberculosis. While, therefore, there is a remote possibility of the passage of tubercle bacilli from mother to fetus, it must be regarded as a very exceptional occurrence.3 Septicemia.—The possibility of the transmission of septic micro-organisms from mother to fetus has been denied by many, but the occurrence of septic infection of the fetus in utero has been strongly affirmed by Koubassoff, Chambrelent, Pyle, Mars, H. von Hoist, and others. Mars,4 of Cracow, injected putrid solutions into pregnant animals, and found often the same bacilli in mother and fetus. Dr. Pyle's observation on the body of a fetus removed by Cesarean section from its mother, who was dying of septicemia, has already been noticed ; and, finally, von Hoist,5 after an extensive search through medical literature, asserts positively that, although intra-uterine septic infection of the fetus is rare, it has undoubtedly occurred. Cholera.—Tarnier6 says that there is nothing to justify the belief that cholera affects directly the fetus in utero; and Queirel7 asserts that it is doubtful whether cholera can be con- veyed to the fetus, but, nevertheless, early abortion is the rule, and if the child should be born near or at term it dies in a few days. Typhoid Fever.—The effect upon the fetus of typhoid fever in the mother is, as a rule, disastrous, resulting in the expulsion of the product of conception in about sixty-five per cent, of the cases,8 the elevation of the temperature, the alteration of the blood, and the respiratory embarrassment (Tarnier) being considered the 1 Quoted by Ott, loc. cit. 2 Quoted by Wolff, loc. cit. 3 See A. S. Warthin, " Ectopic Gestation ; Tuberculosis of Tubes, Placenta, and Fetus," "Med. News," Sept. 19, 1896; Birch-Hirschfeld, " Beitr. z. path. Anat. u. zur allgem. Path.," 1891 ; " Archiv f. Gyn.," Bd. xliii, H. I, p. 162. 4 Abstract "Archiv de Tocol.," 1883, p. 380. 5 Dissertation, Dorpat, 1884 ; Abstract " Centralblatt f. Gyn.," 1885, p. 200. 6 Loc. cit. 7 " Nouv. Archiv d'Obstet. et de Gynec," April 25, 1887, p. 1. 8 Duguyot, " These de Paris," 1879. 11 l62 PREGNANCY. causes of the abortion or premature labor. But that the disease can affect the fetus itself has been shown by Neuhaus,1 who found the specific bacilli of typhoid fever in the lungs, spleen, and kidneys of a fetus expelled at the fourth month from a woman who was convalescing after a prolonged attack of the disease. Articular Rheumatism.—The consideration of this disease among the infectious diseases is perhaps not yet entirely justi- fiable. There are, however, two instances on record of the transmission of the disease from mother to fetus—one described by Pocock 2 and the other by Schaffer.3 In each a woman affected with articular rheumatism at the end.of pregnancy gave birth to a child presenting, in one case at once, in the other at the end of three days, all the symptoms of the disease. Recurrent Fever.—Albrecht 4 has described three cases of con- genital recurrent fever, and in the blood of one fetus he discov- ered the spirilla. Yellow Fever.—Dr. Bemiss,5 of New Orleans, says: "The pregnant woman being attacked by yellow fever and recovering without miscarriage, immunity from future attacks is conferred upon the offspring contained in the womb during the attack." If this is true, it certainly seems that the fetus must have likewise passed through an attack of the disease. Noninfectious Diseases of the Fetus.—The infectious dis- eases are transmitted from mother to fetus. The non-infectious diseases have an independent origin in the latter. It appears occasionally, however, as if a non-infectious disease occurring at the same time in mother and fetus was transmitted from one to the other. So, for instance, in the case described by Dohrn,6 of a mother, affected in the last weeks of pregnancy with pur- pura haemorrhagica, giving birth to a child presenting number- less subcutaneous hemorrhagic extravasations, the fetal disease seemed to be directly derived from the maternal affection ; but it was the same cause—malnutrition—that produced the disease in mother and child. So, in the case described by Strachan,7 the disease might at first seem to have been transmitted from mother to fetus : A woman in the eighth month of pregnancy was admitted to a hospital ward on account of acute pneumonia 1 "Berlin, klin. Wochens.," 1886, p. 389. 2 London " Lancet," 1882, ii, p. 804. 3 " Berlin, klin. Wochens.," 1886, S. 79. 4 "St. Petersburg med. Wochens., 1880, No. 18, and 1884, p. 129. 5 See Parvin's " Obstetrics," p. 222. 6 "Archiv f. Gyn.," Bd. vi, S. 486. 7 " British Med. Jour.," 1886, ii, p. 860. THE DISEASES OF THE FETUS. 163 of the left lung. Shortly afterward she gave birth to a child that lived only a few hours, and which, after death, was found to have also acute pneumonic consolidation of the left lung.x But the ingenious explanation of Geyl,2 who has observed several undoubted cases of acute pneumonia /;/ utero, is no doubt cor- rect. In these cases there has been some interference with the oxygenation of the fetal blood, and the resulting asphyxia has induced efforts at respiration, whereby amniotic fluid has been drawn into the lungs and has there set up an inflammation. Some of the diseases of the fetus owe their origin to a vitiated condition of the maternal blood, or to an inherent weakness in the building material of the fetus, as in cases of chronic systemic affections of either parent, or to a perverted nervous action in the mother. There are others for which a cause is unassign- able. Some of these affections may be passed by with a simple mention. Such are inflammations of the serous membranes,3 and the resulting ascites, hydrothorax, hydrocephalus, due in the majority of cases to syphilis, although there is one case 4 on record of atresia vulvae et recti and a vesico-uterine and utero- rectal fistula, where the urine escaped into the peritoneal cavity through the Fallopian tubes and set up a violent peritonitis ; certain skin diseases, as ichthyosis, alopecia, hypertrichosis, albinism, purpura haemorrhagica, and elephantiasis; 5 intra-uterine brain disease,6 which may consist of sclerosis, atrophy, lack of development, tumors, cysts, or inflammation of the membranes, diseases of the liver, sclerotic or multicystic,7 along with cystic disease, or cirrhosis of the kidneys, and the many varieties of congenital tumors, solid or cystic, malignant or benign, which are better described in text-books on pathology or surgery, or in connection with the study of dystocia. In addition to these affections, however, that have been hastily passed over, there are others deserving more consideration. Rachitis.—Children have been born with the rachitic pro- cesses in their most active stage,—that is, while the bones are still soft and easily distortable,—or at birth the process has evi- dently pursued a longer course, for the bones are abnormally 1 The author has reported a case of pneumonia in utero in the " Amer. Jour. Obstet.," Nov., 1887 ("Trans. Phila. Obstet. Soc"). 2 "Archiv f. Gyn.," Bd. xv, 384. 3 For a reference to endo- and pericarditis see Cruveilhier, quoted in " Ann. di Ostet.," July, Aug., 1887, p. 314; and for congenital valvular defect, diagnosti- cated before birth, see " Trans. Med. and Chir. Fac., Maryland," 1884. 401shausen, "Archiv f. Gyn.," Bd. ii, S. 280. 5 Duhring, "Diseases of the Skin," p. 418. 6 London "Lancet," 1886, i, p. 220. 7 "Trans. London Path. Soc," vol. vii, pp. 229,235. 164 PREGNANCY. hard and thick, and set in the deformed shapes that they have acquired in utero. Schorlau1 collected the records of forty-three cases of con- genital rachitis, and added to the number two of his own ; while Grafe 2 mentions the cases that have been described by Sande- fort, Winckler, Schultz, Virchow, Kehm, and Fischer ; and of late years Fehling 3 and Hennig 4 have also described specimens of fetal rachitis. The author has observed one case. As the etiology of infantile rachitis is by no means clear, it is all the more difficult to explain the occurrence of rachitis in utero. It may be said, however, to depend upon some vice of nutrition, especially if the preg- nant woman is living under un- favorable conditions as to food, light, and ventilation; but the fact that the mother has at some time had rachitis herself, as evi- denced by the shape of her pelvis, seems of itself by no means to predispose the fetus to the same affection. The appearance of a rachitic fetus, especially in the higher grades of the disease, is quite distinctive. It has an enlarged head, perhaps hydroce- phalic ; gaping sutures and fon- tanels, a "chicken" breast, and a much distended abdomen ; the extremities are short, thick, and often bent at an angle, or curved, and the joints are large and prominent. The spine is often curved either laterally or an- teroposteriorly.5 The bones are either abnormally hard and firm or so brittle that they are fractured by the slightest force. This condition of the bones in rachitis may be stimulated by the arrest of bony development in cases of sporadic fetal cretinism.6 Bidder and Miiller have described bone diseases in the fetus which appear to be varieties of rachitis. Fig. 118.—Rachitis congenita micro- melica (author's case). 1 " Monatschr. f. Geburtsh.," Bd. xxx, S. 401. 2 "Archiv f. Gyn.," Bd. viii, S. 500. 3 j^jj g^. x 4 "Transactions of Meeting of German Naturalists and Physicians," Berlin, 5 Grafe, loc. cit. 6 Virchow's " Archiv," Bd. c, S. 256. THE DISEASES OF THE FETUS. 165 Anasarca.—General anasarca of the fetus is occasionally seen. The distention of the fetal skin may reach such dimensions that the expulsion of the child becomes exceedingly difficult.1 Such children are, however, usually born prematurely from the fourth to the eighth month, and are, as a rule, still-born, although cases are recorded in which death only occurred some little time after birth. The causes of this condition must be various. It has been attributed to anasarca of the mother, to syphilis, to absence of the thoracic duct; 2 in one instance to leukemia of the fetus,3 in another to obstruction of the umbilical vein.4 The serous infiltration of the skin is usually accompanied by a collection of fluid in the abdominal and pleural cavities, and the membranes and placenta are often markedly edematous. Fig. 119.—Congenital cystic elephantiasis. Congenital Cystic Elephantiasis.—In this disease there is a great overgrowth of the subcutaneous connective tissue all over the body, and at intervals in the hypertrophied tissue there are cysts varying in size. Malformations of a grave character are commonly associated with the disease. On this account, and because the subjects of the disease have all been born prema- turely, the infants scarcely ever survive their birth. One child, however, lived thirty minutes and another was twenty months 1 Keiller, " Edinburgh Med. and Surg. Jour.," April, 1855. 2 "The Diseases of the Fetus," Ballantyne, Edinburgh, 1895, 2 vols. Com- plete bibliography. 3 Klebs, " Prager med. Wochens.," 1878, No. 49. 4 "Breslauer Klin.," Bd. i, S. 260. 166 PREGNANCY. old when the case was reported. Ballantyne x has collected more than eighteen cases of this very rare disease. Spontaneous Fractures in Utero.—The fetal bones may be broken by external violence, or a child may be born presenting numerous fractures, especially of the long bones, either recent or already undergoing repair, without the history of an accident of any kind to the mother during pregnancy. If in such cases one can exclude a syphilitic osteochondritis, with a separation of the epiphysis and diaphysis, or an injury to the child during labor, there must have been a rachitic condition of the bones or an arrest of ossification, to allow of fracture by the slight force which could be exerted by the fetal muscles or the pressure of the uterine walls. Link,2 however, describes a case of numerous fractures in utero of the ribs, clavicle, and extremities, in which syphilis, rachitis, and chronic parenchymatous osteitis could be excluded, and he, therefore, concludes that these fractures were caused by an " unknown intra-uterine fetal bone disease," in which the bones became soft and brittle. A similar bone disease has been described by Schmidt. Luxations and Ankyloses.—Luxations affect females four times as often as males,3 and are much more common in the lower than in the upper extremities. An apparent ankylosis 4 after birth occasionally appears when, in breech presentations, the presenting part has remained a long time in the cavity of the pelvis. The lower limbs remain in the position—of flexion of thighs upon abdomen and extension of legs upon the thighs— that they occupied in utero, and it is impossible for a while to restore them to a proper position.5 Intestinal Invagination.—Lauro 6 has described a double invagination of the descending colon during intra-uterine life. Intrauterine Amputations.—The complete severance of a portion of a limb in utero is an extremely rare occurrence.7 The explanation of the amputation is most frequently the presence of constricting amniotic bands,—a condition more fully described 1 " Diseases of the Fetus," Edinb., 1895, 2 vols. 2 " Archiv f. Gyn.," Bd. xxx, 2, p. 264, 1887. 3 Tarnier et Budin, loc. cit. 4 Lefour, " Presentation du Siege decomplete Mode des Fesses," Paris, 1882. 5 The fixation of the limbs or trunk in abnormal positions by muscular contrac- tion may occur in utero during pregnancy, as in the interesting case of " contracture " in utero (Ribemont-Dessaigne, abstract in " Nouv. Archiv d'Obstet.," Sept., 1887). In this connection the student should consult also the paper by Matthews Duncan on " Extensions and Retroflexions of the Fetus, especially of the Trunk, during Preg- nancy " (" Trans. London Obstet. Soc," xxvi, 1884, p. 206). 6 " Annali di Ostet. e Ginecol.," Luglio-Agosto, 1887. 7 For an extensive bibliography see " Tarnier et Budin." THE DISEASES OF THE FETUS. l6j under the Pathology of the Amnion. But this explanation will not suffice for all cases ; it has been demonstrated that a gan- grenous process x at a certain point in the limb may determine an amputation, just as it would in extra-uterine life, or that a peculiar morbid process 2 may produce a constriction from the circular contraction of connective tissue at a certain point, or, again, that an amputation 3 may follow a fracture. The ampu- tated part may float loose in the amniotic liquid, may possibly be absorbed if detached early in embryonal life, or may be attached to the sound portion of the limb by a filament more or less bony. Fetal Traumatism.—The position of the fetus in utero is one that secures the greatest possible immunity from external violence, but it may experience injuries of the gravest nature, either in connection with serious injury to the mother or occa- sionally with very slight evidences of violence to the maternal tissues. Thus, in cases of gunshot,4 stab,5 or other perforating wounds of the abdomen in pregnant women, the fetus has like- wise been severely and fatally wounded. Also, in the perform- ance of celiotomy,6 by a mistaken diagnosis the trocar that wras plunged into what was thought to be an ovarian cyst has pene- trated the fetus, and wounds have been inflicted by both sharp and dull instruments ignorantly used to bring on an abortion or in the hands of physicians who overlooked the condition of pregnancy. On the other hand, as instances of fatal injury to the fetus without apparent injury, externally, at least, to the mother, might be cited those cases of Mascka7 and Gurlt,8 in which the cranial bones of the fetus were fractured by the mother falling from a height, or the case described by G. von Hoff- mann,9 of a woman in the fifth month of pregnancy who threw herself out of a fourth-story window and was killed by the fall, although she exhibited no signs of external injury ; the uterus was uninjured, and the fetus externally was apparently unharmed, but on opening its abdomen the liver was found to be almost dis- integrated. The case, however, reported by Dr. Lumley,1 ° shows 1 Chaussier, " Proces verbal de la Distribution des Prixes a la Maternite," 1822. 2 Kristeller, " Monatschr. f. Geburtsh.," Bd. xiv, p. 817. 3 Martin, " Gaz. Hebdom.," 1858, p. 384. 4 Hays, "Ann. de Gyn.," 1880, xiii, p. 153. 5 Fennell, " Trans. N. Y. Path. Soc," iii, 249; Tarnier et Budin, loc. cit., p. 345 ; Guelliot, "Gaz. des Hop.," 1886, p. 405. 6 Goodell, " Lessons in Gynecology," p. 352. 7 " Prager Vierteljahrschrift," 1857. 8 " Monatsch. f. Geburtsh.," 1857, p. 343. 9 " Wien. med. Presse," xxvi, 1885, Nos. 18, 20, etc. 10 ;'N. Y. Med. Rec," 1886, p. 359. 168 PREGNANCY. more clearly how slight violence to the mother may be fatal to the fetus : A pregnant woman, within ten days of term, attempting to enter a doorway, slipped and struck the left lower portion of her abdomen against the edge of the door. The movements of the child thereupon ceased, and eight days after- ward a dead fetus was born with a fracture of the left frontal and parietal bones of the skull. One of my patients was thrown from a carriage two months before her delivery. Her infant, otherwise healthy, had a fractured clavicle, almost entirely healed, but with a large mass of callus about the site of fracture. These cases of fetal injury are not only interesting from their rarity, but they are also important from a medicolegal point of view. Thus, Gorhan1 records the death of a fetus from violence done the mother at the hands of another woman in the course of a brutal quarrel between two sisters-in-law, during which the pregnant woman, being at the time in the sixth month of gestation, was thrown to the ground and stamped upon by her infuriated relative. Two months afterward a dead fetus was born, corresponding in development to the sixth month of pregnancy, and exhibiting a transverse fracture of both parietal bones. It might be important to distinguish injuries experienced during labor, as fractures of the extremities or of the spine,2 or depressions of the skull,3 from the effects of traumatism during pregnancy. Conditions of the Mother Which Injuriously Affect the Fetus.—The Influence of Maternal Fever upon the Fetus.—The well-known experiments of Runge,4 published in 1877, were for some time accepted as conclusive proof of the great danger to the fetus of high temperature in the mother. Pregnant rabbits placed in a hot box until their body-temperature had risen to 105.8° usually died, and almost invariably the fetuses were found dead upon opening the animal's body immediately after its re- moval from the box. But in 1883 Doleris5 showed that if the temperature of the animals was slowly raised to 105 ° or 1060, and not within an hour, as in Runge's experiments, they seemed to bear it without much inconvenience, even if long continued, and, if pregnant, their young remained perfectly healthy. These *J. Taber Johnson, "Trans. Am. Gyn. Soc," vol. iii, p. 107. 2 " Wien. med. Presse," xxvi, p. 370. 3 There are, however, two recorded cases of this injury occurring from traumatism during pregnancy. 4 "Archiv f. Gyn.," Bd. xii, p. 16; Bd. xiii, p. 123. 5 " Comptes rend. hebd. Seances de la Societe de Biologie," Nos. 28, 29. Doleris' results were confirmed by experiments of Dore (" Arch, de Tocol " 1884 p 141) and quite recently by Negri (see abstract in " Nouv. Arch. d'Obstet' etde Gyiiec ")' THE DISEASES OF THE FETUS. 169 results were confirmed by Runge1 in a second set of experiments, in which he found, however, that if the animal's temperature was raised, even very gradually, to 109.40, there occurred the same symptoms—death of the fetus and heat-stroke of the mother— as though the temperature had been quickly raised to 106°. Preyer2 has also shown that the fetus is capable of enduring a much higher temperature than was formerly supposed, for in one instance he actually observed a fetal temperature, in a guinea-pig, of 111.20, taken in ano, the fetus living nine minutes, or until the cord was severed and it was removed from the uterus. In view, therefore, of these experiments, it seems necessary to modify the views formerly entertained, that the existence of fever in the mother must of itself necessarily threaten the life of the fetus, unless, indeed, the temperature should rise suddenly, as in the case of brain-tumor described by Runge, or in cases of recurrent fever recorded by Kaminski,3 or else should reach an extreme height, as it might in insolation. As to the treatment of fever in pregnant women with a view to its influence on the fetus, no special measures are required so long as the temperature rises gradually and remains under 105 °, but above this point the danger to the fetus begins (Kam- inski), and active antipyretic treatment is required. Should a pregnant woman die with a temperature as high as 109°, the performance of postmortem Cesarean section would be useless, for the fetus would inevitably die first, having no means of getting rid of its extra heat by radiation. The operation would likewise be fruitless in a case of death after a very sudden rise of tem- perature (Runge). The Influence of Maternal Emotions upon the Fetus.—Maternal emotions and impressions may affect the embryo or fetus. Many cases of mental peculiarities or diseases, or of physical defects, that have been attributed to a strong impression upon the mother during pregnancy, are no doubt to be explained by the existence of some systemic disease, as syphilis, nephritis, diabetes, cancer, or chronic lead-poisoning in either father or mother ; by an arrest of development; by mechanical disturbance of the ovum, or, in the case of intra-uterine amputations, by the formation of amniotic bands or the disposition of the cord ; but there still remain well- authenticated cases of congenital defects or peculiarities,4 which bear too startling a resemblance to the cause of the impression 1 " Archiv f. Gyn.," Bd. xxv, S. 1. 2 " Physiologie des Embryo," Leipzig, 1884. 3 "St. Petersburg med. Zeitung," 1868, 117. 4 See the very interesting paper by Dr. Fordyce Baker in " Gynecol. Trans.," •vol. xi, 1886. 170 PREGNANCY. upon the mother during pregnancy to be dismissed as mere coin- cidences. One of my patients, less than six weeks pregnant, was, on one occasion, seized by the ear and dragged about the room by her enraged- husband. The child born at term had a triangular piece lacking from the lobe of the corresponding ear. A strong emotion on the part of the mother may be imme- diately fatal to the fetus, as apparently happened in a case reported by Hayes.1 The idiocy of Barnaby Rudge due to maternal shock and fright is a fiction founded upon fact. There is no question that certain maternal conditions may so modify the blood in its capacity of a bearer of oxygen and nutriment to the fetus as to seriously interfere with the latter's health, if not to destroy its existence. Such is undoubtedly the case in pneumonia of the mother, which can prevent a proper aeration of the maternal, and consequently of the fetal, blood, and may so bring about complete asphyxia of the fetus, or may, perhaps, result in inspiratory efforts in utero, the inspiration of liquor amnii, and a subsequent development of pneumonia in the fetus itself.2 Whatever the cause of death, pneumonia in the mother is exceedingly fatal to the fetus. In infectious diseases also the development of specific micro- organisms in the maternal blood may so alter its normal con- stitution as to render it unfit for the respiratory and nutritive needs of the fetus, this condition of the blood, constituting perhaps the chief peril for the fetus, for " the fever is usually the least of the dangers to the fetus in these (infectious) dis- eases" (Runge). The occurrence, also, of exanthematous and hemorrhagic endometritis during the course of certain infectious diseases has been considered under the head of Decidual Endo- metritis. Icterus Gravidarum in its Influence on the Fetus.—The occur- rence of this comparatively rare disease endangers to a high degree the life of the fetus, either by bringing on an abortion or by first destroying the life of the fetus through the poisonous action of the bile-salts,3 or, perhaps, by the induction of cholemic convulsions.4 Thus, Spath5 describes 8 cases, in 4 of which the fetus was born dead; and Frerichs6 mentions 3 cases, all fatal to the fetus. Saint Vel7 has described an epidemic 1 "Lancet," vol. ii, 1874. 2 See Inspiration Pneumonia. 3 Valenta, " Oesterreichische Jahrb.," xviii, 1869, S. 163. 4 Stumpf, "Archiv f. Gyn.," Bd. xxviii, H. 3. 5 "Wiener med. Wochens.," 1854, S. 757. 6 " Klinik der Leberkrankheiten," 1858, Bd. i. 7 "Gaz. des Hop.," 1862, p. 53S. THE DISEASES OF THE FETUS. iyi of jaundice on the island of Martinique, during which, of 30 pregnant women affected, 20 were delivered prematurely, and of these 20 children 19 were either still-born or died shortly after birth. Bardinet1 has also recorded the birth of 6 dead infants out of 13 pregnant women who were suffering from jaundice during an epidemic of the disease in Limoges. Fre- quently as the bile-salts must traverse the uteroplacental septum and enter the fetal circulation, as evidenced by the high per- centage of still-born children in women affected with jaundice during pregnancy, the coloring-matter of the bile seldom stains the fetal tissues. Lomer2 collected 56 cases in which naturally colored children were born of jaundiced mothers, and 43 more in which the color of the child was not mentioned, so that it was presumably natural; and to these might be added another case described by Parrish. There are 6 recorded cases, however, in which the fetus or the whole ovum was undoubtedly jaun- diced (Lomer). Eclampsia.—It has been estimated that about one-half the children are still-born after the eclampsia of pregnancy or labor. The cause of the fetal death is not altogether clear, for it might with equal plausibility be laid to the presence of too much car- bonic-oxid gas in the maternal blood, to the stagnation of the blood-current during a convulsion, or to the presence of excre- mentitious matters in the blood. The Death of the Mother.—The effect of the death of the mother upon the fetus is ultimately fatal, but as to the length of time that life can continue in the fetus after it is extinct in the mother there is considerable difference of opinion. Kergaredec's view that twrenty-four hours might elapse between the death of the mother and the fetus is, of course, preposterous. There is on record, however, a well-authenticated case of the extraction of a living child from the womb of a woman who had been dead two hours.3 Tarnier 4 also performed postmortem a Cesarean section upon a woman who during the Commune in Paris had been killed by a stray bullet in the wards of the Maternite, and extracted a living child, certainly three-quarters of an hour— perhaps an hour and a quarter—after the death of the mother. Numerous other instances are recorded of postmortem Cesarean operations, or the extraction of infants per vias naturalcs, at inter- vals of time ranging from a few minutes to a half hour after the death of the mother. The remarkable survival of the fetus under 1 "Union Medicale," 1863, Nos. 133 et 134. 2 "Zeit. f. Geburtsh.," xiii, p. 169, 1886. 3 Hubert, " Traite d'Accouchements," vol. ii, p. 160. 4 "Tarnier et Budin," ii, p. 571. 172 PREGNANCY. conditions which would seem to make life impossible is explained, perhaps, by the cases of children born asphyxiated, whose hearts continue to beat, although they do not breathe for a long time after birth, or by the experiment performed by Haller x of forc- ing a bitch to give birth to her pups under water, where they crawled about and lived for half an hour. The Death of the Fetus___The death of the fetus in utero may be due to many causes. It may be the result of injuries, deformities, or diseases in the fetus itself or in its appendages, the membranes, and the placenta. It may be due to inherent weakness in either the ovule or the spermatic particle, which does not prevent conception, but which renders the embryo incapable of development beyond a certain point; or it may be the consequence of a misplaced ovum, as in tubal, ovarian, and abdominal pregnancies. The condition of the maternal blood, the existence of a very high temperature in the mother, and perhaps strong emo- tions, must also occasion- ally be held responsible for the destruction of fetal life. All these conditions, how- ever, have been or will be considered in their appro- priate places ; but it remains to notice the effect that the death of the fetus produces upon the mother, the signs by which it may be possible Fig. 120.—Two years in the abdomen (Baer). to determine whether the fetus /;/ utero be alive or dead, the habitual death of the fetus in utero, and the changes that ensue after death in the fetus itself. The effect of the death of a fetus upon its mother is often nil. There may, however, be depression, loss of appetite, and chilly sensations. When the dead body undergoes putrefactive changes, or when, the soft parts being absorbed, there is an attempt to get rid of the fetal bones by ulcerative processes into the bladder, vagina, or rectum, or externally through the abdom- inal walls, the mother's health and safety are seriously endangered. Thus, after ectopic gestation the dead fetus may remain for an indefinite period within the mother's abdomen, without giving rise to greater inconvenience than would be caused by the 1 "Elem. Physiol.," vol. iii, p. 314, quoted in " Tarnier et Budin " op cit., P- 57°. THE DISEASES OF THE FETUS. *73 enlargement of the abdomen ; but should the germs of putrefac- tion gain access to the dead body, as they may by reason of the contiguity of the intestines (Litzmann), then a general sup- purative peritonitis may be developed and rapidly prove fatal. So, too, in the retention of blighted ova1 or in cases of missed labor2 there is usually no evidence of serious harm to the mother until the putrefaction of the dead body begins, when there may be shortly manifested all the symptoms of septicemia, unless the uterine cavity be speedily cleared of its contents and well disinfected. It is by no means an easy matter to determine whether or not the fetus has ceased to live. If its death should have occurred during the early part of pregnancy, the uterus will usually cease developing and the circumference of the abdomen Fig. 121.—Calcification of cap- Fig. 122.—Lithopedion. Two years sule (in abdomen unknown length of in abdomen (Baer). time). will no longer increase steadily from week to week ; the breasts will soon become flabby, although it is not rare for milk to ap- pear for a time after the death of the fetus ; the woman may complain of subjective symptoms, as a feeling of weight and dis- comfort in the hypogastric region (Lusk) ; but the doubt will usually soon be solved by the expulsion of the ovum. " It is not rare for the lacteal secretion to be established three or four days after the death of the fetus, with all the phenomena char- acteristic of that function after delivery" (Tarnier). Should the 1 See Gehrung, "Weekly Med. Review," Chicago, 1885, p. 131; "Westmins- ter Hospital Reports," 1885, i, 119; "TokioMed. Journ.," 1886, No. 439. Graefe, in Ruge's "Festschrift"; Stager, Inaug-Diss., Bern, 1895. 2 Lusk, " Science and Art of Midwifery," 1886, p. 304. 174 PREGNANCY. fetus die in the later months of pregnancy, the movements, there- tofore perhaps active, will no longer be felt by the mother, and the fetal heart-sounds will no longer be heard. Neither of these signs, however, is entirely reliable, for the woman's statement will not always be perfectly credible, and it is impossible occa- sionally to hear the fetal heart-sounds, although the child is alive and well. The urine of the mother commonly undergoes a change after fetal death. Albuminuria sometimes disappears when the fetus dies. On the contrary, I have seen albuminuria appear in consequence of fetal death. Peptonuria may be looked for if there is decomposition of the fetal body, and acetonuria, it is claimed, is an invariable consequence of a dead fetus in utero.1 Negri2 on one occasion was able to make the diag- nosis of fetal death during pregnancy by abdominal palpation, the fetus presenting a rather confused outline and giving rise, upon pressure of the mother's abdomen over the region of the fetal head, to an indistinct crepitus. During labor a doubt will often arise as to whether the fetus is dead or alive, and upon the decision arrived at will often depend the performance of em- bryotomy or of a more conservative operation. Under these circumstances it has been suggested by Cohnstein3 and Feh- ling4 that if the temperature of the uterus be found no higher than that of the vagina, the child may safely be pronounced dead ; for the living fetus, having a higher temperature than its mother, will impart some additional heat to the maternal struct- ures about it. Priestley5 more practically suggests that the hand be introduced into the uterus in order to feel in the precordial region for the impulses of the fetal heart, or to feel the pulsa- tions in the cord. After death the fetal tissues will in time saponify (adipocere), partially calcify, mummify, or else be totally or partially ab- sorbed. The phenomena seen shortly after death consist of maceration and putrefaction. Before the second month the pro- duct of conception may be entirely absorbed. After that time the changes that take place depend to some extent upon the position of the fetus. Within the uterus the dead fetus is first macerated, becoming bloated in appearance, with a grayish- colored skin deprived of its epidermis in spots of greater or less 1 Acetonuria was found 9 times in 139 pregnant women, and in each of the 9 cases it was demonstrated that the woman was carrying a dead fetus. Vicasella, "Wien. med. Presse," 1894, p. 205. 2 "Annali di Ostetricia," May, June, 1885, p. 223. 3 "Archiv f. Gyn.," Bd. iv, H. 3. 4 Ibid., Bd. vii, S. 143. 5 " Lancet," Jan. 23, 1887. THE DISEASES OF THE FETUS. 175 extent; the head is enlarged, the cranial bones are loose under the scalp, and the tissues become so soft and friable that very slight force is sufficient to detach the limbs from the body. Should air be admitted to the fetus in this condition by rup- ture of the membranes, decomposition rapidly ensues. The other changes that affect the tissues after death in utero are a kind of saponification, and possibly mummification, in which latter state they will remain for an indefinite period without change. It is in abdominal pregnancies that the dead fetus be- comes converted into a so-called lithopedion, which consists not of a calcification of the whole mass, but (1) of a calcification of the membranes after absorption of the liquor amnii; (2) of a cal- cification of the membranes and those points on the fetus where the membranes adhere to the fetal surface ; or (3) of a deposition of lime in the vernix caseosa after the membranes have been ruptured and the fetus has escaped into the abdominal cavity.1 The fetus in the abdominal cavity may undergo all the other changes that have been described, including putrefaction, and, in addition, the soft parts may be absorbed, the bony skeleton remaining as a foreign body in the abdomen until it is discharged piecemeal, perhaps through openings into the bladder, intestines, rectum, uterus, and vagina, or externally through the abdominal walls. The Habitual Death of the Fetus—There are women who conceive, perhaps frequently, but who in two or more successive pregnancies, usually at the same period in each, give birth to dead children. It is important in these cases to learn, if pos- sible, the cause of the repeated fetal death, for upon it depends the treatment that may be adopted to secure the birth of a living child. Although by no means the only cause of the habitual death of the fetus in utero, syphilis is by far the most frequent. According to Ruge's2 estimate, eighty-three per cent, of repeated premature and still-births are to be explained by the existence of syphilis in one or both of the parents. But there are many cases in which syphilis can with certainty be excluded, and in which the death must be ascribed to one of the other conditions that modern investigation has shown to be occasionally responsible for a repeated interruption of pregnancy. Certain Conditions of the Uterus which Interfere with the Development of the Fetus.—There are no reliable statistics in regard to the relative frequency of the causes, other than Syphilis, 1 Kuchenmeister, " Archiv f. Gyn.," Bd. xvii, p. 153. 2 "Zeit. f. Geburtsh.," Bd. i. 176 PREGNANCY. of habitual death of the fetus, but I should be inclined to place first chronic endometritis and chronic metritis. Schroeder,1 among others, speaks of the frequency with which a chronic endometritis can bring about an interruption of pregnancy, either by effusions of blood into the hyperemic mucous membrane, and the consequent excitation of muscular action in the uterus, or by an active growth of the decidua and the diversion of the nu- tritive blood-supply from the fetus to the uterine mucous mem- brane. Abarbanell 2 first called attention to chronic metritis as a cause of habitual abortion, from the excessive development of fibrous tissue in the body of the uterus, which by loss of elas- ticity would interfere with a sufficient dilatation of the uterine cavity. Such, perhaps, is the explanation of Baudelocque's case,3 in which, after a Cesarean section, a woman successively gave birth to four children at the seventh month of pregnancy. In two cases under my observation an ill-developed uterus was the cause of repeated premature births. In one the woman gave birth to thirteen children at the sixth month, none of which sur- vived. In the other there were three premature births before the children were viable. In this woman menstruation began in the eighteenth year ; there were long periods of amenorrhea, and a vaginal examination before marriage revealed an infantile uterus. Alterations in the Maternal Blood that are Fatal to the Fetus.—Scanzoni 4 pointed out that a high grade of anemia in a pregnant woman might be fatal to the fetus. The anemia may be due to an exaggeration of the hydremia which is character- istic of pregnancy, or to the development of pernicious anemia ; 5 to sudden loss of blood, or to lack of proper or sufficient food. To this last cause may be attributed the large number of abor- tions and still-births that occurred during the siege of Leyden (Hoffmann), or in Germany during the year 1826, when the crops failed (Nagele), and during the siege of Paris (Priestley). Plethora in the mother, on the other hand, has not such an unfavorable influence upon the fetus, for the very existence of pregnancy usually corrects the evil. It is possible, however, that this condition might prove a predisposing cause to effusions of blood into the membranes or placenta, especially at a time corres- ponding to a menstrual period. 1 " Geburtshulfe," 8th ed., Bonn, 1884, p. 405. 2 " Monatschr. f. Geburtsh.," xix, S. 106. 3 Leopold, "Archiv f. Gyn.," Bd. viii, p. 253. 4 " Geburtshulfe," Bd. ii, S. 3 u. 70. 5 Gusserow, "Archiv f. Gyn.," Bd. ii, S. 218. THE DISEASES OF THE FETUS. 177 The Effect of Chronic Diseases of the Mother upon the Fetus.—Women affected with tuberculosis,1 cancer, or chronic malarial poisoning 2 may give birth to a succession of dead chil- dren. Icterus gravidarum also, whether simple, epidemic, or pernicious, might be a cause of repeated fetal death, although the course of the last two is usually too rapid to allow of repeated impregnation. Nephritis.—Fehling3 has called attention to the influence of maternal nephritis as a cause of repeated still-births. The death of the fetus is often the result of the morbid condition of the blood-vessels in the maternal portion of the placenta, corre- sponding to the condition found in the lungs, brain, and other organs in chronic nephritis. The brittleness of the capillary walls leads to apoplexies and to the formation of large infarcts in the intercotyledonic spaces, which so compress the neighbor- ing placental villi that they can not perform their physiological functions. The effusion of blood may also cause a premature detachment of the placenta.4 Charpentier and Butte5 have shown that an excess of urea in the maternal blood may prove fatal to the fetus by the direct poisonous influence of this substance. Disturbances in the maternal blood-pressure (Runge) and insufficient oxygenation of the maternal blood may also occasionally be responsible for the fetal death. Diabetes.—This disease seems to have a most disastrous in- fluence upon the fetus. Matthews Duncan6 collected the record of 19 pregnancies occurring in 17 women, in 7 of which the fetus died in the latter part of pregnancy. In 2 cases the children were feeble at birth, and 1 child was diabetic. Chronic Poisoning.—Constantin Paul7 was the first to point out the evil influence of saturnism upon pregnancy. Of 123 conceptions observed by him in women the subject of chronic lead-poisoning, 64 ended in abortion, 4 in premature labor, and there were 5 still-births ; only 10 children passed the age of three years. These observations have since been confirmed by Roque8 and Rennert.9 1 Tarnier et Budin, op. cit., p. 89. 2 Bompiani, "Annal. di Ostet.," vii, 42, 46; discussion of Dr. Schrady's paper, " Med. News," 1885, i, 358; Negri, "Annal. di Ostet.," viii, p. 277. 3 "Archiv f. Gyn.," Bd. xxvii, p. 300. 4 Winter, "Zeit. f. Geburtsh.," Bd. xi, S. 398. 5 "Trans. Ninth International Medical Congress." 6 "Obstet. Trans.," London, vol. xxiv, p. 256. 7 Tarnier et Budin, op. cit., p. 31. 8 " These de Paris," 1873. 9 "Archiv f. Gyn.," Bd. xviii, p. 109. 12 178 PREGNANCY. It has also been asserted that female workers in tobacco are peculiarly liable to abortion or to still-births (Jacquemart, Kos- tial), but there is difference of opinion on the subject. Professor Hunter Maguire, of Richmond, Virginia, kindly inquired for me of some of the largest tobacco-manufacturers in that city as to the effect of tobacco on the pregnant women in their employ. There was no evidence of a deleterious influence upon pregnant women or their offspring. Causes of Death Residing in the Fetus Itself.—It has been already stated that syphilitic disease of the fetus or ovum is by far the most frequent cause of habitual death ; but there may be other causes residing in the fetus itself which remain after the rigid exclusion of syphilis. It is well known that deformities may be hereditary in certain families, carried through every member of several generations.1 A woman might, therefore, give birth to a number of children, each presenting the same deformity, grave enough perhaps to destroy life.2 Leopold3 discovered a curious affection to be the cause of death in several dead fetuses born successively of one woman. This consisted of a thickening of the fibrous and muscular coat of the umbilical vein so that its caliber was seriously diminished. Syphilis was excluded. The Causes of Fetal Death Referable to the Father.—In case it is impossible to attribute the habitual death of the fetus to inherent defects or to ill-health of the mother, the explanation may be sought in the condition of the father. He may be too old or too young to furnish a fecundating germ of sufficient vigor to enable the fetus to reach maturity ; or he may be the subject of some chronic debilitating disease, as nephritis, dia- betes,4 phthisis,5 cancer,6 or chronic lead-poisoning,7 which may not affect the fecundating power of the spermatic particle, but will render it incapable of performing its part in building up a healthy embryo. Thus, Priestley tells of a healthy young woman, whose husband had albuminuria, giving birth first to a sickly infant and afterward aborting in three successive preg- 1 "British Med. Jour.," Jan. 22, 29, 1887; "Am. Jour. Obstet.," 1886, p. 1108. 2 A lioness in the Philadelphia Zoological Garden has given birth, on three sep- arate occasions, to cubs that were deformed about the jaws and palate, and lived only a few moments after birth. 3 "Archiv f. Gynak.," Bd. x, p. 191. 4 Priestley, " Lumleian Lectures on the Pathology of Intra-uterine Death," rep. from " British Med. Jour.," 1887, p. 8. 5 D'Outrepont, " Neue Zeit. f. Geburtsh.," 1838, Bd. vi, p. 34. 6 Jacquemier, "Diet. Encyc. des Sc. med.," art. "Avortement," vol. vii, P- 537- 7 Constantin Paul, loc cit. THE DISEASES OF THE FETUS. 179 nancies, or until her husband succumbed to uremia. D'Outre- pont also has related the following case : A woman married to a phthisical man became pregnant five times, in each instance giving birth to a dead child at the eighth month. Remarried to a healthy husband, she gave birth to four healthy infants in succession. Paul, in 39 pregnancies in 7 women whose husbands were afflicted with saturnism, observed 11 abortions and 1 still-born child, while of the 27 children born alive only 9 survived early infancy. The Habit of Giving Birth to Still=born Children.—If one can exclude all the causes in the mother that have been enumer- ated as responsible for the death of the fetus, if there is no sign of abnormality or disease in the fetus or ovum, or if there is nothing in the condition of the father that might account for the repeated still-births, then their' occurrence may be attributed to a habit of the mother of giving birth to dead children. Such cases are extremely rare, as may be imagined, but are by no means unknown. Two examples may be cited : A woman x subjected to a severe fright in the last month of pregnancy after- ward gave birth to a dead child. In twelve successive preg- nancies she gave birth to dead children at the seventh month. The mother of Hohl 2 gave birth alternately to living and dead children. The first child was living and healthy, the second dead, and so on until the tenth pregnancy, when so certain was the lady that her child would be born dead that she provided nothing for it. It was born alive, however, and was no other than Hohl himself. The Diagnosis of the Cause of Repeated StilLbirths.—The suspi- cion of syphilis in the parents will usually first enter the mind of a practitioner who meets with cases of habitual death of the fetus ; but, aside from the possible injustice of such a suspicion, it may suggest inappropriate treatment. It is, therefore, im- portant to discover the true cause of the inability of the woman to bear a living child, for the treatment that may be adopted to prevent a repetition of the still-births must differ radically with each of the many causes that have been enumerated above. Syphilis, as by far the most frequent cause of habitual death of the fetus, must be first excluded before another cause is sought. But this is by no means always an easy matter. It frequently happens that the history of the parents is obscure, and that the fetus is expelled already macerated or with no distinctive marks of disease upon its body. In such a case a careful examination of the fetal body will usually reveal unmistakable evidence of the existence of syphilis. 1 Hayes, London " Lancet," 1874, vol. ii. 2 Tarnier et Budin, op. cit., p. 365. i8o PREGNANCY. To determine the other causes of repeated fetal death, endo- metritis and metritis should be looked for. An anomalous condition of the uterus may be discovered. The blood of the mother should be examined for plethora or anemia. The lungs should be examined for phthisis, and the urine for sugar or for albumin and casts. The history of the patient may point to the existence of malaria or of chronic lead- or tobacco-poisoning. Physical signs may denote a cancer, or there may be unmistak- able jaundice. The fetus itself must be examined for some hereditary defect, and the cord for stenosis of the umbilical vein. Finally, the condition of the father must be inquired into. If all other signs fail, the diagnosis must rest upon a habit or upon a hereditary predisposition of the mother. The Preventive Treatment of Habitual Death of the Fetus.— In the case of syphilis of the parents an appropriate antisyphilitic treatment should be administered. So frequently is an antisyphi- litic treatment successful in these cases that certain writers have recommended the administration of potassium iodid or mercury to every woman who was in the habit of giving birth to dead children. If a woman first comes under observation after im- pregnation has occurred, mercury and iodid of potassium should be administered throughout the whole of pregnancy if there is reason to suspect that the fetus may be syphilitic. If there should be a chronic endometritis, a curetment may be followed by conception and a normal pregnancy.1 A cor- rection of a displacement of the uterus or a repair of a lacerated cervix may be followed by the same result. In anemic women a tonic treatment will often be followed by the birth of a vigorous infant. Plethoric patients, on the other hand, would be bene- fited by increased exercise, by frequent depletion, and by a restricted diet. Phthisis, cancer, diabetes, or nephritis in the mother renders the prognosis for the fetus grave. In chronic malarial, lead-, or tobacco-poisoning the elimination of the poison should enable the woman to bear a living, healthy child. A chronic, incurable disease in the father may so deteriorate the quality of the spermatic particles that, while conception may occur, the development of the embryo will be impossible. Should his condition, however, admit of improvement, the male fertil- izing element may gain sufficiently in vigor to perform its part in the growth of the fetus. There are women who carry a living child up to a certain period of pregnancy, but if allowed to go to term give birth repeatedly to dead infants. Thus, Tarnier2 tells of a woman, 1 Schroeder, "Geburtsh.," 8th ed., p. 405. 2 Loc. cit., p. 365. THE PHYSIOLOGY OF PREGNANCY. l8l apparently in good health, who gave birth to thirteen dead children successively, although it was demonstrated that the fetus was in each instance alive until the last month of pregnancy. The same authority cites another instance of a woman who in seven successive pregnancies experienced the active movements of her child until within fifteen days of the normal time of delivery, and yet always gave birth to a dead infant. In such cases as these it is evident that the birth of a living child could be secured by inducing labor at a time before the period of pregnancy at which the accustomed death of the fetus occurred. CHAPTER VI. The Physiology of Pregnancy. The whole organism shows alterations in sympathy with the development of the pregnant uterus ; but, as might be expected, these alterations are most striking in the genital region. The uterus shows an extraordinary developmental change in all its constituent parts. The muscle-fibers hypertrophy until they are eleven times as long and five times as broad as those of the non-pregnant uterus. A multiplication of the fibers, a true hyperplasia, has not been demonstrated. The connective tissue increases markedly, sending in newly developed fibers between the muscle-bundles and increasing in bulk by a serous infiltra- tion. The peritoneal covering of the womb shows a true hyper- plasia to enable it to keep pace with the growth of the uterus. The development of new cells is not entirely uniform, so that the peritoneum covering the womb varies in thickness. The membrane is quite firmly adherent to the uterus except over the lower uterine segment, where it is readily stripped off. The blood-vessels develop rapidly. The arteries are vastly increased in caliber and length and become extremely tortuous. The uterine artery sends a large branch to the upper margin of the lower uterine segment, and numerous smaller branches penetrate the uterine wall, where in some situations they communicate directly with the veins. At the placental site the arteries termi- nate in the curling arteries of the uterine decidua, emptying directly into the placental lacunae, where the blood bathes the placental villi projecting into them. The uterine body may be regarded from one point of view as a huge venous plexus. The walls of the veins are reduced to the intima, and running between 182 PREGNANCY. muscle-bundles, the contraction of the uterine muscle after labor obliterates them. The nerves are increased more by a development of the con- nective tissue about them (neurilemma) than by an increase of the nerve-elements ; but there is some new development of nerve- tissue, the filaments extending toward the uterine cavity. The main supply of the womb is from the sympathetic system. The ganglia in the genital region show hypertrophy, especially the cervical. The lymphatics are increased by hypertrophy and by hyper- plasia. The lymph-spaces below the uterine mucous membrane Fig- I23-—A, Isolated muscle-elements of the non-pregnant uterus ; B, cells from the organ shortly after delivery (Sappey). are enormously enlarged, and the lymph-tubes leading from them through the uterine muscles reach the size of a goose-quill. These lymph-tubes or vessels are collected in a plexus beneath the peritoneum. This arrangement and development of the lymphatics explain in part the remarkably rapid absorption of a great part of the uterus after labor, and account for the ready absorption of in- fectious material ; with peritonitis oftentimes as an early symptom, from the easy communication between the submucous and the subperitoneal lymph-spaces. Anatomy of the Uterus at Full Term. —The muscle-fibers of the non-pregnant uterus have a very irregular arrangement. In THE PHYSLOLOGY OF PREGNANCY. 183 the pregnant womb late in gestation three layers may be distin- guished : An outer, a middle, and an internal layer. The outer is continuous with the muscular fibers in the round ligaments and tubes, and is mainly longitudinal in arrangement. The middle layer is composed of bundles which pass from their peritoneal attachment obliquely downward and inward to be attached to the submucous tissue. Above the "contraction ring," or "ring of Bandl,"—the upper boundary of the lower uterine segment,—the oblique arrangement is less marked, wrhile below it is more pronounced. The internal layer is thin and poorly developed, 1 1 -r r Limit of DfnclMll Retraction-ring. except around the orifices of the womb. Its arrangement is chiefly circular, and it is most strongly developed at the open- ings of the tubes and at the in- ternal os. Changes in Volume, Capacity, and Weight.—Before impregna- tion the length of the uterine cavity is about 2 y2 inches ; at term it is increased to 12 inches, while its breadth is 9 inches and its depth 8 inches. The capacity changes from little more than 1 cubic inch to more than 400 cubic inches, and its weight in- creases from about 1 ounce to the neighborhood of 2 pounds. Changes in Form, Position, Di= rection, and Topographical Rela= tions.—At first the uterus is changed from a flattened, pyri- form body to a spherical or fig- shape, and, after the fourth month, to an ovoid. During the early months the position of the uterus is altered by its descent into the pelvic cavity, as a result of its increased weight. After the third month it rises steadily until the fundus reaches the epigastrium in the ninth month, but before term (four weeks in primiparae, ten days or one week in Internal os. Vagina Fig. 124.—Section of the wall of the pregnant uterus. The difference in texture between cervix and lower uterine segment, according to Hofmeier, is clearly shown, as well as the loose- meshed and close-meshed muscle- layers of the upper and lower uterine segments (Hofmeier). 184 PREGNANCY. multipara) the fundus sinks again, as the presenting part and lower uterine segment become engaged in the pelvic cavity. This phe- nomenon is explained by contraction of the overstretched ab- dominal walls and a consequent diminution in the area of intra- abdominal space, the uterus and its contents being displaced in the direction of least resistance, namely, downward through the superior strait, into the pelvic cavity. During the first three months the womb exhibits a sharp anteflexion, due to the in- creased weight of the body and the decreased tonicity of the lower uterine segment. Fig. 125.—The relation of the pregnant uterus at term to the intestines. After the third month, as the womb rises into the abdominal cavity, the laxity of the abdominal wall allows it to fall some- what forward, so that the anteflexion persists to a certain degree, but diminishes as the womb increases in length. In consequence of the position of the sigmoid flexure and rectum, almost always distended in constipated women, the uterus is tilted to the right side and is rotated on its longitudinal axis, so that the anterior surface looks toward the right, and the left broad ligament, with its attached structures, becomes more accessible to abdominal pal- THE PHYSIOLOGY OF PREGNANCY. 185 pation. The topographical relation of the intestines is impor- tant. They should always be situated above and behind the uterus, thus giving no resonance over the anterior abdominal wall on percussion ; but in rare cases of excessive tympany the Fig. 126.—The cervix in the fifth month of pregnancy (Leopold). V ,V._ ^j;—-«lv s- 0•*•*.< & >1 'M-i ! Fig. 127.—The cervix in the seventh month of pregnancy (Leopold). intestines prolapse in front of the womb, giving a resonant note on percussion all over the abdomen. A woman in my service in the Philadelphia Hospital was told on this account by the resident physi- cian that she was not pregnant, but she gave birth to a full-term child a few days later. Alterations in the Cer= vix.—The cervix is soft- ened and somewhat hy- pertrophied during the first four months, but its canal is undilated until the first stage of labor begins. Through- out the whole duration of pregnancy the canal remains unaltered in length. The mucous glands of the cervix secrete a peculiarly Fig. 128. -The cervix in the ninth month of pregnancy (Leopold). 186 PREGNANCY. tough mucus (mucous plug), which stops up the cervix like a cork during pregnancy. Alterations in Vagina and Vulva.—The changes in these regions are due mainly to an increased blood-supply, as noticed in enumerating the signs of pregnancy. Thus are explained the darkened color of the mucous membrane, the increased secretion, and the development in the muscular and mucous walls. The pelvic joints show a loosening of their connections and an increase in the motility of the pelvic bones, with the purpose of facilitating the passage of the fetal body in labor. The abdominal walls show a stretching of all the constitu- ent parts, with the formation of white, bluish, or reddish strise, due to thinning and disorder of the arrangement of the connec- tive-tissue layer of the skin, with atrophic changes. If this stretching of the skin is painful, partial relief is afforded by inunc- tions with cacao-butter, sweet-oil, or vaselin, to increase its plia- bility. The recti muscles separate as the abdomen becomes more and more distended, and pain may be experienced in the attach- ments of the abdominal muscles to the ribs and to the pelvis. There is a marked deposition of fat in the abdominal walls, sometimes as early as the second month, giving the woman a much fuller figure than could be accounted for by the size of the pregnant uterus.x The Bladder and Rectum.—The growth of the pregnant uterus mechanically interferes with the functions of these viscera, hence irritability of the bladder and constipation are the rule in pregnancy. By mechanical interference with the blood-supply, in addition to the congestion of the pelvis, hemorrhoids of the anus and rectum are common. Varices of the bladder, too, may develop, rarely giving rise to hematuria. CHANGES IN THE SEVERAL SYSTEMS OF THE BODY. GENERAL CHANGES. Circulatory System.—The whole quantity of the blood is increased, but not equally in all its constituent parts. The water and fibrin-making elements are most markedly increased ; the red corpuscles and hemoglobin, while actually somewhat in- creased, are relatively diminished ; the white corpuscles are actu- ally and relatively increased. The left side of the heart is said to hypertrophy, so that its walls are increased in thickness about twenty-five per cent., and the weight of the heart increases appreciably; but Gerhardt 1 The reader will probably remember how Roderick Random's Narcissa "had grown qualmish of late and remarkably round in the waist," when she was probably not more than six or eight weeks pregnant. CHANGES IN THE SEVERAL SYSTEMS OF THE BODY. 187 showed that the supposed enlargement of cardiac dullness on percussion was due to displacement of the heart, and Lohlein was unable to find an increase in the weight of the heart in a number of specimens.1 In consequence, it is claimed, of unusual determination of blood to the brain there are developed, in about one-half of the cases of pregnane}-, on the inner table of the skull, new formations of bone, called by Rokitansky osteophytes. It has been claimed that the pulse of a pregnant woman does not undergo the usual acceleration when the patient changes from a horizontal to an erect posture (Jorisenne's sign of pregnancy). This symptom, however, is of no value. The heart of the preg- nant woman shares in the nervous irritability of the whole organ- ism, and she is liable to "cardiac nerve-storms." The urine in pregnancy is increased in quantity, becomes more watery, has a specific gravity of about 1014 ; but the quan- tity of urea excreted is normal. The " kyeste'inic pellicle," which develops on the urine of pregnant women when allowed to stand for a while, is no longer regarded as of diagnostic value. The digestive tract is almost constantly disturbed in preg- nancy. Nausea and vomiting, beginning at about the sixth week and lasting to the third month, are so common as to be diagnostic signs of great value. These manifestations are usually worse on first arising from bed in the morning (morning sickness), and are to be explained by a reflex irritation of the sympathetic nervous system by the expansion of the uterus. The assumption of the erect position suddenly increases the congestion of the uterus and aggravates its irritability. Torpor of the intestines and of the rectum, induced by pressure of the growing womb on the abdominal contents, is the cause ordinarily of obstinate con- stipation. If woman may be defined as a " constipated biped," the pregnant woman is "a more constipated biped," and the puerperal woman, for reasons hereafter to be described, " a most constipated biped." The nervous system shows remarkable changes in conse- quence of pregnancy. These are alterations in disposition, perversions of taste (longings), a disposition to melancholia, and possibly severe neuralgias, especially of the face and teeth. Changes in weight must be expected in consequence of seven pounds of baby, one pound of liquor amnii, a pound of pla- centa, and two pounds of uterus wrhich are to be found in a preg- nant woman at term, not to mention the increased deposition of fat all over the body and the additional quantity of blood formed in pregnancy. An increase of y^g part of the original body- 1 " Midler's Handbuch," vol. i. i88 PREGNANCY. weight may be expected on the average, according to Gassner. This estimate, however, is not uniformly correct, as exceptions are frequently observed. In a series of cases which I investi- gated in the Maternity Hospital there was an extreme variation of from one to forty pounds in the gain of weight in pregnant women. The changes in the respiratory apparatus are not of great importance. The lungs are shorter but broader, leaving the capacity little altered. Examination of the expired air has shown an increased activity of the lungs in the excretion of the products of life processes, the lungs sharing the work of the other excrementory organs in disposing of the surplus effete products from mother and fetus. Prolongation of Pregnancy and Missed Labor.—Pregnancy is quite frequently prolonged beyond 280 days. I have many times seen a pregnancy last 310 days.1 It may have a duration of 320 days, or 40 days above the average ; and there are cases on record, though somewhat apocryphal, of even longer duration. In about six per cent, of pregnant women the duration of preg- nancy is over 300 days. The result in labor may be most serious in consequence of overgrowth of the fetus. Some of the worst cases of obstructed labor I have ever seen were due to this cause. It is a rule of my practice, therefore, never to allow any woman to go more than two weeks beyond term. Missed labor means the occurrence of a few labor-pains at term, their subsidence, and the retention of the product of con- ception /// utero ior a varying period thereafter. " Missed labor" usually turns out to be extra-uterine pregnancy or pregnancy in one horn of a uterus bicornis ; it may be due, however, to obstructed cervix from cancer, conglutination, a tumor, or exces- sive rigidity. The Management of Normal Pregnancy.—Too frequently the physician gives his pregnant patients no attention, assuming that their condition is a physiological one and that they may be regarded as individuals in good health till they fall in labor and summon the physician to attend them. No view could be more erroneous. The border-line between health and disease is so easily passed in pregnancy that the most serious complications may acquire irresistible headway, undetected, unless the patient is advised carefully and constantly watched during the whole of her gestation. Constipation must be corrected. The urine should be examined once in two weeks during the whole dura- tion of pregnancy until the last month, when the examinations 1 A very extensive bibliography of prolonged pregnancy may be found in the ten volumes of the " Jahresbericht iiber d. Fortschr. a. d. Gebiet. d. Gyn. u. Geburtsh." THE DIAGNOSIS OF PREGNANCY. 189 should be made once a week. The patient should be cautioned to reduce her physical exercise below what she is ordinarily accustomed to, and always to stop short of fatigue, avoiding par- ticularly any sudden jolt or jar or any of the movements that strain the abdomen and increase intra-abdominal pressure, such as lifting a weight down from a height (a closet-shelf) or lifting up a heavy weight. The diet must be regulated so that the kidneys shall not be overtaxed. Meat should be eaten but once a day, and a raven- ous appetite, which sometimes appears in pregnancy, must not be fully gratified. I have seen a pregnant woman's kidneys break down in consequence of a Thanksgiving dinner. The child's life was destroyed and the woman made a very nar- row escape, eclampsia being averted only by vigorous treat- ment. An excessive amount of food in pregnancy has another disadvantage. I delivered, in consultation, a primipara, with the utmost difficulty, of a child weighing 11 3^ pounds. The phy- sician had recommended her to drink two quarts of milk a day between meals throughout pregnancy. She was easily delivered a second time of a child weighing 7 y2 pounds after a regulated diet in pregnancy. The patient must be cautioned against exposure to cold and wet ; one such exposure or sitting in a draft after being overheated has frequently determined an acute nephritis, with fatal results to both mother and child. Tonic remedies are some- times called for if the hydremia of pregnancy is exaggerated or if there is not a normal gain in weight. The syrup of the lacto- phosphate of lime is administered with advantage to stay the ravages in the teeth of pregnant women, and strychnin in the later months is claimed to influence labor beneficially and to favor puerperal involution. The nipples should be prepared for their future function by application of glycerol of tannin and water, equal parts, twice a day for four weeks preceding confine- ment. THE DIAGNOSIS OF PREGNANCY. It might seem to the inexperienced that the recognition of pregnancy is an easy matter. Every physician has ample op- portunity to familiarize himself with its signs, and these signs are gross and easily appreciable, at least in the later months. But in reality there is scarcely a common condition in the human body that is so often overlooked or mistaken for something else, and there are no mistakes in diagnosis so detrimental to a physician's reputation, or sometimes so fatal to the patient, as mistakes in the 190 PREGNANCY. diagnosis of pregnancy. To cite as illustrations only cases of which the author has personal knowledge: A physician per- formed what he believed would be a Cesarean section on a rachitic dwarf, thought to be in labor at term. Several other physicians examined the patient before the operation, and all agreed that she was pregnant and in labor. There was nothing in her abdomen but the usual contents and a huge mass of omental fat. It was a case of pseudocyesis. A gynecologist on the staff of a large hospital has twice operated for fibroid tumors of the womb, and only after the am- putation of the uterus found that it was pregnant, and not the seat of a fibroid tumor at all. Both patients died. An obstetrician on the staff of another hospital attempted to induce labor on a patient in the last stages of phthisis who evi- dently would not live till term. The bougie, however, could not be inserted more than 2 ^ inches. On the following day the patient died. In anticipation of her death, all the arrangements had been made for a postmortem Cesarean section the moment she expired. The operation was performed before a large audi- ence. The abdominal tumor proved to be an ovarian cyst, and not a pregnant uterus. A woman was admitted to the medical wards of a hospital with what was thought to be a cancer of the stomach. Gastric lavage was energetically carried out with unlooked-for success ; in several weeks all gastric symptoms ceased. At the same time an abdominal tumor wras observed, which, on examination, proved to be a pregnant uterus. The patient had been suffering from the vomiting of pregnancy. A young unmarried girl of good family was about to be operated upon for a splenic tumor when it was discovered that the tumor was a pregnant womb much displaced and distorted by tight lacing. A woman was sent to the author from a distant State for operation on account of a large fibroid tumor of the uterus ; she was pregnant with twins, had no fibroid, and was easily deliv- ered. A young girl was referred to the author for the removal of an ovarian cyst; her physician stated that the eminent re- spectability of the girl precluded the idea of pregnancy. Re- spectability had proved no bar to the penetration of a sperma- tozoon. She was pregnant at term. The author on one occasion examined in consultation a woman who was supposed to be pregnant twelve months. Her physician and nurse had been engaged and every other prepara- tion was made for the expected childbirth. The husband was obliged meanwhile to sell his house, but a clause was inserted in the deed that possession was not to be given the new owner till the vendor's wife should be delivered. An examination showed THE DIAGNOSIS OF PREGNANCY. 191 the womb to be unimpregnated. There had been very scanty but regular menstruation, marked enlargement of the abdomen due to omental and abdominal fat, and many of the subjective signs of pregnancy. It was a typical case of pseudocyesis. Instances of mistakes in the diagnosis of pregnancy could be multiplied to a tedious length from the author's own experience ; but the cases cited should be sufficient to demonstrate the liability to error. If a physician would avoid such mistakes, he should cultivate the habit of making a routine, methodical, careful ex- amination of every patient who may be pregnant, neglecting none of the important subjective and objective signs, and looking for them in a regular order, which will preclude negligence or omission. The signs of pregnancy, in accordance with the laws of symptomatology in general, are divided into the subjective and the objective signs ; the former being the symptoms experienced by the patient herself, and the latter presenting themselves to the senses of the examining physician. Subjective Signs.—Arranged as far as possible in the order of their relative importance, they are : Cessation of Menstruation.—This is the most valuable of the subjective signs. It is always inquired for by the physician, and is usually first mentioned by the patient if she is acting in good faith ; but it is by no means a sure indication of pregnancy, and it is not available if a woman conceives during the amenorrhea of lactation, before menstruation is established, or after the meno- pause. Amenorrhea may depend upon many other conditions, such as change of climate, mental and nervous disorders, peri- uterine inflammations, the growth of pelvic and abdominal tumors, acquired atresia of the cervix, anemia, chlorosis, and phthisis. The fear of impregnation in the unmarried, the ex- pectation of it in newly married women, the intense longing for maternity in some sterile women, and a belief in the existence of pregnancy in some cases of pseudocyesis are mental states that have been known to suspend the function. On the con- trary, menstruation, or a more or less periodical bloody discharge, persists during the first three months of pregnancy in a very small minority of cases. Rarely the flow may recur regularly, though scantily, throughout the first half of gestation. There may, therefore, be cessation of menstruation without pregnancy, or persistence of menstruation in pregnancy. The patient's statements, moreover, are not always to be depended upon. She may deny the cessation of menstruation ; she may even stain her napkins regularly with the blood of animals to deceive her 192 PREGNANCY. family; x or, in cases of spurious pregnancy, she may assert that the flow has stopped, when in reality it persists, although some- times so scantily as scarcely to attract her attention. Nausea and Vomiting.—This symptom depends upon the dis- tention of the gravid uterus in the beginning of pregnancy, and usually first manifests itself at the sixth or seventh week. It appears so constantly and to such a marked degree in many patients as to be regarded by them as a certain indication of their condition, and in such cases considerable value may be attached to the patient's statement by the examining physician. I have had patients in whom nausea and vomiting appeared on the day following the fruitful coitus, though they did not sus- pect that they were pregnant.2 But any irritation of the pelvic organs may produce the same result, as displacement or inflam- mation of the uterus, congestion or inflammation of the tubes and ovaries, and the growth of pelvic tumors. The stomach itself may be disordered and the vomiting may not be reflex. On the other hand, this symptom is entirely absent in a consid- erable proportion of pregnant women. Some degree of saliva- tion is usually associated with the nausea and vomiting of pregnancy. In rare cases the ptyalism is the predominant phenomenon. Changes in the Size and Shape of the Abdomen.—It has been asserted that at first there is a hypogastric flattening, due to the sinking of the uterus during the first few weeks of pregnancy on account of its increased weight, but I have never found a woman who noticed this change in her shape. The descent of the womb, however, is associated with irritability of the bladder, and of this symptom the patient will often complain. Later, the abdomen is steadily and progressively enlarged until the last month, when the subsidence of the uterus diminishes the dis- tention of the abdomen, and at the same time gives rise to symptoms of pressure on the other pelvic organs and on the blood-vessels and nerves of the pelvis and lower extremities. There are many other causes, however, for abdominal en- largement besides pregnancy, as a deposition of fat in the omen- 1 I was called to empty the uterus of a young girl, eighteen years of age, suffering from an incomplete abortion criminally induced. To this day her family have no suspicion of what really occurred. The girl had put her napkins in the wash at the periods when she should have menstruated, stained with beef's blood obtained from an abattoir. 2 A gentleman asked me to attend his wife in confinement, between eight and nine months later. When asked how he could suspect pregnancy so early, he replied that after breakfast that morning he had been seized with nausea and vom- iting,—an infallible sign on several previous occasions that his wife had become pregnant. THE DIAGNOSIS OF PREGNANCY. 193 turn and abdominal walls, accumulation of fluid within the abdominal cavity, and the various abdominal and pelvic tumors. On the other hand, the enlargement of the abdomen due to advanced pregnancy may actually escape the observation of the patient herself,1 or may be so well concealed by tight lacing as to be almost imperceptible. Changes Due to Increased Blood-supply to the Genitalia and Breasts.—Owing to the congestion of the parts there is a tingling sensation and a feeling of fullness in the breasts, with the appearance in them of colostrum. A sense of heat and con- gestion may be experienced in the pelvic organs, and there is very likely to be some leukorrhea. These symptoms are obvi- ously of little value. Quickening.—This is the name given to the sensation experi- enced by the mother as the result of fetal movements, which, as a rule, become powerful enough to be appreciated by her midway between the fourth and fifth month of gestation. They may be felt as early as the third month or not until the last month of pregnancy, and some women do not experience them at all or overlook their presence. They are not felt, of course, when the child is dead. The woman interested to conceal her condition will deny the occurrence of fetal movements ; and other women, deceived by the action of the intestines, may honestly believe that they feel a child in utero. Alterations in the Nervous System.—The nervous system is almost uniformly disordered in pregnancy. Characteristic nerv- ous disturbances will be described by the vast majority of pregnant women. These are changes in disposition, mental peculiarities, and perversions of tastes. There is very often also a sense of dizziness, a disposition to faint, and actual syncope. For example, a woman usually amiable in disposition becomes irritable, sullen, or morose ; a phlegmatic, placid individual may become unusually vivacious, and the strangest fancies for eating unusual and disgusting articles may appear. In some women, however, these nervous symptoms are entirely wanting, or so slight as to escape their own observation. There are many other causes besides for changes in a woman's nervous organiza- tion, such as nervous strain and hysteria. Objective Signs.—These symptoms are obviously of much more importance and value. They present themselves to the physician's senses of sight, touch, and hearing. 1 I have seen an intelligent married woman, the mother of several children, between seven and eight months pregnant, unconscious of the abdominal enlarge- ment and entirely ignorant of her condition. 13 194 PREGNANCY. Signs of Pregnancy Ascertained by Inspection.—The Woman's Face.—Splotches of irregular pigmentation, called chloasmata, appear on the brow and cheeks, and there are often dark rings under the eyes. Moreover, as a physician questions a patient in regard to her condition, he may observe, perhaps, evidences of truth or untruth in her countenance as she replies ; though the pregnant woman determined to conceal her condition is often an actress of consummate ability. Breasts.—The mammary glands are enlarged and obviously distended; they stand out prominently from the chest, and tortuous veins are seen plainly under the skin. As pregnancy advances, striae may be observed in the skin of the breasts. The nipples are more prominent than in the non-pregnant Fig. 129.—Showing the prominence of the breasts, the striae upon them, and the pigmented areola. condition. Around the nipples there is a deepening in the color of the pigmentation areola, and a widening of the pigmented area by the development of the so-called secondary areola of pregnancy (Fig. 129). In the pigmented area may be observed the seba- ceous glands named after Montgomery, who first directed atten- tion to their presence. They are often as large as buckshot in the pregnant woman, and project quite conspicuously from the surface of the skin. They are frequently, however, entirely absent. If the breast is seized at its base and compressed toward the nipple between the outspread thumb and four fingers of one hand, a drop or two of turbid fluid (colostrum) may be seen to collect upon the surface of the nipple. Plate 5. ^'(-# ; Figure I.—Breast of a non pregnant woman of the blonde type. Figures 2 and 4.—Breasts of pregnant women of the brunet type. Figure 3.—Breast of a pregnant woman, a blonde. Painted from nature, showing the irregular distribution of Montgomery's glands and comparative distention of the veins in the pregnant and the non-pregnant woman when the breasts are allowed to hang unsupported by the clothing for a few minutes. THE DIAGNOSIS OF PREGNANCY. 195 All these mammary symptoms, however, may be observed independently of pregnancy, and rarely may be absent altogether in that condition. The mammary glands of some women dis- play a marked physiological activity at each menstrual period, even to profuse milk-secretion, and it is by no means rare to observe all the mammary signs of pregnancy accompanying the growth of a pelvic or abdominal tumor, especially one of the womb itself. Moreover, the woman may be impregnated during lactation, or some activity of the glands may persist long after a previous labor. Under such circumstances the mammary signs of pregnancy are valueless. Fig. 130. —Normal pregnancy at Fig. 131. —Uterus deformed by scoliosis term. of the spine (paralytic). The Abdomen.—As pregnancy advances the abdomen be- comes more and more prominent; obviously containing a tumor pyriform in shape, with the narrow end downward, situated in the median line, and spreading with approximate equality to either side. There are other abdominal tumors, however, which have Fig.132. —Spherical uterusofhydramnios. Fig.133.—Fat, tympany, and anteversion. Fig. 134-—Six months pregnant, Fig. 135.—Breech presentation, at with a large fibroid tumor. Seen in term. consultation with Dr. R. H. Hamill. Fig. 136.—Breech presentation—head under ribs. Multigravida, at term. Fig- 137-—The pendulous belly of rachitis. Pregnant at term. Fig. 138.—A, Four months pregnant; B, five months pregnant. Fig. 139.—A, Six months pregnant; B, seven months pregnant. Fig. 140.—Twins. Fig. 141.—Pregnant uterus distorted by rachitic ■ kyphoscoliosis. THE DIAGNOSIS OF PREGNANCY. 199 the same shape as a pregnant womb, and the gravid uterus is often anomalous in form. In twin pregnancies, in breech pre- sentations, in transverse positions, in some deformities of the fetus, in some varieties of contracted pelvis, and in the presence of other tumors coincident with pregnancy, the pregnant uterus is altered in shape. Displacements of the uterus may also give it an unusual appearance in pregnancy. Fig. 142.—Linea nigra, well marked above and below the umbilicus. Exaggera- tion of the pigmentation around the nipples. Half-breed Indian squaw. (University Maternity.) The umbilicus at the sixth month is level with the surface of the abdomen, and, later, pouts. It is surrounded by a ring of pig- mentation, which extends above as high as the fundus uteri, and below along the linea alba, which in pregnancy becomes the linea nigra (Figs. 142, 143). By a disorder in the arrangement of the fibers in the cutis there appear to be cracks in the skin of the ab- domen, especially toward the flanks, over the surface of the iliac bones, and down upon the outer aspects of the thighs. If the 200 PREGNANCY. pregnancy is far advanced, and if the fetus is alive, fetal movements may be plainly seen. These are of two characters : there is a heaving movement of the fetal back, and a sharp, sudden tap of the fetal extremities. Fetal movements, if unmistakable, are positive signs of pregnancy, but they have been simulated by twitching of the abdominal muscles and by the vermiform movements of the intestines. Vagina and Vulva.—The mucous membrane of the vestibule and of the vagina assumes a purple hue in the later months of gestation, which has been aptly compared in color to the lees of wine. The discoloration of the mucous membrane of the vagina and of the vaginal introitus is usually most marked upon the inner surface of the labia majora and upon the fold of vagi- nal mucous membrane on the anterior wall that comes into view when the labia are separated (Plate 6, Figs. 3 and 4). It is occasionally confined to the fossa navicularis (Plate 6, Fig. 2), or to the deeper portions of the vaginal rugae. The pigmentation of the mucous mem- brane begins in some cases as early as the fourth week. Chadwick x in 281 cases found it diagnostic in thir- teen per cent, at the end of the second month ; in forty-six per cent, at the end of the third month. The sign is by no means an infallible one. It is often absent altogether in early pregnancy, and I have frequently noted its entire absence at term. There are, more- over, other conditions than pregnancy erethism, pelvic tumors, intense con- Even if the blue discoloration is not visible, one may always notice in the later months a transforma- tion of the pink color of the mucous membrane of the introitus into a bright scarlet. Signs Appreciated by the Sense of Touch.—Abdominal Palpa- tion.—By this method are learned the size and shape of the uterus, and after the sixth month the fetal back, head, and ex- tremities may be felt.2 By placing the outstretched hand over the fundus, the intermittent uterine contractions, to which atten- Fig. 143.—Linea nigra, visible only below the umbilicus. which can give rise to it gestion of the pelvis. 1 "Tr. Am. Gyn. Soc," vol. ii, 1886, p. 399. Boston Med. and Surg. Jour.," vol. cxvii, No. 3, \\ See also Farlow, "The 2 For a more extended description of abdominal palpation see "Mechanism of Labor. ' PLATE 6. Figure I.—Normal color of the vaginal mucous membrane in a woman not pregnant (blonde). Figure 2.—Color of vaginal mucous membrane and introitus in a brunet. Figure 3.—Color of vaginal mucous membrane and introitus in a negress. Figure 4.—Color of the vaginal mucous membrane in a light blonde. Note the scarlet color of the mucous membrane of the introitus, in addition to the blue discoloration. The former is always present, even if the latter is absent. The complexion of the individual does not necessarily influence the depth of the blue discoloration. In figure 2, a dark brunet, it is lighter than in figure 4, a light blonde. THE DIAGNOSIS OF PREGNANCY. 201 tion was first called by Braxton-Hicks, are perceived. At inter- vals of about ten minutes throughout gestation the whole uterine muscle contracts as it does in a labor-pain, the uterus hardening under the hand so that its contents can no longer be easily ap- preciated. This sign is available at the end of the third month, and although it may be produced by any tumor distending the uterine walls, as a collection of blood, an intra-uterine polyp, or a soft myoma, it is almost a positive sign. It may, however, occur sympathetically in extra-uterine pregnancy, and it is said that the contractions of an overdistended bladder may be mistaken for the rhythmical contractions of the gravid womb. Finally, fetal movements may be felt as pregnancy advances. The sensation conveyed to the hand is usually that of a finger-tap under a blanket. The other fetal movement, however,—a heaving action of the back,—is equally characteristic. This symptom is natur- ally a positive sign of gestation. Fetal movements may be ex- cited by placing a cold hand suddenly upon the woman's abdo- men, or by pushing the fetus about in the womb. Combined Examination.—The cervix in pregnancy is notably softened as a result of the increased blood-supply and an edema of the part. Goodell is the author of the ready rule of practice, that when the cervix is as hard as one's nose pregnancy does not exist, but when it is as soft as one's lips pregnancy is likely. Rapidly growing myomata, however, acute metritis, and hematometra can produce as soft a cervix as is felt in pregnancy, and should the neck of the pregnant womb be the seat of an old injury, with dense and extensive cicatrices, or should the cervix be cancerous or syphilitic, there may be no appreciable soften- ing in pregnancy. Hegar's sign of early pregnancy depends upon a marked softening of the lower uterine segment, by which it appears on combined examination that the body and the cervix are discon- nected, though on closer examination, the outer edges of the lower uterine segment appearing a little firmer than the inter- mediate portions, it seems that the cervix is joined to the body of the womb by two indistinctly appreciable longitudinal bands. The best method to elicit this symptom is to insert the forefinger far into the rectum and the thumb into the vagina, while the womb is pressed down by the other hand applied upon the abdominal wall. It is not always necessary, however, to make a rectal exami- nation. By combined pressure, either through the anterior or posterior vaginal walls and the abdominal wall above, the finger- tips can be brought into relationship with the lower uterine segment. Hegar's sign is by no means a certain one. It is not 202 PREGNANCY. invariably appreciable in pregnancy, and it might be felt in a non- pregnant uterus, softened by congestion, inflammation, or the presence in it of fluid. Enlargement of the uterus, with a change in its shape and consistency, is one of the most important symptoms in the early weeks. The womb becomes more spherical in outline, softer in consistency, and distinctly enlarged, while there is usually a marked anteflexion in consequence of the weight of the body of the uterus and of the softened lower uterine segment. By plac- ing one hand over the fundus and the fingers of the other in the vagina an impulse may be conveyed by the latter to the uterine contents, which are displaced upward, communicating an impact Fig. 144.—The shape and size of the Fig. 145.—The shape and size of the uterus non-pregnant uterus. altered by early pregnancy (Budin). to the external hand and falling again into its original situation; a tap is felt upon the uterine and vaginal walls by the fingers applied internally. To this symptom the name " ballottement" has been given, and to the experienced examiner it is a positive sign of the condition, though a small cystic tumor of the ovary with a long pedicle may simulate it closely, and the same symp- tom might, of course, be elicited in an advanced extra-uterine gestation. Symptoms Ascertained by Auscultation. — Mayor, a surgeon of Geneva, was the first to discover, in 1818, that the fetal heart- THE DIAGNOSIS OF PREGNANCY. 203 sounds could be heard by applying the ear to the abdomen of a pregnant woman when the child is alive. Three years later this valuable symptom of pregnancy was described in an article by Kergaradec presented to the French Academy. It is a symptom available as early as the fifth month, although its value increases with the advance of pregnancy. The fetal heart beats at the rate of about 120 to 160 a minute, and the sound has aptly been compared to the ticking of a watch under a pillow. The beat is a double one, as in the adult heart. The area of the maximum intensity of the fetal heart-sounds in anterior positions of the vertex is about an inch below the umbilicus to the left or the right of the median line, or in posterior positions of the vertex in the flanks on a line passing through or somewhat below the umbilicus. In breech presentations the maximum intensity is usually above the umbilicus, and in transverse positions the pulsations may be heard low upon the abdominal wall near the symphysis. Occasionally they can best be heard over the fundus uteri, the sound being transmitted by the fetal spine. Their absence by no means excludes the existence of pregnancy. They are not heard if the child is dead, if there is an abnormal quantity of liquor amnii in the uterus, if the abdominal walls are excessively thick, or in certain positions of the fetus. On the other hand, the beat of the maternal aorta has often been mistaken for the fetal heart, though this error is easily avoidable if one feels the maternal pulse as he listens for the fetal heart- sounds, and remembers that the aortic impulse is a single, the fetal heart-beat a double, sound. Another sign of pregnancy appealing to one's sense of hearing is dullness on percussion down the median line of the abdomen and for some distance on either side. It is possible, however, in very rare cases of excessive tympanitic distention of the intestines, to obtain a tympanitic note all over the anterior wall of the abdomen, though the woman may be pregnant at term. In such cases the distended intestines have surrounded the womb and cover its anterior surface. The uterine bruit, synchronous with the maternal heart-beat, is often heard in pregnancy, but it may be heard also in large uterine myomata and in ovarian cysts. It can usually best be distinguished on the left lateral aspect of the pregnant womb, as it is caused by some obstruction to the blood flowing through the uterine artery. The funic souffle, present in about fifteen per cent, of cases, if heard, is diagnostic of pregnancy. It is a high- pitched, whistling, or hissing murmur, synchronous with the fetal heart-beat. It is caused by some obstruction to the flow of blood through the umbilical arteries. 204 PREGNANCY. The fetal movements may be heard, in auscultation of the abdomen,1 as a dull thud against the abdominal walls. It was while listening for the fetal movements that Mayor first heard the fetal heart-sounds. In auscultating the abdomen of a woman for the signs of pregnancy, the examining physician should first use his ear directly applied to the abdomen with nothing but a thin towel intervening. A stethoscope should also be employed, however, in doubtful cases and in situations where the ear can not be con- veniently applied. A positive diagnosis of pregnancy before the sixth week is impossible, and the diagnosis may be only presumptive until the fetal heart-sounds can be heard and fetal movements are felt. Clinically, the signs of pregnancy may be divided into those of three trimesters, or periods of three months each. It is useless for the practitioner to look for certain signs in one trimester only available in the next. First trimester.—In this period the follow- ing signs of pregnancy are available : Enlargement, change in shape and bogginess of the uterine body, soft cervix, enlargement and functional activity of the breasts, Hegar's sign, cessation of menstruation, nausea, and vomiting. The second trimester will exhibit, in addition to the above, enlargement of the abdomen, intermittent contractions of the uterus, feeble fetal movements, ballottement, fetal heart-sounds, and blue discoloration of the vaginal mucous membrane. In the third trimester all the symp- toms just enumerated become more easily appreciable. The outlines of the fetal body are distinguishable by abdominal palpa- tion, and the presenting part may be felt through the roof of the vaginal vault. Estimation of the Duration of Pregnancy.—If the date of the fruitful coitus can be ascertained, labor may be expected, on the average, two hundred and seventy-one days 2 later. Ordi- narily, the history of cessation of menstruation is depended upon in making an estimate of the probable date of labor. Nagele 3 is the author of the convenient rule for predicting the date of the expected confinement by counting back three months from the first day of the last menstruation and adding seven days. For seven months of the year this method is absolutely correct. In April and September six days, in December and January five days, and in February four days should be added to obtain the date of a period two hundred and eighty days after the first day 1 Discovered by Kergaradec in 1822. 2 Ahlfeld, " Monat. f. Geburtsh.," Bd. xxxiv, p. 208, based on 425 cases. 3 " Lehrbuch der Geburtshulfe." THE DIAGNOSIS OF PREGNANCY. 205 of the last menstruation. It is to be noted, however, that the prediction of the date of labor can never be more than approxi- mately accurate, as the labor occurs only exceptionally two hundred and eighty days from the first day of the last menstrual period.x The variation of a few days either way is the rule, and prolongation of pregnancy, even to a month or more, is by no means excessively rare. Lowenhardt has proposed multi- plying by ten the number of days between the last normal menstruation and the one preceding, thus predicting, with a greater accuracy than is otherwise possible, the probable dura- tion of pregnancy. Thus, if the interval is twenty-six instead of twenty-eight days, the pregnancy will last two hundred and sixty days. Lusk says he has seen occasionally a curious con- firmation of Lowenhardt's view, but my own experience would not lead me to prefer this method to Nagele's. If the patient is not menstruating when she conceives, as in lactation, if the his- tory of menstruation is not attainable, or is not to be depended upon, an approximate idea of the date of pregnancy may be gained by noting the height of the fundus. At the fourth month it rises above the pelvic brim ; at the fifth it is midway between the umbilicus and the symphysis ; at the sixth month on a level with the umbilicus ; at seventh month about four fin- gers' breadth above the navel ; at the eighth month about mid- way between the umbilicus and the xiphoid cartilage; at the ninth month the fundus reaches its highest level near the xiphoid cartilage ; during the ninth month the fundus descends again almost to the level at which it was at the eighth month, the pre- senting part having entered the superior strait. The date of quickening is of some value in estimating the duration of preg- nancy. It may be expected in the twentieth week in primigrav- idae, in the twenty-first and twenty-second weeks in multigravidae. But this symptom is exceptionally observed as early as the thirteenth or fifteenth week, and some women do not notice it till the seventh month. Diagnosis of the Life or Death of the Fetus.—The fetal heart-sounds are a most valuable sign of fetal life when they can be heard. Positive knowledge on the part of the patient of fetal movements is also of great value, and if the movements can be felt, seen, or heard by the physician, there is, of course, positive evidence of fetal life. All the signs of pregnancy without fetal heart-sounds or fetal movements usually mean the presence of a dead fetus in utero. The most valuable sign of fetal death in 1 Ahlfeld's statistics, based on 653 labors, show that pregnancy was ended in the thirty-eighth week in 15,93 Per cent., in the thirty-ninth in 27.56 per cent., in the fortieth in 26.19 per cent., and in the forty-first in 10 per cent, of the cases. 206 PREGNANCY. Fig. 146—I, Photograph of a pregnant woman taken three calendar months from the first day of last menstruation; 2, 3, 4, same individual at fourth, fifth, and sixth lunar months. THE DIAGNOSIS OF PREGNANCY 207 Fig- 147-—S> 6, 7, 8, Individual represented in figure 146, photographs taken at the seventh, eighth, ninth, and tenth months. 208 PREGNANCY. pregnancy is the cessation of growth in the abdomen, which is determined by successive weekly measurements of the abdomen with a tape-measure, care being exercised to ascertain on each occasion the maximum girth. If the fetus is alive, there is a steady increase from week to week. If it is dead, there is no increase in the abdominal measurements, and there may be a decrease. For a more extended account of the diagnosis of fetal life and death the student is referred to the section on the diseases and death of the fetus. It is obvious that a diagnosis of life or death of the fetus is often of great importance, as a physician would be inclined to induce labor to evacuate the womb of a dead fetal body if he could be certain that the child had died ; and a knowledge of fetal life or death would influence the treatment of nephritis or of other complicating diseases of gestation. In case of doubt it should be assumed that the fetus is still alive. Diagnosis of the Sex of the Fetus.—It was thought for some time that the diagnosis of fetal sex could be made by listening to the rate of the fetal heart-beat,—a rate of 120 to 140 in the minute indicating the probability of a male fetus, while a quicker heart-beat is indicative of a female child ; but observa- tions conducted by Budin, also those in the Boston Lying-in Hospital, and others made by the author, show that there is such a variability in the fetal heart-rate from time to time that it is impossible to predict by this means the sex of the fetus. Diagnosis of a Prior Pregnancy.—The determination of this point may be of medicolegal importance. A vaginal ex- amination will detect some degree of laceration of the cervix, usually bilateral. The cervix is large and cylindrical. The cervical canal is patulous, usually admitting the first joint of the index finger. There are old scars upon the skin of the ab- domen, pointing to a former distention of the abdominal cavity, and the abdominal walls are more flaccid than in a primigravida or a nulliparous woman. The pelvic floor may be relaxed, and there may possibly be tears of the levator ani muscles. The hymen is not only torn, but is in great part destroyed, the rem- nants forming the carunculse myrtiformes. The vaginal mucous membrane is smooth, and the vulva gapes so that by separation of the labia majora often a great part of the vaginal canal can be brought into view. There is often some degree of cystocele, the anterior vaginal wall bulging downward and forward into the vulvar orifice. The breasts are ill supported and sag down, while upon the skin, especially at the base of the glands, may be seen the white and glistening scars of old striae. THE DIAGNOSIS OF PREGNANCY. 209 Parturition in very rare cases, especially if the child is pre- mature and small, may leave hardly a trace behind it, and the delivery of a submucous fibroid may produce the same lacera- tions of the cervix and pelvic floor that occur in childbirth. Pseudocyesis, or Spurious Pregnancy___In women who ardently desire offspring, in those who fear impregnation, and in individuals who, without longing for or dread of maternity, believe themselves pregnant, the subjective and some of the objective signs of preg- nancy may appear to so striking a degree that the patient herself is com- pletely deceived, and not infrequently her physician shares her belief in the existence of pregnancy. I was once consulted by a prostitute who firmly be- lieved she had been preg- nant for a year, or ever since her occupation had exposed her to the dan- ger of impregnation. The abdomen was distended; the breasts were enlarged and painful, though not se- creting ; menstruation was very scanty and irregular, and the woman asserted that she felt fetal move- ments. The abdominal dis- tention was due to fat and gas. The uterus was un- impregnated. I have fre- quently seen women who put on an excessive amount of abdominal and omental fat as they approach middle age, and who, in consequence of the abdominal enlargement, believe themselves pregnant. Men- struation may be entirely absent or so scanty as scarcely to attract the woman's attention, and all the subjective signs of pregnancy may be accurately described. It often requires in these cases an examination under anesthesia before the unimpregnated condition of the uterus can be detected. Weir Mitchell asserts that once Fig. 148.—Pseudocyesis : Amenorrhea for eight months, but vicarious menstruation from nose every month. The uterus is nor- mal in size, position, movability. The ab- dominal distention is due solely to tympanites and fat. 14 2IO PREGNANCY. these women's minds are disabused of the idea that they are preg- nant, the abdominal enlargement rapidly subsides and all the sub- jective symptoms of pregnancy immediately disappear. I have no doubt of the accuracy of Dr. Mitchell's observation, but I can not confirm his statement because the patient who is assured she is not pregnant disappears from my view. Occasionally it is impossible to convince a woman that she is not pregnant if she has allowed the idea of pregnancy to take entire possession of her mind. There applied for admission on one occasion, at the Maternity Hospital of Philadelphia, a little, wizened old lady with gray hair, who was apparently at least sixty years old. She volunteered the statement that many years before she had subjected herself to the dangers of illegitimate impregnation, and that ever since she had been pregnant. Nothing could convince her of the truth, and she indignantly left the hospital firmly possessed of her monomaniacal idea. The case shown in figure 148 is one of the most curious I have seen. The woman had an attack of pelvic peritonitis just nine months before I first examined her. Her menstruation had been absent ever since, but there had been a vicarious flow regularly from her nose. The abdomen steadily and rapidly enlarged, and the woman was firmly convinced that she was pregnant. With this idea she obtained admission to the maternity wards of the Philadelphia Hospital, having been previously examined by a physician who pronounced her pregnant at term. The abdominal distention was due entirely to tympanites, the result of partial obstruction of the sigmoid flexure, which was involved in the adhesions of the uterine ap- pendages on the left side. CHAPTER VII. The Pathology of the Pregnant Woman. DISEASES OF THE GENITALIA. Displacements of the Pregnant Uterus.—The uterus in pregnancy may be displaced forward, backward, to either side, or downward. It may form part of the sac contents in inguinal and ventral herniae, and it may be twisted upon its pedicle, the cervix. Anteflexion of the Gravid Uterus.—Usually the growth of the uterus upward into the abdominal cavity corrects the anteflexion spontaneously, but if it is bound down by bands of adhesion the result of pelvic inflammation, or the consequence of anterior DISEASES OF THE GENITALIA. 21 I fixation of the uterus by an abdominal or vaginal operation, pain in the uterus and difficulty in urination result, until finally the uterus expels its contents or forces its way up into the abdominal cavity. Several cases have been observed lately in which, after an anterior fixation of the uterus, the uterine cavity enlarged solely by the distention of the posterior uterine wall, the fundus and anterior wall much thickened, remaining at the level of the pelvic brim. Treatment.—Pelvic massage, tampons, and digital pressure upward through the anterior vaginal vault may stretch or break the adhesions and allow the uterus to ascend normally into the abdominal cavity. Late in gestation the whole body of the uterus may fall forward, producing a pendulous abdomen, in consequence of greatly relaxed abdominal walls ; diminution in the length of the abdominal cavity, as in kyphosis ; prevention of the entrance into the pelvis of the presenting part, as in a rachitic pelvis ; or by reason of an exaggerated separation of the recti muscles. This variety of anterior displacement is best treated by an abdominal binder, not tight enough to increase the intra- abdominal pressure injuriously, but firm enough to afford support. Retroflexion or Retroversion.—This displacement is of fre- quent occurrence. It is explained almost invariably by the pre- vious existence of a backward displacement, although an acute backward displacement of the uterus may occur in the first few months of pregnancy from the same causes that determine such an accident at other times. A persistent retrodisplacement of the gravid uterus is more common in contracted than in normal pelves, especially if the promontory is prominent, and the dis- placement is more frequently a retroversion than a retroflexion. Symptoms.—The earliest and most distinctive symptom is dysuria, though there may have been backache, pelvic pain, and a discharge of blood prior to the mechanical obstruction of the neck of the bladder and the urethra. The presence of any of these symptoms indicates an immediate vaginal examination, whereupon the cervix is found just behind and perhaps above the symphysis, and the body of the uterus distends Douglas's pouch, and perhaps pushes the posterior vaginal wall forward and downward to the vulvar orifice. In neglected cases, or if the displacement is not spontaneously corrected, incarceration occurs. By this term is meant the imprisonment of the growing uterus in the pelvic cavity, where growth beyond a certain point is impossible. The bladder and bowels are so compressed that they may become gangrenous, and the pressure to which the uterus is subjected leads to congestion, inflammation, and gan- grene. The symptoms of this condition manifest themselves 212 PREGNANCY. after the third month, often in the fifth, and sometimes as late as the sixth month. They are : Occlusion of the bowel and urethra, with their associated symptoms ; congestion, inflamma- tion, and suppuration of the uterus, which may finally slough with the development of peritonitis, septicemia, or pyemia. Terminations of Retrodisplacements when Artificial Means are Not Employed to Correct the Displacement.—Spontaneous re- position occurs in the majority of cases, though it should not be awaited in practice. It is more likely in retroflexion than in retro- version ;x spontaneous abortion does not occur so frequently as one would expect, on account of the mechanical difficulty of emptying the uterus ; incarceration is the termination which the physician must have in mind as always possible, and against which effective preventive treatment must always be adopted ; expulsion of the uterus from the body as a zuJiole through a rent in the posterior vaginal wall is an effort on the part of nature to correct an impossible condition of affairs, but it can obviously be only partially successful. Rarely the disadvantages and dangers of posterior displacement of the pregnant uterus are overcome by " sacculation of the uterus." In this condition the fundus and posterior wall of the uterus remain deep within the pelvis, while the growing fetal body is accommodated by an enormous distention of the anterior uterine wall. Prognosis.—The outlook is always satisfactory as regards maternal life if appropriate treatment is adopted early. If the condition is overlooked or neglected, death frequently occurs. In fifty-one fatal cases the following, in order of frequency, were the causes of death : Uremia and exhaustion, rupture of the bladder, septicemia, peritonitis from inflammation of the bladder, pyemia, rupture of the peritoneum and of the vagina, errors in treatment, and gangrene of the colon. Treatment.—The appropriate treatment is, of course, replace- ment. If the attempt is made early, manipulation will succeed ; the patient being placed in the lithotomy position, the fundus is pressed upward by two fingers in the posterior vaginal vault in the direction of one or the other sacro-iliac joints to avoid the projecting promontory of the sacrum. Failing in this attempt, the physician should next resort to the knee-chest posture and to a repositor to press upon the fundus. It is always of advan- tage in difficult cases to give an anesthetic. If the knee-chest posture fails, and there is no obstruction from an overfilled bladder, the cervix should next be drawn 1 Even with firm adhesions of long standing binding the uterus firmly backward I have seen spontaneous reposition take place. DISEASES OF THE GENITALLA. 213 downward with a tenaculum, while at the same time pressure is made upward and to one side upon the fundus. If the attempts at reposition succeed, as they always have in my hands, a large- sized pessary or a tampon in the posterior vaginal vault should be applied until the growth of the organ maintains it in the ab- dominal cavity, and its increased size prevents its slipping back under the promontory. The artificial support should be removed midway between the third and fourth months. If the uterus is bound down by strong inflammatory bands, steady and long- continued pressure should be applied by means of large tampons in the posterior vaginal vault, inserted while the patient is in the knee- chest posture, by the aid of a Sims' speculum, and renewed daily. Failing to secure reposition in such a case by this plan abortion should be in- duced, before the symp- toms of incarceration appear. Treatment of Retro- displacement when the Uterus is Incarcerated.— The physician's attention must first be directed to the overfilled bladder. Catheterization is usu- ally easy if a prostatic catheter is employed and if the physician recollects that the lower segment of the bladder as well as the urethra is pressed upon, making of the latter a canal perhaps more than five inches long (Fig. 149). It might be of advantage, in case of difficulty in reaching the accumulation of urine, to catch the cervix with a tenaculum and to pull it backward, as suggested by Cohnstein, so as to relieve the pressure upon the urethra. If catheterization is impossible, suprapubic puncture of the bladder with an aspirating needle is always practicable and perfectly safe if done in an aseptic manner. After the bladder is emptied attempts at reposition should be made as previously described. If these attempts should Fig. 149.—Frozen section of retroverted uterus of three and a half to four months. Death from rupture of bladder. 214 PREGNANCY. prove unavailing, abortion must be induced. If it is impossible to effect an entrance into the cervix for this purpose, it is justifi- able to puncture the uterine wall through the vaginal vault, and thus draw off the liquor amnii. The organ may now respond to efforts at replacement, or it may be possible to draw down the cervix and to dilate its canal, to make feasible the evacuation of the uterine contents. As a last resort, vaginal hysterectomy is justifiable. It is, indeed, the operation of election if the walls of the uterus are badly inflamed, have begun to suppurate, or are gangrenous. Lateral Displacements.—These include lateroposition, latero- version, and lateroflexion. Lateroposition is usually a con- genital defect, due to an abnormally short broad ligament, placing the whole uterine body more to one side of the abdom- inal cavity than the other. Lateroflexion is also congenital, due to imperfect development of one side of the uterine body, so that the imperfectly developed side acts like the string of a bow and bends the sound side on itself. Lateroversion is a tilting of the fundus to one side. Right lateroversion is the rule during pregnancy. These malpositions of the uterus com- plicate labor more than pregnancy (see Dystocia). Prolapse of the Gravid Uterus.—The causes of this displace- ment are : Impregnation in an organ already prolapsed,1 or retroversion, relaxed vaginal walls and outlet, and the increased weight of the uterus in the first few weeks of pregnancy. Vio- lent straining and traumatism, too, are possible causes. The spontaneous terminations are : Complete spontaneous re- position, which is most frequent; incomplete reposition, the uterus continuing in a state of partial prolapse to full term ; fail- ure of retraction, inducing incarceration, with possible gangrene of the uterus ; failure of retraction, inducing abortion, which is most likely to occur, as there is no mechanical obstacle to the escape of the uterine contents. Pregnancy will not continue to term in a completely prolapsed uterus. Treatment.—The appropriate treatment of a prolapsed gravid uterus is reposition and the application of some variety of ball pessary, retained by a firm T-bandage. If the uterus is incar- cerated, attempts at reposition should be cautiously made, but if they fail, owing to adhesions and edema, abortion should be induced and the organ then replaced. If, however, the uterus is infected, it should be removed by a vaginal hysterectomy. 1 A patient in my wards of the Philadelphia Hospital had had a complete pro- lapse for years. Copulation had occurred by means of an enormously dilated cervical canal and the woman had been impregnated in this manner. There was a sponta- neous reposition of the womb before the third month of pregnancy. DISEASES OF THE UTERINE MUSCLE. 215 The Pregnant Uterus forming a Part of a Hernial Protrusion.— This displacement occurs very exceptionally in inguinal and ven- tral, but never in crural, hernia, the uterus falling into the sac before or after impregnation. The ventral variety is most frequent, and may occur between abnormally separated recti muscles, or, more rarely, is seen on the lateral aspect of the abdomen. When it is associated very exceptionally with inguinal hernia, the preg- nancy is apt to be in one horn of an abnormally developed uterus. Treatment.—There should be an attempt at reposition. Fail- ing in this, the cervix may be dilated and the hand inserted in the uterus, to perform version and extraction. The emptied uterus may then be returned to the abdominal cavity. The last resort is Cesarean section or amputation of the pregnant uterus. Winckel has reported such a case, with a successful issue. Torsion.—A slight degree of torsion from left to right is physiological and constant. A more exaggerated degree may be due to some abnormal condition, usually inflammatory, near the uterus, which results in twisting it upon its longitudinal axis. An ovary may thus be brought in front and may be subjected to traumatism during manipulation of the abdomen. Extreme torsion of the pregnant uterus with lateral displacement has led to a mistaken diagnosis of extra-uterine pregnancy. DISEASES OF THE UTERINE MUSCLE. Rheumatism of the myometrium is rare, but is occasion- ally met with in women of rheumatic diathesis. Symptoms.—Great pain, localized in the uterine walls, lasting throughout the latter months of pregnancy, and increased periodi- cally by the intermittent uterine contractipns. There may be a subacute fever. The therapeutic test is the most valuable factor in the diagnosis. Treatment.—The administration of the salicylates is of imme- diate effect. Metritis is almost invariably acquired before impregnation. The disease exercises a most deleterious influence upon gesta- tion, giving rise to a sensation of weight and heaviness in the pelvis, to an exaggeration of the reflex disturbances of pregnancy, and often resulting in abortion. Treatment.—Glycerin tampons may be packed in the vaginal vault to support the womb and to deplete it, although the treat- ment is very likely to induce abortion. New growths complicate labor rather than gestation. Fibromyomata grow rapidly on account of the increased 2l6 PREGNANCY. blood-supply to the genitalia, and in exceptional cases some operative interference is demanded for the pain and pressure symptoms. On one occasion I was obliged to do a myomec- tomy in pregnancy on account of excessive pain, and on another to perform Cesarean section at seven and one-half months, be- cause of the embarrassment of heart action and respiration due to the enormous distention of the abdomen. Ovarian cysts, es- pecially dermoids, may grow rapidly under the stimulus of pregnancy, occasionally giving rise to such severe pain that extra- uterine pregnancy is suspected. This was true of one of my cases, in which I removed a dermoid cyst at the third month. The pedicle may be twisted and the tumor become gangrenous. It is more common, however, to witness an entire absence of subjective symptoms till the onset of labor or during the puer- perium.1 Diseases of the Cervix.—The inflammatory diseases of the cervix may exaggerate the reflex disturbances of pregnancy. Endocervicitis and interstitial cervicitis are found in too many cases of hyperemesis to be a mere coincidence. An annoying leukorrhea during pregnancy may have its origin in the cervical canal. Exacerbations of the inflammation may give rise to bloody discharges, especially at times corresponding to the menstrual period. Supposed menstruation, persisting throughout preg- nancy, has thus been accounted for. Treatment.—Applications of nitrate of silver solution, poured into a cylindrical speculum, give the best results in endocervi- citis. Congestion, inflammation, and hypertrophy of the cervix are best treated by rest in bed and applications of glycerol of tannin tampons. Diseases of the vagina are due to an increased blood-sup- ply or to infection. Vaginal leukorrhea is frequently an annoying complication of pregnancy. A single application of a thirty per cent, solution of carbolic acid in glycerin will relieve it more quickly than the commonly employed astringent and antiseptic douches. Another successful plan of treatment is to pour into a cylindrical speculum a twenty-grain solution of nitrate of silver to the ounce, then to withdraw the speculum slowly so that the successive folds of vaginal mucous membrane are bathed in it. Finally a douche of weak salt solution should be administered. 1 For the statistics of the child-bearing process, complicated by pelvic and ab- dominal tumors, see Dystocia. DLSEASES OF THE VAGINA. 217 Specific infection with the gonococcus should cause anxiety on account of the eyes of the new-born infant and the infection of the mother after delivery, even should there be no great discomfort during pregnancy. The condition requires energetic treatment. A bichlorid douche, 1 : 2000, twice daily, and a tampon dusted with tannic acid, give good results. For the bichlorid douche, a permanganate of potassium solution, %j to Oij, may often be substituted with advantage. A study of vaginal secretions during pregnancy (Doderlein) has thrown additional light on the ques- tion of septic infection after labor. In the normal secretions, especially of virgins, there is a large non-pathogenic bacillus, which seems to have a destructive action upon other micro- organisms by producing an intensely acid environment (prob- ably due to lactic acid). In pathological secretions the reaction is weakly acid, neutral, or alkaline ; there is also in pathological secretions an increased amount of mucus, bubbles of gas, epithe- lial cells, and a large number of mixed micro-organisms. Out of 195 pregnant women examined by Doderlein, 44.6 per cent. had pathological secretions. Varices of the vagina may be dangerous if the veins are large and their walls thin. The part should be guarded from trau- matism, which might result in rupture of the distended veins and an alarming if not a fatal hemorrhage. Colpohyperplasia cystica is a disease of the vaginal mucous membrane, described by Winckel, in which little retention cysts are scattered throughout the hypertrophied mucous membrane. In rare cases the fluid disappears from the cysts and its place is taken by gas. Polypoid hypertrophies of the vaginal mucous membrane, usu- ally at the site of the carunculae myrtiformes, may attain con- siderable size, causing discomfort during pregnancy, and possibly obstructing the canal in labor. I have seen one case of such enormous hypertrophy of the tissues surrounding the meatus urinarius that the urethra completely filled the vaginal entrance (Fig. 150). Suburethral abscess is an accumulation of pus in the anterior vaginal wall, bulging out at the vulvar orifice like a cystocele, and on pressure discharging the pus slowly and imperfectly into the urethra through the opening of Skene's glands. The abscess should be opened through the vagina.1 The diseases of the vulva are also largely due to an in- creased blood-supply. 1 "Archives de Tocol.," Oct., 1894. 218 PREGNANCY. Varices in the labia majora may attain a large size. They have been ruptured by muscular strain in an effort to preserve the equilibrium, by sitting down violently upon a hard sub- stance, or by a kick. The hemorrhage is always dangerous, and has proved fatal. Vegetations of the vulva may reach excessive size in preg- nancy. They are likely to give rise to an irritating, foul secre- tion. I found it possible to excise the growth in one case. Excessive hemorrhage, however, is to be feared, and the opera- tion might terminate pregnancy. Pruritus vulvae may be a neurosis or may be due to irritating vaginal discharges and to glycosuria. The disease is oftentimes most intractable to treatment. Antiseptic vaginal injections may Fig. 150.—Hypertrophy of the urethral walls in pregnancy (author's case). be tried, or a wash of two per cent, solution nitrate of silver (Zweifel); menthol ointment, and other analgesic applications; very hot water, vinegar, and an infusion of tobacco are house- hold remedies of some value. In the worst cases the woman becomes almost maniacal. I have seen a patient walk the floor all night, tearing at the vulva with her finger-nails until the labia were raw and the fingers were stained with blood. In such cases the induction of labor must be considered. Edema of the vulva may be unilateral or bilateral, and in some pregnant women reaches an extreme degree. It is due to pres- sure upon the pelvic veins, to kidney insufficiency, or, in the uni- lateral form, to labial abscess. There are some women who DISEASES OF THE VULVA. 219 develop a vulvovaginal abscess regularly in every pregnancy, and not at other times. Treatment.—If the cause can be removed, the edema will disappear. The treatment of kidney insufficiency will remove the dropsy of the labia associated with that condition, as it will the other dropsies of the body. If the edema is due to pressure, Fig. 151.—Varices of the vulva. rest in bed, with the occasional assumption of the knee-chest posture, will often give relief. If the edema fails to yield to gen- eral treatment and to hot fomentations locally, the labia may be punctured. It should be remembered, however, that even this slight operation may terminate pregnancy. The vitality of the part, moreover, is so lowered that infection and even gangrene may follow the puncture. In the unilateral edema, associated 220 PREGNANCY. with labial abscess, the vulvovaginal gland should be laid open in the last month of pregnancy, curetted, cauterized with car- bolic acid, and packed with gauze. One of the worst cases of puerperal sepsis I have ever seen was due to infection from a vulvovaginal abscess that ruptured during labor. Periuterine Inflammations and Adhesions.—Old cases of pelvic adhesions may be benefited by massage and tampons. The most satisfactory results, however, are secured by appropriate treat- ment during the intervals between pregnancies. Fresh attacks of periuterine inflammation in pregnancy, depending upon oopho- ritis and pyosalpingitis, are exceedingly dangerous. Unlikely as it may seem, a woman may be impregnated, though she have at Fig. 152.—Edema of vulva in the eighth month of pregnancy, due to pressure. Justominor pelvis. Fetal head unengaged above the pelvic brim. Swelling dis- appeared in a few hours after multiple punctures. conception a pyosalpinx and densely adherent tubes and ovaries. The inflammation of the adnexa may be lighted up afresh by the congestion of pregnancy. In such cases a septic peritonitis may be averted only by a prompt abdominal section and the removal of the appendages. Loosening of and Pain in the Pelvic Joints.—If the normal relaxation of the pelvic joints in pregnancy is carried to an ab- normal degree, it may interfere with locomotion. The diagnosis is made by a vaginal examination, the patient, in the erect posture, taking a step or two, while the examiner holds his index-finger in the vagina against the posterior surface of the symphysis. DISEASES OF THE ALIMENTARY CANAL. 221 Treatment.—Application of a firm binder about the hips will usually make the patient comfortable. Rest in bed may be necessary in exaggerated cases. The pelvic joints, especially one sacro-iliac, may be the seat of severe pain of rheumatic origin. The patient may be entirely disabled by her suffering. This pain will yield immediately to antirheumatic remedies like the salicylate of cinchonidin, and to no others. Breasts.—Mammary Abscess.—Its cause, course, and treat- ment are the same as when it occurs during the puerperium. Eczema of the nipples may be very obstinate in its resistance to treatment. Relief may only be secured after delivery. Mean- while the usual treatment for eczema may be tried with more or less success. Mammary tumors may take on a very rapid growth under the stimulus of pregnancy. I have seen a simple adenoma the size of a walnut, for years before quiescent, reach the size of a cocoa- nut during pregnancy. DISEASES OF THE ALIMENTARY CANAL. Mouth.—Caries of the teeth frequently troubles a pregnant woman. It is a common saying that for every child a woman will lose a tooth. As a rule, prolonged and painful dental opera- tions are inadvisable during pregnancy. Temporary work only should be done by the dentist, who should be acquainted with his patient's condition. The syrup of the lactophosphate of lime, fej t. i. d., should be prescribed for all pregnant women who dis- play a tendency to dental decay. Gingivitis.—In this disease the gums are spongy, inflamed, bleed easily, and are possibly ulcerated. The condition may obstinately resist treatment until pregnancy is concluded. Occa- sionally the gingivitis extends to a stomatitis, and rarely lasts through, and is aggravated by lactation, only disappearing when the child is weaned. The inflammation may extend down the esophagus to the stomach, producing dyspepsia and an obstinate vomiting. Astringent and cleansing mouth-washes, containing tincture of myrrh, give the best results in the treatment of this affection. Toothache may develop with or without pathological changes in the mouth, and in the latter case may resist all treatment. It usually subsides in the second half of gestation if it is a neurosis. If it is due to dental caries, temporary dental treatment should give relief. 222 PREGNANCY. Ptyalism.—The cause is not known. It is a neurosis or a reflex irritation of the sympathetic nervous system. Astringents, belladonna, chloral, etc., may be employed. It disappears usu- ally in the latter months, but may recur in each succeeding preg- nancy. One of my patients had salivation in five successive pregnancies. Every night a large receptacle was placed by the bedside into which saliva was expectorated in astonishing quan- tities. The Stomach.—There is a physiological, an exaggerated, and a pernicious vomiting in pregnancy. The last is a serious disease, with a high mortality. Pernicious vomiting is such an exaggeration of the physio- logical nausea and vomiting of pregnancy that the stomach becomes almost or quite unretentive. Causes.—The commonest cause is a reflex irritation of the stomach from the distention of the uterus and an irritation of the latter's sympathetic nerve-endings, due to the stretching of the uterine walls. It is, therefore, more common in primigrav- idae, especially in elderly women ; in twin pregnancies ; in hydram- nios ; in chronic metritis or displacement of the uterus ; in cases of chronically thickened, inelastic, or diseased cervices, and in a hyperesthetic or disordered condition of the nervous system. Another cause may be found in inflammation of the lining mucous membrane of the cervix or of the uterus. Engorgement or inflammation of neighboring organs, as inflamed tubes or ovaries, or an old or fresh appendicitis, increases the irritation of the distending womb, usually by reason of adhesions which bind it down. A pathological condition of the stomach, as chronic gastritis or gastric ulcer, will naturally increase gastric irrita- bility, so that the stomach feels acutely the reflex irritation of pregnancy. There may rarely be some pathological condition of the intestinal tract, as polypi or bands of adhesions as a cause of pernicious vomiting. Immoderate indulgence in sexual intercourse is a not infrequent cause. Kidney insufficiency should always be suspected if the vomiting recurs late in pregnancy. Diagnosis.—The recognition of the cause may be difficult, but the diagnosis of the condition is easy. There is usually a subnormal temperature, but there may be fever ; there is great emaciation, pallor, and loss of strength. The lips are dried and cracked, the tongue is brown and coated, and the breath foul. There is constant retching, and everything put into the stomach is either immediately rejected or comes up undigested in a short time. Whether anything is ingested or not, mucus and bile are vomited from time to time. A gastric ulcer is not uncommonly the result of the disordered secretion of the stomach and the DLSEASES OF THE ALIMENTARY CANAL. 223 reduced vitality of its walls. In such cases the vomiting becomes bloody and the patient may succumb to repeated gastric hemor- rhages, which she can not endure in her enfeebled condition. The most unfortunate mistake in the diagnosis of the pernicious vomiting of pregnancy is the failure to recognize the existence of gestation and the consequent belief that the emesis is that of hysteria, gastric ulcer, or cancer. Persistent vomiting in a woman of child-bearing age should always arouse a suspicion of pregnancy and should always indicate a vaginal examination. The treatment of hyperemesis gravidarum should be directed toward the cause if it is ascertainable or amenable to treatment. The various remedial measures required in individual cases may be conveniently studied under the following heads : Hygienic.—This includes regulation of the diet, attention to the gastro-intestinal tract, to the woman's sexual relations, and to her mode of life. The physician should advise a light breakfast of tea and toast or milk, taken in bed before getting up, the patient lying flat upon her back. Resting quietly for a half-hour or so after the ingestion of light, simple food, the distressing nausea and vomiting usually felt on first rising in the morning may be entirely avoided. Sexual intercourse should be forbidden. Oc- casionally there is improvement when the sensation of swallowing is removed by a cocain spray of the fauces, or by injecting food into the stomach through an esophageal tube. Rectal alimen- tation must be resorted to in the worst cases, the enemata being non-irritating, so as not to provoke an exhausting diar- rhea, partially digested, easily absorbed, and not administered in too large amounts or too frequently. Four to six ounces may be given three or four times a day, of liquid peptonoids, pancrea- tized milk, or peptonized beef-tea. The rectum should be washed out twice a day, and after the irrigation a pint of normal salt solution should be injected high up in the bowel for the relief of the distressing thirst that is a constant symptom. A toler- ance of the stomach may at times be secured by allowing appar- ently unsuitable articles of food if they are strongly craved by the patient. In all cases of true pernicious vomiting the patient must be confined to bed, the room should be darkened and kept absolutely quiet, and every atom of the patient's strength should be saved by careful nursing. It can not be too emphatically stated that the vomiting of pregnancy is a neurosis. Hence a strong nervous impression upon the patient or the establishment of a moral control over her, as in the treatment of hysteria, will often give brilliant re- sults. I have cured many a case of hyperemesis by making a vaginal examination, and on several occasions my entrance into 224 PREGNANCY. the patient's bedroom as a consultant immediately checked a vomiting previously uncontrollable. Again, a positive statement that a certain remedy would unfailingly check the vomiting has made it immediately successful. The Medicinal Treatment.—The drugs that have been lauded as specifics in the treatment of hyperemesis include a large pro- portion of those in the pharmacopeia. The remedies most worthy of mention are : Iodin, gtt. j-ij in water; oxalate of cerium, subnitrate of bismuth, tincture of nux vomica, antipyrin, wine of ipecacuanha in small doses, menthol, hydrobromate of hyoscin, and cocain. The nerve sedatives—the bromids, chloral, and opium—are the most reliable (sodium bromid, gr. x, in aq. camph., 5iv, four times a day, is a useful routine prescription). If the stomach is intolerant of drugs, recourse may be had to enemata of sodium or potassium bromid, gr. xl, and chloral, gr. xx, two or three times a day, dissolved in several ounces of water. The Gynecological Treatment.—If the vomiting of pregnancy becomes exaggerated and resists the ordinary hygienic and medicinal treatment, a vaginal examination should be insisted upon. Various abnormal conditions of the pelvic organs may be discovered and must be treated. A displaced uterus must be replaced. If the cervix is engorged, thickened, or cicatricial, or if its canal is inflamed, applications may be made to it through a cylindrical speculum, a twenty-grain solution of nitrate of silver, for example, being poured into the speculum until the cervix is submerged in it. Multiple punctures of the cervix or the use of glycerin tampons may be considered, though these measures would be employed at the risk of inducing abortion. Peroxid of hydrogen has been found useful poured into the speculum as just described. It is obvious that if applications to the cervical canal are made with an applicator and cotton, abortion might result. If there is metritis, with a large, heavy, inelastic womb, treatment may not accomplish much during pregnancy. Glyc- erin tampons may be tried if the knee-chest posture, rest in bed, and free purgation fail, but they may induce abortion. An adherent, displaced womb, with old or recent peri-uterine inflam- mation, is not infrequently responsible for a particularly obstinate and violent form of emesis. Pelvic massage and vaginal packing must be resorted to at the risk of terminating pregnancy. A strong solution of cocain, applied to the cervix and to the vaginal vault, has proven beneficial in a few cases. Dilatation of the cervix with the fingers or with a bougie has been occasionally wonderfully successful. This so-called Copeman plan of treatment has many enthusiastic advocates, but experience has taught me DISEASES OF THE ALIMENTARY CANAL. 225 that it is unreliable. When it has succeeded it has been due, I believe, to the nervous impression produced upon the patient. The Obstetrical Treatment.—Induction of abortion or of pre- mature labor should be regarded as the last resort, but yet it should not be delayed too long. If a patient retains absolutely nothing on her stomach and must be fed by the rectum ; if she vomits incessantly whether anything is put into the stomach or not; if the pulse rises to 120 and the prostration is really alarm- ing, abortion must be induced. As a rule, I do not continue rectal alimentation more than a week. There is one case on record in which rectal feeding was employed with success for almost two months, but this single instance should not encourage physicians to persist for an inordinate length of time in rectal alimentation. There are many deaths recorded of women fairly well nourished by food injected in the bowel, but fatally ex- hausted by incessant retching and vomiting. The mortality of the pernicious vomiting of pregnancy is high. Of 239 cases, 95 died ; of 57 cases treated by the usual means, 28 died; of 36 cases treated by the induction of abortion, 9 died. I have induced abortion for hyperemesis twelve times. Two patients died. In one case I was called to see the woman in consultation when she was almost moribund. The induction of abortion proved too great a shock to her, easy and simple as the operation is. In the other case the religious scruples of the family prevented the termination of the pregnancy when I first advised it. Ten days later, the patient being obviously at death's door, the operation was demanded. The Intestines.—Constipation should be guarded against to prevent overwork of the kidneys. The small compressed pill of aloin, belladonna, cascara, and strychnin, kept in stock by all pharmacists, is the best routine remedy. The weaker mineral waters and pulv. glycyrrhizae comp. may be used. Active purges not only disturb the digestion, but may interrupt the course of gestation. Diarrhea.—When the ordinary astringent remedies fail to check a diarrhea in pregnancy, nerve sedatives should be tried. There is a nervous diarrhea of pregnancy due to the mechanical irritation of the intestines by the growing uterus. Gastric and Intestinal Indigestion.—The latter is not uncommon in primigravidae, and may give rise to such severe abdominal pains that a suspicion of extra-uterine pregnancy seems justified. These conditions, too, may be a neurosis, and may yield to valerian, bromids, and similar remedies after the ordinary treatment for dyspepsia has failed completely. The Liver.—Jaundice may result from a mild catarrhal con- 226 PREGNANCY. dition of the bile-ducts, which may have existed before pregnancy. This class of cases is of little clinical importance. It should be remembered, however, that a serious condition may develop in pregnancy as the result of excessive work thrown upon the liver, —namely, an acute degeneration of the whole hepatic structure. Localized degenerations of the liver are seen in all fatal cases of eclampsia, and the poisonous substances circulating in the blood in that disease may act upon the liver like phosphorus, pro- ducing acute yellow atrophy. Treatment.—The simple catarrhal jaundice is treated by regulation of diet and of the bowels, and by the administration of calomel to secure a free discharge of bile. The graver form of hepatic degeneration is likely to be rapidly fatal. Appendicitis in Pregnancy—Fifteen cases have been collected by Abrahams1 with seven maternal deaths. Called on one occa- sion to see a woman with acute peritonitis in the fifth month of preg- nancy, I found, after opening the abdomen, pools of pus lying be- tween the coils of intestines, a gangrenous appendix, and two perforations of the caput coli. The pregnant uterus was turned out of the abdominal cavity, the pus was carefully sponged out with gauze pads, the appendix was amputated, and the perforations in the colon were closed by a seroserous stitch. The uterus was then returned to the abdominal cavity, and the wound was closed with gauze drainage for eighteen hours. Not only did the woman recover, but pregnancy continued undisturbed to term. Hemorrhoids.—The pelvic congestion of pregnancy and the mechanical interference with the circulation by the bulk of the gravid uterus predispose to hemorrhoids, and aggravate them if they antedate conception. Palliative treatment alone is per- missible. An ointment of equal parts of ung. gall, and ung. stramon. will be found serviceable. Cocain, lead salts, and opium may also be useful. Rest in the horizontal posture, the knee-chest posture several times a day, and the routine use of laxatives may be necessary. As in all cases of hemorrhoids, the bidet gives great comfort. DISEASES OF THE URINARY APPARATUS. Kidneys.—The Kidney of Pregnancy.—There is a pathological condition of the kidneys so frequently developed in pregnancy (fifty-eight out of seventy, Fischer2) that it deserves the name of " kidney of pregnancy." 1 " Amer. Jour. Obstetrics," Feb., 1897. 2 " Prager med. Wochens.," 1892, No. 17. DISEASES OF THE URINARY APPARATUS. 227 Pathology.—There is anemia with fatty infiltration of the epi- thelial cells, without acute or chronic inflammation. Etiology.—The causes of the common changes in the kidney during pregnancy are still obscure. They have been attributed to pressure on the renal blood-vessels, to the direct compression of the kidneys by the gravid uterus, to a serous condition of the blood in pregnane)', to the influence of the weather, to pressure upon the ureters, and to spasmodic contraction of the renal arteries. It is most likely that the condition is due to a diminution of the blood-supply, most probably brought about by increased intra-abdominal tension and by a contraction of the arterioles in the kidneys, due to the irritation to which they are subjected by the effete substances contained in superabundance in the blood of pregnant women. Symptoms.—There is often albuminuria in advanced degrees of the condition. Hyaline and granular casts, with epithelium filled with fat, may be found. The kidneys may prove physio- logically insufficient, and there may appear all the symptoms of renal insufficiency observed in true nephritis. Frequency and Course.—About six per cent, of all pregnant women have albumin in the urine, though a vastly larger pro- portion show some degree of the kidney of pregnancy, if there is an opportunity for a postmortem examination. Albuminuria occurs most frequently in primigravidae. The kidney disturbance runs a subacute course, manifesting itself most plainly in the latter months of gestation. It may influence the general health, the course of pregnancy, and the occurrence of eclampsia, just as inflammatory renal diseases wrould do. The renal insufficiency exerts a malign influence upon the fetus, also, especially in the production of placental apoplexies. If the mother becomes uremic, the fetus is also poisoned and rarely survives its birth more than a fewr hours. The dangers to both mother and child are greatest if the condition develops suddenly. The renal in- sufficiency of the kidney of pregnancy disappears with the cessation of gestation. The treatment is practically the same as for true nephritis, so that the management of the kidney complications of pregnancy will be considered without reference to the cause of the kidney insufficiency. Acute and Chronic Nephritis.—These diseases may occur at any time during pregnancy, with their usual symptoms. The extra amount of work thrown upon the kidneys during pregnancy makes the prognosis of kidney diseases graver than at other periods of adult life, and a more energetic treatment may be demanded in the pregnant than in the non-pregnant woman. 228 PREGNANCY. Premature expulsion of the ovum and outbursts of eclampsia are frequent. Chronic nephritis may be acquired before or during pregnancy. Acute nephritis or a sudden insufficiency of the kidneys may be the result of exposure to cold, wet feet, sitting in a draft when overheated, or a single gratification of a ravenous appetite. Differential Diagnosis between True Nephritis and the Kidney of Pregnancy.—If the kidney disease existed before pregnancy, well-marked symptoms will develop in the earlier months. The appearance of the first symptoms after the sixth month usually justifies the assumption that the disease has had its origin during pregnancy, and is nothing more than the tempo- rary disturbance of that condition. I have, however, seen eclampsia break out in the last month of pregnancy or during labor in a woman who had a history of violent headaches and scanty urination for two years before conception, and in another who had had scarlet fever during girlhood. In both these women there was probably a latent nephritis, though there was not a sign of it in pregnancy until the onset of the convulsions. The following differential signs may aid one in the diagnosis of a doubtful case : Chronic Nephritis. The history may point to its existence before pregnancy. Quantity of urine increased and its spe- cific gravity low; but these condi- tions are normal in pregnancy. Sudden diminution in quantity may appear. Occasional presence of albuminuric retinitis. The symptoms of kidney insufficiency —albuminuria, edema, somnolence, headache—apt to be pronounced in the earlier months. The autopsy shows inflammatory changes, chronic or acute. Persists after delivery. Casts appear early and in abundance. Kidney of Pregnancy. The history would indicate that the kidneys were normal before concep- tion. Quantity of urine likely to be increased and its specific gravity is low. Sudden diminution possible, as in true nephritis. Does not appear in the kidney of preg- nancy, so far as my observation goes. Do not appear, as a rule, until after the sixth month of gestation. Anemia and fatty degeneration of the kidney are found postmortem. No inflammatory changes, though the kidneys may become secondarily congested if convulsions have oc- curred. Disappears after delivery. Casts only in bad cases, not appearing usually until the other symptoms of kidney insufficiency have developed. Treatment.—It is always of paramount importance to know, in any case of pregnancy, what the condition of the kidneys may be ; hence in all cases the urine should be repeatedly examined, DISEASES OF THE URINARY APPARATUS. 229 at least every two weeks during the earlier months and once a week during the last month. If albumin appears, but if its quantity is small, if there are no casts, no history of a previous nephritis, and no symptoms of general systemic disturbance, dietetic and hygienic management may be sufficient, so long as the case is kept under careful observation. Meat should be eaten but once every other day. Large drafts of water should be systematically drunk. The greatest prudence must be exer- cised about adequate underclothing, exposure to cold and wet feet, and a laxative should be taken regularly, if it is required. If the amount of urine voided is decidedly diminished, if casts are discovered and edema appears, the patient should keep her room or should be put to bed ; the bowels must be kept freely open ; the diet should be reduced to milk and Basham's mixture, or some other diuretic should be given. Three-grain doses of caffein have given good results. Benzoic acid is also satisfactory. If an exclusive milk diet is impossible, milk soups, a small amount of toast, the lighter vegetables,—squash, asparagus, beets, salad, spinach, etc.,—may be allowed in small quantities. If under this plan of treatment the symptoms grow progres- sively worse, the termination of pregnancy is necessary. There is no disease of pregnancy with which the physician can so ill afford to trifle as this. Obscurity of vision or actual blindness, demonstrating usually the presence of albuminuric retinitis, indicates the induction of labor or of abortion without a moment's unnecessary delay. Both ophthalmologists and obstetricians of experience are agreed that if the woman's vision, nay, if her life, is to be saved, preg- nancy must be terminated at once. It should be remembered that if interference is long postponed, it may come too late. After the uterus is emptied eclampsia may occur, if the woman's system is allowed to become thoroughly saturated with the effete products of life activity in both mother and fetus, which the physiologically insufficient kidneys do not excrete. I am in the habit of depending upon the quantity of albumin as a guide to determining the question of inducing labor. In every case of albuminuria in pregnancy I have daily examinations made with an Esbach albuminometer. If, in spite of confinement to bed, a milk diet, ingestion of large quantities of water, diuretics, and hot baths every other day, the albumin steadily or suddenly increases, I terminate pregnancy. A sudden diminution in the quantity of urine, excessive edema, and somnolence would also decide the question indubitably in favor of terminating gestation. The quantity of urea excreted would always be of great interest and value in deciding for or against the induction of labor, but 230 PREGNANCY. unless the total amount of urine in the twenty-four hours is measured, the exact estimation of the quantity of urea excreted is impracticable. Renal tumors are rare. They are to be diagnosticated and treated according to the individual features of the case, but it must be borne in mind that any disease or abnormality of the kidney predisposes to insufficiency of excretion. The anatomi- cally perfect kidney is likely, but not certain, to be physiologically sufficient. The unhealthy kidney will probably, but not certainly, be insufficient. Dislocation of the Kidney.—The right kidney is almost always the one affected. The displacement of the kidney is not infre- quently associated with displacements of the gravid uterus. Abortion may result if the floating kidney happens to become twisted upon its pedicle. From the pressure to which the displaced kidney is subjected, and in consequence of interference with the renal circulation by torsion of the vessels, the kidney of pregnancy may develop. A congenital fixation of the kidney in the pelvis has been noted in the child-bearing woman.1 It is usually the left (fourteen out of fifteen cases (Cragin)). Diseases of the Pelvis of the Kidney.—Pyelitis has the history of all the infectious diseases in pregnancy ; it is aggravated by the condition, and reacts unfavorably upon it. Premature expulsion of the fetus is apt to occur. Pyelitis rarely develops primarily in pregnancy. It arises much more frequently after labor. Hydronephrosis.—A displaced and adherent gravid uterus may occlude the ureters, with this result. The condition requires the reposition of the uterus. A renal calculus is apt to induce abortion. Renal colic in pregnancy is to be treated in the usual manner, without regard to the patient's condition. The surgical treatment is not contra- indicated. Diseases of the Bladder.—Irritability is a functional disturb- ance, and occurs in an exaggerated degree in hyperesthetic in- dividuals, who feel acutely the pressure of the gravid uterus. Some degree of irritability of the bladder is seen, as a rule, in pregnant women. The treatment, if any is required, may consist of the reposition of a displaced uterus. If the disturbance is purely neurotic, nerve sedatives are indicated. 1 Cragin has collected five cases in addition to his own. The author has re- ported a case not included in Cragin's statistics: "Am. Journ. of Obstet.," July, 1898. DISEASES OF THE BLADDER. 231 The incontinence of retention is one of the most distinctive symptoms of a backward displacement of the gravid uterus. There may be, however, a neurotic incontinence and a paretic incontinence in pregnancy. Vesical hemorrhoids are due to an increased blood-supply to the part and an interference with the circulation by the pressure of the pregnant uterus. Hematuria may be a symptom. If the loss of blood becomes alarming, astringents may be injected into the bladder; the knee-chest posture should be assumed at fre- quent intervals, and the bowels must be kept freely opened. Cystitis is more frequent after labor than in pregnancy ; com- plicating pregnane)-, it may be due to gonorrhea. Vesical Calculi.—It is important that vesical calculi be dis- covered before labor. They should be removed through the urethra or by vaginal lithotomy during the last month of preg- nancy, so that if labor is induced by the operation, the child shall not suffer by reason of its prematurity. It is unfortunate for the woman if she fall in labor with an undetected stone in the bladder. A vesicovaginal fistula is likely to be the result. Anomalies of the Urine in Pregnancy.—Polyuria is an ex- aggeration of the physiological increase of the urine in pregnancy. It sometimes reaches an astonishing degree. I have had under my charge a woman who passed 220 ounces of urine a day. There is usually great thirst and the urine has a very low specific gravity, but should contain no albumin or sugar. The woman's health remains unimpaired, and it is unwise to attempt to diminish the excretion. After delivery, the polyuria disappears. The urine may be diminished in quantity, may be high colored, and may have a high specific gravity, as the result of errors in diet and inactivity of the skin and bowels. This condition should never be regarded with indifference. It shows an in- creased strain upon the kidneys that may determine their break- down. Meat should be temporarily excluded from the diet. The bowels should be kept open, and water must be drunk in large quantities. Lipuria, occasionally observed in the pregnant woman, is ex- plained by the unusual quantity of fat in all the tissues of the body, making its way even into the blood-current. An oiled catheter may be the source of the fat. This abnormality does not necessarily affect the woman's general health. Chyluria occasionally, but very rarely, appears. It is of no pathological import. Peptonuria and acetonuria may develop in pregnancy in con- sequence of fetal death or without ascertainable cause. The latter condition is not infrequently associated with eclampsia. 232 PREGNANCY. The characteristic odor of the woman's breath may be well marked. Hematuria may be the result of vesical hemorrhoids. It may, however, indicate acute cystitis, a vesical tumor, stone, or acute nephritis. Glycosuria in the pregnant woman ranks next in clinical im- portance to albuminuria. It has been found by some observers in from sixteen to fifty per cent, of cases, but this is not my ex- perience. In the routine examination of the urine of all pregnant women under my charge, I do not find sugar by Fehling's test in one per cent, of the cases. There are two distinct varieties of glycosuria in pregnancy. One is due to absorption from the breasts, and the sugar in the urine is lactose, and not glucose. There are no systemic symp- toms in this variety. The other is true diabetes mellitus, which is said to occur more frequently in pregnant than in non-preg- nant women,1 and if it exists before pregnancy is aggravated by the latter condition. In 7 out of 19 cases the disease determined fetal death, and in 4 out of 1 5 cases the mother died shortly after labor.2 Diabetes mellitus may appear in pregnancy with all its characteristic symptoms and may disappear after labor. I have one patient who regularly develops the disease in every preg- nancy. It is not certain, however, to reappear in subsequent gestations. Albuminuria is found in about six per cent, of pregnant women, as already stated. Its cause is the kidney of pregnancy or nephritis. DISEASES OF THE NERVOUS SYSTEM. The Brain.—The inflammatory diseases of the brain are acci- dental complications of pregnancy and are rare ; they exert no special influence upon gestation, nor do they modify its course, except cerebrospinal meningitis, which is infectious, and therefore has the same influence upon and is influenced in the same way by pregnancy as the other infectious fevers. That is to say, it is aggravated by the woman's condition and exercises a deleteri- ous influence upon that condition. Congestion of the brain predisposes to apoplexy, an accident which, serious as it is, has no influence upon the course of preg- 1 The idea that diabetes mellitus is more likely to occur in pregnant than in non-pregnant women may have been due to the rather common appearance of lac- tosuria. In 157 cases of true diabetes mellitus in women, reported by Griesinger and Frerichs, only three were in pregnant women. 2 Matthews Duncan, "On Puerperal Diabetes," "Obstet. Tr.," vol. xxiv, p. 256. DISEASES OF THE NERVOUS SYSTEM. 233 nancy or labor if the woman recovers from the cerebral hemor- rhage. The Spinal Cord.—Inflammatory diseases of this structure are also accidental complications, and are without influence upon pregnancy or labor. Paralyses:—The woman may be the subject of paraplegia and yet pregnancy and labor are entirely uncomplicated. The latter process, indeed, is easier in such women. It would appear, there- fore, that the spinal nerves exercise an inhibitory action upon the uterine muscle, the removal of which facilitates parturition. The Peripheral Nerves.—Obstinate neuralgias appear in preg- nancy, which may be little benefited by treatment, and only disappear after labor. It should be remembered that localized pains of a neuralgic character in the head, face, or breast are often indicative of advanced kidney disease in pregnancy. Mul- tiple neuritis may have its origin in gestation, especially in alcoholic subjects. The Neuroses of Pregnancy.—Chorea.—The milder grades of the disease are not uncommon in pregnancy. Buistx collected 225 cases. Sixty per cent, of the cases occur in primigravidae. Heredity, chlorosis, rheumatism, and the existence of the disease in the patient's childhood are predisposing causes. Chorea is almost always aggravated by the coexistence of pregnancy, though in one case recorded the chorea ceased when the woman became pregnant.2 In the graver variety of the disease premature expulsion of the ovum is apt to occur, followed by death of the mother in about one-fourth of the cases. Buist's statistics give 45 deaths out of 225 cases,—17.6 per cent. Insanity is not infrequently associated with or follows chorea in the child-bear- ing woman. Treatment.—Fowler's solution, iron, nerve sedatives, change of air, and nutritious diet are indicated in the milder cases. The graver cases may actually require an anesthetic for the temporary control of the violent movements until the induction of prema- ture labor can be effected, whereupon there is usually a spon- taneous recovery unless the termination of pregnancy has been delayed too long. Epilepsy is a rare complication of pregnancy. As a rule, epilepsy does not influence unfavorably the course of gestation. The convulsions are often absent during pregnancy, but make 1 "Trans. Edinb. Obst. Soc," 1894-95. 2 In a patient in the Maternity Hospital, a young girl illegitimately pregnant, a chorea which she had had in childhood reappeared within a week of the fruitful coitus. I was obliged to induce labor in the eighth month on account of the severity of the symptoms. 234 PREGNANCY. their appearance again during and after the puerperium or upon the reappearance of menstruation after the child is weaned. This disease is most likely to be confused with eclampsia (see Eclamp- sia). Cases have been reported in which the infant, after birth, presented the symptoms of the maternal disease and died. Hysteria occurs frequently during pregnancy in its minor grades, but, as a rule, does not exert an unfavorable influence upon the course or duration of gestation. Tetany may have its origin in pregnancy.1 It is usually mild in type, ending in recovery, but it may possibly end fatally, in consequence of interference with respiration, by the firm con- traction of the thoracic muscles. Uncontrollable hiccup, vomiting, and coughing are usually pure neuroses, and yield most readily, if they yield at all, to anti- spasmodic remedies, or to a profound nervous impression. Organs of Special Sense.—Eyes.—Failing vision should always indicate an examination of the urine for signs of advanced kidney disease. Occasionally, however, there occurs complete temporary blindness, associated only with anemia of the eye- ground, due to a reflex contraction of the retinal artery. Hearing.—Disturbances of this sense are rare and are usually temporary, but they may be permanent. They are often inex- plicable. Some anomaly of the external auditory canal may be found, as a hematoma, which was the cause in one reported case of deafness in a gravid woman. In my experience the hearing of a deaf person has been worse during pregnancy than at other times. Psychical Disturbances.—Insanity.—Frequency.—Of all cases of insanity in women, about eight per cent, have their origin in the child-bearing process. About one in four hundred women confined become insane. Predisposing Causes.—The nervous excitation of gestation in women predisposed by hereditary influence to mental breakdown, great reduction in physical strength, and prolonged mental strain or worry should excite the physician's anxiety for his patient's mind. Exciting causes may be exaggerated anemia, as from prolonged lactation ; septicemia ; albuminuria ; profound emotions, as exag- gerated fear of impending danger ; the remorse and shame of illegitimate pregnancy ; the grief of a deserted woman ; accidents, as hemorrhage ; great physical or mental exhaustion. Chorea, associated with insanity, results rather from the same predis- 1 Neumann, " Zwei Falle von Tetanie Gravidarum," "Archiv f. Gyn.," Bd. xlviii, H. 3. PSYCHICAL DISTURBANCES. 235 posing or exciting causes, and should not be considered in itself as a cause of the insanity. In my experience, insanity in the child-bearing woman has almost always resulted from some pro- found emotion. One of my patients became insane after the death of her child ; another, because her husband deserted her; a third, some days after her delivery, received a letter from her seducer casting her off She fainted on reading it, became a raving lunatic that same night, and died of maniacal exhaustion within two weeks. A number of women under my observation have lost their minds from the shame of illegitimate impregnation. Symptoms.—The form of insanity may be mania, melan- cholia, or a condition of profound lethargy, stupidity, and mental confusion. If a woman in this condition is asked a question in a sharp tone of voice, there is a momentary flicker of intelligence in her face, but before the import of the question reaches her brain she is sunk again in her extraordinary apathy and indiffer- ence to her surroundings. Time of Occurrence.—Most frequently mental breakdown occurs during the puerperium, next in frequency during lactation, and least frequently during pregnancy. Mania is the most, mental apathy or confusion the least, frequent form of puerperal insanity. Melancholia is commoner in pregnancy than in the puerperium. The diagnosis of insanity is usually easy. It is, however, important to distinguish puerperal insanity from the temporary delirium of labor, delirium tremens, the delirium of fever, especially that of septicemia, and from preexisting insanity. The temporary delirium of labor is common. It is usually momentary, in the midst of the most acute suffering of labor, and varies in degree, from an outbreak of hilarity to violent mania. Delirium Tremens.—Labor, like an accident or surgical ope- ration, may precipitate an attack in hard drinkers. The history of the patient, and her symptoms, should demonstrate the nature of the case. The delirium of fever in child-bearing women is commonly due to septic infection. It is frequently necessary to wait until the fever subsides to determine if it be the cause of the mental symptoms. Preexisting insanity is recognized by the previous history of the patient, if it can be obtained. Prognosis.—About two-thirds of the women recover their reason in from three to six months ; of the other third, from two to ten per cent, die of septic infection or exhaustion ; the rest remain permanently insane. The treatment is best carried out in an asylum. Many patients, 236 PREGNANCY. however, will not be allowed by their families to enter an asylum. In such cases a modified rest-cure, combined with administration of iron, arsenic, and a nutritious diet, together with systematic exercise in the open air, will hasten the cure. The most careful supervision must be exercised at all times, to prevent the patient doing an injury to herself, her infant, or her attendants. DISEASES OF THE CIRCULATORY APPARATUS. Under this heading are considered those diseases of the heart, of the thyreoid gland, of the blood-vessels, and of the blood, which have their origin in pregnancy or are much aggravated by that condition. The Heart.—Valvular disease of the heart usually antedates impregnation. It may, however, owe its origin to septic infection during the child-bearing process, or to rheumatism acquired after conception. Prognosis.—Abortion is induced in about twenty-five per cent, of all cases, as the result of placental apoplexies, or of the stimulation of the uterus to contraction by the accumulation of carbon dioxid gas in the blood. Pregnancy distinctly increases the danger of the heart-lesion. In fifty-eight serious cases, twenty-three died after a premature delivery of the child. In milder cases the prognosis is not grave, yet the woman's con- dition is by no means free from danger. The complications particularly to be dreaded during gestation are : a fresh outbreak of endocarditis, fatty degeneration of the papillary muscles, and, especially, congestion of the lungs. If the disease be of long standing and serious in character, it appears, from statistical studies, that about half the women will die.1 If there is good compensation, however, there may not be an untoward symptom, or, at most, occasional palpitations, some dyspnea, edema, and a tendency to renal congestion, with albuminuria. Treatment.—The pregnant woman with valvular disease of the heart must be carefully watched. Her urine should be examined at frequent intervals. On the first appearance of symptoms pointing to inadequate compensation, digitalis or strophanthus must be administered, and it is commonly necessary to increase the dose as pregnancy advances. The bowels must be kept freely opened. Moderate exercise in the open air is an advan- tage, but rest in the recumbent posture must be ordered at fre- quent intervals during the day. Meat should be eaten sparingly 1 This is not, however, my experience ; with proper treatment I have no fear of heart disease in pregnancy (see Dystocia). DISEASES OF THE CIRCULATORY APPARATUS. 237 on account of the likelihood of kidney breakdown, and extra pre- cautions must be taken against suddenly throwing greater work upon the kidneys by chilling the skin. Flatulent dyspepsia is not infrequent in cardiac weakness. It should be carefully treated. It is almost unnecessary to state that the woman must avoid any sudden, violent physical effort, and should be spared any cause for mental excitement. Finally, pregnancy should never be allowed to continue longer than the thirty-sixth week in a woman who exhibits any symptom of imperfect compensa- tion. The Heart=muscle.—Suppurative myocarditis is only seen in connection with septic infection. Brown atrophy of the myo- cardium has been noted as a very rare complication of preg- nancy ; fatty degeneration of the heart-muscle may occur acutely in consequence of general systemic septic infection, or as a result of the accumulation of poisons in the blood when the kidneys are functionally insufficient. Graves' Disease and Goiter.—These diseases are unfavor- ably influenced by pregnancy. The former may have its origin in gestation. It predisposes the woman to uterine hemorrhages and may be a cause of fetal death. It may and usually will dis- appear after delivery. I have one patient in whom exophthal- mic goiter with all its classical symptoms has recurred regularly in three successive pregnancies, the woman at other times being quite free from the disease. A goiter may take on so exag- gerated a development during pregnancy that asphyxia is threatened, and tracheotomy may be necessary. The Blood=vessels.—The disease of most clinical interest in these structures is varicose veins in the rectum, anus, broad ligament, bladder, vagina, external genitalia, the abdominal walls, and lower extremities. In the last there may develop a pressure edema, associated usually with varicose veins. The causes of varices in pregnancy are changes in the invest- ing muscular sheath of the veins, the increased quantity of blood, and mechanical obstruction to the circulation by the bulk of the growing uterus. Atheroma and degenerative changes may be found in the vessel-walls as the result of kidney insufficiency. Complications.—There may be rupture, with possibly a fatal hemorrhage, a severe interstitial bleeding, or extensive extravasa- tion of blood under the skin. Thromboses and phlebitis, with suppuration and septic infection, may occur. As the result of itching and scratching, eczema or even erysipelas of the affected part may develop. Treatment.—An elastic bandage or stocking should be ordered for varices of the legs. Small doses of heart-tonics are 238 PREGNANCY. often of service. Constipation must be avoided. The patient should be advised to lie down at intervals during the day. Abso- lute rest must be ordered in cases of thromboses, to prevent em- bolism. Lead-water and laudanum should be applied when there is any inflammation. Abscesses along the course of a diseased vein should be opened early. A mechanical protection (soap- plaster) should be applied to the affected part to prevent the development of eczema or of erysipelas. Itching may be relieved by weak solutions of carbolic acid or by cocain. The woman herself should be instructed how to check hemorrhages, in case the distended veins burst. Aneurysms are naturally unfavorably affected by pregnancy. The hypertrophy of the heart, the increased quantity of blood, and the mechanical interference with the circulation in gestation are all unfavorable factors. Such a case should be managed on the same principles that govern the treatment of cardiac complica- tions. By this plan I have successfully delivered a young woman with an enormous aneurysm of the arch of the aorta. The Blood.—Pregnancy may have a decided influence in producing those blood diseases which are characterized by a marked alteration in its constituent parts. Pernicious anemia and leukemia may have their origin in gestation, and should they already exist, they are aggravated by the existence of pregnancy. Pregnancy should be promptly interrupted if these blood diseases are obviously progressing from bad to worse. The anemia of pregnancy may be so exaggerated as to appear pernicious, but arsenic, iron, and nutritious diet after delivery will usually effect a cure. Purpura hcemorrhagica is apt to be rapidly fatal in preg- nancy, which it always interrupts. The disease usually destroys the fetus before it is expelled. The maternal death may be due to postpartum hemorrhage or to sepsis. DISEASES OF THE RESPIRATORY APPARATUS. The Nose.—The sense of smell may be more acute, and peculiarities in this sense are developed, as abhorrence for certain odors, which may excite nausea and vomiting in neurotic indi- viduals. More important is the disposition to epistaxis, which may be so severe as to threaten life. Epistaxis, however, is a more serious complication of parturition than of pregnancy. It can only be checked by the rapid termination of labor. Meanwhile the nares should be packed. The Larynx.—If a tumor, tubercular or syphilitic disease be DISEASES OF THE RESPIRATORY APPARATUS. 239 present, there is a constant danger of edema of the glottis, which will require tracheotomy. The Bronchi and Lungs.—Bronchial catarrh ordinarily is not harmful, but prolonged coughing may cause abortion, and the hydremic condition of the blood in pregnancy predisposes to pulmonary edema. The cough may have a neurotic element in it, and may be most persistent. In its treatment I have obtained better results from oil of sandalwood than from any other single remedy. Pneumonia.—The symptoms of this disease are much aggra- vated by gestation, the mortality is increased, and in the vast majority of cases the fetus is prematurely expelled (see Pathology of Puerperium). Emphysema is quite common. The symptoms in a pregnant woman are aggravated, and abortion is apt to occur. In ad- dition to the usual treatment inhalations of oxygen may be given to counteract the accumulation of carbon dioxid in the blood, which stimulates the uterine muscle to contract, and thus is the chief factor in determining an interruption of pregnancy. Asthma in some women may only appear during pregnancy. In such cases the disease disappears the moment gestation is terminated. In other cases asthma may only appear in labor. In asthmatic subjects the attacks may be much aggravated by gestation and may obstinately resist all treatment. Radical change of air and scene has proved efficacious when all medicinal remedies have failed. Phthisis Pulmonalis.—The influence of pregnancy upon this disease is most unfavorable, and in women predisposed to tuber- culosis gestation may be the determining factor in lighting up an attack. There is a superstition prevalent among the laity that pregnancy is beneficial to a phthisical patient. This idea has its origin in the accumulation of fat commonly seen in the pregnant woman, which gives her a fictitious appearance of improved health. In reality the strain and drain of child-bearing exhausts the vitality of the tuberculous subject so seriously that her death is hastened by many months, and a pulmonary phthisis that might have been arrested becomes incurable. It is the duty of a physician to advise strongly against marriage and maternity in the case of a woman already infected with or predisposed to tuberculosis. Miliary tuberculosis is rapidly fatal in pregnancy or shortly after delivery. It may be mistaken for septic infection. I have seen several cases in child-bearing women in which this mistake was made. The diagnosis is extremely difficult to make. Pulmonary embolism is a possible accident in pregnancy. 240 PREGNANCY. Pleurisy exerts no deleterious influence upon, nor is it af- fected by, gestation. Hemoptysis may occur in the latter months of pregnancy without phthisis or other lung disease. It is in these cases the result of " cardiac nerve-storms " in pregnant women of neurotic character. The cheeks are suffused, the eyes are bright, and the heart beats powerfully and tumultously. The woman looks as though she had a high fever, but her temperature is normal. Chloral and the bromids will control the attack. Diseases of the Osseous System.—Osteomalacia of pregnancy is a decalcification of the bones due to a peculiar osteitis and periosteitis, the result of malnutrition.x Pott's disease, in its active stage, is aggravated by pregnancy, and the mortality is much increased. The infectious diseases are always more serious when com- plicating pregnancy, their symptoms being more severe and their mortality greater. Even measles at this time may become a deadly disease. Upon pregnancy their influence is, as a rule, unfavorable. Sixty-five per cent, of typhoid=fever cases are complicated by abortion or premature labor. The development of the infant may be seriously affected in prolonged infectious fevers during gestation. Idiocy has been noted in a considerable number of cases. Syphilis exerts its malign influence chiefly upon the fetus. If the mother is diseased before impregnation, the fetus and appendages exhibit characteristic pathological alterations. If the mother acquires the disease from the fetus, she may possibly exhibit secondary symptoms without the appearance of a primary lesion. If the woman acquires a chancre during gestation, she alone, as a rule, is affected, the fetus escaping, although the latter is not so absolutely exempt from infection as was at one time claimed. In about twenty-five per cent, of such cases the child acquires the disease. Should infection occur at the time of impregnation, the primary sore and mucous patches in the vagina may assume an almost malignant character, ulcerating the vaginal mucous membrane, resisting treatment, and seriously complicating the puerperal state. The treatment of all the infectious diseases in gestation is to be conducted with little reference to pregnancy. If abortion is threatened, the tendency should not be combated, as the termina- 1 See Deformities of the Pelvis. SKIN DISEASES. 24I tion of pregnancy is often of advantage to the mother, and at any rate can not be averted. The treatment of syphilis in the pregnant woman is dealt with in a preceding section. Skin Diseases.—The following skin diseases are said to have their origin in pregnancy : Impetigo Herpetiformis.—The favorite seat of the eruption is in the groin, around the umbilicus, on the breasts, in the axilla. The small pustules become crusts, around which new pustules develop until the entire surface of the skin is covered in the course of three or four months. Rigors, high intermittent fever, great prostration, delirium, and vomiting accompany the erup- tion. The disease appears, as a rule, during the second half of ges- tation. Recent observation has shown that it is not absolutely confined to pregnancy. Of twelve cases ten terminated fatally, but the disease did not terminate gestation prior to the maternal death. Herpes gestation is is characterized by a pemphigoid efflores- cence, exhibiting erythema, vesicles, and bullae. It appears early in pregnancy, continues during gestation, and disappears during the puerperal state. Neurotic symptoms are associated with it, showing its probable nervous origin. Pruritus.—Its usual seat is the external genitalia,—pruritus vulvce. It may, however, in rare cases be general. Causes : The disease is often a neurosis, but it may depend upon irritat- ing discharges, parasites, or glycosuria. Treatment: Rarely in general pruritus it may be necessary to induce premature labor, and in pruritus vulvae the irritation is sometimes so great that the woman walks the floor the greater part of the night, tearing at the vulva with the finger-nails until the flesh is raw. I have seen women brought to the verge of insanity in this affec- tion, and have seriously considered the artificial termination of pregnancy, but have not yet been obliged to resort to it. In my experience, the commonest cause of pruritus vulvae in pregnancy is an irritating vaginal discharge, and the most successful treat- ment has been a thorough disinfection of the vaginal mucous membrane by pouring into a cylindrical speculum a twenty-grain- to-the-ounce solution of nitrate of silver, then slowly withdrawing the speculum so that all the folds of the membrane are success- ively bathed in the solution. The treatment should be concluded by a douche of sterile water to wash out any excess of silver nitrate solution. In cases of purely neurotic pruritus nerve seda- tives and a moral control of the patient, with a management on the lines of a rest-cure, will be most effective. In the pruritus of 16 242 PREGNANCY. glycosuria dietetic management is required. A boric-acid oint- ment on the skin will protect it until the sugar in the urine is reduced in quantity. There are three domestic remedies that enjoy a consider- able reputation : very hot fomentations, vinegar, and infusion of tobacco. The last must be used sparingly and cautiously. The best medicinal applications are cocain, menthol, and carbolic- acid preparations. The pruritus dependent upon seat-worms is treated by rectal injections of infusion of quassia. Exaggerated Pigmentation.—Spots of quite dark pigmentation may appear on the breasts, thighs, and abdomen, as large as ten- cent pieces or a quarter of a dollar. The chloasmata on the face may be so exaggerated as to disfigure the countenance. This skin affection disappears after delivery, and is not amenable to treatment during pregnancy. Loosening of the finger nails is a painful affection of pregnancy, apparently dependent upon malnutrition, and usually appearing in neurotic individuals. Nerve tonics, especially strychin, good hygiene, and a general tonic treatment do something to arrest the progress of the disease; but in the few cases under my observa- tion (one recurring in three successive pregnancies) the treatment was only palliative as long as pregnancy continued. Injuries and Accidents.—Severe injuries to a pregnant woman usually result in abortion. Among the most serious accidents - of pregnancy are rupture of varicose veins in the ex- ternal genitalia, the vagina, or lower extremities. One of the rarest accidents of pregnancy is rupture of the uterus. It may occur spontaneously in consequence of a previous Cesarean sec- tion, a myomectomy, or a healed rupture of the uterus at a former labor, the scar bursting open ; it may be the result of chronic inflammation and degeneration of the uterine walls, reducing them to little more than connective tissue ; or it may be due to traumatism. Spontaneous rupture of the uterus in pregnancy almost always occurs at the fundus, and frequently at the pla- cental site. The accident is almost invariably fatal to both mother and child. A very serious accident of pregnancy is de- tachment of a normally situated placenta, with concealed internal hemorrhage (see Dystocia). Surgical Operations.—If a pregnant woman's life or health is seriously threatened by delay until the completion of puerperal convalescence, surgical operations are justifiable, and permission may be given for their performance without great fear of an abor- ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 243 tion if septic infection is avoided. My friend, Professor W. W. Keen, successfully amputated the thigh at the hip-joint for sar- coma in a woman five months pregnant, without interrupting gestation. Tumors of the pelvic regions may be excised with no more risk of abortion than any woman runs (twenty per cent.). It is even possible to remove a myoma from the uterine wall without inciting uterine contractions. I had the privilege of assisting Dr. Wm. J. Taylor in a myomectomy on a woman some four months pregnant. The tumor was enucleated from the uterine wall, leaving a raw surface as large as the outspread hand. The woman was prematurely delivered, but it was some time after the operation, which appeared not to have caused the miscarriage. In nervous and irritable women, however, slight operations, such as the extraction of a tooth may interrupt gestation. The proper course, naturally, is to avoid operative interference in the preg- nant woman, if it can be deferred without serious detriment to the patient. If, on the contrary, there is a positive indication for immediate operation, it should be undertaken without hesitation. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. The term "abortion" is usually applied to the expulsion of the ovum before the fourth month, at a time when the placenta is not yet fully differentiated from the remainder of the chorion. Premature labor signifies the birth of a fetus that is viable. For the expulsion of the ovum during the intervening time from the fourth to the sixth month of pregnancy a distinctive term is needed, as the process, in combining some of the features of both abortion and premature labor, presents a clinical picture different from either of them. To denote the interruption of pregnancy at this time the word " miscarriage " will here be used. The Causes of Premature Expulsion of the Ovum.—Many of the conditions which interrupt the course of pregnancy have been referred to. The death of the fetus ; abnormalities and diseases of the membranes, including the deciduae ; pathological conditions of the placenta and apoplexies of the ovum ; trau- matism and certain diseases of the mother have all been noticed. But the maternal diseases have been regarded chiefly as to their effect directly upon the embryo, fetus, or ovum. There are, however, certain conditions of the mother having as their primary effect the active contraction of the uterine muscle, which results secondarily in the premature expulsion of the ovum, although the latter may be normal in every respect. Under this head come : Irritable Uterus.—From clinical observation one must feel in- clined to ascribe to every uterus a special temperament, which, 244 PREGNANCY. as the case may be, is irritable, equable, or apathetic. It is notorious that some pregnant women are liable to lose the product of conception from a trivial cause. A long walk, coitus, congestion of the pelvis from any cause, ovaritis, irritation of the breasts or nipples, the extraction of a tooth, irritation of the vulva, a dose of some mild purgative, the jolting of a carriage ; a misstep, especially wiiile descending a staircase ; not to mention a sea-bath, exercise on horseback, or dancing, have been followed by expulsion of the ovum. The mere sight of another woman in labor has been sufficient cause for abortion in some nervous women. In case the disposition of the woman to abort is known, the greatest care must be exercised to guard her from anything which might stimulate uterine contractions, and at the time corre- sponding to the menstrual period, when the uterus is particularly irritable and prone from habit to contract, the precautions must be doubled. The opposite picture, while not so familiar, is occasionally seen. Some women can make the most violent exertion, can receive the roughest treatment, without bringing pregnancy to an end. English writers tell of women who follow the hounds over the most difficult country in the early months of pregnancy without aborting. Sounds have been introduced into the preg- nant uterus ; intra-uterine injections have been given \x strong applications have been made to the endometrium ; trocars have been plunged through the uterine wall ;2 a pregnant woman has been thrown violently from her carriage ;3 another fell from a third-story window, fracturing her skull and breaking a leg ;4 in one case a young girl, five months pregnant, cast herself from the Pont Neuf into the Seine ;5 in another, fifteen leeches were applied to the cervix of a pregnant uterus ; Emmet's operation has been performed upon the cervix during the second month of pregnancy; ovariotomy and other serious surgical operations have been repeatedly performed,—all without inducing abortion or premature labor. Spasmodic Muscular Action in the Mother as a Cause of Prema= ture Expulsion of the Ovum.—Pregnant women affected with cho- rea, eclampsia, uncontrollable vomiting or coughing, epileptic, hysterical, or cholemic convulsions, or with tetany, are very liable to expel the product of conception prematurely. 1 Scanzoni, " Lehrbuch d. Geb.," Wien, 1867, p. 83. 2 Many cases are reported of tapping a uterus distended by hydramnion in mis- take for an ovarian cyst or ascites. 3 Tarnier and Cazeaux, 8th ed., p. 567. Also one of my patients. 4 A patient of mine in the Philadelphia Hospital. She recovered from her injuries, received at the fifth month of pregnancy, and was delivered at term. 5 Juillard, " Nouvelles Archives d'Obstet. et de Gynec," 1886, p. 1645. AB OR TION, MISCA RRIA GE, AND PRE MA TURE LAB OR. 245 Chorea.—Less than half of the women affected with chorea gravidarum will go to term. Of 57 cases collected by Barnes, only 22 completed the full time of pregnancy. Bamberg's statistics of 64 cases show 33 arrived at term, and Spiegelberg, of 69 cases, saw only 29 delivered of mature infants.1 The reason for the premature termination of pregnancy in these cases is not quite clear. Perhaps the physical exhaustion due to almost incessant muscular action explains it. It may be that the muscular contraction disturbs the venous circulation, brings about a stasis in the uterine veins and a consequent excess of carbonic oxid gas, which may excite the uterine muscle to action (Brown-Sequard). In a case recently under my observa- tion the uterine muscle toward the end of pregnancy seemed to take part in the choreic movements that convulsed the muscles of the extremities. Through the abdominal wall the uterus could be felt firmly contracting at intervals of not more than a minute. Every contraction was extremely painful, but during the four days that this condition of the uterus lasted the os showed no signs of dilatation. The suffering finally became so great that labor was induced by Krause's method.2 Eclampsia.—The eclampsia of pregnancy in the great majority of cases determines the premature expulsion of the ovum. Fre- quently, no doubt, the life of the fetus is first destroyed ; often, however, the immediate effect is seen in expulsive efforts of the uterus, due to the asphyxia of the organ, to the irritating effect of urea, carbonate ammonia, or excrementitious products in the blood, or perhaps to the fact that the uterine muscle shares in the convulsive action of the whole muscular system. Uncontrollable Vomiting and Coughing.—The constant violent action of the diaphragm in cases of uncontrollable vomiting dur- ing pregnancy often leads to the expulsion of the ovum. Of 51 cases of uncontrollable vomiting collected by Gueniot, 20 ended in abortion or premature labor.3 A violent and per- sistent cough will also, in rare instances, by the constant succus- sion in the abdominal cavity, be the cause of premature expul- sion of the ovum. Epileptic, Hysterical, Choiemic, and Tetanoid Convulsions.— According to Tarnier, attacks of epilepsy during pregnancy can be disastrous for the fetus, either in killing it outright or in bring- ing about its premature expulsion. Tanner mentions a case of hysterical convulsions which was followed by the expulsion of a 1 Herve, "These de Paris," 1884. 2 For a report of the case see " Trans. Philadelphia Obstet. Soc," Dec, 1887. 3 Tarnier et Budin, op. cit., p. 59. 246 PREGNANCY. dead fetus at the seventh month.x Cholemic convulsions occur perhaps more frequently than is generally suspected,2 and they always interrupt pregnancy, either by the death of the mother or the expulsion of the ovum. Meinert 3 has collected 11 cases of a tetanoid condition in pregnancy, in 6 of which there was true tetany. In 2 of the 11 cases dead children were born, 1 prematurely at the seventh month, the other at term. In one other case the child was expelled at the eighth month, and in another eleven days before term. Conditions of the Maternal Blood which Stimulate the Pregnant Uterus to Contract.—The poisons of all the infectious diseases in the maternal blood are likely to excite active contractions in the pregnant uterus. Whether this is due to some irritative action of the micro-organisms, or to the development of toxins, or to a diminution of the oxygenating power of the blood, as yet re- mains in doubt. The last condition explains the abortions occurring in pneumonia, as well as in cases of chronic heart disease, in which the circulation is much interfered with. It is possible also that strong emotions alter the blood in some way that would account for the action of the uterus when women have been terrified. But it is more likely that the action is analogous to that of the rectal and vesical muscles in cases of nervous defecation and urination. Thus, Baudelocque said in his lectures that, after the explosion of the powder-mill of Grenelle, he was called to see sixty-two women, either aborting or threatened with abortion. In all maternal diseases accompanied by fever the thermic irritation of the uterine muscle might be held responsible for the expulsive efforts of the uterus, but there are in these cases other conditions offering a more probable explanation for the abortion. Uterine Contractions Excited by an Abnormal Situation or Posi= tion of the Uterus.—Retroflexion and prolapse of the gravid uterus may induce abortion, for the uterus is unable to properly expand in its unnatural position. This is true likewise of pregnancy in one born of a deformed uterus.4 Perimetritis also, resulting in adhesions between the uterus and neighboring organs, or cellulitis, with plastic exudate in the broad ligaments, as well as diseases of a tube and ovary leading to adhesions, will, if pregnancy should occur, usually interrupt its course by interfering with the expansion of the gravid uterus. Appendicitis, with adhesions involving the uterine adnexa, may 1 "The Signs and Diseases of Pregnancy," London, 1867, p. 304. 2 Stumpf, loc. cit. 3 " Archiv f. Gyn.," Bd. xxxi, S. 444. 4 L. Munde, "Case of Pregnancy in One Horn of a Double Uterus, with Successive Miscarriages," " Amer. Jour. Obstetrics," 1887, pp. 337, 346. ABORTION, MISCARRIAGE, AND PREMATURE LABOR. 247 also have the same result. Fibromyomata of the uterine wall may act in the same manner, or else, by the congestion of the organ to which they lead, or by acting as a mechanical irritant, may stimulate the uterine muscle to contraction. Overdistention of the Uterus as a Cause of Premature Expulsion of the Ovum.—If the uterus is unduly distended in hydramnios or in cases of multiple pregnancy,1 especially when there are three or more fetuses, the distention of the muscle may irritate it to expulsive efforts. In twin pregnancies, should one fetus die, the uterine muscle is occasionally stimulated to contraction, and the entire uterine contents are cast off, although the remaining fetus may be healthy and normal. In cows epidemics of abortion have been observed, which have been attributed to a specific form of micro-organism, said by Franck and Roloff to resemble the leptothrix buccalis.2 Brocard 3 has also called attention again to this disease. It is improbable that the same disease can affect a woman, but in lying-in hospitals an epidemic of abortion or premature labor might occur from septic infection during pregnancy. Clinical History of Abortion and Miscarriage.—Premature labor is not referred to. Its course, management, complications, and after-treatment may be considered in the description of labor at term, from which it does not materially differ. The Frequency of Abortion.—It is almost impossible to arrive at a correct estimate of the frequency of abortion. So many women lose an impregnated ovum at an early period of its development, when they are not conscious of being preg- nant ; so many others fail to seek medical advice for an abortion uncomplicated by hemorrhage or decomposition of retained secundines, that almost all the estimates of the relative fre- quency of abortion and labor at term place the figure for the former too low. Hegar 4 says that one abortion will occur to every eight or ten labors at term ; but the estimate of Guillemot and Devilliers,5 of one abortion to every four or five pregnancies, is doubtless more nearly correct,—an opinion in which Tarnier coincides. Priestley6 found that 400 women, among whom there had been 2325 pregnancies, gave a return of 542 abortions, or about one abortion to every four pregnancies. My own case- books also show this proportion. 1 See Doleris, " Nouvelles Archives d'Obstet. et de Gynec," 1886, p. 318. 2 Schroeder, " Geburtshulfe," 8. Aufl., 1884, p.460. 3 " Recherches sur l'Avortement epizootique des Vaches," Broch., Paris, 1886. * " Beitrage zur Pathologie des Eies," "Monats. f. Geburtsh.," Bd. xxxi, S. 34. 5 Tarnier et Budin, op. cit., p. 474. 6 " Pathology of Intra-uterine Death," London, 1887, p. 8. 248 PREGNANCY. Clinical Phenomena of Abortion.—The main clinical phe- nomena of abortion are: (1) Hemorrhage, (2) pain, and (3) the expulsion of more or less characteristic portions of an impreg- nated ovum. But these symptoms are rarely all manifested in a typical manner in every case. Pain may be absent, hemorrhage not excessive, and the whole ovum when cast off so small that it escapes unnoticed among the clots of blood that are discharged from the uterus. Such cases occur shortly after conception, and often pass for disordered menstruation, while the fact that preg- nancy had begun is not suspected. The duration of abortion varies to an extraordinary degree. The French speak of an avortement instantanc and Cazeaux gives an example of a woman who fell upon her buttocks, and, on rising, found on her linen considerable blood and a Fig- 153.—An embryo surrounded by thickened deciduous membrane (Hodge Obstetrical Collection, University of Pennsylvania). six-week ovum. In some cases the expulsion of the ovum may occupy about the time consumed in a normal labor, but very frequently the process is a much slower one. Days, and even weeks, may be required for the uterus to get rid of its contents if left unaided to nature, and it is not rare for a fragment of the placenta or a portion of the uterine decidua to remain behind indefinitely, firmly attached to the uterine wall and often continuing to grow and develop, constituting within the uterus a true pathological new formation.1 Of the two symptoms, pain and hemorrhage, the former is, in early abortions, usually the sub- ordinate one. The hemorrhage is not often excessive, but may become alarming. The blood is not expelled in a steady flow, 1 A condition described under the names "placental polyp," "polypoid hema- tomata." ABORTION, MISCARRIAGE, AND PREMAPURE LABOR. 249 but from time to time as coagula. When the uterus discharges its contents the appearance of the substance expelled differs as the ovum is cast off entire with its shaggy, chorional coat, or surrounded by the decidua, which is often much thickened; as Fig. 154.—Thickened decidua, forming cast of uterine cavity. Cavity empty (Hodge Obstetrical Collection, University of Pennsylvania). Fig. 155. — An embryo in its amni- otic sac (from the Hodge Obstetrical Col- lection of the University of Pennsylvania). the embryo, enveloped by its amnion, is extruded without the decidua and chorion, or as the embryo, its delicate umbilical cord being ruptured, is expelled alone. The appearance of the embryo will, of course, vary with the different periods of preg- nancy : if still inclosed in its amni- otic sac, a thin-walled, transparent vesicle may be found floating in the blood or imbedded in a clot, and within the sac the embryo is seen floating in the liquor amnii. In other cases the ovum will resemble a ball of flesh, which, on being opened, discloses an embryo con- fined within a sac with very thick walls, composed mainly of greatly hypertrophied decidua. Or, again, the substance expelled from the uterus may be a fleshy mass, the deciduous membrane, in shape a cast of the uterine cavity, which on section reveals within itself an empty cavity. The embryo in these cases has either died and been absorbed, or else has been previously cast off unnoticed in the bloody discharge. Fig. 156.—Embryo of about four weeks, with its membranes entire. 250 PREGNANCY. If the ovum proper is cast off entire,—that is, with its cho- rional covering intact, without adherent shreds of deciduous membrane,—it presents an appearance quite characteristic, espe- cially if floated in water; the chorional villi show to the best advantage, giving the ovum much the appearance, except for its color, of a chestnut-bur. Most frequently it is the embryo alone, or at most the ovum, in whole or in part, covered often by the ovular decidua that is cast off, while the uterine decidua remains behind within the uterus. Duhrssen,1 from a rich experience in the service of the Charite in Berlin, says that "the retention of portions of the decidua vera is not the exception, but the rule " ; and Tarnier says that " ordinarily the uterine decidua remains adherent to the uterus." The retention of this membrane after abortion can not be regarded with indifference, for the uterine mucous mem- brane in the early part of pregnancy, greatly hypertrophied and thickened, before it has undergone the physiological atrophy that begins in the third month is very different from the delicate membrane which lines the uterus at term. This thickened uter- ine decidua, suddenly cut off from the greater part of its blood- supply by contraction of the uterine wall, becomes a mass of dead animal flesh within the uterus, and soon begins to putrefy, or else portions of the decidua attract an increased blood-supply, retain their original development, or even increase in size, form- ing new growths within the uterus which give rise to frequent and alarming hemorrhages. It is this complication of abortion that often makes the prog- nosis uncertain, and is perhaps the main factor in raising the mortality after abortions almost as high as that of childbirth at term. In New York City, between the years 1867 and 1875, inclusive, 197 deaths were reported as a result of abortion,—a number doubtless far short of the truth. In the Rotunda Hos- pital of Dublin, during the mastership of Dr. Johnston, 234 abortions occurred, with but 1 death, and that from heart dis- ease. 2 But of 120 cases treated in the clinic and polyclinic of the Charite in Berlin, 2 died.3 Of 82 abortions in the Obstet- rical and Gynecological Institute of Florence,4 5 resulted fatally 1 "Zur Pathologie und Therapie des Abortus," "Archiv f. Gyn " Bd xwi, H. 2. J 2 Lusk's "Obstetrics," 1886, p. 313. 3 Duhrssen loc. cit. This same author mentions the statistics of 520 cases of abortion collected in the inaugural thesis of Lechler (Berlin). Half of these treated by active interference, showed 4 deaths—3 from intercurrent affections, I the result ot abortion. Marcels?' " ^ ^^ ^ tdenn0' l883"85/' " Annali di Ostet. e Gynecol.," ABOR TION, MISCARRIA GE, AND PRE MA TURE LAB OR. 2 5 I to the women,—a death-rate of six per cent. In the Charite at Paris (1883-86) there were 57 cases of abortion without a death ; and in the Maternite, 153 cases with 1 death (Tarnier). Hos- pital statistics, however, as to the death-rate after abortion, are unsatisfactory. The reliable records of some large out-door dis- pensary service would tend to throw light upon the matter. Diagnosis.—It may be necessary in cases of suspected abor- tion to determine the existence of pregnancy; that fact being established, it becomes necessary to distinguish between threat- ened abortion, inevitable abortion, and an abortion partially or wholly accomplished. The Diagnosis of Threatened Abortion.—If a patient should present a history of suppression of the menses, perhaps for only one period ; if it could be learned that she had been exposed to the possibility of impregnation ; if there were, in a wrord, the signs of early pregnancy, and a hemorrhage should occur from the uterus, associated with more or less pain, the supposition that an abortion was threatened would be justified. Irregularities in menstruation, the suppression of the function from causes other than pregnancy, and its reestablishment by a profuse flow, accompanied by pain, might well arouse a suspicion of abortion. In these cases, however, the signs of pregnancy are absent and the os is not patulous. This is by no means true of every case, however; and if the symptom should be due to an effort of the uterus to expel a polypoid tumor, the case may so closely resemble one of abortion that the diagnosis will only be made after the expulsion of the uterine contents or the dilatation of the os. In cases of doubt the diagnosis should rest on abortion and the treatment should be adapted to this idea. The Diagnosis of Inevitable Abortion.—It is always desirable to determine when a threatened abortion becomes inevitable, for if its prevention is no longer possible, the treatment should be radically altered. Unfortunately, however, the signs which usually denote an unavoidable expulsion of the ovum are not always to be depended upon. If there is persistent hemorrhage, abortion will usually occur, but even in spite of a bleeding which may continue for a considerable time or return at intervals dur- ing the vvhole duration of pregnancy, the case may go on to term. If the cervix becomes markedly softened and the os dilates, the ovum will ordinarily be cast off; and yet the os has dilated sufficiently to admit two fingers, but has again retracted, and pregnancy has pursued its course. If portions of the uterine contents should be expelled, it would seem that abortion was surely inevitable ; but Playfair, Charpentier, and Doleris have reported cases in which pieces of decidua Avere expelled from the 252 PREGNANCY. uterus without the interruption of pregnancy. In Playfair's case four or five fragments of decidua, each as large as a fifty-cent piece, were cast off in the third month of pregnancy as a result of the introduction of a sound into the uterus ; but the woman went on to term. The only two conditions which can be said to render the abortion almost inevitable are the rupture of the membranes and the death of the embryo ; but even were it pos- sible to ascertain with certainty, during the early months of pregnancy, that the membranes were ruptured or that the embryo was dead, cases might be recalled in which the liquor amnii was resupplied after puncture of the pregnant uterus with the trocar (Chiara), or many other cases might be collected of the retention of an ovum after the death of the embryo for months or for an indefinite number of years. If, however, the hemorrhage is per- sistent ; if the os dilates ; if there is felt presenting within the os a cystic tumor—the ovum; x if the pain is considerable ; and, above all, if portions of the ovum are expelled, the abortion may be pronounced inevitable. Tarnier 2 calls attention to another sign which he believes to be valuable as indicating an unavoid- able abortion. This is the effacement of the rather acute angle formed anteriorly between the neck and body of a pregnant uterus. The disappearance of this angle indicates a contraction of the longitudinal fibers of the uterus and a descent of the ovum. The Diagnosis of an Abortion Partially or Wholly Accomplished. —It is always important to determine, in a case diagnosticated as one of abortion, whether a part or the whole of the uterine con- tents has been expelled. To make the diagnosis of an abortion partially or wholly effected it is necessary to examine everything discharged from the uterus ; the clots should be floated in water, and should be carefully teased apart, wrhen an embryo, alone or enveloped by its membranes, maybe discovered. But frequently the embryo and ovum are so small that they are lost in the com- paratively great volume of blood that surrounds them, or the discharges are removed from the patient and are not preserved. In such cases an internal digital examination will ordinarily serve to determine the true nature of the case. The os will usually be found patulous ; the finger, passing into the cavity of the uterus, will detect shreds of deciduous membrane more or less closely attached to the uterine wall, and often a placenta, still adherent, or some portions of the fetal membranes may be plainly distinguished. If the abortion has been wholly accomplished, 1 It will be well to bear in mind in this connection the possibility of the cervical pregnancy of Rokitansky, already referred to, of which several cases have been reported. 2 Tarnier and Cazeaux, vol. i, p. 574. ABOR TION MISCARRIA GE, AND PRE MA PURE LABOR. 253 —that is, if all the uterine contents, including the hypertrophied decidua, have been completely expelled,—the uterus is firmly contracted, the os is small, and a digital examination of the uterine cavity will be difficult or impossible. The diagnosis must depend upon the history of the case, upon the examination of the discharge, upon the enlarged uterus,—which does not at once return to its normal size,—upon the lochial discharge, and upon the establishment of the milk secretion. The last phe- nomenon is all the more marked the later the date of pregnancy at which abortion or miscarriage occurs, and is more evident in multiparae than in primiparae ; but Budin has observed a young girl in whom the menses were suppressed for only twenty days, and then returned as a profuse flow, who exhibited shortly after- ward all the signs of commencing lactation. In some cases the disappearance of all the presumptive signs of pregnancy, which had been before well marked, would justify the opinion that an abortion had occurred ; but it might denote nothing more than the death of the embryo, which can be re- tained within the uterus for varying periods of time, and when cast off may give rise to unjust suspicions as to the woman's moral character. Thus, if a woman whose husband has been absent many months should expel from her uterus an embryo corresponding perhaps to the second month of intra-uterine life, it by no means invariably follows that she has been unfaithful. Finally, if in the early months of pregnancy there is hemor- rhage and a discharge of deciduous membrane, it would be well, while making the digital examination, to feel on either side of the uterus for a tumor that might indicate a tubal pregnancy, and to inquire for the characteristic pain of that condition. Prognosis of Abortion and Miscarriage.—The prognosis as regards the product of conception need not be considered, for its destruction is inevitable. Statistics have been already given showing that every abortion or miscarriage entails a cer- tain amount of risk upon a woman. The hemorrhage, if rarely so great as to be immediately fatal, may, by its persistence, so weaken a woman that she quickly succumbs if attacked by any intercurrent affection, or the syncope produced by loss of blood may favor the formation of heart-clot. The retention of masses of decidua or of the placenta is often followed by the decom- position of these substances in utero, chronic salpingo-oophoritis, or even by fatal septicemia as a result. Tetanus is another complication post abortum which will, in rare cases, help to raise the mortality of abortion.1 Criminal abortions, with the addi- 1 For twenty-one cases of tetanus after abortion see Bennington, " British Gyn. Jour.," 1885. 254 PREGNANCY. tional risk of traumatism from the unskilful use of instruments, and the probability of infection from unclean hands and imple- ments, would probably show a very high rate of mortality if it were possible to collect accurate statistics. The prognosis of abortion depends in great part upon the treatment. If every case could be treated by an aseptic curetment at the hands of a skilled gynecologist, the mortality of abortion would be nil. Treatment.—If a pregnant woman presents any of the con- ditions which a physician's experience or knowledge teaches him may lead to the premature interruption of pregnancy, the treat- ment of these conditions will constitute the preventive treatment of abortion. Much has been said upon this subject when the diseases of the embryo and fetus and of the ovum were under consideration. The proper conduct to pursue in the other com- plications of pregnancy just described may be briefly indicated. In cases of irritable uterus the woman must be jealously guarded against any nervous shock, undue physical exertion, errors in diet, sexual intercourse—anything, in a word, that would furnish the uterus an excuse for throwing off its contents. In exaggerated cases of this condition prolonged rest in bed, especially at the time corresponding to the menstrual periods, or perhaps for the whole duration of pregnancy, may be neces- sary to secure the birth of a mature infant. If the pregnant uterus is displaced downward or backward, it must be restored to its proper position, and be kept in place by a suitable pessary until its increasing size prevents its displacement again. If there should be uncontrollable vomiting or coughing, these conditions must be treated appropriately. Asthma, which in some cases will determine a premature interruption of pregnancy, is best treated by change of climate.x In general muscular spasms, as in eclampsia, cholemia, chorea, epilepsy, hysteria, and tetany, the convulsions must be combated by appropriate remedies. The infectious and febrile diseases of pregnancy must be man- aged on general principles, without special regard to the danger of abortion, which is often unavoidable. Chronic metritis and endometritis, fibromyomata of the uterus, lacerated cervix, peri- metritis and cellulitis, disease of a tube or an ovary, must be treated before impregnation occurs. If, however, in spite of every precaution, the signs of threatened abortion manifest them- selves, the treatment resolves itself into: (i) The treatment of threatened abortion ; (2) the treatment, if necessary, of inevitable abortion ; and (3) the treatment of the woman post abortum. The Treatment of Threatened Abortion.—The two main principles of the treatment adopted to avert a threatened abor- 1 See note by Harris to Playfair's " Midwifery," p. 243. ABOR TION, MISCARRIA GE, AND PRE MA TURE LAB OR. 255 tion should be perfect rest and the administration of drugs that will diminish nervous sensibility and weaken muscular action. The first can only be secured in bed in a perfectly supine posi- tion. The room should be darkened and kept quiet, that the rest may be mental as well as physical. The second object of the treatment can be accomplished by giving opium, bromid of potassium, and chloral. Opium enjoys a well-deserved reputa- tion in these cases ; many instances might be cited of its benefi- cent working. It may be administered by the mouth as laudanum, hypodermatically as morphin, or, best, by the rectum as extract of opium in suppositories. Women on the verge of abortion display usually a remarkable tolerance of opium, and to be effec- tive the dose must often be large. As much as a dram or more of laudanum has been given within twenty-four hours without ill effect, but, of course, the patient must in such cases be carefully observed. With the opium it is often of advantage to combine moderate doses of chloral and bromid of potassium. Viburnum prunifolium x has of late years been much vaunted as almost a specific in the prevention of abortion, and its use has become very general throughout this country. The verdict in regard to this drug is, on the whole, favorable. Lusk speaks well of it; in England it has been tried by Campbell 2 and Napier,3 who both recommend it; and its employment seems to have spread even to Russia.4 It may be given in the form of a fluid extract, in teaspoonful doses5 three times a day. My routine medicinal treatment is a suppository of a grain of the extract of opium morning and evening, and a dram of the fluid extract of vibur- num three times a day. Treatment of Inevitable Abortion.—As soon as all hope of arresting the abortion is destroyed by the appearance of signs pointing to the unavoidable expulsion of the uterine contents, the treatment must be radically altered. Absolute rest is no longer necessary, while the administration of drugs that diminish sensi- bility and weaken muscular action is positively harmful, for it prolongs a process which in the interests of the patient were best completed as speedily as possible. But in many cases the woman will linger on, perhaps for days, before the greater part of the uterine contents is expelled, and it may be weeks before she is rid of the thickened decidua, which usually remains behind, or 1 Jenks, " Viburnum Prunifolium," "Trans. Amer. Gyn. Society," vol. i, p. 130. 2 "British Med. Jour.," 1886, i, p. 391. 3 Ibid., p. 489. * Reference in " Index Med.," 1887, Lvov. 5 Negri has recommended large doses of asafetida in cases where there had previously been a tendency to abort or to give birth to dead children. Great virtue is claimed for this drug, but it has not yet been given a sufficient trial to war rant an expression of opinion in regard to it. 256 PREGNANCY. of the adherent placenta, which is often retained in the uterus after the escape of the embryo and the remainder of the ovum ; and all this time there may be recurring hemorrhages of an alarming character or a constant dribbling of blood, and the lochial discharge becomes abundant, and is probably foul- smelling. In such a case the question naturally arises as to the advisability of interference to clean the uterine cavity thor- oughly of substances that might give rise to future trouble. This question receives different answers from authorities equally entitled to respectful attention. If the hemorrhage is severe before the os is at all dilated or any portion of the ovum discharged, there is no difference of opinion as to the necessity of controlling the bleeding. This is best effected by a vaginal tampon of sterile or iodoform gauze. A Sims speculum will facilitate the introduction of the tampon. The vaginal tampon should be removed after twelve or twenty- four hours, and replaced by a fresh one if necessary ; but often as the first tampon is removed the ovum or fetus comes with it and the immediate symptoms may in great part subside. But the uterus may not yet be empty; in the early months the large mass of deciduous membrane has almost entirely remained behind in the uterine cavity ; later, the placenta will frequently be retained. Whether now to treat the case expectantly until serious symptoms develop, or to remove at once the substances in the uterus which may give rise to future complications, is a problem that must frequently confront every practitioner. In the hands of a general practitioner without special knowledge of gynecological technic, the best results would probably be se- cured by the expectant treatment, so long as there was no fever, no excessive hemorrhage, or no odor of putrefaction to the dis- charge. In the hands of a trained gynecologist the best and safest treatment of an abortion is an aseptic curetment. Expectant Treatment.—When an abortion becomes inevitable, ergot may be substituted for the drugs that have been em- ployed to inhibit muscular action ; if there is much bleeding, tampons are to be used in the manner already indicated, and re- moved from time to time until the ovum is expelled, or else so well separated from the uterine wall that it may be gently ex- pressed or easily extracted by the fingers. The greatest care must be exercised to avoid rupture of the membranes, for this will probably lead to the retention of a portion of the ovum, whereas the expulsion of the ovum en bloc is particularly de- sirable in cases managed after this fashion. If a part of the embryo or its appendages should remain behind in the uterus, the woman is to be kept quiet in bed, small doses of ergot are AB OR TION, MISCARRIA GE, AND PRE MA TURE LAB OR. 2$? to be administered, and the vagina and, if possible, the uterine cavity are to be kept aseptic by injections of some effective germicide, preferably bichlorid of mercury in solution. If, in spite of every precaution, the discharge becomes foul, if the tem- perature rises, or if hemorrhages occur, the uterine cavity must be cleaned out. The manner of doing this will be indicated later. Active Treatment.—The first step of this plan of treatment resembles that already described. The tampon is used to con- trol bleeding, and as soon as the dilatation of the os is suffi- ciently advanced to admit a finger efforts are made, in early abor- tions, to turn out the ovum by sweeping the fingers around it, and then extracting it with the finger crooked behind it like a hook ; or Hoennig's method of expression may be tried.1 The ovum being wholly or in part expelled, everything left behind in the uterine cavity, whether thickened decidua or placental tissue, is to be extracted. Various means have been proposed for ac- complishing this purpose. For an adherent placenta nothing is better, in the writer's opinion, than the finger, which can be made to reach the fundus, the patient being anesthetized if necessary, by pressing the uterus down from above through the abdominal walls. By the finger the placenta is peeled off from the uterine wall, and afterward easily extracted. So much force is often necessary to do this that the use of an unyielding and insensible instrument is not advisable. To clear out the thickened decidua, which almost invariably remains behind in early abortions, noth- ing is so good as a curet. Duhrssen has demonstrated that the decidua removed from the uterus in this manner is not rudely torn off, but is separated in a natural manner in the cellular layer. A very valuable and, indeed, indispensable adjuvant to the curet is Emmet's curetment forceps, used as a placental forceps. If the os is so retracted that neither a finger nor an instrument can be introduced, the introduction of Hegar's graduated cervical dilators or the use of branched dilators will obviate the difficulty. After the uterine cavity is evacuated, it should be washed out by an intra-uterine injection.2 The After=treatment of Abortion.—If an active treatment has been pursued, the after-treatment will be very simple, for the lochial discharge in these cases is slight and the involution of the uterus rapid. Until this latter condition is perfected the woman, of course, should be confined to bed. It is never safe, 1 The uterus is squeezed between the fingers in a combined examination, and the uterine contents are pressed out as one would express a stone from a cherry. 2 I have tried every model of a two-way uterine catheter on the market and find Fritsch's modification of Bozeman's by far the best. 17 258 PREGNANCY. even in the earliest cases, to allow her to get up in less than a week or ten days. The after-treatment when an expectant plan has been pursued has already been indicated. Should septicemia develop, it is to be managed on the same principles that govern the treatment of this condition after delivery at term. Missed Abortion.—By this term is meant the death of the embryo, threatened abortion, the subsidence of symptoms, and the retention of the ovum for a varying length of time—occasionally very great—in utero. I was called in consultation to see a young woman who discharged at term an ovum about the size of a lemon retained in utero some seven months after the death of the embryo. The young wife and her husband were wealthy and heartily wel- comed the prospect of a child and heir. They had provided an elaborate and expensive outfit for the baby, even including a coach. Finally, at the end of nine months from the date of the last normal menstruation, labor-pains appeared. The family physician made repeated examinations and assured the husband and wife that the progress was satisfactory. At length, after twenty-four hours of hard pains, a little two-month ovum was expelled, to the inexpressible astonishment of the parents and the chagrin of the doctor. Miscarriage.—Much that has been said of abortion is applic- able to miscarriage as well; but by the time pregnancy has reached a period from the fourth to the seventh month it is not likely that the condition will be overlooked, so that one great difficulty in the diagnosis of abortion, the doubt as to the exist- ence of pregnancy, does not, as a rule, obtain in cases of mis- carriage. In these cases, too, it is easier to detect the two acci- dents which make the expulsion of the ovum almost inevitable— rupture of the membranes and the death of the fetus ; for the liquor amnii has reached such a quantity that its escape would almost always attract attention, while the death of the fetus, fol- lowed by a cessation of fetal movements and of growth in the uterus, by a disappearance of the reflex and psychical disturb- ances characteristic of pregnancy, and also, perhaps, by the ap- pearance of the milk-secretion, is not likely to pass unnoticed. The pain associated with miscarriage is greater than in abortion, and assumes the type of labor-pains. During the periodic con- tractions of the uterus the organ can be felt through the abdom- inal walls, becoming hard and firm and relaxing again as the pain passes off. The expulsion of the ovum resembles also a labor at term, as the fetus usually is first expelled and the mem- branes and placenta follow after. As pregnancy advances this sequence becomes more and more the rule, but occasionally the ovum is cast off entire, even at a late period of pregnancy. I EXTRA-UTERINE PREGNANCY. 259 have seen such an occurrence at the seventh month, and it has actually been reported to have occurred at term. Miscarriage is chiefly distinguished from abortion by the for- mation of the placenta, and from premature labor by the fact that this organ is quite adherent to the uterine wall, and often fails to become attached after the expulsion of the fetus, remaining wholly or in part adherent to the uterus, preventing proper con- traction of the uterine muscle, and consequently giving rise to serious hemorrhages, and, by its putrefaction, to infection. EXTRA-UTERINE PREGNANCY. By extra-uterine or ectopic pregnancy is meant the develop- ment of an impregnated ovum outside of the uterine cavity. The condition was described by Riolanus, Benedict Vassal (1669), and by Regnier de Graaf. Abdominal sections for extra-uterine pregnancies were performed by Nufer (1500) and by Dirlewang (1549). Bohmer (1752) differentiated the tubal, ovarian, and abdominal forms of ectopic gestation. Schmidt (1801) described interstitial pregnancy. Frequency.—The exact proportion of extra-uterine to intra- uterine gestations is difficult to determine. It has been said to be about 1 in 500 normal pregnancies. Winckel, however, saw but 16 cases in 22,000 births, and Bandl, in Vienna, but 3 out of 60,000. In the larger cities of this country a considerable num- ber occur annually. I have operated on nine patients for extra- uterine pregnancy in a single winter. Classification Based upon the Situation of the Developing Ovum. Tubal. Tubo-uterine, or interstitial. The ovum develops in that portion of the tube which runs through the uterine wall. Tubal proper. Tubo-ovarian. The ovum is attached to the ovarian fim- bria. Ovarian. The ovum develops in a Graafian follicle. Abdominal. In primary abdominal pregnancy the ovum at- taches itself to the peritoneal investment of the uterus, the broad ligament, or the intestines. Secondary abdominal. Ovario-abdominal. The ovum, beginning its growth in the ovary, pushes its way out into the abdominal cavity. Tubo-abdominal. The ovum, at first contained in the tube, escapes into the abdominal cavity by rupture or by a gradual separation of the fibers in the tubal coat. There 26o PREGNANCY. is a form of tubal pregnancy often called secondary ab- dominal or tubo-abdominal, in which the ovum grows downward and backward behind the peritoneum. This should be known as a broad-ligament or retroperitoneal pregnancy. Utero-abdominal. The ovum grows at first in the uterine cavity, but, in consequence of a spontaneous rupture or separation of an old scar in the uterine wall, becomes an abdominal pregnancy, retaining its connection with the uterus by the placenta. Etiology.—The causes of ectopic gestation are obscure. Any disease of the mucous membrane of the tube depriving its cells of their cilia, forming mucous polypi or otherwise obstruct- ing- 157.—Bifurcation of tubal canal (Hennig). ing its caliber, predisposes to an arrest of the impregnated ovum in its passage to the womb. So does any condition interfering with the normal peristalsis of the tube. Chronic salpingitis, therefore, is often found associated with and preceding tubal pregnancy. Peritoneal adhesions constricting or distorting the tubes and congenital narrowness of their canals may also obstruct the tubal canals. A diverticulum in the tube, an accessory tubal canal, external transmigration of the ovum, accessory abdominal ostia, and atresia of the tube have been noted in connection with ectopic gestation. Clinical History.—In each of the situations noted above the course of gestation may be somewhat different, and each may present an individual clinical picture on account of the difference in the surrounding anatomical structures which are involved. The general presumptive signs of pregnancy are commonly the EXTRA-UTERINE PREGNANCY. 26l same as in intra-uterine gestation, but there is usually severe pain. Extra-uterine pregnancy occurs oftenest between the twentieth and thirtieth years. The youngest woman affected was fourteen, the oldest forty-seven years of age. Changes in Uterus and Vagina.—In all the forms these changes are rather constant. Most of the alterations character- istic of intra-uterine pregnancy are found : hypertrophy of the vaginal mucous membrane, with increased blood-supply (purple tinge) and increased secretion ; a soft cervix and a patulous os ; an enlarged uterus, and, in the vast majority of cases, a develop- ment of a deciduous membrane, undergoing the same change as in intra-uterine gestation pre- paratory to its separation and extrusion, which occurs in extra- uterine gestation usually be- tween the eighth and twelfth week, the membrane being ex- pelled as a complete cast of the uterus and even of the tubes, or in shreds. The usual clinical history of ectopic gestation is absence of menstruation until the death of the embryo or rupture of the sac, when the menses return with the discharge of the decidua. The metrorrhagia which thus begins may continue for a long time. The other changes in the maternal organism may vary with the situation of the develop- ing ovum. Clinical History and Pathology of Tubal Pregnancy— Usually the woman has had children, but a long time has elapsed since the birth of the last child. The most frequent situation of an extra-uterine gestation is the outer third of the tube (the ampulla1). In this position it may grow upward into the abdominal cavity, distending the tube-walls to the point of rupture, or it may grow downward between the layers of the broad ligament, and then backward and upward behind the posterior parietal layer of the peritoneum (broad-ligament gesta- tion). The tubal walls grow thicker from the development of 1 Martin's statistics of 55 cases of extra-uterine pregnancy give this situation in 49. Fig. 158.—Decidual cast of the uterine cavity in extra-uterine preg- nancy (Zweifel). 262 PREGNANCY. their muscle-fibers, except at spots, especially on the upper and posterior surfaces, where rupture may occur, the woman experi- encing severe cramp-like pain, followed by symptoms of pro- found shock and death from hemorrhage, perhaps, in a few hours. Fever is often seen, sometimes to a high degree, even before rupture occurs. The usual temperature before rupture is between 990 and ioo° F. Exceptionally, the tubal gestation may proceed to full term (six per cent, of tubal pregnancies (Winckel)). In these cases the ovule has probably at first grown downward and backward. If rupture occurs, it usually takes place between the eighth and twelfth weeks, but it may be seen as early as the fourteenth day,1 or after the sixth month. If the tube ruptures upon the upper or posterior aspect of the sac, the sac-contents are extruded into the peritoneal cavity with an intra-peritoneal hemorrhage. If rupture occurs on the lower aspect, the contents of the ovum and the blood find their way between the layers of the broad ligament and pelvic fascia, giving rise to an extraperi- toneal hematocele. The first variety is usually fatal; the last is not always directly dangerous to life, but the layers of the broad ligament may rupture when distended with blood, and the bleed- ing then becomes intraperitoneal and unlimited. The bleeding may also be limited by peritoneal adhesions shutting off the peri- toneal cavity and forming a closed sac in the iliac region. From adhesions to intestines, complications, such as perforation and obstruction of the bowel, may occur. The mucous membrane of the tube undergoes a change, being converted into a decidua as in the uterus, but there are in the tube connective-tissue bundles between the decidual cells; the layers of the decidua are not well differentiated, and in the deepest layer muscle-fibers, connective-tissue bundles, and decidual cells are intermingled. It has been asserted by many observers that there is no decidua reflexa in tubal pregnancies, but Winckel has demonstrated it twice. The plications of the tubal mucous membrane are unfolded as the tube expands. There may be multiple (twin and triplet2) extra-uterine gesta- tion ; coincident intra- and extra-uterine pregnancy ; pregnancy first in one tube and then in the other ; simultaneous pregnancies in both tubes ; or two successive pregnancies in the same tube.3 1 Ross, "Am. Jour. Obstet.," October, 1895. According to Hecker's statistics of 45 cases rupture occurred 26 times in the first two months, 11 times in the third, 7 in the fourth, and once in the fifth. 2 Sanger, " Centralbl. f. Gyn.," No. 7, 1893. 3 Coe, "N. Y. Med. Record," May 27, 1893; Dorland, "Repeated Extra- uterine Pregnancy," " Amer. Jour. Obstetrics," April, 1898; Royster, " Combined Intra- and Extra-uterine Pregnancy at Term," ibid., 1897, vol. xxxvi, p. 820; Mosely, ibid., 1896, thirty-eight cases of intra- and extra-uterine pregnancy. EXTRA-UTERINE PREGNANCY. 263 Fig. 159.—A ruptured broad ligament pregnancy. Fig. 160.—Ruptured broad ligament pregnancy. ,.«■*■•£■-Os* ^Y. 3 Fig. 161.—Ruptured broad ligament pregnancy. The embryo in situ. 264 PREGNANCY. Hydramnios was noted in one case of tubal pregnancy1 and a thoracopagus was found in another.2 Clinical History of Interstitial Pregnancy.—In these cases the ovum develops in the uterine wall, the inner side of the sac Fig. 162.—Broad ligament pregnancy (Zweifel). often projecting into the uterine cavity, and having on its outer side the round ligament and the whole length of the tube. The usual termination of this kind of ectopic gestation is rupture into the peritoneal cavity. Hecker collected twenty-six cases, all end- Fig. 163.—Tubo-ovarian pregnancy. Sac ruptured. ing in rupture before the sixth month. Rupture into the uterine cavity and expulsion of the fetus through the cervix are possible. Rupture into or growth between the layers of the broad liga- ment is also possible. 1 "Archiv f. Gyn.," Bd. xxii, S. 57. 2"Centralbl. f. Gyn.," 1894, p. 232. EXTRA-UTERINE PREGNANCY. 265 Clinical History of Tubo=ovarian Pregnancy.—The ovum develops between the fimbriae of the tube and the ovary. The sac may rupture with the usual consequences of such accident. It is possible, however, to see a development of the fetus to maturity. The ovum may lodge upon the ovarian fimbria and may thence grow inward between the layers of the broad ligament. Clinical History of Ovarian Pregnancy.—The ovum, im- pregnated while it is still within the Graafian follicle, reaches some degree of growth and development within the ovary. The condition is exceedingly rare, but there are a few indubitable cases on record.1 One case in Philadelphia, reported by Dr. Baer, went to term. Miiller and Widerstein have reported cases of the prolapse of a pregnant ovary into the inguinal ring and canal. Clinical History of Abdominal Pregnancy.—Primary ab- dominal pregnancy is exceedingly rare. Many gynecologists deny its occurrence, but there have been a few authentic cases.2 The conditions in the free abdominal cavity favor the progress of pregnancy to the mature development of fetus. The peritoneum is converted into decidua-like membrane wiienever the ovum comes in contact with it, and from this source the chorion and placenta derive nutriment. The ovum is surrounded by a fibrous and vas- cular capsule. In abdominal and in advanced tubal gestation abortive labor-pains appear at term. The child dies at or shortly after this period, and the liquor amnii is absorbed after the death of the fetus. The abdomen is consequently reduced in size and the tumor is changed in consistency. The fetus may be con- verted into a lithopedion and may remain as an innocuous tumor in the abdomen for years (see Termination of Extra-uterine Pregnancy, and Changes in Fetal Body after Death). The child is likely to be small and ill-formed, but occasionally over- grown children are reported, no doubt on account of an existence of the fetus prolonged beyond the usual duration of pregnancy. In advanced cases of abdominal pregnancy the fetal movements are exceedingly painful to the mother. Abdominal pregnancies may end in rupture of the sac or there may be profuse hemor- rhage into the sac-cavity. Clinical History and Pathology of Utero=abdominaI Preg= nancy.—This condition is very rare. The pregnancy is at first 1 Cases are reported by Potenko, Werth, Paltauf, Leopold, and Martin. See Winckel, "Geburtshulfe" ; Kelly, article in "American Text-book of Obstetrics." 1 Schlechtendahl has reported a case of primary abdominal pregnancy in which a fetus fifteen centimeters long was found incapsulated near the spleen. The tubes and uterus were normal ('■ Frauenarzt," 1887, ii, pp. 81-86). Braun's and Zweifel's cases (" Archiv f. Gyn.," Bd. xii, H. I and 2), in which the placenta was attached to the posterior uterine wall and to the sigmoid flexure, and Koberle's case, in which impregnation occurred through a vagino-abdominal fistula after hysterectomy, were unquestionably, to my mind, primary abdominal pregnancies. 266 PREGNANCY. Fig. 164.—Reported as an ovarian pregnancy. Fig. 165.—Reported as an ovarian pregnancy. Fig. 166.—Prof. August Martin's case of ovarian pregnancy. The intact tube is seen lying above the ovarian sac containing the fetal envelopes. EXTRA-UTERINE PREGNANCY. 267 intra-uterine, but the ovum escapes into the abdominal cavity through an opening in the uterine wall, retaining a connection by the placenta with the uterine cavity. The process of extru- sion must be gradual. These cases follow either a Cesarean section or a rupture of the uterus at a previous labor. The fetus may grow to full term.1 Terminations of Extra=uterine Pregnancy.—Death and Ab- sorption of the Young Embryo with Absorption of the Liquor Amnii, and Atrophy of the Gestation Cyst.—Of all the terminations of ectopic gestation, this is the most favorable. It is exceptional, and should never be counted on in practice. The embryo must die before the second month to be completely absorbed. At the best, chronic salpingitis with adhesions persists, and the woman may, therefore, be left a chronic invalid. Rupture of the sac and profuse hemorrhage occur most com- monly in tubal gestation, when the growth is upward toward the abdominal cavity. At least two-thirds of all ectopic gesta- tions end in rupture of the sac. The rupture may occur when the ovule grows downward between layers of broad ligament; also in tubo-uterine, tubo-ovarian, ovarian, and abdominal preg- nancies. The accident commonly destroys the embryo, which may escape into the abdominal cavity. Up to the second month the extruded embryo may be absorbed. Later, it may be found lodged among the intestines, perhaps far removed from the pel- vic organs and usually surrounded by clotted blood.2 The hem- orrhage may be fatal in as short a time as two hours ; it usually takes from eight to sixteen hours, however, for the woman to bleed to death, and perhaps longer. The hemorrhage may be fatal as late as the second, third, or fourth day, or there may be successive hemorrhages, perhaps days apart, until the patient is gradually exhausted or is suddenly destroyed by an unusually profuse outpour of blood. Surprisingly small tubal gestation sacs may, on rupture, give rise to fatal hemorrhage. The determining cause of rupture is not always apparent. It may occur while the patient is lying quietly in bed, but may follow the straining of defe- cation or urination, coitus, a blow upon the abdomen, a gynecolog- ical examination, an operation like curetment, or any sudden physical effort or mental excitement. The rupture may be due 1 " Ausgetragene secundare Abdominalschwangerschaft nach Ruptura uteri, im vierten Monat," Leopold, "Archiv f. Gyn.," Iii, 2, 376. Fullerton, "Annals of Gyn.," October, 1891. 2 Burford reports an extraordinary case in which the tube ruptured, the fetus was extruded through the rent, the cord was torn across, and the fetus with the cord attached was found in the abdominal cavity inclosed in an adventitious sac. The pla- centa remained in the tube and the rent in the latter, through which the fetus escaped, had healed. "Brit. Gyn. Jour.," 1892. 268 PREGNANCY. Fig. 167.—Ruptured tubal pregnancy; sac involving the isthmus.1 to contraction of the tube-walls, to menstrual congestion, or to the steady growth of the tumor. Rupture of the sac or of a blood-vessel in its wall, with profuse hemorrhage, has occurred long after the destruction of the embryo and cessation of growth in the sac (two years in one case). Fig. 168.—Ruptured tubal pregnancy ; sac involving the whole length of the tube. 1 Figs. 159 to 161 and 167 to 176 inclusive, also figs. 163 to 165, are from photo- graphs presented to me by the late Dr. Formad, for some time coroner's physician of Philadelphia. He obtained the specimens in his official capacity, while investi- gating the cause of sudden deaths. EXTRA-UTERINE PREGNANCY. 269 $% Fig. 169.—Ruptured tubal pregnancy ; sac involving the ampulla. Fig. 170.—Ruptured tubal pregnancy; sac situated wholly in the isthmus. The size of the sac is very small to occasion, on rupture, a fatal hemorrhage: its situation, however, near the uterus, is a very dangerous one. Fig. 171.—Ruptured tubal pregnancy; sac occupying the middle third of the tube. 270 PREGNANCY. Fig. 172.—A very small gestation sac in middle third of tube. Rupture; death. Fig- 173.—Ruptured tubal pregnancy; the sac occupying the ampulla and fimbriated extremity of the tube. Fig- 174-—Ruptured tubal pregnancy; the sac situated at the uterine insertion of the tube. EXTRA- UTERINE PRE GNANC i'. 271 Rupture of sac with extrusion of its contents, and interstitial hemorrhage into the sac-ivalls, without escape of blood into peri- toneal cavity or between the layers of broad ligament, was the termination of one case of tubal gestation under my observation. This occurrence might well be followed by atrophy of the ovum and sac. Tubal moles are frequently seen as the result of an old tubal pregnancy ; the ovum is infiltrated and surrounded by blood, clotted and often organized. The tubal walls are also infiltrated with blood and are much thickened. The whole mass constitutes a solid tumor of the tube in which the embryo may not be found, and atrophied chorion villi in small numbers are only discovered after a careful microscopic search. Growth of the Fetus after Third Month ; Its Death at or before Maturity and the Changes that Occur Afterward.—A continued de- velopment of the fetus in the later months of pregnancy is seen most often in abdominal or in tubo-ovarian pregnancies, though it is possible in the tubal gestation with retroperitoneal growth (broad-ligament pregnancy). The fetus after death may be converted into a lithopedion or may be mummified, and in these conditions may remain in the abdominal cavity indefi- nitely (in Sappey's case fifty-six years), or may be removed by operation through the abdomen, vaginal vault, or possibly by the rectum. The soft parts may macerate and may be absorbed, leaving the bones, which remain as an innocuous abdominal tumor or ulcerate into the bladder, intestines, or through the anterior abdominal wall. Ulceration into the bladder is a par- ticularly unfortunate complication. I have seen an old lady die of peritonitis caused by the ulceration of a parietal bone through the transverse colon. Her history indicated an abdominal preg- nancy having its origin many years before. The fetal body may putrefy from the contiguity of the intes- tines and their contained micro-organisms and the consequent access of bacteria to the highly putrescible sac-contents. In the same way the gestation-sac is converted into an abscess. Terminations of Ovarian Pregnancy.—There may be an ar- rest in the development of the ovum at an early period. In one case the small, cystic, ovarian tumor containing the fetal bones was retained in the abdomen for years. In another case the fetus went on to full development, then died, and was removed in a good state of preservation at least one year later. Rupture of the sac and profuse hemorrhage may occur. In tubo-uterine or interstitial pregnancies the ovum and em- bryo may be discharged into the uterine cavity, and may be evacuated by the natural passages. There are at least two such 272 PREGNANCY. cases well authenticated. Rupture of the sac and hemorrhage into the peritoneal cavity is, however, the rule. In Mascka's case the head of the fetus passed into the abdominal, the breech into the uterine, cavity. In cases of so-called tubal abortion (so named by Werth) there is an internal rupture of the tubal wall or of its connection Fig. 175.—Tubal abortion. Fig. 176.—Tubal abortion. with the ovum, and blood is poured through the fimbriated extremity of the tube into the abdominal cavity. The blood clots filling the pelvis in such a case may have a peculiar sausage- like form imparted to them by the tubal canal. The whole ovum may possibly be extruded through the abdominal orifice of the tube, and in one case in which the fimbriated extremity was EXTRA-UTERINE PREGNANCY. 273 closed by inflammatory adhesions the outer end of the tube was converted into a hematoma. It is possible that a tubal pregnancy may rupture in its early stages, the embryo be expelled into the abdominal cavity, retain- ing its connection with the tube by the cord and placenta, and the fetus thus continue to further or to full development. This is called a secondary or tubo-abdominal pregnancy.x Rupture in cases apparently of this character may not have occurred. There may have been a retroperitoneal growth of the ovum and an enormous dilatation of the tubal walls. Growth and development of the placenta after fetal death has been described, but has not yet been demonstrated beyond Fig. 177.—Diagram showing pelvic hematocele posterior to the uterus, which is crowded forward with the bladder behind the symphysis pubis, while the rectum is compressed behind against the sacrum (Skene). doubt. It would seem impossible, arguing from the behavior of the placenta in utero after fetal death. Profuse hemorrhage into the gestation sac, forming a large hematoma, occurred in one case under my observation. Hematoceles and hcmatomata in the abdomen, pelvis, and pelvic connective tissue in one-third or more of the cases are due to the hemorrhage from a ruptured gestation sac. The blood may collect in front of the uterus (ante-uterine hematocele), more 1 Lusk has collected three such cases. The fetus survived the rupture of the tube, or the extrusion may have been gradual by a separation of the fibers in the tube wall. 18 274 PREGNANCY. commonly behind the uterus (retro-uterine hematocele), may be encapsulated in the neighborhood of either broad ligament, or may be contained in the pelvic connective tissue on either side of the uterus. These accumulations of blood may suppurate, and may thus prove fatal. They may be evacuated through the abdo- men or often through the vaginal vault. If not too large, they are absorbed. Symptoms of Extrauterine Gestation.—The Subjective Signs.—In the early weeks or months the subjective signs of ectopic pregnancy may be indistinguishable from those of normal Fig. 178.—Diagram of intraperitoneal rupture of tubal pregnancy. Free blood in Douglas' cul-de-sac, and among the intestines: S, Symphysis; R, rectum (Dickinson). intra-uterine gestation. In the tubal variety, which is by far the commonest, there may be no indication of any abnormality until rupture occurs. In the vast majority of cases, however, rupture is preceded by severe cramp-like pains, usually in one or the other iliac region, often accompanied or followed by the discharge of deciduous membrane. The pain of extra-uterine pregnancy is its most distinctive symptom. It may be defined as a pain described by the patient in strongest terms ; occurring in paroxysms, with intervals free from suffering ; appearing at any time from a few days to months EXTRA-UTERINE PREGNANCY. 2y$ after a normal menstruation ; situated often in one groin, though frequently indefinitely referred to the lower abdomen ; extending down one leg or up to the epigastrium ; and a pain so severe as to occasion profound systemic disturbance—syncope, followed by nausea and vomiting, a cold sweat, hysterical outbreaks, complete disability, and every appearance of excessive shock. The temperature is almost always slightly elevated. There may be high fever, and the general health may be much im- paired. When advanced development occurs, as in abdominal and in some cases of tubal gestation, no symptoms may arise until the time for labor has passed, when pain and other com- plications, due to the peculiar character of the abdominal tumor, may appear. There is usually cessation of menstruation for one or two periods ; then a return of the flow as an irregular bleeding, which may last for months. In some cases irregular bleedings begin with conception and last until rupture—there is no cessation of menstruation. In others one period is slightly delayed ; those after and before are normal. Again, the delayed period may be unnatural in character. In exceptional cases the menstruation occurs at the normal time, but is more profuse or scantier than normal. The subjoined table, made up from my case-books, shows the menstrual history in twenty-three cases of which I have records : Cessation of Menses. For two months. For thirty-eight days. None. None. For thirty-eight days. None; a flow of blood occurred three weeks after last normal pe- riod. Return of Flow. None. Patient died from ru In thirty-eight days. Menstruation reg- ular, except that one period con- tinued a month. Regularly every month ; no cessa- tion of menstrua- tion. On thirty-eighth day; did not re- appear at time for next period. In two weeks after discharge noted in preceding col- umn. Continuance. Two days. Discharge of Decidua. None. second month. None. None. None. At the appearance of the delayed menstruation. At the fifth week after last normal menstruation ; in the second flow of blood. None. :ure in a few hours at Lasted twenty- seven days. One period con- tinued a month, the flow persist- ing at time of operation. The normal length of time three to five days; fetus, two and one-half months, removed at time of opera- lion. None. 276 PREGNANCY. Cessation of Menses Two and one-half months. None. For eight weeks. For fifty-three days. None. Missed two periods. Missed one period; returned ten days late. For three lunar months. Twelve days late ; cessation of men- ses for forty days from last normal period. Three weeks late. None; a flow appeared fifteen days after cessa- tion of last nor- mal sickness. For six weeks ; two weeks late. For seven weeks ; three weeks late. For two calendar months. Return of Flow. In two and one-half months. Two weeks after last normal pe- riod. In eight weeks. In fifty-three days. (At preceding menstrual period there had been a few drops of blood.) In four weeks. In two and one-half months. In thirty-eight days. None. In twelve days; then in eleven days, and again in a lunar month. In seven weeks; again in a week ; again in three weeks ; again in a week. Continued for a month. In six weeks; again in seven weeks. In seven weeks; again in four weeks; again in forty days. In two months. Continuance. For three weeks. For two weeks. For four months. For two weeks. For six weeks. Twelve days. Lasted one day; returned in ten days; slight dis- charge for three weeks, then a more profuse flow lasting almost continuously for three and one-half months. Rupture occurred with profuse internal bleeding; no discharge until five days after operation, three and one-half months after cessation of menses. Discharge of Decidua. None ; rupture oc- curred at third month; death in seven hours. None. None. At the third month. None. On third or fourth day of flow. None. Lasted one day; then two days; and on third re- appearance, three weeks. No long-continued flow. For a week; dis- charge continuing at time of opera- tion. Last menstrual dis- charge continued a week and was very profuse. Lasted three weeks. On the first day of third reappear- ance. On the third day of first return of flow. None. None. On the first day of the first return of the flow. On the first day of return of flow. EXTRA - UTERINE PRE GNANC Y. Cessation of Menses. Return of Flow. Continuance. Discharge of Decidua. Two and one-half months. Missed three pe-riods. Missed two periods. In two and one-half months. Three months and three weeks. None. Six weeks. Six weeks. None. After four weeks of continuous flow. On second or third day of flow. Decidua discharged on the day of the operation, sixty-two days after last menstruation. Even with the dis-charge of the de-cidua, there was no bleeding. Other symptoms noted have been irritable bladder or dys- uria ; marked constipation or even obstruction of the bowels if the tumor is on the left side ; edema of the corresponding limb and aching pain in it, especially at the groin ; or numbness and loss of power. Pulsating vessels may be felt in the vaginal vault.x Objective Signs.—In tubal pregnancies an exquisitely sensi- tive tumor may be felt to one side of, behind, or possibly in front.2 of the uterus, quite firmly fixed after the third or fourth week, and doughy in consistence. The uterus is much smaller than would be expected from the duration of the pregnancy. After the third month ballottement may possibly be practised upon the tubal tumor. The uterus is usually displaced forward, backward, or to the side opposite the tumor. The decidua is expelled from the uterus in a large proportion of cases (fifty per cent, of my own). If the discharged membrane can be obtained, it will present, under the microscope, unmistakable character- istics of decidua. It may be extruded in fragments or as a com- plete cast of the uterus. Symptoms of Interstitial Pregnancy.—A diagnosis is diffi- cult or impossible. The uterus enlarges to a greater degree than in any other variety of ectopic gestation, and it may be im- possible to determine whether or not it is symmetrically enlarged. The condition is recognized after an abdominal section or upon a careful intra-uterine exploration. 1 Hofmeier claims that the pulsation of arteries on one side of the cervix and not upon the other is a valuable sign of extra-uterine pregnancy ; and, moreover, that it is a sign of life in the ovum, ceasing when the embryo dies and the ovum stops growing. r 2 For three or four weeks the tubal tumor is free; quite suddenly it sinks into the pelvis from its increasing weight, and wherever it comes in contact with the pelvic peritoneum the latter is changed into a decidua-like structure to which the tube walls adhere. 278 PREGNANCY. Abdominal pregnancy may be recognized when the ovum occupies Douglas' pouch, as the fetal parts may be made out with startling distinctness through the posterior vaginal vault. A sacculated uterus, however, might easily be mistaken for an abdominal pregnancy. Diagnosis.—A diagnosis of extra-uterine pregnancy can usually be made before rupture. I have made a positive diag- nosis in the majority of my cases. In spite, however, of careful attention to the patient's history and a painstaking physical ex- amination by an expert, a diagnosis before rupture is sometimes impossible. Usually the condition is not recognized in general practice until rupture has occurred. At this time a history of early pregnancy, a paroxysm of frightful pain, sudden collapse, symptoms of internal hemorrhage, with abdominal distention, and a vaginal examination showing a pelvic tumor with possibly the physical signs of effusion into peritoneal cavity make the diag- nosis perfectly clear, and indicate an immediate celiotomy. These symptoms have been closely simulated by rupture of a varicose vein in the broad ligament, by rupture of an ovarian cyst or torsion of its pedicle, and by pelvic tumors coincident with intra-uterine pregnancy. But as all these conditions demand the same treat- ment, a mistake in the differential diagnosis between them is of no consequence. If the cramp-like pains of ectopic gestation lead a patient to consult a physician ; if she give a clear history of impregnation ; if she present all the earlier signs of pregnancy, with the discharge of blood and membrane which the microscope shows to be decidual; if there be a very sensitive tumor in the neighborhood of the uterus, on which ballottement may, perhaps, be practised, and if the uterus is not so large as it should be,—the diagnosis is justified, and the necessary treatment, also, involv- ing, as it does, a serious operation. Among the conditions in the pelvis that may make the diagnosis impossible are : Abortion, in consequence of or coincident with some growth near the uterus ; pyosalpinx, with an indistinct or untrustworthy history of pregnancy; intra-uterine pregnancy, with rapid development of a fibroid on one side of the uterus ; development of an im- pregnated ovule in one horn of a unicornate or bicornate uterus, or on one side of a double uterus. Prognosis.—Without surgical treatment about two-thirds of the cases die ; one-third escape the immediate danger of death.1 1 In 265 cases without surgical intervention, 36.9 per cent, recovered, 63.10 per cent, died (Winckel's "Geburtshulfe," 2. Aufl., S. 254). In 100 cases col- lected by Kiwisch, the mortality was 82 per cent. ; in 132 collected by Hecker, 42 per cent. ; in 150 by Hennig, 88 per cent. ; in 500 cases collected by Parry up to 1876 the mortality was 67.2 per cent. ; in 626 cases collected by Schauta, from 1876 to 1890, 241 ended spontaneously, 75 in recovery, and 166 in death, a mortality of 68.8 per cent. Martin states that of 585 cases operated upon, 76.6 per cent, recov- ered ("Centralbl. f. Gyn.," No. 39, 1892). EXTRA-UTERINE PREGNANCY. 279 Treated by abdominal section, the mortality should be about five per cent., or lower if the operator sees the patient in time. I have the records of twenty-four operations performed by myself with three deaths. Two of the fatal results were in women already exsanguine, who died a few hours after the operation without regaining consciousness. The other was in a chronic drunkard, who died on the fifth day from cirrhosis of the liver. Of those patients who do not die directly in consequence of the tubal ges- tation a large proportion remain invalids, and many die at a remote period from various complications, as bowel obstruction, ulceration, suppuration, or hemorrhage. Treatment.—As soon as the diagnosis is established with reasonable certainty, whether the sac has ruptured or not, the re- moval of the gestation sac by celiotomy is the only treatment worthy of consideration. Electricity is an uncertain and unre- liable remedy, and the recoveries ascribed to its use are the result of nature's effort to effect a cure. Injections into and puncture of the sac to destroy the embryo should be relegated to the category of discarded and discredited procedures. Abdominal section is the only reliable and trustworthy plan of treatment. The removal of a gestation sac and the control of hemorrhage is sometimes a difficult operation, and is not to be undertaken rashly by an unskilled operator. In favorable cases in which a trained nurse is kept in constant attendance, and in which the physician can reach the patient quickly, it might be justifiable to wait, after diagnosticating extra-uterine pregnancy before rupture, for the death of the embryo and the atrophy of the sac, wiiich will occur in about one-third of the cases. As a rule of practice, however, the only safe plan is either to operate immediately one's self, or to refer the patient to a competent surgeon without delay. After rupture, the patient's only hope lies in an immediate abdominal section, evacuation of the blood from peritoneal cavity, the ligation of the blood-vessels supplying the sac, and its com- plete removal. The Technic of Abdominal Section for Tubal Pregnancy.— The operation is often performed in an emergency, and must, therefore, be hurried. Plenty of time, however, should be taken to secure an absolutely aseptic condition of the field of operation in the patient, of the surgeon, assistants, dressings, and imple- ments. If possible, the patient should be transported to a well- appointed hospital. If there has been much bleeding and the patient's condition is bad, the anesthesia should be limited and the operation should be finished in the fewest minutes possible. I have concluded the operation, to the last abdominal stitch, in 280 PREGNANCY. less than eleven minutes and with less than an ounce of ether.* No attention should be paid to the blood that gushes in enor- mous quantities from the abdominal cavity when the peritoneum is incised. It has already been shed and is of no use to the patient. The side affected should have been learned by the his- tory,2 if not by the physical signs. This tube should at once be grasped between the thumb and fingers of one hand, the broad ligament should be transfixed by a pedicle needle to the inner side of the round ligament, and ligated en masse.3 The tube and ovary are then cut away. The abdominal cavity should next be flushed with a large quantity of sterile water4 and drained with both a glass tube and gauze packing.5 For twelve or twenty-four hours after the operation vigorous stimulation and an active treatment for the acute anemia will be necessary. The glass tube is sucked out every twelve hours. The gauze is removed at the end of forty-eight hours, and the glass tube is then with- drawn after a rubber tube is slipped within it to take its place. Through the rubber tube the pelvic cavity is irrigated once a day with sterile water. The irrigation is continued for about ten days, or until the water returns perfectly clear without bringing with it small snow-flake-like clots and the debris of the decidu- ous formation on the peritoneum which constitutes the adhesions between the tubal sac and surrounding intraperitoneal structures. By this technic in twenty-four operations I have not lost a patient from the operation itself; there has been no fever during con- valescence ; every wound healed promptly within three weeks, and there was not a single persistent sinus. 1 This patient was at first treated by her physician for a miscarriage—the com- monest mistake in the diagnosis of extra-uterine pregnancy. After rupture the true condition was recognized, but the woman was so reduced by the internal hemorrhage that she was pronounced a hopeless case, and the physician left the house late at night saying he would call the next morning to sign her death certificate. To his surprise he found her alive. A few hours later I operated on her with success, though she was pulseless and in as desperate a condition as possible. 2 It is often impossible to tell from a physical examination which tube is in- volved, but I have found the history of pain down one leg and not the other of great value in diagnosticating the side affected. 3 It is waste of invaluable time in the majority of cases to ligate the blood- vessels separately. 4 I have practically given up douching the abdominal cavity after abdominal sections, except in extra uterine pregnancy. There is no other means which so rapidly and surely removes blood-clots from the abdomen. It is, moreover, a great advantage to leave the large quantity of hot water which remains in the abdominal cavity after irrigation. 5 In common with the majority of gynecologists, I now avoid abdominal drain- age as much as possible. In extra-uterine pregnancy, however, it is almost always of great advantage. Without it high fever must be expected during convalescence, and I believe the mortality will be greater. The objection against drainage after abdominal operations for extra-uterine pregnancy that the patient is exposed to a greater risk of infection, applies only to surgeons whose aseptic technic is faulty. In not a single one of my cases has there been fever after the operation. EXTRA- UTERINE PRE GNANC Y. 28l The vaginal operation for tubal pregnancy in the first three or four months is, as yet, in its infancy. It has the serious dis- advantages that, on account of uncontrollable hemorrhage, a vagi- nal hysterectomy or hasty abdominal section may be necessary, and if the tube is simply incised and not removed, a diseased and useless pelvic organ is left behind to be the source of future trouble. Moreover, as in all vaginal sections, nicety and pre- cision of work is impossible through the vaginal vaults. In interstitial pregnancy, on account of the difficulty of diag- nosis, little can be done until rupture and hemorrhage have occurred, when an abdominal section must be performed. The sac should be cleared of all its contents, and its edges should be sewed to the abdominal wall; after the bleeding vessels are se- cured, the sac should be drained. If this technic is impossible, ligation of the uterine and ovarian arteries is indicated, drainage of the sac, or possibly supravaginal amputation of the uterus. It might be well, the, diagnosis being clearly established, to try to effect evacuation of the gestation sac into the uterine cavity after thorough dilatation of the cervical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intra-uterine pregnancy. Tait describes a case in which he found it possible to incise the sac, turn out its contents, and drain it, after fetal death.x Engstrom treated a case successfully by incising the uterine wall, extracting the dead fetus and its appendages, making and enlarging an opening between the ges- tation sac and the uterine cavity, sewing the uterine wall firmly together, as after a Cesarean section, and closing the abdomen without drainage.2 Ovarian pregnancy is to be treated as a tubal pregnancy,— namely, by excision of the sac with the ovary. As a matter of fact, the operation is undertaken in these rare cases for an ovarian tumor, and the operator discovers, to his surprise, after opening the abdomen, the contents of the ovarian cyst. In advanced extra-uterine pregnancy the operator should delay interference until just short of term, when the fetus and, if possi- ble, the fetal sac should be enucleated and extracted whole. It is not infrequently necessary to cut the cord off short, stitch the sac wall to the abdominal wall, and drain the sac. Forty opera- tions (1889-1896) after the seventh month of gestation, with liv- ing and viable infants, have been collected by Dr. R. P. Harris.3 In this number there were ten maternal deaths ; twenty-seven infants survived the operation. When death of the fetus has ^occurred, it is best not to subject the woman to the danger of the 1 London "Lancet," 1894, I, p. 38. 2"Centralbl. f. Gyn.," No. 5, 1896. 3 Kelly's "Operative Gynecology," vol. ii. 282 PREGNANCY. several possible ultimate terminations, but to perform celiotomy and to remove the fetus and its entire surrounding sac. If the exsection of the sac is found to be too difficult or dangerous, it is permissible, some weeks after fetal death, to cut the cord off short, leaving behind the atrophied remains of the placenta. If this is done, the sac-wall should be stitched to the abdominal wall, and thus drained for a length of time until the placenta comes away. Meanwhile daily irrigations are required and antiseptic powders may be dusted in the sac-cavity. In case the gestation sac is low down in Douglas' pouch, bulging the poste- rior vaginal wall, vaginal section and the delivery of the fetus by the natural passage may be considered ; but the dangers and disadvantages of the vaginal operation should be carefully con- sidered ; these are : Difficulty of extracting the fetus, if it is large, uncontrollable hemorrhage, puncture of an intestine, infection of Fig. 179.—Pregnancy in the rudimentary horn of a uterus unicornis, which has become, secondarily, abdominal (author's collection, Obstetrical Museum, University of Pennsylvania). the general peritoneal cavity, either at the time of the operation, or in subsequent irrigations of the sac, and adhesions involving the uterus and appendages after the woman's recovery from the operation.x Vaginal section is applicable in case of an old gesta- tion sac undergoing suppuration and containing a much macerated or disintegrated fetus. In some cases of intraligamentary preg- nancy it is possible to open the sac extraperitoneally by an inci- sion above Poupart's ligament. It is always advisable, however, to make a preliminary abdominal section to learn the relations of the gestation sac. Pregnancy in One Horn of a Uterus Bicornis or Unicornis. —Pregnancy in an ill-developed horn of a uterus unicornis may 1 For a good bibliography of the removal of extra-uterine fetuses through the vagina and by the rectum see J. T. Winter, "Am. Jour. Obstet.," 1892, p. 34. EXTRA- UTERINE PREGNANCY. 283 exactly resemble a tubal or interstitial pregnancy, and will probably end in rupture at the apex of the cornu.1 This is par- ticularly true if the impregnated ovule develops in a rudimentary horn, in which the conditions are almost the same as in a tube, except that rupture takes place later. On the other hand, a pregnancy in a uterus bicornis may terminate prematurely, or even at term, by expulsion of the product of conception through the natural passage. The diagnosis of pregnancy in a uterine horn is difficult or impossible. It is mistaken, usually, for tubal gestation. The removal of a gestation sac in a rudimentary uterine horn is commonly easy, as a convenient pedicle is formed by the attach- ment of the horn to the lower segment of the better-formed half of the uterus. Hydrorrhea Gravidarum.—A watery discharge from the vagina of a pregnant woman may have three sources : catarrhal endometritis, rupture of the membranes, and edema of the uterine walls. The last is a very rare cause indeed, and I am somewhat skeptical as to the possibility of serum leaking from the uterine walls, but it has apparently been operative in a few cases.2 In catarrhal endometritis the fluid is discharged suddenly in considerable quantities ; it reaccumulates and is again dis- charged, the recurrent hydrorrhea continuing, perhaps, until term, although usually after the second or third discharge labor is brought on. The fluid discharged in a case of catarrhal endo- metritis is thin mucus. In a typical case under my observation there was a discharge of more than a pint of fluid at the seventh month of pregnancy, while the patient was lying quietly in bed. It was supposed that the membranes had ruptured and that labor was imminent, but no pains appeared, and after confinement to bed for a week the patient was allowed to get up. A month later there was another profuse discharge,—certainly more than a pint,— again occurring while the patient was quietly at rest in bed. Twelve hours later labor-pains appeared ; in the latter part of the second stage of labor the membranes ruptured and about a quart of liquor amnii was discharged. A careful examination of the membranes failed to detect a perforation remote from the seat of rupture. Rupture of the membranes and the discharge of liquor amnii in pregnancy are commonly followed by labor-pains within thirty - 1 Three cases of pregnancy in rudimentary horns are reported by Turner, Werth, and Solin (Lusk's " Obstetrics "). Kussmaul collected thirteen cases. 2 Chazan, " Centralblatt f. Gyn.," No. 5, 1894, p. 105. 284 PREGNANCY. six hours. It is not very unusual, however, for three or four days to elapse from the time of rupture to the onset of labor. I have several times seen a month intervene between the rupture of the membranes and the beginning of labor, and in one case under my care the membranes were perforated at four and one- half months without inducing labor. The patient was the wife of an English officer in India. She had been told by a skilful Indian masseuse that she was pregnant, but an English physician whom she consulted assured her she was not, and, to prove that he was correct, inserted a sound into the uterine cavity. There was immediately a gush of liquor amnii. In spite of a journey of some 1500 miles from the interior to the coast, the long voy- age from India to England, and thence to the United States, liquor amnii flowing from the vagina at every roll of the ship or jolt of a carriage, labor did not appear until term, four and a half months from the time the membranes were punctured. 1 found, after delivery, a round, regular opening in the membranes, about the caliber of a lead-pencil, midway between the seat of rupture and the placenta, which was attached at the fundus. PART II. THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM. CHAPTER I. Labor. This chapter deals with an important practical subject,—the management of a woman in labor. The questions involved in this study confront every practitioner of medicine at some time. Every one in possession of a medical diploma is popularly sup- posed to possess the ability to manage a labor case, and every one who essays the practice of medicine will have his ability put to the proof before his medical career has run a very long course. To a beginner in obstetric practice there is much that is trying and embarrassing. The novel and intimate relations in which the physician is brought with his patient; her very evident distress and dread at the idea of being subjected to the necessary examinations and manipulations more or less revolting to every woman ; the doctor's keen consciousness of a lack of experience ; a feeling of mistrust in his capacity to make the necessary diag- nosis as to stage of labor, the presentation and position of the fetus; the knowledge that his every movement is watched by critical friends or attendants of the patient, who possess, perhaps, just what he lacks,—practical experience,—all unite to produce a most unenviable frame of mind in the practitioner attending his first few cases of labor. Some consolation, however, can always be found in the reflection that labor is a natural and a comparatively easy process, in the large majority of cases ; that a physician's duty is one mainly of inaction and non-interference, and that most prob- ably the labor will terminate fortunately for mother and child, in spite of his inexperience. It is evident, however, that no one can predict what may occur in any given case. There may sud- denly arise some accident of the gravest nature, which must be immediately recognized and promptly treated. It is under such circumstances that a physician's education and knowledge are 285 286 LABOR AND THE PUERPERIUM. put to the test. It is plain, therefore, that in a work on obstet- rics it must be the writer's aim to impart the requisite knowl- edge to cope with all sorts of dangerous emergencies. This consideration makes it necessary to dwell at length upon all the possible complications, accidents, and difficulties of the child- bearing process, with the result, I am quite sure, of leaving upon the student's mind the impression that parturition is a more dan- gerous process than is really the case. It is well to recollect, there- fore, that nature alone, in the majority of cases, with very little artificial aid, is capable of terminating safely the birth of the child ; but at the same time it should not be forgotten that at any moment a dangerous complication may occur, which must be immediately recognized and promptly dealt with. It is convenient to begin the study of labor with a definition of the process. Labor is that natural process by which the female expels from her uterus and vagina the ovum at its period of full maturity, which is reached, on the average, two hundred and eighty days after the first day of the last menstruation. The process is divided into three main stages or acts,—the expansion of the birth-canal, the expulsion of the fetus, and the delivery of the remainder of the ovum. This is a brief description of an important and complex function in woman, but as one studies the causes, the premonitory signs, the symptoms, and the phe- nomena of labor, it will be seen that it is comprehensive and correct, but that it needs some amplification. To analyze the first declaration as to the time that labor occurs, the intelligent student would naturally inquire why it is that labor comes on just two hundred and eighty days, or forty weeks, or ten lunar months from the beginning of the last men- strual flow. This question has given rise to endless speculation in all ages of medicine, some of it very far from the truth. Several explanations may be offered, each reasonable, and each no doubt in part accountable for the occurrence of labor in the majority of cases at a distinct and specific time. The period of two hundred and eighty days, or forty weeks, or ten lunar months must at once direct attention to the fact that labor comes on at the tenth menstrual period since pregnancy began. At the menstrual period in the non-pregnant uterus there is always dis- tinct muscular action, induced probably by the presence of a foreign body—blood—in the uterine cavity. During pregnancy it has long been known that by the unconscious memory of living tissue there recurs, at regular intervals corresponding to the menstrual period, a disposition to muscular action, which is sometimes so exaggerated as to bring about an expulsion of the LABOR. 287 ovum,—an accident especially to be feared at such times in women prone to abort. Here, then, is a cause predisposing to uterine muscular effort at each recurrence of the time for the absent menstrual flow, especially the tenth, and this, therefore, must be accepted as one at least of the causes of labor. It is described conveniently as periodicity. A study of all the hollow muscles in the body shows that they admit of distention up to a certain point, but, that point being reached, they are immediately stimulated to con- traction. This is well illustrated in the stomach of the young infant, which nurses until the organ, overfilled, contracts and expels the excess of food which its cavity can not contain. So, too, in the ventricles of the heart, distention with blood goes on to a certain extent, when contraction occurs and the blood is driven into the great arterial trunks. Precisely the same action may be seen in the pregnant uterus. It admits of distention up to a certain point, until it is well filled by the mature fetus, when the great tension of its walls, no longer endurable, stimulates them to muscular action which terminates in the expulsion of the ovum. This cause of labor is defined as ovcrdistcntion of the uterus. Just as in plant life certain degenerative changes occur in the supporting stem of fully ripe fruit which makes its connection with the parent branch so frail that a slight breath of wind will cause it to fall to the earth, so in the human ovum that has reached full maturity there occurs a degenerative process, a fatty change, in the connections which bind the ovum to the uterus, which brings about a separation more or less extensive between the uterine wall and the ovum, and the latter, becoming a foreign body in the uterine cavity, is cast off. This cause of labor is called the maturity of the ovum. Finally, heredity, the unconscious memory of tissue trans- mitted from generation to generation, plays a most important role in the causation of labor. Thus, at the end of two hundred and eighty days the fetus has reached such a size that it is just possible for the woman, at the expense of much effort, to expel it through the birth-canal. Had it grown much larger, its expul- sion wrould be difficult or impossible. On the other hand, an infant born much before two hundred and eighty days is not sufficiently well developed to endure the lower temperature that it encounters, and the necessity for obtaining its own nourish- ment and oxygen, and consequently it will not survive. There- fore, it is plain that only those women who gave birth to their offspring about the two hundred and eightieth day of pregnancy could successfully perpetuate the human species. Those that 288 LABOR AND THE PUERPERIUM. fell in labor later probably died ; those whose young were born earlier were not able to rear them ; and so the habit of bear- ing children at the end of forty weeks from conception, trans- mitted from generation to generation through many ages, became, perhaps, the most powerful influence in determining the duration of pregnancy. To recapitulate, then, labor comes on at about the two hundred and eightieth day from the beginning of the last menstrual period, because of the influence of periodicity; as a result of the over- distention of the uterine cavity; in consequence of the maturity of the ovum, and by reason of heredity. All these causes being operative together, it requires only some very slight stimulus or none at all to inaugurate effective uterine contractions. Just as a single blow of a workman's hammer will start the launch of a ship when everything is prepared for it, so here a little exercise, a dose of purgative medicine, a jolt or a jar may provoke mus- cular action on the part of the uterus that will end in the expul- sion of the child. This knowledge is often put to good practical use. If one fears that labor might be delayed in a given case, and there were factors in that case which made such delay undesirable, by resorting to some stimulus a little more effective than the ordinary occurrences of every-day life, one secures the onset of labor at its proper time. Thus, if the two hundred and eightieth day from the beginning of the last menstrual flow is accurately determined, one might, the night before this last day, give a dose of some purgative medicine—castor oil—and follow this the next morning by a good dose of quinin—say, ten grains —to insure the beginning of labor at its normal date. Before entering upon a study of labor the student should be sure that he is able to recognize its occurrence. The diagnosis of labor, therefore, is a necessary preface to the study of its physiology and management. First and fore- most, in the woman supposed to be in labor, the existence of pregnancy should be determined. Many ludicrous and some tragic errors have been committed by a disregard of this rule.x There is a valuable premonitory sign of labor which should always be inquired for : the subsidence of the uterine tumor at periods varying from four weeks in the primigravida to two weeks or less in the multigravida before the actual advent of labor. 10ne of my students, on duty in the out-patient obstetric department, receiving his first call, hurried to the woman's house, spent some fifteen minutes sterilizing his hands, and made a prolonged vaginal examination, much to the patient's surprise, as she had sent for a physician on account of rheumatism. She was not pregnant. On one occasion I figured as an expert witness in a trial for damages on account of an attempted Cesarean section. The patient, a rachitic dwarf, was not even preg- nant when the operation was performed. LABOR. 289 This sinking of the uterine tumor is the result of the engage- ment of the lower uterine segment with the presenting part of fetus in the superior strait and in the cavity of the pelvis. It has its cause, I believe, in the action of the muscles inclosing the abdominal cavity. Just as the stomach, the heart, and the uterus will bear distention up to a certain point, so the abdominal mus- cles allow a certain distention of the abdomen to occur, but resent anything beyond it. This point is reached in primi- gravidae at about the thirty-sixth week of pregnancy, but later in multigravidae owing to a greater laxity of their muscles. The abdomen being distended to its utmost, the abdominal mus- cles contract vigorously and drive the lower part of the uterus down through the superior strait into the cavity of the pelvis by diminishing the area of intra-abdominal space, thus accomplish- ing the first step in the expulsion of the child, the passage of the head, presuming it to be a cephalic presentation, through the superior strait, long before the labor itself begins. This sinking of the fetus and uterus occurs often suddenly, so that the pregnant woman may rise one morning entirely relieved of the distressing abdominal pressure symptoms that had previously, perhaps, tormented her. But the relief in one direction is fol- lowed by an aggravation of the varices about the vulva, anus, or lower limbs, by neuralgic pains extending down the thighs, by increased vaginal secretion,—all due to the greater pressure within the pelvic cavity. So constant is this phenomenon, the descent of the pregnant uterus near term, that, should it fail to occur, some cause for the failure should be looked for. It will usually be found to be a malposition of the fetus or a deformity of the pelvis. There are three signs indicating that labor has actually begun : (1) Recurrent pains of characteristic duration, situation, and nature ; (2) the escape of a small quantity of blood-tinged mucus from the vagina, and (3) the dilatation of the os. The characteristic pains of commencing labor recur at intervals of from five minutes to half an hour, usually being about fifteen minutes apart. The pain is located in the abdomen, or is de- scribed as passing from the umbilicus in front to the sacrum behind, or in some cases is confined altogether to the back. It comes on suddenly. The woman will be walking about the room, or perhaps conversing, when suddenly she will pause, bend over, contort the facial muscles a little, set her lips, and clinch her teeth. The pain rarely lasts more than a minute; when it passes off the woman resumes her inter- rupted occupation. If the hand were laid over the abdo- men when the pain came on, the uterus would be felt as a 19 290 LABOR AND THE PUERPERIUM. firm, hard, well-defined body, more globular than in its relaxed condition. As a consequence of the beginning dilatation of the internal os, the lower portion of the ovum begins to sever its connection with the uterine wall, and in doing so the delicate blood-vessels that may yet run in isolated places into the decidua are torn, and there is a slight oozing of blood, which stains the large plug of tenacious mucus that has filled the cervical canal during preg- nancy. The cervix being gradually obliterated from above downward by the descending ovum, the blood-stained plug of mucus is expelled from the cervix into the vagina, whence it escapes externally and becomes what is popularly called the show, which is regarded, and rightly, too, as a valuable sign of beginning labor. But the uterus may contract quite vigorously and bloody mucus may escape externally in many a case when labor has not really begun. The most reliable sign, after all, is the obliteration of the cervical canal and the dilatation of the os. If these conditions become plainly appreciable, one may safely diagnosticate a beginning labor, although it would be well to bear in mind exceptional cases in which the os has actually dilated up to an inch or more, but has afterward re- tracted and remained undilated until true labor finally appeared.1 Having made a diagnosis of beginning labor, the physician will immediately be plied with questions by the patient or her family as to its probable duration. This is a question that is put to every practitioner of obstetrics in almost every case, but, unfortunately, it can not be given a definite answer. It is a common experience to see a variation in the length of labor from one hour or less to many hours ; indeed, in rare cases to a week or more. So that it is impossible to predict with any degree of accuracy how long a given labor might last. One can usually obtain an approximate idea, however, by bearing in mind the average duration of labor in multiparae, eight hours, while in primiparse the time is usually double that or longer. One should recollect that a large parturient canal with a normal fetus, or one undersized, along with vigorous muscular action, means a quick labor ; that the opposite conditions mean delay. In the case of multiparae one should always inquire into the history of past labors, for many women have marked individual peculiari- ties in regard to the duration of parturition, in some the process being usually rapid and easy, in others the reverse. A consid- 1 I have seen a young primipara with the os dilated so that I could put four fingers side by side into it, and with the membranes bulging into the vagina, who walked about the house for a week in this condition before labor-pains appeared. In this and in similar cases, however, the cervical canal was not effaced. LABOR. 29I eration of all these factors will enable one to form some definite idea in his own mind of the probable duration of labor, but he would do wisely to keep his opinion to himself. To the inquiring family a non-committal statement should be made, such as " the length of the labor will depend on the strength of the pains."1 Before proceeding to a consideration of the management of labor, the student will find it of service to observe the process as a passive spectator. Nothing is so conspicuous in the first stage of labor as the contractions of the uterine muscle. It has been asserted that the uterine walls contract in a sort of peris- taltic wave, beginning at the cervix, running up over the-fundus, and returning again to the cervix ; but this action has never been actually demonstrated, and it is more convenient, if, indeed, it is not strictly correct, to regard the uterus as a hollow muscle which contracts at once and equally in all its parts. The effects of these contractions are : (1) To drive the liquor amnii in the direction of least resistance, which is through the internal os into the cervical canal, where, contained in the membranes, it dilates the cervical canal in the very best manner for the mater- nal tissues, as a hydrostatic dilator. (2) To drive down the fetal mass in the same direction by diminishing the area of the intra-uterine space. (3) To distend the lower uterine segment and upper cervical canal by mechanical pressure, and, finally, to dilate the os in the same manner after the circular, sphincter-like muscle of the cervix has been paralyzed by stretching and pro- longed pressure. The average duration of these uterine con- tractions during labor is one minute. The intervals between them decrease as labor goes on, and the pains become more powerful until, finally, there should intervene between them but two or three minutes. No one could observe the process of parturition in the capacity of a scientific observer without re- garding the action, appearance, and condition of the woman. It will be found that her whole bearing and manner present two distinct types in the course of the process. At first the advent of each pain is announced by a sudden setting of the teeth, a distortion of the facial muscles, suffused eyes, and a flushed face, and, the pain increasing in intensity, she suddenly emits a sharp cry of pain. The woman, if in bed, will assume almost any attitude that is most comfortable to her. In a normal first labor of some seventeen hours' duration, this condition of 1 As those labors which end in the day-time often begin at night, and vice versa, an obstetrician's rest is disturbed in a very large proportion of his cases. There is' consequently, a prevalent idea that almost all confinement cases occur at night. As a matter of fact, forty per cent, only are delivered between the hours of 11 p. m. and 7 A.m., according to the statistics of West, based on 2019 cases (" Araer Med Jour.," 1854). 292 LABOR AND THE PUERPERIUM. affairs will last about fifteen hours, when a marked change may be observed in the woman's action. If she were left entirely to herself she would be very likely to assume a squatting posture in bed or upon the floor,—a position assumed by the women of many savage tribes during the latter stage of labor. Now, as a pain comes on the woman draws a deep breath, clinches her teeth, fixes her diaphragm, and evidently, from her behavior, calls into play the action of the abdominal muscles with all her might. Her face is suffused, the eyebrows knit, and beads of perspiration stand out upon her brow. As long as the breath can be held this straining action is continued, Fig. 180.—The bag of waters or pouch of membranes. until the air is suddenly expelled from the lungs with a charac- teristic grunting sound, the diaphragm is again relaxed, and the abdominal muscles cease for a moment to act until a full in- spiration is taken, when the straining again begins, and continues until the uterine contraction passes off. If one made a vag- inal examination at this time, he would find a good reason for the change in the clinical aspect of the case. It would be found that the os is fully dilated and that the presenting part is begin- ning to descend, either carrying the membranes before it or else, as is more common, the membranes rupture just as the os is fully dilated and the child's presenting part is driven through the rent in the amnion and chorion. In this condition of affairs LABOR. 293 is found a good explanation for the action of the abdominal muscles ; so long as the presenting part acts simply as a wedge, dilating the os, but not descending to any appreciable degree, the muscles of the abdomen are useless, and are, in fact, inhibited, for their action would drive the presenting part against the undi- lated cervix with such force as to give great pain, if not to do great damage. The main obstruction to the descent of the child, the cervix, being removed, the abdominal muscles are called into play, and act effectively in the displacement of the fetal body downward along the birth-canal. For convenience definite names are given to these stages of labor, presenting each such distinctive features. The period of dilatation is called Fig. 181.—The distention of the vulva and the appearance of the child's scalp. the first stage ; the period of descent or expulsion is called the second stage. The first stage begins with the onset of labor and ends with the complete dilatation of the os. The second stage begins with the dilatation of the os and ends with the complete expulsion of the child. As labor is not complete until the whole ovum is expelled, there is a third stage of labor, that period of time from the extrusion of the fetus until the pla- centa and membranes are expelled. To return, however, to the clinical phenomena of labor. The woman has passed from the first to the second stage. As the latter progresses the pain becomes more frequent and violent, the woman's suffering is increased, and her complaints grow 294 LABOR AND THE PUERPERIUM. louder. Finally she declares, perhaps, that she must rise to evacuate her rectum and bladder, and the reason for this feel- ing is clear when one sees the perineum bulging far outward, the anus widely dilating, the rectum becoming slightly everted, and the presenting part, the head, filling up the whole lower part of the pelvis and pressing as firmly on the bladder in front as it does on the rectum behind. And now, with his eye upon the vulva,—for this part of the labor, in the best interests of the Fig. 182.—The escape of the head and the resumption of its oblique position (external restitution). patient, ought always actually to be observed, both in a scientific study of the process and in its management,—the physician sees the labia separate during a pain and the child's scalp come into view, but, with the subsidence of the pain, disappear. With the next uterine contraction a little more of the head appears, again, however, to disappear as the pain passes off, and so on with every pain for perhaps twenty minutes or an hour, although every time, as more and more of the head appears, it looks to the inexperienced observer as if that pain must be the last, until LABOR. 295 finally the vulva is stretched to its utmost limit and the largest diameters of the head are engaged, when, with a sudden shriek of pain from the woman, the child's head is born. There comes then a pause in the uterine action ; the head may protrude from the vagina for a minute or much longer, while the woman's natural powers are being recuperated, after their tremendous ex- ertion, for a fresh effort. Meanwhile, the child's face turns im- mediately after birth toward one or the other tuber ischii, and Fig. 183.—The transverse rotation of the head (external rotation). from the constriction about the neck becomes livid, and it seems that the child's life is threatened by strangulation. The medi- cal attendant feels at first an almost irresistible impulse to pull on the head and terminate labor. But this is a useless, indeed, a reprehensible procedure, for the child is perfectly safe, its respiration still going on normally in the placenta, and to ex- tract the shoulders rapidly through the overstretched and bruised maternal tissues is almost certain to lacerate the peri- 296 LABOR AND THE PUERPERIUM. neum. Moreover, the child is insensible at this time ; it has been almost comatose during its passage through the pelvic canal, and is now recovering, its brain-centers, especially that of respi- ration, becoming ready to respond to the stimulus to act when the child is born. Any unnecessary interference, therefore, at this stage of labor may harm both mother and child. The woman's uterus having regained power, in a few minutes begins to contract. The abdominal muscles aid it. The child's face turns still more to one side or the other until it looks quite transverse. The expulsive force still acting, the anterior shoulder appears under the symphysis pubis, the posterior shoulder shortly afterward sweeps over the perineum and escapes ; the Fig. 184.—The support of the head and the escape of the anterior shoulder. anterior shoulder follows it, and the rest of the body, too small to present any longer an effective resistance, is expelled im- mediately and the child is born. Its birth is announced, as a rule, at once by a lusty cry, which expands its lungs and initiates the pulmonary respiration. Immediately after the ex- pulsion of the child the woman becomes perfectly quiet and composed, no matter how noisy she may have been before. The passive pleasure of being free from suffering is so great that it becomes a positive enjoyment simply to be quiet, and the woman does not wish to be disturbed. In the course, however, of some fifteen or twenty minutes, in a perfectly natural and LABOR. 297 normal case, such as is now under description, the patient again experiences pain ; the uterus is again contracting, and the woman is again instinctively aiding it with her abdominal muscles, until after one or two such pains the placenta with the membranes is expelled. The manner in which the placenta is separated from the uterine wall and is expelled from the uterine cavity is a matter still under dispute, and there is the greatest difference of opinion in regard to it. "If," says Dr. Berry Hart, the distinguished obstetrician of Edinburgh, " the delivery of the placenta de- pended upon obstetricians knowing how it separated, no woman in labor would complete her third stage." This lack of definite information is unfortunate, for an accurate idea of the mechanism of labor in the third stage is most desirable if one would treat this period of labor intelligently. To explain the first phenom- enon, the separation of the placenta, many theories have been ad- vanced, of which I shall give only the three most reasonable, each of which has its prominent adherents. These three theories are : (1) The diminution in the area of the placental site ; (2) the de- trusion theory, which is founded on the belief that the uterus seizes the placenta and pushes it off from the uterine wall ; and (3) the theory that an effusion of blood occurs behind the placenta, and that this " retroplacental effusion," as it is called, pushes off the placenta from the uterine wall. Of these three theories, I am an adherent of the first. In a strictly normal case the retraction of the placental site is alone sufficient to account for the separation of the placenta. It has been demonstrated that, as the uterus contracts, the placenta follows the retrac- tion of the uterine walls up to a certain point without becom- ing detached, until the placenta is reduced to about one-half its natural size. Now, this is easily explained if one recol- lects the structure of the placenta, like nothing so much as a sponge, with its branching villi and intervening natural blood- spaces. But as soon as these villi are squeezed together so that the placenta forms one solid mass, it can no longer follow the retraction of the uterine wall, but is that moment, in a typically normal case, sprung off from its attachment to the uterus, and is for a varying period of time loose within the uterine cavity, until, acting as an irritating foreign body upon the uterus, it is finally driven out into the cervical canal and upper part of the vagina by the uterine contractions that its presence within the uterus excites. In the cervix and vagina, however, the placenta may remain a long time without exciting the benumbed and almost paralyzed muscles of these regions to action. And thus it is that, in civilized women, at 298 LABOR AND THE PUERPERIUM. least, it is often impossible to leave the third stage of labor entirely to nature, for the placenta may remain so long undeliv- ered that its succulent mass may putrefy and so become a source of septic infection. In describing a perfectly normal case of labor, I must presume that the placenta is expelled by the natural forces, and must describe the manner of its expulsion. But here, again, one encounters the greatest difference of opinion, even about so apparently simple and trivial a matter. One set of observers, led by the English obstetrician, Matthews Duncan, declares that in natural labor the placenta comes out edgewise, and that any other mode of exit indicates something abnormal; while Schultze, of Germany, and his followers de- clare that the placenta always escapes like an inverted umbrella. My observation compels me to adopt the latter view. In consequence of the enormous effort put forth, the nervous excitation, the acute suffering, and the injury inflicted upon the soft structures of the birth-canal, it is not surprising that sys- tematic thermometry of the recently delivered woman shows almost always some elevation of temperature in the first twelve or twenty-four hours after child-birth. After a brief observation of the main clinical phenomena of labor, the student is better prepared to take up a consideration of its management. The advice offered applies to private and not to hospital practice, and to the beginning of the process. In the vast majority of cases a physician is engaged to attend a woman in confinement a considerable length of time before labor is expected, and there are certain important points in the pre- liminary management of the patient which it is important to appreciate, but they have been considered in the section upon the management of pregnancy. The present section begins with the first intimation that the doctor receives of beginning labor, the summons to attend his patient in confinement. The call may come at the most inconvenient time,—late at night; in the early hours of the morning ; at the beginning of a meal; in the midst of a press of other work,—but no one should practise ob- stetrics who does not make it an inflexible rule to give such a summons precedence over everything, over personal con- venience and all other engagements. It is customary, in this connection, to offer advice to young practitioners in regard to their personal demeanor and appear- ance when about to attend a woman in labor. While such ad- vise is usually superfluous, it does no harm to remind the phy- sician of the especial requirements in this particular kind of medi- cal work. He should remember that the irritability and in- creased sensibility characteristic of pregnancy are even more LABOR. 299 exaggerated during labor. Any unusual appearance in the medical man—slovenliness of dress, abruptness of speech and manner, harshness of voice, the odor of liquor on his breath or that of tobacco in his clothing—may have the most unfortunate effect upon his patient. Bearing in mind the increased sensitive- ness of women in labor, recollecting that the agony which they are about to endure, and that the despondency which comes of the dread of impending suffering, if not of death, demand espe- cial sympathy and consideration, no one fitted by nature for the practice of medicine will go far astray in his conduct toward his parturient patients. A more important question arises as soon as a physician is summoned to a case of labor. What shall he take with him ? As a part of his management of the pregnant woman he has directed the patient or her friends to have at hand some brandy, ether, fluid extract of ergot, a binder for the woman, the ordinary clothing for the child, scissors and tape for the cord, and other articles enumerated in the list of directions to mother and nurse on pages 347-349. A fairly well-equipped obstetrician should take with him in his obstetric bag, to an ordinary case of confinement, the following articles : A metal box containing scissors, needles, suture material, perforated shot, at least two hemostats, needle-holder, and a small alcohol lamp to boil the above. A box of five per cent, carbolated vaselin. A bottle of aseptic silk ligatures for the cord. A small package of absorbent cotton. A hypodermatic needle, with the customary pellets. A bottle of the fluid extract of ergot. An obstetric forceps. A bottle of bichlorid of mercury tablets. A small Gaiffe battery, or other electric battery, and a soap- box and nail-brush. Arrived at the dwelling to wiiich he has been summoned, the physician finds the woman in the room selected for her con- finement, which should be, if possible, the sunniest and best ventilated in the house, and in care of a nurse in whom he has confidence from past acquaintance or from good recommenda- tion. He has been summoned because the woman believes her- self to be in labor, but she may be mistaken, or, on the other hand, may be much farther advanced than she imagines. It is the physician's first care to determine this point, and to do it he must make an examination. This the patient fully expects and will in no way object to, but it must be done in a manner as little revolting to her feelings as possible. After a few indifferent 300 LABOR AND THE PUERPERIUM. remarks in a quiet tone to the patient ; a few questions in regard to the time the pains first came on, their duration, character, and situation, and the intervals of time between them ; after feeling the pulse, perhaps, and looking at the tongue, and assuring her that her general condition is very good indeed, the nurse is informed that she is to be prepared for abdominal palpation. While the nurse is arranging the patient on her back with a single layer of some thin material, as a bed-sheet, spread smoothly over the abdomen, the physician himself either leaves the room or turns his back upon the bed while he dons a surgical gown and gives his hands a preliminary washing. This whole subject of the obstetric examination is so im- portant that some space may well be devoted to its con- sideration. Abdominal palpation is described fully in the chapter upon The Mechanism of Labor. It is, therefore, only necessary to state here that, after determining the position of the fetus in utero, and investigating the condition of the fetus by listening to its heart-sounds, the nurse is directed to place the patient upon that side toward which the fetal back looks and to pre- pare her for a vaginal examination. For this purpose the parturient woman is placed upon her side, with the hips brought well to the edge of the bed, the thighs flexed upon the abdomen, the legs upon the thighs. The clothing is rolled up above the waist, or so arranged that it shall not interfere with the access of the examining hand, and the bed-sheet is draped over the patient so that a wide margin of it falls over the side of the bed. While this is attended to the physician is cleansing his hands by a method described in the chapter on the preventive treatment of puerperal sepsis. He uses that hand for the internal examination wrhich is next the patient, as he takes his seat alongside of the bed, facing the patient's genitalia. Everything being in readi- ness for the vaginal examination, the examining fingers are anointed with carbolated vaselin, the nurse lifts up the sheet covering the buttocks, the obstetrician raises the upper buttock with his free hand, and by the sense of sight inserts the forefinger of the examining hand directly into the vaginal orifice. Nothing is more foolish than the common practice of groping about under a sheet for the woman's genitalia, thus dangerously soiling the examining hand which had been made sterile by a painstaking disinfection, only to be infected again before its insertion into the vagina. The ability to derive easily all the desired information from a vaginal examination only comes from practice and an education of the tactile sense. It would be well, therefore, for the practitioner, in the beginning of his obstetric experience, to LABOR. 301 bear in mind a series of questions in their natural sequence, which he desires to have answered, and to persist in his earlier cases until repeated and long-continued examinations have satis- fied his mind. Thus : the character of the vaginal discharge ; the state of the perineum, whether relaxed, rigid, or torn perhaps from a previous labor; the rigidity and distensibility of the vaginal walls and the quantity of secretion upon them,—nature's lubricant; the capacity of the pelvis ; the condition of the cervix, whether it is rigid or yielding, thickened, edematous, or thinned out; the degree of dilatation of the os ; the portion of the fetal ellipse which is presenting itself at the os ; the position that the presenting part may have assumed ; the rupture or the integrity of the membranes ; and, if the examination continues during a pain, the effect of the expulsive forces upon the fetal mass. All these are questions of great importance in their bearing upon the diagnosis of the woman's present condition and upon the prognosis as to the character, duration, and termination of the labor. Having satisfied his mind upon all these points, the obstetri- cian enters upon the management of labor. The very first step in the treatment of the first stage of labor should be to evacuate the rectum. The capacity of even a nor- mal pelvis is none too great to permit the passage of the fetal body ; but if the pelvic canal is occupied by a distended rectum full of feces, labor may be delayed, the woman's suffering is materially increased, and the danger of a tear in the greatly dis- tended vagina is considerably augmented. It is only the rectum and sigmoid flexure that need be emptied, and this result is best secured by an enema of a pint of soapsuds with a teaspoonful 1 of turpentine in it. A well-trained nurse will already have done this, perhaps before the doctor's arrival, if she thinks that labor has really begun. The enema will act quickly and effectu- ally, whereas a purgative administered at the beginning of labor, as has been recommended by some, will begin its action possibly when the os is too much dilated to allow the woman to use a commode. The lower bowel being emptied, the woman may, with advantage and comfort to herself, be allowed to walk about the room or to sit up in a chair, the physician making an ex- amination from time to time to determine the progress of labor and to avoid the serious accident of a precipitate delivery in the erect posture, an accident dangerous to the mother and usually fatal to the child. This statement leads to the inquiry how often and how long to examine a parturient woman in the first stage of labor, and how long she should be allowed to re- main out of bed in a standing or a sitting posture. In a normal 302 LABOR AND THE PUERPERIUM. case during the first stage of labor, the intervals between the examinations are from two to four hours, or even longer. But two or three examinations need be made during the whole labor. As to the time for putting a woman in labor to bed and keep- ing her there, it is usual to lay down the rule that as soon as the os has reached the size of a silver dollar the woman should be confined to bed. Many patients might be allowed to be up longer than this, while others with a history of, or conditions predisposing to, quick labors must be put to bed earlier. Many patients will express a desire to go to the water-closet at about this time, but their request can on no account be allowed. Many a woman has discharged her infant into the seat of a water-closet or into the well of a privy, either by design or under the impression that she was having an evacuation of the bowels.x Before the woman is put to bed it should be arranged for the labor in the manner illustrated in figure 185. The mattress is protected by a mackintosh and the bed-sheet is guarded by a pad of nursery cloth. As the first stage of labor advances, the suffering of the woman will increase with each succeeding pain. She will, per- haps, complain bitterly, and the suffering becomes so great, in occasional instances, that the patient seems to be maniacal or to become completely exhausted, not so much from muscular effort as from an agony that is beyond endurance. She will appeal to her medical attendant to do something to relieve her suffering, and her appeal will be enforced by all the appearances of the greatest anguish, perhaps, that a human being is called upon to endure. Any sympathetic person must feel impelled to grant this request, to resort to some of the well-known agents for lessening pain that medical science is now possessed of. The only consideration that could deter him would be the fear that these remedies entailed dangers upon the woman that he dare not risk even to secure the immense relief of pain that they 1 The resident physician on my service at the Howard Hospital was called to a house in the neighborhood, and fished out of the privy-well, twelve feet deep, an infant which had been immersed in the contents of the well up to its neck for eight hours. The mother had deliberately sat upon the seat until her baby dropped from her. She had then thrown three bricks down upon it. In spite of these disadvantages the child was extracted alive, by means of a pole and some twine. It was received into my wards at the Philadelphia Hospital, where it thrived. On another occasion one of the patients in the University Maternity locked herself in the water-closet, dropped her baby down the bowl, and turned on the water. A nurse's attention was at length attracted to a stream of water running across the floor of the corridor. The water-closet door was broken open, the woman pulled off the seat, and the child, whose head accurately stopped up the exit-pipe of the bowl, was extracted alive, though it had been under water probably five minutes. All cases of this kind do not end so fortunately. LABOR. 303 would afford. I am convinced that such a fear is not justified by facts. The dangers and disadvantages that, it is claimed, result from the use of anesthetics in labor are : a prolongation of the process by weakening the uterine contractions and increasing the intervals between them ; a disposition to postpartum hemor- rhage ; an increased liability to sepsis after labor by a relaxation of the uterine muscle, and a subinvolution of the uterus. These objections are ill-founded if the anesthetic is administered Fig. 185.—Bed arranged for child-birth. The mattress is protected by a mackin- tosh, over which a clean sheet is spread. The upper bed-clothes are rolled up at the toot o: the bed. The woman's buttocks rest upon a square yard of nursery cloth. rri 1 • • r 1 , - - ----------- -j*w* «. ovjuaiv, ;oiu VJl 1IUISCIV LlOUl. 1 he chair is for the obstetrician ; at his feet is a waste-bucket, into which the pledgets of cotton used to clean the anus are thrown. The table, in easy reach, has upon it a large basin of sublimate solution, 1 : 2000, in which are many large pledgets of cot- ton ; a small tin cup on an alcohol lamp to boil the scissors for the cord; a half dozen clean towels ; a pot of carbolated vaselin ; a tumbler of boric-acid solution with squares of clean soft linen in it for the child's eyes and mouth ; a tube of sterile silk for the cord. in a proper manner. Accurate observation in some of the large German lying-in hospitals has demonstrated that an anesthetic, if not pushed too far, has no influence on the power, duration' or frequency of the pains. By relieving the dreadful suffering in some cases that causes an exhaustion as profound as would rollow tremendous physical effort, the danger of postpartum hemorrhage is actually avoided. Subinvolution is never seen as a result of anesthesia, unless it is pushed too far. Upon these 304 LABOR AND THE PUERPERLUM. negative facts ; upon the gratification that it gives every medi- cal man to relieve intense suffering; upon the enormous relief experienced by the patient and her gratitude for the aid afforded her is based the practice of giving an anesthetic in every labor in which its use is required. There are many women—and they will form the majority of a physician's patients in the country, I think—to whom labor is not so trying an ordeal ; is, in fact, little more than an inconvenience or a discomfort, and by no means an agony. I have even seen women expel a full-term child when they were hardly conscious that labor had begun. To resort, therefore, to an agent to abolish suffering when it does not exist or can be easily endured is obviously absurd. Granting that in many cases anesthesia in labor is an advan- tage, if not a necessity, the physician must select the anesthetic agent he shall employ, and must determine when and how he shall use it. The choice lies between ether and chloroform. Cocain, it was thought at one time, would be an efficient local anesthetic, but it proved a failure. Belladonna, applied locally to the cervix, is also of no service to relieve pain, although it diminishes rigidity; the same may be said of chloral, taken internally. I take it that the choice in the eastern seaboard of the United States will usually be for ether. Chloroform is in disfavor in this part of the world, although, perhaps, un- justly. Ether is an efficient, convenient, and satisfactory agent as an anesthetic in obstetrical practice, except, of course, in the treatment of eclampsia. There are, however, two precautions to be observed in its administration,—not to give it too long, and not to give too much of it. The first error is avoided by beginning its administration as late in labor as possible; it is better to put off the resort to an anesthetic until the second stage of labor, when the suffering in the first stage is not too great. One avoids giving too much : (i) By using a light towel thrown over the face and dropping only a few drops at a time, just below the tip of the nose, at the end of an expiration, so that the whole vapor is sucked into the lungs with the succeeding inspiration ; (2) by only beginning the administration of ether as the pain comes on, and discontinuing it in the intervals ; and (3) by endeavoring to produce not complete anesthesia, but only analgesia. It is astonishing how little ether it takes to do this. Any one can demonstrate in his own person that a few deep inspirations make the skin insensible to a sharp pinch or to the prick of a knife. A succession of these inspirations from pain to pain soon dulls the edge of the woman's suffering, and makes it quite endurable. As labor advances and the first stage is about to pass into LABOR. 305 the second, one should expect the rupture of the membranes and the escape of liquor amnii; so he will wisely make some prepara- tion for the occurrence. Provision must be made for the sudden escape, often rather startling to the patient or to an inexperi- enced practitioner, of a pint or more of liquor amnii, which must be caught in some clean towels or on a large, new sponge, one which has never been used before and should never be used again about the patient. If the membranes fail to rupture at the end of the first or at the beginning of the second stage of labor, the physician must consider whether he shall artificially break the bag of waters. In the case of a primipara such interference is not justifiable. The bag of waters is a perfect hydrostatic dilator, acting without great force, and in primiparae a slow, gradual, and conservative dilatation of the maternal soft parts is most desirable, to avoid lacerations of the cervix, vagina, or perineum. In multiparas the artificial rupture of the membranes is admissible after the completion of the first stage of labor; the interference certainly hastens the expulsion of the child, and as the soft parts of a woman who has already borne children are distensible there is not the same necessity for care to preserve nature's conservative dilator. Under no circumstances, in any ordinary uncomplicated labor, should the membranes be ruptured before the full dilata- tion of the os. Any one who has observed what in the nurse's parlance is called a dry labor—that is, one in which the mem- branes rupture earl}'—will not dispute this assertion. Occasion- ally, even in primiparae, the first intimation that a woman receives of the beginning labor is the escape of the liquor amnii, the mem- branes having ruptured before the os is at all dilated. In these cases the labor is longer, the woman's suffering is much greater, and the likelihood of damage to the maternal tissues is very con- siderably increased, as can readily be imagined when one considers that the dilatation of the birth-canal is effected not by the yielding, elastic bag of waters, but by the hard, unyielding mass of the fetal head. Occasionally, however, in the case of a multipara in the second stage of labor with unruptured membranes, the phy- sician must be prepared to perform the rather trivial manceuver of artificial rupture of the membranes with skill and without injury to the fetal or maternal structures. This sounds simple enough, and yet experience has shown that certain precautions are necessary. In the first place, the membranes are not to be ruptured during a pain, for the sudden gush of liquor amnii might carry with it a loop of the cord. It must be clearly established that the tissues to be punctured are the membranes, and not the child's scalp or the distended lower uterine segment. It 20 306 LABOR AND THE PUERPERIUM. is often possible to hook the finger-tip into a fold of the mem- branes and to tear them by pulling outward. They may also be pinched through between the forefinger and the thumb or middle finger. If these manual methods do not succeed, an ordinary match with the phosphorus cut off, sharpened at one end and then well soaked in a sublimate solution, may be introduced held between two fingers, and the membranes perforated with this simple instrument ; or an ordinary hairpin, straightened out, after being flamed, proves an efficient implement. During the second stage of labor a new and a very important element enters into its mechanism,—the powerful action of the abdominal walls. Indeed, it has been claimed that the con- traction of the abdominal muscles is the principal, the uterine force the secondary, expulsive power in this stage of labor. By the employment of a "puller" which fixes the chest above and the pelvis below, the power of the abdominal muscles may be utilized to its utmost extent. This is done by fixing the feet against the foot-board of the bed, and attaching to one corner of it a rope or a twisted sheet on which the woman can pull with her hands. The straining accompanying the uterine action, denoting that the second stage of labor has begun and that the presenting part is descending into the birth-canal, lasts in the typically normal case about an hour and a half or two hours, when, if the physician observes the genitalia,—and the period of labor has arrived when it is desirable actually to observe the process,—he notices that the anus is opened and the rectal mucous membrane is exposed to view ; with every pain small masses of feces are extruded from the anus which must be wiped away always toward the coccyx with large pledgets of cotton soaked in sub- limate solution ; the perineum bulges outward, and the vulvar orifice opens a little, disclosing a small portion of the child's scalp. With every pain the perineum becomes more distended, the vulva gapes more widely, until, finally, the perineum, by the tremendous tension to which it is subjected, becomes almost as thin as paper, and it seems a physical impossibility for the head to escape through the vulva without tearing the over- stretched tissues that form the pelvic floor. In fact, frequently the fetal head does make a way for itself through the perineum, instead of over and in front of it as nature intended, and after labor there is found a more or less extensive laceration of the pelvic floor. Schroeder's statistics show that in primiparae the fourchet, the little fold of skin at the posterior commissure of the vulva, is torn through in 61 per cent., while in 34 per cent. of all primiparae and in 9 per cent, of multiparae the peri- LABOR. 307 neum is more or less lacerated. Labor should be a physio- logical and a natural process, and it seems strange at first sight that such a process is so often associated with serious damage to the woman. But this is the price that civilized woman pays for her elevation from the original savage state, and the higher or the more artificial the civilization, the dearer the cost. I have been told by army surgeons that Indian squaws on the plains are very rarely injured in this way, for with their strong muscles and elastic tissues, and with the smaller fetal head that is the sign of a lesser mental development of the race, the maternal soft parts are subjected to nothing like the strain that is put on them in the case of women bred in towns, ill-developed physically, and bearing children that spring from a long succession of brain- workers, and whose heads are extraordinarily large in compari- son with their bodies. The problem presents itself, therefore, to every obstetrician in every case to avoid this accident if possible, or, if it must come, to make it as slight in degree as may be. Although the management of a perfectly normal labor is here considered, so frequent an accident is laceration of the perineum, and so constant is the danger of it, that it is necessary to take up, in this connection, the study of its causes, in order to devise an effective preventive treatment. The causes of laceration in the female perineum may in a general way be divided under three heads: (1) A relative disproportion in size between the outlet of the birth-canal and any part of the fetus, which makes the escape of the latter a physical impossibility unless the aperture is enlarged by tearing its least resisting border; (2) such a rapid expulsion of any part of the fetal body that the maternal tissues can not gradually dilate, but give way before the sudden strain imposed on them ; and (3) any abnor- mality in the mechanism of labor which pushes the present- ing part backward against the center of the perineum and prevents its propulsion forward under the symphysis pubis. In the first category, relative disproportion, might be put those cases in which the head is too large or the vulva too small; and, further, those cases in which the head presents its largest instead of its smallest diameters, as happens in insufficient flexion in vertex presentations. Under the second heading, precipitate expulsion, might be put all cases in which the expulsive forces are too strong; cases of straight sacrum, in which the fetal head is shot through the pelvic canal and suddenly puts great strain on the perineum ; cases in which too powerful traction is made with the forceps. Under the third head, an abnormal backward direction of the presenting part, might be placed those cases in which a pelvis of a male type, with approximated pubic rami, 308 LABOR AND THE PUERPERIUM. pushes the head backward and throws a greater strain on the perineum ; cases again, in which the woman, just as the head is passing through the vulva, suddenly straightens her legs and brings them close together; further, cases in which a straight sacrum allows the head to descend directly upon the perineum instead of directing it forward toward the vulvar opening, as a normally curved sacrum should do ; and, finally, cases in which overflexion brings the vertex to bear directly upon the center of the perineum. It must appear, from these many different causes, that the preventive treatment of laceration of the perineum will differ con- siderably in order to meet the diverse conditions that threaten the integrity of the pelvic floor; thus, if there is a very great relative disproportion between the head and the vulva and the opening must be artificially enlarged, instead of allowing the perineum to tear, perhaps into the rectum, it is better to nick the margin of the vulva on the side, and allow the tear to occur where it can not extend too far, and can do no harm. This simple operation is called episiotomy. It should be distinctly understood that it is called for only in rare and exceptional cases. Personally, I have no confidence in it whatever, as I believe it to be based upon an incorrect idea as to the mechanism of pelvic tears. After the delivery of the child and the placenta the small wound is to be closed by catgut or silkworm-gut sutures. If the danger to the perineum comes from a precipitate expulsion of the head, the proper preventive treatment is a retardation of labor, either by holding the advancing head back with the hand or with the forceps, by giving an anesthetic to control the voluntary muscles, or by administering chloral, which lessens the force of both involuntary and voluntary muscles. If there is some vice in the mechanism, as overflexion or extension, it may be corrected by the forceps. It is evident, therefore, that no one single plan of preventive treatment, no one inflexible method of " supporting the perineum," as it is called, will avail in all cases. There is, however, a routine practice directed against the commonest cause of " lacerated perineum " that will often prevent a laceration, and will at least keep any one individual's record down to the proportion already given as the average, and will, moreover, almost surely prevent a very extensive tear, say, into the rectum. There are excuses for the lesser grades of lacera- tion, and it is true that no physician, be his skill what it may, can absolutely avoid this accident; but a complete destruction of the perineum, a tear through the rectum, is rarely justifiable. It is most frequently the result of some blunder, carelessness, or error of technic. LABOR. 309 As the head distends the vulva almost to the utmost, it fails to recede as it has done after the previous pain, but remains in view until the next uterine contraction, which, with the abdominal contraction that accompanies it, suddenly expels the head through the widely stretched external outlet. The expulsive force acting suddenly and being much greater than is necessary to overcome the slight resistance now offered by the soft parts, lacerates the tissues instead of dilating and stretching them, as would happen were the expulsion of the head more gradual, less rude and sudden. This being the most frequent cause of lacer- ated perineum, it is easy to devise a means to meet and over- come the difficulty. The main requirement is to regulate the expulsive force so that it is just sufficient to overcome the slight resistance offered by the distended perineum, and as an auxiliary measure to restrain the progress of the head should this force become too great or be exerted too suddenly. It is obvious that one can not govern the force of the uterine contractions, which are involuntary; it is just as plain that one can regulate the force and duration of the abdominal contractions by appeal- ing to the woman's will. Thus, the physician can call upon her to strain forcibly or gently, as the case may require, bringing into more or less active play the expulsive action of the abdom- inal walls ; he can command her to stop straining, or to open her mouth and breathe rapidly, which amounts to the same thing, thus inhibiting the greater part of the expulsive force ; or, if a powerful uterine contraction should come on, or if the woman should exert her voluntary muscles too violently, or should fail to obey the command to stop straining, the expulsive forces may be neutralized simply by making such firm pressure against the child's head with the hand that it will not budge. At the same time the outspread hand, which can most conveniently be used for the purpose, is applied to the distended perineum so that the thumb and forefinger encircle the posterior commissure of the vulva. This hand helps to flex the head when the occiput is anterior; it restrains the progress of the head, and it pushes it forward under the arch of the pubes, away from the overstretched muscle of the pelvic floor. This is the best plan of supporting the perineum, as it is called, though it is not really a support of the perineum at all, but a diminution of the ex- pulsive forces and a regulation of the progress of the fetal head, which is supported, restrained, and directed by pressure, partly through the perineum, partly directly upon the head itself. Presuming that these precautions have been successful, that the perineum has been safely retracted over the child's head, and that the head is born, the face at first appears white, but 3IO LABOR AND THE PUERPERLUM. almost immediately turns quite purple and looks as if the child must be choking to death. It is, as a rule, however, in no seri- ous danger. The head being the only part of the fetal body free from pressure the blood is determined to it, and is prevented from returning freely by the pressure about the neck, thus giving the child's head, as it protrudes from the vagina, a most alarm- ing appearance of deep asphyxia. There is, however, in some cases, a more serious element in the asphyxiated look of the child; in one out of four labors the cord is found coiled about the child's neck, usually only once, and that lightly, but occa- sionally many times, nine coils having been recorded in one Fig. 186.—Retarding the escape of the head and pushing it away from the perineum. case, and so tightly occasionally as to completely strangulate the infant, not by pressure upon the neck, but upon the cord. This anomaly occurring so frequently, and having such serious results, must always be borne in mind, and as soon as the head is born and the neck becomes accessible the medical attendant must at once ascertain whether the cord encircles it or not, by sweeping a forefinger between the child's neck and the maternal symphysis. If the cord is found in this situation, it should be gently pulled upon, and whichever portion yields should be drawn out, so enlarging the loop that it may be slipped over the head ; or, if that is impossible, making the loop at least large enough LABOR. 3H to allow the shoulders to pass through ; or if that, again, is not feasible, if the cord so firmly constricts the child's neck that the loop or loops can not be loosened, it may be hastily ligatured with a double thread and then cut between the ligatures. The child, in such a case, must, of course, be extracted immediately, else it will be fatally asphyxiated. The cord not being felt, or having been attended to, if found around the neck, the physician next turns his attention to the child's head. The head is protruding from the vulva, the face is swollen and almost purple, looking as if the only hope for the fetus lay in speedy delivery ; the labor is almost concluded, the medical attendant sees his anxiety and attendance almost at an end, and for all these reasons, especially if he is inexperienced, he will feel strongly impelled to bring to a close a process that seems to endanger the fetus, that has caused his patient much suffering, and himself, perhaps, fatigue, by pulling on the head and rapidly extracting the fetal body. If he does so, however, the shoulders hastily pulled through the vulva will almost surely lacerate the perineum, perhaps deeply. Many a case of lacerated perineum, even into the rectum, is explained in this way. A still more serious consideration is that immoderate traction upon the head may seriously injure the child's spine and the spinal column. As experience has shown that the fetus is not subjected to great danger in this situation, and as premature efforts to extract it entail upon both woman and child a danger more imminent than that which it is endeavored to avert, it is better to do nothing at this stage of labor but simply to support the head upon the hand, waiting for the action of the natural expulsive forces, which will rotate the shoulders, and with them the head, and shortly after expel the rest of the body. The physician may, if he chooses, stimulate the uterus to act by rub- bing or kneading it, and, as it begins to act, may assist its con- tractions by pressure upon the abdominal walls over the fundus. This is all the assistance that need be offered in a natural case. With this slight addition to the natural forces the shoulders descend and rotate ; the anterior shoulder slips out first under the symphysis pubis, the posterior shoulder and arm quickly follow, the anterior arm then emerges, and, the shoulders being born, the rest of the body is immediately expelled so rapidly that it is difficult to follow the mechanism of its expulsion. The moment the child escapes from the birth-canal it emits a lusty cry, which is usually synchronous with a sigh of intense satisfaction from the mother, who has in an instant been entirely relieved of long and intense suffering, and in whom the passive pleasure of relief from great pain is so great as to become a positive en- 312 LABOR AND THE PUERPERLUM. joyment. There are now two patients on the physician's hands at once, and, although he must in practice devote his atten- tion to both equally and at the same time, it is more conve- nient here to consider their management separately. Although the child's expulsion from the mother gives her such immense relief, it by no means terminates the labor nor brings her an immunity from all danger; indeed, the chief, the most common danger of parturition, hemorrhage, may be said to begin with the expulsion of the child, and sometimes a most difficult and dangerous complication of labor, adhesion of the placenta to the uterine wall, only manifests itself after the complete escape of the child from the birth-canal. There are, therefore, two problems with which to deal in the third stage of labor in almost every case, no matter how normal it may appear,—the delivery of the placenta and the prevention of hemorrhage. As hemorrhage may occur before the expulsion of the placenta, and therefore stands first in point of time ; as this accident is of the gravest nature and its prevention of the greatest importance, the first thought of the medical attendant should be the routine means to adopt in every case to prevent its occurrence. Provided the uterus contracts and remains contracted, the enormous blood-vessels in its walls are obliterated and hem- orrhage is impossible. On the other hand, if the uterus remains flaccid and uncontracted while the placenta is being separated, or if the organ, at first contracted, afterward relaxes, hemorrhage of the most alarming character must as necessarily occur. The whole problem, therefore, of preventing hemorrhage after delivery resolves itself into a problem of securing and of maintaining uterine contraction. Luckily, nature takes this task off our hands in a vast majority of cases. In a healthy, vigorous woman little concern need be felt in regard to the action of the uterus ; its muscular fibers will contract firmly ; its whole body will assume a solid, hard consistence, and there will be no hem- orrhage. Unfortunately women who have lived in the midst of an artificial civilization, who are often of an enervated habit and imperfect physical development, in whom a natural process re- quiring vigorous muscles will not always run a natural course, are more or less prone to bleed after labor, and, therefore, one can never afford to be remiss in his efforts to prevent relaxa- tion of the uterus after confinement, never knowing surely in whom it may or may not occur. Firm Contraction of the Uterus After Labor is Secured by Ex- ternal and by Internal Stimuli to Contraction.—The latter con- sists of a dram dose of the fluid extract of ergot in a little water, administered as soon as the child's body is born. The LABOR. 313 former consists of manipulation of the uterus. Luckily the uterine muscle is irritable, and shows its irritation by contracting its fibers. Luckily, again, it is accessible. One can easily grasp it through the abdominal walls; can rub it and exert direct pressure upon it, these actions exercising a powerful irritant in- fluence upon the uterus and bringing about, in the ordinary case, firm contraction. This is the most efficient, readily applied ex- ternal stimulus to uterine contraction, and one that must be in- variably applied, and that, too, continuously from the moment the infant's body is expelled until a milder form of external stimulus which is to maintain uterine contraction is adjusted,—the obstet- rical binder. The moment that the child escapes from the woman's body the physician or nurse seizes the uterus through the ab- dominal wall and exerts constant pressure upon it, irritating it still more from time to time by a kneading or a rubbing motion. If the woman is fortunate enough to have a good nurse, this duty may safely be left to her, while the doctor washes his hands and takes a brief rest. Some fifteen minutes having elapsed, the placenta being delivered, the woman having been cleaned and made more comfortable, the constant pressing and kneading of the uterus may be replaced by the more gentle and more con- tinuous external stimulus of the binder and abdominal pad. This binder holds an important place in the treatment of Eng- lish-speaking women at least. In some civilized countries it is not used at all, and, it must be confessed, it is unneces- sary, from the medical point of view, after the first twenty- four hours. The obstetrical binder, however, adds greatly to the woman's comfort by maintaining the intra-abdominal pressure and thus preventing cerebral anemia. It undoubtedly preserves the figure,—a fact to which no woman is indifferent,—and it de- creases the danger of postpartum hemorrhage by maintaining a tonic contraction of the uterus. For all these reasons the use of the obstetrical binder is well justified—is, in fact, demanded— in the intelligent management of the puerpera. The best binder is a piece of unbleached muslin, about a yard and a quarter long and wide enough to reach from the trochanters to the floating ribs. It is pinned together from above downward, and is made to fit more snugly and comfortably by making gores at the sides above and below the hips. The pad should consist of one or two folded towels put above the ?iavel to fill the hollow in the epigastrium left by the evacuation of the womb and its reduc- tion in size. The second problem of the two that confront a physician in the management of the woman in the last stage of labor is the 314 LABOR AND THE PUERPERIUM. delivery of the placenta. To superintend this process intelli- gently it is necessary to recall the chief phenomena of the mechanism of the third stage of labor. The placental structure resembles nothing so much as a sponge, and as the uterine wall contracts and retracts, the placenta follows the reduction in the size of the placental site by a corresponding reduction in the placental area, up to a cer- tain point. The placenta diminishes in size until all its villi come in ac- tual contact with one another; until, instead of being a spongy organ with the intervillous blood-spaces separating the villi from one an- other, the whole organ becomes a solid mass, and can not accom- pany a further reduction in the area of uterine wall to which it is attached, so that the smallest addi- tional contraction of the uterine muscle must spring off the whole placental mass at once. This point is reached when the placenta has become reduced to about one-half of its natural area — a fact that has been demonstrated on uteri removed by the Porro Cesarean section or on postmortem exami- nations of the organ in patients who had died during or directly after labor. As to the expulsion of the placenta after its detachment, that is a matter easily understood ; lying in the uterine cavity as a loose foreign body, all that is required is the vigorous action of the uterine muscle to drive this substance out of the uterine cavity. But, once beyond the province of the thick, muscular portion of the uterus, above the contraction-ring, there is no further force to drive the placenta on, for now it rests in the semiparalyzed lower uterine segment (see Fig. 187), in the cervix or in the vagina both, also, in a measure, paralyzed by the extreme overdistention to which they have been subjected, and there it may rest for hours or days, until it undergoes de- Fig. 187.—Dilated lower uter- ine segment and cervix after labor, from a frozen section (Benckiser and Hofmeier). LABOR. 315 composition.1 Arguing from the fact that animals never re- quire an artificial delivery of their after-births, many obstetri- cians of the last century and the beginning of this, headed by William Hunter, declared that the delivery of the placenta should be left entirely to nature. The result was disastrous, as may be imagined. It is, therefore, a necessary part of the management of the third stage of labor to secure the separation of the placenta by stimulating the uterus to contract and by aiding it to expel its contents by exaggerating its expulsive power. These two objects are best obtained by what is known as Crede's method, a method first proposed to the profession in a systematic manner Fig. 188.—The expression of the placenta. by the late Professor Crede, of Leipsic,2 in 1861. A somewhat similar plan had been in use in Dublin for a long time before, and many primitive and savage people have employed, perhaps for ages, methods based upon the same principle. In applying Crede's method the uterus is seized in a grasp illustrated in figure 259, is kneaded and rubbed until it con- tracts with vigor; only then, and only in conjunction with the uterine contraction, should it be firmly pressed down in the direction of the axis of the pelvic inlet, while it is compressed between the fingers and thumb with considerable force. The placenta is thus squeezed out as the stone is pressed out of a cherry. As it slowly emerges from the vulva it should be 1 V. Campe ("Zeit. f. Geburtsh. u. Gyn.," Bd. x, H. 2) in 120 observations found that in 24 instances the placenta had not been expelled in twelve hours. 2 " Monats. f. Geburtskunde," xvii, p. 274. 3 l6 LABOR AND THE PUERPERLUM. caught in the obstetrician's hand, while a nurse holds a basin pressed close into the mother's lower buttock, to receive the blood that usually spurts out with the after-birth. The mem- branes trail after the placenta, running up into the vagina and the uterine cavity. To extract them without tearing them, and thus leaving a portion behind, they should be seized between the whole length of the thumb and forefinger and gently pulled, first forward toward the symphysis, then backward toward the sacrum, the uterus meanwhile being allowed to relax. It is a mistake to turn the placenta over several times to make a " rope " of the membranes. To return, now, to the infant which has just been born. The head and shoulders having escaped, the rest of the body slips out almost immediately, the child's arrival being announced Fig. 189.—The reception of the placenta in a basin. usually by a vigorous cry, a purely reflex action caused by the sudden shock which the new-born experiences on suddenly emerging from an aquatic existence, in which its immediate sur- roundings have a temperature of about 990, into the atmosphere and a temperature not over 700. This violent shock produces not only a spasmodic action of the diaphragm and the muscles of respiration, but also of the bladder, and of all of the muscles of the body as well, so that often urine is voided directly after birth, and the arms and leg are moved about quite violently. As soon as the child is born, it is well to see that its air-passages are clear and not clogged by mucus or blood that might have been inspired during labor. This is done by crooking the little finger and introducing it back of the epiglottis ; if, however, the child at once emits a vigorous cry, it is proof enough that the LABOR. 317 respiratory tract is not obstructed. The infant is then placed on its right side, this posture favoring the closure of the foramen ovale and facilitating the passage of the blood from the ascend- ing cava over the Eustachian valve into the right auricle. The position should also be so arranged as to turn the child's face from the mother's genitals and to protect the infant's air-passages from the maternal discharges incident to the third stage of labor, care being taken, also, not to put the cord too much on the stretch, for all this time, of course, the infant remains attached to the mother by the umbilical cord. Now arises the question, in every case, as to the advisability of severing the cord at once and getting the child out of the way. The placenta, it has been argued, no longer performs its vital functions ; the child breathes, and, therefore, it might be better to cut the cord, to remove the infant from the bed, and to turn it over to the nurse. This plan, Fig. 190.—The position in which the child should be placed after birth. however, does not take into account the fact that there remains a considerable quantity of fetal blood in the placenta ; that it is an advantage to have all of this blood, if possible, returned to the infantile body where it belongs, and that, further, the deple- tion of the placenta renders its expulsion easier. The blood in the placenta will return to the child's body, if time is allowed for it ; on the one hand, the action of the respiratory muscle exerts a suction upon the placental vessels, which aspirates the blood from the placenta; on the other hand, the pressure upon the placenta by the uterus drives the placental blood into the fetal body. To demonstrate the advantage of late ligation of the cord, Budin x conducted a series of experiments, with the following results : the cord ceased beating in 22 cases, on the 1 Publicationsdu " Progres Medical," 1876 ; also " Obstetrique et Gynegologie," 1886. 318 LABOR AND THE PUERPERIUM. average, in two and one-half minutes. In these cases the aver- age weight of the placenta was 520 gm., and the amount of blood that escaped from the umbilical vein in 20 cases was 92 gm. less in late than after immediate section of the cord. Thus, by immediate ligation 92 gm. (2.8 oz.) of blood are lost to the infant's body. Moreover, in contrasting the weights of children after immediate and late ligation of the cord there was a gain of two to three ounces in favor of late ligation. It is better, therefore, to wait two or three minutes after the birth of the infant before cutting its cord.1 The proper time having arrived, the cord should be ligated about two fingers' breadth from the child's body with a piece of stout surgeon's silk, sterilized. The ligature is tied firmly once around with a double knot. The ends are then doubled around again and are tied with a single and a bow knot, so that the nurse, after the child is washed, may slip this last knot Fig. 191.—Cutting the cord. and may then retie the ligature firmly. This precaution surely avoids a primary or secondary hemorrhage from the cord, which sometimes occurs in consequence of a shrinkage of the mucous tissue, making the original ligature too loose. The obstetrician is now ready to cut the cord. The child is slippery and hard to hold; its legs and arms are jerked about in a very disconcerting manner to the beginner, so that carelessness in the use of scissors at this juncture might result in injury to the fingers, the toes, or, in the male child, to the penis. The manner of cutting the cord illustrated in figure 191 surely avoids all such accidents. The 1 There has been a good deal of criticism upon Budin's proposition to ligate the cord late ; several German authors have attributed a number of infantile complications to it. I have carried out the practice for ten years, and have convinced myself by experience of its advantages. LABOR. 319 child's connection with its mother being severed, it is wrapped in a blanket ready to receive it and is put in some safe place, where it will not be trodden nor sat upon. Its own crib is the best place for it. The cut end of the cord attached to the placenta is not tied, but is allowed to drain into a basin, so as to lessen as much as possible the bulk of the placenta. In case of twins, however, a double ligature on the cord is required, else the second child might bleed to death on account of anastomosis between the vessels of the placenta. CHAPTER II. The Puerperal State. The moment that labor terminates with the expulsion of the placenta, there begins an effort on the part of nature to restore to their normal condition those organs and systems that have been in an active state of development for nine months before; there is destroyed in a few weeks that which it has taken months to build up, and side by side with this destructive process goes on with equal rapidity one of growth and repair. One sees the reduction of the sexual, the circulatory, and the nervous systems to their normal capacities and functions by the destruction of redundant material; but one sees with this the reparation of the injuries of child-birth, the formation of a new endometrium, and the rapid development of an entirely new and complicated func- tion, lactation. And yet, by a provision of nature which is almost beyond comprehension, these two opposed processes of decay and regeneration go on at the same time in one body, involving whole systems and organs, without manifesting themselves in the slightest derangement of the individual's health. Under no other circumstances could an organ weighing two pounds, and as large as the liver, degenerate and in great part disappear without the gravest symptoms of constitutional disorder. In no other condition could the whole composition of the blood be materially altered; the heart changed in size, power, and capacity; the nervous system modified in sensibility; a large body-cavity, stripped of its mucous membrane and again resupplied with a new lining; large organs, as the breasts, suddenly assuming great functional activity, without very marked evidence of dis- ease ; and yet in the puerperal state there are all these remarkable changes while the woman in appetite, feeling, and temperature is in perfect health. But it is obvious that in a condition which, 320 LABOR AND THE PUERPERIUM. though it is called physiological, borders so closely on the pathological, very little is required to pass the boundary-line into disease. Anomalies of excess and deficiency in the natural processes occur easily; the raw surface of the uterus with the wounds of the vagina and vulva give ready entrance to infectious poisons, and the whole individual seems especially sensitive to unfavorable external influences, both mental and physical. Consequently this is the period in the history of the child-bearing woman that is most beset with difficulties and dangers and most likely to be marked by accidents and com- plications. The preventive and curative treatment of these com- plications is one of the most difficult tasks in obstetrics, and success here, as elsewhere in medicine, depends to a great extent upon a thorough knowledge of the natural process, for only on such knowledge can one base a rational management of the normal case and a satisfactory treatment of the abnormal con- ditions which are so apt to develop during the puerperium. The puerperal state, or the puerperium, comprises the time from the termination of labor until the uterus has regained its natural size. This is a period, in the normal case, of six weeks.1 The study of the physiological phenomena in the puerperium, or puerperal state, involves a study of the reduction of the uterus directly after delivery to the uterus of the healthy non-pregnant woman,—a process called technically " the involution of the uterus " ; it involves a study of the involution of the vagina, of the destruction of the deciduous mucous membrane, and the regeneration of the endometrium ; of the retrograde changes that occur in the uterine ligaments and peritoneal covering and in the ovaries ; of the alterations by which the blood and the heart regain their normal condition and the changes in the pulse; of the changes in the body-weight, the temperature, the skin; the action of the bladder and of the alimentary canal. An important factor also in the puerperium is the establishment of the milk secretion. The Involution of the Uterus.—Three theories may be advanced to account for it : (i) A fatty degeneration of the muscle-fibers and the absorption of the fine granular fat-globules to the complete destruction of the uterine muscle, its place being taken by a new growth of muscle-fibers developed from the embryonal muscle-cells in the outer layers of the uterine mus- culature. (2) A partial degeneration and an atrophy of the large 1 The word puerperium comes from puer, a child, and pario, to bear, and denoted, in the original Latin, the child-bed period, the lying-in period; so it is an appropriate term to designate this one of the four periods in obstetrics,—pregnancy, labor, the puerperium, and lactation. THE PUERPERAL STATE. 321 muscle-fibers seen in a pregnant uterus at term. (3) The con- version of the muscle-cell contents into a peptone, its absorption into the blood-current and discharge through the kidneys, giving rise to the peptonuria of puerperal women (Fischel). Kilian,1 in his examination of rabbits' uteri thirty to thirty- six hours after they had expelled their young, found fat-globules in the epithelial covering of the uterus, noticed that the muscle- fibers looked fainter and paler than in pregnane}', and saw in their interior very fine, shining fat-globules ; alongside of these degenerated muscle-fibers Kilian found some quite young fibers, as he had seen them in the uteri of young animals. Heschl2 confirmed Kilian's observations, and went even further in de- claring that the muscle-cells were completely destroyed by fatty degeneration ; this writer sawr, in the outer portion of the uterine body, at first nuclei; which, developing cell-contents around them, gradually transformed themselves into typical unstriped muscle-fibers. Thus, after labor the uterine muscle was destroyed and a new development of muscle-tissue occurred to take its place. Robin,3 on the other hand, claimed that the involution of the uterine muscle is essentially atrophy of the individual muscle-cells. Kolliker4 says that the involution of the puerperal uterus consists of a diminution in the size of the contractile fibers in the muscle-layer, alongside of which may be seen fatty degeneration. Mayor,5 from a study of fourteen specimens dating from the first day after delivery until the ninth month of lactation, concludes that, while the fatty degeneration of the muscle-fibers is more pronounced than Robin thought, it is far from having the importance that Heschl attributed to it; it does not seem, as this author believes, to cause the destruction of the muscular elements. Mayor, therefore, attributes to atrophy the predominant role in the involution of the uterus. Winckel6 still holds that the reduction of the puerperal uterus is due to fatty degeneration. Sanger,7 from the observation of twelve uteri obtained at periods varying from four hours to fifty-five days after labor, recognizes the fatty degeneration in the muscle-cells, 1 " Die Structur des Uterus bei Thieren," Henle u. Tfeuffer's " Zeits. f. ration- die Medicin," 149 u. 1850, Bd. viii u. ix. 2 " Untersuchungen iiber das Verhalten des menschlichen Uterus nach der Geburt.," " Zeits. der k. k. Gesellschaft der Aerzte in Wien," 1852, viii, 2. 3 " Diet, encycl. des Sc. med.," 2e serie, t. x, p. 14. 4 " Gewebelehre," 5. Auf!., p. 565. 5 " Etude histologique sur 1'Involution uterine," " Archives de Physiol, norm, et path.," ix, x, 1887, P- 560. 6 "Lehrbuch der Geburtshulfe," 1889. 7 Abst. in Schmidfs " Jahrbucher," No. 3, 1888, p. 250. 21 322 LABOR AND THE PUERPERIUM. but does not believe that they are destroyed.x Microscopic sections of five uteri in my possession, obtained respectively in the last week of pregnancy, two hours, thirty-six hours, seventy- two hours, and seven days after confinement, indicate that fatty degeneration plays a most important part in the reduction of the large muscle-cells characteristic of pregnancy to the much smaller muscular fibers of the unimpregnated uterus. My own belief is that the redundant material within each cell is Fig. 192.—a, Uterine muscle-fibers nine days postpartum; b, uterine muscle- fibers eight days postpartum; c, uterine muscle-fibers in the eighth month of pregnancy. destroyed by some degenerative process (chiefly fatty), but that the cell is not destroyed in toto. Measurements made by Sanger2 show plainly that the reduction of the uterus after labor is 1 Sanger says that "the fat-globules and other degeneration products do not enter, as such, into the circulation, but are oxidized on the spot. There is no such thing as a puerperal lipemia " ("Die Riickbildung der Muscularis der puerperalen Uterus"). 2 Loc. cit. THE PUERPERAL STATE. 323 effected by a diminution in the size of the individual fibers, and not by their destruction.x There is a greater unanimity of opinion in regard to the invo- lution of the serous covering, connective tissue, blood-vessels, and mucous membrane of the puerperal uterus. Mayor 2 found, in the peritoneal covering of the uterus after delivery, a number of folds in the membrane ; at the bottom of these folds the endothelial cells seemed to be transformed into a spherical shape. Kilian 3 found the cells in this region infil- trated with fat-globules. Bernstein,4 in a study of involution in the rabbit's uterus, paid especial attention to the behavior of the connective tissue. He found that the reduction of this tissue in the puerperal uterus was effected by a fatty degeneration of the connective-tissue cells, and by a drying out, as it were, of the connective-tissue fibers ; these, deprived of the excessive blood- Fig. 193.—Muscular tissue of the pregnant and of the puerperal uterus. supply of pregnancy, dry up and shrink. Bernstein incidentally mentions the fatty degeneration of the peritoneal endothelium, and expresses the opinion that the muscle-cells, while they do undergo a fatty degeneration, are not completely destroyed. The chief changes in the blood-vessels seem to be shrinkage, the obliteration of many large vessels by a connective-tissue growth in the intima, associated with fatty degeneration of the 1 Fiber-length in pregnant uterus............208.7^. " " in first few hours postpartum........158.3 fi. " " until the fourth day postpartum.......1IJ.4/i. " " in first half of second week postpartum . ... 82.7/z. " " in beginning of third week postpartum. ... 32.7^. " " at end of fifth week postpartum....... 24.4 fi. 2 Loc. cit. 3 £0C- c{t * "Ein Beitrag zur Lehre von der puerperalen Involution des Uterus," D. i, Dorpat, 1885. 324 LABOR AND THE PUERPERIUM. media,1 and the development in the adventitia of the vessels not obliterated of new elastic fibers. The involution of the endometrium is now clearly under- stood, thanks to the investigations, first, of Friedlander,2 then of Kundrat,3 Engelmann,4 Langhans,5 Leopold,6 and others. When the ovum is cast off at term, it carries with it, in the strictly normal case, the whole ovular or epichorial decidua and Fig. 194.—Lochia on the fourth Fig. 195.—Lochia on the second day: a, Decidual cells ; b, white blood- day (lochia cruenta), showing a few corpuscles ; c, a few red blood-corpus- cocci and streptococci: a, Decidual cles,; d, epithelium; e, micro-organisms cells; b, red blood-corpuscles; c, (Winckel). white blood-corpuscles ; ^epithelium (Winckel). Fig. 196.—Lochia on seventh day ; afebrile case: a, Blood-corpuscles ; b, diplo- cocci and monococci; c, white blood-corpuscles; d, epithelium ; e, decidual cells (Winckel). the upper cellular layer of the uterine decidua, leaving behind on the uterine wall the lower cellular layer and the glandular por- tion of the uterine mucous membrane. This membrane, deprived 1 Balin, " Ueber das Verhalten der Blutgefasse im Uterus nach stattgehabter Geburt," "Archiv f. Gyn.," Bd. xv. 2 " Physiol.-Anatom. Untersuchungen iiber den Uterus," Leipsic, 1870; "Archiv f. Gyn.," Bd. ix. 3 " Wien. med. Jahrbucher," 1873. 4 Hid. 5 "Archiv f. Gyn.," Bd. viii. 6 Ibid, Bd. xii. THE PUERPERAL STATE. 32S in great part of its nutriment by the contraction of the uterine wall and the obliteration of many of its blood-vessels, loses its vitality in that portion furthest removed from its source of nutri- ment—the superficial layer of decidual cells. These die and are cast off with the lochial discharge in a condition of fatty degen- eration or disintegration. By the shedding of these cells the glandular layer of the decidua is laid bare. Now the involu- tion of the endometrium ceases and a regeneration of the membrane begins. The epithelial cells within the glands take on an active growth and reproduction ; the interglandular con- nective tissue shares in the new development; by its growth it rises in embankments between the glands, making them deeper, and so in time reproduces the characteristic utricular glands of the uterine mucous membrane. This process requires some time. Mayor says : " On the twenty-fourth day after delivery I have not found glands in the region of the placental insertion. The mucous membrane, although reconstructed at the second month, is then furnished with fewer glands, less regularly disposed, and of a greater caliber than in the normal state." The uterus is not the only organ of the sexual system that experiences a retrograde change after labor. The ovaries and tubes, the broad and round ligaments, the pelvic connective tissue, blood-vessels, and lymphatics, all undergo modification. That portion also of the birth-canal—the lower uterine segment, the cervix, the vagina, and the vulva—which is dilated to an extreme degree to allow the passage of the fetal body, must likewise exhibit rapid involution to regain its wonted tone and caliber. In these structures the process is mainly one of retrac- tion of overstretched tissue; but there is, in addition, a certain amount of degeneration and atrophy of the redundant cells that the increased blood-supply and increased stimulus to growth of pregnancy called into existence. Particularly is this true of the lower uterine segment and cervix, which in their involution dis- play an intermediate process between that by which the reduc- tion of the uterine body is effected and that by which the lower portion of the parturient tract regains its normal state. The involution of the uterine adnexa will progress satisfac- torily if the uterine involution itself is normal. The reduction of the overstretched vagina and vulva is sure to occur if these parts have not been seriously lacerated, although, like all over- stretched muscular canals, they never quite return to their original caliber. From the large sinuses at the placental site, laid bare after the separation of the placenta; from the innumerable little ves- sels of the decidua that have been torn in the separation of the 326 LABOR AND THE PUERPERIUM. ovum from the uterus ; from the rents of various degrees that have been made in the cervix, vagina, and vulva during labor, it is inevitable that there should be, for some time after delivery, an oozing of blood in considerable quantity. As the residue of the decidua and the blood-clots remaining in the uterine cavity are disintegrated, the products of this decomposition must also escape externally. And as the whole genital canal, lined by a mucous membrane, is stimulated and irritated by foreign sub- stances and a large blood-supply, it is obvious that the mucous secretion of the genital tract will be considerably increased, and must make its escape also from the vagina. This composite discharge after labor, made up of blood, degenerated epithelial cells, the debris of disintegrating animal material, mucus, and large quantities of harmless micro-organisms, is called " the lochia." * It is important to appreciate the normal character of this discharge, for changes in its quantity, odor, or constituent parts often point to some morbid process. The older writers on obstetrics paid great attention to this feature of the puerperal state, and gave to the discharge three names, which indicate the three changes that it undergoes in appearance. For the first five days it is called lochia rubra; for the next two days, lochia serosa; and after that, lochia alba. At first, as might be ex- pected, the discharge is almost wholly bloody—the lochia rubra. As, however, the repair of the injuries of parturition progresses and the hemorrhage ceases, the discharge is the result simply of a serous exudation and a species of catarrh affecting the mucous lining of the genital tract—the lochia serosa. Soon, however, the dead tissue in the genital canal is cast off; disintegrated and fatty epithelial cells are mixed in the discharge ; micro-organisms are found in it, while the pus from the granulating wounds all along the genital tract forms an important constituent of the discharge after the sixth or seventh day. To the lochial dis- charge at this period is given the name lochia alba,—appropri- ately enough,—for it looks like, and is, practically, healthy pus. The last stage of the lochial discharge lasts from the seventh until the tenth, twelfth, or fourteenth day, or even longer. Two other features of the lochial discharge are also of clinical inter- est—the quantity and the odor. The amount of discharge at the three different periods may be expressed scientifically thus : During the first four days the amount of discharge is I kilo- gram, or 2.2 pounds ; during the next two days, 280 grams, or about 9 oz. ; and until the ninth day, 205 grams, or nearly 7 ounces, the entire loss amounting to 3^ pounds. These figures, however, are of no value to the practical clinician. 1 A word derived from the Greek Aoxoc, pertaining to a woman in child-bed. THE PUERPERAL STATE. 327 No physician in private practice can accurately measure the amount of lochial discharge ; so that the convenient method of estimating it has been adopted of noting the number of napkins or pads that are soiled in the twenty-four hours. The normal puerpera should not require a change of the vulvar pads oftener than six times in the twenty-four hours for the first four or five days. The importance of being able to distinguish between a normal and abnormal amount of lochial discharge is obvious. Without this ability on the physician's part a dangerous hemor- rhage might go undetected, or a marked diminution or even suppression of the lochia might be unnoticed. The odor of the lochia during the period of sanguinolent discharge is very much that of fresh blood or raw meat. Later, when the mucous secretion forms a considerable part of it, the predominant odor is that peculiar to the secretion from these parts. Should there, however, be retained within the uterus, unusually large masses of decidua, placenta, membranes, or blood- clots, and should the germs of decomposition gain access to these highly putrescible bodies in a situation most favorable to their decomposition, the lochia at once takes on a putrid odor. This is frequently the first danger-signal that the uterus has become the seat of a process which places the woman's life in constant peril. It is none too pleasant a duty this, of investi- gating the odor of the lochia, but an examination by the sense of smell of the napkins that have just been removed forms an important part of the duties of the physician at every visit until the discharge has almost ceased. The involution of the uterus has been described as if it were one continual process, moving on evenly from beginning to end. But as the involution of the uterus depends primarily upon the contraction of the muscular fibers in its walls, one might cor- rectly infer that this process is not one of smooth and even progression, but that it might be indicated graphically by a series of waves, representing contractions of the uterus of more or less force and frequency and intermissions of less firm con- traction ; the retraction of the uterine muscle, however, main- taining fairly well what is gained by contraction. Each case has a certain degree of individuality; in one the contractions are firm and the intervals between them short; in another it is the reverse and all gradations may be found between the extremes ; but while there are in every case individual pecu- liarities, the action of the uterus after labor is governed by a few general laws. Thus, in primiparae, the uterus being more powerful, better supplied with muscular tissue than it will ever be again in a subsequent confinement, contracts so vigorously, 328 LABOR AND THE PUERPERLUM. relaxes so little, that after the expulsion of the placenta the uterine cavity is almost obliterated, and the amount of bloody lochia is reduced to a minimum. On the other hand, in mul- tiparas, the uterine muscle being in some degree weakened by stretching and perhaps by some destruction of muscle-substance that has occurred in previous pregnancies, the uterus after labor does not contract so firmly and the relaxations between the contractions are greater in point of degree and duration. More- over, when the uterine muscle has been overstretched, as it is in plural pregnancies or in cases of hydramnios, or when the labor has been exceedingly long or unusually precipitate, very firm contraction does not appear after labor and there are apt to occur periods of over-relaxation. This condition, in civilized women, is so very common that it is necessary to study it under the head of the physiology of the puerperium, and yet the consequences of a failure on the part of the uterine muscles to contract with maximum intensity after labor are always un- pleasant, and may be disastrous. A relaxation of the uterine muscle-fibers implies a loosening of the countless living ligatures that bind the large vessels of the puerperal uterus. The imme- diate effect is an escape of blood into the uterine cavity. Oozing out gradually from the imperfectly closed blood-vessels and sinuses, and, finding space in the enlarged uterine cavity to collect, it forms clots often of considerable size, which act upon the uterus, like any foreign body in it, as an irritant, exciting it to active contractions which only cease when the foreign substance is expelled. These active contractions of the uterus are always painful, with a pain like that of a cramp in any muscle. These painful contractions, affecting the uterus after delivery, caused primarily by lack of firm contraction, and immediately by the presence of clots of blood in utero, are called, appropriately enough, after-pains,—the painful contractions of the uterus after labor. For the reasons already given they are not experienced by primiparae unless the uterus has been unduly distended or the labor has been too prolonged or too precipitate. On the other hand, they are a constant phenomenon in multiparas, and the physician's treatment of them will constitute almost always a part of his routine management of the puerperal state in such patients. Apparently a trifling matter, it is really one of con- siderable importance. In the first place, the pain is sufficiently distressing to demand relief, but, more important still, these after- pains indicate, to the educated physician, the presence within the uterus of blood-clots or other putrescible material; and until they are expelled, and the uterus is induced to remain in a state THE PUERPERAL STATE. 329 of firm contraction, the woman is not entirely safe from the dangers of septicemia. And, moreover, it is necessary to be familiar enough with the clinical features of after-pains to be able to distinguish them from the pain of peri-uterine inflammation, which often denotes the onset of septic infection. It should not be difficult to do this. The intermittent character of after-pains ; their cramp-like nature ; the fact that pressure does not increase the pain, and that the pulse and temperature are unaffected, suffice to distinguish the painful contractions of the uterus after labor from the pain of inflammation. The appropriate treatment of after-pains is suggested plainly by what has been said as to their cause and nature. It consists of the administration of ergot to stimulate vigorous contraction and firm retraction of the uterine muscle, and opium to diminish the pain of the contraction. A mixture of fluid extract of ergot and paregoric is a useful prescription, though, in cases of extreme pain, ergot by the mouth and morphin hypodermatically give a better and quicker result. Although the most remarkable changes that occur in a woman's organism after labor are seen in the genital organs, the whole body undergoes a modification. The respiratory, circulatory, nervous, and excretory apparatus are affected, with accompanying peculiarities of respiration, pulse, temperature, weight, the excretion of urine and sweat, and the evacuation of the bowels, while the nervous system shows a gradual change from the nervous irritability characteristic of pregnancy to the degree of equanimity that the individual may have before pos- sessed. Alterations in the Circulatory Apparatus of the Puerpera. —The pulse of a woman during labor is rather rapid, full, and bounding ; directly after delivery it becomes preternaturally slow ; if the individual's normal pulse-rate were 70 to 80, it might, during labor, rise to 90, but directly afterward it sinks, perhaps, to 60 or even lower ; I have counted it as low as 40 in a perfectly healthy young woman. In looking for the cause of this altera- tion in pulse-rate one must recall the influence of gestation upon the heart and the alterations in the constitution of the blood during pregnancy. The whole volume of the latter is in- creased, but not by an equal increase of all the constituent parts ; the corpuscles are relatively decreased in proportion to the liquor sanguinis ; the watery element of the blood is propor- tionately increased, making the condition of the blood during pregnancy one of hydremia. There is a relative decrease of albumin, blood-salts, and the percentage of hemoglobin, a relative increase of the fibrin-making ferment. Expressed definitely, this 330 LABOR AND THE PUERPERLUM. decrease is to the extent of about 700,000 red blood-corpuscles per cubic millimeter and about eight per cent, of hemoglobin. Within the first twenty-four hours after labor the decrease in red blood-corpuscles and hemoglobin is yet more marked, on account, no doubt, of the escape of blood in the third stage of labor and immediately after it. But after the first twenty-four hours the blood begins to recover its normal constitution, and at the end of two weeks it is so far on the road to perfect involution that it is much nearer a normal condition than it was in the latter half of pregnancy, although it is still somewhat deficient in red blood-corpuscles and in hemoglobin. These changes, however, do not explain the cause of a slow pulse in the puerperal state : it is discovered in the heart. It has long been believed that the area of cardiac dullness is in- creased in pregnancy, and that there is a hypertrophy of the walls of the left ventricle. As the whole volume of blood is in- creased in pregnancy, and as additional resistance to the circula- tion is offered by increased intra-abdominal pressure and by direct pressure of the uterus upon the pelvic vessels, it is reasonable to assume that the heart, in addition to being hypertrophied, is also dilated. The additional force and capacity of the heart is acquired to meet the additional demands of pregnancy: A greater volume of blood is propelled through the vessels by an enlarged and strengthened heart, beating with a normal rapidity. Labor comes on, the uterine cavity is emptied, and suddenly the increased vascular power has become unnecessary if not dangerous. The amount of work done by the heart is repre- sented by two factors ; the rapidity plus the strength of the beat and the power of the heart can be lessened by diminishing either one of these factors. It is obvious that the increased power of the hypertrophied heart-muscle can not be abrogated in a moment. It is equally obvious that the other factor in heart- power can be modified at once to suit the new and lesser requirements. And this, probably, is the method nature adopts to avoid excessive heart-action and an excess of blood in important organs after labor. The heart-beats are reduced some twenty to thirty in a minute. Changes in the Urinary System After Labor.—The phy- sician is often annoyed in obstetrical practice to find that many women after labor are unable to empty their bladders and con- sequently require the use of a catheter, which must be employed in the majority of cases by the physician himself, especially in country practice. To comprehend the changes in the urinary system it is necessary again to revert, for a moment, to pregnancy. The THE PUERPERAL STATE. 331 main changes in the kidney, bladder, and urine in that condi- tion may thus be summarized : The kidneys, by reason of addi- tional supply of blood and extra work to do, are hypertrophied ; the urine is increased in its aqueous element, diminished in solid constituents, except chlorids. The bladder, in pregnancy, from the pressure of the gravid uterus behind, is unable to expand in a normal manner, but must accustom itself to a distention, chiefly upward. When the uterus is empty and has shrunk to half its former size, the bladder has room at once to distend in all directions, and can thus hold a very large quantity of urine before its walls are subjected to the same degree of tension to which they were accustomed dur- ing pregnancy. Thus large quantities of urine may collect before there is a disposition to urinate. Moreover, the abdomi- nal walls, so long kept on the stretch, are suddenly released from the intra-abdominal pressure, and do not for some time regain their tone ; so that the action of the abdominal muscles, which are, perhaps, the chief factors in emptying the blad- der, become, to some extent, inhibited. In some women re- cently delivered the abdomen is scaphoid, so that a contraction of the abdominal muscles actually decreases, instead of increasing, intraabdominal pressure. There is a third reason for the retention of urine after labor : The tissues immediately behind the symphysis pubis bear the brunt of the pressure of the child's head as it descends the birth-canal; and this pressure is exerted, moreover, not directly forward, but to one side or the other, by the oblique position of the head; the tissues about the urethra are left edematous after labor, from the contusion they have suffered, and the urethra is dragged a little to one side, so that in a twofold manner the urethral canal is partially occluded, namely, by the edema of surrounding parts and by the acquired tortuosity in its course. The urine itself does not differ much from that of pregnancy. The aqueous portion is increased; the urea and solids are both relatively and actually below the normal. Glycosuria is quite common. Blot claims that the sugar in the urine is the result of the absorption of lac- tose from the mammary glands, and that the larger the secre- tion of milk, the greater would be the quantity of sugar in the urine, and therefore he proposed that the quantity of sugar in the urine be taken as a test for the suitability of a wet-nurse. It has been claimed, by others, that the sugar has a hepatic origin. Fischel declares that peptonuria is a constant phenomenon of the normal puerperium.x '"Arch. f. Gyn.," Bd. xxiv u. xxvi, S. 120 u. 400. 332 LABOR AND THE PUERPERIUM. The sweat=glands after labor take on an unwonted activity. The skin of a pregnant woman is often harsh and dry, and during labor, unless the muscular effort is very great or the weather very warm, the same condition of the skin persists. But in the puerperal state the sweat-glands are unusually active; the skin is constantly moist, and during sleep the sweat, always increased, may become very excessive. This action of the sweat-glands plays an important part in the involution of the whole organism after labor. It is one of the factors by which the hydremia of pregnancy is corrected, and by the dissipation of heat that ac- companies the rapid evaporation of water all over the body the temperature in the puerperal state is retained at a normal level, in spite of many provocations to fever. The lungs after labor take on a slightly different action. Their capacity is increased, for the pressure from below is re- moved and the play of the diaphragm becomes much freer. Each inspiration drawing in more air than common, the number of respirations in the minute becomes lessened ; the breathing is deeper, fuller, quieter, and slower than it has been during preg- nancy, and if the expired air were carefully examined, it would, in all probability, be found to contain an excess of water and of effete products, the result of tissue-destruction. As a result of the great excretion of water from the kidneys, the skin, and, to a lesser extent, the lungs, the thirst of the lying-in woman is in- creased ; the appetite, on the other hand, is much diminished. One can understand the last statement if he recalls the fact that more than a pound of meat in the involuting uterus is absorbed into the system during the puerperium, and if he remembers that the woman is lying, in bed absolutely quiet and expending no force whatever in muscular action. There is still another factor to account for the disinclination toward food. During pregnancy there is no one tissue, except that contained within the develop- ing uterus, which increases with so much rapidity as does the subcutaneous fat. It seems as if there were provided by nature a store of material which shall take the place of food in supply- ing heat and force during a period when woman in her natural, primitive state could not be supposed to provide for herself. This deposition of subcutaneous fat during pregnancy and its subsequent absorption during the lying-in period account for the remarkable changes in zv eight which may be noted in a woman during pregnancy and after labor. This is a matter of some practical importance, which does not usually obtain the attention that it deserves. It has been studied systematically by only two observers, by Gassner many years ago and lately by Baumann. According to Gassner, the gain in weight during THE PUERPERAL STATE. 333 pregnancy and the loss afterward are about one-thirteenth of the body-weight. This, I am inclined to think, from some investi- gations of my own, is an underestimate, and Baumann's obser- vations bear me out; he found that the loss of body-weight was about one-tenth after labor, the greater part of it, of course, occurring in the first week, when a woman of average weight will lose some nine or ten pounds. All the remarkable changes observed in the lying-in woman occasion no manifestation of disease, not even fever. This assertion some years ago would have been most heterodox, and would, indeed, have been incorrect, for fever was so common in the puerperal state that it was regarded as physio- logical ; it occurred usually within the first few days after labor and as, at this time, there were marked manifestations of con- gestion in the breasts, due to the inception of lactation, it was called milk fever. In reality it was the fever of infection. If, however, the temperature in the puerperal state is studied closely, it must be confessed that there is some little irregularity, but that irregularity is measured, in the normal case, by tenths of degrees. Directly after labor, for instance, the body-heat is always a little raised. Although there is distinctly no such thing as milk fever, the temperature is slightly affected when the breasts suddenly assume their immense activity ; but the rise is rarely more than a few tenths of a degree. So many causes, however, transitory in their effect, can produce slight disturbances in the temperature of the lying-in woman, who is peculiarly sensitive to external influences, that the rigid boundary which divides fever from a normal tempera- ture at other times must be a trifle relaxed. Thus, it is agreed among obstetricians not to regard as fever a transient rise of temperature, lasting only a few hours, which does not go above ioo.50. This is the so-called physiological limit to the rise of temperature in the puerperal state. The Mammary Changes in the Puerpera.—Heretofore the involution of important organs and systems in the puerperal state has claimed attention. The mammary action after delivery is a process of evolution. The mammary glands, as their name denotes, are glandular organs, only reaching their full develop- ment, as a rule, in the female ; situated, usually, toward the lateral aspect of the pectoral region ; occupying the space bounded above by the third and below by the sixth rib, to the inner side by the edge of the sternum, to the outer side by the axillary line. They are derived from the epiblastic layer of the blasto- dermic membrane, and belong essentially to the skin, as do the 334 LABOR AND THE PUERPERIUM sweat and sebaceous glands. They are closely akin to the latter, occurring in rare instances on indifferent parts of the body, as the axilla, the abdomen, or even the thighs, where a sebaceous gland has undergone a specialized development. In the female they are hemispherical in shape ; they are held in their normal position upon the pectoral muscles by the super- ficial fascia, which splits into two layers, one running above, the other below, the breast. Externally, a little below the middle Fig. 197.—CE, Cuboidal epithelial cells ; F, fat globules stained black with osmic acid, and seen both in the cells and in the central cavity of the acini; CV, connective-tissue frame with blood-vessels. Magnified 600 diameters (C. Heitzmann). Fig. 198.—Mammary gland of dog, showing the formation of the secretion: A, Medium condition of growth of the epithelial cells; B, a later condition (after Heidenhain). of the organ, is a protuberance,—the nipple ; around this is an area of pigmented skin,—the areola ; in this space are a number of large sebaceous glands,—the glands of Montgomery. Internally the breast is divided into excretory ducts, lobes, and lobules; between the lobes and lobules are connective tissue and fat. The lobules are ultimately divided into little vesicles; these empty into a small excretory duct; the small excretory ducts from contiguous lobules unite to form a single large, lactiferous THE PUERPERAL STATE. 335 canal; of these there are some fifteen or twenty, each conveying the secretion from a separate lobe to the nipple ; just before emerging upon the surface of the nipple each duct is dilated to form a small ampulla or reservoir for the milk ; as it passes through the skin of the nipple, however, it is again con- tracted. The epithelium of the gland is continuous with that of the integument; in the superficial portions of the lactiferous ducts it is squamous ; in the deeper portions of the gland, columnar. The function of the gland is the secretion of milk. Colostrum.—During the latter part of pregnancy a thin, opalescent fluid may be squeezed out of the breast; directly Fig. 199.—Mammary gland: 1, Fig. 200. —Colostrum and ordinary Lacteal ducts; 2, glandular acinus milk-globules, first day after labor; '(Playfair). primipara aged nineteen (after Hassall). after labor this fluid is somewhat increased in quantity, and be- comes a little whiter and more opaque. At the end of about forty-eight hours a decided change takes place in the breasts ; they suddenly enlarge ; the skin over them becomes tense; the cutaneous veins are engorged with blood, and show swollen and distinct beneath the skin ; the nipple projects ; to the feel the breasts are hard and lumpy ; to the woman they are painful and tender on pressure. If the ■child be now applied to the nipple, there runs out, almost with- 336 LABOR AND THE PUERPERIUM. out suction, a quantity of human milk—a fluid different from the colostrum just described. It is white, opaque, of a specific gravity about 1025, is said to have a sweet, agreeable taste, and is without odor. The quantity of milk secreted in the twenty-four hours is dif- ficult to determine. It might seem easy enough to draw the milk from the breast at stated intervals with a breast-pump and to measure it, but it is difficult to get a breast-pump as mechanically effective as a child's mouth, and, moreover, the secretion of milk depends, to some extent, upon the maternal emotion ; the breast might almost be described as an erectile organ; certainly, the sight of the child arouses a maternal instinct which sends an additional blood-supply to the mammary gland and undoubtedly increases the supply of milk. It has been estimated that at first the quantity of milk is about 300 to 400 grams ; by the seventh day it is 400 to 500 grams ; after the second week, 1500 to 2000 grams—y2 to 2 liters. In a microscopic section of a mammary gland, procured during lactation, there may be seen large epithelial cells in the process of proliferation. Toward their inner periphery may be seen globules of fat. One of two things must happen to account for the production of the milk : either the whole cell, winch has begun to show signs of fatty degeneration, or rather fatty metamorphosis, is cast off, then bursts and discharges its con- tained fat, as well as other cell-contents, into the liquid medium which has exuded from the blood, or else each cell, having accu- mulated its store of fat, discharges it in little globules, along with the casein, which must also be derived from the cell- contents. Which of these two explanations is correct is a matter still in dispute. It is probable that the cells are multi- plied, cast off, and rapidly replaced,—an action which occurs in the production of sebaceous matter. This action of the mam- mary gland is also in accord with the undisputed belief in the close relationship between the breast and a sebaceous gland. Biologists claim that one is but a great development of the other ; that at birth the mammary gland in both sexes is very like a sebaceous gland in every way, and that, in rare cases, as already stated, a mammary gland may be developed in all sorts of odd places on the skin, and that the usual number in the human race may be multiplied four or five times. The Diagnosis of the Puerperium.—Occasionally it is impor- tant for a physician to be able to decide by an appeal to his own senses, without regard to the woman's statement, whether or not she has been recently delivered. To give a case in point, a short time ago, in a farm near Philadelphia, a dead infant was THE PUERPERAL STATE. 337 found under a hay-rick. A servant girl in the farmer's family had attracted attention for some time before by her increased size ; she had disappeared one morning for a few hours, and had returned considerably altered in appearance, but able to go about her work in a perfectly natural manner. Suspicion, of course, pointed to her, and an examination confirmed it. The diagnosis, in such a case, is not difficult. The large uterus, reaching to the umbilicus ; the bloody discharge, showing, under the micro- scope, decidual cells ; the secretion in the breasts ; the charac- teristic fragments of decidua that may be scraped out of the uterine cavity with a curet; the rents in the cervix, the vaginal mucous membrane, and the perineum ; the relaxed abdominal walls, and the striae upon them,—all unite to make the diagnosis easy to establish and absolutely sure. Management of the Puerperium.—The prevention of in- fection must be the chief care of both doctor and nurse in charge of a puerpera (see The Preventive Treatment of Puerperal Sepsis). Having secured, so far as possible, a perfect cleanliness of physi- cian, patient, all her surroundings and attendants, and of the air of the room in which the woman lies, one has performed by far the most important part of his duty in the management of the puerperal state, and has averted the commonest and most fatal accident of this period—septic infection. Being secure of this most desirable result, the physician may turn his attention to some lesser matters, of no little importance, however, to the comfort and even safety of the patient. Visits.—It is wise to wait in the house for an hour after the woman's delivery, to see that there is no hemorrhage. She should be visited again in about twelve hours ; then once a day for the first two weeks, every other day during the third week, and once or twice in the fourth week. For the first week at least the following items should be investigated routinely at each visit: The pulse ; the temperature ; the odor, quantity, and char- acter of the lochia ; the condition of the bladder and size of the womb, learned by abdominal palpation ; the condition of the breasts and nipples ; the occurrence of after-pains ; the evacua- tion of the bladder and bowels, and last, but by no means least, the condition of the infant. Many physicians fall into the habit of neglecting the baby altogether. There could be no worse policy, not to speak of higher considerations. The mother will resent an indifference to her infant's condition, and a failure to make a routine investigation at each visit of the child's feeding, sleeping, and gain in development; of its umbilicus, bowel and bladder evacuations, and digestion, will often result in a failure to correct some abnormality until it is too late. Many a sudden 22 338 LABOR AND THE PUERPERIUM. and inexplicable death in the new-born could have been avoided by greater watchfulness and care. Rest and Quiet.—The woman recently delivered is the picture of perfect restfulness and repose. There is reason enough for this mental and physical quiet after delivery. The relief from great suffering and tremendous muscular effort would naturally induce a feeling of lassitude, and fortunately it is preeminently the case after labor, for this condition of perfect repose is most favorable for the occurrence of the complicated phenomena of the puerperium without detriment to the woman's health. It seems almost superfluous to insist upon the advisability of ac- cepting this hint from nature in the management of the puerperal state,—of preventing any mental or physical disturbance, mus- cular effort, a glaring light, loud conversation, and, more than all, the entrance into the lying-in room of a single person whose presence is not necessary,—and yet this is a matter that in many cases requires the physician's express attention. Among more ignorant people particularly, and especially if there has been some unusual complication or accident in the labor, the patient, upon the second visit, may be found restless, with a rapid pulse, an anxious expression, and an elevated temperature, and on in- quiry it is learned that a constant stream of her female neigh- bors has been pouring into her room with minute inquiries into the particulars of the case, and often with gloomy forebodings as to the result, based upon their recollection of just such a case which ended fatally. This is not a fanciful picture, but a per- sonal experience, many times repeated in my earlier practice as a district physician. I have sometimes thought that our lower classes have not much improved in this particular upon the peasantry or bourgeoisie of France in the seventeenth century, who were accustomed to baptize the infant on the third or fourth day, on which occasion a collation was served in the lying-in room, to which all the friends of the family were invited, who were all expected to drink the mother's health with much hilarity and many congratulations,—a ceremony which lasted through a whole afternoon. Mauriceau speaks of this as a "very ill custom"; I think we all agree with him, and should be inclined to go to the opposite extreme in enforcing rest and seclusion during the whole lying-in period. The physician must give specific directions in regard to the following matters, under the head of Rest and Quiet: i. The position that the patient must occupy in bed, and how long she must retain it. The length of time she must remain in bed. The earliest date she may stand upon her feet, and the time when she may go down-stairs. THE PUERPERAL STATE. 339 2. The degree of quiet and decorum to be observed in the room ; and— 3. The admission of visitors. The rules in regard to these matters, expressed, as rules, dogmatically, might run as follows : 1. The patient shall lie flat on her back and shall not be allowed another posture for at least a week. For the first six hours after labor the head shall not be supported by a pillow, but shall be on a level with the body, in order to avoid a disposition to cerebral anemia and syncope, from the greatly decreased abdominal pressure. The woman must lie in bed until the involution of the uterus is so far complete that the fundus uteri has sunk to the level of the symphysis pubis or below it. It is a safe rule to insist upon strict confinement to bed for fourteen days. Then the patient may be allowed to shift herself from the bed onto a lounge rolled alongside of it, passing the day upon the lounge and sit- ting up as long at a time as she can without fatigue. At the end of three weeks she begins to walk about the room, and at the end of four goes down-stairs for the first time. 2. The woman's rest must be mental as well as physical; therefore, no loud noises should offend her ear, no glaring light should irritate the eye, and no extended conversation should be allowed in the lying-in room; at any rate, for the first few days. 3. No visitor should be allowed in the lying-in room except the patient's mother and her husband, and it is sometimes neces- sary to restrict the visits as to frequency and length. These rules in regard to quiet after labor will suit the aver- age case among the upper classes. They must, however, be modified on occasion. The length of time, for instance, required for the involution of the uterus varies greatly in different classes of society. An Indian tribe on the march will not halt because a woman falls in labor; she retires to the bushes, gives birth to her infant, cuts the cord, dresses the child, and plunges into the nearest stream to cleanse herself; remounting her pony, she soon rejoins her tribe with the new-born infant slung on her back. The involution of her uterus goes on rapidly, in spite of this heroic treatment. In the Frauenklinik in Munich, in which I once served as volunteer interne, and where the patients are mainly strong Bavarian peasant girls, the fundus of the uterus was usually beneath the symphysis pubis on the sixth day. On that day the patient left her bed ; the following morning she walked out of the hospital with her infant in her arms. In the more artificial life of a member of what is called the upper 340 LABOR AND THE PUERPERIUM. classes, especially in this country, much of the primitive woman's physical vigor is surrendered for increased mental culture. In these women labor is usually difficult and painful, if not danger- ous ; the puerperal state is often a far more complicated period than it should be, and the return of the uterus to its natural size may take much longer than the average time. No patient should be allowed to leave her room before a careful vaginal examination has been made, to ascertain the position of the uterus. This one examination, however, is not sufficient. Even after involution is almost completed, when the woman resumes, to a certain extent, her normal activity, a uterine displacement is not unlikely to occur. Overexertion or exposure will almost certainly bring on a renewal of the bloody lochia; the involution of the uterus may be arrested before its perfect completion ; even septic inflammation may attack the uterus and its appendages as late as the fourth week. I make it an invari- able rule of practice, therefore, to examine every child-bearing woman under my charge six weeks after her delivery, digitally and with the speculum, noting the position of the uterus, its involu- tion, possible injuries to the cervix or pelvic floor, erosions of the cervix, and the character of the uterine discharge. I have many times found abnormalities at this period, which were not noticeable or were not present before the woman left her room. The question whether the routine administration of ergot would insure perfect involution or hasten its completion has, of course, occurred to many minds, and has found its answer in practical experimentation. Large numbers of women in several lying-in hospitals in Europe, under the independent observation of com- petent observers, have been placed on a routine treatment of ergot three times a day, and the progress of these cases has been carefully compared with that of an equal number of women left to nature. The result of these observations has not been favorable to ergot as a sure means of shortening the duration of the puerperal state : nothing was gained in point of time, while disadvantages were found to attach to this plan of treat- ment that might have been foreseen. The stomach will rebel against a prolonged use of the drug in considerable quantities. While contracting the uterus, it has an astringent action also on the breast and so diminishes milk secretion, and, passing from the maternal blood into the milk and into the infant's stomach, it exerts an unfavorable influence upon both mother and child. The Diet.—This is a matter of no small importance, about which there is considerable difference of opinion. On the one hand it is held that the woman after labor is weak from loss of THE PUERPERAL STATE. 341 blood and from fatigue ; that she must, therefore, receive the most nourishing food in the largest possible quantities. And, moreover, that the demand which will soon be made upon her economy for the nourishment of the child is an additional reason for the administration of a generous diet from the first. But a close observation of nature should lead, I think, to the opposite view. A large part of the involuting uterus is absorbed into the system; some two pounds of meat are thus, as it were, devoured, the greater part of it in the first few days of the puerperium. A large quantity of fat is stored up in the body during pregnancy with the express purpose, it would seem, of providing a means of supporting the woman during the early part of the puerperal state. Thus nature provides a sustenance which in quantity certainly appears sufficient for at least the first few days after confinement, and in form and manner of ingestion, so to speak, is best calculated to support the woman's strength, with none of the expenditure of force involved in mastication and digestion. Moreover, it must be remembered that almost all the vital functions are performed in a sluggish manner for the first few days after labor. The pulse is less rapid, the respiration slower, the bowels are inactive, and there should be no voluntary muscular effort. All this seems to argue for the wisdom of a system which allows, for the first few days, nourishment small in quantity, of a form easily ingested, and of a quality readily digested. After the third day, however, a new element must be taken into account. At that time there begins the milk secretion, which undoubtedly entails a great drain on the whole system to provide the large quantity of fat and nitrogenous material which are excreted when the breasts have assumed their full activity. To meet this additional demand upon the resources of the body the simple diet of the first few days should be materially, though gradually, increased ; for the first onset of the physiological mammary action is usually so violent as to stop just short of a pathological condition,—inflam- mation,—and suddenly to exhibit large quantities of nutritious food at this time would very likely cause a transgression across the boundary-line between health and disease. This, however, is mere theoretical reasoning, and if applied in practice it fails to give the best results, the system dependent upon it should be ruthlessly discarded, no matter how reasonable it may appear. But a practical test has given the result that might be expected. No one who has compared the two methods—one, of giving a forced diet from the first; the other, of giving a very light diet, chiefly of milk, for the first two days, and afterward gradually increasing it until, on the sixth or seventh day, the patient is 342 LABOR AND THE PUERPERIUM. taking the food that would be suitable to any healthy person confined in bed without physical exercise—can fail to notice that the latter plan secures a far greater immunity from inflammatory disturbances about the genitalia and the breasts, and from irreg- ularity in the milk secretion and the action of the stomach and bowels. Urination.—The tendency to retention of urine that is so often met with, especially among women city bred and in easy circumstances, has already been noticed. This is an abnor- mality in the puerperal state of civilized woman that is, per- haps, as annoying as any one feature of a normal case. Its causes have already been described. Its detection would seem perfectly easy, and yet it is just as easy to overlook it without the careful attention which should be, but is not always, directed toward this point. It is a common experience for a consultant to be asked to see a woman some days after labor, because the attending physician thinks that alongside the uterus there is a large and peculiar abdominal tumor, and the patient suffers great pain. What is taken for the uterus is an immensely distended bladder, reaching half-way to the umbilicus ; the peculiar ab- dominal tumor is the uterus itself pushed far upward and to one side, almost always the right. Catheterization removes immedi- ately both tumor and pain. The mistake on this point often arises from the trust that the physician puts in the woman's statement that she has urinated regularly. One should never trust any one's assertion as to action of the bladder, but should always examine for himself, by abdominal palpation, to see whether it be full or not. A nurse will sometimes falsely assert that her patient has urinated, because she is ashamed to confess her inability to pass a catheter. If the urine must be drawn, the catheter is used by a trained nurse, should there be one. Among the patients, however, which fall to the lot of most physicians when they begin to practice, a trained nurse is a luxury abso- lutely unobtainable, and the physician himself must attend to the catheterization ; even if a skilful nurse is in attendance, the physician is not infrequently appealed to, as the nurse can not discover the urethra, or is unable to insert the catheter. It is well, therefore, under all circumstances, to know how to use a catheter and to have a definite opinion as to the kind of instru- ment that should be employed. A soft-rubber catheter is to be preferred, because it is incapable of doing any harm, does not irritate the urethra, and is easily cleansed and kept clean. After being used it should be rinsed out and should be kept per- manently immersed in a I : 2000 solution of sublimate. Before being used it must be dipped in a basin of sterile water, and its THE PUERPERAL STATE. 343 tip should then be oiled. The hands of the individual who inserts it must be aseptic. As to its manner of introduction : It is necessary to expose the urethra to view, to wipe off its mouth, as well as the surrounding mucous membrane, with a piece of absorbent cotton moistened with a sublimate solution, 1 : 2000, and then to introduce the catheter, being sure that it is going into the right place and that it is not carrying with it into the bladder some of the decomposing vaginal discharge, which would be very likely to set up a very troublesome or a very dangerous cystitis. The old practice of locating the urethra by the sense of feel, using the finger of the left hand and then introducing the catheter held in the fingers of the right hand, under a sheet, is to be unreservedly condemned. In the Directions to Nurses, appended to this chapter, occurs the passage, " Twelve hours after labor the woman shall be catheterized, and after that three times a day if necessary." Twelve hours may seem a rather long period to allow urine to collect after labor ; but the bladder is capable of great distention at this time ; almost all the natural processes are sluggish ; the kidneys directly after labor are not very active, perhaps because the sweat-glands at this time take on unwonted activity, and if the catheter is used too soon, the patient is very likely committed to its use throughout the greater part of the lying-in period, whereas if the woman can be induced to urinate naturally at first, there will be no difficulty afterward. At the same time it would be unwise to allow an overdistention of the bladder; twelve hours, therefore, is a good compromise time for the first use of the catheter. After that three times a day is usually quite sufficient; it should not be used less frequently, and if the patient's feelings demand it, the bladder must be emptied more frequently. By this plan I find it necessary to use the catheter in about thirty per cent, of primiparae. It is possible, by a longer delay, to reduce this proportion materially. In the Baudelocque Clinic they wait twenty-four hours or longer and have used the catheter in 6666 cases only twenty times.1 Before resorting to catheterization every effort should be made to induce the woman to urinate naturally. Sometimes this is accomplished by putting hot water in the bed-pan, by the use of a turpentine stupe over the bladder, and by the sound of running water. The Bowels.—On account of the small amount of food in- gested during the early part of the puerperium, the flaccidity of the abdominal walls, the torpor of the intestinal muscles from long pressure, and the general muscular inactivity, there is a re- markable sluggishness of the bowels, and an exaggeration of the 1 Recht, " These de Paris," 1894. 344 LABOR AND THE PUERPERIUM. constipated habit almost invariably acquired in pregnancy. This is no great disadvantage at first, as the food is principally liquid and small in quantity, so that there is very little detritus to be thrown off by the intestines. It is not advisable, however, to allow the feces to accumulate too long. If the woman eats in a day perhaps a third of what an ordinary person would devour, by the third day there would be a considerable collection in the lower bowel; at this time, too, the diet is a little increased, and the sudden onset of milk secretion on the third day always seems, at least, to threaten an inflammation of the breasts, which might be averted by a derivative and depletive course. For all these reasons, therefore, it is customary to administer as a routine treatment a laxative on the evening of the third day. What this laxative is may be decided by the patient's inclination or prejudice. Castor oil is undoubtedly the most suitable agent; most efficient, least apt to be harmful. But there are many persons who will not take it. A good way to administer it in cases where it may be given is to put it in warm milk ; there is nothing else perhaps which disguises the taste so well. Or it may be given in the more common way along with the froth of malt liquors, especially porter, or in soda-water. My routine prescription is a half-bottle of citrate of magnesia on the evening of the second day, the rest of the bottle the following morning before breakfast, and, if the bowels are not moved two hours later, an enema. If the patient is plethoric or the mammary glands are very swollen and tender, a more active saline purge would be preferable. The Mammary Glands.—The mammary glands require judi- cious management in the puerperal state. There are many pathological conditions, functional and structural, which often arise and which demand care and skill in their treatment. These, however, will be considered in their appropriate place. There are other conditions, not a little troublesome to deal with, of such fre- quent occurrence that they must be considered in discussing the management of a normal case. In almost every instance the establishment of lactation is accompanied by some local disturb- ance. The increased blood-supply to the breast, the proliferation of cells, and the transudation of a serous exudate are phenomena usually characteristic of inflammation ; and the enlarged breast, the engorged veins under the skin, the hard, tense feel of the gland-tissue, and the great tenderness, all seem to point to an inflammatory attack instead of a natural physiological process. This state of the breasts usually demands some treatment, not only to ameliorate the discomfort that is almost always experi- enced, but to prevent the transition of a natural process so THE PUERPERAL STATE. 345 closely bordering on the pathological to a condition of actual disease. If the engorgement of the breasts is very marked and the accompanying symptoms of heat, pain, and fullness are very pronounced, the administration of a saline purge will usually prove a sufficient derivative, and will relieve some part of the mammary congestion. Care must be taken, in addition, to secure the evacuation of the secretion collecting within the gland, and for this purpose nothing is so good as the infant's mouth, which should be applied to the nipple regularly every two hours. If these simple devices are not sufficient; if the child is not living or must be weaned, more active measures should be employed. If the secretion is excessive, a breast-pump must be used, and the nurse, in addition, should rub and massage the breast with oiled finger-tips in a direction toward the nipple, thus making the skin more supple and emptying the breast at the same time. Often, in addition to this, it is well to apply some lotion of an astringent and soothing nature. I have found nothing so good for this purpose as lead-water and laudanum. Cloths should be soaked in it and applied over the whole breast. If the infant is nursing, care must be taken, of course, to remove any poisonous substance that might be on the nipple. The constant dragging upon the nipple when the child is nursing, the pinching and squeezing it receives from the infant's gums, and its continual moisture from milk and the secretions of the infant's mouth, all tend to bring about an un- healthy condition of the skin upon and around the nipples. It becomes at first irritated and inflamed, then excoriated, chapped, and fissured, and, consequently, exceedingly sensitive and pain- ful, so that the application of the child is regarded with dread. Nor is this the only disadvantage; in the little cracks and fissures the milk collects and decomposes ; the patient or nurse may, in careless handling of the breasts, deposit, in these raw places, some of the many forms of septic micro-organisms, and the consequence is very likely to be septic infection of the connective tissue of the breast and the formation of a mammary abscess—of all the minor complications of the puerperal state the one to be most dreaded. The preventive treatment of this com- plication plays an important part in any scheme of managing the puerperal state. The main thing, obviously, to be secured is cleanliness and a healthy condition of the skin. This is obtained by carefully washing the nipples after every nursing with some absorbent cotton, warm water, and Castile soap ; by cautioning nurse and patient against handling the breasts with fingers not aseptic, and by smearing the skin of the nipples and that of .surrounding parts with sweet-oil after every washing, applied by a piece of clean linen or a pledget of fresh absorbent cotton. 346 LABOR AND THE PUERPERIUM. There is another point in the management of the breasts, which, if it does not aid in preventing so serious a disturbance as mam- mary abscess, does increase the patient's comfort by relieving the feeling of distention and weight which is experienced during the first few days of lactation. This is the adjustment of a suitable mammary binder. I find the best one for this purpose to be the Murphy binder (Fig. 201). The Child.—While devoting careful attention to the man- agement of a woman after confinement, the physician must not forget that he has another patient on his hands, of almost equal importance,—the infant. Fortunately, the management of a healthy infant is not a very heavy charge on one's ingenuity. If a few common-sense rules are observed, nature will do the rest. The management of the new-born child consists simply in seeing that food is administered at proper and regular inter- 1 1 1 1 1 1 J_______________________________________________________________________ [ 1 Fig. 201.—The Murphy breast-binder. vals, that attention is paid to bodily cleanliness, and that ample opportunity is afforded for an almost unlimited amount of sleep ; with ordinary precautions, of course, in regard to warmth, for the infant has just emerged from a constant temperature of 99° and can not offer much resistance to cold. The proper interval between the nursing should be two hours during the day, four to five hours in the night. If the child is taught regular habits in this respect, the burden of its care-takers is immensely lightened. The infant will arouse itself and be ready for nursing at the proper feeding-time, and in the intervals will sleep peace- fully. Regularity in nursing is of importance, further, from its favorable influence upon the constitution of the milk. Too frequent nursing results in a concentrated milk, which is difficult to digest. Too infrequent nursing results in a watery milk, THE PUERPERAL STATE. 347 which is not nutritious. If, on the contrary, the infant is allowed to be irregular in the hours for feeding, bathing, and sleeping, it grows fretful, wakeful, and capricious in its appetite. One word of caution is necessary about the infant's bath. The tem- perature of the water should be about 900 ; certainly not much higher, nor, on the other hand, too low. Nurses are often extraordinarily insensitive to hot water. The temperature of the bath, therefore, should not be tested by their hands, but by a bath-thermometer. The bath should be given about midday, in the warmest part of the room, preferably in front of an open fire. There are many apparently small, but really important, details in the preparation for and management of labor and the puer- perium, which might easily be forgotten. I find it convenient, therefore, to give to my patients and nurses the appended list of instructions. DIRECTIONS FOR THE MOTHER. Send a specimen of urine (mixed night and morning), about four ounces, every two weeks until the last month, then every week. Report at once scanty urination, severe headache, swelling of the feet or face. Have ready for the labor: towels, ether (one-half pound), brandy (two ounces), vinegar (four ounces) ; four ounces tincture of green soap; a bottle of antiseptic tablets (corrosive sublimate); a large, coarse, new sponge ; a skein of bobbin ; a fountain syringe ; bed-pan; new, soft-rubber catheter ; a small package of absorbent cotton ; a one-ounce bottle of carbolized vaselin ; two yards unbleached muslin (for binder); a one-pound package of salicylated cotton; five yards of carbolized gauze ; eight yards of nursery cloth. The last is to be boiled for half an hour in clothes-boiler, dried thoroughly, pinned up in a clean sheet, and put away out of the dust. A mackintosh or rubber cloth is necessary to protect the mattress; two yards of rubber cloth, one yard wide, is sufficient. Prescription No. 11 is to be procured about four weeks before expected confinement. It is to be applied to the nipples, night and morning, with absorbent cotton. Prescription No. 22 is to be obtained about a week before- hand and kept in readiness. Baby-clothes. Four to six dozen diapers. Four to six pairs knit (woolen) socks. Three to four shirts (woolen). 1 R. Glycerol of tannin, Aqua,..... 01. rosse, .... 2R. Ext. ergot, fid., . ■ ■ g«. ij 348 LABOR AND THE PUERPERIUM. Four flannel night-skirts. \ ^% ^ be made wkh waigts ingtead " " day-skirts. > f, , Four to six white day-skirts. ) Six to ten slips. " " dresses. Material for four or five flannel bands (45- to 50-cent flannel). Soft pillow (good size, 14 x 18 inches). " " covers. Knit wrapping blankets. Sacques, wrappers, bibs, caps, blankets, veils, etc. Baby's Basket. Large and small safety-pins. Talcum powder (box and puff). Fine, soft sponge. Soft brush (for hair). Castile soap. Cold cream. Alcohol for rubbing child. Blunt scissors for nails, etc. Old linen for cleaning mouth. Soft towels for bath. Bath-blanket. Wooden forms for drying socks. DIRECTIONS FOR THE NURSE. Give rectal enema as soon as pains begin (pint of soapsuds, dram of turpentine). Have the patient wash the external genitals thor- oughly with soap and warm water. As soon as labor begins, fill three pitchers with water that has been boiling for half an hour ; tie clean towels over their tops. This water is to be used for all purposes about the patient and for making the antiseptic solutions. No vaginal injection to be given unless ordered. Take the temperature three times a day,—morning, noon, and evening. Place pad of nursery cloth under patient; change it when soiled. Occlusive bandage to be made up of salicylated cotton and carbolized gauze, with clean hands, and to be changed, for the first five days, every four hours. The external genitals to be washed off four or five times a day with warm corrosive sublimate solution, 1 : 4000, made up with boiled water. Use absorbent cotton for this purpose. If, at the end of twelve hours, the bladder can not be emptied naturally, use a catheter. Afterward, if necessary, catheterize patient three times a day. The patient is to lie on her back; she may be moved from one side of the bed to the other several times a day ; her limbs may be rubbed with alcohol and water or bathing-whisky once a day. THE PUERPERAL STATE. 349 The nurse's hands are to be washed with a nail brush, soap, and water, and rinsed in a i : 3000 sublimate solution before catheterizing the patient or cleansing the genitals or breasts. Diet.—First 48. hours.—Milk (1^ to 2 pints a day), gruel, soup, one cup of tea a day, toast and butter. Second 48 hours.—Milk toast, poached eggs, porridge, soup, cornstarch, tapioca,wine-jelly, small raw or stewed oysters, one cup of coffee or tea a day. Third 48 hours.—Soup, white meat of fowl, mashed pota- toes, beets, in addition to above. After sixth day, return cautiously to ordinary diet,—that is, three meals a day, meat at one of them, of an easily digested character,—white meat of fowl, tenderloin of beef, etc.,—and a glass of milk at least three times a day, between meals and before going to sleep at night; also a glass in the middle of the night. Child.—After being well rubbed with sweet-oil, the child is to be washed on the nurse's lap. The bath-tub may be used by the end of the first week. Water not over ioo° F. The cord is to be dressed with salicylated cotton. Ob- serve carefully for bleeding. A good dusting-powder for the navel is salicylic acid 1 part, starch 5 parts. The child should be bathed daily, about midday, in the warmest part of the room. Use Castile soap and a soft sponge; avoid the eyes. Diapers changed often enough. For chafe, use cold cream and talcum powder. Nursing.—The child is to be put to the breast every four hours for the first two days. No other food is to be given it. After the second day it should be nursed every two hours, from 7 a. m. to 9 p.m., and twice during the night (1 a.m. and 5 a.m.). After every nursing the nipples are to be carefully dried and then smeared with a little sweet-oil for the first week or two, applied with fresh pledgets of absorbent cotton. PART III. THE MECHANISM OF LABOR. The mechanism1 of labor is the manner in which a fetus and its appendages traverse the birth-canal and are expelled. It takes into account the complicated structure of the maternal and fetal parts, considering their movements and the mechanisms of their motions. It is necessary to define, further, certain terms that will be used constantly in the study of the mechanism of labor. By presentation is meant that part of the fetal body which presents itself to the examining finger in the center of the plane of the superior strait. The term position may be applied to the position of the child in utero, whether it is longitudinal, oblique, or transverse; or, in another sense, it is the varying relations which the present- ing part of the fetus bears to the surrounding maternal structures at the plane of the superior strait. The presentation and position of the fetus are determined by abdominal palpation, by auscultation, and by vaginal exami- nation. Abdominal Palpation.—For this kind of obstetrical exami- nation the woman should be placed on her back, with the abdomen exposed. The examiner, standing to one side of the patient, by a series of stroking, patting, and rubbing motions with his hands, determines the height of the fundus uteri, the tension of the abdominal walls, the irritability of the uterus, the quantity of liquor amnii, the size of the fetus, its position, and its presentation. It has been claimed that in favorable cases the placenta can be felt, and that its position can thus be diagnosti- cated (Spencer). It is further asserted that if the greater bulk of the uterus is anterior to the insertion of the tubes, the pla- centa is anterior, and vice versa (Leopold). 1 From the Greek fis^oc, a manner, a way, a means. 35o ABDOMINAL PALPATION. 351 The Diagnosis of Fetal Position and Presentation by Abdomi- nal Palpation.—The examiner stands alongside the patient, facing her head ; the tips of the fingers of both hands, moving together and at equal distances, are carried up the sides of the abdomen by a series of tapping movements ; and upon one side (for example, the left, in the L. O. A. position) is noticed a firm, Fig. 202.—Abdominal palpation : locating the fetal back. Fig. 203.—Abdominal palpation: finding the lower extremities of the fetus. broad, even sense of resistance, contrasting with the cystic, tumor- like sensation of the other side, with the occasional encounter of firm, irregular bodies,—the fetal extremities. This firm, broad, even resistance is produced by the fetal back, and, to confirm this fact, the extremities are felt for by a rubbing motion with one outstretched hand on the opposite 352 THE MECHANISM OF LABOR. side. They are felt as cylindrical, irregular bodies, slipping away from the hand, and changing their position from time to time. Having located the back and the extremities, the portion of the fetal ellipse presenting at the superior strait is next ascertained. The examiner now faces the woman's feet, and, with the out- stretched hands, the fingers parallel with and the middle finger over the center of Poupart's ligament, on either side, the fingers dip down beneath the ligament into the pelvic cavity. If the head is presenting, it is felt as a hard, regular, round body, the greater mass of the occiput, the sharp point of the chin, and the groove between occiput and back being often distin- guishable. At the same time, the density of the head, its com- pressibility, its approximate size, and its relative size to the pelvis may be learned. By auscultation the fetal heart-sounds are located, and their rate and intensity are noted. The uterine bruit and the funic souffle are often heard. The position on the abdomen at which the fetal heart-sounds are heard with greatest intensity is of diagnostic value in confirming the find, by abdominal palpation, as to position and presentation. By vaginal examination the finger detects the varying por- tions of the fetal body which may present at the superior strait, as the cranium, the face, the shoulder, the buttocks, the knees, feet, and, exceptionally, the elbow or hand. The position of the fetus in utero is longitudinal in 99^2 Per cent, of all cases. The cephalic extremity presents in about 95/^ Per cent-> 95 per cent, being vertex presentations. In about one-half of I per cent, of cases the face presents ; the brow very rarely. In about 3 per cent, of all cases the breech PRESENTATIONS AND POSITIONS. 353 presents, and in about one-half of I per cent, the fetus will occupy a transverse position in utero. An explanation of the great frequency of cephalic presentations is found in a voluntary assumption of that position by the fetus, because it affords it the greatest degree of comfort and the best opportunity for growth and development, the largest room being found in the fundus uteri for the lower extremities, which are freely moved and exercised. An explanation of the great frequency of presentations of the vertex is afforded by the mechanical arrangement of the connec- tion between fetal head and body, diagram matically represented by two bars attached to each other,—that representing the head joined to that representing the spinal col- umn, not at its middle, but at a point nearer one end of the bar (Fig. 205). An equal force exerted upon both ends of the lever represented by the child's head Fig. 205.—Diagram will result in the greater flexion of the jllust5*tini the =ause of *p _ the frequency ot vertex longer bar, which is that portion of the presentations. fetal skull in front of spinal column. The positions of the various presentations are named by the relationship which the most prominent anatomical feature of the presenting part bears to the acetabula or the sacro-iliac junctions of the maternal pelvis. They are, therefore, four in number. Positions of Vertex Presentations.— I. L. O. A., left occipito- anterior, the occiput looking to left acetabulum. 2. R. O. A., right occipito-anterior. 3. R. O. P., right occipitoposterior, the occiput looking to the right sacro-iliac joint. 4. L. O. P., left occipitoposterior. Of all vertex presentations about seventy per cent, are L. O. A., thirty per cent. R. O. P. The long axis of the fetal skull very rarely lies in the left oblique diameter of the maternal pelvis. Explanation of the Frequency of L. O. A. and R. O. P.—The position of the rectum shortens the left oblique diameter of the pelvis ; therefore the long diameter of the head, seeking the direction of least resistance, adjusts itself in the right oblique diameter of the pelvis and the projection of the lumbar spinal column, to which the fetus by choice adapts its anterior concave surface, usually results in the back being turned forward and tilted a little toward the right, because of the usual right lateral version of the pregnant uterus. Thus, the left occipito-anterior position of the vertex is the commonest position in labor. Should the child's back be directed to the right, the occiput will be turned posteriorly, because the chin would be pushed forward 23 354 THE MECHANISM OF LABOR. by the sigmoid flexure and rectum, this being a stronger force in the arrangement of the head than the child's inclination to adapt its concave abdominal surface to the convex surface of the lum- bar spine. THE FORCES INVOLVED IN THE MECHANISM OF LABOR. There are certain forces operative in every labor irrespective of fetal presentation and position. These are the forces of expulsion contributed by the uterine muscle and the abdominal muscles, and the forces of resistance contributed by the lower uterine segment, the cervix, vagina, vulva, the pelvis, and the fetal body. Fig. 206.—Diagram showing the diminution of the upper uterine segment and the expansion of the lower segment during each contraction. The forces of expulsion are furnished by a great part of the uterine muscle (the upper uterine segment) and by the muscular action of the abdominal wall. That portion of the uterine canal which must be dilated to allow the escape of the fetus is called the lower uterine segment. Its boundaries are : above, the firm attach- ment of the peritoneum to the uterine wall, and, below, the internal os. That portion of the uterine wall above the point at which the dilatation of the uterine cavity begins is called the upper uterine segment; the boundary-line between these seg- ments, often marked by a perceptible ridge, especially in ob- structed labors, is called the contraction ring, or the ring of Bandl. FORCES INVOL VED IN MECHANISM OF LABOR. 355 The manner in which the uterine muscle exerts its force upon the fetal body is by a diminution of the intra-uterine area. The uterine muscle in contraction somewhat increases the longitu- dinal diameter of the uterus, but decidedly diminishes the lateral and anteroposterior diameters. The abdominal muscles likewise diminish the area of intra-abdominal space. The degree of force exerted by the combined action of uterine and abdominal walls has been estimated at from seventeen to fifty-five pounds. The forces of resistance are furnished by that portion of the parturient tract which must be dilated,—/. e., from the contraction ring to the vulva, including the lower uterine segment, the cervix, the vagina, and the vulva. The dilatation of the cervix is effected, if the membranes are preserved, by the displacement of the most easily displaceable of the uterine contents, the liquor amnii, in Fig. 207.—Diagram illustrating the alteration in the shape of a cross- section of a uterus during its contrac- tions. The heavy line represents the non-contracted, the dotted line the con- tracted, uterus (compare Fig. 208). Fig. 208.—Diagram illustrating the alteration in the shape of a sagittal section of the uterus during its contrac- tions. The heavy line represents the non-contracted, the dotted line the con- tracted, uterus. the direction of least resistance,—through the cervical canal. A pouch of the membranes insinuated in the canal subjects the surrounding ring of cervical muscle to water-pressure, equally exerted in all directions, but felt by the cervix only in a lateral or horizontal direction. If the membranes are ruptured and the presenting part impinges directly on the cervix and lower uterine segment, the former is subjected to a lateral pull from all sides at once, as the presenting part pushes from above downward. The presenting part, moreover, whatever it be, is somewhat con- ical in form, and subjects the cervix to a lateral push as it is wedged into the cervical canal (Fig. 209). The dilatation of the lower uterine segment and of the cervix is not, however, simply mechanical, the serous infiltration of the lymph-spaces and the 356 THE MECHANISM OF LABOR. separation of the muscle-fibers lessening the power of resistance gained by cohesion of muscle-bundles. The dilatation of both the lower uterine segment and the cer- vical canal is also assisted by the longitudinal muscle-fibers in these regions drawing the cervix up over the presenting part. Finally, the circular muscle of the cervix, subjected to the strain of constant push and pull, becomes fatigued and, at length, para- lyzed. Below the cervix dilatation is effected mainly by the mechanical stretching of the walls of the birth-canal. The bony walls of the pelvis, in a normal case, only offer enough resistance to sufficiently delay the progress of the present- ing part to insure a gradual dilatation of the soft resisting structures. The Fetal Body.—The head is by far the most important anatomical division of the fetal body in labor, on account of its bulk and density. The fetal head may be divided into the yielding and the unyielding portions. The former consists of the cranium, composed of the two frontal, the two temporal, the Fig. 209.—Diagrams illustrating the lateral "pull" and "push" on the cervix. two parietal, and the occipital bones. These bones are separated from each other as follows : The two frontals by the frontal suture, the frontal from the parietal by the coronal suture, the two parietal by the sagittal suture, and the two parietal from the occipital by the lambdoidal suture. At the junction of the lambdoidal and the sagittal sutures there is a membranous space, called the posterior fontanel, triangular in shape. At the junction of the frontal, coronal, and sagittal sutures there is also a membranous space, called the anterior fontanel, kite- shaped, and larger than the posterior fontanel. This portion of the skull yields to pressure, and is reduced in size by an over- lapping of the bones. The unyielding portion of the skull comprises the face and the base of the skull. The bones of this region are fixed and unyielding. A transverse vertical section of the skull is somewhat wedge- shaped, the wedge tapering toward the neck. A longitudinal medial section is distinctly conical in form. Plate 7. Fetal skull seen from the side, (2) from above, (3) from behind, and (4) from in front, showing sutures, fontanels, and diameters. MECHANISM OF PRESENTATIONS AND POSITIONS. 357 Possible Presentations of the Head.— Vertex.—By this term is meant that conical portion of the skull with its apex at the smaller fontanel and its base at the planes of the biparietal and trachelobregmatic diameters,—the face; the brozv; the larger fontanel; the parietal eminence ; the ear. THE MECHANISM OF THE SEVERAL PRESENTATIONS AND POSITIONS. The Mechanism of Labor in a Vertex Presentation and a Left Occipito=anterior Position.—It is convenient to begin the study of each presentation with a consideration of its diagnosis. The diagnosis of position and presentation is made by abdom- inal palpation, auscultation, and vaginal examination. By these Fig. 210.—Left occipito-anterior position of a vertex presentation. methods of examination in the position and presentation under discussion the fetal back is found to the left, the extremities to the right and above, the head below ; the heart-sounds are heard most distinctly about an inch below and to the left of the umbili- cus ; the examining finger in the vagina detects the vertex pre- senting, with the occiput directed toward the left acetabulum ; the sagittal suture is in the right oblique diameter of pelvis ; the smaller fontanel, recognized by the junction of the lambdoidal and the sagittal sutures as the most dependent portion of the presenting part, and the tip of the occipital bone, overlapped by the parietal bones. As the direction or axis of the pelvic canal diverges from that of the uterine cavity, running, at first, more 358 THE MECHANISM OF LABOR. posteriorly, there is usually a lateral inclination of the head so that the sagittal suture is posterior to the normal position of the oblique diameter of the pelvis, and one parietal bone (the anterior) is deeper in the pelvis than the other one. The mechanism of labor in a left occipito-anterior position of a vertex presentation may be taken as a type of the mechanism of all labors, the variations in the process imposed upon it by Fig. 211.—Vertex presentation, left occipito-anterior position. the different positions and presentations of the fetus being readily understood if the typical mechanism of the commonest presenta- tion and position is thoroughly mastered. It is convenient to divide the mechanism of labor into a number of steps or acts, as follows : First Step.—Accommodation of the size of the fetal skull to the size of the pelvic canal by flexion ; accommodation of the shape MECHANISM OF PRESENTATIONS AND POSITIONS. 359 Fig. 212.—Genital tract with fetus removed, showing divergence of the pelvic axis from that of the uterine cavity: a, a, Membranes; b, b, contraction ring; c, c, point down to which membranes are unseparated; d, promontory ; e, region of os internum (above which fragments of decidua are found, and below it cervical glands) ; /, bulging of wall into neck of fetus ; g, g, os externum ; h, pouch of Douglas ; i, posterior vaginal wall (elongated and thinned) ; j, rectum ;' k, stretched anal canal; /, placenta; m, uteroyesical peritoneum; n, region of os internum (above which fragments of membranes are found, and below it portions of cervical glands) ; o, lower limit of bladder; /, anterior vaginal wall (not elongated); * / Fig. 235.—Breech presentation, left sacro-anterior position. ABNORMALLTLES IN MECHANISM. 3«3 Fig. 236.—Breech presentations, left sacro-anterior position. **'g- 237-—Breech presentations, anterior and posterior positions. 384 THE MECHANISM OF LABOR. Fig. 238.—Same as figure 237, showing descent of breech through the pelvic canal. Fig. 239.—Same as figure 237, showing engagement of the shoulders in the pelvis. ABNORMALLTLES LN MECHANISM. 385 Fig. 240.—Same as figure 237, showing escape of extremities. Fig. 241.—Breech presentation—rotation of the hips. 25 386 THE MECHANISM OF LABOR. entered the pelvis with its long diameters in the oblique diameter of the pelvis, opposite to that in which the shoulders engaged. The head descends the birth-canal to the pelvic floor in a position of extension. The occiput, which is always the part first to strike the pelvic floor, is rotated forward under the Fig. 242.—Breech presentation. Waldeyer's section of an X para at full term, who died from hemorrhage some hours after both her legs had been cut off by a loco- motive: a, First lumbar vertebra; b, placenta; c, fractured first sacral vertebra; d, coronary vein; e, blood extravasation ; f pouch of Douglas; g, cervical canal; h, os externum ; i, rectum ; j, umbilicus; k, os internum ; /, uterovesical reflection of peritoneum ; m, bladder; n, symphysis pubis ; 0, vagina. pubic arch. There follows then the delivery of the head in the following order : Chin, face, forehead, anterior fontanel, sweep- ing successively over the perineum and appearing in the vulvar orifice. Prognosis.—The fetal mortality of breech presentations is about thirty per cent., including badly managed cases in gen- ABNORMALLTLES LN MECHANISM 387 eral practice. There is some added danger of injury to maternal soft parts, on account of the necessity for rapid and sometimes violent extraction of the after-coming head. Treatment.—Before labor external version may be attempted. It will not always be found practicable, and after the fetal body has been turned there is a disposition on the part of the fetus to resume its original position. The application of two long cylin- drical compresses to the sides of the uterus, and a firm abdomi- nal binder, may prevent a return of the breech presentation. When labor has begun, inaction should be the physician's policy until the fetal body is born to the umbilicus, unless maternal or Fig. 243.—Delivery of the after-coming head when it is flexed. fetal life is threatened or an indication for rapid delivery arises. As soon as the trunk appears the patient should be placed in the lithotomy position across the bed, and delivery of the shoulders and head should be effected by pressing upon the fundus with one hand, the other hand being inserted in the vagina to favor anterior rotation of the shoulder, anterior rotation of the occiput, and to direct the passage of the head through the vagina (Wiegand's method ; see Delivery of the After-coming Head). Abnormalities in Mechanism.—The most frequent and impor- tant anomalies are backward rotation of the occiput and excess- 388 THE MECHANISM OF LABOR. ive rotation of the breech. Backward rotation of the occiput is very exceptional. The mechanism of the delivery of the head in these cases differs as the head remains flexed or becomes extended. When flexed, the chin, face, forehead, and anterior fon- tanel slip out under the symphysis in the order named, and the head is delivered. When extended, the chin catches upon the symphysis, the head is extremely extended and is born by the •occipital protuberance, small fontanel, cranial vault, and face slipping over the perineum. The following rules for managing the extraction of the head in these cases should be remembered : If the head is flexed, the body of the child should be carried dowmvard ; if it is extended, the body should be carried upward over the mother's abdomen. Excessive rotation of the breech occurs as the result of a prolapse of a posterior extremity, and is of no great practical importance. Fig. 244.—Chin arrested at symphysis; head extended (Chailly-Honore). The Mechanism of Shoulder Presentations.—A transverse position of the child in utero almost always resolves itself into a shoulder presentation as the result of uterine contraction when labor begins. Presentations of the umbilicus (Fig. 253) and of the back (Figs. 250, 25 1) are possibilities, but are extremely rare. Shoulder presentations are classified according to the positions of the back and head. When the head is to the right, the back may be in front or behind. The same is true when the head is to the left. The back is directed anteriorly twice as often as posteriorly, and the head more than twice as often is found toward the left-hand side of the maternal pelvis. Diagnosis.—Abdominal palpation reveals the fetus in a trans- verse position. The heart-sounds are more distinct at a point corresponding to the interscapular region of the child, but some- times can not be heard. A digital examination shows the characteristic anatomical peculiarities of the shoulder and adja- ABNORMALLTLES IN MECHANISM. 389 Fig. 245. — Shoulder presentation. Fig. 246.—Shoulder presentation. 390 THE MECHANISM OF LABOR. Fig. 247.—Shoulder presentation. Fig. 248.—Shoulder presentation. ABNORMALITIES IN MECHANISM. 391 Fig. 249.— Transverse position of the fetus; extremities presenting. v., fo, •% Fig. 250.—Back presentation; the left arm is projecting. The trans- verse furrow gives the appearance of a breech presentation (Budin). Fig. 251.—Back presentation, the two arms projecting from the external genital organs (Budin). THE MECHANISM OF LABOR. Fig. 252.—Trunk presentation, dorsal variety (Budin). Fig. 253. — Presentation of the umbilicus. ABNORMALITIES IN MECHANISM. 393 cent parts—namely, the axilla, the clavicle, the spine of the scapula, the acromion process, the head of the humerus, and the ribs. Causes.—The causes of a shoulder presentation may be divided under three heads : (i) Abnormalities in the shape and position of the uterus, as a pendulous abdomen; a uterus bicornis; the broad uterus accompanying a kyphotic spine; the distorted uterus due to uterine fibroids and other abdominal tumors, and to multiple pregnancy. (2) Conditions preventing Fig. 254.—Spontaneous evolution. engagement of the cephalic or the pelvic extremity of the fetus, as deformities of the pelvis ; abnormally large child ; monstrosi- ties ; placenta praevia. (3) Abnormal mobility of the fetus, as occurs in hydramnios, after fetal death, or in premature births. Mechanism.—Strictly speaking, there is no mechanism of shoulder presentations. The course of these cases is impaction of the shoulder, enormous dilatation of the lower uterine seg- ment, ascension of contraction-ring, destruction of the fetus by prolonged pressure, and death of the mother by rupture of the uterus or by exhaustion. As a matter of fact, however, nature 394 THE MECHANISM OF LABOR. can, in very exceptional cases, effect delivery by one of three methods : Fig. 255.—Rare form of mechanism, known as birth with doubled body (one- sixth natural size, redrawn from Kiistner). Fig. 256.—Impending rupture of uterus in a shoulder presentation: oe, External os; oi, internal os; cr, contraction-ring (much modified from Schroeder). F'g- 257-—Frozen section of shoulder presentation. If the mother had survived, spon- taneous evolution might have occurred (Chiara). Spontaneous version. The transverse position is converted into a longitudinal position by the uterine contractions. Spontaneous evolution. The breech slips past the shoulder ABNORMALITIES IN MECHANISM. 395 and is delivered first, the rest of the body following as in a breech presentation. The body doubled up (corpore reduplicato) is expelled in one mass. This termination is possible only in premature births with a small child, usually macerated. Treatment.—The treatment of shoulder presentations may be summed up in a single word—version. If the child is dead ; if the shoulder is tightly impacted and the lower uterine segment is so distended that the slight additional strain upon its walls of turning the child will probably determine a rupture of the uterus, the child should be decapitated. MECHANISM OF THE THIRD STAGE OF LABOR. The mechanism of the third stage of labor is divided into two acts—the separation and the expulsion of the placenta. The most probable explanation of placental separation is found in the Fig. 258.—Pinard and Varnier's section of the uterus of a V-para who died from collapse (rupture of uterus with hemorrhage) shortly after the expulsion of the fetus : a, Fundus uteri; b, membranes still attached ; c, retraction-ring ; d, retroplacen- tal blood-clot; e, inverted placenta; f contracted os externum ; g, cord presenting. theory of a diminution in the area of the placental site, which the placenta follows to a certain point, when, becoming solid by the approximation of the villi and the obliteration of the lacunae, it 396 THE MECHANISM OF LABOR. can no longer follow the contraction and retraction of the uterus, and is sprung off from the uterine wall. It requires usually several pains to accomplish this result; so that the placenta is not, as a rule, completely detached until about fifteen minutes after the delivery of the child, when it may be found lying in the dilated pouch of the lower uterine segment and cervical canal. The walls of this portion of the birth-canal are so flaccid from pressure paralysis and overdistention that the placenta Fig. 259.—Crede's method of expressing the placenta (photographed from nature) (Dickinson). might remain there many hours, perhaps days, unexpelled. Hence it is that artificial assistance is almost always required to express the placenta. The placenta is usually expelled like an inverted umbrella, the fetal surface coming first with the membranes trailing after it. It occasionally, however, escapes edgewise. Abnormalities in the Mechanism of the Third Stage of Labor.—Retention of the placenta occurs very frequently. As the placenta is fully separated, the hemorrhage is slight. The MECHANISM OF THE THIRD STAGE OF LABOR. 397 placenta simply lies in the dilated lower uterine segment and the upper portion of the vagina. The treatment consists of the proper application of Crede's method of expression. Sometimes the placenta lies across the Fig. 260.—The more favorable mechanism of expulsion of the placenta (Varnier). os uteri in such a manner that atmospheric pressure determines its retention. In such cases a finger may be hooked over one edge to pull it down. Adhesion of the placenta to the uterine wall occurs about once Fig. 261.—The less favorable of the common methods of expulsion of the placenta (Varnier). in 312 cases. The adhesion is rarely complete; a part of the placenta is usually detached. This condition of affairs neces- sarily gives rise to profuse hemorrhage. The placental sinuses are torn when the placenta is detached, but the womb can not 398 THE MECHANISM OF LABOR. contract and close them, because of the attached area and in consequence of the retention of the whole placental mass within the uterus (see Fig. 262). Diagnosis.—Crede's method of expression fails completely to express the placenta ; the womb will not firmly contract, and there is alarming hemorrhage. Treatment.—The hand should be inserted along the cord as Fig. 262.—Partial detachment of the placenta. Vertical mesial section from a case of eclampsia, delivered in articulo mortis by forceps: a, Placenta still attached; b, placenta separated from its site and hanging free; c, membranes; d, blood; e, membranes (Stratz). a guide to the placenta. A detached edge should be sought, under which the fingers are inserted, and the separation is com- pleted with the finger-tips, moving them from side to side. Oc- casionally it will be necessary to pinch through a dense spot of adhesion with the nails of the thumb and forefinger. The pla- centa being separated, the fingers should be closed about it. MECHANISM OF THE THIRD STAGE OF LABOR. 399 The fundus should be stimulated by friction through the abdom- inal wall, and the uterine contractions should be allowed to expel the hand and the contained placenta. It is unwise to pull the placenta out, even when it is completely detached, for the combined mass of the placenta and hand may act like the piston of a syringe and draw the uterus inside out. Prognosis.—Many women die from hemorrhage ; about seven per cent, lose their lives from sepsis. Most exceptionally the Fig. 263.—Method of manipulation for artificial separation of the adherent placenta (Dickinson). placenta is retained in utero for months without doing harm.1 The rarest anomalies in the mechanism of the third stage of labor are hernia of the placenta through the muscular coat of 1 Wallace, "Indian Medical Record," abstract in London "Lancet," 1891, re- ports the retention in utero of an almost full term placenta for two months without inconvenience to the mother. Loisnel (" Nouv. Arch, d' Obstet.," May, 1892, sup- plem.) reported a case in which the fetal head, after decapitation, was left in the uterus for three months without symptoms of sepsis. Herrgott, in the discussion of this report, stated that he had seen the placenta retained within the uterus for seven months after childbirth. 400 THE MECHANISM OF LABOR. the uterus and prolapse of the normally situated placenta. The latter is most likely to happen with twins, after rupture of the uterus, or in premature labor, but it has been observed at term, without injury to the uterus, and in a single pregnancy. There is not necessarily profuse hemorrhage nor other disadvantage to the woman, but the fetus dies unless it is extracted at once.x 1 " Prolapsus Placentae," Ingerslev, " Centralbl. f. Gyn.," No. 40, p. 941, 1893; "Zur Kasuistik des Prolapsus Placentae bei normalem Sitz derselben," ibid., No. 5, 1893. "Hernia of the placenta through the muscular coat of the uterus during labor," J. G. Lynds, '-Med. News," 1893, p. 77- PART IV. THE PATHOLOGY OF LABOR. CHAPTER I. Dystocia* ANOMALIES IN THE FORCES OF LABOR. In a normal labor the active forces of expulsion (the uterine and abdominal muscles) and the passive forces of resistance (the fetus, the pelvis, and the maternal soft structures) are so nicely balanced that the expulsive forces are just sufficiently resisted to insure a slow and gradual passage of the fetus along the birth- canal. The walls of the birth-canal and the structures around the vulvar orifice are by this arrangement slowly and gradually dilated, and are not rudely torn apart, as they would be by a more rapid expulsion of the fetus. This balance between the powers of labor, however, is easily disturbed. There may be anomalies by deficiency and anomalies by excess in the com- ponent parts of the forces of expulsion and in all the sources of resistance. Thus, the uterine muscle may be too weak or too strong compared with the resistance it must overcome ; and so also with the action of the abdominal muscles. The resistance furnished by the pelvis, the soft structures, and the fetus may be excessive or deficient. i. Deficient Power of the Uterine Muscle; Inertia Uteri. —In this condition the uterine muscle is unable to overcome the normal resistance offered by the weight of the fetal body, by the friction of the pelvic walls, and by that of the undilated maternal soft structures. Inertia uteri is manifested, in the vast majority of cases, during the first stage of labor. The weakened uterine force, therefore, is almost always neutralized by the obstruction of an undilated cervix. There is scarcely another condition in obstetric practice that can be traced to such a variety of causes or that demands so many different plans of treatment. Etiology.—Deficient power of the uterine muscle in labor 26 401 402 THE PATHOLOGY OF LABOR. may be due to a defect of the muscle itself, to some anomaly of innervation, or to a mechanical interference with the full and effective action of the muscle. Examples of the first-named cause may be found in imperfect development of the uterus or in anomalies of development, as in uterus bicornis. The uterine muscle may be exhausted by rapidly succeeding pregnancies. It may be overdistended by twins or by hydramnios, thus losing the power gained by cohesion of muscular bundles. The uterus may be weakened by some cause—as an adynamic fever or a wasting disease—that weakens the whole organism, but it does not necessarily follow that uterine weakness always accompanies a reduction of body-strength. Women in the last stages of phthisis or in the midst of an attack of typhoid fever or pneu- monia occasionally exhibit a uterine power in labor above the normal. The uterus may be weakened by profuse hemorrhage, as in placenta praevia. It may be rendered incapable of exerting normal force in dry labors. The liquor amnii having drained off completely early in the first stage, the uterus retracts upon the child's body, thus being subjected in certain regions to severe and long-continued pressure, and becoming in those spots anemic and friable, while in the areas free from the pressure of the child's body the uterine wall becomes congested, swollen, and edematous. Above all, the uterine muscle may become fatigued. This is the commonest cause of uterine inertia. It is seen oftenest in primip- arae, in whom inertia is more than twice as common as in mul- tiparas, on account of the difficulty of dilating the rigid cervical tissues. Inertia may appear in consequence of any serious obstruction in labor. At first the pains are feeble, infrequent, and inefficient, but as labor continues the uterine contractions gather force. The inertia from this cause is likely to be only temporary, seen at intervals between periods of stormy uterine action or of long-continued tonic spasms, until finally ex- haustion of the whole organism threatens the patient's life or the uterus ruptures. It has been asserted that an anomaly of innervation in the anatomical sense, a deficient supply of the terminal nerves in the individual muscle-cells, is a cause of uterine inertia, but it is not yet clearly demonstrated to be so. An inhibitory nervous im- pulse to the uterine muscle, on the contrary, is a frequent cause of uterine inaction. It is the result of some emotion or of great pain. That the "doctor has frightened the pains away" on his first arrival has become proverbial in the lying-in room. The presence of any one who is a cause of embarrassment or is disagreeable to the patient may have the same effect. In hyper- esthetic women the uterine contractions may be so exquisitely ANOMALIES IN THE FORCES OF LABOR. 403 painful that their first onset is followed by an inhibitory impulse which cuts them short almost immediately. Every clinical observer has seen the phenomenon of rapidly recurring, very painful uterine contractions, which are, however, of short dura- tion, and which secure no appreciable dilatation of the cervical canal. A woman may be tortured thus for hours in the early part of the first stage of labor, when this inhibitory nervous im- pulse is commonly observed. With the continuance of labor the individual becomes more or less indifferent to her surroundings or more inured to suffering, and the inhibitory nerves, probably derived from the spinal cord, apparently lose the powrer of responding to the stimulus of pain. Among the mechanical causes of inefficient uterine action during labor are fibroid tumors of the uterine walls, displace- ments of the uterus, old peritoneal adhesions, and fresh out- breaks of periuterine inflammation. Diagnosis.—The recognition of uterine inertia should always be easy. The contractions of the muscle are of short duration and are separated usually by long intervals, and by palpation the observer may convince himself that they are feeble. The uterus during the pain does not assume that intensely hard consistency which normal vigorous action of the muscle in labor occasions. The patient's expression, action, and demeanor point to deficient force during the pains. The woman is more placid, the face is less contorted, and there is less outcry during the contractions than in the normal parturient patient, except in those cases in which excessive pain inhibits uterine action. In these cases, however, abdominal palpation and the short duration of the pains are sufficiently plain signs of the inertia. Finally, labor is de- layed. During the first stage dilatation is slow or does not progress at all, and in the second stage the presenting part does not advance. One fatal error in the diagnosis of inertia uteri should be avoided : the physician should be sure that labor is not delayed by some obstruction. It has happened in a careless and superficial examination that the observer has taken the distended and thinned lower uterine segment for an inert uterus. In such a case the measures adopted to stimulate the supposedly inactive uterine muscle to overcome an obstacle that is insuperable might easily be interrupted by rupture of the uterus. A methodical and careful examination will guard one against this error. The source of obstruction will be discovered. The firmly, perhaps tetanically, contracted upper uterine segment may be contrasted with the inactive lower segment by palpation of the whole anterior surface of the uterus. The contraction-ring should be visible, and the whole uterus stands out with unusual 404 THE PATHOLOGY OF LABOR. prominence, from the anteversion that always accompanies pro- longed and powerful uterine contraction. Treatment.—From the diversity in the causes of inertia uteri it follows that no single plan of treatment can be depended upon. If uterine action is inhibited by emotion, the cause of nervous disturbance should, if possible, be removed. An objectionable person should leave the room. If excessive pain prevents effective contractions, an analgesic should be administered. Nothing is better for this purpose than chloral administered in 15-grain doses, repeated, if necessary, twice at intervals of fifteen minutes. A quarter of a grain of morphin hypodermat- ically comes next in order of efficiency. If the uterine muscle is simply apathetic, it can be aroused by some direct irritant. The insertion of a bougie as for the induction of labor answers the purpose well. A more effective but more troublesome measure is the dilatation of the cervical canal by Barnes' bags. These not only irritate the uterine muscle, and thus bring on strong contractions, but they also artificially dilate the cervical canal, and thus relieve the uterine muscle of a great part of its task in the first stage of labor. If the head should be well engaged in the pelvis, however, the insertion of the bags is difficult, and they are likely to cause malpositions of the head. In such cases, if the os is dilated to the size of a silver dollar, nothing is so effective as the application of forceps,—not to drag the head through the undilated cervical canal, but to pull it at intervals firmly down upon the cervix. The impact of the head upon the cervix acts as a powerful reflex irritant, and will excite as strong contractions as any direct irritant can do. Not only so, but the pull of the head upon the cervix will gradually dilate the canal as effectually as could strong propulsion from above. As soon as effective pains are estab- lished and the dilatation of the cervical canal progresses satisfac- torily, the forceps should be removed. Inertia uteri so profound as to demand the somewhat radical measures just described is, fortunately, rare. More commonly the physician sees the minor grades, in which there is simply a flagging of uterine effort during the first stage, especially in primiparae, accompanied by every evidence of temporary physical and mental exhaustion. After a period of rest effective contrac- tions reappear, even if nothing whatever is done to aid the patient. The more complete the rest, the more vigorous is the uterine action when it is resumed, and for this reason the administration of chloral and opium is often followed, after a time, by a satisfactory progress in labor. But these drugs neces- sarily retard the termination of labor by the time of rest they ANOMALIES IN THE FORCES OF LABOR. 405 secure. It is ordinarily desirable, therefore, to resort to drugs of a stimulant character that shall at once revive the flagging uterus and so hasten the delivery. Many medicaments have been recommended for this purpose, but, of them all, alcohol, quinin, and ergot alone deserve consideration. The last was employed extensively at one time, but clinical experience forbids its use to-day. The contractions of the uterus induced by ergot are likely to become tetanic. The uninterrupted contractions interfere with the fetal circulation ; they may cause fatal intra- uterine asphyxia, and they often produce such exaggerated blood-pressure and stagnation of the current in the fetal body as to induce extravasations in important viscera, especially the brain. Further, the circular fibers of the cervix come under the influence of the drug, and by their firm contraction neutralize the contraction of the longitudinal fibers of the uterine body, and thus retard labor almost indefinitely; and, worst of all, should there be some obstruction to the descent of the child in the maternal pelvis or in the fetal body, the administration of ergot predisposes to rupture of the uterus. For these sufficient reasons this drug, as a stimulant to the uterine muscle in the first and second stages of labor, should be banished from the obstetri- cian's pharmacopeia, except in the single instance of the birth of the second of twins. Owing to the recommendations of Albert H. Smith and of Fordyce Barker, quinin has had, and still has, a great reputation as a stimulant to the uterus in labor. My experience with the drug, however, does not permit me to sub- scribe unreservedly to a belief in its efficacy as a uterine stimu- lant in labor. Quinin has the positive disadvantage, moreover, that in certain susceptible individuals it will, occasionally, produce a violent postpartum hemorrhage. In the minor grade of inertia under description, so often seen in primiparae, and almost always the result of exhaustion, the writer has found nothing so useful as alcohol, in the shape of a wineglassful of sherry, taken slowly with a biscuit, and given with the positive assurance that it will bring back the pains and hasten the conclusion of labor, for the patient often needs moral and mental support as much as she re- quires a physical and muscular stimulus. An impression prevails among general physicians that inertia uteri in the first stage of labor, before rupture of the membranes, may safely be disregarded. In a measure this view is correct. There is often a partial dilatation of the os and then an entire cessation of uterine contractions for many hours and even for days. I have seen one case in which the cervical canal was sufficiently dilated to receive four fingers, and it remained so for more than a week, the patient all the while going about on 4o6 THE PATHOLOGY OF LABOR. her feet in perfect comfort, without a single painful contraction of the uterus. But should inefficient uterine contractions be accompanied by much pain, as happens in some cases of inertia, the long-continued first stage should not be regarded with indif- ference. The patient will in time show the irritant and depress- ant effects of long-continued suffering in an elevated temperature, an accelerated pulse, and a lessened resisting power of body-cells, the last playing an important role in the predisposition to sepsis after labor. Another consequence of delayed, painful labor may be seen in sensitive, nervous individuals who are at first thrown into a state of excitement and then from gloomy forebodings of harm to themselves and to their infants, pass into an almost maniacal condition of terror and dread. It should be a rule of practice, therefore, to watch carefully all cases of inertia uteri, and to interfere as soon as the patient's mental condition or her pulse, temperature, and general vigor are demonstrably affected by the delay in labor. 2. Excessive Power in the Expulsive Forces of Labor.—An actual excess of power in the expulsive forces in labor suffi- ciently great to expel the fetus precipitately is extremely rare. A relative excess is not uncommon. The child's body may be so small, the pelvis so abnormally large, the maternal soft parts so relaxed, that the ordinary power exerted by the uterine and abdominal muscles is far in excess of that .'required to over- come the weak resistance offered, and the child is fairly shot out of the birth-canal. The rapid delivery may cause serious re- sults to both mother and child. In the woman the structures on the pelvic floor may be lacerated severely ; the sudden evac- uation of the uterus predisposes to hemorrhage from inertia; the placenta may be detached prematurely; and the sudden evacuation of the abdominal cavity predisposes to dangerous syncope. For the child the chief danger is the possibility of unexpected delivery of the mother in the erect posture. The umbilical cord may rupture, and the child, falling to the ground, may be fatally injured. Precipitate and unexpected labors occur most frequently when women are seated upon the water-closet. The child is evacuated into the waste-pipe or down a well and may be destroyed. Some astonishing examples of infantile vitality, however, are furnished by such cases. Unfortunately, the physician is usually not at hand to pre- vent a precipitate delivery and to avert its consequences. Should he find an infant descending the birth-canal with a rapidity dangerous to itself and to its mother, he can easily retard its progress by pressure with his hand against the presenting part. ANOMALIES IN THE FORCES OF LABOR. 407 3. Excess in the Resistant Forces in Labor.—1. Deformities of the Pelvis—Comprehensive and satisfactory knowledge of deformities in the female pelvis has been gained only in the latter half of the present century, since the appearance of Michaelis' work in 1851.1 Until the announcement by Arantius in the last quarter of the sixteenth century that a contracted pelvis is a serious obstacle in labor, the prevailing belief had been that difficult labors from mechanical ob- struction by the maternal bones were due to a failure on the part of the pelvis to expand sufficiently for the passage of the child. This idea continued in force for a number of years after Arantius' time. According to Litzmann, Heinrich von Deventer (1651 to 1724) should be regarded as the real founder of our knowledge of the pelvis and its anomalies. He described the inclination of the pelvis, the axis of the pelvic inlet, the con- tracted pelvis, and the flat pelvis. Pierre Dionis was the first to point out (1718) the relationship between rachitis in childhood and a deformed pelvis in the adult. William Smellie's con- tributions to the study of the female pelvis were remarkably full and clear, when one considers how little was known before his time. His description of the rachitic pelvis, his reflections on its cause, and his accounts of illustrative cases may be read with profit to-day. Roderer, Stern, Cooper, Vaughan, Denman, Baudelocque, and Fremery added much to the stock of knowl- edge during the latter half of the eighteenth century. The men of the present century to whom we owe most of our present information about the pelvis and pelvimetry are Naegele, Kilian, Rokitansky, Michaelis, Robert Litzmann, Neugebauer, and many others to whom reference will be made in the sections devoted to the particular varieties of deformed pelvis.2 Frequency of Deformed Pelves.—It is difficult to estimate the frequency in America of pelves sufficiently deformed to influence decidedly the course of labor. Statistics from our lying-in hospitals afford little aid to a correct conclusion, because the inmates are chiefly European immigrants and negresses. In the Boston Lying-in Hospital, however, deformed pelves were found in two per cent, of native-born and in six per cent, of foreign-born women (Reynolds).3 My experience in private and consulting practice convinces me that deformed pelves are by no means rare among native-born women in the densely populated centers of the Eastern States. No general practi- 1 " Das enge Becken." 2 Litzmann, " Drei Vortrage iiber die Geschichte von der Lehre der Geburtbei engem Becken," in his " Geburt bei engem Becken," etc., 1884. 3 " Trans, of the Amer. Gyn. Soc," 1890, p. 367. 408 THE PATHOLOGY OF LABOR. tioner, in a large city at least, can hope to avoid such cases, and it is likely that each year will afford him one or more striking examples. It follows that an ability to recognize deform- ities of the female pelvis is a necessary accomplishment for every practitioner of medicine who may be called upon to attend women in confinement, and that a knowledge of pelvimetry is as essential to the intelligent and successful practice of obstetrics as are percussion and auscultation to the practice of medicine. European statistics bearing on the frequency of contracted pelves give the following results : Michaelis found in iooo parturient women 131 contracted pelves ; Litzmann, 149. Winckel found in Rostock 5 per cent., in Dresden 2.8 per cent., and in Munich 9.5 per cent, of contracted pelves among pregnant and parturient women. Winckel believes that 10 to 15 per cent, of child- bearing women have contracted pelves, but that in only 5 per cent, -is the obstruction serious enough to be noticed. Kaiten- bach puts the frequency of contracted pelvis at 14 to 20 per cent. In Marburg it was found to be 20.3 per cent, in Gottin- gen 22 per cent., in Prague 16 per cent. Schauta estimates it at 20 per cent. Classification of Anomalies in the Female Pelvis.—All classifica- tions are merely a convenience for the teacher and student. It is rarely possible to draw sharply defined lines between varying manifestations of a condition. The majority of German authors follow Litzmann's classification of abnormalities of the female pelvis, by which they are broadly divided into those of size and those of shape. Modern French authors adopt the still less satisfactory division of oversize, undersize, and anomalies of inclination. Schauta's classification is, in my opinion, the most convenient, and I have utilized it, with a slight modification.1 ANOMALIES OF THE PELVIS THE RESULT OF FAULTY DEVELOPMENT. Simple flat pelvis. Generally equally contracted pelvis (justo-minor). Generally contracted flat pelvis (non-rachitic). Narrow funnel-shaped, fetal, or undeveloped pelvis. Imperfect development of one sacral ala (Naegele pelvis). Imperfect development of both sacral alae (Robert pelvis). Generally equally enlarged pelvis (justo-major). Split pelvis. 1 Midler's " Handbuch." ANOMALIES IN THE FORCES OF LABOR. 409 ANOMALIES DUE TO DISEASE OF THE PELVIC BONES. Rachitis. Osteomalacia. New growths. Fractures. Atrophy, caries, and necrosis. ANOMALIES IN THE CONJUNCTIONS OF THE PELVIC BONES. Abnormally firm union (synostosis), which is found in elderly primiparae, particularly at the sacrococcygeal joint and in the joints between the coccygeal bones : Synostosis of the symphysis. " " one or both sacro-iliac synchondroses. " " the sacrum with the coccyx. Abnormally loose union or separation of the joints : Relaxation and rupture. Luxation of the coccyx. ANOMALIES DUE TO DISEASE OF THE SUPERIMPOSED SKELETON. \/ Spondylolisthesis. \f Kyphosis. v Scoliosis. -J Kyphoscoliosis. J Lordosis. ANOMALIES DUE TO DISEASE OF SUBJACENT SKELETON. Coxalgia. ^ ^ Luxation of one femur. Luxation of both femora. Unilateral or bilateral club-foot. Absence or bowing of one or of both lower extremities. Diagnosis of Pelvic Anomalies; Pelvimetry.—Deformities of the female pelvis may be detected by the history of the patient, by her appearance, by palpation of the exterior and interior of the pelvis, and by external and internal measurements of those pelvic diameters that are accessible, or of salient points on the woman's body corresponding as nearly as possible with the internal measurements desired, the relations between the two last having been ascertained by many observations on dead and living bodies. For taking pelvic measurements the examiner's fingers, a tape-measure, and a modified mathematician's calipers —a pelvimeter—are usually employed. Baudelocque (1775) was the first to devise the pelvimeter in ordinary use. He laid 410 THE PATHOLOGY OF LABOR. Fig. 264.—Osiander's pelvimeter. Fig. 265.—Modern combination of Baudelocque's and Osander's pel- vimeter. Fig. 266.—Martin's pelvimeter. Fig. 267.—Harris-Dickinson portable pelvimeter. ANOMALIES IN THE FORCES OF LABOR. 41 I the foundations of pelvimetry, and his instrument and methods are in use at the present time (Figs. 265-268). It is con- venient to describe the measurements of the diameters of the pelvic inlet, pelvic cavity, and pelvic outlet separately. Measurement of the Anteroposterior Diameter of the Superior Strait.—This measurement, the most important in the pelvis, can not be taken directly. It must be estimated by several Fig. 268.—Measuring the external conjugate diameter upon the living female (Dickinson). plans. Baudelocque was the first to point out the relation be- tween the measurement from the depression under the last spinous process of the lumbar vertebrae to the upper edge of the symphysis pubis, and the true conjugate diameter of the pelvic inlet. To this external measurement the name " external conju- gate " was given, but it is often called " the diameter of Baude- locque " (Fig. 268). Its discoverer believed the relation 412 THE PATHOLOGY OF LABOR. between the external and internal diameters to be constant,— that the one exceeded the other by 8 to 8 34 centimeters,—but in this he was mistaken. The line of the external diameter does not usually coincide with the line of the internal, and the thickness of bones and superimposed structures differs, of course, in each individual. In thirty cases in which Litzmann had an opportunity to compare the measurement of the external conju- gate taken during life with the actual measurement of the true conjugate taken after death, there wras an average difference of 9.5 centimeters, but the maximum difference was 12.5 centi- meters and the minimum 7 centimeters,—a variation of 5.5 centimeters in a small number of cases. Michaelis found a difference of 0.6 to 3.2 centimeters and Schroeder i*£ to 3 centimeters between the external conjugate of the living body and that of the dried specimen. The measurement of the exter- nal conjugate, therefore, is not to be relied upon in making an estimate of the size of the true conjugate. It simply serves to indicate the probability or the improbability of pelvic contrac- tion. An external conjugate of 16 centimeters or under means certainly an anteroposteriorly contracted pelvis; between 16 and 19 centimeters the pelvic inlet will be contracted in more than half the cases ; between 19 and 21.5 centimeters there will be but ten per cent, of contracted pelves ; and above 21.5 centi- meters it is almost certain that the conjugate diameter of the pelvic inlet is not contracted at all. The external conjugate can not be measured accurately without some practice. The beginner in pelvimetry will do well to remember the following rules : Have the patient dressed for bed. Place her upon her side, with the thighs slightly flexed and the clothing rolled well up out of the way, the lower part of the body being covered with a sheet. The examiner stands at the patient's back, facing her head. The depression below the last spinous process of the lumbar vertebrae is found by rubbing a finger-tip over the lumbar spines from above downward until the finger sinks into the de- pression sought and feels no more prominent spinous processes below.x The knob at the end of one branch of the pelvimeter is placed firmly in this depression and is held there with one hand, while the fingers of the other hand find a point on the symphysis pubis about y of an inch below its upper edge, on which point the other branch of the pelvimeter is firmly set; the pelvimeter having been so placed that the indicator is turned toward the examiner, the measurement is therefore easily 1 Michaelis preferred the measurement from the tip of the last lumbar spinous process, instead of from the depression below it. ANOMALIES IN THE FORCES OF LABOR. 41 3 read off as soon as the pelvimeter is in proper position. It is on the average, in well-built women, 20^ centimeters. The best measurements for determining the length of the anteroposterior diameter of the pelvic inlet are those taken from the lower edge of the symphysis pubis to the promontory of the sacrum,—the diagonal conjugate diameter,—and the distance between the upper outer surface of the symphysis pubis and the promontory of the sacrum. The diagonal conjugate diameter is one side of a triangle, the other two sides of which are the height of the symphysis and the true conjugate. The distance between the outer upper surface of the symphysis and the pro- montory of the sacrum differs from the true conjugate by the thickness of the upper portion of the symphysis. Smellie was accustomed to estimate roughly the length of the true conjugate by a digital examination, basing his estimate on the ease with Fig. 269.—Stein's instrument for direct measurement of the conjugate. which the promontory could be reached. In the latter part of the eighteenth century Johnson x proposed, for estimating the size of the pelvic inlet, a method wilich consisted of inserting the fingers of one hand in the mouth of the womb and then spreading them between the promontory and the sacrum. A few years later the elder Stein devised a graduated rod for measuring the distance between the lower edge of the symphysis pubis and the division between the second and third sacral vertebrae. This dist- tance he believed to be one-half to one inch greater than the true conjugate. Stein later constructed the instrument for the direct measurement of the conjugate shown in figure 269. Many instruments have since been constructed on this principle, but they are impracticable in the living female, for obvious reasons. Baudelocque was the first to propose the measurement of the diagonal conjugate and the subtraction from it of an average 1 Robert Wallace Johnson, "A New System of Midwifery," etc., London, 1769. 414 THE PATHOLOGY OF LABOR. figure (y of an inch) to determine the length of the true con- jugate. His method, exactly as he described it, is still in use, with the exception that two fingers instead of one are employed in measuring the distance between the symphysis and the pro- montory. To measure the diagonal conjugate correctly, the examiner must have the skill that comes of practice, and he must conduct his examination in a careful and methodical man- ner. The patient is put in the lithotomy position and is brought to the edge of the table or bed on which she lies, so that the buttocks project well over it. The examiner cleanses his left hand and anoints the first two fingers with an unguent; he then inserts these fingers, held stiffly extended, inward and upward, until the tip of the second finger finds and rests upon the pro- montory of the sacrum. Care must be exercised not to take the last lum- bar for the first sacral vertebra or vice versa, nor the second for the first sacral vertebra,— mistakes easily made in cases of so-called " double promontory." With the tip of the sec- ond finger resting firmly in place upon the mid- Fig. 270.—Measuring the diagonal conjugate die line of the promon- diameter (Dickinson). tory, the radial side of the hand is elevated until the impress of the arcuate ligament under the lower edge of the symphysis is plainly felt upon it. With a finger-nail of the other hand a mark is made upon this point of the examining hand, which is then withdrawn (Fig. 270). The distance between this mark and the tip of the middle finger held extended is taken by a pelvimeter. This distance is the diagonal conjugate. By the observation of many subjects, alive and dead, an agreement has been reached that I y centimeters should be subtracted from the diagonal conjugate to obtain the true conjugate diameter. But the acceptance of this average difference depends upon a normal height of the symphysis, 4 centimeters ; a normal angle ANOMALIES IN THE FORCES OF LABOR. 41 5 between the axis of the pubis and the true conjugate, 1050; a normal thickness of the symphysis, and a normal height of the promontory (Figs. 271 to 275). These factors, however, are not constant, and if they vary much from the normal, the most skilful and most experienced obstetrician may be misled woefully in his estimation of the true conjugate. I have had under my care a rachitic dwarf in whom there was more than 3 cen- timeters' difference between the diagonal and true conjugates, and Pershing found, among ninety pelves in the museums of Philadelphia, a difference varying from 0.8 centimeter to 3.6 centimeters. It is declared that these sources of error may be eliminated by the following corrections : For every degree of Fig. 271 —Effect of different inclinations of the pubis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). increase in the conjugatosymphyseal angle add half the number of millimeters to the sum to be subtracted from the diagonal conjugate, and vice versa ; also, for every 0.5 centimeter increase in the height of the symphysis over the normal add 0.3 centi- meter to the sum to be subtracted from the diagonal conjugate, and vice versa. While these rules are admirable for the study of the dried specimen in a museum, they are not easily applied to the living pregnant female. The height of the symphysis can be measured in the living subject, but an allowance for variations in this respect eliminates error in only a small propor- tion of cases. The variations in the angle of the symphysis, a much more important source of error, can only be surmised. In cases upon the border-line between the relative and absolute 416 THE PATHOLOGY OF LABOR. indications for Cesarean section in which the difference of a centimeter would decide one for or against the operation I Fig. 272.—Effect of different thicknesses of the symphysis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). Fig. 273.—Effect of different heights of the promontory upon the relationship be- tween the true and the diagonal conjugate diameter (Ribemont-Dessaignes). prefer the measurement between the upper outer edge of symphysis pubis and the promontory of the sacrum for ANOMALIES IN THE FORCES OF LABOR. 417 Fig. 274.—Effect of different heights of the symphysis upon the relationship between the true and the diagonal conjugate diameter (Ribemont-Dessaignes). Fig. 275.—Effect of the lessened slant outward of the symphysis in a rachitic pelvis upon the relationship between the true and the conjugate diameter (Ribemont- Dessaignes). 27 4i8 THE PATHOLOGY OF LABOR. estimation of the true conjugate, having demonstrated its supe- rior accuracy in practice. For taking this measurement the patient is put in the dorsal posture, with the buttocks projecting beyond the edge of the table or bed on which she lies. A mark with the point of a lead-pencil is made on the skin over the symphysis pubis, about y of an inch below the upper edge. The two fingers of the left hand are inserted in the vagina, as in measuring the diagonal conjugate. The tip of the middle finger, having found the middle line of the promontory, is moved a little to the patient's right, and tip b of the pelvimeter, shown in figure 278, is made to take its place. While the examining physician holds the shaft of the pelvimeter firmly in Fig. 276.—Author's pelvimeter : a, For measuring the true conjugate plus the thickness of the symphysis; b, with extra tip added for measuring the thickness of the symphysis. place, an assistant adjusts tip a of the movable bar over the mark made on the symphysis. This bar is then screwed tight, the whole pelvimeter is removed, and the distance between the tips is found by a tape-measure. This distance is the con- jugate plus the thickness of the symphysis (Fig. 279). The latter I have found to be 1 centimeter in twenty-six dried pelves, 1 y centimeters in nine, 1 y centimeters in thirteen, 1 y centi- meters in four, and 2 centimeters in three specimens—one a high-grade rachitic pelvis, another of the masculine type, and the third a justomajor pelvis. The thickness of the symphysis is measured as shown in figure 278. In living subjects the index- finger of the left hand must find the inner surface of the symphy- sis pubis, and must follow it up to within about y of an inch ANOMALIES IN THE FORCES OF LABOR. 419 of the top, where it bulges to its full thickness. On this point one tip of the pelvimeter is placed, and it is then held in position between the ends of the first and second fingers ; the other tip of the instrument is adjusted over the mark made on the skin Fig. 277.—Measuring the true conjugate, plus the thickness of the symphysis, with the author's pelvimeter. Fig. 278.—Measuring the thickness of the symphysis, with the author's pelvimeter. externally; the distance is read off from the indicator provided for the purpose. It is not necessary to make an allowance for the thickness of the tissues over the symphysis, for this is included in both measurements, and on subtracting one from the other the necessary correction is made. The tissues over 420 THE PATHOLOGY OF LABOR. the inner surface of the symphysis can usually be so com- pressed by the knob of the pelvimeter as to be practically elimi- nated. If this is impossible, as may happen in some primiparae, a small allowance may be made for these tissues—say, at the most, 0.5 centimeter. In measuring a pelvis by this method it may be necessary to anesthetize the patient; and this is well worth while if a decision between some of the more serious ob- stetrical operations is to be based, as it must be, upon an accur- ate estimation of the true conjugate.1 Measurement of the Transverse Diameter of the Superior Strait.—The transverse diameter of the pelvic inlet can not be measured directly, nor can it be estimated accurately. Fortu- nately, it is not necessary to do it. It is sufficient to deter- mine whether there is a decided diminution of the measurement, without determining the exact degree of lateral contraction. To do this the following measurements are relied upon: The distance between the anterior superior spinous processes of the iliac bones, which in well-formed women is 26 centimeters; the distance between the crests of the iliac bones, 29 centi- meters ; the distance between the trochanters, 31 centimeters ; the distance between the posterior superior spinous processes of the iliac bones, 9.8 centimeters ; the distance between the subpubic ligament and the upper anterior angle of the great sacrosciatic notch, which, according to Lohlein, is 2 centimeters less than the transverse diameter of the inlet; finally, an estimation of the width of the pelvic inlet by a vaginal examination. In taking the external measurements the woman is placed upon her back. The salient points are easily found except in the case of the iliac crests. They are discovered by moving the knobs of the pel- vimeter evenly along the crests of the ilia until the two opposite points most widely separated from each other are found. If the crests are no further, or even less, separated from each other than the spines, points five centimeters back of the latter are arbi- trarily selected as the sites of the crests. The posterior superior spinous processes are often marked by distinct dimples on the woman's back. The internal measurement of Lohlein is made by the fingers in the vagina. If all these measurements are much less than normal, a lateral contraction of the pelvis may be assumed, and the degree of contraction is roughly estimated by the amount of decrease in the measurements, although the relation between these measurements and the distance sought is 1 Wellenbergh was the first to employ this principle in pelvimetry. His pelvimeter was improved upon by van Huevel, and in recent times by Skutsch and by Bullitt ("Deutsche med. Wochen.," No. 13, 1890; " Amer. Jour. Obstetrics," 1893 ; Midler's " Handbuch der Geburtshulfe," vol. ii, pp. 255, 260,261). ANOMALIES IN THE FORCES OF LABOR. 42 I Fig. 279.—Skutsch's method of measuring the conjugate diameter. Fig. 280.—Skutsch's method of measuring the transverse diameter of the pelvic inlet. 422 THE PATHOLOGY OF LABOR. very variable. The efforts of Skutsch and of others before him, accurately to measure the transverse diameter of the pelvic inlet by combined internal and external measurements, have not yet been crowned by success. The softness of the tissues exter- nally permits the external knob of the pelvimeter to sink into the flesh to a varying degree, and the same is true of the struc- tures within the pelvis. It is difficult also to keep the pelvimeter in the same straight line when the internal knob is changed from one side to the other (Figs. 279 and 280). Moreover, better results in practice may be obtained by an estimate formed by a vaginal and a combined examination, under anesthesia if neces- sary, of the relative size of the transverse diameter of the pelvic inlet and the anteroposterior diameter of the child's head. Measurement of the oblique diameters of the pelvic inlet is required only in obliquely contracted pelves. It will be referred to in the description of these pelves. The Measurement of the Capacity of the Pelvic Cavity.—The capacity of the pelvic cavity must be estimated by vaginal ex- amination. There is no plan by which accurate measurements can be made. It is sufficient to estimate the size and the shape of the pelvic canal by palpating the lateral walls of the pelvis; by determining the curve, perpendicularly and laterally, of the sacrum ; by noting the height of the sacrosciatic notches, the approximation of the tuberosities of the ischia, the depth of the pelvis, and the direction of its P canal ; by detecting, possibly, the \ presence of an exostosis, an osteo- ~"'\ sarcoma, an abnormally project- ing spinous process, an old frac- ture, or asymmetry of the pelvic walls from any cause. \ Measurement of the Transverse Diameter of the Pelvic Outlet.—The anteroposterior diameter of the in- ferior strait is enlarged during labor by the displacement backward of the coccyx. The transverse diam- ant^;^_HMeTemfn,Vofth,eeter between the tuberosities of anteroposterior diameter of the pel- . , vie outlet. the ischiatic bones is constant, and if there is contraction of the outlet the greatest resistance to the escape of the fetus is furnished by these firm bony eminences. The transverse diameter of the pelvic outlet can be measured directly with ease. The woman is placed in the dorsal posture, with thighs and legs flexed. The distance between the tuberosities of the ischia is measured with a pel- ANOMALIES LN THE FORCES OF LABOR. 423 vimeter, or the examining physician places his thumbs squarely on the tuberosities, and an assistant measures the distance be- tween the physician's thumb-nails. If it should be desired to measure the anteroposterior diam- eter of the pelvic outlet, this may be done as is shown in figure 283, 1.5 centimeters being subtracted for the thickness of bone and superimposed structures. Or, the extended first and second finger of the left hand may measure the distance from the lower edge of the symphysis pubis to the tip of the sacrum. 4. Description of the Several Varieties of Abnormalities in the Female Pelvis.—The simple flat pelvis (Fig. 282) is the earliest recognized form of contracted pelvis—the pelvis plana of Deventer, who did not, however, make a distinction between the simple flat and the rachitic flat pelvis. It is doubtful, indeed, if he knew the difference between the two. Betschler was the first to point out the distinctive features of this form of pelvis. In Europe it is the commonest variety of de- formed pelvis. Schroder states that it is seen more frequently than all the other forms put together. In America it is also common, but the equally generally contracted pelvis is encountered here as often or perhaps oftener. Out of a series of 316 pelves in women of American birth, I have found eighteen (a percentage of 5.6) with the measurements characteristic to some degree of a simple flat pelvis. Characteristics.—In the simple flat pelvis the sacrum is small and is pressed downward and forward between the iliac bones, but is not rotated forward on its transverse axis. The antero- posterior diameter is contracted, therefore, throughout the whole of the pelvic canal. The contraction, however, is not often great. It is scarcely ever below 8 and is usually not under 9.5 centimeters.2 Fig. 282.—Simple flat pelvis: C. v , 8^£ cm.; tr., 13^ cm.; obi., 12^ cm.l (model in author's collection, University of Pennsylvania). 1 The abbreviations, c. v., tr., and obi., will be used throughout to designate the true conjugate, the transverse, and oblique diameters of the pelvic inlet. 2 Engelken has described a specimen with a true conjugate of 4.8 centimeters, a diagonal conjugate of 7.5 centimeters, with transverse and oblique diameters of the inlet 13.3 and 12.4 centimeters respectively. This specimen is unique. 424 THE PATHOLOGY OF LABOR. The transverse diameter is as great as, or possibly greater than, that of the normal pelvis. Occasionally, however, in pelves approaching the type of the generally contracted flat pelvis the transverse diameter may be found somewhat diminished. There is in these pelves quite frequently a double promontory formed by the abnormal projection of the cartilaginous junction between the first and second sacral vertebrae. The line drawn between the lower promontory, or the second sacral vertebra, and the symphysis is often as small as, or smaller than, the true con- jugate.1 Etiology.—The simple flat pelvis has been ascribed to heredity, to an arrested rachitis, to overwork before puberty (especially the carrying of heavy weights), to premature attempts to walk or to sit up, and to the weight of a heavy trunk upon a pelvis ill fitted to bear it on account of weakness of its ligaments. It is probable that in the majority of these pelves the form is inherited and congenital. It has been found by Fehling in a number of fetuses and new-born infants. Diagnosis. — The simple flat pelvis is easily overlooked. There is nothing in the patient's appearance or history to sug- gest the deformity, unless she has had difficulty in previous labors. The characteristic signs are the diminished anteropos- terior diameter, determined by internal and external measure- ments, and a transverse diameter as great as, or greater than, normal, or perhaps a trifle under the normal measurement. This last point is determined by measurements externally and by the internal palpation of the pelvic canal. In measuring the conju- gate diameter of the flat pelvis one must take into account the lessened inclination of the symphysis outward, its height, some- what below the normal, and the low position of the promon- tory. Usually the average sum of I y centimeters is a sufficient amount to subtract from the diagonal conjugate. If there is a double promontory, as is frequently the case in this form of pelvis, the conjugate must be measured from the promontory nearest to the symphysis, usually the lower (Fig. 283). Influence Upon Labor.—From the failure of the presenting part to enter the pelvis during the last weeks of gestation there is frequently some degree of pendulous abdomen, especially in women with abdominal walls relaxed from previous pregnancies. The uterus is sometimes broader than common, and is often tilted to one side. The presenting part, if the head, may be loose 1 Crede found, in nine pelves with a double promontory, the conjugate from the true promontory longer in four and shorter in three cases than the conjugate measured from the false promontory. In two cases the two conjugates were of equal length (" Klin. Vortrage iiber Geburtshulfe," Berlin, 1853). ANOMALIES IN THE FORCES OF LABOR. above the superior strait, resting on one iliac bone or on the symphysis, or it may be pressed down firmly upon the brim in a transverse position, to accommodate its longest diameter to the longest diameter of the pelvic inlet. Malpresentations are com- mon, as is also prolapse of the cord and of the extremities. The membranes may protrude in a cylindrical pouch from the external os as the liquor amnii is forced out of the uterus without obstruction from the imperfectly engaged head. From the same cause an early rupture of the membranes is likely. According to Litzmann, natural forces end the labor in seventy-nine per cent, of cases, but in fifty per cent, the head is not fully engaged Fig. 283.—The two conjugates of a double promontory: Prow., true promontory; F. P., false promontory (Ribemont-Dessaignes). until the os is completely dilated. The dilatation of the os pro- ceeds slowly, for the head does not descend low enough to press upon the cervix. Consequently the dilatation must be effected by a retraction of the cervix over the head or by the distended membranes. Should the latter rupture, the os, although consider- ably dilated, may retract until the head at length descends and again dilates it. After the obstruction at the superior strait is passed,—where, of course, it is greatest,—the head usually de- scends the remainder of the birth-canal with ease and rapidity, but labor may be prolonged by an exhaustion of the natural forces in the attempt to secure engagement. The apparent anomalies in 426 THE PATHOLOGY OF LABOR. the mechanism of labor characteristic of this deformed pelvis are in reality the best possible provision for the spontaneous obviation of the obstruction. The transverse position of the head at the inlet, the increased lateral inclination, and the imperfect flexion are designed to accommodate the size and the shape of the head to the unnatural size and shape of the pelvic inlet. An explana- tion of these peculiarities in the engagement of the head may be found in the altered relation of expulsive and resistant forces. The head, forced down upon the flattened brim and free to move upon the neck, rotates until its longest diameter is adjusted to the greatest diameter of the inlet—the transverse. It seeks the direction of least resistance, as any inert body will when propelled through a contracted canal. But the transverse position of the head alone is not sufficient to overcome the obstruction. The biparietal diameter of the head is too large to enter the conjugate of the pelvis. The occiput, the bulkiest portion of the skull, seeks the greater space to one side of the promontory, and is pushed against the lateral brim of the pelvis—the iliopectineal line. Here it is arrested. Further propulsion of the head is secured by a movement of partial extension, which brings the small bitemporal instead of the larger biparietal diameter of the head in relation with the contracted conjugate. Still, the obstruc- tion may not be overcome. Both sides of the head may be unable to enter the pelvis at once. One side is propelled into the pelvic canal, the other is held back. That side which encounters the most resistance will naturally be the last to enter. Thus it is that usually the anterior parietal bone, slipping more easily past the symphysis, enters first. To this result also the inclination of the pelvic axis to the axis of the trunk contributes. Owing to the anterior position of the wiiole sacrum and to the diminished anteroposterior diameter of the pelvic outlet; on account, also, of the transverse position of the head and of its imperfect flexion, rotation of the head on the floor of the pelvis occurs late, and occasionally fails altogether, the head being expelled from the vulva in its original transverse or in an oblique position. The localized pressure to which the maternal structures are subjected results sometimes in necrosis of cervical tissue over the promontory and of the anterior vaginal wall behind the sym- physis. On the child's head the caput succedaneum is not exaggerated, because the head, when once firmly engaged in the pelvis, descends the birth-canal rapidly, but there is apt to be a depression on that portion of the skull applied to the promontory —namely, on the posterior parietal bone between the greater fontanel and the parietal eminence, usually quite close to the ANOMALIES IN THE FORCES OF LABOR. 427 sagittal suture (Fig. 284). Sometimes a succession of these depressions or a gutter-shaped groove may be noted in a line running outward and forward on the child's skull. More fre- quently the course of the head and face over the promontory is marked by a red streak running from the depression before noted in a line parallel with the coronal suture toward the temple if the head is well flexed after engagement, or to the outer corner of the posterior eye, or, in case of extreme flexion, to the cheek (Fig. 285, a, b, c). Usually the posterior parietal bone is depressed below the anterior, which overlaps it at the sagittal suture. The posterior side of the skull is also flattened from the greater and more prolonged pressure to which it is subjected. Ordinarily Fig. 284.—Depression in the parietal bone caused by the pressure of the promontory (Winckel). the lateral inclination of the child's head is in a direction from before backward, so that the anterior parietal bone presents at the center of the superior strait. Occasionally this inclination is so exaggerated that the ear is the presenting part. Exceptionally the lateral inclination takes the opposite direction, the anterior parietal bone catches on the rim of the pubic bones, and the posterior parietal bone is the first portion of the child's head to enter the pelvis. The presentation of the posterior fontanel occurs even in normal pelves as a rare exception, but is seen in about ten per cent, of contracted pelves (Schauta), and is the result in them very likely of firm abdominal walls and an increased inclination of the pelvic inlet to the axis of the trunk. 428 THE PATHOLOGY OF LABOR. In these cases the anterior parietal bone is pushed under the posterior at the sagittal suture. When the posterior side of the head by descent finds room in the hollow of the sacrum and moves backward, the anterior portion of the skull glides over the symphysis and the sagittal suture moves from its original position, just behind the symphysis, toward the median line of the pelvic canal. In addition to these anomalies of mechanism Breisky describes what he calls an " extramedian " engagement of the head in cases of flat pelvis in which there is considerable Fig. 285.—Marks made by the promontory on the child's head and face (Fritsch and Kiistner). lordosis of the lumbar vertebrae. The head in extreme flexion is forced down upon half of the pelvic inlet, and enters the pelvic canal on this side alone. Directly the obstructing promontory and lumbar vertebra are passed the head descends the pelvic canal with rapidity and ease. This mechanism was noted nine- teen times in Breisky's clinic among 2002 labors.1 1 "Die Becken Anomalien," by Friedrich Schauta, in Midler's " Handbuch der Geburtshulfe," Bd. ii; Betschler, " Annalrn der klinischen Anstalten," i, pp. 24, 60; ii, p. 31 ; Engelken, " Dis.-Inaug.," Miinchen, 1878; " Zur Kentniss der extra- median Einstellung des Kopfes," Kohn, " Prager Zeitschrift f. Heilkunde," Bd. ix. ANOMALIES IN THE FORCES OF LABOR. 429 Justominor Pelvis.—In this type of contracted pelvis the form of the female pelvis is preserved, but the size is diminished. Three divisions of this pelvis are commonly made : The juvenile, in which the bones are small and slender; the masculine, in which the bones are large, heavy, and thick ; and the dzvarf, or pelvis nana, in which the pelvis is very diminutive in size and the pelvic bones are not joined by bony union, but are separated by cartilage as in the infant. The innominate bones are divided into their three parts, and the sacral vertebrae are distinct from one another. The justominor pelves pass by insensible grada- tions into the simple flat, the transversely contracted, and the generally contracted flat pelves. In the larger cities of the United States the justominor pelvis is very frequently encountered. It is certainly as common here as is the simple flat pelvis, and if one were to judge from hospital patients, among whom there is a large proportion of shop- and factory girls, this variety of contracted pelvis would be regarded as the commonest. Characteristics.—While it is convenient to speak of the justo- minor pelvis as the normal female pelvis in miniature, the de- scription is not strictly accurate. There are peculiarities due to an arrest of development which give to the equally generally contracted pelvis some of the features of an infantile pelvis. The alae of the sacrum are narrower than they should be in comparison with the bodies of the vertebrae. The sacrum is short and is not pushed as far forward between the iliac bones as it usually is ; it shows also a diminished forward inclination, and on its anterior surface a greater lateral and a less marked perpendicular concavity than common. The distance between the posterior superior spinous processes of the iliac bones is relatively great, on account of the posterior position of the sacrum and its slight rotation forward. The conjugatosym- physeal angle is greater than normal, by reason of the lessened inclination outward of the symphysis and the pubic bones. The promontory is high and not prominent, and the inclination of the pelvic entrance to the abdominal axis as the individual stands erect makes a more obtuse angle than it does in the normal pelvis. The bones in this form of contracted pelvis are com- monly small and slender, except in the rare masculine pelvis, in which they are firm and thick beyond the normal. Women with a justominor pelvis are ordinarily of slight build and below the medium height; but this pelvis may be found in individuals of ordinary stature, and sometimes actually in tall women with a large frame. The true dwarf pelvis is very rare. It is found only in women of dwarf stature. The bones are slender and fragile, 430 THE PATHOLOG Y OF LABOR. and the cartilaginous junction between the original divisions of the pelvic bones is preserved. There is extreme contraction of the pelvic canal. In the commoner kinds of justominor pelvis the contraction is not often very great. The conjugate diameter is seldom below nine and scarcely ever as low as eight centimeters. The pelvic outlet in some cases is laterally contracted ; in others it is com- paratively roomy. Etiology.—The justominor pelvis is the result of arrested development; it may be found in women descended from a stock that has deteriorated phys- ically, or in women sub- jected during childhood, infancy, or intra-uterine existence to unfavorable hygienic surroundings or conditions. Diagnosis.—The jus- tominor pelvis is easily confused with a rachitic pelvis, but the distinction is readily made by careful pelvimetry. All the meas- urements, while equally reduced, bear their normal proportion to one another, except in the case of the external conjugate diam- eter, which is apt to be longer than would be ex- pected, on account of the Fig. 286.—Dwarf pelvis (model in author's posterior position of the collection). sacrum and its lessened inclination forward. In estimating the true conjugate diameter from the diagonal conju- gate one must often take account of the increase in the conju- gatosymphyseal angle, and must remember that the sum to be subtracted from the diagonal conjugate is not infrequently greater than common. The symphysis is less in height than in the normal pelvis, but the error of computation from this source may be disregarded. Lohlein lays special stress upon the importance of measuring the pelvic circumference in making the diagnosis of this form of contracted pelvis. It is always far below the normal, ninety centimeters. An internal examination of the pelvic cavity and inlet should be made carefully, to determine approxi- ANOMALIES IN THE FORCES OF LABOR. 43 I mately their capacity, with a special regard to the approximate length of the transverse diameters. Influence on Labor.—The mechanism of labor shows far fewer anomalies in this than in any of the other forms of con- tracted pelvis. The head, from the greater resistance encoun- tered, is strongly flexed. It may be placed transversely, but is quite commonly oblique, and may even be anteroposterior in position if there is a tendency to lateral contraction of the pelvic canal. By the perfect flexion of the head the obstruction to the progress of labor is in great part obviated. If anything inter- feres with this movement of the head, as a faulty application of the forceps, engagement and descent may become impossible. Pelvic presentations in labor are a great disadvantage by reason of the difficulty experienced in freeing the arms and in bringing the head last through the generally contracted pelvic canal. To secure its rapid passage, the child's head must be flexed strongly by the oper- ator's finger in its mouth before an attempt is made to secure engagement in the superior strait. While the woman escapes local- ized necroses of the soft tissues following labor in the justominor pelvis, there is greater likelihood of rupturing pelvic joints in this than in any other variety of contracted pel- vis, and there is also an extraordinary liability to eclampsia (Fig. 287). The caput succedaneum, which is very large on account of the early fixation of the head and the long labor, is situated directly over the smaller fontanel. There is an overlapping of the cranial bones, both laterally and antero- posteriorly. The generally contracted, flat, nonrachitic pelvis presents the combined features of the flat and the generally contracted pelvis. Characteristics.—All the diameters are below normal, but the conjugate is less in proportion than any of the others. This pelvis has many of the features of a rachitic pelvis, but the anterior half of the pelvic circumference is not markedly broad- ened ; indeed, it is often the reverse. The sacrum is small and is not rotated on its transverse axis ; it is placed further back Fig. 287.—Justominor pelvis with rup- tured pelvic joints, following forceps applica- tion: C. v., 91^ cm. ; tr., 12)4 cm.; obi., 11^ cm. (author's collection). 432 THE PATHOLOGY OF LABOR. between the innominate bones than in the normal pelvis, and very much further back than in the rachitic pelvis. The pro- montory is high and is not prominent. The influence of this deformity of the pelvis upon labor is that of a flat pelvis, but the difficulties are greater than in the case of the simple flat pelvis, for there is less compensatory room in a transverse direction. The generally contracted, non-rachitic, flat pelvis is comparatively rare. The flattening, according to Litzmann, is due to a short- ening of the innominate bones, especially at the iliopectineal line. In estimating the true conjugate diameter of the generally contracted flat pelvis it is safer to subtract 2 instead of I y cen- timeters from the diagonal conjugate, on account of an increase in the conjugatosymphyseal angle, the result of the high posi- tion of the promontory and the diminished slant outward of the symphysis. Etiology.—The generally contracted flat pelvis is due to hereditary influence or to an arrest of development in the embryo, fetus, or infant. It is claimed, however, that it may be produced by premature attempts to walk and by long standing upon the feet in very early life. Diagnosis.—The recognition of a generally contracted flat pelvis is difficult. The measurements usually resemble those of a generally equally contracted pelvis, but the conjugate diameter is less than one expects in that form of contracted pelvis, and the mechanism of labor is that of a flat pelvis. The diagnosis can be made by finding the reduced conjugate diameter and by the ease with which one can reach the lateral pelvic wall in the palpation of the interior of the pelvic canal. A certainty of diag- nosis can be obtained during life only by the direct measurement not only of the conjugate diameter, but also of the transverse, by the methods of Lohlein and of Skutsch. The Narrow, FunneUshaped Pelvis; Fetal or Undeveloped Pelvis. —This variety of pelvis is contracted transversely at the pelvic outlet, or both in the transverse and anteroposterior diameters, without abnormalities in the spinal column. The depth of the pelvic canal is much increased by the length of the sacrum, of the symphysis, and of the lateral pelvic walls. The sacrum is narrow, has little perpendicular curve, and is placed far back between the ilia (Fig. 288). Schauta ascribes this form of contraction to an anomaly of development by which the pelvic walls are length- ened downward and the weight of the body is thrown backward upon the sacrum. It is said to be very rare, but it has been found quite frequently in those hospitals where the outlet of the pelvis is regularly measured. It comprises from five to nine per cent, of all contracted pelves, according to Breisky, and Fleisch- ANOMALIES IN THE FORCES OF LABOR. 433 Fig. 288.—Narrow, funnel-shaped pel- vis: C. v., 10T< cm.; tr. (inlet), 8^ cm.; tr. (outlet), 7 cm. ; ant. post, outlet, 7^ cm. (specimen in the author's collection). mann found twenty-four examples in 2700 parturient women.1 A slight manifestation of the deformity is often called a " mascu- line" pelvis, by reason of the diminution in the breadth of the pubic arch. This degree of the funnel-shaped pelvis is frequently encountered (Fig. 289). Diagnosis.—The diag- nosis of a narrow, funnel- shaped pelvis is made by a comparison of the measure- ments of the pelvic inlet with those of the outlet. The former are found to be normal or even greater than normal, while the measure- ments of the outlet are di- minished. If, as is the rule in extreme degrees of this deformity, the inlet and cavity are contracted, the outlet is still smaller in proportion. A careful palpation of the pelvic canal is an important aid to a correct diagnosis. The pelvic walls are felt to converge as they approach the outlet; the narrowness of the pelvic arch is appre- ciated, and the approxima- tion of the tuberosities and spines of the ischiatic bones is noticeable. Influence upon Labor.— The peculiarities of mech- anism in labor are malpo- sitions of the head at the outlet (as backward rota- tion of the occiput), oblique and transverse position of the head, and imperfect flexion. There is also an insufficiency of the expul- sive forces, the greater part of the fetal body being con- tained in the lower uterine segment, cervix, and vagina, while the upper muscular segment of the uterus is in great part emptied and therefore powerless. Fig. 289.—Minor grade of narrow, funnel- shaped pelvis with contracted pubic arch (from a plaster cast in the author's collection). 1 " Prager Zeitschrift f. Heilkunde," Bd. ix, H. 4 and 5. 434 THE PATHOLOGY OF LABOR. By the approximation of the pubic rami the presenting part is forced backward, and serious lacerations of the perineum are to be feared. The pressure of the head upon the lower birth- canal may result in necrosis of soft structures or in lacerations along the descending rami of the pubis and the ascending branches of the ischium. The tissues over the projecting spines of the ischiatic bones are also the seat of tears or of necroses. The narrowing of the pubic arch may lead to serious injuries if the forceps be applied. I have seen long, clean cuts in the anterior vaginal walls and profuse hemorrhage fol- lowing the use of instruments. In well-marked examples of the narrow, funnel-shaped pelvis, with a transverse diameter at the outlet not much below three inches, symphysiotomy gives the best chance of a successful termination for mother and child. Higher grades of contraction with a diameter of two inches and under demand Cesarean section. In lesser grades the woman may be delivered spontaneously or by forceps. Obliquely Contracted Pelvis from Imperfect Development of the Ala on One Side of the Sacrum {Naegele Pelvis).—This pelvis was first described in 1834 by Franz Carl Naegele,1 but had been noticed as early as 1779 without a full understand- ing of its significance (Fig. 290). Characteristics. — The pelvic inlet has an oval shape, with the small point of the oval directed to the atrophied side of the sacrum. The sacral ala is atrophied or is absent not only in that portion of the bone entering the sacro- iliac joint, but also in the Fig. 290.—Obliquely contracted pelvis. transverse process along its whole length. The sacro-iliac joint on this side is ankylosed in the vast majority of cases, but not invariably. The sacrum is narrow, asymmetrical, and turned with its anterior face toward the deformed side of the pelvis. The promontory is not only turned in this direction, but is also pulled over to the diseased side. The innominate bone on the 1 "Die Heidelberger klinischen Annalen," Bd. x, p. 449. More elaborately described in his folio atlas. " Das Schrag verengte Becken, nebst einem Anhang iiber die wichtigsten Fehler des Weibl. Beckens Ueberhaupt,"mit 16 Tafeln, Mainz, i837- ANOMALIES IN THE FORCES OF LABOR. 435 deformed side is pushed as a whole upward, backward, and inward, and its anterior face is pushed inward and backward. The tuber- osity of the ischium, as a necessary consequence of the displace- ment of the innominate bone, is higher than its fellow, projects further into the pelvic canal, and is so turned that it looks rather anteroposteriorly than laterally. The spine of the ischium is brought quite close to the corresponding edge of the sacral bone and juts prominently forward into the pelvic canal. The whole in- nominate bone on the diseased side lacks its normal curvature at the iliopectineal line, and may run almost straight from the sacro- iliac junction to the symphysis pubis. The opposite innominate bone has a greater curvature than common, especially in its anterior half; otherwise it is practically normal in structure, position, and inclination. The symphysis pubis is pushed toward the healthy side of the pelvis, and its outer surface, instead of looking directly forward, is inclined to the diseased side. The pubic arch likewise faces somewhat in this direction ; its aperture is asymmetrical and irregularly contracted, as the ischiac and pubic rami on the diseased side are pushed inward upon the pelvic canal and over toward the healthy side (Fig. 290). Etiology.—The cause of the obliquely contracted pelvis under description is an absence of the bony nuclei in the ala or lateral process on one side of the sacrum. The lateral process conse- quently fails to develop, and the innominate bone is brought in re- lation with the bodies of the sacral vertebrae. As a result, there must be some distortion of the innominate bone even in fetal and infantile life, but this is increased to an exaggerated degree when the individual begins to walk. Instead of receiving the pressure from the lower extremity approximately on the keystone of an arch, as does a normally curved innominate bone, the deformed bone in a Naegele pelvis transmits the pressure in almost a straight line upward and backward, so that the extremity of the posterior arm of the arch slides past the sacro-iliac joint instead of resting firmly on it as an arch does on its abutments. The irritation and strain of this unnatural movement bring about in time the atrophy and ankylosis of the joint. That the deformity in this kind of oblique pelvis does not follow a primary ankylosis of the sacro-iliac joint is proven by the fact that the innominate bone is pushed backward and upward on the sacrum—a movement that would be impossible were this joint first ankylosed. As a further proof of primary lack of development and secondary ankylosis, there is no trace of inflammation in or about the ankylosed joint, and the alae or transverse processes of the sacrum are atrophied or are absent along the whole length of the sacrum, and not only in that 436 THE PATHOLOGY OF LABOR. portion of it which enters into the composition of the sacro-iliac joint. Diagnosis.—The recognition of an obliquely contracted pelvis from arrested development of the sacral alae may be very difficult. There is nothing to direct the attention of the phy- sician to the possibility of the deformity. There is no history of previous disease or of accident, no scar of an old fistula over the joint, and the patient does not limp. The diagnosis can be made only by a methodical external and internal palpation of the pelvis and by careful measurements. If the outspread hands are laid over the innominate bones, it will be noticed that the dorsal surfaces are directed obliquely forward and backward as they lie upon the diseased and healthy sides. An internal palpation of the pelvis will detect one lateral wall much nearer the median line than the other, and the diagonal conjugate will be found to run not anteroposteriorly in direction, but from before backward and from the healthy to the diseased side of the pelvis. There are a number of points from which measurements may be taken that will show inequalities where in the normal pelvis the dis- tances should be the same or should differ by a very small sum. Naegele recommended the following measurements : (i) The distance of the tuber ischii on one side from the posterior superior spinous process of the ilium on the other ; (2) from the anterior superior spinous process of one ilium to the posterior superior spinous process of the other; (3) from the spinous process of the last lumbar vertebrae to the anterior superior spines of both ilia ; (4) from the trochanter major of one side to the posterior superior spinous process of the opposite iliac bone; (5) from the lower edge of the symphysis pubis to the posterior superior spinous processes of the iliac bones. In addition to these measurements, others of value have been suggested by Michaelis and by Ritgen. These are the distances from the middle line of the spinal column to the posterior superior spinous processes of the iliac bones, and the distance from the lower edge of the symphysis to the ischiac spines, and from these spines to the nearest point on the edges of the sacrum. In this latter measurement it will be found that the distance from the symphy- sis to the ischiac spine is longest on the diseased and shortest on the healthy side, while the distance from the ischiac spine to the edge of the sacrum is very much shorter on the diseased than on the healthy side. The last, which is a very important meas- urement, can easily be taken by laying finger-breadths between the points to be measured. Influence on Labor.—The mechanism of labor in an obliquely contracted pelvis is, in the main, that of labor in a generally ANOMALIES IN THE FORCES OF LABOR. 437 contracted pelvis. The shape of the pelvic entrance and canal is symmetrically ovoid, and the head can enter the contracted space only by extreme flexion. There are none of those anoma- lies of position, flexion, and inclination of the head which are seen in the flat pelvis. As the head descends, the birth-canal anomalies of mechanism may appear resembling those described in the narrow, funnel-shaped pelvis—namely, abnormal and imperfect rotation and anomalies of flexion. Depending upon the degree of deformity, there is more or less interference with the progress of labor to complete obstruction. The head is almost invariably found entering the pelvis and passing through the canal with its longest diameter in coincidence with the longest oblique diameter of the pelvis, from the diseased sacro- iliac joint to the opposite iliopectineal eminence. Prognosis.—In the recorded cases the results of labor in the Naegele pelvis have been bad. Of 28 women reported by Litz- mann, 22 died in their first labor, 5 of them undelivered. Three of these women died in consequence of their second labor, and 2 after the sixth. Out of 41 cases, 6 were delivered spontane- ously, 12 by the forceps, 14 by craniotomy, 5 by version and extraction, 4 by premature labor, and 2 by Cesarean section. The following accidents were noted in the course of labor or shortly afterward: Rupture of the uterus or vagina, vesico- vaginal fistula, fracture of the horizontal ramus of the pubis, rupture of the sacro-iliac joint and of the symphysis. In another series of cases, 28 women furnished forty-two labors with the following results : 21 died as the result of the first labor, 3 of the second, and 1 after the sixth. These women were delivered seven times by craniotomy, once by Cesarean section, four times by premature labor, and in a number of instances by forceps. Out of 41 children in Litzmann's statistics, there were only 10 delivered alive, 2 of these by Cesarean section and 2 by premature labor. The 6 other living children were all born of the same mother.1 Treatment.—Forceps and version are not, as a rule, success- ful in the treatment of labor obstructed by an obliquely con- tracted pelvis unless the degree of deformity is slight. The induction of premature labor and the performance of Cesarean section are the most successful means of delivery, but the former should be resorted to only when the distance between the lower edge of the symphysis pubis and the sacro-iliac joint of the healthy side is not under 8.5 centimeters. In twenty forceps operations thirteen women died. The proposition of Pinard to 1 The writer is indebted for these statistics to Schauta {loc. cit.). 438 THE PATHOLOGY OF LABOR. do what he calls ischiopubiotomy has not met with favor. The room gained by the movement outward of the innominate bone on the healthy side, the other being, of course, immovable, will be sufficient only in pelves so slightly contracted as to allow a delivery by much simpler means. Transversely Contracted Pelvis the Result of Imperfect Develop- ment of Both Sacral Alae.—This pelvis was first described in 1842 by Robert, and is generally known as the " Robert pelvis" (Figs. 291 and 292). It is the rarest of all contracted pelves. Schauta was able to find but six examples recorded in child- bearing women. Ferruta has recently reported another case.1 Herman gives eight as the number of recorded cases. The anatomical conditions are the same as in the Naegele pelvis, Fig. 291.—Transversely contracted Fig. 292.—Transversely contracted pelvis, showing contraction at outlet pelvis: C. v., 9^ cm.; tr. (outlet), 5 (model in author's collection). cm.; tr. (inlet), 8 cm. (model in Mut- ter Museum, College of Physicians, Philadelphia). except that both sides of the sacrum are affected instead of one. Other parts of the sacrum besides the alae may show imperfect development. There is a case reported in which the whole lower portion of the bone was absent. The sacrum in the Robert's pelvis is extremely narrow, and the posterior superior spinous processes of the iliac bones are brought close together. The degree of contraction in the transverse diameter is so extreme that natural labor is out of the question. An asymmetry of the Robert pelvis has been observed, one side showing a greater degree of the deformity than the other, and thus approaching the type of an obliquely contracted pelvis. The cause of this deformity is an absence of the bony nuclei in the sacral alae of both sides. Secondarily, as in the Naegele 1 " Studii di Ostetricia e Ginecol.," Milan, 1890. ANOMALIES IN THE FORCES OF LABOR. 439 pelvis, there is usually an ankylosis of the sacro-iliac joints. That this ankylosis is secondary and not primary is demonstrated by the same condition which proves that ankylosis is not a primary cause of the oblique contraction and ill-development of one side in the Naegele pelvis—namely, a displacement of the ilia on the sacrum necessarily occurring before the ankylosis. The treatment of labor obstructed by a transversely contracted pelvis of this kind is Cesarean section. Justomajor Pelvis.—A generally equally enlarged pelvis is found in women of gigantic stature, but it may also be demon- strated in a woman of medium height. The pelvis of the Nova Scotian giantess was large enough to give passage to a child weighing 28^ pounds. The largest pelvis that has ever come under my notice was found in a woman somewhat below the average height, without an abnormally great development of any other portion of her frame. Diagnosis.—The diagnosis of a justomajor pelvis is made mainly by external measurements. If all of them are found far in excess of the normal while preserving their normal relative proportion, the diagnosis of a justomajor pelvis is justifiable. The internal examination, if considered necessary, will show that the promontory is quite inaccessible, and that it is much more difficult than common to reach the lateral pelvic walls. This anomaly of the pelvis does not, of course, obstruct labor; on the contrary, it predisposes to precipitate delivery, although the resistance of the soft parts may be quite sufficient to delay the process considerably, even though the pelvis present no obstacle whatever. During pregnancy it is noted that the uterus has a tendency to sink deep within the pelvic canal, so that pressure- symptoms of the pelvic viscera and blood-vessels are common in the latter weeks of gestation, and these symptoms may become so exaggerated as to make locomotion difficult. In labor there may be anomalies in the mechanism dependent upon insufficient resistance to the engagement of the head. Thus imperfect flexion at the superior strait may be observed, and there may be a tardy rotation of the head on the pelvic floor. Split Pelvis.—The split pelvis, which is due to a defect in the development of the lower portion of the trunk in front, is almost invariably associated with exstrophy of the bladder. This pelvis has very rarely been observed in the child-bearing woman ; there are on record but seven examples complicating labor. The split pelvis presents no obstacle in parturition. There are the same peculiarities in labor as in the justomajor pelvis— namely, a tendency to precipitate birth, and anomalies in the mechanism the result of imperfect resistance. After labor it is 440 THE PATHOLOGY OF LABOR. almost certain that there will be a prolapse of the uterus. The diagnosis of this deformity presents no difficulties, and no ob- stetric treatment is called for in labor (Fig. 293). The Rachitic Pelvis.—In the healthy life and growth of bones two opposed processes are found : On the periphery there is an active proliferation of cells to form the bone-structure, while in the interior, bone-substance is being constantly absorbed by the marrow. In rachitis the absorption of bone-substance goes on more rapidly than it does in healthy bone, and at the same time there is in the periphery a very much more rapid proliferation of cells, which do not, however, develop normal bone-structure. Their growth and multiplication result in the formation of an osteoid material deficient in lime-salts and much more pliable than healthy bone. The result of this pathological process in the Fig. 293.—Split pelvis (Schauta). Fig. 294.—Typical flat rachitic pelvis: C. v., 5^ cm.; effec. tr. diam., II cm. (Mut- ter Museum, College of Physicians). pelvic bones is to make the pelvis more sensitive than it should be to the mechanical forces that are brought to bear upon it. In the rachitic pelvis the size and shape of the pelvic canal are modified by three factors : the pressure from the trunk above and the counterpressure from the extremities below; the pull on the pelvic bones by ligaments and muscles ; and an arrested development. Characteristics.—The effect upon the shape and size of the pelvic canal of rachitis in the pelvic bones is not uniform. Several varieties of contracted pelvis may result. The com- monest is the flat pelvis with some contraction of all the diam- eters, but a most marked diminution in the anteroposterior diameter (Fig. 294). There may be found, in addition to this common form, a simple flat rachitic pelvis without alteration of the transverse diameters, a generally equally contracted rachitic ANOMALIES IN THE FORCES OF LABOR. 441 pelvis (Fig. 295), and a so-called " pseudo-osteomalacic " pelvis, in which the effect seen in osteomalacia is produced by pressure upon the bones softened by rachitis. There are other rare forms of asymmetrical development, in connection usually with spinal disease of rachitic origin, that will be described elsewhere. Fig. 295.—Generally equally contracted rachitic pelvis (author's collection). Characteristics of the Flat, Generally Contracted Rachitic Pelvis.—The sacrum is pressed forward and downward between the iliac bones, and is rotated on its transverse axis, mainly by the pressure of the trunk upon it, but partly by the pull down- Fig. 296.—Flat rachitic pelvis, with unusual descent of the promontory, rotation of the sacrum, and lordosis (Mutter Museum, College of Physicians, Philadelphia). ward of the psoas muscles upon the spinal column and the pull upward upon the posterior surface of the sacrum by the erectores spinae muscles (Fig. 294). The effect of this movement would naturally be to throw the tip of the sacrum and the coccyx 442 THE PATHOLOGY OF LABOR. directly backward, so that the posterior surface of the sacral bone would run an almost horizontal course as the woman stood upon her feet. The attachments of the sacrosciatic ligaments and muscles to the lower sacrum and coccyx, however, prevent this backward movement of the bone as a whole, and, pulling the lower portion of the bone forward, cause a sharp bend in it, usually at the junction of the fourth and fifth sacral vertebrae. The sacrum is narrowed in its transverse diameter, and the lateral concavity of the anterior surface is effaced by the forward movement of the bodies of the verte- brae between the alae. The anterior surface of the sa- crum, indeed, may be con- vex from side to side. By the pull of the strong sacro-iliac ligaments run- ning from the sacrum to the posterior superior spi- nous processes of the iliac bones the latter are pulled downward and forward by the descent of the sacral promontory, and are con- sequently made to ap- proach one another behind, but they do not keep pace with the movements of the sacrum, and consequently project more prominently than common on either side. The natural result of this movement forward and inward on the part of the posterior superior por- tions of the ilia would be to throw the anterior half of the innominate bones outward, but this movement is opposed by their junction at the symphysis, and to a less degree by the attachment of Poupart's ligament to their anterior superior spinous processes. The ilia, however, restrained by a somewhat yielding force, are thrown to a certain degree outward and back- ward, so that their upper edges run almost horizontally outward, and the distance between their anterior spines becomes little less Flg- 297-—Flat rachitic pelvis with bowed femora: C. v., 5 cm.; tr., 12^ cm. (Mutter Museum, College of Physicians, Philadelphia). ANOMALIES IN THE FORCES OF LABOR. 443 than, the same as, or even greater than, the distance between their crests. A further result of these combined forces pulling the innominate bones inward and forward behind and hold- ing them in place in front is to produce in them an abnormal curvature, as in the case of the sacrum, or as in a bow- bent between one's hand and the ground (Fig. 298). The point of angulation or greatest curvature is found on the ilio-pectineal line, back of the median transverse line of the pelvic inlet, near the sacro-iliac joints. On account of the flexion of the innominate bones the transverse diameter of the rachitic pel- vis is relatively increased, but, as the whole pelvis is com- monly below the normal in size, this diameter rarely exceeds, if, indeed, it equals, the normal transverse measurement. A further consequence of the exaggerated curvature of the innom- inate bones is to throw the acetabula forward, so that the Fig. 298.—Schematic representation of the anterior position of the acetabula in a rachitic pelvis. The pressure of the femora from before backward contributes to the flattening of the pelvis (Schroeder). counterpressure of the lower extremities is exerted more antero- posteriorly than in the normal pelvis (Fig. 298). The pubic rami and the symphysis are diminished in height and show a lessened slant outward. The cartilage at the junction of the symphysis projects inward upon the pelvic canal, standing out above the level of the bones to such a degree that it is some- times a source of injury to the head or to the maternal struct- ures. The force of resistance at the symphysis to the outward movement of the innominate bones sometimes bends the ends of the pubic bones inward upon the pelvic canal, giving to the pelvic inlet the shape of a figure 8. From the traction of the adductor and rotator muscles of the thigh upon the tuberosities of the ischiatic bones (increased in rachitis by the positions of the acetabula and the bowing of the femora), the latter are pulled outward and forward so that the pubic arch is greatly widened 444 THE PATHOLOG Y OF LABOR. and the transverse diameter of the pelvic outlet is increased. The anteroposterior diameter of the outlet is somewhat dimin- ished by the excessive perpendicular curvature of the sacrum, but the contraction is relatively much less than in the conjugate of the inlet. The whole pelvis is tilted forward on its transverse axis, so that the inclination of the superior strait is increased and the external genitalia are displaced backward. The bones of a rachitic pelvis are usually slighter and more brittle than common. They may, perhaps, show no peculiarities in structure, or in rare cases they may be found much thicker and heavier than normal. In the generally equally contracted rachitic pelvis—a rare type—is seen mainly an arrest of development, the consequence of rachitis in very early life, which retarded growth without much affecting the shape of the pelvic inlet and canal, from the Fig. 299.—Pseudo-osteomalacic pelvis. fact that the pelvis had not been subjected to the pressure of the trunk during the active stage of the disease, because it ran its course to complete recovery before the child attempted to sit up or to walk. Possibly, also, the disease in some of these cases is not severe and lasts but a short time. As the deformity is the result of arrested development, a transverse contraction is found as in the fetal ill-developed pelvis. The diagnosis of the rachitic origin of this type of pelvis is made by the relations of iliac spines to crests, perhaps by the history of rachitis in early infancy, and possibly by the signs of the disease in other portions of the body. In the pseudo-osteomalacic pelvis (Fig. 299) the rachitis has progressed to an extreme degree and has been long continued. Efforts to walk have been made while the disease was in active ANOMALIES IN THE FORCES OF LABOR. 445 progress, and possibly the weight of the trunk has been exag- gerated by attempts to carry heavy burdens. As a consequence of the pressure of the trunk and the counterpressure of the lower extremities, the pelvis bends under the forces imposed upon it. The sacrum sinks far down into the pelvic canal and is sharply curved or bent from above downward ; the innominate bones are bent at a sharp angle laterally, and the acetabula are pressed inward upon the pel- vic canal. When at length the bone disease has run its course, the pelvis is firmly set, by the hardening of the bones, in its unnatural posi- tion and shape. The differ- ential diagnosis between this pelvis and the true osteo- malacic pelvis is made by the direction of the iliac crests, by the firm constitu- tion of the bones after the disease has been arrested, and by the signs of rachitis in other portions of the body. Osteomalacia, be- sides, has certain peculiari- ties of its own that enable one to recognize it without difficulty. Diagnosis.—The diag- nosis of a rachitic pelvis is made by external and inter- nal measurements, by pal- pation of the exterior and tinerior of the pelvis, by the woman's history, and by her Fig 3oo.-Pendulous belly of rachitis appearance. An individual (Charpentier). who has had rachitis in childhood is usually of small stature, with short, thick, curved extremities ; a low, broad brow ; a large, square head ; a flat nose ; a " chicken breast," and enlarged joints. The lumbar lordosis and the rotation of the sacrum produce a sway-back, most noticeable when the woman lies on her back upon a hard surface. When she stands erect the pregnant uterus near term falls abnormally for- ward and downward, on account of the short abdomen and lack of engagement of the presenting part (Fig. 300). The most charac- 446 THE PATHOLOGY OF LABOR. teristic facts in her history are that she walked first at three or four years of age and was late in getting her teeth. By the pelvimeter the normal relation between the iliac spines and crests is found disturbed. The difference in distances between the former and between the latter is much reduced. The posterior superior spinous processes are approximated, and the depression under the last spinous process of the lumbar vertebra approaches or is actually in the line drawn between them. The external antero- posterior diameter of Baudelocque is below the normal. Inter- Fig. 301.—Appearance during life Fig. 302.—Skeleton of a rachitic of the highest grade of rachitis; pseudo- dwarf (Medical Museum, University osteomalacia (Pippingskjold). of Pennsylvania). nally, the diagonal conjugate is found considerably reduced. The symphysis has less of a slant outward than it should have; the promontory is found low and prominent ; the sacral bone is sharply bent upon itself, and the pelvic canal is remarkably shallow. On account of the increase in the conjugatosymphys- eal angle due to the lessened slant outward of the symphysis, at least two centimeters should be subtracted from the diagonal conjugate. The difference between the two would be greater were it not for the low situation of the promontory, which com- pensates to a certain extent for the lessened slant of the sym- ANOMALIES IN THE FORCES OF LABOR. 447 physis, but does not entirely neutralize it. If a double promon- tory is found, which in these pelves is not uncommon (Fig. 306), the measurement should be taken from the promontory nearest the symphysis. Occasionally the lordosis of the lumbar vertebrae, the result of spinal rachitis, is so great as to constitute itself an obstruction above the pelvic inlet. In such a case the effective Fig- 303-—Rachitic dwarf; height, 4 feet, 1 inch. Conj. vera, 6 cm. Cesarean section (Howard Hospital). conjugate must be taken from a point above the sacrum to the symphysis pubis. Influence on Labor.—The influence of a flat rachitic pelvis on labor is much the same as the influence of a simple flat pelvis, except that the contraction, and consequently the obstruction to labor, is greater in the rachitic form, and that the promontory of the sacrum is more prominent and more sharply defined. The anomalies of mechanism at the inlet are the same in both varie- ties of pelvis, but they are exaggerated in the flat rachitic pelvis. As soon as the obstruction at the inlet is overcome, the descent 44& THE PA THOL OGY OF LAB OR. Fig. 304.—Woman with congenital Fig. 305.—Flat rachitic pelvis rachitis (Ribemont-Dessaignes). complicated bycoxalgia. Cesarean sec- tion (seen in consultation with Dr. Geo. I. McKelway). Fig. 306.—Rachitic pelvis with double promontory: C. v., from first and from second sac. vert., 6^ cm. ; tr., 12^ cm. (Mutter Museum, College of Physicians, Philadelphia). ANOMALIES IN THE FORCES OF LABOR. 449 Fig. 307.—Pressure of the promontory upon the head in a contracted pelvis (Smellie). Fig. 308.—Overlapping of the cranial bones in a futile attempt of the head to engage in the superior strait of a rachitic pelvis (Smellie). 29 450 THE PATHOLOGY OF LABOR. of the head and its escape are more rapid in the rachitic pelvis, because of the shallow canal and the expanded outlet. Injuries to the child's head and to the maternal tissues from pressure are common. In the former, a sharp indentation may be seen on that portion of the skull pressed against the promontory in the efforts to secure engagement, the so-called " spoon-shaped " depression, with fracture of the parietal bone. Localized necroses are not infrequently seen in the maternal structures, where they have been nipped between the child's head and prominent portions of the pelvic bones—namely, in the cervical tissues over the promon- tory, or very rarely in the posterior vaginal vault, and in the anterior vaginal wall behind the symphysis and the ridge of the pubic bones. When the slough separates, openings may be established between the birth-canal and the peritoneal cavity, the bowel, the bladder, and a ureter. Osteomalacic Pelvis.—Osteomalacia, a soft condition of the bones in consequence of an osteomyelitis and an osteitis, is ex- Fig. 309.—Minor grade of osteomalacic Fig. 310.—Schematic representation of pelvis. an osteomalacic pelvis (Schroeder). ceedingly rare in America. There are certain parts of the world where it is frequently seen, notably Italy, Germany, and Austria, but in America there are but three or four examples on record. The bones of the pelvis in this disease become so soft that they yield to every force imposed upon them. They bend before the pressure of the trunk from above, the extremities from below, and the pull of the muscles attached to the pelvic bones. The flexi- bility of the pelvis in extreme cases of osteomalacia may be appre- ciated when it is stated that the superior iliac spines may be bent backward until they touch the spinal column ; the horizontal rami of the pubis may be pushed inward until they almost oblit- erate the pelvic inlet; and the tuberosities of the ischium may ANOMALIES IN THE FORCES OF LABOR. 45 1 be approximated until they nearly close the pelvic outlet. Not only are the pelvic walls so compressed that they almost oblit- erate the pelvic canal, but the spinal column also, sinking under the weight of the trunk, bends far forward and descends low into the pelvis, occupying the little remaining room in the inlet and canal, and becoming itself a serious obstruction to the engage- ment of the presenting part. From the lateral pressure of the Fig. 311.—Minor grade of osteomalacic pelvis. Fig. 312.—Osteomalacia, showing asymmetrical contraction at outlet. thigh-bones the ischia and pubes are pushed inward and back- ward, making, by the former movement, a sharp, beak-like pro- jection of the pelvic inlet between the pubic rami, and by the latter much diminishing the size of the pelvic canal (Figs. 309, 310, and 311). The sacrum is rotated on its transverse axis and is driven far down into the pelvic canal—an exaggeration of the movement seen in a rachitic pelvis. The lower portion of the sacrum and the coccyx are pulled far forward by the mus- 452 THE PA THOL OGY OF LAB OR. cles attached to them, so that the sacrum is bent at a sharp angle in its lower third. The innominate bones are bent laterally at a point slightly anterior to the sacro-iliac junction, and the iliac bones may be folded upon themselves horizontally. The inclina- tion of the pelvis as a whole is much increased. The diagnosis may be based upon the following symptoms: The disease begins usually during preg- nancy or lactation, with dull aching pains in the extremities, the back, the lumbar region, and over the anterior portion of the pelvis. Every movement increases these pains. As the disease progresses, the bones of the spinal column are so bent and compressed that the individual is dimin- ished in stature to an extra- ordinary degree. She may lose as much as a foot and a half in height (Fig. 313). The gait of an osteomalacic patient is peculiar. In order to compensate for the approximation of the thighs brought about by the collapse of the pelvis, the individual must turn almost through a half-circle in order to bring one foot in front of the other. By palpation of the pelvis ten- derness upon pressure is Fig. 313.—Author's case of osteomalacia. discovered over its anterior walls. The flexibility of the pelvic bones may be demonstrated by direct pressure, and an internal examination reveals, in the early stage of the disease, the peculiar beak-like space behind the symphysis, and later the almost entire oblitera- tion of the pelvic outlet and canal by the sinking in of the pelvic walls. If it is possible to make a satisfactory internal examina- ANOMALIES IN THE FORCES OF LABOR. 453 tion of the pelvis, the low position and the projection of the promontory at once attract attention, and the sharp angulation on the anterior face of the sacrum can be felt. On account of the exaggerated inclination of the pelvis, it may be necessary to make an examination with the patient upon her side. An osteo- malacic pelvis has been taken for a kyphotic, a Robert, a pseudo- osteomalacic, a cancerous, or a fractured pelvis, but a careful, methodical examination of the patient will always lead to a cor- rect diagnosis. Influence Upon Labor.—The results of labor in osteomalacic pelves show that the obstruction is a serious one, although by reason of the flexibility of the pelvis in some cases the head can distend the pelvic canal sufficiently to pass through. In 85 cases collected by Litzmann, 47 ended fatally. In another series of 128 cases the labor had a spontaneous termination in 27 cases, in 4 there was premature delivery, and in 5 abortion ; 4 times the labor was naturally terminated; in 8 cases version was per- formed, in 4 the child was extracted by the feet, in 25 forceps were employed, in 11 craniotomy was performed, and in 36 Cesarean section ; rupture of the uterus occurred in 5 women before any operation was undertaken. In still another series of cases reported from Milan, the flexibility of the pelvis was so great that the child was delivered in only two instances by Cesa- rean section. The most successful treatment is the performance of Cesarean section, and the operator should at the same time remove the ovaries, or, what is better, perform a complete Porro operation. It is beyond dispute that the cessation of sexual functions favorably modifies or actually cures the disease. Tumors of the Pelvis.—The commonest pelvic tumors are bony excrescences, usually found over one of the pelvic joints. The excrescences are originally cartilaginous projections which become ossified by an extension of bony tissue from the two bones between which they lie. These exostoses may be found over the sacro-iliac joints, over the crests of the pubis, at the iliopectineal eminences, and over the promontory of the sacrum (Figs. 315, 316, 317,318). They may attain the size of a pigeon's egg, though they are usually not larger than a pea or nut. In the exostoses occupying the seat of the pubo-iliac junctions, directly above the acetabula, the bony growth is apt to assume a sharp, thorny shape, projecting with its point into the pelvic inlet. Kilian was the first to direct attention to this fact ; he called a pelvis thus deformed " acanthopelys" (Fig. 319), or a ''pelvis spinosa." Another possible seat for a bony pro- jection is along the crests of the pubic bones, the exostosis 454 THE PATHOLOGY OF LABOR. taking here the form of a long, sharp edge, and probably owing its origin to an ossification of the attachment of the iliac fascia, a transformation of tissue analogous to the ossification some- times seen in Gimbernat's ligament. These bony outgrowths Fig. 314.—Cystic enchondroma Fig. 315.—Button-like exostosis on the (Zweifel). promontory (Schauta). Fig. 316.—Exostosis on the symphysis (Schauta). are a serious obstruction in labor, not so much from their encroachment upon the room of the pelvic inlet, as from the sharply localized pressure which they exercise upon the maternal structures and upon the fetal head. In the four cases ANOMALIES IN THE FORCES OF LABOR. 455 reported by Kilian, death, it was claimed, resulted in each case from a perforated uterus. Other tumors of the pelvis obstruc- ting in labor are enchondromata, fibromata, sarcomata, carcino- mata, and cysts (Figs. 314, 320). These tumors are rare, and Fig. 317.— Exostoses at sacro-iliac junctions. Fig. 318.—Exostoses around the pelvic brim (model in the author's collection). their importance as obstacles in labor depends, of course, upon their size. Cysts of the pelvis are formed usually in sarcomata and in enchondromata, or are hydatid cysts. Cancer of the pelvic bones is always a secondary growth or is metastatic. It 456 THE PATHOLOGY OF LABOR. may result in a number of small tumors in the bony pelvic walls, or may take on the form of cancerous infiltration with a conse- quent softening of the bones like that of osteomalacia. The treatment of labor obstructed by tumors of the pelvis is ordi- narily the performance of Cesarean section. There is one case on record (Abernethy's) in which the tumor, an enchondroma, was removed by an incision in the posterior vaginal wall, but in the vast majority of cases these growths can not be reached or Fig. 319.—Acanthopelys. Fig. 320. — Enchondroma (Behm). safely excised. In 49 cases of labor obstructed by a pelvic tumor, 50 per cent, of the women and 90 per cent, of the children lost their lives (Winckel). Fractures of the Pelvis.—Out of 13,200 fractures reported from nine large hospitals in America and in Europe, but T8¥ of one per cent, were fractures of the pelvis. When one considers that almost all grave injuries of the pelvis end fatally, the rarity of a pelvic deformity dependent upon a united fracture of a pelvic bone in a woman of child-bearing age may be appreciated. Most ANOMALIES IN THE FORCES OF LABOR. 4$/ frequently the fracture is found in the pubes, next in the ilium, next in the ischium, next in the acetabulum, and least frequently of all in the sacrum. The effect of a fracture of the pelvis upon the shape and size of its canal depends on the location of the fracture, and the deformity may be due to distortion of the pelvic walls, to excessive callous formation, or to ossification of the pelvic joints nearest the seat of fracture. In a fracture of the acetabu- lum the result of hip-joint disease, the head of the femur may Fig. 321.—Fracture of the pelvis (Otto). Fig. 322.—Fracture of the acetabulum in consequence of coxalgia (Otto). project into the pelvic canal (Fig. 322). Fracture of the pubes results in an irregular distortion of the pelvic inlet, most marked, of course, on the injured side (Fig. 321). A fracture of the upper portion of the sacrum may result in a spondylolisthetic deform- ity (Fig. 323). Fracture of the lower portion of the sacrum is followed by a dislocation of the lower fragment inward. In a case under my observation the lower half of the sacral bone was turned in at right angles to the rest of the bone by the pull of 458 THE PATHOLOGY OF LABOR. the pelvic muscles attached to it. A fracture of the sacral alas may cause an oblique contraction of the pelvic inlet like that of the Naegele pelvis (Fig. 324). Neugebauer x reported an ex- Fig. 323.—Transverse fracture of the sacrum with spondylolisthetic deformity (Neugebauer). Fig. 324.—Fracture of the right ala of the sacrum (Fritsch). traordinary case of bilateral fracture of the pubic rami in which there was union with callous formation on one side and an ununited 1 " Jahresbericht iiber d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vol. iv, p. 188. ANOMALLES IN THE FORCES OF LABOR. 459 fracture on the other, the fragments moving on each other two or three centimeters when the woman walked. Caries and Necrosis.—The only effect of these diseases of the pelvic bones is the production, in rare cases of tuberculosis of a sacro-iliac joint, of an oblique contraction of the pelvis. When the sacro-iliac joint is affected, the ultimate result is the same as that produced by imperfect development of the sacral alae in a true Naegele pelvis. There is loss of tissue, ankylosis of the joint, and an arrest of development in the affected part if the disease occurs in early childhood. Ankylosis and Relaxation of the Pelvic Joints.—Synostosis may develop in any of the pelvic joints ; in the symphysis it occurs not infrequently, and often at an early age. A number of operators have encountered difficulty on this account in at- tempts to perform symphysiotomy. In otherwise unobstructed labor synostosis of the pubic symphysis is not a serious condi- tion, although it limits the slight expansion which every normal pelvis should exhibit preparatory to and during labor. If synostosis of the sacro-iliac joint develops in the indi- vidual's early childhood, it is followed by ill-development of the sacral alae on the affected side, and of that portion of the in- nominate bone concerned in the formation of the joint, an obliquely contracted pelvis of the Naegele type being the result; but such cases are rarer than those in which lack of development in the sacral alae is the primary occurrence. If the synostosis of the joint occurs after puberty, the effect upon the pelvis and upon the course of labor is practically nil. If both joints are early ankylosed, a form of laterally contracted pelvis like the Robert pelvis is the result. This kind of contracted pelvis is rarer than the transversely contracted pelvis due primarily to lack of development in the sacral alae. The sacrococcygeal joint becomes ankylosed, as a rule, between the thirtieth and fortieth years, but as the joint between the first and second coccygeal vertebrae is ordinarily unaffected, the pelvic outlet is capable of expansion during labor in its anteroposterior diameter nearly as well as if the sacrococcygeal joint were normal. Rarely, there is an ankylosis of all the coc- cygeal joints as well as of that between the sacrum and the coccyx. In these cases labor can be terminated only by a fracture of the coccyx or a laceration of the sacrococcygeal joint. The ex- pulsive forces of labor may be sufficient to cause the fracture, and the bone has been heard to give way with a loud crack as the head was passing through the pelvic outlet. This accident, however, is more likely to be caused by the artificial extraction of the head. 460 THE PATHOLOGY OF LABOR. An abnormal relaxation of the pelvic joints may be a simple exaggeration of the natural process by which the pelvic canal is made somewhat expansible preparatory to labor. It is more likely, however, to be due to some pathological condition within the pelvic joints, as an inflammatory process followed, perhaps, by suppuration, an accumulation of fluid within the joint, osteo- malacia, caries, or new growths. In pregnancy the pathological relaxation of the pelvic joints may occasion some difficulty in locomotion. During labor an exaggerated relaxation of the joints predisposes to their rupture. The Spondylolisthetic Pelvis.—The spondylolisthetic pelvis was first described in 1839 by Rokitansky, who reported two cases ; Kiwisch and Kilian each followed with a description of a specimen ; but we owe our knowledge of the condition mainly to the indefatigable researches of Neugebauer,1 who collected more than ninety cases and specimens, and to the discoveries of Lane, who has done much to clear up the etiology. The name "spondylolisthesis"2 indicates the condition—a slipping down or dislocation of the vertebrae. To affect the pelvis the spon- dylolisthesis must be in the lumbosacral region (Figs. 325— 327)- Characteristics.—As the name denotes, there is a dislocation of the last lumbar vertebra in front of the sacrum, the body of the former slipping down in front of the first sacral vertebra, so that its inferior border, or in advanced cases its anterior surface, comes in contact with the anterior face of the sacrum, to which it becomes united by bony union. There is, also, of necessity, an exaggerated lordosis of the lumbar vertebrae and a descent into the pelvic inlet of at least the fourth and third, and even of the second, lumbar vertebrae, which diminish by their bulk and anterior projection the anteroposterior diameter of the pelvic canal. It is only the body of the last lumbar vertebra that is displaced, and not the arch, held fast by the lower posterior articular surfaces, nor the laminae surrounding the spinal cord; so that the latter does not necessarily suffer compression by the displacement of the vertebrae, although this result has been noted in a few cases (Fig. 326). To allow the displacement of the 1 Franz Ludwig Neugebauer, " Bericht iiber die neueste Kasuistik und Littera- tur der Spondylolisthesis," etc., " Zeitschrift f. Geburtshulfe und Gynakologie," Bd. xxvii, H. 2,1893; "Spondylolisthesis et Spondylizeme," " Resume des Re- cherches litteraires et personelle depuis 1880 jusqu'en 1892," Paris, G. Steinheil, 1892 ; " Contribution a la Pathogenie et au Diagnostique du Bassin vicie par le Glissement vertebral," " Annales de Gynecologie," Feb., 1884; " Zur Entwicke- lungsgeschichte des spondylolisthetischen Beckens und seiner Diagnose," Halle and Dorpat, 1882, p. 294; see also "Archiv f. Gynakologie," Bd. xx, H. I, und Bd. xxi, H. 2. 2 cndvdvXoq, vertebra, and bXiodqcrct;, a slipping out or down. ANOMALIES IN THE FORCES OF LABOR. 461 body of the last lumbar vertebra the interarticular segment of the spinal arch and the pedicles are enormously lengthened from behind forward and are bent at an angle downward (Fig. 327). After a time this segment may exhibit a transverse fracture or a solution of continuity from pressure and attrition. The deform- ity is always gradual in development. If it begin during the child-bearing period, successive labors become increasingly diffi- cult. As the vertebra descends, it pushes the sacrum backward Fig- 325.—Spondylolisthesis, well marked Fig. 327. — Last lumbar (Schauta). vertebra of spondylolisthesis {a), contrasted with a normal fifth lumbar vertebra (Neugebauer). and downward, and with it depresses the posterior portion of the pelvic brim. To compensate for this movement the anterior half of the pelvic brim rises and the height of the symphysis is increased. This movement of the pelvis diminishes very markedly its inclination, and disturbs the normal relationship between the bones and the soft structures that overlie them. The base of the triangle formed by the pubic hair in women is well below the upper edge of the symphysis, and the external genitalia are pulled so far forward that the vulvar orifice is 462 THE PATHOLOGY OF LABOR. directed anteriorly as the patient sits or stands. There are, more- over, the same displacements of the pelvic bones that are seen in kyphosis—a rotation backward of the sacrum on its transverse axis ; a rotation outward of the upper portions, and inward of the lower portions, of the innominate bones on their antero- posterior axes. The descent of the lumbar vertebrae drags the large arteries of the lower trunk into the pelvic inlet, so that the iliac vessels and the bifurcation of the aorta may be felt in a vaginal examination. The degree of contraction in the conjugate diameter of the inlet depends upon the descent of the last lumbar vertebra and the degree of the lordosis. The contraction is usu- ally not excessive, but it may be so great as to preclude the pos- sibility of the engagement of the fetal head. Etiology.—The etiology of spondylolisthesis at the lumbo- sacral junction is still obscure. It has been attributed to direct injuries of, and to faults of development or ossification in, the interarticular segments of the spinal arch. It is certain that these are predisposing causes, but the observations of Lane appear to demonstrate that the commonest cause of the deformity is an exaggerated pressure from the trunk above exerted often upon healthy bone. As a result of this pressure a joint is formed in the intervertebral disc, and the interarticular segments of the last lumbar vertebra undergo stretching, pressure, angulation, and atrophy until the bone is actually severed. Following or accompanying these changes in the arch, the body of the last lumbar vertebra is displaced further and further downward and forward. Spondylolisthesis has followed an injury, presumably a fracture, of the lumbar vertebrae. Diagnosis.—The diagnosis of a spondylolisthetic pelvis is not easy; it can be made only by close attention to the patient's history, by a careful observation of her appearance, by an inter- nal and external examination of the pelvis, and by pelvimetry. In the history of the case it may appear that the individual was the subject of a serious accident, such as a fall from a height or a fracture of the pelvis by the passage over it of a heavy weight, or it may be learned that she has carried excessively heavy bur- dens for a long time. The woman's height is diminished and the length of the abdomen is shortened. Viewing the patient from behind, there appears what is called the saddle-shape or " sway " back, the lumbar vertebrae projecting visibly far forward and being displaced downward, throwing into bold relief the posterior superior spinous processes and the rims of the iliac bones, and producing quite a deep furrow along the course of the spinous processes of the lumbar vertebrae. The apposed articular processes of the first sacral and the last lumbar verte- ANOMALIES IN THE FORCES OF LABOR. 463 brae stand out as button-shaped prominences on the inner surface of the posterior rims of the ilia. The buttocks are flat and are pointed below, giving to the region a cordiform appearance. In front there is a pendulous belly ; a deep crease is observed run- ning across the lower abdomen a short distance above the sym- physis. Laterally, the floating ribs are seen almost to rest upon the crests of the ilia or actually to sink between them, and the soft structures of the flanks are thrown outward in prominent folds. The trunk is shortened, and the limbs appear relatively too long (Fig. 328). The patient's body being thrown forward by the deformity of the spine, an effort to maintain an equilib- Fig. 328.—Breisky's case of spondylolisthesis. rium is made by carrying the shoulders far back ; as the indi- vidual walks, a disposition to fall forward may be noted, and she will state, perhaps, that she is unable to carry any load upon her arms in front of her body, for fear of toppling over upon her face. She may also complain of a grating sensation and sound in the small of the back (crepitus). The gait is peculiar ; the toes are not turned outward, and the feet are swung around each other so that the foot-prints fall in a straight line. Upon an internal examination of the pelvis,—best conducted, according to Neugebauer, in an upright or lateral position,—the lordosis of the lumbar vertebrae is at once discovered. The angle formed by the attachment of the last lumbar vertebra to the sacrujn may be detected with ease, and it should be noted that the body 464 THE PATHOLOGY OF LABOR. of this vertebra does not possess lateral projections, transverse processes, or alae. By their absence one is sure that he is not feeling a projecting promontory. Pulsating iliac arteries may be felt, and it is possible even to reach the bifurcation of the aorta, —as first pointed out by Olshausen,—but this symptom is not pathognomonic. It is possible to reach the bifurcation of the aorta in a vaginal examination in the extreme lordosis of some rachitic pelves and of the osteomalacic pelvis, in lumbosacral kyphosis, and in some cases of dorsolumbar kyphosis. The external palpation of the pelvis reveals its decreased inclination. A measurement of the pelvis will show a marked diminution in the external conjugate diameter, an increased height in the symphysis pubis, an increased distance between the posterior superior iliac spines, and a diminished distance between the anterior iliac spines and the crests. There is also some diminution in the diameters of the outlet. The internal conju- gate diameter must be measured from the lumbar vertebra near- est the symphysis pubis, usually the fourth. This is called the "false" or "effective" conjugate diameter of the spondylolis- thetic pelvis. On account of the decreased inclination of the pelvis it is not necessary to subtract more than the ordinary sum from the diagonal conjugate. In fact, the diagonal conjugate may approach very nearly the length of the true, or may actu- ally measure less than it. Influence Upon Labor.—The influence of a spondylolisthetic pelvis upon labor is that of a flat pelvis. The obstruction in the former may be overcome more easily on account of the bow- like shape of the projecting vertebra and the coincidence of the uterine and pelvic axes. The obstruction to labor depends entirely upon the projection of the lumbar vertebrae. This pro- jection may be so slight as scarcely to influence the progress at all, or it may be so great as to make delivery by the natural channel quite impossible. There is noticed in labor something of the same mechanism that is seen in the flat pelvis for the pur- pose of overcoming the obstruction—namely, decreased flexion, transverse position, and exaggerated lateral inclination of the head. On account of the forward dislocation of the external genitalia and of the pelvic floor, lacerations of the latter are the rule, and the tears are often complete into the rectum. This liability to injury is explained by the fact that the presenting part impinges directly upon the middle of the pelvic floor as it descends the birth-canal, instead of being directed forward to the vulvar orifice. Fistulae of the anterior vaginal wall are likewise cemmon, from the localized pressure to which this region is subjected while the head is passing the obstruction at the inlet. ANOMALIES IN THE FORCES OF LABOR. 465 The presenting part is thrown forward by the projecting ver- tebrae, and is received upon the prominent ridge of the pubic bone, greater in height and higher in situation than in the nor- mal pelvis. Treatment of Labor Obstructed by Spondylolisthetic Pelvis.— The management of labor in these cases is governed by the same principles that obtain in the management of labor in a flat pelvis. If the effective conjugate is over 9.5 cm., the woman can be delivered spontaneously, by forceps, or by version. With an effective conjugate of between 7 and 9.5 cm., the induction of Fig. 329.—Angulation of the spine in kyphosis. premature labor and the performance of symphysiotomy must be considered ; or craniotomy should be done if the child is dead. If the effective conjugate is well under 7 cm., delivery must be effected by a Cesarean section. These rules presuppose, of course, a child of average size. Kyphosis.—The kyphotic pelvis was first adequately de- scribed in 1865 by Breisky, although its peculiarities had been recognized before by Litzmann in 1861 and by Neugebauer in 1863. The condition was called by Herrgott " spodylizema," a name adopted by Neugebauer and others (Figs. 330, 331). 3° 466 THE PATHOLOGY OF LABOR. Characteristics.—The degree of deformity in a kyphotic pel- vis depends upon the situation of the hump : the nearer this is to the sacrum, as a rule, the greater is the deformity in the pelvis. Lumbosacral kyphosis is almost as frequent as the lumbar and dorsolumbar combined. There is a compensating lordosis of the lumbar spine, but not enough to keep the center of gravity of the trunk from being too far forward. In conse- Fig- 331-—Contracted outlet of a kyphotic Fig. 332.—Kyphosis: greatest pelvis (Barbour). transverse diameter at outlet. 7 cm. (Mutter Museum, College of Physi- cians, Philadelphia). quence, the weight of the trunk is transmitted in a direction from before backward, so that the sacrum is rotated on its transverse axis in a direction the reverse of that seen in rachitis—namely, backward and scarcely at all downward. The result of this movement is to make the sacrum straighter, narrower, more curved from side to side, and longer (Fig. 330); to pull the pos- terior superior spinous processes of the iliac bones closer to- ANOMALIES LN THE FORCES OF LABOR. 467 gether, and to separate the anterior spines more widely. The diminished width between the posterior superior spinous pro- cesses is caused partly by the pull of the sacro-iliac ligaments. The sacrum can not move in any direction without dragging the ilium on each side by these ligaments, thus approximating their upper posterior surfaces. The diminution of the interspinous Fig. 333.—Lumbosacral kyphosis, front and profile views (author's case). measurement posteriorly depends also upon the narrowness of the sacrum. To compensate for the movement of the upper portion of the sacrum backward, the lower portion of the bone projects forward, into the pelvic outlet. To preserve the body from falling forward, the knees and thighs are slightly flexed and the pelvic inclination is almost entirely lost. This posture puts 468 THE TATHOLOGY OF LABOR. the iliofemoral ligaments on a stretch, which pull outward the upper portions of the innominate bones. To compensate for the movement outward of the iliac bones the lower segments of the innominate bones move inward upon the pelvic inlet; in other words, there is a rotation of the innominate bones upon their an- teroposterior axes. The result of these movements in the pelvic bones is to enlarge decidedly the pelvic inlet in its anteroposterior diameter, and to contract the canal toward the outlet, where the diminution of the diameters is most marked in the transverse (Fig. 331). In the cases of lumbosacral kyphosis the upper portion of the sacral bone may be involved in the necrotic process and the sacrum may exhibit deformities by destruc- tion of its tissues (Fig. 337). The other characteristic deformities of the kyphotic pelvis are most marked in this type, unless, as in one instance, the body is bent almost double, and it is necessary to rest the anterior portion upon an artificial support, as a cane. In this case the pelvis, although relieved of the weight of the trunk, is obstructed by the overhanging lumbar vertebrae to such a degree, perhaps, that the inlet is practically obliterated (pelvis obtecta). In all cases of exaggerated lumbosacral kyphosis the pro- jecting lumbar spine blocks the pelvic inlet and seriously obstructs labor. The conju- gate diameter must be measured to the lumbar or even to the dorsal vertebrae, and is exceedingly short. In 21 labors compli- cated by this deformity of the pelvis, 66 per cent, of the mothers and 75 per cent, of the Fig. 334.—Lum- children were lost (Winckel). bosacral kyphosis Influence on Labor.—The influence of ^rear)' the kyphotic pelvis upon labor is usually not felt until the presenting part has de- scended to the pelvic floor. In consequence of the shortened perpendicular diameter of the abdominal cavity there is always a tendency to a transverse position of the fetus in utero, but this position is ordinarily corrected by the first few labor-pains. The head presents in 95 per cent, of cases, the breech in 2 per cent., according to the statistics collected by Klein,1 embracing 172 1 "Archiv f. Gyn.," Bd. 1, H. 1. ANOMALIES IN THE FORCES OF LABOR. 469 births in 95 women. When the head arrives at the pelvic floor, if the occiput is directed backward, as it is in a third of the cases, anterior rotation will very likely be prevented and there will be a Pubes Fig. 335.—Head arrested by spines of ischia in a kyphotic pelvis (Budin). Fig. 336.—Vertical section of kyphotic pelvis, showing the head arrested by the spines of the ischia (Budin). persistent posterior position. A posterior rotation of the occiput originally directed anteriorly is not rare. It occurred in five of Klein's cases and in one of the author's. If the occiput is 47o THE PATHOLOGY OF LABOR. directed anteriorly, the transverse diameter of the head may be caught between the approximated spines or tuberosities of the ischiatic bones, and labor be brought to an indefinite standstill (Figs. 335, 336). The head usually enters the pelvis obliquely or transversely. Rotation only occurs as the head emerges from the outlet. Face presentations occur in a large proportion of cases —four per cent, of the head presentations. Management of Labor i:i Kypliotic Pelves.—An exact meas- urement of the pelvis is essential to a determination of the proper means of delivery. If the child is of normal size, pregnancy may be allowed to go to term in pelves measuring 8.5 cm. and more in the transverse diameter of the pelvic outlet. Any asymmetry of the ischia will constitute a serious complication, necessitating operative interference that might be avoided in a symmetrical pelvis with smaller diameters. Below 8.5 cm. down F'g- 337-—Lumbosacral kyphosis (pelvis obtecta). to 6 cm. in the transverse measurement of the outlet, labor should be induced at the thirty-sixth week. With a measure- ment less than 6 cm. Cesarean section is indicated absolutely. If the woman is first seen in labor at term, the head, if it is presenting, should be allowed to descend to the pelvic floor and the woman should be encouraged to make vigorous ex- pulsive efforts. If the occiput shows a disposition to rotate posteriorly, the movement should not be interfered with, for the greater bulk of the occipital region will find more room'pos- terior to the tuberosities than it will anteriorly. The author has seen an occipito-anterior position of the vertex remain stationary until the head rotated from an anterior to a posterior position, when the vertex was expelled without further difficulty. With a transverse diameter to 8.5 cm. spontaneous delivery may be ANOMALIES IN THE FORCES OF LABOR. 471 possible, though it may be necessary to use forceps. Below 8.5 cm. the forceps may be tried cautiously, but symphysiotomy is likely to be required. In no other form of contracted pelvis is this operation so successful. Klein found, by experiments on the cadaver, that by a separation of the symphysis to 6 cm. in a kyphotic pelvis, the tuberosities moved 4.5 cm. further apart. Symphysiotomy, therefore, might be expected to be successful in a transverse diameter of 6 cm. or even a trifle less. If the child is dead or if the graver obstetrical operations are not admissible, craniotomy should be performed, in case the forceps fail. In employing forceps the operator must remember the dangers of rupture of the symphysis and deep tears of the vaginal walls to which kyphotic subjects are particularly liable. Version has given the worst results of all the obstetrical operations in kyphotic pelves. It is, therefore, as a rule, contraindicated. Klein's Fig. 338.—Asymmetrical contraction of the outlet from kyphoscoliosis. statistics show that in fifty-eight to sixty per cent, of cases the labor must be terminated by operative interference. Diagnosis.—The diagnosis of a kyphotic pelvis presents no difficulties. The humpback is obvious, and the history is easily obtained that the spinal deformity was developed early in life. The pelvic measurements diagnostic of this deformity show an increased separation of the iliac crests and the anterior spines, an abnormally long conjugate diameter of the inlet, a diminished distance between the posterior superior spines, an approximation of the tuberosities of the ischiatic bones, and some diminution in the anteroposterior diameter of the pelvic outlet. The buttocks are flat and pointed below, the external genitalia are displaced forward and upward, and the upper edge of the symphysis is above the upper edge of the pubic hair. Care should always be exercised to detect asymmetry in these pelves, to discover an 472 THE PATHOLOGY OF LABOR. arrested development with general contraction which is common, and to diagnosticate lateral contraction at the pelvic inlet. These complicating deformities constitute often insuperable obstacles in labor, even though the transverse diameter of the outlet is not excessively contracted. Klein gives the following table, showing the contrast between kyphotic, normal, and rachitic pelves, taking a typical example of each, the measurements being made upon the dried specimen : Sp. il. ant. sup.,............ 22.3 Cr. il.,............... 26.8 Conj. extern., ............ 16.3 Spin. il. post, sup.,........... 7.7 Height of anterior surface of sacrum, ... 10.4 Height of posterior surtace of sacrum, . . . | 9.3 Diagonal conjugate,........... 12.5 True conjugate,............ 10.9 Transverse diameter of pelvic inlet, .... 12.9 Spines of the ischia,.......... 10.2 Tuberosities of the ischia,........ II.4 22 m X O a. J h X w OS III 28.1 25 21.7 28.7 27 3 -5-2 18 18.5 15-5 5-7 b-4 3-5 14.2 8.2 8 9-4 7.2 6.2 19-3 13-b 14-5 17.7 13.2 13.6 14-5 11.8 11.2 9-5 6.6 5-9 10.1 4.6 4-5 HO. 27.25 27-75 H-5 8.7 7.6 14.2 13-5 13-2 Prognosis.—The outlook for the mother and child depends upon the degree of the deformity and upon the management of the labor. In the minor grades of contraction in the cases collected by Klein, the maternal mortality was 6.6 per cent. In the graver cases it was 16 per cent. Neugebauer puts the maternal mortality at 24.3 per cent. The mortality of the in- fants has varied in the different statistical tables from 36 to 49 per cent. Frequency.—The kyphotic pelvis is said to be somewhat infrequent, but the practitioner in active practice will surely encounter several examples in the course of his career. The writer has had under his care six well-marked cases of kyphotic pelvis, in two of which Cesarean section was necessary. In three delivery was spontaneous. The fourth required forceps. Klein found, in 42,113 labors, only 7 women with kyphosis—a pro- portion of 1 : 6016. Scoliosis.—In the scoliotic pelvis there is some degree of oblique contraction. The innominate bone, toward which the lumbar vertebrae are bent, receiving the greater part of the weight of the trunk, is pushed upward, inward, and backward by the ANOMALIES IN THE FORCES OF LABOR. 473 extra pressure exerted upon it by the head of the femur. The acetabulum on this side is displaced anteriorly and upward ; the symphysis is pushed over on the opposite side. The degree of asymmetry is rarely sufficient to constitute an obstruction in labor. The scoliotic pelvis is, however, most often rachitic, and in addition to the asymmetry of scoliosis there may be the con- traction of a rachitic pelvis (Figs. 339, 340). Kyphoscoliosis.—In a combination of kyphosis and scoliosis of the spinal column the pelvis will show, perhaps, the combined Fig. 339.—Scoliosis. Rachitic Fig. 340.—Scoliotic rachitic pelvis. pelvis: C. v., 8.25 cm. Craniotomy on a dead child (author's case). features of both, but the kyphosis, being of rachitic, not of carious, origin, will not be angular, and will be situated high in the dorsal region, where it may be compensated for entirely by lumbar lordosis (Figs. 341, 342 ). The kyphoscoliotic pelvis is usually an asymmetrically contracted rachitic pelvis (PI. 8, Fig. 1). Lordosis.—Primary lordosis not the result of pelvic deform- ity or of spinal disease is very rare. Aside from some illustra- tions of it in an article by Neugebauer (loc. cit.), the writer knows of no reference to the subject except his own (PI. 8, THE PATHOLOGY OF LABOR. ' * Fig- 341-—Kyphoscoliosis (Leopold). PLATE 8. i, Lumbodorsal kyphoscoliosis (Schauta) ; 2, lordosis from paralysis of spinal muscles (author's case) ; 3, skeleton of a girl with coxalgia (Medical Museum, University of Penna.) ; 4, rear view, 5, side view, of obliquely contracted pelvis, the result of tuberculous disease in one knee-joint (author's case) ; 6, scoliosis from unilateral atrophy of spinal muscles (author's case). ANOMALIES IN THE FORCES OF LABOR. 475 Fig. 2).x It may readily be seen what an influence this deformity would have upon coition and parturition, and how it might be an insuperable obstacle to the natural completion of the latter. Fig. 342.—Kyphoscoliosis. Pelvis of rachitic type: C. v., 8.50 cm. (seen in con- sultation with Dr. Geo. I. McKelway). 5. Anomalies Due to Diseases of the Subjacent Skeleton.— Coxalgia.—The deformity of the pelvis due to coxalgia in early childhood is of two types. In one there is an oblique contraction by a displacement of the innominate bone on the healthy side up- 1 Hirst, " The Influence of the Habitual Inclination of the Pelvis in the Erect Posture upon the Shape and Size of the Pelvic Canal," " University Med. Maga- zine." 476 THE PATHOLOGY OF LABOR. Fig. 343.—Skeleton of woman shown in figure 342, who died in consequence of labor. Fig. 344.—Same case as figure 343. ANOMALIES IN THE FORCES OF LABOR. 477 ward, backward, and inward, on account of the pressure of the femur, the weight of the body being received mainly upon the sound leg. This form of coxalgic pelvis, as a rule, presents no serious obstacle to delivery unless it is associated with a rachitic deformity (Fig. 345). Special attention, however, should always be paid to the length of the conjugate diameter of the inlet, and to the transverse diameter of the outlet. In the other variety of coxalgic pelvis the deformity is also an oblique con- traction, but it is the bone on the diseased side which is driven inward upon the pelvic canal. This displacement of the innomi- nate bone is the result of an arrested development on the corre- sponding side of the pelvis, and is usually associated with an atrophy of the sacral ala and an ankylosis of" the sacro-iliac joint. The contraction of the pelvic canal is much more serious in this Fig. 345.—Coxalgic pelvis (Mutter Museum, College of Physicians, Philadelphia). form, and there may be all the difficulties in labor encountered in the true Naegele pelvis. Luxation of the Femora.—Dislocation of the thigh-bones, if congenital or occurring early in childhood and not corrected, has some effect upon the size and shape of the pelvis, but usually not enough seriously to obstruct labor. If one thigh is dislo- cated, the weight of the body may be thrown mainly upon the other leg, and this may produce an oblique contraction of the pelvis of the kind already described. If the thigh-bone is displaced forward, the anterior half of the pelvis may be driven in a little upon the pelvic canal, and the head of the thigh- bone, as in one case reported, may project over the horizontal ramus of the pubis into the pelvic inlet (Fig. 346). In the con- genital luxation of both femora backward upon the iliac bones there is an excessive rotation forward of the sacrum, an increased width of the pelvic canal, and from the drag of the attached 478 THE PATHOLOGY OF LABOR. Fig. 346.—Anterior dislocation of femur. Fig. 347.—Congential luxation of both femora: C, Crest of ilium; F, trochanter of femur (Henry). Fig. 348.—Congenital dislocation of hips, rear view, showing wide sep- aration of the thighs with the feet to- gether (author's case). ANOMALIES IN THE FORCES OF LABOR. 479 muscles and ligaments between the thighs and the pelvis the ischiatic tuberosities are pulled outward, upward, and backward, so that the pelvic canal is made shallow and its outlet very wide. The heads of the femora move up and down on the ilia when the patient walks, and the distance between the lower edge of the symphysis and the inner condyles of the femora is shortened. There is a very peculiar waddling gait, a marked lordosis, and the shoulders are carried far back. The rear view of the patient shows an unusually wide separation of the thighs as the individual stands erect with the heels together. In the absence of one lower extremity the pelvis may be contracted obliquely to a serious degree, as in La Chapelle's case,1 by the pressure on one side of the remaining leg. Any condition which throws the weight of the body mainly on one leg Fig. 349.—Congenital luxation of both femora. may produce the same effect, as is shown in a case of the author's (PI. 8, Figs. 4, 5), in which there was tuberculous disease of a knee-joint early in infancy, followed by marked shortening and atrophy of the leg. The weight of the body falling mainly on the sound leg, the corresponding innominate bone is pushed upward, backward, and inward, diminishing the area of in- trapelvic space on its own side. Torggler reports an inter- esting case of this kind in which the disability of one leg was due to scleroderma.2 In the absence of both lower ex- tremities there is the characteristic " sitz-pelvis," in which the innominate bones are usually rotated on an anteroposterior axis, so that the crests of the ilia are approximated and the tuberosi- 1 " Pratique des Accouchements," iii, p. 413 ; according to Schauta, the only case on record. 2 " Centralbl. f. Gyn.," 1889, p. 612. 480 THE PATHOLOGY OF LABOR. ties of the ischia are separated. Minor deformities of little prac- tical importance may be the result of unilateral or bilateral club- foot or of the bowing of one or both lower extremities. In the former there is an increased inclination of the pelvis, and approxi- mation of the acetabula and of the ischiatic tuberosities, and a narrow pubic arch (Fig. 350). Fig. 350.—Pelvic deformity, the result of double club-foot (Meyer). 6. The Management of Labor Obstructed by the Com= monest Forms of Contracted Pelvis: a Simple Flat, a Rachitic Flat, and a Generally Contracted Pelvis.—There is nothing in medicine requiring more experience and good judgment than the management of labor obstructed by a contracted pelvis. It is extremely difficult to formulate hard-and-fast rules for the guid- ance of the inexperienced when so many factors must be taken into account. The rules given below govern the writer's prac- tice in the average case, but due attention must be paid to the history of past labors, the size of the child, its development, and the compressibility of its head, the age of the woman, the build of both parents, and the probable strength of the ex- pulsive forces, greatest in the primipara and less with successive labors. If the diagnosis of a conjugate diameter of 9.5 cm. or less is made during pregnancy, the physician must choose either induction of premature labor, or forceps, version, symphysiotomy, or Cesarean section at term. If the conjugate diameter meas- ures as low as 9.5 cm., it is a safe plan to induce labor four weeks before the expected termination of pregnancy. This course entails no additional risk upon the child if its parents are in a position to afford it the best care and nursing, and it is much the safest plan for the mother, the induction of labor, done prop- ANOMALIES IN THE FORCES OF LABOR. 48 I erly, having no maternal mortality.x It is true that many women with a conjugate of 9.5 cm. can deliver themselves without difficulty at term. Spontaneous delivery with a measurement as low as eight centimeters and under has been recorded. But the majority of women with a conjugate of 9.5 cm. will ex- perience abnormal delay and difficulty in labor, with added risk to themselves and to their children ; and in a certain propor- tion of cases a conjugate of 9.5 cm. proves an insuperable obstruction in labor, and is the cause of ruptured uterus or death from exhaustion in the mother or of injury to the child's brain. These results are to be feared especially if the child be over- grown or if the mother's expulsive powers be weak—two con- ditions impossible to predict with absolute certainty. For these reasons, then, the rule to induce premature labor when the con- jugate is at or below 9.5 cm. is a safe one. If the conjugate measures between seven and eight centimeters or more, the most successful treatment is still the induction of premature labor at the thirty-sixth week. By this plan the majority of women with a conjugate of eight centimeters or a trifle less will be delivered spontaneously or with no more serious operation than the appli- cation of forceps. If the conjugate measures seven centimeters or less, the induction of premature labor four weeks before term can not be expected of itself to secure a spontaneous delivery. Either symphysiotomy in suitable cases or Cesarean section would, as a rule, be required in addition. In such cases, there- fore, the physician may wait until term or shortly before it, so that his operation shall secure the birth of a child vigorous in development. With a conjugate diameter of the superior strait at and below 7 cm., the woman should be allowed to go to term and should usually be delivered by Cesarean section. If the physician sees the patient for the first time in labor, or only discovers the deformity after labor has begun, he must choose one of the following modes of delivery : A waiting policy, to allow the engagement of the head by natural forces ; the ap- plication of forceps ; the performance of version, symphysiotomy, or Cesarean section. While the child is alive, craniotomy should not be considered. The selection of the best mode of delivery in contracted pelves is one of the most difficult problems in obstetrics. If the patient is a primipara and the conjugate is above nine centimeters, natural forces will, in the majority of cases, provided the fetus be not overgrown, secure the engagement of 1 This statement is based upon the writer's experience in private practice, and not upon hospital statistics. It does not hold good for labors induced before the thirty-sixth week. 31 482 THE PATHOLOG Y OF LABOR. the head,x although it may be by the expenditure of considerable force, after long delay, and only after prolonged molding and an adaptation of the size of the head to the size of the contracted inlet by apparent anomalies in the position and flexion of the former. It is wonderful how successfully an obstruction may be overcome even in cases of contracted pelves with a conjugate of eight centi- meters or less. But while waiting for spontaneous delivery, the physician may see the uterus suddenly rupture or may find the child's head after birth seriously injured. It is permissible in most cases to wait for the full, or almost full, dilatation of the os, keeping careful watch upon the woman's pulse, temperature, and general condition, upon the situation of the contraction-ring and the distention of the lower uterine segment, and taking whatever operative measures may be required in plenty of time to forestall the possibility of uterine rupture. The application of forceps to the head above the superior strait for the purpose of securing its engagement by forcible traction should in general be condemned, but it must be admitted that there are important exceptions to this rule. If one is skilled in the application of the forceps, bears in mind the transverse position of the head, and can gage the degree of traction which may be exerted without injury to the child's skull or to the maternal soft structures, he will occasionally succeed in securing an engagement with the in- strument that would otherwise, perhaps, be impossible. As a rule, however, it is safe to say that the choice lies between in- action and the performance of version. By the latter operation the smaller end of the wedge represented by the child's head is engaged in the contracted inlet, and there can be exerted upon the head coming last, both by traction on the body from below and by pressure on the head through the abdominal walls above, a degree of force that is impossible with forceps. It is well, however, to bear in mind the danger entailed upon fetal life when version is performed in a contracted pelvis. There is a con- siderable risk2 that the head will be retained long enough above the superior strait, or in it, to asphyxiate the child beyond re- vival.3 Or the pressure upon the head by the pelvic walls may 1 From 1881 to 1887 there was spontaneous delivery in 163 out of 444 cases of con- tracted pelvis in the Vienna Hospital, and in 47 women the conjugate was not above 8.5 centimeters (Braun u. Herzfeld, " Der Kaiserschnitt u. seine Stellung zur kiinst- lichen Friihgeburt, Wendung, atypischen Zangenoperationen, Kraniotomie bei u. zu den spontanen Geburten," Wien, 1888, ii, p. 144). In the Moscow Maternity there were 84 contracted pelves among 4000 births in 1894; 71 percent, of these cases were spontaneously delivered (Kiister, "Centralblatt f. Gyn.," No. 10, 1895). 2 The infantile death-rate will be at least twenty-five per cent., or more likely higher (Nagel, " Die Wendung bei engen Becken," " Archiv f. Gyn. " Bd xxxiv). 3 Nagel reports sixty cases of version for contracted pelvis, with a fetal mor- tality of twenty-five per cent, {ibid., p. 168). ANOMALIES IN THE FORCES OF LABOR. 483 fracture the skull and crush the brain, and the force employed in extraction may break the neck. If in the judgment of the oper- ator the danger entailed upon the fetus by version is too great, natural forces having failed to secure engagement, and if he has tried the forceps cautiously without success, his choice must rest between symphysiotomy and Cesarean section. The former will be selected only in isolated instances with most favorable con- ditions if the conjugate is above seven centimeters ; the latter, always in cases of greater contraction than seven centimeters, and occasionally as a relative indication with a conjugate as large as 8.5 cm. These rules for the treatment of labor obstructed Fig. 351.—Walcher posture : the conjugate of the brim is a black line, and the amount of space gained is a dotted continuation of this line. « by a contracted pelvis presuppose, of course, a fetal body and head of average size. This point must always be investigated carefully by abdominal palpation, although it is most difficult to determine.x If the physician has reason to believe that the child is oversized, he must allow himself sufficient latitude to insure delivery. This advice applies particularly to cases in which 1 The relative size of head and pelvis may be determined approximately by the method of Miiller and Schatz. The fetal head is grasped between the extended fingers of the physician, and is pressed down steadily and for some time upon the pelvic brim, the direction of the force coinciding with the axis of the superior strait. If this manceuver succeeds in pressing the head within the pelvis, then natural forces will surely secure engagement. If it fails, the converse by no means necessarily follows. 484 THE PATHOLOGY OF LABOR. the operator is in doubt whether to select symphysiotomy or Cesarean section. If, on the one hand, there is good reason to fear that the child can not with safety to itself be extracted through the birth-canal after the former, his choice should rest upon Cesarean section. On the other hand, if the child is under- sized (a condition easier to detect by palpation than is overgrowth), spontaneous delivery may be expected through a pelvis that would not permit the passage of a child of normal size. Klein and Wal- cher declare that by raising the buttocks and letting the limbs hang down as much as possible the conjugate diameter is length- ened by almost a centimeter. Clinical tests of the method are Fig. 352.—The Walcher posture. described, attended, apparently, with success.1 The Walcher posture has been indorsed by a number of observers in Germany and in other countries. The author has found it of decided ad- vantage, and would recommend its systematic trial. 7. Obstruction to Labor on the Part of the Soft Maternal Structures in the Parturient Canal.—Congenital Anomalies of Development in the Uterus.—A double or septate uterus may com- plicate labor in several ways. The bulk of the unimpregnated half may obstruct delivery, especially if this half is retroverted 1 " Zeitschrift f. Geburts. u. Gyn.," Bd. xxi, H. 1, and "Med. Korresp Bl. des Wurtemb. Aerztl. V.," Bd. Ix, 5. ANOMALIES IN THE FORCES OF LABOR. 485 and is increased considerably in size in sympathy with the de- velopment of the impregnated side, and is hardened in consist- ency by sympathetic contraction during the labor-pains. The septum itself may prove an obstacle in labor, and sometimes labor is obstructed by the strong vesicorectal ligament that runs between the horns of a bicornate uterus. If the placenta is at- tached to the septum, alarming hemorrhage may occur from im- perfect contraction of the sparsely supplied muscular fibers in it. Malpresentations of the fetus and a faulty direction and insuffi- cient power of the expulsive force are common. Rupture of the uterus is to be feared on account of the ill-developed uterine walls. Laceration of the septum frequently occurs. It has been noted that a decidual membrane may be retained within the non-pregnant half of the uterus, where, undergoing putrefaction after delivery, it may give rise to septic infection. There seems also to be a disposition to the retention of membranes in the pregnant side of the womb. Retention of the placenta is not uncommon, partly because of insufficient expulsive force, partly on account of its situation,— perhaps attached in both divisions of the uterine cavity. The- vard1 reports the retention of the placenta in a double uterus for fifty days, when it was spontaneously discharged. It has hap- pened, in cases of double uterus and vagina, that the physician ex- amined the wrong side, and was ignorant of the progress of labor until the child was about to be born ; also that he examined first one side and then the other, finding first a dilated and then a contracted external os. In one woman with a double uterus there was noted a dis- position to become pregnant in regular alternation first on one side and then upon the other.2 Closure and Contraction of the Cervix.—The cervix may ob- struct labor by reason of atresia, cicatricial infiltration, contrac- tion, and rigidity, or there may be longitudinal or transverse septa in the canal. Atresia of the cervix in a pregnant woman must, of course, be acquired after impregnation {conglutinatio orificii uteri extend) ; it is rarely, however, complete. There is always an indication at least of the external os in a dimple evi- dent to the sense of sight if not to that of touch. By pressing upon this point with a finger-nail or with the tip of a uterine sound, a small artificial opening may be made. Directly this is secured, the dilatation of the external os proceeds in a remark- ably rapid manner, although hours of vigorous labor-pains before had been insufficient to begin it. If this plan fails, a 1 " Nouvelles Archives d'Obstetrique et de Gynecologie," 1890, p. 640. 2 Southermann, " Berliner med. Wochen.," 1879, 41. 486 THE PATHOLOGY OF LABOR. crucial incision must be made in the cervical tissues at the site of the external os. The dilatation of the small opening thus made is then left to nature. If hemorrhage follows the incisions, the bleeding points should be secured by sutures. An active treatment is always called for. Without it the uterus may rup- ture, the vaginal portion of the cervix may be torn off from the womb, or the head may emerge completely covered by the enormously distended cervix as by a caul.x Cicatricial contrac- tion or infiltration of the cervix is the result of old, unrepaired tears, of operations upon the cervix, of cauterization, of syphilis, or of cancer. In the first instance the resistance to dilatation is scarcely ever great, and what there is may be almost always overcome by hydrostatic dilators, by the application of the forceps and forcible delivery of the head through the cervical canal, or by the performance of version followed by rapid extraction. If the cicatrices are of syphilitic or of cancerous origin, the obstruc- tion is more serious. It may be overcome by radiating incisions with scissors or with a probe-pointed bistoury, but it is not un- likely to demand the performance of Cesarean section. Rigidity of the cervix is seen normally in all primiparae, and to an exaggerated degree in elderly primiparae. It yields often to copious douches of warm water directed against the anterior wall of the cervix and frequently repeated—as often as once every fifteen minutes if necessary. Chloral internally and bella- donna ointment applied directly to the cervix have been recom- mended, but these remedies are not to be depended upon except in the slight rigidity characteristic of all primiparae. If there is delay in such cases, fifteen grains of chloral every fifteen minutes for three doses may advantageously be given. An anesthetic, after all, is the most valuable medicinal agent that we possess for the relaxation of this as well as of other rigid tissues. The rigid cervix yields at length to the steady pressure of the presenting part, and it is rarely necessary on account of rigidity alone to resort to artificial dilatation or to incisions. In the course of a slow dilata- tion of the cervical canal and external os the anterior lip may be- come incarcerated between the head and the pelvic walls. In con- sequence of the pressure and the disturbance of circulation in the part the cervical tissues rapidly become edematous, and the bulk of the anterior lip becomes so great as actually to constitute a mechanical obstruction to the descent of the head. It is usually possible in such cases to push up the anterior lip over the head and above the symphysis in the intervals between the pains. If there is hypertrophy of the anterior lip in consequence of an old 1 Jeutzen, " Archives de Tocologie," Paris, 1890, H. 8. ANOMALIES IN THE FORCES OF LABOR. 487 laceration and eversion, or, all the more, should there be hyper- trophy of the whole infravaginal portion of the cervix, the ob- struction may become quite serious, and it may be impossible to push the cervix above the head. In such cases forcible traction on the forceps or radiating incisions in the cervix may be necessary. Longitudinal septa in the cervical canal are usually seen with duplicity of the uterine cavity from failure of the Miillerian ducts to fuse completely. Occasionally the lack of fusion is confined to the cervical canal alone (uterus biforis). Rarely, transverse septa have been found in the cervical canal.1 It may be neces- sary to cut them before the child can pass into the vagina. Fig. 353. — Double vagina. Closure and Contraction of the Vagina or Vulva.—There may be obstruction of the lower birth-canal by longitudinal and trans- verse septa, by cicatrices, by hematomata, by partial atresia, es- pecially at the upper third of the vagina, by unruptured hymen, by anus vaginalis, by vaginal tumors and cysts, by cystic and solid tumors of the vulva, by enlarged carunculae myrtiformes, by varices, by vaginismus, by congenital narrowness of the 1 Cases are reported by Miiller, Breisky, Budin, Flenry, Bidder, and Blanc (Pozzi's " Gynecology," vol. ii, p. 456). 488 THE PATHOLOGY OF LABOR. vagina and vulva, and by rigidity of the tissues, especially in elderly primiparae. Longitudinal and Transverse Septa.—These are not ordinarily very dense in structure, and they give way commonly before the advance of the presenting part. If they do not yield, it is easy to cut them in one or more places, the hemorrhage being con- trolled, if necessary, by sutures afterward, or, in the case of trans- verse septa, by a double ligature applied first, the septum being cut between, though there is not much tendency to bleeding even in those as thick as one's finger (Fig. 354). Fig. 354.—Transverse septum of the Fig. 355.—Anus vestibularis. Dot- vagina (Heyder). ted lines show the limit of mucous membrane; thickened skin marks the normal site of the anus (Dickinson). Hematomata.—Hematomata of the parturient tract usually occur at the vaginal orifice, and most often between the birth of twins. They are considered here only as mechanical obstacles to labor. If the blood-tumor is large enough to constitute an obstruction to the escape of the child, its walls must be incised and its contents be turned out, and if hemorrhage follows, it must be checked by a firm tampon, preferably of iodoform gauze, in the cavity of the tumor. Extensive cicatrices in the vagina from syphilitic, malignant, or other ulceration, or from former injuries, may be stretched sufficiently by hydrostatic dilators or may be severed by multiple incisions, followed by the application of forceps if the head is ANOMALIES IN THE FORCES OF LABOR. 489 presenting ; but they may be too dense and extensive to yield to these measures, and a Cesarean section may be required. Unruptured Hymen.—An unruptured hymen is not neces- sarily a bar to conception. There are a number of cases on record in which a persistent hymen with a small orifice has ob- structed to some degree the escape of the child's head in labor. In two cases under the author's notice the advance of the pre- senting part ruptured the hymeneal membrane without difficulty, but it has been found necessary by others to incise it.1 Atresia of the Vagina.—This anomaly of development has its seat usually at the upper third of the canal, where the vagina may be contracted to a narrow tract barely admitting the uterine probe, or the canal may be obstructed by an annular membrane like the hymen. Although Cesarean section has been done for this con- dition, the majority of cases on record have not required it. The advance of the presenting part has dilated the narrowed vaginal canal with little more difficulty than it experiences in dilating the cervical canal. At the worst, the obstruction should be over- come by digital, instrumental, or hydrostatic dilatation. In com- plete or almost complete acquired atresia of the lower portion of the vagina, in which insemination has taken place by way of a dilated urethra and a vesicovaginal fistula, the imperforate portion of the vagina may be opened by a transverse incision, the rectum and bladder being guarded by a finger in the one and a sound in the other. Anus Vaginalis or Vestibularis.—This condition may com- plicate labor by the accumulation of feces in the rectum, due to the unnatural position of the anus (Fig. 355). In one case in which this anomaly was associated with partial atresia of the vulvar orifice it wras necessary to cut the perineal structures up- ward from the rectum toward the pubis, in order to permit the escape of the child's head. Cystic and Solid Tumors of the Vagina and Vulva, Edema, Suppuration, and Gangrene.—In the case of solid tumors ex- cision may be necessary, by transfixing the pedicle if they have one, and ligating it to prevent hemorrhage, or by an incision of the vaginal wall over them and their enucleation, followed by the immediate extraction of the child, and the control of hemor- rhage by the needle and thread or by direct pressure. In the case of large cystic tumors a puncture is sufficient to remove the obstruction. Guder 2 collected 60 cases of vaginal tumors compli- 1 Ahlfeld, " Zeitschrift f. Geburtshulfe und Gynakologie," Bd. xxi, p. 160; ibid., Bd. xiv, p. 14. 2 "Ueber Geschwulste der Vagina als Schwangerschaft und Geburtskompli- kationen," " Diss.-Inaug.," Bern, 1889. 490 THE PATHOLOGY OF LABOR. eating labor—23 cysts and echinococcous sacs; 18 fibroids,. fibromyomata, and polypi; 14 carcinomata, 1 sarcoma, and 4 hematomata. Delivery was accomplished by the following diverse methods: Spontaneously, 14; by forceps, 18 ; by ver- sion and extraction, 2 ; by traction on the feet, 1 ; by removal or puncture of the tumor, 16 ; by Cesarean section, 7 ; by in- duction of premature labor and craniotomy, 2; by premature labor, 3 ; by laparo-elytrotomy, 1 ; by craniotomy 1 ; by pushing back the tumor and extracting the child past it, 2. Among the mothers there were 15 deaths; among the children, 13. In 11 of the mothers and in 22 of the children the result was not reported. Edema of the vulva may be the result of kidney insufficiency Fig. 356.—Edema and beginning gangrene of the vulva from prolonged pressure in an obstructed labor. Cesarean section (author's case). or of pressure in a prolonged labor. The increased bulk of the dropsical labia may interfere with the escape of the presenting part, or, what is more likely, the edematous tissues lose their elasticity, obstruct labor by their rigidity, and are prone to deep tears at the time of birth and to gangrene afterward. Punctures or incisions in the labia may be necessary to escape more serious injury, but it is well to avoid them if possible, for they are apt to be followed by infection and gangrene. An abscess of Bartholin's gland is seldom large enough to retard labor, though it has done so (Miiller), but it is likely to cause trouble afterward. It should be opened freely in the early ANOMALIES IN THE FORCES OF LABOR. 491 Congenital part of the first stage of labor, curetted, swabbed out with car- bolic acid and glycerin, and packed with iodoform gauze. Gangrene of the vulva is very rare before the termination of labor. Should it exist, it might determine an operator in favor of Cesarean section in a doubtful case, on account of the rigidity of the vulvar tissues, the certainty of laceration, and the likeli- hood of grave infection. Enlarged CaruucuUe Myrtiformcs and Varicose Veins.—These tumors do not possess sufficient bulk, as a rule, seriously to ob- struct the last stage of labor. They may, however, be so bruised by the passage of the head as to slough afterward, or the veins in them may be ruptured, giving rise to subcutaneous or frank bleed- ing of an alarming character. Vaginismus may be overcome by an anesthetic narrozvness of the vagina and vulva is usually overcome by the advance of the presenting part, though often at the ex- pense of vaginal and perineal lacerations. It may be neces- sary to resort to hydrostatic dilatation, or even, in rare in- stances, to Duhrssen's plan of multiple incisions. In the case of extreme narrowness of the vulva there may be a central tear of the perineum, through which the presenting part begins to emerge. To avoid a rectal tear in such a case the perineum should be cut from the anterior border of the perforation to the posterior commissure of the vulva (Fig- 357)- Rigidity of the tissues in the cervix, the vaginal wall, and at the outlet occasions delay in the majority of all primiparae, but especially in the case of elderly primiparae—those over thirty years of age. Eckhard found the infantile mortality in such cases to be 19.81 per cent, the maternal mortality to be three times as great as in younger primiparae ; and the necessity for operative interference increases steadily with the age of the primiparae until, in those past forty, almost two-thirds are delivered by some operative procedure, usually forceps. Craniotomy should be done if the child is dead. Version is the least successful opera- tion in these cases. Displacements of the Uterus.—The uterus in labor may be Fig. perineum, 357-- with -Central tear in the contracted vulvar ori- fice (Ribemont-Dessaignes). 492 THE PATHOLOGY OF LABOR. displaced forward ; to either side ; downward ; or backward, by the so-called " sacculation " of the womb. It may be twisted on its pedicle, the cervix, or it may form part of the contents of a hernial sac in inguinal or ventral hernias. Anterior Displacement of the Uterus in Labor; Pendulous Belly.—This is a common anomaly in labor, seen to some degree in all cases of obstructed labor, as in deformed pelvis, and in all cases in which the length of the abdominal cavity is decreased, as in kyphosis. A peculiar example of forward displacement is seen in those rare instances of hernia of the parturient womb between the recti muscles or to one side of the median line dur- ing the second stage of labor (Fig. 358). The pregnant womb Fig- 358-—Hernia of the gravid womb through the linea alba (Dickinson). may fall forward also into an umbilical hernia or into a ventral hernia following celiotomy. The removal of the obstruction to labor in the first class of cases will ordinarily obviate the anterior displacement. If the displacement depends not upon obstruction, but upon flaccid abdominal walls, the application of an abdominal binder surely corrects the anteversion. In cases of hernia of the uterus through the anterior abdominal wall, artificial delivery with forceps or by version may be necessary ; when the uterus is evacuated, it can easily be returned into the abdominal cavity. A tight abdominal binder and the diminution of intra-abdominal pressure after de- livery will promote the approximation of the separated recti ANOMALIES IN THE FORCES OF LABOR. 493 muscles. In inguinal hernia the pregnant womb in the hernial sac is usually unicorn or bicorn (Fig. 359). Delivery may be effected by version, and this may be followed by a reduction of the hernia, but it is best to lay open the sac, incise the womb, extract its contents, and then amputate it. Adams x has collected ten cases of inguinal hernia of the gravid womb, including Dorin- gius's, which he calls "crural." In eight Cesarean section was done ; in one the delivery was spontaneous. Labor Complicated by a Former Operation to Suspend or Fix the Womb Anteriorly.—The number of operations performed for posterior displacement of the uterus on women of child-bearing age has become so large of recent years that ample opportunity has been afforded to judge of the influence of anterior fixation Fig. 359.—Inguinal hernia containing a gravid womb (Winckel). and suspension of the uterus on pregnancy and childbirth. Dor- land 2 has collected the statistics of 179 pregnancies following operations for ventrosuspension, ventrofixation, and vaginal fixa- tion. It appears from these statistics that, the firmer the womb is fixed and the lower the fundus is fastened, the more certainly will there be serious disturbances in pregnancy and dangerous complications in labor. Thus, abortion occurred in 14 per cent, of the ventrosuspensions and in 27 per cent, of the vaginal fixations. In 12.29 Per cent- °f a^ the cases there was dys- tocia, requiring in three instances Cesarean section. The com- 1 Adams, "Hernia of the Pregnant Uterus," " Amer. Jour. Obstetrics," vol. xxii, p. 225. 2 " University Med. Mag.," Dec, 1896. 494 THE PATHOLOGY OF LABOR. plications noted in labor were : inertia uteri, transverse position of the child, abnormal positions of the head, cervical rigidity, uterine rupture, placental anomalies, postpartum and puerperal hemorrhages, and a mechanical obstruction in labor from the thick anterior wall of the uterus, held firmly down over the pelvic inlet, the distention of the uterus in pregnancy having been accom- plished by the expansion mainly of the posterior uterine wall. Pregnancy was seriously disturbed in 8.37 per cent, of the cases, not including those in which abortion occurred, by pain and trac- tion at the site of the incision, dysuria, and excessive nausea and vomiting. A sure indication of the difficulty to be expected in labor is afforded by the behavior of the fundus and cervix of the womb in pregnancy. If the latter remains fixed over the pelvic inlet and the former is steadily drawn upward and backward untilit reaches the promontory of the sacrum or actually ascends above it, the labor will be so seriously complicated in all probability that, in the hands of an expert abdominal surgeon, the best results may be obtained in the future by opening the abdomen and sever- ing the adhesions between the fundus uteri and the abdominal wall. If version is demanded in labor at term, great care must be exercised not to rupture the overstretched posterior uterine wall. The best preventive treatment of difficulty in pregnancy and labor after the operative treatment for posterior displacement is the choice of the appropriate operation and its proper perform- ance. Vaginal fixation should not be selected. Shortening of the round ligaments has not yet given rise to any difficulty in subsequent pregnancies and labors, nor has ventrosuspension, properly performed. If the operator uses fine silk and includes only a portion of the rectus muscle with the peritoneum in the abdominal portion of the stitch, the artificial suspensory ligament is so flexible and stretches so easily that no difficulty need be apprehended if the patient conceive. In not one of the numer- ous women operated upon by the author has there been the slightest complication traceable to the operation in pregnancy and labor. Lateral Displacement.—A tilting of the uterus to the right side is a physiological occurrence in pregnant and parturient women. The lateral inclination is sometimes exaggerated to such a degree that a great part of the expulsive force is lost by the propulsion of the presenting part against the lateral wall of the pelvis. The displacement may be corrected by turning the woman on the side—usually the right—toward which the fundus uteri is inclined, and placing under her flank a rolled blanket or a pillow. ANOMALIES IN THE FORCES OF LABOR. 495 Sacculation of the Uterus.—A backward displacement of the gravid womb in rare cases goes on to full development by what is called "posterior sacculation," the distention of the uterus to •accommodate the full-grown fetus being accomplished by stretch- ing the anterior uterine wall, the posterior wall and the fundus remaining fixed within the pelvis (Fig. 362). In these cases the cervix is high above the pelvic inlet and is pressed close against the anterior abdominal wall, the posterior vaginal wall bulges out- ward and downward, and fetal parts can be felt through it with a distinctness that suggests ab- dominal pregnancy. Cesarean section has in one instance at least been performed on account of this anomaly, but a study of recorded cases shows it to be unnecessary. By the artificial dilatation of the cervical canal and the performance of podalic version, delivery may be effected without difficulty. Partial Prolapse with Hypcr- Lrophic Elongation of the Cervix. —It is impossible for pregnancy to proceed to term with com- plete prolapse of the womb, although the size of the uterine tumor projecting from the vulva in some cases has given rise to a belief in this possibility (Fig. 360). A careful examination has always shown the major portion of the uterine body to be within the pelvic and abdominal cavities. Commonly, the fundus is at a normal level, and the descent of the cervix has been accomplished by stretching the lower uterine segment and by hypertrophic elongation of the cervix itself. When the contraction of the uterine muscle begins in labor, a partial prolapse of the womb is usually spontaneously corrected by the retraction of the cervix within the vagina. This the author has seen in several instances. In exceptional cases, however,—usually on account of a rigid cervix,—the prolapse becomes aggravated or suddenly makes its appearance, and the cervical tissues, growing edematous and be- coming enormously swollen, constitute, by their bulk and in- ■creased rigidity, a serious obstruction to the delivery of the child. Fig. 360.—Partial prolapse of the womb in labor (Wagner). 496 THE PATHOLOGY OF LABOR. Fig. 361.—Prolapse of a double uterus in a pregnant woman (Maygrier). This difficulty was overcome in an ingenious manner in a case reported by Faivre.x The woman was placed in the dorsal posi- Fig. 362.—Sacculation of the uterus (Oldham). Fig- 363.—Partial prolapse of the womb and hypertrophy of the cervix (Faivre). 1 " Nouvelles Archives d'Obstetrique," 1890. ANOMALIES IN THE FORCES OF LABOR. 497 tion across the bed, a forceps was applied to the child's head, and an assistant, standing astride the woman's body, hooked his fingers Fig. 364.—Partial prolapse of the womb and hypertrophy of the cervix: A, Lateral position; B, dorsal position ; C, cervix ; V, bladder (Faivre). Fig. 365.—Displacement of the cervix. into the cervix and pulled upward to counteract the traction of the forceps upon the child's head and the incarcerated cervical 32 498 THE PATHOLOGY OF LABOR. tissues. It might be necessary in such a case to enlarge the cervical canal by radiating incisions. The hemorrhage following might be controlled temporarily by clamping sutures over the wounded surfaces without uniting them (Figs. 363, 364). Displacement of the Cervix.—It is not uncommon, in prim- iparae with a narrow cervical canal, for the cervix to be displaced backward, so that the external os, almost inaccessible to the ex- amining finger, points directly backward or even backward and upward. The anterior lower uterine segment is much distended by the presenting part and occupies the whole vaginal vault. The expulsive force in labor is exerted against the lower uterine segment, and the cervical canal remains undilated. The difficulty may be overcome by applying an abdominal binder and by hook- ing the cervix forward with the finger during two or three pains (Fig. 365). Tumors of the Genital Canal.—Carcinoma of the Cervix.—In a large proportion of cases cancer of the cervix will interrupt ges- tation at various stages, but in a certain percentage (sixty-six, according to Miiller) the pregnancy goes to term. If the disease is not too far advanced ; if it is confined to one lip of the cervix, and that the anterior; and if there is not too much cicatricial infiltration around its periphery and up the cervical walls, the labor may be terminated spontaneously, but this is rather the ex- ception. The performance of Cesarean section is commonly the proper treatment for labor obstructed by carcinoma of the cervix, and this operation should be selected if there is good reason to doubt the possibility of spontaneous or artificially assisted delivery by the natural passage-way. The woman's life is surely doomed in the near future, and the child at any rate should be saved, even at considerable risk to the mother. It may be desirable to operate before the fetus has reached maturity, if the disease is making such rapid progress that the woman is likely to die before the natural end of pregnancy. Fibromata.—Fibroids of the uterus and cervix low enough in situation to become incarcerated in the pelvis are likely to con- stitute insuperable obstructions in labor, besides complicating parturition by favoring abnormal positions of the child, by pre- disposing to adherence of the placenta, to prolapse of the ex- tremities and cord, and to hemorrhage during and after labor. If the tumor grows on the anterior wall of the uterus, the first few labor-pains and the contraction of the longitudinal fibers of the cervix may dislodge it above the pelvic brim, though it had been impossible to do this before by manipulation. The author has seen one such case. It is also possible for tumors on the anterior wall of the cervix to be pushed out of the vulva in front ANOMALIES IN THE FORCES OF LABOR. 499 of the presenting part, thus making room for the escape of the latter. If, however, the tumor is situated laterally or posteriorly, its artificial displacement upward into the abdominal cavity, so that the child may escape past it, is often impracticable (Fig. 366). On the contrary, the attempt at descent of the presenting part in labor must fix it more firmly in the pelvic cavity.x In this case, if attempts under anesthesia to dislodge the tumor and to push it above the pelvic brim fail, a Porro-Cesarean operation should be performed, even though the tumor is not of so great a Fig. 366.—Large fibroid blocking the pelvis (Spiegelberg). size as absolutely to prevent the delivery of the child. The physician must consider the effect upon it, owing to its low vitality, of the pressure to which it will be subjected by dragging the child past it (Fig. 367). Sloughing, gangrene, and fatal in- fection are likely to follow. This was the history of the case 1 It is barely possible that a tumor low down on the posterior wall of the cervix, the most unfavorable of all positions, may be suddenly elevated after many hours of labor, and thus allow a spontaneous delivery; but this event is not to be counted on in practice. 500 THE PATHOLOGY OF LABOR. illustrated in figure 367, communicated to the author by Dr. J. P. Simpson, of South Carolina. If the fibroid is submucous and grows from the cervix, it may be enucleated when labor begins. The bed of the tumor should be packed with gauze after labor.x It is, unfortunately, a common error to overlook a fibroid tumor obstructing the pelvis in labor, or to mistake it for the fetal head. The woman is allowed to die of ruptured uterus, exhaustion, or hemorrhage, while the physician is waiting for the descent of the presenting part, or is endeavoring to apply the forceps to what he takes to be the head. Ordinary care and a little experience in making obstetrical examinations should guard a practitioner against such an egregious mistake. Fig- 3°7-—Small fibroid past which the child was extracted. The tumor became gangrenous, and the woman died (Simpson). The prognosis of labor complicated by a fibroid tumor de- pends upon the early recognition of the growth and upon the treatment. In general practice the results have hitherto been bad. Nauss found a maternal mortality of 54 per cent, among 225 women and an infantile mortality of 57 per cent, in 117 cases. Susserott found in 147 cases a maternal mortality of 50 per cent, and an infantile mortality of 66 per cent.2 1 Sutugin is an enthusiastic advocate of vaginal operations for all cases of fibroids impacted in the small pelvis. For intramural tumors the cervix is split until the tumor is reached. For subserous tumors the vaginal vault is opened. Nine such operations sub partu are reported with only one death (" Jahresb. ii. d. Fortsch. a. d. Gebiete der Geburtsh.," etc., vol. v, p. 175). 2 Sutugin, loc. cit. ANOMALIES IN THE FORCES OF LABOR. 50I In Lefour's statistics of 300 cases of fibroids complicating labor, the mortality of delivery by the natural passage was 2 5 to 55 per cent, for the mothers, JJ per cent, for the children.1 A fibroid tumor may prolapse into the pelvis after the birth of the child and prevent the delivery of the placenta. Polypi.—Polypoid tumors obstructing labor usually spring from the cervical canal or the anterior lip of the cervix, and are mucous in character. They may, however, be fibromyomatous, Fig. 368.—Subperitoneal fibromata. The growth attached to the lower uterine segment was impacted in the pelvis, insuperably obstructing labor. Celiohysterecto- my: woman recovered, although she had been in labor four days; child dead (author's case). fibrous, or sarcomatous, and may have a situation high in the uter- ine cavity or in its wall. They may increase very markedly in size during pregnancy. Their pedicle is usually small, and in the case of cervical polypi their removal is easy. The operation should be postponed, however, until the woman falls into labor, for any operative interference in this region would very likely interrupt gestation. When the dilatation of the os begins, the pedicle may be transfixed and ligated and the tumor be cut away. Even if these 1 Phillips, " British Med. Jour.," 1888, i, p. 331. 502 THE PATHOLOGY OF LABOR. growths are not sufficient in bulk to obstruct parturition me- chanically, they have been known to give rise to profuse hemor- rhage in the first few days of the puerperium, and their removal is desirable, therefore, even though they be small in size. In the case of fibromyomatous polypi of the uterine body, the tumor has on rare occasions been torn from its pedicle during labor and expelled in front of the child. Tumors of Neighboring Organs.—Ovarian Cysts.—An ovarian cyst is a rare complication in labor. In 17,832 births in the Berlin Frauenklinik, an ovarian cyst was found only five times. The number of abortions in pregnancies complicated by ovarian cysts is somewhat larger than common, but still a large pro- portion of these cases proceed to term. Of 321 pregnancies Fig. 369.—Dermoid cyst containing hair and teeth and puerperal uterus, removed in a Porro-Cesarean section (author's case). complicated by the presence of ovarian cysts, there was prema- ture interruption in 55 (Remy). If the cyst is discovered during pregnancy, its removal should be attempted. Ovariotomy during gestation is not necessarily a difficult or dangerous operation, nor does it, as a rule, interrupt pregnancy.1 If the tumor is first discovered after the woman has fallen into labor, and if it has become displaced downward into the pelvic cavity and is incar- cerated, resisting all efforts to displace it upward, even under anesthesia, its puncture through the vaginal vault, after a 1 Dsirne has collected statistics of 135 operations with a mortality of 5 9 per cent. Pregnancy is interrupted by the operation in about 20 per cent, of cases (Flaischlen, '• Zeitschrift f. Geburtshulfe," xxi\, p. 49). ANOMALIES IN THE FORCES OF LABOR. 503 thorough cleansing of the vaginal mucous membrane and with a thoroughly aseptic technic, is said to give the best results. It is a matter for serious consideration, however, whether Cesarean section followed by the removal of the tumor is not better. It is the author's conviction that it is.1 By this plan many dangers in the puerperium are escaped. Twisted pedicle, intracystic bleed- ing and shock, occlusion of the bowels, rupture of the cyst, sup- puration of the cyst-contents, and consequent peritonitis are all surely avoided. A number of cases treated thus should give a better mortality record than has hitherto been secured. In Heiberg's statistics of 271 cases there was a maternal mortality in pregnancy of more than 25 per cent, and a fetal mortality of more than 66 per cent. In deliveries by forceps without punc- ture of the cyst the maternal death-rate has been 50 per cent. ; with puncture, almost as great; and after version without punc- ture, more than 50 per cent. Flaischlen recommends the vaginal puncture, or, if necessary, a vaginal incision and thorough evac- uation of the tumor, then the delivery of the child, and on the following day at the latest an abdominal section for the removal of the tumor. This procedure does not seem to me so good a plan as the coincident Cesarean section and ovariectomy. Should the physician prefer vaginal puncture,—which requires, of course, no special surgical skill,—he should remember that if the tumor be densely adherent, possess thick walls, and possibly be a dermoid cyst, puncture through the vaginal vault is likely to be followed by gangrene of the tumor-contents and walls and by general infection. This will necessitate a hurried abdominal section in the puerperium, with the patient in a bad condition to endure it. Moreover, if the cyst is multilocular, it may be im- possible to reduce its size sufficiently by vaginal puncture to per- mit the delivery of a living infant. The author has experienced both the disadvantages of this plan of treatment. Spontaneous delivery in spite of an ovarian cyst incarcerated in the pelvis has been noted after the cyst ruptured, after it had been spontaneously dislodged upward above the pelvic brim, or had perforated the vaginal vault or the rectum. As an ovarian cyst must be impacted in the pelvis to obstruct the delivery of the child, it is easily understood that there is more difficulty and danger in labor from a small than from a large tumor (Fig. 370). After the child is born, a cyst that had before been above the brim may descend into the pelvis and obstruct the delivery of the placenta. Vaginal Enierocele.—Vaginal hernia is a very rare obstruction 1 I have performed Cesarean section twice for large dermoids impacted in the pelvis obstructing labor, with a successful result for both mother and child. 504 THE PATHOLOGY OF LABOR. labor. The author has been able to collect but twenty-seven cases from medical literature. Of these, only two were anterior entero- celes ; the others were lateral and posterior. The distention of the hernial sac in labor is apt to become excessive, and to threaten its rupture with protrusion of intestinal loops. An effort should be made to reduce the hernia as soon as it is discovered. The reduction may be facilitated by placing the woman in the knee- breast posture and by inserting the whole hand into the vagina. If this treatment is instituted in pregnancy, it should be followed by the insertion of a large tampon or a globe pessary and by pro- longed rest in bed ; in labor the presenting part should imme- diately be brought down past the hernial ring. If there are adhesions about the latter, preventing the reduction of the hernia, Fig. 370.—Ovarian tumor incarcerated Fig. 371.—Cystocele obstructing labor. in the pelvis during labor. the tumor should be supported and held to one side by assistants while the child is artificially extracted by forceps or after version. Should the sac rupture and the intestines protrude, the child must be delivered hastily, the intestines be cleansed thoroughly and replaced, and the opening be sewed up. In the case of a very large irreducible vaginal hernia, Cesarean section would be preferable in a labor at term. Other growths or tumors in the pelvic inlet and cavity ob- structing labor have been fibrocystic tumors of the ovarian liga- ment, requiring an abdominal section ; fibroma of the ovary; sarcoma of the ovary ; a displaced adherent kidney at the pelvic inlet, necessitating version and forcible extraction j1 hydatid cysts 1 Runge reports four cases ("Archiv f. Gyn.," xii, p. 99). The writer has had one. Albers-Schoenberg reports another in which the uterus ruptured (" Centralblatt f. Gyn.," Dec. I, 1894). ANOMALIES IN THE FORCES OF LABOR. 505 of the pelvis, demanding Cesarean section ; a displaced and en- larged spleen ; masses of exudate, and an aneurysm of the gluteal artery. A cystocele and a rectocele should be replaced if they pro- trude to a great extent in front of the head, and should be held back until a forceps is applied and the head is pulled past them (Fig. 371). Version and extraction have occasionally been found necessary. Large fecal masses in the rectum must be re- moved by an enema or must be dug out.1 Calculi in the blad- der should, if possible, be discovered and removed by the urethra or by vaginal lithotomy before the second stage of labor. They may become nipped between the head and the pubic bones, and may pinch a hole through the anterior vaginal wall and bladder if they are overlooked or neglected.2 The diagnosis of vesical calculus in the parturient woman appears to be somewhat diffi- cult : it has been taken for a pelvic exostosis or some other pelvic tumor, and in one case at least Cesarean section was performed on account of this mistake. Fortunately, vesical calculus in the female is rare. In 10,000 women examined by Winckel in fifteen years, it was found only once. The following conditions in and about the rectum may pre- sent mechanical obstacles to delivery : Cancer, anus vestibularis or vaginalis, foreign bodies, contraction of the levator ani mus- cles, benignant tumors, such as cysts of the rectum, ovarian cysts which have perforated the rectum, and retrorectal dermoid cysts. Each of these conditions must be treated according to the indi- vidual indications. Incisions in the perineum may be required, foreign bodies must be removed, resisting muscles on the pelvic floor may be overcome by an anesthetic and by the application of forceps, and cystic tumors, should be punctured or removed after ligation of their pedicles. Cancer of the rectum may demand the performance of Cesarean section by reason of the size of the tumor and the cicatricial infiltration of the birth-canal, as in Freund's case. 8. Obstruction in Labor on the Part of the Fetus.—Over= growth of the Fetus.—Excessive overgrowth of the fetus is rare. The writer searched the records of more than 1000 children in the Maternity Hospital of Philadelphia before he found one that weighed more than 12 pounds ; weights, however, of 15, 16, 18, 1 Corradi tells of a case in which seven pounds of hardened feces were removed before the woman was delivered. 2 Kotschurowa has reported a case in which labor lasted three days. At the end of that time a gangrenous tumor protruded from the vulva, which tumor proved to be the bladder and anterior vaginal wall. The midwife in attendance perforated the tumor with her finger, whereupon a calculus eighty-five grains in weight was dis- charged (" Jahresbericht ii. d. Fortschr. a. d. Gebiete der Geburtsh.," etc., vi, 225). 506 THE PATHOLOGY OF LABOR. 23 y2, and 28^ pounds have been recorded. The causes of over- growth in the fetus are prolongation of pregnancy, oversize and advanced age of one or both parents, and multiparity. Rarely, it may be inexplicable. The first named is, in the writer's experi- ence, the most common cause. In six per cent, of women preg- nancy may be expected to be prolonged beyond the three- hundredth day, and for every day that the fetus is retained in the womb beyond the usual time there is an increase in its size and Fig. 372.—Overgrowth of head obstructing labor. weight above the normal. So much difficulty and danger may be experienced from this cause that it is a good rule in practice to allow no woman to exceed the normal duration of pregnancy by more than two weeks. By inducing labor at that time one will occasionally interfere unnecessarily, but he will often avoid complications and difficulties of the most serious nature. Oversize and advanced age of one or both parents may be a cause of overgrowth in the fetus—the latter usually because it predisposes to a prolongation of pregnancy. It is commonly ANOMALIES IN THE FORCES OF LABOR. 507 asserted that the size of children increases in successive pregnan- cies up to the fourth or fifth, and then remains stationary or even decreases ; but there are important exceptions to this rule. The writer has seen the tenth child vastly exceed in size the nine pre- ceding ; it weighed 15 pounds, and it was necessary to deliver it by Cesarean section. The other children had been born natu- rally through a flat pelvis with a conjugate diameter of nine centi- Fig. 376.—Craniopagus. Fig. 377.—Ischiopagus parasiticus. meters. The increase in size of successive children must be borne in mind in cases of contracted pelvis. The first two or three infants may be delivered spontaneously, but the larger size of the fourth or fifth may make natural delivery impossible.x 1 Lehmann in 712 labors through 198 contracted pelves found increasing diffi- culty in delivery with each succeeding labor. In first labors 50 per cent, ended spon- taneously ; in second, 43.8 ; in fourth, 38.4; in fifth, 33^ ; and in labors after the fifth only 9.8 per cent. ("Diss. Inaug.," Berlin, 1891). 508 THE PATHOLOGY OF LABOR. Overgrowth of the fetus is the most difficult condition in obstetric practice to diagnosticate with precision. A careful pal- pation of the head and body and an attempt to push the former into the pelvic inlet may give one an approximate idea of the Fig. 378.—Dipygus (Wells). Fig. 379. —Dipygus parasiticus. Fig. 380.—Prosopothoracopagus. Fig. 381.—Xiphopagus. Fig. 382.—Janiceps. relative size of fetal body and pelvic canal, but as a matter of fact the large size-of the fetus is usually discovered in practice only after prolonged delay when attempts at artificial delivery, especially by version, have failed. By this time the fetus is com- ANOMALIES IN THE FORCES OF LABOR. 509 monly dead, and should be delivered by embryotomy. But the practitioner must be on his guard against futile attempts to de- liver an infant too large, even when mutilated, to pass through the pelvis. The writer has seen, in consultation practice, several maternal deaths due to this cause. Premature Ossification of Cranium ; Wormian Bones;x Large Heads ; Malformations and Tumors of the Fetus.—No single rule Fig. 383.—Dicephalus : neither head engaged. of treatment can be laid down for the management of these cases. Forceps, version, or some form of embryotomy is usually de- manded. Spontaneous labor, however, is possible even in cases of monstrous bulk in which delivery through the birth-canal 1 Dr. Grace Peckam ("New York Med. Record," April 14, 1888) has reported three still-births, attributed in each instance to the development of Wormian bones in the smaller fontanel, and to the consequent interference with overlapping of the cra- nial bones at the sutures. This observation has not yet been verified by others. 5io THE PAIHOLOGY OF LABOR. Fig. 384.— Hydrencephalocele (anterior). Fig- 385'—Sacral teratoma obstructing labor. ANOMALIES IN THE FORCES OF LABOR. 5H would seem out of the question. Thus, in double monsters joined loosely by the front or back (xiphopagus, the Siamese twins ; pygopagus, the Hungarian sisters), one child will be born Fig. 386.—Sacral teratoma. by the head, the other afterward by the breech, or vice versa. In dicephali one head may be pressed into the neck of the other or may rest upon the iliac bone of the mother until the first head makes its escape from the vulva. Even in thoracopagus, the Fig- 387-—Myxoma of neck Fig. 388.—Sacral tumor (Mutter (Longaker). Museum, College of Physicians). commonest double monstrosity, in which two trunks are inti- mately joined front to front, spontaneous labor is possible by the mechanism shown in figures 390 and 391. On the other hand the 512 THE PATHOLOGY OF LABOR. greatest difficulty may be encountered in labor, and the most serious operation may be demanded to deliver the woman. Fig. 389.—Anasarca. Fig. 390.—Mechanism of labor with Fig. 391.—Mechanism of labor in thora- dicephalus (Kiistner). copagus (Kiistner). Fetal tumors obstructing delivery may be hydrencephaloceles, lymphangiomata, myxomata, sacral teratomata. Cystic tumors 1 There are two recorded deliveries of thoracopagi by Cesarean section (Hirst and Piersol, "Human Monstrosities"). ANOMALIES IN THE FORCES OF LABOR. 513 should be punctured. Solid tumors may call for version or for embryotomy. Craniotomy may be required in monstrous en- largement of the cephalic extremity, as in syncephalus or in diprosopus. Decapitation may be necessary in duplicity of the cephalic extremity, as in dicephalus or in thoracopagus. In Reina's case of tricephalus the first head was perforated and then amputated, the second was perforated, crushed, and amputated, and the third was amputated. Diseases and Death of the Fetus.—All diseases of the fetus that increase its bulk may constitute thereby an obstruction in labor. Cystic tumors, effusions in the serous cavities, anasarca, an enlarged liver, polycystic disease of the kidneys,1 and distended bladder from atresia of the urethra 2 are examples. Liquid accumulations should be evacuated by puncture or by incisions. Hydrocephalus is the most important of the diseases increasing fetal bulk. It is not very rare,3 is often overlooked, and is a frequent cause of ruptured uterus. The diagnosis may be made by a vaginal examination, by abdominal palpation, and by a com- bined examination, or, if necessary, by anesthetizing the woman, introducing the whole hand into the vagina, and thoroughly palpating the enlarged head resting above the pelvic brim. The gaping fontanel, the great width of the sutures, the fluctua- tion to be felt perhaps in these regions, the large size of the head appreciated by bimanual examination, and possibly the ab- normal mobility of the cranial bones, and in some cases their extreme tenuity, indicate the condition. Hydrocephalus is very often overlooked in practice as the result usually of a careless, superficial examination. A painstaking and methodical investi- gation of a suspected case should obviate this error. There are cases, however, in which there is no increased width of the sutures, no enlargement of the fontanels, and such slight en- largement of the head that it can not be appreciated ; and yet the fluid contents of the cranium prevent compression of the skull and make the engagement of the head impossible. The writer has seen one such case (see Fig. 392). Hydrocephalus should always be suspected if the head in labor remains above the brim, although the pelvis is normal in size and no good reason can be found for the failure of engagement. 1 Fussell, "Med. News," Philadelphia, 1891, p. 40. 2 Schwyzer (" Archiv f. Gyn.," Bd. xliii) has collected 13 cases of dilatation of the fetal bladder from atresia of the urethra, stenosis of the urethra, and obstruction of the urethra by a valve-like formation of mucous membrane. Miiller reports a case and quotes another ("Archiv f. Gyn." Bd. xlvii, H. 1). 3 Schuchard found it sixteen times in 12,055 births ; Lachapelle and Duges, fifteen times in 43,555 ; Merriman, once in 900. In 159 cases there were 38 maternal deaths, 20 of which were from rupture of the uterus. 33 5H THE PATHOLOGY OF LABOR. The treatment of labor obstructed by hydrocephalus is punc- ture of the cranium with a perforator and evacuation of its fluid contents. A child with this disease deserves no consideration. After the reduction in the size of the head the labor may be left to the natural forces. If these prove insufficient, a cranioclast may be fastened to the skull and the child be extracted artificially. A cardinal rule in the treatment of these cases is to avoid at- tempts to deliver with forceps—a common error in practice, and one that has cost many a woman her life from ruptured uterus, Fig- 392.—Hydrocephalus: very Fig. 393.—Hydrocephalus : enormous moderate distention of the cranium, but collection of fluid (author's collection: sufficient to prove an insuperable ob- specimen presented by Dr. Alex. Fulton). stacle in labor. from deep tears when the instrument slips, as it will, and from extensive sloughs after delivery. If the pelvic extremity of the hydrocephalic fetus presents,— as it does in almost a third of all cases,—and if the head remains inaccessible above the superior strait, so that it can not easily be punctured, the spinal canal may be opened, a catheter be passed through it into the cranial cavity (Van Huevel's method), and the fluid thus be evacuated (Fig. 394). Usually, however, there is no special difficulty or danger in the delivery of the after- ANOMALIES IN THE FORCES OF LABOR. 5 I 5 coming head of a hydrocephalic infant. The force required for its extraction not infrequently ruptures the walls of the ventricles and converts the case into one of external hydrocephalus, or possibly drives the fluid out of the foramen magnum into the tissues of the neck and back, so reducing the bulk of the head as to permit its extraction. At any rate, the condition can Fig. 394-—Tapping a hydrocephalus through the spinal canal (Varnier). scarcely escape the notice of the medical attendant, and a diag- nosis is made before the lower uterine segment is dangerously stretched or ruptured. The difficulty in the delivery of a hydrocephalic fetus is not in direct proportion to the quantity of fluid in the ventricles and the size of the head. In cases of extreme distention, the cranial 5 16 THE PATHOLOGY OF LABOR. vault is likely to rupture, while in moderate grades of hydro- cephalus the quantity of brain-substance surrounding the ven- tricles and the strength of the brain-membranes forbid this means of spontaneous delivery. Malpresentations and faulty positions include shoulder, face, brow, deviated vertex, and compound presentations. All but Fig. 395.—Compound presentation : head and hand. Braun's section of a multipara who committed suicide by hanging in the last month of pregnancy: a, Venous sinuses ; b, uterovesical reflection of peritoneum; c, symphysis pubis; d, bladder ; e, vagina ; /, first lumbar vertebra ; g, promontory of sacrum ; h, rectum; i, cervix ; j, pouch of Douglas. the last are considered elsewhere. By compound presentation is meant the presentation of two or more parts at the same time, as a head and a hand, a head and a foot, a hand and a foot, nuchal position of the arm, or the head and all four extremities. A compound presentation is met with about once in 250 ANOMALIES IN THE FORCES OF LABOR. 5 17 labors. It is usually a head and a hand. The following table is furnished by Pernice from 2891 births in the clinic at Halle : Hand and head,.....................26 Arm and head,......................8 Hand and umbilical cord,.................5 Both hands,.......................4 Foot and hand,...................2 Two hands, umbilical cord, and foot,............. I Face, hand, and cord,................... I Kietz found in 7555 labors the foot and head presenting in 23.x The cause of compound presentations is usually a lack of Fig. 396.—Compound presentation : head and foot (author's case). conformity in the presenting part with the pelvic inlet, as in mal- position of the fetus, a head of abnormal size, a displaced uterus, twins, hydramnios, contracted pelvis, and anomalous shape of the uterus. In the treatment of compound presentations before rupture of the membranes an attempt should be made to overcome the difficulty by postural treatment. The woman should be placed on that side opposite the prolapsed extremity. After rupture of the membranes an attempt should be made to dislodge the pro- lapsed extremity and to restore it to its natural position. Version 1 " Diss. Inaug.," Berlin, 1890. 5i8 THE PATHOLOGY OF LABOR. may, however, be required if this attempt fails, or even crani- otomy if the child is dead. If the head and extremities present, and if the former is engaged, it is usually best to apply forceps and to disregard the prolapsed extremities. In the case of nuchal position of the arm, an effort should be made to dislodge the latter, but it may be necessary to fracture it before the delivery of the child can be secured. Fig- 397-—Twins ; breech and face presentations. Multiple Births.—Twin labors are usually easy and uncom- plicated (75 per cent.), but complications are more frequent than in single labors. Malpresentations are common. The following table from Spiegelberg, based on 1138 labors, gives the combined presentations in the order of their frequency: Both heads presenting, . Head and breech, . . . Both pelvic presentations, Head and transverse, . . Breech and transverse, Both transverse, .... 49 per cent. 3L70 8.60 6.18 4.14 •35 ANOMALIES IN THE FORCES OF LABOR. 519 It may be noted that a transverse position is found in 10.67 per cent, of cases. Mechanical difficulties in labor are frequent: the uterine muscle is usually weakened by overstretching, and there may be trouble in the third stage of labor in the delivery of the placenta. Some form of operative interference is demanded in about 25 per cent, of all cases. Fig. 398.—Impaction of heads in twin labor. Fig. 399.—Locking of heads in twin labor. In the majority of cases (79 per cent.) the interval between the delivery of twins is less than an hour. A longer delay than this indicates the likelihood of some obstruction to the birth of the second infant or a failure of expulsive forces. Serious difficulty in twin labors may arise in one of three ways : Both heads present at once, one a little in advance of the other, the second impacted in the neck of the first (Fig. 398) ; the first 520 THE PATHOLOGY OF LABOR. child descends by the breech, and the head of the second child is caught by the chin of the first and pushed into the pelvis (Fig. 399); one child sits astride of the other, which is transverse. If both children should be found attempting to engage by the head in the superior strait at one time, one child should be retarded while the other is artificially extracted. If this is impossible, the first head should be extracted by forceps, the second be treated in like manner, and then the trunks should be delivered one after the other. Embryotomy is a last resort, but is scarcely ever necessary. A coiling of the cords (Fig. 400) and their entanglement may be a source of difficulty and delay in unioval twins. It may be necessary to cut one or both cords between ligatures before the children can be delivered. In case one child presents by the head and the other by the feet, both may come down together, and the two heads become locked in the pel- vic entrance and canal. An effort may be made to push back the child presenting by the head. If this suc- ceeds, the child presenting by the breech should be extracted immedi- ately, for it is in imminent danger from asphyxia. It may be possible with forceps to pull the child pre- senting by the head past the body of its fellow presenting by the breech. Failing in these attempts, the child presenting by the breech will almost surely have died, and there will be no pulsation in its cord. It should then be decapitated, whereupon the infant presenting by the head can be extracted without difficulty by forceps. In any case of twin labor, as soon as the first child is born, and the cord, ligated with a double ligature, is cut, the attendant should immediately investigate the position and presentation of the second child. A neglect of this rule leads very often to the impaction of an unrecognized shoulder presentation in the second child, and its consequent death. If an abnormality is discovered in the presentation of the second child, it should at once be cor- rected. Then, after waiting perhaps half an hour, the amniotic sac should be ruptured, and ergot may be administered in a full Fig. 400.—Entanglement of cords in twins (Winckel). ANOMALIES IN THE FORCES OF LABOR. 52 I dose to secure a speedy delivery, or, if the stomach will not retain it, the hypodermatic syringe should be used, for, the birth- canal having been dilated thoroughly, there is no obstacle to the birth of the second infant in twin labors, and consequently no objection to the employment of ergot, which not only hastens the conclusion of labor, but promotes subsequent contraction of the much-distended uterus, and so prevents postpartum hemorrhage. As a further precaution against this accident which is always Fig. 401.—Twins, head and breech (modified from Hunter). threatened in twin labors, the fundus should be compressed for an hour or two after birth by the nurse. There may be difficulty in the delivery of the placentae in twin labors. Commonly the children are born first and the placentae afterward. Their bulk may make expression difficult, and it is often necessary to make^some traction upon the cords—first upon one and then upon the other—to determine which placenta will 522 THE PATHOLOGY OF LABOR. come first and to assist in its expulsion. Occasionally one and rarely both placentae may be expelled after the birth of the first child. In a case of the writer's the placenta of the first child, prolapsing in front of the second, necessitated a difficult forceps operation for the extraction of the second. On account of the frequent and extensive anastomoses between the vessels of the placentae in unioval twins it is a necessary precaution to tie the cord of the first child with a double ligature and to cut it between the ligatures ; otherwise the second infant might bleed to death. The prognosis of twin labors is always doubtful. There are so many possible dangers for both mother and children that multiple labors must be regarded as distinctly pathological. Albuminuria in the mother is the rule in multiple pregnancies, and eclampsia is ten times more frequent than in single births.1 There is a disposition to inertia uteri during and after birth from distention of the cavity, and consequently a likelihood of post- partum hemorrhage. Some operative interference or intra- uterine manipulation is called for in about twenty-five per cent. of cases, and this, in addition to the frequency of kidney insuf- ficiency, predisposes to sepsis. Finally, there may be insuperable obstruction in labor if locked twins are not managed properly, and the woman may die of ruptured uterus or of exhaustion. The maternal mortality in the Budapest Maternity was four times as great as in the single births, and Kleinwachter's statis- tics give a mortality of thirteen per cent. For the children there is greater danger than for the mother. Twin pregnancy is almost always prematurely interrupted, and even if it is not the children are, as a rule, under the normal size and weight. There is always the possibility that the development of one child at least will be seriously interfered with by the lack of room in the uterine cavity. Hydramnios of one sac and oligohydramnios of the other are not uncommon. In labor there are frequently complications from malposition, operative interference, entangle- ment of or pressure upon the cords, and more rarely the engage- ment of both bodies at once in the pelvic canal. In Klein- wachter's and Kezmarszky's statistics the fetal mortality was nearly forty per cent. Of thirty-eight children in cases of locked twins, only six survived,—a mortality of eighty-four per cent. Cases are on record in'which an extra-uterine fetus has obstructed the delivery of the intra-uterine twin. It has been necessary to make a vaginal incision through which the former was extracted before the latter could be born. Death of the fetus during or before labor, followed by rigor 1 Of 627 cases of eclampsia, 69 were multiple pregnancies (Winckel). ANOMALIES IN THE FORCES OF LABOR. 523 mortis, has proven a source of obstruction in labor by the rigidity of the child and the consequent interference with the normal mechanism of its delivery, especially of the shoulders and trunk.x Ankylosis of the large joints of the extremities may have the same effect to a less degree. Labor Complicated by Abnormalities in the Fetal Appendages.— Membranes.—If the membranes are too thin, they may rupture prematurely, and thus give rise to what is called a " dry labor," in which the birth-canal must be dilated by the hard, unyielding presenting part instead of by that conservative hydrostatic dilator, the bag of waters. Such labors are longer and more painful than the average, and there is a greater likelihood in them of lacerations in the cervix and a more frequent demand for an artificial termination with forceps. If the membranes are too thick, they rupture late, being preserved perhaps until the child's head presents at the vulvar orifice, or even until the complete escape of the head from the mother's body. In these cases the head and face are covered by the membranes as though by a veil, and care must be taken to free the mouth and nose quickly, that respiration may be instituted without interference. The mem- branes thus covering the head and face are spoken of as a " caul." It is possible for the whole ovum to be extruded unbroken at term. The writer has seen this occur as late as the seventh month, and it is actually recorded at the full period of gestation. Difficulties in labor may be encountered in consequence of an abnormality in the quantity of liquor amnii. If there is too little, the labor has the same clinical features as though there had been a premature rupture of the membranes. If there is too much liquor amnii, there may be inertia as the result of overstretching of the uterine muscle-fibers. Umbilical Cord.—If the umbilical cord is too short, it may cause premature detachment of the placenta or may prevent the advance of the child. The diagnosis of a short cord in labor is always difficult. It may be suspected, however, if there is exaggerated pain at the placental site, marked recession of the head after each pain, and an obvious retardation of labor without other ascertainable cause. Forceps should be applied in such a case if the presentation is cephalic. If the cord is too long, it may possibly prolapse should there be other conditions in the labor favorable to such an accident; or it may be coiled about the child's neck, trunk, or extremities, and may consequently be fatally compressed during labor (Fig. 402). Obstruction of a mechanical character in labor on the part of 1 Feis, "Ueber intrauterine Leichenstarre," "Archiv fur Gynakologie," Bd. xlvi, H. 2. 5^4 THE PATHOLOGY OF LABOR. the placenta is seen only in placenta prasvia and in prolapse of the placenta. The placenta may be adherent as the result of syphil- itic or other inflammation of the endometrium during pregnancy, and, becoming partially detached in the third stage, may cause alarming hemorrhage. It is very commonly simply retained in Fig. 402.—Placenta praevia: umbilical cord, caught in the axilla, encircling the shoulder and prolapsed (Hunter). the lower uterine segment or in the vagina, whence it may be expressed by the proper application of Crede's method. In some cases the atmospheric pressure obstructs the delivery of a retained placenta so effectually that it is necessary to hook one's finger over the edge of it, to allow the access of air behind it, LABOR COMPLICA TED B YACCIDENTS AND DISEASES. 525 before its expression is possible. Retention of the placenta may be due to its great bulk, as in twin placentae, or to tumors increasing its size. In such cases it may be necessary to extract the placenta manually. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. Hemorrhage.—One of the gravest and, unfortunately, one of the commonest accidents during and directly after labor is hemor- rhage. The causes of hemorrhage during the first and second stages of labor are placenta praevia, premature separation of a normally situated placenta, rupture of the uterus, lacerations along the lower birth-canal, and rupture of a blood-vessel or of a hematoma. The causes of hemorrhage during the third stage of labor and directly afterward are relaxation of the uterus, lacera- tions of the birth-canal, rupture of blood-vessels or of hema- tomata. Placenta Praevia.—By placenta praevia is meant the attach- ment of the placenta to the lower uterine segment. In some varieties of the condition the placenta presents itself first to the examining finger, and may even emerge before or in front of the child ; hence the name. History.—Early writers (Guillemau and Mauriceau, 1609- 1668) recognized placenta praevia, but they explained it as an accidental prolapse of the placenta. Portal (1685) described it more correctly, though indistinctly. Schaller (1709) demon- strated the condition in the dissection of a body. From Levret's time placenta praevia was well understood. Rigby (1789) defines it as the attachment of the placenta to that part of the womb which always dilates as labor advances—a definition that is strictly accurate to-day. It is to Rigby, too, that we owe the term "unavoidable hemorrhage " to describe the hemorrhage of placenta praevia, as opposed to the "accidental hemorrhage" from premature detachment of a normally situated placenta. Frequency.—Placenta praevia varies in the frequency of its occurrence in different localities and at different times, as the following table demonstrates : Cases of Number of Placenta Reporter. Labors. Previa. Proportion. C. V. Braun............ 7,853 15 1-522 Hugenberger............ 8,036 42 I-191 Lomer............... 6,862 136 1-50 Winckel (1873-78)......... 6,324 7 1-903 Winckel (1879-87)......... 8,500 30 1-283 Miiller..............876,432 813 1-1078 Luck............... 1,550 o 0-0 Schwarz..............S'9,328 332 i-T564 Midwives'report in Saxony (1878) . . 119,553 7$ l-T532 526 THE PA THOL OGY OF LABOR. The frequency of placenta praevia may be estimated at about I in 1200 labors. If the situation of the placenta were investi- gated by a careful examination of the rent in the membranes after every labor, placenta praevia would be found quite fre- ig- 403-—Central placenta praevia, the os partly dilated (Hunter). quently. In my experience it has occurred about once in 300 labors ; but in only a quarter of the cases was the condition manifested before and during labor by its most characteristic symptom, hemorrhage. LABOR CO MP LICA TED BY A CCIDE NTS AND DISEASES. $2/ Etiology.—A perfectly satisfactory explanation for the occur- rence of placenta praevia has not yet been found. Clinical ob- servation shows that any chronic inflammation or congestion of the womb predisposes to it. Hence placenta praevia is three to six times more common in multiparae than in primiparae, and is more often met with in the working classes. Uterine myomata and carcinoma of the cervix are predisposing causes, on account, no doubt, of the endometritis that accompanies them. Ingelby reports two cases of abnormally low situation of the tubal orifices, in one of which placenta praevia occurred three times ; in the other, ten. Multiple pregnancies, according to Winckel, furnish four times as many cases of placenta praevia as do single preg- nancies, and a woman beginning to bear children late in life is liable to placenta praevia in subsequent pregnancies. Uterine malformations are apparently a predisposing cause. A case is reported by Schwarz of uterus bicornis in which placenta praevia recurred three times. Hofmeier and Kaltenbach1 furnish the best explanation for the abnormal situation of the placenta. These observers have demonstrated, by the examination of young ova, that the chorion villi in the lower pole of the ovum may develop in an hyper- trophied decidua reflexa, thus carrying the placenta down to and across the internal os. At first an adhesion between the decidua vera and the reflexa is prevented by catarrhal discharge, but as the ovum develops the reflexa may adhere to the vera, thus fixing the placenta in its abnormal situation, permitting its con- tinued growth, and giving rise to an apparent hypertrophy of the decidua serotina. Varieties.—Four divisions are made of cases of placenta praevia —central, partial, marginal, and lateral. In the first the center of the placenta lies over the internal os; in the second the greater mass of the placenta lies upon one side of the lower uterine segment, usually the left (56 : 37, Miiller), though the in- ternal os is completely covered by it; in the third a margin of the placenta projects over the internal os ; in the fourth the placenta is situated upon one side of the lower uterine segment and only the edge of it projects into the cervical canal, if it does so at all, when the os is fully dilated. This classification is justified upon clinical grounds. In central and partial placenta praevia the hemorrhage begins early in pregnancy, is profuse and frequently repeated, and in labor is more dangerous than is the hemorrhage of the lateral variety. There is an added difficulty, too, on account of the obstruction offered by the placenta, 1 " Lehrbuch der Geburtshulfe." 528 THE PATHOLOGY OF LABOR. stretched across the internal os, to the spontaneous descent of the child, or to the physician's efforts to reach and extract it. In lateral placenta praevia hemorrhage usually does not occur till labor is well advanced, and often does not appear at all. Lateral and marginal placenta praevia are the commonest varieties. In 270 cases the placenta was marginal and lateral 217 times ; cen- tral and partial 53 times (Winckel). Strictly speaking, central placenta praevia is very rare. There is almost invariably more of the placenta on one side the internal os than on the other. Fig. 404.—Varieties of placenta praevia: in A there are seen the normal, lateral, and marginal implantation; in B there are represented the implantation of the pla- centa at the fundus, which is rare, and implantation over the internal os ; in C lateral implantation and that of a cotyledon immediately over the internal os; and in D partial implantation (Dickinson). Clinical History.—A woman with placenta praevia may begin to bleed as early in pregnancy as the second month, but the first hemorrhage usually occurs in the last trimester. There is a sudden gush of blood, often without apparent cause and without pain. The bleeding commonly recurs in increasing amounts and at de- creasing intervals as pregnancy advances. In very rare cases the blood leaks away continuously (stillicidium), though this is LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 529 more characteristic of the premature separation of a normally situated placenta. The cause of the hemorrhage during preg- nancy is the impact of the embryo and fetus upon the placenta, the pressure of the ovum upon the lower uterine segment, and the imperfect attachment of the placenta in certain areas to the uterine wall. A prediction of the amount of bleeding in labor can not always be made by the amount of blood lost or the fre- quency of the hemorrhages in pregnancy. The first hemorrhage may occur in labor, which may be ushered in by a tremendous outpour of blood, even in lateral placenta praevia. Ordinarily, however, the greater the bleeding during pregnancy, the more likelihood is there of serious hemorrhage in labor. The bleed- ing in labor is easily explained. The placenta is attached in that portion of the uterine cavity which must be dilated to allow the advance of the presenting part. The stretching of the uterine walls expands the area of the placental site, and necessarily de- taches the placenta, while the reversal of the ordinary mechanism of placental detachment keeps the gaping mouths of the torn uteroplacental vessels wide open, and allows the blood to pour from them till the hemorrhage is checked by syncope, by throm- bosis, by the pressure of the presenting part, or by a vaginal tampon. The source of the bleeding in rare cases is a rupture of the circular sinus of the placenta, a laceration of the fetal vessels or of the cervix. The bleeding is usually most profuse just as the uterine con- traction passes off. During the height of the pains it may cease altogether, from the pressure of the presenting part or of the intra-uterine contents upon the placental site. As the placenta occupies a portion of the space in the lower uterine segment and may prevent the descent of the presenting part, abnormalities in the presentation and position of the fetus are common. Transverse and oblique positions are ten times, breech presentations four times, more frequent than in normal labor. In the first stage of labor, inertia uteri is common, partly be- cause the cervix is not pressed upon and reflex irritation is absent, partly on account of the loss of blood. The os is usually patulous, even before labor begins, and the cervical canal is easily dilated. Occasionally, however (twelve per cent.), the os is contracted and the cervix rigid. The insertion of the cord is often marginal or velamentous, and prolapse of the cord is common. The placenta is often anomalous in shape, size, thickness, and weight. There is frequently a placenta succenturiata. As the os dilates the placenta may be torn and thus separated into two 34 53O THE PATHOLOGY OF LABOR. parts. An adherent placenta may be expected in more than a third of the cases (Miiller, thirty-nine per cent.). After labor there is a tendency to inertia, and consequently to postpartum hemorrhage, and there is an extraordinary liability to septic infection. Placenta praevia, as a complication in labor, would be much more common than it is if it did not so often interrupt pregnancy. The frequency of abortion and miscarriage is placed in different statistics at forty to sixty per cent. In quite a large proportion of cases placenta praevia would be unrecognized in labor without a careful examination of the membranes and placenta afterward. Even in the marginal variety the presenting part, unobstructed, may descend quickly, exerting such pressure upon the placental site that bleeding does not occur. Symptoms and Diagnosis.—Repeated hemorrhages during the latter part of pregnancy make the diagnosis of placenta praevia almost certain. On digital examination the cervix is found enlarged in all directions ; the vaginal vault is soft and boggy ; the presenting part can not be plainly felt; pulsating vessels are detected around the. cervix; the external os is dilated and the cervical canal is patulous to the internal os, through which a finger can easily be pushed. Under favorable conditions the placenta may be felt through the abdominal walls, as was first pointed out by Spencer. Finally the maternal face of the placenta or its margin is felt over the internal os, the uneven surface of the cotyledons and a gritty feel distinguishing it from a blood-clot, the membranes, or the presenting part. During the first stage of labor the causes of hemorrhage are lacerations of the birth-canal, rupture of blood-vessels, and placenta praevia. The hemorrhage of placenta praevia occurs early, with unruptured membranes, with feeble pains or in their absence altogether, and the symptoms of uterine rupture and of lacerations along the lower birth-canal are absent. In the rare event of a ruptured blood-vessel along the lower birth-canal, the blood would not flow from the uterine cavity. Treatment.—If a placenta praevia is detected during preg- nancy, gestation should be terminated at the end of the seventh month, or at any time thereafter that the diagnosis is estab- lished. The hemorrhage before the thirty-second week is scarcely ever dangerous, * though in one case I was obliged to induce abortion before the fifth month on account of a loss of blood that was almost incessant. After the seventh month the 1 In the 128 deaths of Midler's statistics there was not one before the seventh month. LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 53 I Fig. 405-—One leg has been drawn down, so that the os is tamponed and the placenta directly compressed by the hips of the child (Miiller). 532 THE PATHOLOGY OF LABOR. woman may bleed to death at any time before medical aid can reach her. The induction of labor and its conduct should be as follows : Send for an assistant to administer an anesthetic; place the woman in the lithotomy position, with her knees sup- ported by nurses or attendants ; cleanse both hands and arms as for a surgical operation ; wash out the vagina with tincture of green soap and hot water by means of pledgets of cotton ; give a vaginal douche of bichlorid of mercury i : 4000 ; dilate the cervix by inserting first one finger, then a second, and next the Fig. 406.—Placenta praevia: vagina tamponed with gauze (Dickinson). thumb of the right hand ; search on the woman's left side for the edge of the placenta ; pass two fingers beyond it; perform bipolar version, assisted by the left hand externally ; rupture the mem- branes ; seize a foot and extract it until the knee appears -at the vulva; then withdraw the anesthetic. If the bleeding has been alarming up to this time, it will cease as soon as the child's breech is impacted in the pelvic canal. From time to time the protruding leg may be gently pulled upon to hasten the dilatation of the cervical canal, but plenty of time must be allowed for this ■ LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 533 otherwise the head will be caught by the circular fibers of the cervix and the child will be asphyxiated by the pressure upon the cord. At the expiration of an hour or more the child may be safely extracted. If the operator finds a rigid cervix and experiences great difficulty in its manual dilatation, he may employ Barnes' bags ; but under anesthesia, and with a fair amount of strength in one's fingers, hydrostatic dilatation will scarcely ever be required. If a physician discovers placenta praevia for the first time in labor by a profuse outpour of blood when the dilatation of the cervical canal begins, he should imme- diately pack the vagina as full as it can possibly be packed. The best material for this purpose is iodoform gauze if it is at hand, but a clean towel torn into strips will answer. The tampon serves the double purpose of surely controlling the hemorrhage and assisting the dilatation of the os. After a delay of an hour or two to allow time for the os to dilate, the patient is anesthe- tized and the operator proceeds as before described. If there is great difficulty in finding the margin of the placenta and the membranes beyond it, too much time should not be lost in the search. The placenta should be perforated and the child's leg pulled through the perforation. If the operator distrusts his ability to perform the version as quickly as it should be done (for the hemorrhage is likely to be furious during the attempt), he may adopt a plan of treatment proposed by Wigand at the end of the last century. This consists in tamponing the vagina firmly and allowing the tampon to remain in place till the os is fully dilated. If the labor lasts too long, the tampon must be removed, the vagina douched, and a fresh tampon inserted. It is well to unite with the tampon treatment the procedure recommended by Barnes—separating the placenta by a sweep of the fingers around and beyond the internal os. This plan was suggested by the clinical observation that when the placenta separated and the presenting part descended the hemorrhage ceased. The com- bination of the Barnes and the Wigand treatment gives fairly good results so far as the mother is concerned, though it increases the risk of the sepsis. For the child it would seem to be bad, but we have testimony from Wigand, Murphy, and Winckel to the contrary. The fetal mortality is 48.5 per cent. (Winckel). In cases of marginal placenta praevia in which hemorrhage first occurs after the os is fairly well dilated, in which the head presents and is easily accessible, the best treat- ment is rupture of the membranes, application of forceps, and traction upon the head till the bleeding ceases ; whereupon the instrument may be removed and the labor allowed to terminate spontaneously. 534 THE PATHOLOGY OF LABOR. It may finally be necessary to detach an adherent placenta, to control a postpartum hemorrhage, and to treat the woman for acute anemia. Prognosis.—The study of the mortuary statistics of placenta praevia is not very profitable. It appears that the maternal death- rate in general has been about forty per cent., including the deaths from sepsis. But with the plan of treatment just described, car- ried out by men who understand aseptic methods, the mortality almost disappears. Thus, Lomer (16), Hofmeier (37), Behm (35), and the writer (16) have had 104 cases, with I death (Hof- meier's). For the children a mortality of fifty per cent, and over may be expected. The outlook for the child is worse the more nearly the placenta praevia is central. Fig. 407.—Showing separation of the placenta with external bleeding (Dickinson). Premature Detachment of a Normally Situated Placenta.—The placenta may become detached during pregnancy or before the third stage of labor, though it occupy a normal position near the fundus uteri. The necessary consequence is hemorrhage, often called " accidental," to distinguish it from the " unavoidable " hemorrhage of placenta praevia. If the lower margin of the pla- centa is detached, the blood separates the.membranes from the uterine wall and escapes externally. The bleeding may, how- ever, be entirely concealed (1) if the center of the placenta is alone detached ; (2) if the upper margin is detached and the blood accumulates between the membranes and the uterine wall ; LABOR COMPLICA TED B Y A CCIDENTS AND DISEASES. 535 (3) if the membranes are ruptured far from the internal os and the blood mingles with the liquor amnii ; (4) if the cervix is ob- structed by a blood-clot, the membranes, or the presenting part (Goodell). Concealed hemorrhage is, fortunately, rare. Causes.—The cause of premature detachment of the placenta may be obscure. The accident may occur during sleep and without ascertainable cause. The causes are often, however, those of abortion : nephritis, congestion of the pelvis, external violence, physical effort, emotion. Prolongation of pregnancy, with irregular uterine con- tractions, was accountable for one of my cases. Death and disease of the fetus, hydramnios, a short um- bilical cord, and multiple pregnancy may cause it. It occurs more frequently in multiparae and toward the close of pregnancy. Symptoms and Diagno- sis. — Accidental hemor- rhage, especially if con- cealed, should be recog- nized without delay. The accident usually occurs be- fore labor begins or in the first stage. The uterine contractions become weak and finally cease, being re- placed by persistent and severe pain, usually at the placental site. There is shock, the signs of internal hemorrhage become more and more apparent, and the uterus is distended by the accumulation of blood within it. Feeble but persistent contrac- tion of the upper part of the uterine muscle may be felt. If there is a retroplacental effusion, a localized bulging at the placental site may be made out by abdominal palpation. The symptoms resemble somewhat those of rupture of the uterus. In both there are hemorrhage, shock, and perhaps sud- den excruciating pain. But in rupture of the uterus the accident occurs late in labor, the membranes are broken, the presenting part recedes, the uterus is well contracted, and perhaps its con- Fig. 408.—Premature detachment of the placenta occupying its normal site. Frozen section of an undelivered woman dead of eclampsia. A blood-mass under the placenta (after Winter). 536 THE PATHOLOGY OF LABOR. tents are evacuated into the peritoneal cavity ; while in accidental hemorrhage the detachment of the placenta occurs early in labor, the membranes are not ruptured, the presenting part does not recede, and in concealed hemorrhage the uterus is distended by the accumulated blood. In frank accidental hemorrhage the diagnosis rests between detachment of a normally situated pla- centa and placenta praevia. The presence or absence of the latter is determined by a careful internal examination. In exceptional cases a frank accidental hemorrhage appears as early in pregnancy as the fourth month. Abortion usu- ally follows, but I have seen two cases in which the bleed- ing continued uninterruptedly for weeks, a large blood-clot formed between the site of the placental separation and the external os, and septic symptoms supervened. In spite of these unfavorable con- ditions pregnancy continued, and the fetus lived until I was obliged to terminate gestation on account of the anemia and the symptoms of systemic in- fection. Prognosis.—The mortality in accidental hemorrhage is high. Goodell's statistics, the best ever collected, give 54 maternal deaths out of 107 cases, and of the 108 children (there being one case of twins) only 7 were saved. Treatment.—The main ob- ject of treatment is to evacuate the womb as speedily as possible, so that the uterine muscle may contract. At the same time it must be remembered that the woman is in no condition to endure much additional shock. The best procedure is to dilate the cervix with Barnes' bags or with the fingers, to perforate the membranes, and then to extract the child by the quickest plan available. If the presenting part is not engaged, the child should be rapidly extracted by the leg. If the head is engaged and a rapid forceps operation is practicable, the instrument should be employed. If not, crani- Fig. 409—Accidental hemorrhage. Blood collected between placenta and part of membranes and the uterine wall (Pinard and Varnier). LABOR COMPLICA TED BY ACCIDENTS AND DISEASES. 537 otomy should be performed. Ergot should be administered hypodermatically, for postpartum hemorrhage is to be feared. A Porro-Cesarean section should be considered in the gravest cases, in which a continuance of hemorrhage and the shock of a forced delivery are more to be dreaded than abdominal section and puerperal hysterectomy. Postpartum Hemorrhage.—Hemorrhage may occur during the third stage of labor, or in the first twenty-four hours of the puer- perium, from relaxation of the uterine muscle, from injuries along the birth-canal, from ruptured vessels, tumors, malignant growths, or ulceration in the parturient tract. Postpartum Hemorrhage from Relaxation of the Uterine Muscle. —When the placenta is separated from the uterine wall and the large maternal blood-vessels communicating with it are neces- sarily torn across, every woman after labor would bleed to death were it not for the following provisions on the part of nature to prevent hemorrhage: Leukocytes begin to block the uterine sinuses in the latter weeks of pregnancy, and the excess of the fibrin-making elements in the blood of pregnant women, together with the sluggish blood-current in the sinuses, favor the forma- tion of firm blood-clots in their orifices when they are torn ; the uterine muscle contracts the moment the uterine cavity is emptied, so that the blood-channels running through the uterine walls are ligated throughout their whole length by the contracting muscle- fibers that encircle them ; the quality of retraction in the uterine muscle maintains what is gained by contraction. It is to the last two actions mainly that a woman owes her immunity from hemor- rhage after labor. The causes of postpartum hemorrhage are, therefore, those which interfere with uterine contraction. They are : Systemic weakness from disease ; unfavorable hygienic surroundings or anxiety ; weakness in the uterine muscle-fibers themselves, as when they are undeveloped, fatigued, overstretched by hydram- nios or twins, inactive by reason of surrounding inflammatory products, exhausted by many previous labors, or too suddenly called upon to contract by a rapid labor, especially if it is instru- mental ; anomalies in the innervation of the muscle-fibers ; a mechanical obstacle to firm contraction, as a retained placenta or clots within the womb, old adhesions upon its peritoneal surface, or a tumor such as a uterine fibroma, an ovarian cyst, a dis- tended bladder or rectum, that by its bulk keeps the womb distended or displaces it. Some sudden effort may displace the clots in the uterine sinuses and thus favor hemorrhage, as coughing, sneezing, sitting up in bed, or defecation. Heart and lung disease or arterial tension from any cause may produce 538 THE PATHOLOGY OF LABOR. a congestion of the womb that predisposes to postpartum hemorrhage. Symptoms and Diagnosis.—There is no difficulty in recogniz- ing postpartum hemorrhage when the blood soaks through the mattress and runs across the floor in a stream. The bleeding should be detected early, however, that it may be arrested at once. There is usually a sudden gush of blood, followed by the expulsion every few seconds of several ounces of liquid blood and clots. The uterus is relaxed and it is difficult to outline it through the abdominal wall. There is an absence of that firm, round, easily palpable tumor usually filling the hypo- gastrium, characteristic of a firmly contracted womb. The con- stitutional signs of hemorrhage become rapidly more and more evident. The face is blanched, the pulse is quick and feeble, vision fails, there is air-hunger, and the woman, to satisfy her in- stinctive craving for more oxygen in the rapidly emptying blood- vessels, makes a curious sound between that of a gape and a sigh. Finally, there are restlessness, jactitation, convulsions, coma, and death. In exceptional cases one tremendous outpour of blood, last- ing not more than five minutes, kills the patient. One can not always judge the extent of the hemorrhage by the amount of blood that escapes externally. The dilated womb may contain enough within its cavity to cost the woman her life. Very rarely, indeed, an uncontrollable postpartum hemorrhage is seen from a firmly contracted and an uninjured uterus. It occurred once from a ruptured aneurysmal vessel ; again in con- nection with nephritis, presumably from atheromatous or diseased vessels ; in one case from a ruptured hematoma of the cervix ; in another from ulceration of the cervix that opened the uterine artery ; in another from a ruptured varicose vein in the cervix. Cases have been reported of paralysis of the placental site, with firm contraction of the remainder of the womb.x In high altitudes postpartum hemorrhage is said to be much more common than at lower levels, from the lessened atmos- pheric pressure. I have been told, by physicians practising in the high regions bordering upon the Rocky Mountains and in South Africa, that they have this complication to contend with very frequently. Treatment.—Postpartum hemorrhage may occur after any labor. Measures to prevent it consequently form part of the routine management of labor, as already described. If any of the predisposing causes of uterine relaxation exist during 1 Midler's " Handbuch," Veit, vol. ii, pp. 121, 130. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 539 labor, additional precautions should be taken. As soon as the presenting part emerges from the vulva a syringeful of the fluid extract of ergot should be injected into the woman's thigh, the placenta should be expressed without too much delay, and the womb should be kneaded and compressed more vigorously and for a longer time than usual, until it remains firmly contracted and shows no disposition to relax. Then a large abdominal pad should be laid above the umbilicus and a firm abdominal binder should be adjusted. The nurse should receive instructions to watch the patient's appearance closely, to count the pulse fre- quently, and occasionally to turn down the bedclothes and observe the quantity of the discharge. Should hemorrhage occur in spite of these precautions, it must be controlled with the least possible delay, for so much blood is lost in a short time that the woman may die of acute anemia, even though the bleeding be finally checked. The beginner will do well to bear in mind the following plan of action that he may put it into immediate effect, without de- pending too much upon his presence of mind, readiness of re- source, or self-command—qualities that will perhaps be lacking when he is first confronted with one of the most alarming acci- dents of obstetric practice : Seize the fundus uteri with one hand through the anterior abdominal wall; knead, compress, and rub it vigorously with the fingers applied to the posterior uterine wall, the palm to the fundus and the thumb in front, until the womb is felt firmly con- tracting. If external irritation does not effect the desired result, insert the free hand into the vagina, pass it into the uterine cavity, feel for retained fragments of the placenta, blood-clots, or other substances that might by their bulk prevent contraction, remove them, and while doing so rotate the hand somewhat roughly, so as to bring it in contact rather forcibly with the uterine wall; at the same time continue the kneading, rubbing, and compression externally. If the combined irritation of the exterior and interior of the womb fails to secure firm contraction, try next the irri- tating effect of cold. Rub a piece of ice upon the hypogastrium and pass another piece into the interior of the womb. If the effect of cold is not immediately satisfactory, do not persist in its use, for the ultimate effect is relaxing rather than stimu- lating. A ready and convenient method of violently chilling the hypogastric region is to pour some ether upon it. The irritation of cold having proved ineffective, a clean handkerchief should be soaked in vinegar, carried to the fundus of the uterine cavity, and squeezed out. Vinegar is irritating and astringent; it is clean and readily procurable in every household. It has proven itself 540 THE PATHOLOGY OF LABOR. a valuable agent in securing the contraction of a relaxed uterine muscle, and in checking postpartum hemorrhage. Should this means fail, the uterine cavity should be packed with iodoform gauze ; or, in the absence of this material, a clean towel may be cut in strips and used instead. In the intra-uterine tampon we possess the surest and most reliable means of controlling post- partum hemorrhage.1 The technic of inserting the tampon is shown in figure 410. The end of the strip should be inserted as far as the fundus by a long placental forceps, and the whole uterine cavity firmly packed with the successive layers. Other agents of value in promoting uterine contraction are hot water, electricity, and styptic or irritating drugs, such as Monsel's solution, iodin, and turpentine. An intra-uterine injection of very hot water (1200 F.) is effect- ive, but it is difficult to regu- late the temperature in private practice without the assistance of a trained nurse. A strong faradic current is extremely efficient, but a battery is scarcely ever at hand when it is needed. Monsel's solution will stop the bleeding, but it leaves such firm and adherent clots in the uterine cavity that sep- ticemia will very likely follow Fig. 410. — Packing the puerperal from their decomposition, and uterus with gauze to control postpartum there is danger, besides, of an hemorrhage (Edgar). . ? ,, ,, . . v ' extension of the thrombosis to the uterine and pelvic ves- sels. Iodin and turpentine have done good service by their irritating qualities, but there is danger of metritis from their use, and they might leak into.the abdominal cavity through the tubes. Great virtue has been claimed for special modes of compressing the uterus (Fig. 411) that are supposed to close the mouths of the bleeding vessels. When these methods are effective it is by irritating the uterine muscle, rather than by the pressure exerted upon the vessels of the placental 1 Duhrssen, " Ueber die Behandlung der Blutungen post parium," Volk- mann'sche Sammlung, 347. LABOR COMPLICA TED BY ACCIDENTS AND DISEASES. 541 site. Compression of the abdominal aorta has been proposed as a means of checking postpartum hemorrhage by diminishing the blood-supply to the womb. This plan, in my opinion, is absurd. When it has apparently succeeded it was by the irrita- tion of the womb, or of the sympathetic nerves supplying it, on account of the deep abdominal pressure above the fundus. Finally, the bleeding may cease spontaneously by thrombus formation or by syncope, but these agencies are never to be awaited in practice. The physician's duty is not always done when he has checked the bleeding. An acute anemia must be dealt with that, if dis- regarded, will be as dangerous as a continuance of the hemor- rhage. There is a rapid, feeble pulse ; or, it may be, an entire absence of radial pulsation. The body-surface, especially of the Fig. 411.—Bimanual compression of the uterus. extremities, is cold, and there is a disposition to syncope on the slightest effort. There is loss of vision, and the acute anemia of the brain may even lead to convulsions. With the dangers of heart-failure and cerebral anemia in mind, the physician, while engaged in stopping the bleeding, directs the nurse to raise the foot of the bed on some books or bricks, and, if there is a tendency to repeated syncope, to give a hypodermatic injection of ether; or, if it is at hand, of nitroglycerin (two drops of one per cent, solution). As soon as the hemorrhage is checked, an enema of a pint of hot water containing about forty grains of common salt should be given. There is no better method of trans- fusion than the rectal injection of a normal salt solution, and the hot water raises, somewhat, the body-heat. The patient should, in addition, be surrounded by hot bottles, should be well covered 542 THE PATHOLOGY OF LABOR. with blankets, and should be kept at absolute rest, with the body and head on a straight line and the foot of the bed well elevated to keep as much blood as possible in the brain. Heart-stimu- lants—digitalis, strychnin, nitroglycerin, and ether—should be given hypodermatically if the heart-action fails to improve. There is likely to be nausea and vomiting, but, as soon as the stomach will retain what is put in it, the woman should receive very small quantities of hot milk, hot concentrated coffee, hot water and brandy, frequently repeated. When reaction is once established, a hypodermatic of morphin hastens the patient's recovery from the effects of the hemorrhage and prevents sec- ondary shock by promoting physical quiet, calming nervous rest- lessness, and producing some degree of cerebral congestion. In desperate cases in which the measures just de- scribed are without satis- factory result, a pint to a quart of a sterile nor- mal salt solution (0.6 per cent), at blood heat, should be injected by gravity into the loose cellular tissue between the shoulder-blades (hy- podermoclysis), under the breasts, or directly into an artery or a vein. A convenient apparatus for this purpose is shown in figure 412, but it will scarcely ever be at hand when wanted, and, be- sides, time is wasted looking for and laying bare a blood-vessel. A good substitute for the transfusion apparatus is a large aspirating needle and a fountain syringe or funnel. With this appliance, with which every obstetrician should be provided, fluid may be forced into the cellular tissue or into a blood-vessel. The funnel and needle should have a place in every well-supplied obstetric-instrument bag. The extremities should be bandaged toward the trunk (auto- infusion) so as to force as much blood as possible to the heart, the large blood-channels, and the brain. Compression of the abdominal aorta helps to this end. Actual transfusion of blood from one person to another, or from some animal, is no longer Fig. 412.—Intravenous injection. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 543 advisable. It is rarely practicable, and the results are no better, if as good, than are obtained by the injection of salt solution. The physician should make it an invariable rule to stay with his patient until her condition is entirely satisfactory. The anemia persisting after the hemorrhage is checked and reaction is estab- lished should be treated by a full liquid diet, animal broths, and iron. The intense headaches of cerebral anemia that may per- sist or recur for some time are best treated with opium. Lacerations of the Walls of the Birth=canal.—Any portion of the soft structures surrounding the birth-canal, from the fundus uteri to the vulva, is liable to spontaneous rupture, or to trau- matic perforation during labor. Rupture of the Uterus.—The uterus may be ruptured by over- distention of the lower uterine segment. It may burst open from top to bottom in certain diseased conditions of its walls. It may be perforated by the operator's hands or by instruments. Its wall may be perforated by a localized necrosis and ulceration. If the rupture involves all the coats and opens a way into the peritoneal cavity, it is called complete. If it spares the peritoneal covering of the uterus, it is called incomplete. Frequency.—The statistics of the frequency of ruptured uterus vary greatly. Bandl found...............I in 1200 labors. Jolly found...............I " 3403 " Lusk found...............I " 6000 " Collins found..............I " 482 " McClintock found............1 " 737 " Ramsbothan found............I " 4429 " Garrigues found.............I " 3-5000 " Winckel found..............1 " 666 " Harris found..............1 " 4000 " Koblanck found.............1 " 402 " Rupture of the uterus is much more common in the poorer than in the richer classes, chiefly because the former have less skilful medical attendants. Multiparae are more liable to the accident than primiparae (88 per cent. : 12 per cent., Bandl). Dis- ease of the uterine wall, as fatty degeneration, a myoma, a pre- vious injury to or operation upon the uterus, as a former rupture or Cesarean section, are predisposing causes. Causes.—The most frequent cause of ruptured uterus in labor is overdistention of the lower uterine segment, due to some ob- struction which prevents the descent of the child through the pelvic canal.1 Bandl first pointed out this fact.2 1 A contracted pelvis is the most common cause of uterine rupture, and a justo- minor pelvis is the kind of contracted pelvis most often accountable for it. In 1218 ruptures a contracted pelvis was the cause in 570 (Koblanck, " Uterusruptur," Stutt- gart, 1895). 2 " Ueber Ruptur der Gebarmutter," Wien, 1875. 544 THE PATHOLOGY OF LABOR. In a normal labor the lower pole of the uterine ovoid is gradu- ally dilated until the fetal body passes through it into the vagina. If there is an insuperable obstacle to the descent of the child, as a contracted pelvis, rigid soft parts, a tumor in the pelvis, over- growth or enlargement of the child, hydrocephalus, an impossible presentation or position, the contraction of the upper uterine seg- ment continues until the child's body is driven in great part out of it, but, descent of the child being prevented, it is crowded into the enormously distended lower uterine segment and cervical canal, while the firmly contracting upper uterine segment is drawn up under the ribs until it sits upon the child's body like a cap. There is a sharply defined line between the firmly con- tracted thick wall of the upper uterine segment and the very thin wall of the distended lower uterine segment, a line visible and palpable running across the abdomen between the symphysis and the umbilicus, approaching nearer the latter the greater the distention of the lower uterine segment, the upper boundary of which is normally about the level of the pelvic brim. This line is called the "contraction-ring" or the "ring of Bandl." It ordinarily coincides with the coronary vein of the uterine wall and with the firm attachment of the peritoneum to the uterus. It is not, as it was once supposed to be, the margin of the inter- nal os or the upper limit of the cervical canal ; it is the boundary- line between that portion of the uterine muscle which contracts firmly in labor, diminishing the area of intra-uterine space and driving the child out of the uterine cavity, and that portion of the uterine muscle which must be distended in labor to allow the passage of the child through the pointed end of the uterine ovoid. If there is a greater bulk of the fetal body in one side of the lower uterine segment, the contraction-ring is higher upon that side and thus runs an oblique course across the abdomen. There is a limit, of course, to the capacity of the lower uterine segment and to the stretching and tenuity of its walls. That limit being reached, the overstretched wall tears and the fetus may pass from the uterine into the abdominal cavity. In rare cases the uterine wall is weakened by a previous rupture, by a blow or fall during pregnancy, by the scar of a Cesarean section, or by the removal of a portion of the uterine wall in the excision of a myoma ; the wall may be weakened by fatty degeneration, associated, perhaps, with excessive general obesity ;x prolonged pressure upon a small area may destroy its vitality and lessen its resistance. In such 1 In a case of uterine rupture seen with Dr. U. G. Heil, of Philadelphia, the woman had become suddenly and enormously obese before her last pregnancy. ' She had experienced no special difficulty in the births of her other children, but in the last the uterus ruptured after a few hours of moderate labor-pains. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 545 cases rupture of the uterus may occur early in labor, or even in pregnancy, without distention of the lower uterine segment. Finally, external violence has ruptured or perforated the womb, instruments inserted in the vagina have pierced its walls, and the operator's hand inserted in the uterine cavity to perform version has often been the immediate cause of rupture.1 Morbid Anatomy.—The tear in the uterine wall almost always begins in the lower uterine segment, and usually runs trans- versely. It may be upon the anterior, lateral, or posterior sur- face. The edges of the tear are usually ragged, swollen, and infiltrated with blood. The peritoneal covering of the uterus is often stripped off for a considerable distance beyond the tear, and Fig. 413.—Laceration of lower uterine segment: a, Right ovary; b, rectum ; c, laceration ; d, left tube (Winckel). in the sac thus formed between the peritoneum and the body of the uterus the placenta may lie concealed, or even the fetus may be contained. There may be an enormous subperitoneal hema- toma or profuse intraperitoneal hemorrhage. The tear may run upward toward the fundus, or may extend so far transversely as almost to sever the upper and lower uterine segments. The rent may extend through the mucous and muscular coats without in- volving the peritoneum. The latter, in rare cases, may alone be 1 Koblanck {loc. cit.) gives the following causes in 80 cases: Contracted pelvis, 8; transverse position of fetus, 7 ; other abnormal positions, 4; hydrocephalus, 4; overgrowth of child, I ; misfit of presenting part in pelvis, administration of ergot, I; violence, 5; version, 29; Hofmeier's grip, 1; forceps, II ; decapitation, I; myoma, I. 35 546 THE PATHOLOGY OF LABOR. Fig- 414-—Transverse or semicircular tear of the lower uterine segment. Fig. 415-—Laceration of lower uterine segment. LAB OR COM PLICA TED BY A CCIDE NTS AND DISEASES. 5 47 split, and it is recorded in one case that the peritoneal and mus- cular coats were torn while the mucosa remained intact.x If the tear is extensive and complete, the fetal body will probably pass into the abdominal cavity, and intestines may prolapse into the uterus and into the vagina. In one remarkable case2 there was a tear of the lower uterine segment and of the right lateral fornix of the vagina, through which the fetus entered the vagina, passing to one side of the undilated cervix. Fetal death is usually syn- chronous with the rupture of the womb, and if the child's body passes into the peritoneal cavity it rapidly putrefies, generating Fig. 416.—Perforating lacera- Fig. 417.—Perforating laceration of tion of the cervix : a, Posterior lip; the cervix : a, Perforation ; b, peritoneum ; b, anterior lip ; c, perforation. c, muscle; d, posterior lip of the cervix; e, vaginal laceration (Winckel). gases of decomposition so quickly that its bulk is enough in- creased thereby to enhance considerably the difficulties of its ex- traction. From the decomposition of the fetal body, or perhaps from the entrance of atmospheric air, there may be emphysema of the pelvic connective tissue and even of that of the thighs, 1 J. M. Withrow (" Lancet-Clinic," December, 1891) reports a case of ruptured uterus, the rent beginning in front, midway between the insertion of the tubes, ex- tending up over the fundus and down along the posterior wall to Douglas' pouch, involving the peritoneal coat and the muscular tissue, but not the mucous membrane. The uterus, filled with water after removal from the body, did not leak. A heavy dose of ergot had been given during labor. 2 Slajmer, " Centralblatt f. Gyn.," No. 18, 1895. 548 THE PATHOLOGY OF LABOR. buttocks, mons Veneris, and abdomen. Septic peritonitis of a viru- lent kind usually develops with great rapidity. In a minority of cases the site of the rupture is walled off by a rapid outpour of lymph and by agglutination of coils of intestines, leaving a compar- atively small cavity to be drained through the tear. This cavity may secrete ascitic fluid in large quantities for a time, and during the woman's convalescence there may be a profuse watery dis- charge from the womb. I have seen two such cases. Occasionally a large area of intraperitoneal space is drained through the tear. Even the fetal body may be encapsulated and there may be a Fig. 418.—Uterus perforated by the pressure of the promontory: a, Perforation ; b, laceration of cervix ; c, c, c, vaginal tears; d, contraction-ring; e, posterior lip of cervix (Winckel). lithopedion formed. In the uterine ruptures or perforations due to pressure necroses the opening is round in shape, regular in outline, and small in extent. The opening is almost always on the posterior wall over the promontory of the sacrum. In the rare cases of exostoses of the pelvis the bony outgrowth may pinch a hole in the uterine wall. In these cases the opening corresponds with the site of the exostosis. Clinical History, Symptoms, and Diagnosis.—Rupture of the uterus usually occurs after labor has lasted a long time, after rupture of the membranes, and with a well-dilated os. There is LAB OR CO MPLICA TED BY A CCIDE NTS A ND DISEASES. 5 49 usually an obstruction in the labor that should have been recog- nized, the lower uterine segment is enormously distended, and the contraction-ring is palpable and visible near the umbilicus ; the pains have been vigorous and frequent, the woman's suffering has been extreme, and the abdominal muscles have been employed, perhaps, with each contraction, though the presenting part does not descend the birth-canal. Suddenly there is a sharp, excruci- ating, lancinating pain ; the woman may cry out that something has happened to her; the uterine contractions cease, blood flows from the vagina, perhaps in alarming quantities, and the patient presents every evidence of shock. On making a vaginal ex- amination the physician finds that the presenting part has re- ceded ; hitherto easily reached, perhaps at the very outlet of the pelvis, it may be altogether inaccessible, and on passing the hand into the uterine cavity the rent may be felt, or intestines may be found within the uterus and protruding from the os. On abdominal palpation the upper uterine segment may be felt firmly contracted to the size of the uterus after labor, and the child's body may be easily detected in the abdominal cavity alongside of it. If the rupture of the womb is not complete, or is not large, it may not be discovered until the child is born, and may never be suspected at all unless the woman develops septic peritonitis after labor or discharges ascitic fluid from the uterus. There may be no pain at the time of rupture, no hemorrhage, no abnor- mality of uterine contractions. Even with a complete tear of large dimensions and escape of the child into the peritoneal cavity there is occasionally an astonishing absence of symptoms. I have seen a case in which the child passed into the abdominal cavity twenty-four hours before I was summoned, and yet there was no alarming symptom of any kind until suddenly, at the end of twenty-four hours, the signs of virulent septic peritonitis appeared. The accident of labor most commonly mistaken for ruptured uterus is premature detachment of a normally situated placenta. The distinction between the two should be made easy by attention to the following differences in symptoms : Rupture of the Uterus. Occurs late in labor. Membranes ruptured. Uterus diminished in size by evacuation of some or all of its contents into the abdominal cavity. Recession of presenting part. Discharge of blood from vagina. Exploration of the interior of the womb easy, and rent accessible to touch. Accidental Hemorrhage. Occurs before labor or early in the first stage. Membranes unruptured. Uterus dis- tended, perhaps irregularly in retro- placental effusions. Position of presenting part unchanged. No external bleeding in the concealed variety. Exploration of the interior of the womb impossible. 550 THE PATHOLOGY OF LABOR. As the placenta is often detached when the uterus ruptures, and as it may prolapse in front of the child, a ruptured uterus may be mistaken for placenta praevia. If the physician should have reason to suspect that the uterus is ruptured during labor, he should extract the child without delay and should then explore the uterine cavity, preferably under anesthesia, from top to bottom. By unvarying adherence to this rule he will not be guilty of the serious fault of overlooking a ruptured womb with few symptoms until septic peritonitis occurs and all treatment is unavailing, or until the bleeding, internal or external, is so profuse that the patient can not be revived. The symptoms during the puerperium indicative of a ruptured womb in labor are : septic peritonitis, profuse uterine hydrorrhea, secondary hemorrhage (as late possibly as the twelfth day— Winckel), and the prolapse of the intestines. The last is the only positive sign, unless, on the occurrence of the others, a digital or instrumental examination of the uterine cavity reveals the rent. Prognosis.—The prognosis of ruptured uterus depends upon the site, extent, and degree of the tear, and upon its treatment. In ten cases of rupture of the anterior wall in the Berlin Mater- nity every one ended fatally, and in three ruptures at the fundus the result was the same. Incomplete ruptures are not so fatal as those in which the peritoneum is also involved, and the result depends somewhat upon the escape of meconium, liquor amnii, blood, placenta, and fetus into the peritoneal cavity. Before the advent of asepsis and the improvement in the technic of abdom- inal surgery the mortality of ruptured uterus averaged about 90 per cent. Of late years the mortality has been much reduced. In 60 cases of complete rupture without active treatment the mortality was 78.8 per cent., in 70 cases treated by irrigation and drainage the mortality was 64 per cent., and in 193 cases treated by ab- dominal section the mortality was only 55.3 per cent.1 In about one-half the fatal cases death occurs within the first twenty-four hours. The great majority of the remainder die within three days. In some fatal cases, however, death occurs as late as the tenth or fourteenth day. The causes of death, in the order of their fre- quency, are sepsis, hemorrhage, and shock. The mortality of the infants is usually over 90 per cent. In the 80 cases from the Berlin Maternity 10 children were saved, but this is an unusually large proportion. If the woman recovers from the rupture, she runs a great risk of a repeated rupture in a subsequent pregnancy 1 Schultz, " Internat. med. Rundsch.," Jan. 10, 1892. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 5 5 I and labor. There are cases on record, however, of women safely delivered in a subsequent labor. Treatment.—The preventive treatment of uterine rupture con- sists in obviating, in time, the obstructions in labor that predis- pose to the accident. The treatment of the rupture itself differs as the rent is com- plete or incomplete, as its situation admits of good drainage or otherwise, and it depends greatly upon the escape of foreign matter into the peritoneal cavity. The first care of the physician must be to extract the child and to control the hemorrhage. If the child has escaped into the abdominal cavity, no effort should be made to extract it by the natural passages, but it should be removed through an abdominal incision. If the rent is small, and the child has only in part passed from the uterine cavity, it should be delivered rapidly by version, the application of forceps, or by craniotomy. The last is to be preferred. The placenta may be removed by the vagina, even though it has passed into the abdominal cavity ; but if difficulty is experienced in finding it, if the cord should break off by the efforts to pull the placenta through the rent, or if the placenta lies hidden under the perito- neum stripped off the womb, its extraction should be postponed until the abdomen is opened. In an incomplete tear it is sufficient to pack the rent with iodoform gauze, in order to control hemor- rhage and to secure good drainage. This may be preceded by irrigation, which may be repeated with advantage when it becomes necessary to renew the gauze packing. If the rent is complete, but small, and situated low down upon the posterior wall; if there has been little, if any, foreign matter injected into the peritoneal cavity, the same treatment will suffice ; but if the tear is exten- sive, if considerable blood has passed into the peritoneal cavity, and, all the more, if the peritoneum has become contaminated by the entrance of liquor amnii, of the placenta, or of the child itself, an abdominal section will be necessary. With the abdomen open a decision must be made between several plans of procedure. Usually, it is best to amputate the womb, if possible, below the site of the tear. Occasionally, if the wound is not too ragged and can be thoroughly approximated, it will be sufficient to unite it with deep and superficial sutures, care being taken to cover over the line of rupture with inverted peritoneum. In case the peritoneum is stripped off the womb for a considerable distance, and it is impossible to secure a good stump, a flap of peritoneum may be dissected off the uninjured side of the womb and used to cover over the upper portion of the stump and its denuded sur- face ; or it may be preferable to do a panhysterectomy, sewing up the opening left in the vagina in such a manner as to cover 552 THE PATHOLOGY OF LABOR. any denuded surfaces. If the tear is on the anterior wall, or at the fundus, an abdominal section is necessary. On opening the abdomen one of the procedures detailed above may be adopted, or it may be possible, as it was in one of Leopold's cases, to splint the womb by gauze packing in the pelvis and abdomen, so as to bring the torn surfaces firmly together. In an abdominal section for ruptured uterus the toilet of the peritoneal cavity must be made, of course, with the greatest care. It is better, if possible, to cleanse the abdominal cavity with pads of gauze, rather than to flush it with water; but the latter plan is sometimes necessary to remove small clots of blood scattered throughout coils of intestines or hidden in the depths of the pelvis. Injuries to the Cervix.—The cervix is injured to some extent in every labor, but serious tears, that cause at the time profuse hemorrhage and give rise to symptoms subsequently, are com- paratively rare. The causes of serious injuries to the cervix are : precipitate delivery, premature rupture of the membranes, forcible extraction of the child by the forceps or after version before the os is thoroughly dilated, incarceration of the anterior lip of the cervix above the child's head and the pelvis, and abnormal rigid- ity of the cervix. The tear is usually bilateral, occasionally uni- lateral, in rare cases multiple, and in one instance under the writer's observation directly in the anterior median line. In rare instances the tear, instead of being longitudinal, may be circular, and in consequence the vaginal portion of the cervix may be completely torn off from the womb. The cervical tear manifests itself directly after the delivery of the child, usually by some hemorrhage, occasionally by profuse and dangerous bleeding. A digital examination of the vagina directly after the extraction or expression of the placenta always informs the careful physician of the condition of the cervix, and, if the good rule is followed to inspect the cervix through a speculum before ceasing to attend an obstetric case, a torn cervix that needs attention should never be overlooked. The hemorrhage from a torn cervix directly after labor may be controlled in two ways. First, by ligatures, which are per- fectly certain to effect the desired result, but which are not always easy to insert, and which increase the danger of septic infection, unless the attendant possesses gynecological skill and has the necessary equipment for operating in a perfectly aseptic manner. The easiest, and on the whole safest, plan for checking the hem- orrhage from a torn cervix in general practice is to insert a tampon in the form of a half ring in the lateral vault of the vagina. The best tampon material is iodoform gauze, but in the LABOR COM PL ICA TED BY A CCIDENTS AND DISEASES. 553 absence of this a perfectly clean handkerchief or strip of towel wrung out in vinegar will answer the purpose admirably. I have never known this device to fail in checking hemorrhage from a torn cervix. It is a moot question whether a torn cervix should always be immediately repaired. My conviction is that, in general practice, the attempt had better not be made, for the following reasons : Stitches placed in a relaxed cervix directly after labor will probably not be tight enough at the end of twenty-four hours to approximate the wound. To place them properly re- quires considerable skill, and necessitates dragging the cervix into view by bullet forceps. The necessary instruments are rarely to be found in the general practitioner's armamentarium, and, the most cogent reason of all, the majority of lacerated cervices heal spontaneously, if the woman is kept quiet on her back in bed for a sufficient length of time, without vaginal douching or other interference that could disturb the approxi- mation of the edges of the tear. If it appears better in an in- dividual case to repair immediately a torn cervix, the operation should be done as follows : The woman should be placed in the dorsal posture on a table, her buttocks projecting well beyond its edge, the thighs flexed on the abdomen, the legs upon the thighs. An anesthetic is not absolutely necessary. The anterior and the posterior lip of the cervix should each be caught by a bullet forceps. The cervix is pulled into sight, and by separating the bullet forceps the tears are made to gape. Sutures (silkworm gut) are then inserted in exactly the same manner as for the secondary operation by Emmet's straight cervix-needles. Three sutures on a side are usually sufficient. They are knotted or shotted as the operator prefers, and the ends are left at least an inch long to facilitate their removal. The sutures may be re- moved in two weeks. Circular Detachment of the Vaginal Portion of the Cervix During Labor.—In very rare cases the whole vaginal portion of the cervix is torn off from the womb and emerges from the vulva in front of the child's head. This accident may be the result of extreme rigidity of the cervix, or of the cervix being caught between the walls of the pelvis and the child's head, if the former is contracted or the latter is very large. I have seen two examples of this accident, both due to extreme rigidity of the cervix (Figs. 419 and 420). In each case the woman was an elderly primipara, and was quite obese. In one case (Fig. 419) there was a narrow tab of cervical tissue left in the median line pos- teriorly. Although the injury at first sight appears serious, 554 THE PATHOLOGY OF LABOR. there is no hemorrhage in consequence of it, nor is the puerperal convalescence disturbed. This accident could almost always be averted by multiple incisions in the cervix. Lacerations of the Vagina.—The vagina may be torn by the insertion of the hand by the rapid extraction of the child, by Figs. 419 and 420.—Author's cases of annular detachment of the cervix. the extension of tears irom the cervix, by the propulsion of the child's body against the posterior wall without sufficient deflec- tion forward to facilitate its escape from the vulvar orifice, and, most frequently of all, by the blade of a forceps which does not fit the child's head properly, or which is not used with sufficient LAB OR CO MP LLC A TED BY A CCIDENTS AND DISEASES. 555 care as to the direction of the force that is applied in the extrac- tion of the head. The tears of the vagina accompanying a lacerated perineum or injured pelvic floor are described under the latter heading. Tears of the vagina extending from the cervix involve usually the lateral vaginal vaults, occasionally opening deep rents into the base of the broad ligaments, and involving possibly the uterine arteries or even the ureters. The hemorrhage from these tears is best controlled by ligating the bleeding vessels if they can be found, or by firmly tamponing the rent if it is impos- sible to locate the bleeding points. Drainage must be secured by gauze packing, and, when the wound begins to granulate, daily washing with sterile water should be employed. The tears of the posterior vaginal wall sometimes result in perforations of the rectum, and in consequence a portion of the child, as an extremity, may emerge from the anus.1 These perforations should be repaired immediately after labor by buried sutures of catgut and interrupted stitches of silver wire or silkworm gut. The tears of the anterior vaginal wall made by a forceps- blade are almost always clean-cut, and are apt to bleed pro- fusely. They should be closed by a running catgut suture. In one case under my care the hemorrhage was so profuse that it was impossible to see the wound at all, and there was danger of the woman bleeding to death while I attempted to sew it up. After several abortive attempts the wound was successfully repaired without further bleeding by pushing a tampon into the vagina and following the tampon as it was pushed up along the course of the wound with a needle and thread, until the upper end of the tear was reached. Lacerations of the anterior and posterior vaginal vaults pen- etrating to the peritoneal cavity are usually associated with rup- ture of the uterus. They are to be treated by gauze packing and drainage. Lacerations and Abrasions of the Vulva, of the Vestibule, and of the Vaginal Entrance.—The most frequent site for injuries in this region is the upper portion of the vestibule and the tissues on one side of the clitoris or of the urethra. Tears in this situation bleed profusely, and they are so common that it is a valuable rule of practice always to look in this region for injury when there is a hemorrhage from the vagina after labor with a well-contracted womb. The bleeding points are in plain sight, and the hemor- rhage is easily controlled by a stitch or two, deep enough to undersew the whole depth of the tear. A catheter should be 1 Piering, " Centralblatt f. Gyn.," No. 48, 1891. 556 THE PATHOLOGY OF LABOR. Figs. 421, 422, and 423.—Lacerations and abrasions of the vestibule and vaginal entrance (Bar). LAB OR CO MPLICA TED BY A CCIDENTS AND DISEASES. 557 ciiMM& Figs. 424, 425, and 426.—Lacerations and abrasions of the vestibule and vaginal entrance (Bar). 558 THE PATHOLOGY OF LABOR. placed in the urethra to guard against occluding it. In abrasions of the labia and of the vestibule, care must be taken that the raw surfaces shall not unite, causing atresia of the vagina. This can easily be prevented by laying oiled lint over the raw surfaces, and by the use of douches. Figs. 427 and 428.—Perforations and lacerations of the nymphse (Bar). Lacerations of the Perineum.—The causes and preventive treat- ment of lacerations of the perineum are considered elsewhere. The repair of the injury is dealt with in this section. The com- monest form of torn perineum is shown in figures 430 and 431. It may be seen that the tear rarely involves the perineum alone, but usually extends up the posterior wall of the vagina, on one or both sides of the posterior column. Experience teaches, more- over, that lacerations of the perineum alone, when they do occur, have very little effect upon the patient's after-condition, even though they reach to the anus and sever the transverse perineal muscle (see Figs. 434, 435). The greatest care should be ex- ercised, therefore, to ascertain the extent of the injury to the vagina winch may be associated with the tear of the perineum. This is best done by placing the woman in the dorsal position across the bed, with her thighs well flexed upon the abdomen and widely separated, and with the buttocks projecting beyond the edge of the bed. A nurse or other assistant, whose hands are protected by clean towels, holds the labia apart, and the physician cleanses the torn surface of the posterior wall of the vagina with pledgets of cotton soaked in bichlorid of mercury solution. In this way the exact nature and the extent of the LAB OR COMPLICA TED BY A CCIDENTS AND DISEASES. 559 injury may be seen. The laceration should usually be immedi- ately repaired ; the woman is very likely still stupid from the effects of the anesthetic that has been administered in the second stage of labor, and the parts are benumbed by the pressure to Fig. 429-—Abrasions of the vulva and Fig. 430.—Deep laceration of the lacerations of the vaginal sulci (Bar). perineum and of one sulcus ; splits in the vaginal mucous membrane (Bar). Fig. 431-—Laceration of the perineum Fig. 432.—Laceration of the peri- andof one sulcus (Bar). neum and of the sulci; abrasions of the vulva (Bar). which they have been subjected, so that the pain of the small operation is slight. But if the physician is tired out by long attendance upon a case, if the light is poor, if sufficient help is 5 60 THE PA THOL OGY OF LAB OR. not at hand, or if he does not possess all that he needs in the way of implements, he had much better postpone the repair of a lacerated perineum until a more convenient time, within twenty- Fig. 433.—Laceration of the vaginal sulci without a tear of the perineum proper (Bar). Figs. 434 and 435.—Lacerations of the perineum without involvement of the pelvic floor. Such tears would not affect the woman's health or comfort subse- quently (Bar). four hours of its occurrence. The simplest way to sew up a lacerated perineum that does not involve the sphincter ani is shown in figure 436. All that is needed for the operation is a curved needle set upon a handle and a few strands of silk- LAB OR CO MPLICA TED BY A CCIDENTS AND DISEASES. 5 61 worm gut. The suture material and the needle should be im- mersed in boiling water for five to ten minutes before they are used. The woman is kept in the dorsal position across the bed ; the thighs are well flexed and widely separated, the feet resting upon chairs. The operator inserts the forefinger of his left hand in the rectum and measures the depth and extent of the tear with his thumb in the vagina. The needle is then plunged deeply into the pelvic muscles, so that it encircles the wound throughout its whole depth and emerges on the opposite side near the upper margin of the tear. The eye is threaded by an assistant, and the needle is then withdrawn. This suture is re- Fig. 436.—An efficient and simple method for the primary repair of laceration of the perineum and of the pelvic floor. peated from three to six times, according to the extent of the tear. If care is taken to insert the needle deeply enough, and to put the first stitch near the upper margin of the tear through- out its whole depth, a thoroughly satisfactory and strong union of the parts can be secured by an operation of the simplest pos- sible nature, easy for the veriest tyro in surgery to perform, and lasting not more than five minutes. Another plan to be recom- mended in the hands of experts accustomed to gynecological surgery is to sew up the lacerated perineum and torn vagina in the same manner that one inserts stitches for the secondary- operation upon the perineum, after the plan of Emmet. If the perineum is torn through the sphincter into the rectum, the best 36 562 THE PATHOLOGY OF LABOR. Fig. 437-—Complete laceration of perineum through sphincter. The sutures in the rectal wall introduced. Fig. 438.—The rectal sutures have been tied on the rectal side and the ends cut short. The remaining sutures are in place. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 563 mode of suture is shown in figure 437. Silkworm-gut sutures are inserted first in the rectum and knotted there, with the ends left long enough to hang an inch or more outside the anus. Two stitches should be inserted from the rectal side, through the ends of the torn sphincter muscle ; and directly above the sphincter a stitch should be placed triangularly in the torn perineum, skirt- ing the whole extent of the rectal tear, entering and emerging upon the skin of the perineum just above the anus. This resem- bles somewhat the stitch recommended by Emmet for a torn sphincter and rectum, but of itself it is not to be depended upon. Fig. 439.—Vaginoperineal lacer- Fig. 440.—Complete laceration of the ation involving both lateral sulci. perineum; perineorrhaphy. Emmet's meth- Three internal, or vaginal, and two od ; tightening the posterior suture, which external, or perineal, sutures in place includes the sphincter. ready to be tied. As a reinforcement of the sphincter and rectal stitches, however, it does good service. The torn perineum is then repaired in the manner already described, either by long, deep stitches passed with a curved needle, as in the first operation described, or by stitches inserted as in the Emmet or Hegar secondary operation. In the rare cases of central tears of the perineum, an attempt should be made to repair the injury by vaginal and perineal sutures, but a secondary operation for a perineovaginal fistula may be necessary. Inversion of the Uterus.—This is the rarest of all the acci- dents to a parturient woman. In the Vienna Maternity, from 564 THE PATHOLOGY OF LABOR. 1849 to 1878, in more than 250,000 labors, there was not a case. In the Rotunda Hospital, in Dublin, there were 100,000 labors, with only one inversion of the womb. Winckel has not seen a case in 20,000 labors. My own experience amounts to three cases—two complete and one partial. In general practice, espe- cially among the poorer classes, inversion of the womb is not so Figs. 441, 442, 443, and 444.—Varieties of central tear of the perineum (" Precis d' Obstetrique "). rare. The accident happens with equal frequency before and after the delivery of the placenta. The inversion may be partial or complete, the former when the fundus simply protrudes into the uterine cavity, the latter when the womb is turned completely inside out. In a complete inversion the fundus is just within the LABOR COMPLICATED BY ACCIDENTS AND DISEASES. 565 vulva ; the cavity of the womb is formed by the peritoneal sur- face, the orifice looking upward into the peritoneal cavity. From this cavity the tubes and the ovarian and round ligaments run upward ; the ovaries are usually above and to either side of the orifice. In the rarest instances inversion of the womb may be associated with inversion of the vagina. In such a case the in- verted womb is also prolapsed. Causes.—Inversion of the uterus may occur spontaneously. In the so-called paralysis of the placental site,—a condition in which this portion of the uterine wall becomes so relaxed and flabby that it sags down into the uterine cavity,—the projecting portion of the wall, it is said, is seized upon by the remainder of the uterine muscle as a foreign body, and depressed further and further toward the cervical canal, as a polypoid tumor might be expelled. The explanation, how- ever, is strained. A contraction of the uterine muscle under these circumstances would reinvert the womb. A much more plausible explanation for spontaneous in- version is found in an adherent placenta and entire relaxation of the uterine walls. In this condi- tion of affairs the mere weight of the placenta is enough to drag the fundus down into the uterine cavity. A most favorable predis- posing cause is furnished by a complete inertia uteri at the close of the second Stage of labor. The Fig. 445. —Partial inversion of the expressive force of the abdominal uterus. muscles not only expels the child's body, but drives down the uterus after it. Inversion of the uterus may be most frequently explained by traction on the cord in the third stage of labor, when the placenta is adherent. It may occur in consequence of a short cord pulling upon the pla- centa during labor. In a case under my observation the cord was wound three times around the child's neck. It is sometimes due to too vigorous compression of the fundus in efforts to ex- press the placenta, and I have seen it occur on one occasion in an effort to extract an adherent placenta, in which the hand and the placenta grasped within it acted like the piston of a syringe and drew the fundus down into the uterine cavity. A necessary 566 THE PATHOLOGY OF LABOR. predisposition to inversion of the womb is relaxation of its walls. If the uterus is firmly contracted, the accident can not occur. Symptoms.—Inversion occurs suddenly, and is usually asso- ciated with profound shock, and often with some hemorrhage. The patient at once passes into a most alarming condition, that can scarcely fail to attract any one's attention. The only causes for her condition would be hemorrhage, rupture of the uterus, Fig. 446.—Complete inversion with prolapse: A, Mons veneris; B, labia majora ; C, labia minora ; D, clitoris ; E, urinary meatus ; F, external anterior bor- der of the vagina ; G, external border of the os uteri; H, the internal surface of the uterus, now external (Boivin and Duges). syncope, or inversion. An immediate vaginal examination should always be made, whereupon the nature of the trouble should mani- fest itself at once. The inverted uterus is found filling up the vagina, and almost projecting from the vulva. By abdominal palpation one notes the absence of uterine tumor in the hypo- gastrium, and can detect, moreover, a groove or slit running across what remains of the cervix. If necessary, a rectal exam- LABOR COMPLLCA TED BY ACCIDENTS AND DISEASES. 56/ ination would reveal the absence of the womb and the depression in the cervix where it is inverted even more plainly than these signs could be detected by abdominal palpation ; but a rectal ex- amination should scarcely ever be necessary. The cervix itself remains uninverted as a collar about the lower uterine segment. Between the cervix and the uterine wall a sound or the finger may be inserted a little way, but it is impossible to find a uterine cavity. This fact should always make the distinction between an inverted womb and a fibroid polypus or other tumor projecting from the uterine cavity. Mistakes, however, of the most serious character have been made in this connection. In one case the inverted womb was torn away in the belief that it was a fibroid tumor, and in another the wire of an ecraseur was adjusted about an inverted womb, and was about to be screwed tight, when the true character of the mass in the vagina was detected. Treatment.—Occasionally, a spontaneous reduction of the inversion occurs, especially when inversion is partial. This occurred in one of the three cases under my observation. If the inversion is complete, spontaneous reduction can not be ex- pected. If the placenta is still attached to the uterus, it should be first removed, and then pressure exerted with the fingers upon the lower uterine segment in a direction forward and slightly upward. To do this, the hand must be inserted well into the vagina and back toward the sacrum, and the fingers must then be directed well forward toward the anterior abdominal wall, in the direction of the axis of the superior strait. The mistake is almost always made of pressing upward against the sacrum, so that the efforts to reduce the womb may fail altogether, and a chronic or permanent inversion may be left for the gynecologist to deal with after the puerperium is completed. With the proper direction of force in one's effort to reduce an inverted uterus, failure ought to be almost unknown, if the reposition of the womb is undertaken at Once, as it always should be. Strange as it may seem, the inversion has been overlooked for some days or altogether in quite a large proportion of the cases. If the cervix is allowed to contract firmly, as it will in a few hours, the reposition of the womb becomes extremely difficult. In one of my cases, seen in consultation, five days had elapsed since the woman's delivery. She had suffered great pain, had considerable fever, with a foul discharge, and had a very rapid pulse, yet no vaginal examination had been made, although the patient was in charge of a professed expert in gynecology ! I found the womb completely inverted. Repo- sition was accomplished, after most fatiguing exertion, by the fol- lowing plan : One hand, made into a cone shape, was inserted in 568 THE PATHOLOGY OF LABOR. the vagina and the finger-tips were pressed steadily against one side of the lower uterine segment, forcing it into the cervical ring. After steady pressure for almost an hour, the cervix yielded considerably. Then an assistant helped in the dilatation of the cervical ring, in the manner shown in figure 447, and at the same time made counterpressure downward upon the cervix. The womb was returned to its natural position shortly after this manoeuver was tried. The woman recovered. Fig. 447. — 1, Complete inversion of the uterus; 2, first manceuver to rein vert the lower uterine segment; 3, second manceuver to widen cervical ring and afford counterpressure by an assistant. Prognosis.—The mortality of inversion of the womb has been extremely high. In one series of 109 cases there were 80 deaths, and 72 of these within a few hours after labor. In another series of 54 cases there were 1 2 deaths (Winckel). The three cases under my care recovered. The causes of death are: shock, hemorrhage, sepsis, peritonitis, and exhaustion from long- continued loss of blood. LABOR COMPLICA TED B Y ACCIDENTS AND DISEASES. 569 Rupture of the Symphysis and of the Sacroiliac Joints. —This accident occurs not infrequently,x usually in consequence of some disease within the joint itself, occasionally as the result of great force in the extraction of the head with forceps or after version. The accident may be recognized at the time of its occurrence by feeling the bones give way, or by actually hearing them snap apart. But it may not be detected until the woman complains of great pain in the symphysis, and of inability to sit up or walk when she rises from bed. Not infrequently rupture of the symphysis is followed by suppuration of the joint. The accident must be treated by a firm binder around the hips, such as is used after a symphysiotomy, and by keeping the patient in bed four or five weeks. If the joint suppurates, it should be opened as early as possible and should be well drained. The prognosis of the injury is not serious. Recovery may be expected as the rule, without impairment of locomotion or other disagree- able consequences, if the symphysis alone is injured. Separation of the sacroiliac joints has the same causes as rupture of the symphysis, and is often associated with it. In- flammation and suppuration in these joints often follow their injury. The only treatment available is firm support of the pelvis by a pelvic binder, and, if possible, in the case of suppuration of the joints, an incision into them from behind to evacuate the pus and to allow of drainage. The mortality of injury to the pelvic joints in labor has been thirty per cent. Fracture of the Pelvic Bones.—This very rare accident in labor has been the result of the unskilful use of forceps. It is serious but not necessarily fatal. In a case reported by Studley,2 of a fracture of the horizontal and of the descending rami of the pubis, the woman recovered. Fracture of the sacrococcygeal joint, or of the coccyx, occurs very rarely in elderly primiparae, in whom not only the sacrococcygeal joint, but the joints of the coccyx as well, are ankylosed. The fracture may be caused spontaneously by the expulsive efforts of the mother driving the presenting part down upon the pelvic floor ; but it is more commonly the result of the application of forceps and the forcible extraction of the head through the pelvic outlet. There are, in my experience, four types of cases in which the coccyx is injured in labor. In one there is an oblique fracture of a coccygeal vertebra involving a joint and resulting in painful mobility of the bone. In the 1 Ahlfeld collected 100 cases, to which number Schauta added 14 (Midler's "Handbuch"). 2 " American Journal of Obstetrics," April, 1879. 570 THE PATHOLOGY OF LABOR. second there is ankylosis of the two fragments with the lower one drawn in at a right angle, where it is out of the way and causes no inconvenience or discomfort except in a subsequent labor. In the third the lower fragment is ankylosed in a per- pendicular position, causing great pain when the patient attempts to sit. In the fourth there is a strain or sprain of a coccygeal joint, leading to chronic inflammation. The injury often results in the condition known as coccygo- dynia after the completion of the puerperium. Diastasis of the Abdominal Muscles.—Reference has been made to the escape of the uterus from the abdominal cavity between the recti muscles in labor. After the delivery these muscles stand widely apart and threaten the woman with abdominal hernia when she rises from bed. Even without the escape of the uterus be- tween the muscles and the probable rupture of some of the aponeurotic fibers of the median line, the recti muscles may be separated so widely during pregnancy and labor, and may lie so far apart after delivery, as to cause some anxiety that abdominal hernia will result when the woman gets up. The condition can usually be corrected by a firm abdominal binder during puerperal convalescence. Rupture of Some Part of the Re= spiratory Tract, and Subcutaneous Emphysema.—During the straining of the second stage of labor, the larynx or trachea may be ruptured. This accident is followed by emphy- sema of the neck and face. The accident, if confined to the trachea or larynx, and resulting only in emphysema of the neck and face, is not dangerous. If the emphysema is more extensive, however, or if there is a rupture of the pulmonary vesicles, with emphysema of subpleural and interlobar connective tissue, with embarrassment of heart and lungs, the prognosis is not so good. As soon as the nature of the injury is recognized the patient must be forbidden to strain, and should be delivered as quickly as possible by forceps or version. Fig. 448.—Median section of coccyx imbedded in paraffin, showing an oblique fracture run- ning through the second verte- bra. The vacant space between the lower end of the anterior fragment and the main body of the bone was filled with an ex- uberant mass of spongy bone- tissue that dropped off when the bone was taken out (author's case). LABOR COMPLICATED B YACCIDENTS AND DISEASES. 571 Sudden Death During or Directly After Labor.—The causes of this accident to the parturient woman are set down, as far as possible, in the order of their frequency. Shock.—A certain number of sudden deaths, during and after labor, may be explained by surgical shock. This is, of course, all the more likely in consequence of some serious accident, such as ruptured uterus in labor, but it is possible to witness serious surgical shock from the strain and suffering of parturition in weak, hyperesthetic individuals, without any serious compli- cation. Heart=failure.—Heart-failure may be due to advanced kidney disease, to fatty degeneration of the heart itself, to a fibroid patch in its walls, to rupture of an aneurysm, to myocarditis, and to a number of other conditions that might interfere with normal heart-action. In women with diseased and weak hearts so small a matter as an intra-uterine injection has caused heart-failure. Accidents of Labor.—Any of the serious accidents of labor may produce death by shock or by hemorrhage, as accidental, unavoidable, or postpartum hemorrhage ; rupture or inversion of the womb. Rupture of Hematomata.—A rupture of a hematoma, exter- nal or internal, may kill a patient by shock or by hemorrhage. In a case under my care a hematoma in the outermost part of the left broad ligament, rupturing eighteen hours after delivery, caused the woman's death in a very short time by internal bleeding. Syncope.—There is a disposition in most women after labor to faint, but even complete syncope at this time is rarely fatal. If it depends, however, upon hemorrhage, thromboses may form in the heart, or those in the uterine sinus may be prolonged, and embolism may result. Prolonged syncope, associated with air- hunger and other symptoms of profuse internal hemorrhage, is almost always fatal. Embolism and Thrombosis of the Pulmonary Artery.—This may be the result of syncope, or may be caused by the detach- ment of an embolus from the pelvic blood-vessels. The embolus, it is claimed, may be a globule of air,1 or may be fat from the pelvic connective tissue. The symptoms of the acci- dent are : sudden shock, a rapid-running pulse, heart-failure, rapid respiration, air-hunger, followed usually in a few moments by death ; but the accident is not invariably fatal. I have seen one well-marked case recover. The only treatment possible is 1 Since I saw my friend, Professor H. A. Hare, inject whole syringefuls of air into the jugular vein of a dog without detriment to the animal, I confess to a skepti- cism in regard to air-embolism as a cause of death in the child-bearing woman. 572 THE PATHOLOGY OF LABOR. stimulation, slight elevation of the body, and lowering of the head, with absolute quiet. Profound Mental Impressions.—Profound emotion may cause a woman's death during or directly after labor. The following case was described to me by a friend who witnessed it. A widow, in good position, applied for treatment for abdominal tumor. She was told that she was pregnant, but she vehemently denied the possibility of her condition. A little later her phy- sician was summoned to attend her in what he found to be labor. He told her again of her condition, but she again denied it, and throughout the whole of her labor she vehemently protested that it could not be so. Finally, when the child was delivered, it was held up before her as a proof that her physician was correct. She passed at once into a maniacal condition, crying out that the child was a tumor, that she had not been pregnant at all, and after a few minutes she died. A careful postmortem examination revealed no physical cause for her death. Other causes of sudden death during and after labor that have been reported are : rupture of a gastric ulcer, acute purpura haemorrhagica, rupture of peritoneal adhesions, rupture of the aorta, rupture of a cyst in the auricular septum of the heart, and angina pectoris. Effect of Maternal Death upon the Fetus.—The fetus rarely survives its mother's death more than a few minutes, and usually the death of mother and child is synchronous. An interesting case was reported to me by a surgeon on one of the American vessels in Rio Janeiro during the revolution in Brazil. A preg- nant woman, near term, was struck by a fragment of an exploding shell. She was killed immediately. She had scarcely fallen to the ground when a surgeon, who was standing near her, cut open her abdomen and uterus with a penknife, but the child was ex- tracted dead. Tarnier reports an extraordinary case in which it appeared that the child lived for two hours after its mother's death. During the Commune in Paris the rioters fired upon the Maternity Hospital. A pregnant woman, sitting upon her bed in a ward, was shot through the head and instantly killed. After a while she was discovered dead, and Tarnier was summoned to do postmortem Cesarean section, as fetal heart-sounds were still heard. Beginning the operation with his assistant, the rioters fired upon the operators, and it was necessary to remove the woman to the cellar before the attempt could be renewed. After an interval of an hour and three-quarters, or more, the operation was at length performed, and a living child extracted from the mother's womb. In case of death in a pregnant woman near term, the fetal heart-sounds should be listened for carefully, and, if they are LAB OR CO MPLICA TED BY A CCIDENTS AND DISEASES. 573 heard, an immediate attempt should be made to extract the child. This can be done by postmortem Cesarean section, or, better, I think, by forced dilatation of the cervix, version, and rapid ex- traction. I have had one experience in such a case, in which the dilatation of the cervix and the extraction of the child pre- sented no difficulties at all, and were completed in a very few moments. If the patient is seen in articulo mortis, it is unques- tionably better to deliver her by forcible dilatation of the cervix and version rather than to await her death and then to perform a postmortem Cesarean section. Postmortem Delivery.—There is reported from time to time the birth of a child in its mother's coffin, giving rise to the horri- ble suspicion that the pregnant woman had been buried alive, and had fallen into labor when she awoke from her trance and realized her dreadful position. These cases, however, may be explained by the accumulation of gas within the abdominal cavity due to decomposition. This so increases the intra-abdominal pressure as to drive the fetus out of the woman's body. Such cases are more common in hot climates, where decomposition progresses rapidly. Accidents to the Fetus.—Prolapse of the Cord.—The cord is said to be prolapsed when it presents with or slips beyond the presenting part. Frequency.—According to Winckel, the frequency of prolapse of the funis varies in different clinics from 1 : 65 to 1 : 500. Churchill found it once in 245 labors ; Christisen, once in 65 ; Meachem, once in 93 ; Bland, once in 1897. Causes.—The causes of prolapse of the cord are, in the first place, a lack of conformity of the presenting part with the shape and size of the pelvic inlet, as a flat pelvis or a compound pre- sentation, and with this condition an exaggerated length of the cord, placenta praevia, marginal insertion, hydramnios, sudden rupture of the membranes and violent expulsion of the liquor amnii; delivery in the semirecumbent, sitting, or erect posture, and violent jolts or jars such as a parturient patient would ex- perience while transported to a hospital in an ambulance. The diagnosis should present no difficulty. There is nothing else in the cervical canal or vagina, during labor, which feels like the cord or should be mistaken for it. It is sometimes actually visible at the vulvar orifice, and may, in case of doubt, be pulled out and inspected. If the child is alive, the pulsating vessels in the cord may be felt. I was once called in consultation, how- ever, by a young physician who believed that a coil of intestine had prolapsed in the vagina. The prognosis for the child is grave. The mortality in gen- 574 THE PATHOLOGY OF LABOR. eral is more than fifty per cent. The child obviously dies of asphyxia from pressure upon the cord ; hence the danger is twice as great in head presentations (sixty-four per cent.) as in breech presentations (thirty-two per cent.). The danger to the mother lies in the operative procedures which are often required for the reposition of the cord, such as version and rapid extrac- tion. Treatment.—The cord should be replaced by manipulation with the woman in a knee-chest posture, or, better, the Trendelen- burg posture—over the back of a chair. It is advisable to hook a loop of the cord over an extremity or the chin to prevent its Fig. 449.—Trendelenburg posture over a chair to guard a prolapsed cord from pres- sure and to facilitate its reposition (Dickinson). prolapsing again, which is extremely likely. The whole hand must be inserted in the vagina, and perhaps within the lower uterine segment; so that anesthesia is usually required. While the anesthetic is administered, and while the physician makes his preparations for the reposition, the patient should be kept in the Trendelenburg posture, so as to guard the cord from fatal pres- sure. If the cord is satisfactorily replaced so that it will not come down again, forceps should be applied to the head to fix it firmly over the pelvic inlet. If manipulation fails to replace the cord, podalic version should be performed without waste of time. The breech being firmly impacted in the pelvis, the case is man- aged as one of breech presentation—by delay until the os is well LABOR COMPLICA TED B YACCIDENTS AND DISEASES. $/$ dilated and the cervix paralyzed, and then by rapid extraction. If the head is presenting and is engaged so that version is out of the question, the cord should be so disposed as to be least pressed upon (for example, opposite the left sacro-iliac junction in a left occipito-anterior position of a vertex presentation) and the head rapidly extracted with forceps. In prolapse of the cord with a breech presentation, the cord should be replaced by manipulation in the Trendelenburg posture ; a foot should be seized and brought down until the breech is firmly impacted in the pelvis. The instrumental reposition of the cord is usually unsatisfactory and unnecessary. Man- ipulation accomplishes more than can be done by a repositor. Occasionally, however, it might be convenient to remember the device illustrated in figure 450. A loop of string or tape is tied double around the end of a stiff catheter or bougie. The free loop is caught over the cord and the end of the instrument which is carried high up into the uterine cavity. Should it be desirable to withdraw the instrument, it can be vised repositor. done without pulling the cord out with it. Rupture of the Cord.—It has been shown by experiments that the healthy umbilical cord can stand a strain of Sy pounds on the average, the weakest 5 y pounds, and the strongest 15 pounds. It is obvious, therefore, that the weight of an ordinary fetus may be enough to rupture the cord, and it is almost certain to do so if the weight is increased by a drop or violent expulsion, and if the placenta remains attached. Hence, precipitate delivery in the erect posture is often accompanied by rupture of the cord usually at the umbilicus, although in one of my cases it tore off at the placental insertion. Spaeth and Budin have each reported a case of rupture of the cord while the woman was recumbent, and the latter has also reported a case in which the weight of the placenta, suddenly expelled and dropping the full length of the cord, snapped the latter in two. A ruptured cord usually does not bleed. If it is torn off at the umbilicus and the vessels bleed, they should be pulled out by a tenaculum and ligated, or, if this is impracticable, hare-lip pins should be inserted under the umbilicus and a figure-of-eight liga- ture applied. The treatment of rupture of the umbilical cord is pre- ventive. Labor in the erect posture should, of course, never be allowed, and a precipitate labor must be retarded ; violent 576" THE PATHOLOGY OF LABOR. traction upon a coiled cord has ruptured it. It is better, in such cases, to cut the cord between ligatures and hastily extract the child. DYSTOCIA DUE TO DISEASE. Convulsions.—Convulsions in the child-bearing woman may be defined as muscular spasms, with or without unconsciousness, occurring during pregnancy, parturition, or the puerperium. Causes.—The convulsions may be due to eclampsia, hysteria, epilepsy, tumors of the brain, meningitis ; to the profound an- emia following postpartum and other hemorrhages, and to apoplexy; or there may be an exaggeration of the nervous irri- tability characteristic of the child-bearing period, in consequence of which convulsions may arise from some trifling irritation, as that of an overdistended bladder, overloaded bowels, the intro- duction of the hand in performing version, the pressure of the head upon the perineum, and excessive after-pains. Puerperal convulsions, therefore, are a symptom indicative of a variety of pathological conditions. Eclampsia.—This name is given to the most frequent variety of convulsions in the child-bearing woman, the result of kidney insufficiency. The name is derived from a Greek word signify- ing to shine or flash out, and was conferred upon the condition on account of its sudden onset. Causes.—The etiology of eclampsia is still obscure. It has been attributed to the accumulation of urea in the blood, or to the formation of carbonate of ammonia in the system. It has been ascribed to sudden anemia of the brain, and, by some French observers, to microbic infection. All that can be said at present is that eclampsia is the result of the retention in the body of substances that should have been disposed of by the excretory organs, mainly the kidneys, but which, owing to the insufficiency of these organs, remain stored up in the body. The probable result of these poisonous substances in the blood is the irritation of the arterioles, causing sudden and extreme contraction of their walls, producing in this manner an acute anemia of the brain, which is in all likelihood the immediate cause of the con- vulsions. There must be taken into account also, however, the extreme irritability of the child-bearing period, predisposing to convulsive outbreaks, as it is not yet demonstrated that the substances in the blood (whatever they are) do not act directly upon the mus- cular centers in the brain and spinal cord. The kidneys in pregnancy may become insufficient for the work of disposing of excrementitious matters from both maternal DYSTOCIA DUE TO DISEASE. 577 and fetal bodies, by reason of the kidney of pregnancy, of ne- phritis, of increased intra-abdominal pressure, or of direct pres- sure upon the ureters. It is important in practice to appreciate that the kidneys may be diseased and yet functionally sufficient, or that they may be healthy anatomically, but functionally insuf- ficient for their double work. Frequency.—Eclampsia occurs about once in 300 cases of pregnancy. It is most frequently seen in primiparae, and more frequently in women illegitimately pregnant. It most often occurs during labor, is next in frequency during pregnancy, and occurs least frequently during the puerperium. It is ten times as frequent in multiple pregnancies as in single pregnancies, and occurs with greater frequency in climatic conditions which inter- fere with the free activity of the skin and throw extra work upon the kidneys. Symptoms.—Eclampsia should always be feared if there are signs of kidney disease or disturbance during pregnancy, for diseased kidneys are more likely to be insufficient than healthy kidneys. The prodromal symptoms of the attack itself are : Sharp pains in the head, epigastrium, or under the clavicle ; muscae voli- tantes, with failure of vision, great restlessness, or stupor. A few moments after the appearance of the prodromal symptoms the attack comes on with a stare ; the pupils are at first contracted ; the eyelids twitch, the eyeballs roll, the mouth is pulled to one side, the neck is then affected, and the head is pulled first toward one shoulder and then toward the other. The spasm finally spreads to the trunk and upper extremities ; the arms are strongly flexed, the fingers are bent over the thumb, and the upper ex- tremities work spasmodically to and from the median line in front of the chest. The lower extremities are rarely affected, although the thighs may be flexed tonically upon the abdomen. Con- sciousness is lost during the convulsive attack and for some time afterward ; with each recurring fit the stupor deepens, until at length there is unbroken coma. The temperature usually rises higher with each convulsion. Differential Diagnosis.—The convulsions of eclampsia must be distinguished from those of epilepsy, hysteria, brain disease, hemorrhage, or of some source of irritation within the body, as mentioned above. The distinction should be made without diffi- culty by an examination of the urine. If the patient is catheter- ized, and the urine is heated in a spoon over a gas-lamp flame, it will turn almost solid by the coagulation of albumin in it.' About sixteen per cent, of the cases of true eclampsia show no albuminuria before the convulsions appear, but in every case, after the second convulsion at least, the urine becomes strongly 578 THE PATHOLOGY OF LABOR. albuminous. The other conditions causing convulsions in the child-bearing woman have their distinctive signs (which it is not necessary to recapitulate here) that serve to make the diagnosis easy. Prognosis.—In general practice it may be stated that the mor- tality of eclampsia is thirty per cent., but in different localities, and at different times, the mortality varies widely. For example, the mortality in nine lying-in hospitals in this country during a period of five years was 38.4 per cent, in 78 cases. The mor- tality of the Royal Maternity in Edinburgh has been 66.6 per cent. That of Guy's Charity, in London, averages 25 per cent. In 209 cases in the Maternite, in Paris, from 1850 to 1856, the mortality was 33 per cent. Winckel reports 92 cases, with 7 deaths—a mortality of 7.6 per cent. Veit reports more than 60 cases, with 2 deaths—a mortality of 3.3 per cent. In 46 cases in the Charite, in Berlin, there were 6 deaths, 2 of these being due to complications, so that the mortality of the eclamptic cases was 8.5 per cent. It is claimed that in Germany in general the mor- tality in the last ten years has been reduced to between 7 and 10 per cent, but during this period, in 80 cases in the University Maternity of Berlin, the death-rate was 21.25 Per cent. The causes of death may be edema of the brain, of the lungs, or of the larynx ; apoplexy, asphyxia, exhaustion, heart-failure ; thrombosis and embolism in important vessels, especially the pul- monary arteries, or an overwhelming accumulation of the poison of eclampsia in the system. The mortality is greatest during pregnancy and least in the puerperium. The mortality of the child, if eclampsia occurs during preg- nancy or labor, is about 50 per cent. Treatment.—The preventive treatment of eclampsia has been referred to in the section upon the Management of Pregnancy, and under the head of Kidney Diseases during Pregnancy. The treatment of the eclamptic convulsions themselves is best dealt with by considering, first, the different plans of treatment separately, with their results, so that their relative merits may appear plainly. Anesthetization.—Chloroform will here be considered as the only anesthetic to be employed. When this drug first came into general use it was regarded by many as a specific for eclamp- sia, and is so regarded by a few to-day. Series of 20, 12, and of 9 cases, treated by chloroform alone, have been re- ported without a death. Charpentier reports 63 cases treated by chloroform alone with 7 deaths—a mortality of 11 per cent. But, on the other hand, the mortality from this treatment in the Maternite was 50 per cent. The place of chloroform in DYSTOCIA DUE TO DISEASE. 579 the treatment of eclampsia is now settled. No one would rely on it alone ; but every one is willing to admit its value as an ad- junct to other treatment. Diaphoresis and Catharsis.—Eclampsia is the result of some poisonous matter in the blood, and can not be cured until this poison is eliminated. The only emunctories available for quick and effectual action are those of the skin and bowels. No matter, therefore, what plan of medicinal treatment may be adopted, diaphoresis and catharsis must also be employed. The action of the skin may be excited by a hot wet-pack, by hot air or vapor, or by a hot bath. In private practice the hot wet-pack or the hot-air bath are the most practicable, and are to be recom- mended. The injection of normal salt solution into the subcu- taneous cellular tissue or under the breasts is an indispensable aid to free elimination by the skin. It seems literally to wash the blood of its impurities. Free catharsis is produced best by the use of croton oil, wiiich may be administered in drop doses upon the back of the tongue, and can therefore be given to a woman whether she is able to swallow or not. Elaterium in quarter-grain doses, rubbed up with a little butter, may be administered in the same manner. If the patient can swallow, a concentrated solution of Epsom salts is administered, in dessert- spoonful doses every fifteen minutes, until free catharsis begins. For the stupor that often succeeds convulsions, and in which the patient frequently dies from the accumulation of poisonous matter in the blood, the use of Epsom salts is most suitable. I have in such cases given as much as sixteen ounces of the con- centrated solution, in repeated doses, before the bowels began to move. Venesection.—Phlebotomy is at present somewhat in disfavor. The reaction against the indiscriminate use of the lancet has, however, gone too far. While bleeding in every case of eclampsia will show bad results, there are many cases in which it rescues women from impending danger of pulmonary edema and apo- plexy. Physicians in the country, who have to deal with strong, full-blooded people, are obliged, in the treatment of pneumonia in routine practice, to use the lancet. In the same class of people blood-letting in eclampsia is equally necessary. In a report of fifteen cases in which bleeding seems to have been the only thing done, there was but one death. In appropriate cases the vene- section should be done in time, and not, as recommended from some sources, only when symptoms of pulmonary edema appear. The measure is preventive of this accident, not curative. Morphin.—Older statistics of the morphin treatment for eclampsia show a death-rate of 57 percent. (Winckel), but lately 58o THE PATHOLOGY OF LABOR. Veit has published his plan of giving morphin in convulsions, with results so striking as to arouse the attention of the medical world. In more than 60 cases there were but 2 deaths—a mortality of only 3.3 per cent., the lowest death-rate yet obtained by any plan of treatment. This result can only be obtained by giving very heavy doses of the drug. Veit has injected one-half grain in each convulsive seizure, and has administered as much as three grains in four to seven hours, and four and one-half grains in twenty-four hours. Chloral.—This drug has many advocates to speak for it. Charpentier prefers it above all others, and presents statistics to justify the preference (114 cases, mortality 3^2 per cent.). Winckel recommends it most heartily, and by its use has saved 85 out of 92 cases. This drug, too, must be given in large doses to be effective. Thirty to sixty grains should be adminis- tered by enema at a dose, and the physician should not hesitate to give as much as three drams in the twenty-four hours, or even more in bad cases. Veratrum Viride.—The use of this drug is the American treatment of eclampsia. For the past twenty-five years it has been extensively employed in different parts of the country. Fearn, in 1871, reported 11 cases of his own and 2 cases from the practice of professional friends treated with very large doses of veratrum viride. None of the women died of the convulsions, but one succumbed later to puerperal sepsis. Rushmore has collected 85 cases of eclampsia treated with veratrum viride, with 20 deaths—a mortality of 23^ per cent. Jewett reported to the American Gynecological Society, in 1887, 22 cases of eclampsia treated with veratrum viride. Four of the women died of the convulsions—a mortality of 18 per cent. In 50 cases of eclampsia collected by Trimble, veratrum gave much the best results. In 26 cases treated by this drug there were 3 deaths, while in the remaining 24 cases there were 6 deaths—a mor- tality, respectively, of 11.5 and 25 per cent. The remedial measures detailed above comprise all that should be seriously considered. The treatment of eclampsia by antemortem Cesarean section, proposed first by Halbertsma, has not been successful, and can scarcely be regarded as justifi- able. Caffein, oxygen, and nitrite of amyl have not been used often enough to justify an opinion of their worth, and this judg- ment must be passed also on a number of other drugs recom- mended from time to time. Pilocarpin is simply mentioned to be condemned. There is no other treatment of eclampsia that gives so high mortality. In the Edinburgh Maternity, where this drug was employed for a time, the mortality was 66.6 per DYSTOCIA DUE TO DISEASE. 58l cent. Pilocarpin strongly predisposes to pulmonary edema, which explains the high mortality. In eclampsia during parturition the obstetrical treatment must receive consideration. As a rule, it is better to avoid inter- ference with the progress of labor, unless the os is fairly well dilated. Should eclampsia come on before labor begins at all, or in its earlier stages, the physician's attention should be confined to combating the convulsions. Having succeeded in subduing them, attention may be directed to the delivery of the patient. It is usual to find that the os has dilated rapidly during the convulsive attacks. It has been recommended to resort to forced delivery (accouchement force) in all cases of eclampsia during labor, resorting to deep multiple incisions, if necessary, according to Duhrssen's plan. The advantage of this procedure has not yet been demonstrated, and is not likely to be. The necessary operation for the delivery of the woman distracts one's attention from the treatment of the convulsions, and adds for the time being a violent source of irritation to the already highly wrought nervous system. Moreover, by waiting for a brief period, during which energetic treatment may be directed to the convulsive attacks, sufficient dilatation of the os may be secured naturally to permit the delivery of the woman without excessive violence or without too much loss of time. As soon as the os is dilated beyond the size of a dollar, delivery may be hastened with advantage by applying forceps if the head is engaged in the pelvis, or by performing version and extraction by the feet if the head is not yet engaged, or if the breech should be presenting. It may be useful for the student to have a scheme of treat- ment for the average case of eclampsia that he can put into effect without delay or confusion from considering the relative merits of the different plans just detailed. The following plan should be successful in the majority of cases : During the attack itself administer chloroform. As soon as the attack has passed off, inject under the skin fifteen drops of the fluid extract of veratrum viride, and administer by the bowel a dram of chloral in solu- tion. Place upon the back of the tongue two drops of croton oil diluted with a little sweet oil. Wring out three or four blan- kets in very hot water, and envelop the woman's nude body in them, wrapping one around each limb and covering the trunk with another, and over all piling as many dry blankets and heavy coverings as can be procured. Inject by gravity under the breast or breasts a pint or more of normal salt solution, or, if the appara- tus for subcutaneous injection is not at hand, inject several quarts of the solution by gravity into the bowel. If convulsions recur, repeat the veratrum viride in five-drop doses if the pulse is quick 582 THE PATHOLOGY OF LABOR. and strong. If the face is very congested and swollen, and the pulse still remains full and bounding, venesection should be re- sorted to, withdrawing sufficient blood from the veins to reduce the tension of the pulse. The chloral may be repeated in the course of the attack two or three times. If the face is pale and the pulse rapid and weak, stimulation may be required in the shape of brandy, ether, or ammonia hypodermatically. If the convulsions cease and the patient lies in a stupor, but can be aroused somewhat and is able to swallow, concen- trated solution of Epsom salts, in dessertspoonful doses, should be given every fifteen or thirty minutes until catharsis is established. Shock.—The strain of labor in a weak woman, some of the accidents of parturition, or even forci- ble attempts to expel the placenta, may occasion shock after delivery, with lowered temperature,leak- ing skin, and a running, rapid pulse. Cases of this sort have been reported from compression of the left ovary in attempts to expel the placenta by Crede's method, the womb being turned upon the cervix so that the left side looks forward, and the ovary is grasped between the thumb and the uterine wall, when the hand is placed on the fundus of the womb in the effort of expression. The condition calls for the ordinary treatment of shock—heat externally and stimulants hypodermatically. Typhoid Fever, Pneumonia, and Other Adynamic Dis- eases.—These diseases, though rare complications, do occur in the pregnant woman, and in the majority of cases occasion pre- mature delivery. In typhoid fever this occurs in sixty-five per cent, of the cases, and in pneumonia the proportion is quite as 1 Day of 1 Disease 107° 106° 105° 104° 103? 102° 101° 100° 09° 98° 97° M E Ml ' M E M £ M E M E M £ $ I »•. k^ f \ y \ S/ 1 \ V \ \ \ V \ : r i V '■ j i: ■ Fulse ft -9i Reap. \ 4 '*l H* Fig. 451.—Temperature-chart of a patient falling in labor in the midst of an attack of typhoid fever (author's case). DYSTOCLA DUE TO DISEASE. 583 large. The advent of labor in the midst of these diseases is usually disastrous to the patient. Profound shock is often de- veloped ; the temperature falls abnormally low, even to 950 F., and the heart-action may be extremely weak. Active stimu- lation should be employed during the first stage of labor, and, as soon as the os is sufficiently dilated, the child should be artificially extracted as rapidly as possible without serious injury to the mother, in order to save her the strain of voluntary muscular effort in the second stage. Valvular Disease of the Heart.—Mitral disease is the most serious. Certain statistics show a mortal ity as high as fifty-three per cent. As pregnancy advances the heart becomes more and more embarrassed, and respiration more labored. The most dan- gerous period, however, is just after the expulsion of the child, when the circulation is much disordered and an extra quantity of blood is thrown back upon the heart. It has been noticed that when the discharge of blood is profuse, cardiac failure rarely occurs. This clinical observation points to the most successful treatment in cases of threatened heart-failure,—namely, venesection,—with the removal of from eight to sixteen ounces of blood, if there is not much blood lost from the parturient tract after labor. Nitrite of amyl and nitroglycerin are the most valuable stimulants to employ during labor and directly after its completion. Digi- talis should be administered hypodermatically during the first stage in large doses, and as soon as it is possible to insert the forceps through the os, or to grasp the child's feet if the head is not engaged, the infant should be rapidly and, if necessary, forcibly extracted. Deep incisions of the cervix are of the great- est value in cutting short the duration of labor and in lessening the force required in the artificial delivery of the child. With this plan of treatment the mortality of heart disease in labor will be much reduced. It has been my fortune not to lose a case, although charged with the care of a number, some of which were of the most serious character. PART V. PATHOLOGY OF THE PUERPERIUM. CHAPTER I. Abnormalities in the Involution of the Uterus after Child-birth, An abnormal course in the return of the uterus from the post- partum condition to the ordinary dimensions and weight of a non- gravid womb may manifest itself by excess or by deficiency ; there may be superinvolution or subinvolution. Superinvolution.—This condition is the result of an abnor- mal prolongation or an exaggeration of that process by which the gravid womb returns, after delivery, to the dimensions of a healthy non-pregnant uterus, in consequence of which the organ is left, some time after labor, much smaller than in its virgin state. Sir James Y. Simpson first directed attention to morbid de- ficiency and morbid excess in the involution of the uterus after labor. Since his time many writers have called attention to de- ficient involution ; a smaller number have described the rarer anomaly of the two—excessive involution. Trommel detected superinvolution in 29 out of 3000 cases ; Simpson x saw it in 22 out of 1300 cases ; Sinclair,2 in measuring 108 uteri after child- birth, found in 22 instances a uterine cavity of less than 2){ inches, and Fordyce Barker 3 has declared that he sees from 1 to 3 cases every year, and that in his opinion superinvolution consti- tutes about one per cent, of uterine diseases. Hansen,4 among 120 nursing women, found 2 with a uterine cavity below 6 cm. 1 A. R. Simpson, " Superinvolution of the Uterus," " Trans. Edinburgh Obstet. Soc," i882-'83, viii, p. 88. 2 "Trans. Amer. Gyn. Soc," vol. iv. This series of measurements, as well as others made later by Sinclair and Richardson ("Trans. Amer. Gyn. Soc," vols, vi and vii), are sharply criticized by Hansen, who declares them to be in great part in- correct. The criticism is apparently merited. 3 " Trans. Amer. Gyn. Soc," viii, 1883; discussion on Dr. Johnson's paper. 4 " Ueber die puerperale Verkleinerung des Uterus," " Zeitschr. f. Geburtsh. u. Gyn.," xiii, S. 16. 5§4 ABNORMALITIES LN INVOLUTION OF THE UTERUS. 585 (5.6, 5.4) respectively at the eighth and tenth week after de- livery. Johnson x gives an account of 3 cases which occurred in his practice, and Simpson 2 refers to those described by Chiari, Chiarleoni, Jaquet, and Whitehead. A case 3 has been reported after abortion. The etiology of the condition is somewhat obscure. It has been ascribed to wasting diseases, as phthisis, cancer, etc.; to anemia from hemorrhage at a previous birth or miscarriage ; to nervous derangements, as puerperal insanity or chorea ; to over- lactation ; to a rapid succession of labors ; to local inflammations, especially those which attack the ovaries and abrogate their func- tions. The degree to which the superinvolution may occasion- ally progress is surprising. A. R. Simpson reports a case in which the uterine cavity measured but % of an inch, and a still greater reduction in the size of the uterus and its appendages after labor has been reported. Subinvolution.—Subinvolution may be described as an arrested or a retarded involution of the puerperal uterus. Causes of Subinvolution.—There is a difference of opinion in regard to the exact nature of the changes which occur in the individual muscle-cells during involution of the uterus ; but there can be no doubt as to the cause of these changes, whatever they may be. It is a great reduction of the blood-supply. In a gen- eral way, therefore, it may be asserted that any condition which tends to prevent a rapid diminution of the blood-supply to the puerperal uterus may be a cause of subinvolution. Nature's only method of decreasing the quantity of blood in the puerperal uterus is by the agency of the contracting muscle-fibers ; there- fore, it may again be asserted that any condition which interferes with the contraction of the uterus will be a cause of subinvolu- tion. It is necessary to make these two broad divisions in the etiology of subinvolution, for, although frequently interdepend- ent, they are not rarely independent of each other. In point of frequency there should be placed first those causes which pre- vent the normal decrease of blood-supply to the uterus after labor. Prominent among these should stand hyperplasia of the endometrium. Subinvolution by an excess of blood-supply may occasion- ally be traced to the presence, throughout the uterine wall, of small fibroids. Other causes, besides the two already given, responsible for subinvolution, are lacerations of the cervix and peri-uterine inflammations ; inflammations of the uterine body and 1 "Superinvolution of the Uterus," "Trans. Amer. Gyn. Soc," viii, 1883. 2 Loc.cit. 3 C. M. Hansen, "Med. Record," Oct. 6, 1888. 586 PATHOLOGY OF THE PUERPERIUM. of its lining membrane, usually the result of sepsis ; retention within the uterus of placental fragments, shreds of membranes, placental or fibrinous polypi, and blood-clots ; chronic consti- pation ; displacements of the womb ; premature getting up ; pre- mature resumption of sexual intercourse ; and anything which interferes with the return of the venous blood to the heart, causing a passive congestion of the pelvic organs, as increased intra-abdominal pressure from abdominal tumors, certain diseases of the liver, and valvular disease of the heart. Many examples of subinvolution by the mechanical prevention of perfect uterine contraction may be observed, as large intra- mural and submucous fibroids ; unusually large masses of hyper- trophied decidua that sometimes develop at the placental site; the retention within the uterus of considerable portions of the placenta, or placentae succenturiatae ; large blood-clots ; the dis- placement of the uterus by a retroversion or flexion of the organ, or by an overfilled bladder; peritoneal adhesions from old or recent inflammatory attacks, involving the serous covering of the uterus and adjacent parts. One fact stands out clearly from an observation of such cases : The cause of subinvolution is always some local disturbance, and not a constitutional de- rangement. The puerperal state may be complicated by any of the acute or chronic febrile affections, without the slightest in- fluence upon uterine involution.1 One exception, however, must be made to this general state- ment : nervous derangements do influence involution. A. R. Simpson assigns to puerperal insanity a prominent role in the causation of superinvolution. On the other hand, a sudden mental shock, some powerful emotion, may temporarily arrest involution. The diagnosis of subinvolution is easy. The fundus uteri should be a finger's breadth above the umbilicus on the first day of the puerperal state, higher than it is directly after birth ; on the second day, at the level of the umbilicus ; the third day, a little below ; the fourth day, about the same ; the fifth and sixth days, two fingers' breadth below the umbilicus ; the seventh, eighth, and ninth days, three or four fingers' breadth above the sym- physis pubis ; the tenth, eleventh, and twelfth days, at the level of or a little below the pubes.2 Hansen, by measurements of 120 nursing women from the tenth day until the third month after 1 Temesvary and Backer ("Studien auf dem Gebiet des Wochenbettes," " Archiv f. Gyn.," Bd.xxxiii, H. 3, S. 331, 1888) actually make the assertion that fever favors the involution of the uterus. 2 For an extensive bibliography of uterine measurements in the puerperal state see Schroeder's " Lehrbuch," 8thed., 1884, p. 230, and Hansen, loc. cit. ABNORMALITIES IN INVOLUTION OF THE UTERUS. 587 delivery, gives the following as the normal course of involution from the tenth day of the puerperium until the completion of the process : Average Intra-uterine Measurement Tenth day (114 measurements) . . . 10.6 cm. Fifteenth day (119 " ) . . . 9.9 '• Third week (05 " ) ... 8.8 " Fourth week (80 " ) . . . 8.0 " Fifth week (64 " ) ... 7.5 " Sixth week (56 " ) . . . 7.1 '• Seventh week ( 40 " ) . . . 6.9 " Eighth week (31 " ) • • 6.7 " Tenth week (22 " ) ... 6.5 " Twelfth week ( 15 " ) . . . 6.5 " In two-thirds of the cases Hansen found involution completed in six to ten weeks ; in one-sixth, not until the last half of the third month or later ; in again a sixth, within six weeks. The most rapid involution occupied four weeks. Any great deviation from the normal course may easily be detected, either by ab- dominal palpation or by the use of a sound, while along with the arrest or retardation of involution will usually be found a profuse lochial discharge. Ahlfeld1 claims that free perspira- tion after labor is a valuable sign of firm uterine contraction in the early part of the puerperal state ; when it fails to appear, he always looks for uterine relaxation. Treatment.—The treatment should be directed not so much toward the symptom (subinvolution), as toward its cause. It is evident, therefore, that the treatment of this condition must vary greatly in individual cases. If the subinvolution depends upon the retention of hypertrophied decidua, a curet will promote rapid involution more effectively than anything else. If placentae or membranes are retained /'// uteri, they should be removed. If involution is retarded by the presence of fibroids, the adminis- tration of ergotin, strychnin, and quinin in pill form, and the application of a faradic current have given good results. The bladder should never be allowed to remain distended with urine nor the rectum with feces. Inflammation in or about the uterus must be combated by appropriate treatment. If the heart-valves are imperfect or the heart-muscle weak and the abdominal and pelvic veins are consequently engorged with blood, a heart-tonic, as digitalis or strophanthus, will often assist involution. Char- pentier has asserted that the routine administration of ergot in the puerperal state will hasten involution. This would seem 1 " Der Zusammenhang zwischen Schweisseruption postpartum und Uteruscon- tractionen," " Ber. u. Arbeit, a. d. Geburts. Gynak. Klinik zu Marburg," i885-'86, Bd. iii, S. 81. Minimum. Maximum. 8 cm. 13.5 cm. 8.3 " II.5 " 7-5 " 10.5 " 7.0 " 9-3 " 6.5 " 9.0 " 6.2 " 9.1 " 6.0 " 8.5 " 5.6 " 8.5 " 5-4 " 7.5 " 6.0 " 7-5 " 588 PA THOLOGY OF THE PUERPERIUM. reasonable, but clinical experience has not borne out the state- ment. Herman and Fowler1 did find, in experimenting on two sets of patients,—one, 58 in number, receiving an ergot mixture daily for a fortnight after labor; the other, 68 in number, receiving a single dose of ergot after labor,—that in the first set involution advanced more rapidly, but that there was no difference in the lochial discharge. Boxall2 also declared him- self in favor of the routine practice of giving ergot during the puerperium, asserting that in two series of cases, comprising each 100,—one treated without, the other with, ergot,—there were fewer blood-clots ; these were more quickly discharged, and the after-pains were less frequent, of shorter duration and diminished intensity in the latter series. Dakin,3 however, dis- sented from these views, and claimed, likewise, after testing the matter in practice, that the routine administration of ergot re- tarded the involution by at least twenty-four hours. Blanc4 also declared that the administration of ergotin during the first five or ten days of the puerperal state has not a favorable influence upon involution, but seems to interfere with it to some extent. As it is doubtful, therefore, whether ergot does aid involution, as there are many obvious disadvantages connected with its routine ad- ministration in the puerperal state, the adoption of the practice would be unwise, and is not to be recommended. Puerperal Anemia.—This condition might not inaptly be called a subinvolution of the blood. After the first twenty-four hours of the puerperal state there begins a change in the consti- tution of the blood by which it is converted from the hydremia of pregnancy to the normal proportion of its constituent parts in the non-gravid woman. At the end of two weeks the process is so far complete that the blood is more nearly in a normal condi- tion than it was during pregnancy.5 Many causes, however, may disturb the recovery from the hydremia of pregnancy. Ill- ness of any kind during pregnancy, hemorrhage during labor,0 nervous affections—as insanity or chorea—during the puerperal state, kidney disease, fevers, etc., may all induce puerperal 1 "On the Effect of Ergot on the Involution of the Uterus," " British Med. Jour.," 1888, i, 299. 2 Ibid. 3 Ibid. 4 " Ann. de Gyn6c," March, 1888. 5 Meyer, " Untersuchungen iiber die Veranderung des Blutes in der Schwanger- schaft," "Archiv f. Gyn.," Bd. xxxi, S. 145. 5 It is extraordinary, however, to see how rapid occasionally is the recovery of puerperse, even from severest hemorrhage. A loss of 2000 to 2500 grams of blood is usually fatal to an adult, but Ahlfeld reports two cases in which, respectively, 2000 and 2500 grams of blood were lost without serious anemia afterward (" Ber. u'. Arb. a. d. Geb. Gyn. Klinik zu Marburg"). ABNORMALITIES IN INVOLUTION OF THE UTERUS. 589 anemia. The treatment of the condition must be governed by the circumstances of the individual case. The cause of the anemia being removed, the blood will improve, and the improvement may be accelerated by tonic drugs and good diet. After hemor- rhages, beef-tea, animal soups, and as nutritious a diet as the patient can bear, along with tonic medicines, will hasten recovery. Under the prolonged use of Blaud's pills I have seen the blood- corpuscles rise from less than three to nearly four and a half mil- lion per cubic millimeter, and the hemoglobin increase from forty to seventy-five per cent, in a few weeks. In some cases arsenic alone succeeds where iron fails. Osier x has reported an inter- esting case of the kind. Repair of the Injuries of Child=birth.—Slight cracks in the mucous membrane, small rents in cervix, vaginal wall, and vagi- nal outlet,—unavoidable occurrences in almost every labor,— either unite firmly or else are healed by granulation. Occasionally, very extensive injuries are repaired by natural processes. Per- forations of the vaginal vault, fistulous openings into bladder and rectum, deep tears and perforations of the perineum, transverse rents and perforations of the labia, lacerations about the urethra,— all have been known to unite without interference. Winckel states that perineal tears, when left to themselves, will be found healed in two and a half to five weeks. Extensive injuries, how- ever, should be repaired, wherever practicable, by sutures. Rents in the vaginal mucous membrane and cervical tears do not usu- ally require this treatment, unless there is profuse hemorrhage. Lacerations of the perineum, of the pelvic floor, and of the vagi- nal sulci should never be neglected. If the stitches are inserted carefully, primary union will be secured almost invariably. In fistulae the result of sloughs after labor, if the opening be not too large, a cure can occasionally be effected by touching the edges of the fistula with a strong caustic, like nitric acid. To do this the diagnosis must be made in the lying-in period, wrhich, as a rule, is not difficult. The escape of feces and gas from the vagina, and a constant trickling of urine, point respectively to a rectovaginal or a genito-urinary fistula. It is necessary in the latter case to exclude the incontinence of urine due to paresis of the vesical sphincter, and the overflow of retention sometimes seen in the puerperal state. All doubt is cleared away by find- ing the anomalous opening between bladder or ureter and vagina or cervical canal. In abrasions and wounds along the parturient tract it is necessary occasionally to apply lint saturated with car- bolized oil to prevent an acquired atresia of the birth-canal. If 1 "Boston Med. and Surg. Jour.," 1888, p. 454. 59O PATHOLOGY OF THE PUERPERLUM. the abrasions and wounds are infected and covered with exudate they should be cauterized with nitrate of silver solution, g-fgj. Edema of the external genitals, the result of injuries, pres- sure, or contusions during labor, gives rise to considerable pain and discomfort, which are best relieved by the application of cloths wrung out in a hot sublimate solution, I : 4000. The influence of injuries in the genital tract upon the course of the puerperal state is unfavorable. The danger of septic infection is materially increased, and fever is consequently more common, not only from this cause, but as a direct result of the injury and irritation of tissue. Retention of urine is another consequence of injury to the vagina during labor, according to Winckel1, who says that he has seen obstinate cases of retention, lasting from ten to four- teen days, due to this cause. Puerperal Hemorrhage. — The term "puerperal hemor- rhage" is used to denote profuse bleeding from any point along the genital tract of the female, occurring after the first day of the puerperium until involution of the uterus is completed—a period of about six weeks. The causes of this accident are numerous and should be well considered, for the treatment will be governed in most cases by a knowledge of the cause. The causes are placed as far as possible in the order of their frequency. Retained Placenta and Membranes.—The retention within the uterus of the placenta, as a whole or in part, will very likely give rise to hemorrhage during the puerperal state. The reten- tion of the whole placenta is not now a cause of puerperal hemor- rhage, for no practitioner of the present day would allow this large mass to remain within the uterus many hours after delivery. Toward the end of the last century and in the beginning of this, however, it was not rare to find followers of William Hunter, who trusted altogether to nature to deliver the placenta, often with most disastrous results. White 2 gives an account of four cases of retained placenta, with fatal hemorrhage occurring on the first, second, third, and fourth days, respectively. The retention of placental fragments is by no means rare. A careful inspection of the placenta after delivery often shows a defect, and the missing piece must be sought for and re- moved ; but occasionally it is difficult or impossible to tell whether the placenta has come away entire ; and if the retained portion is an accessory growth, there is, of course, nothing to 1 " Lehrbuch der Geburtshulfe," p. 741. 2 "A Treatise on the Management of Pregnant or Lying-in Women," Worcester, Mass., 1793, p. 215. PUERPERAL HEMORRHAGES. 591 indicate its existence in the appearance of the placenta proper. Stadfelt states that, in 70 examinations of puerperae postmortem, placental fragments were found in 7 cases, varying from the size of a hazel-nut to that of an egg. Clinical observation alone makes this complication of the puerperal state appear more rare. Of 2960 births in the Frauenklinik at Munich, from 1884 to 1887, there were reported 9 cases of retained placental fragments.1 It is possible, however, that small portions of placental tissue might escape unnoticed in the lochial discharge, or else by their dis- integration form a part of the discharge. The retention of pla- cental tissue in utero does not always cause hemorrhage. I have seen a placenta succenturiata expelled on the second day of the puerperal state without any previous bleeding, and a very large piece of the placenta discharged four days after a premature birth, very fetid, but with no bleeding. In the 9 cases reported by Martini there was a prolongation of the bloody lochia in 1, a severe hemorrhage in 2 ; in 6 there was no excessive loss of blood. The cause of the retention of placental fragments is either some abnormal form of placenta (marginata, multiloba, suc- centuriata, etc.), an abnormal adhesion to the uterine wall, or too forcible or premature efforts at extraction or expression.2 Retention of the membranes after labor is of frequent occur- rence. Martini reports 71 cases out of 2960 births.3 Reihlen4 found a retention of some portion of the chorion in 152 out of 3534 labor cases (4.3 per cent). Another investigation gave 5.1 per cent, from an analysis of 11,381 births. Crede5 reports 91 cases of retained chorion in 2000 births. Membranes retained in utero may give rise to septic infection ; whether or not they can be a cause of puerperal hemorrhage is still a disputed question. Crede6 has expressed his belief that retention of the chorion is not at all dangerous. Olshausen has declared that the retention of the chorion should never justify interference to extract it.7 Reihlen 8 says that he never saw hemorrhage as a result of retained chorion. Schroeder 9 asserts 1 Martini, " Ueber das Zuruckbleiben von Eihaut u. Placentarresten bei vor- u. rechtzeit. Geburt," " Munchen. med. Wochenschr.," 1888, p. 653. 2 Ahlfeld in 996 deliveries saw only 4 cases of puerperal hemorrhage. He attributes the freedom from this accident in his clinic to his conservative manage- ment of the third stage of labor. He insists upon waiting one and a half hours be- fore expressing the placenta ("Ber. u. Arbeiten," Marburg, Bd. iii). 3 Loc. cit. 4 "Zur Frage der Behandlung der Chorion-Retention," "Archiv f. Gyn.," Bd. xxxi, S. 56. 5 "Archiv f. Gyn., Bd. xvii, S. 278. 6 Loc. cit. 1" Klin. Beitr. zur Gyn. u. Geburtsh.," 1884, S. 146. 8 Loc. cit. 9"Lehrbuch," 10. Aufl., 797. 592 PATHOLOGY OF THE PUERPERIUM. that retained amnion and chorion practically never cause bleed- ing, even when retained in toto. On the other hand, Winckel1 and Hegar 2 have shown that retained membranes could give rise to puerperal hemorrhage, as well as to septicemia. Martini re- ports 28 cases of retained chorion in which there was no fever— that is, no pathological condition, as uterine inflammation, decomposition of thrombi, etc.—to account for bleeding, and yet among these cases there were two severe hemorrhages, eight of minor grade, and six times a prolongation of the bloody lochia. Fig. 452-—Fibrinous polypus (Frankel). That retention of hypertrophied and angiomatous decidua can be an etiological factor in puerperal hemorrhage there can be no doubt. If the decidua is hypertrophied during pregnancy, the amount of tissue retained in utero may be considerable! The mass may act as a foreign body within the uterine cavity, preventing firm contraction, and so predisposing to hemorrhage! or else, adhering to the uterine wall, may attract an unnecessary 1 " Berichte u. Studien," i874-'79 ; " Path. u. Therap. des Wochenbettes." 2 " Path. u. Therap. der Placentar-Retention," 1862. PUERPERAL HEMORRHAGES. 593 amount of blood to the whole organ, with the same result Even a small portion of deciduous membrane, as well as shreds of adherent chorion and amnion, or placental fragments may form the foundation of polypoid tumors reaching occasionally considerable size, composed chiefly of firmly clotted blood or fibrin. The growth of these bodies is like stalactite formations on stone. The same thing occurs in different shape when the placental site is left unusually rough and vascular. The blood oozing from the sinuses may deposit successive layers of fibrin until quite a thick mass is formed. Diagnosis and Treatment.—The fact that a portion of the ovum has been retained in utero is usually easy to discover A careful examination of the secundines after labor will enable one to detect missing parts, which must have remained behind in the genital tract. It is not wise, as a rule, to invade the internal genitalia in order to remove small shreds of amnion and chorion ; if, however, a greater part of these membranes has been retained, it is advisable to remove it. The diagnosis of re- tained placenta is, as a rule, easy. When the whole organ re- mains in utero, the cord dangling from the external genitals points clearly enough to the condition. If one or more cotyledons remain behind, their absence may be noted from the placenta after its delivery. Occasionally, the diagnosis is more difficult, even if the whole placenta is retained. I recall a case in which a woman was delivered on her feet; the child dropped to the floor, the cord was dragged off from the fetal surface of the placenta! and the latter remained behind in the uterus; it was tightly adherent to the uterine wall, and its discovery, with no cord to guide one, was by no means an easy matter. It was finally peeled off and extracted, the woman meanwhile bleeding furiously. Cotyledons torn off the periphery of the placenta may easily go undetected, and in certain roughly lobulated placentae it is very difficult to be sure that no placental tissue has remained behind.1 If the medical attendant suspects the retention of placental masses after labor, he must attempt their removal. This is usually not difficult. The hand—the only trustworthy instru- ment under the circumstances—is inserted into the uterine cavity, the placental substance is felt for, caught by the fingers, and removed ; if the placenta is adherent, the tip of the finger must be gently inserted, wherever most practicable, under the edge, and the whole organ gradually peeled off. If the uterine muscle is too firmly contracted to allow the introduction of the hand, the 1 "Zur Frage der Behandlung der Placentar-Retention," etc., " Zeitschr. f. Geburtsh.," xvi, pp. 292, 302. 38 594 PATHOLOGY OF THE PUERPERIUM. resistance must be overcome by firm, gradual pressure, first in- serting one finger, then two, and so on until dilatation is effected. To accomplish the dilatation it is often necessary to administer an anesthetic. If puerperal hemorrhage occurs, the presence of membranes or placental fragments within the uterus should be suspected, Fig. 453.—Stratz's section of a primipara, who died from hemorrhage with fatty heart within an hour after delivery: a, a, Contraction-ring; b, b, os internum; c, uterovesical reflection of peritoneum ; d, bladder; e, symphysis pubis; f, urethra; g, promontory of sacrum ; h, pouch of Douglas ; i, posterior fornix ; J, os externum. and their removal should be attempted unless some other con- dition is clearly seen to be the cause of the bleeding. To reach the uterine cavity after involution and retraction have made some progress, it is often necessary to dilate the cervical canal. Hegar's bougies will be found the safest and most convenient instruments for the purpose. Branched dilators, unless used PUERPERAL HEMORRHAGES. 595 with the greatest care, are dangerous in the puerperal womb. Not rarely, however, the cervical canal remains patulous in con- sequence of a foreign body in utero; in this case access to the retained mass and its removal are easy. Displacements of the Uterus.—The dislocation of the puer- peral uterus will often manifest itself in puerperal hemorrhage. Inversion, prolapse, displacements forward and backward and Fig. 454.—Section of a primipara who died from sepsis five and a half days after delivery (Barbour). upward by a distended bladder, are all likely to be followed by profuse bloody lochia, if not by an active hemorrhage. In- version and prolapse have already been considered ; retroversion, retroflexion, and anteflexion are noticed here. Hemorrhage is likely to occur in these displacements as a result of the passive congestion always associated with them, due to interference with the venous circulation ; or the bleeding 596 PATHOLOGY OF THE PUERPERIUM. may be the consequence of the retention of blood within the uterine cavity, due to the mechanical interference with its escape ; in the latter cases clots are formed, increasing gradually in size, often undergoing putrefaction, and acting not only as a foreign body, preventing uterine contraction, and attracting by their irri- tating action an extra amount of blood to the uterus, but consti- tuting as well a favorable nidus for the development of septic germs, which may extend their operations to the thrombi at the placental site, disintegrating them.1 The causes of uterine displacements in the puerperal state are the increased weight of the puerperal uterus, with loss of tonicity. They are, therefore, not infrequently associated with subinvolu- Fig. 455.—Retroflexion of puerperal uterus (Schatz). Fig. 456.—Frozen section of puer- peral uterus in a state of anteflexion (Stratz). tion. Backward displacements of the puerperal womb are most frequently the result of a displacement antedating conception. They are frequently due also to some sudden physical effort soon after leaving the bed, especially if the woman has risen too early, before involution has advanced sufficiently far. Another common cause is the faulty application of a compress under the binder. Many nurses, unless they are properly directed, place a thick compress in direct relation with the anterior uterine wall, thus crowding the whole organ backward, instead of adjusting it over the fundus of the uterus, where it will maintain a condition by Grafe 1 Five cases of puerperal hemorrhage due to uterine displacement are reported rafe in " Zeitschrift f. Geburtsh.," xii. •228. PUERPERAL HEMORRHAGES. 597 of anteversion, and by constant pressure promote firm contrac- tion and rapid involution. Retroversion and retroflexion may persist after premature delivery, if these displacements existed during pregnancy. Neglect to empty the bladder at proper intervals may be found a cause in some cases. The diagnosis is easy if a careful physical exploration is made ; and it should be an invariable rule to make a careful vaginal examination in every case of puerperal hemorrhage. It is not rare to find some portion of the ovum or blood-clots retained within the uterine cavity in consequence of the " steno- sis by angulation " of the cervical canal.1 It is, therefore, not *}g- 457-—Anteflexion. Webster's section from a case of death from eclampsia about thirty-six hours after delivery: a, Fundus; b, bladder; c, symphysis pubis; d, promontory ; e, cervix; /, pouch of Douglas ; g, vagina. sufficient to rest satisfied with the diagnosis of displacement in puerperal hemorrhage, but it is necessary to be sure that there is nothing retained within the uterus. It should be remembered that there may be no hemorrhage, but, for a time, suppression of the lochia, with displacements of the womb. Occasionally, if the dislocation occurs acutely, it may be associated with grave symptoms, as intense pain, a condition verging on shock, and high fever, these symptoms disappearing immediately upon the reposition of the womb. 1 Fernley, "British Med. Jour.," 1888, ii, 739. 598 PATHOLOGY OF THE PUERPERIUM. The treatment of puerperal hemorrhage due to a displaced uterus is the rectification of the displacement. This will occa- sionally be followed by the expulsion of blood-clots or remains of the ovum, which, imprisoned within the uterus, were the true causes of the bleeding.1 The uterus, restored to its natural position, should be retained there, for a while at least, by some mechanical support. Dislodgment and Disintegration of Clots at the Placental Site.—The thrombus formation in the large sinuses at the pla- cental site plays a subordinate part in the prevention of hemor- rhage after delivery. In consequence of sudden exertion, sitting upright in bed, or actually standing on the floor soon after labor, some of these clots, plugging up important vessels, might be dislodged. It is with this possibility in mind that every pre- caution should be taken to secure quiet and repose for the woman after labor. Disintegration of the clots at the placental site occurs occasionally in consequence of their invasion by micro-organisms. This is, therefore, one of the phenomena of puerperal infection. The bleeding that follows is, of all puer- peral hemorrhages, by far the most dangerous. Diagnosis.—The hemorrhage that follows displacement of thrombi at the placental site is startling in its suddenness, and alarming in the amount of blood lost. There need be nothing in the uterine cavity to account for it; the uterus may be in good position. The true condition can, of course, only be inferred. Treatment.—The best treatment for this kind of uterine hemorrhage is thus described by its author.2 He takes with him to every case of labor a strip of twenty per cent, iodoform gauze three yards long, two hands' breadth in width, in four layers. On this is scattered loose iodoform powder. To tampon the uterus the anterior lip of the cervix is seized as high up as possible with two bullet-forceps ; the strip of gauze is then caught by the end in a long pair of forceps and is introduced within the uterus. As soon as the point of the forceps enters the uterine cavity the left hand grasps the fundus, and only then is the forceps pushed in as far as it will go. The forceps is then loosened, withdrawn a little, a lower portion of the gauze strip is seized, and so the uterus is filled with gauze, lying in fan-shaped folds. "It is astonishing," says Duhrssen, " how soon the uterine cavity is filled." The uterus is stimulated to contraction ; so one gets the 1 Strachan reports an interesting case of the kind associated with anteflexion. Six weeks after labor there was a severe hemorrhage; the uterus was straightened by upward pressure through the anterior vaginal vault. The following day a cotyledon of the placenta was discharged (" British Med. Jour.," 1886, i, 587). 2 Duhrssen, " Die Uterus-Tamponade mit Iodoform-Gaze bei Atonie des Uterus nach normaler Geburtsh.," "Centralblatt f. Gyn.," 1887, xi, 553. PUERPERAL HEMORRHAGES. 599 combined advantage of a tampon and a uterine stimulant. When the gauze is removed, it has very few blood-clots in it, and has not a trace of putrid odor. Every one who has ever used extensively the intra-uterine tampon for hemorrhage will attest the statement that it is of inestimable value. There is no other means so absolutely sure to check uterine bleeding. Emotional Causes.—Sudden emotion of any kind will arrest uterine contraction during labor and in the puerperal state. In the latter condition the usual result is a hemorrhage, which may be alarming. Barker x gives an interesting example : A healthy young primipara almost bled to death in the second twenty-four hours after labor in consequence of the brutal con- duct of her husband, who was disgusted that his child was a girl. I have seen a sudden and profuse hemorrhage on the seventh day, the result of fright. The patient's step-son returned home late at night in a violent state of intoxication. Relaxation of the Uterus.—This is a rare cause of hemor- rhage after the first twenty-four hours. It is scarcely ever seen later than the third day, and when it occurs after the first twenty- four hours it is in women depressed in mind and body, exhausted by prolonged labor, weak from insufficient food or bad hygienic surroundings. It is to be treated on the same general principles as a primary postpartum hemorrhage from the same cause. Retention of Blood=clots.—This is usually the result of uterine relaxation, uterine displacements, or a retention of por- tions of the ovum, around which the clot is formed. If these conditions are promptly treated, the retention of blood-clots will be prevented. The effect of a clot of large size retained in utero is often a hemorrhage, possibly also septicemia. The mass of clotted blood should be removed as soon as the symptoms lead the medical attendant to suspect the presence of a foreign body within the uterus. Fibroids.—If the puerperal state is complicated by intra- mural or submucous fibroids of the uterus, there will be certainly a prolongation and increase in amount of the bloody lochia, pos- sibly a serious hemorrhage. The latter is peculiarly liable to happen if the tumor assumes the shape of an intra-uterine polypus. The diagnosis is only to be made by a careful physical explora- tion. The best treatment is the removal of the growth by scissors after ligature of the base, or with the wire ecraseur. In case this treatment can not be carried out, and in other forms of fibroid tumors in the puerperal state, ergotin, with quinin and strychnin, 1 "The Puerperal Diseases," p. 15. 600 PATHOLOGY OF THE PUERPERIUM. and the daily application of thefaradic current, if practicable, will do much to secure firm uterine contraction and prevent hemor- rhage. Hematomata.—Blood-tumors along the genital tract may burst during the puerperal state, with most serious external hemorrhage. The condition is described elsewhere. Pelvic Engorgement.—Congestion of the pelvic blood- vessels may lead to puerperal hemorrhage. The congestion may be due to heart, kidney, or liver disease ; to increased intra- abdominal pressure from any cause ; to the determination of blood toward internal organs during a chill; x to premature sex- ual intercourse ; to the erethism following the return of the hus- band to the wife's bed ; to inflammation about the uterus ; to subinvolution from any cause ; to ovarian irritation, and to con- stipation. Mauriceau 2 describes a case of puerperal hemorrhage that continued quite profusely for five or six days, and which was only checked when " a pretty strong clyster " resulted in the evacuation of " a panful of gross excrements." Wounds in the Genital Tract.—Secondary hemorrhage may occur from wrounds in the cervix, vagina, and vulva. Occasion- ally, abnormally large blood-vessels are injured in these regions. On one occasion I saw a hemorrhage from an anomalous artery in the perineum that nearly proved fatal. It is possible that a vessel of considerable size might be wounded during labor, and yet, in consequence of pressure from the child's head or of an unstable plug of clotted blood, would not bleed until, at some time in the puerperal state, the tissues recovering their tone or the clot being dislodged hemorrhage would occur. The diagnosis is easily made if the parts are exposed to view. The bleeding vessel may be detected and should be ligated. Carcinoma of the Corpus Uteri and of the Cervix.—Carci- noma (syncytial) or sarcoma may develop at the placental site during the puerperium. Epithelioma of the cervix, if at all ad- vanced, will surely cause some hemorrhage. The best treatment for the immediate control of hemorrhage from this cause would be a uterine or a vaginal tampon. Vaginal hysterectomy should be performed, if possible, without delay. Fritsch has shown that the operation is perfectly practicable immediately after labor. As rare causes of puerperal hemorrhage might be mentioned rupture of the uterine artery, as occurred in a case reported by 1 Winckel (" Path. u. Therap. des Wochenb.") reports 4 cases of this kind out of 114 of puerperal hemorrhage. I once observed a striking example during a malarial attack some days after labor. 2 " Diseases of Women with Child and in Child-bed," translated by Hugh Cham- berlen, London, 1752. PUERPERAL HEMORRHAGES. 601 Hewitt,1 with a fatal result six weeks after labor ; the rupture of a distended vein in the cervix, followed by fatal bleeding, as hap- pened in a case described by Hecker.2 Meschek 3 reports a similar case, with like result, due to an eroding ulcer which opened a large vessel in the cervix. Johnston has reported a fatal puerperal hemorrhage due to rupture of a hematoma of the cervix.4 Puerperal Hematoma.—A form of hemorrhage in the female genitalia during or after labor, much more rare than the second- ary hemorrhages just described, is an interstitial effusion of blood, with the consequent formation of a blood-tumor, varying in size with the degree of the hemorrhage. Levret seems to have been familiar with the accident, but with this exception a knowledge of the nature of hematoma in puerperae has been acquired in quite recent times. The first systematic treatise on the subject is Deneux's monograph.5 It was also fully described by Dewees.6 The accident is of rare occurrence, but individual experience differs widely as to its frequency. Deneux was able to collect 62 cases, but had himself only seen 3 in a practice of four- teen years. Paul Dubois saw but 1 case in 14,000 labors. Velpeau,7 writing five years after the appearance of Deneux's article, declared that it would be easy to collect the detailed ac- counts of 100 cases; that he himself had seen 25. Barker, of New York, reported 22 cases that came under his personal observation. Winckel quotes McClintock's claim that he had observed 25 cases, and places an exclamation mark after the quotation, evidently as a sign of incredulity.8 The former has only met with 6 well-marked cases in an experience of almost 20,000 confinements. Bossi found hematomata twice among 5660 women in child-bed; Hugenberger, 11 times in 14,000 deliveries;9 in Vienna it was noted 18 times out of 33,241 births.10 This would indicate a frequency of 1 to 1600 births. I have seen two cases in twelve years. The situation is most frequently, by far, in one or the other labium majus, rarely in both. The blood-tumor may, however, 1 " London Obstet. Trans.," vol. ix. 2 "Archiv f. Gyn.," Bd. vii, S. 2. 3 " Zeitschr. d. Ges. d. Wien. Aerzte," 1854, x. * Sinclair, " Pract. of Midwifery," 1858, p. 501. 5 " Tumeurs sanguines de la Vulve et du Vagin," Paris, 1830. s " Midwifery." 7 " Traite complet de l'Art des Accouchements," Brussels, 1835. 8 " Lehrbuch der Geburtshulfe," 1889. 9 " Hsematoma Vulvae imVerlauf der Schwangerschaft," "Archiv f. Gyn.," Bd. xxxiv, H. I. 1 ° These latter statistics are taken from Winckel's book, where a reference to the original authorities may be found. 602 PATHOLOGY OF THE PUERPERIUM. occupy a position beneath the vaginal wall, to either side, pos- teriorly or anteriorly in the labia minora; in the carunculae myrtiformes ; under the skin of the perineum, between the super- ficial and median fascia ; in the cervix ; in the peri-uterine con- nective tissue ; within the broad ligament ; in the subperitoneal connective tissue, on the posterior and anterior abdominal walls, extending as high as the kidneys and navel (Cazeux, Hugenberger, Winckel); under the skin of the mons veneris or. over the in- guinal ring (Velpeau). If the effusion occurs above the pelvic fascia, the blood forces its way upward toward the diaphragm ; if below, downward toward the vulva. Size and Form.—Small extravasations of blood are to be met with along the genital tract very frequently after labor ; this form of thrombus is due to the fact that the mucous membrane is pushed in front of the presenting part with a glacier-like move- ment over the underlying tissues, and there thus occurs a rupture to some degree of the submucous connective tissue and the small blood-vessels contained in it. On a careful examination one may often see numerous hematomata after labor, varying in size from that of a pigeon's egg to that of a walnut. It is the larger tumors that are rare. They may vary in size from that of a hen's egg to that of a child's head ; in extreme cases, if the blood is diffused throughout a great part of the subperitoneal connective tissue, the size of the effusion would be very large were the blood contained within a limited, circumscribed tumor. In shape, blood-tumors of the genital tract may be globular; in the cervix they distend the tissues of one or both lips down- ward and outward, giving to the cervix the form of a shark's nose. In the vagina they may hang from the anterior or posterior wall in the form of a polypus (Fleischmann). In the labia the hematoma is sausage-shaped (see Plate 9). Etiology.—The predisposing causes of puerperal hematomata are the engorged condition of the blood-vessels along the genital tract and the strain that is imposed upon them either by the pressure of the fetal mass or by the great muscular effort put forth during labor. The more engorged the vessels are, the more likely is the occurrence of hematoma. Winckel says it is self- evident that varicose veins predispose to the accident. Barker, however, denies this emphatically. It is certainly true that many a case of varicose veins may be met with before a hematoma is seen, and in many instances of the latter the veins were in no- wise affected. Halliday Croom x attaches great importance to anteversion of the parturient uterus as a predisposing cause 1 "On the Etiology of Vaginal Hematoma Occurring During Labor," " Edin- burgh Med. Jour.," vol. xxxi, pt. ii, p. 1001. Plate 9. > ^Aa-rgaYEUa. WaokLrvgtg^ Hematoma of the vulva (author's case). PUERPERAL HEMORRHAGES. 603 of vaginal hematoma, believing that thus an excessive strain is put upon the whole posterior vaginal wall, and a rupture of dis- tended blood-vessels in this region is therefore more probable. This explanation seems reasonable, but it leaves unexplained the hematomata in other situations along the birth-canal. Hypertrophic elongation of the cervix certainly predisposes to the formation of hematomata in that region during and after labor. The determining cause of the accident may occasionally be found in direct injury to the tissues by forceps, and rarely by a fall or a blow, or it might be explained by violent straining efforts during the second stage of labor. In the majority of cases, however (eighty-six per cent., Winckel), the occurrence of hematomata is apparently spontaneous. The immediate cause of the hematoma is the rupture of a blood-vessel and the inter- stitial extravasation of blood ; the vessel injured is commonly a vein, not rarely of large size. Possibly a number of smaller vessels may be ruptured. The injury to the blood-vessels is either a direct and immediate laceration or else, later, a perfora- tion by pressure necrosis. Clinical History and Diagnosis.—The interstitial hemorrhage that results in a hematoma begins, with rare exceptions, during labor. The extravasation of blood may at first be gradual, so that it does not attract attention until some time in the puer- peral state. The distention of the vagina by the presenting part of the fetus may prevent all bleeding until the maternal tissues are relieved of pressure. If the bleeding results from necrosis of tissue, the result of prolonged pressure, the formation of a hematoma may first begin after delivery. In cases in which the accident has seemed to be the result of violent coughing or other exertion during the child-bed period, there had been, no doubt, some injury done the vessels during parturition. The sub- cutaneous or submucous laceration of tissue occurring, as a rule, during the second stage of labor is almost always associated with great pain of a sharp, lancinating character, quite different from labor-pains. The suffering increases as the hematoma grows in size, and, in addition to the sharp pain of torn tissue, there is developed exaggerated and painful expulsive efforts excited by the presence of the tumor within the vagina. This is a symptom almost constant, but Barker tells of a painless case, and says that his is not the only one recorded. The hemorrhage into the tissues may be profuse enough to occasion the most marked signs of acute anemia. Pallor of the coun- tenance, failure of vision, a thready pulse, air-hunger, loss of consciousness, and, finally, death, may all be noted without the slightest external escape of blood. An examination of 604 PATHOLOGY OF THE PUERPERIUM. the patient will reveal a tumor occupying the situations already described, of varying size, and differing in consistency as the blood contained in it is fluid or clotted. If the hematoma is submucous, it presents a dark, purplish color, like clotted blood. If it is covered with skin, it presents a bluish, ec- chymotic hue, although in the labium majus the color may be the same as in a submucous hematoma. As a rule, the swell- ing only appears after labor. It may, however, occur before the expulsion of the child, and it has repeatedly devel- oped between the birth of twins.1 If the tumor is formed during labor, it may present a formidable obstacle to delivery ; if it appears in the puerperal state, it may dam back the lochia or give rise to dysuria or to retention of feces. With the history of a sharp attack of pain during labor, the subsequent rapid de- velopment of a tumor along the genital tract characteristic in its appearance and situation, the signs of internal hemorrhage, the diagnosis of the true condition ought not to be difficult; and yet a mistake is quite possible. Puerperal hematoma has been confused with varicose tumors of the labia, inguinal hernia, and inversion of the vagina. Once in Barker's experience a vaginal hematoma wras mistaken for a fetal head, and once for placenta praevia. Auvard2 says that on first sight he took a hematoma o f the anterior lip of the cervix for a clot of blood lying in the vagina. The Barneses,3 in describing their case of cervical hematoma, write that they found a fleshy tumor projecting from the vulva which looked like a mass of coagulated blood, or which might have been mistaken for an inverted uterus. The diagnosis seems to be more difficult in cervical hematoma than in those lower down in the genital canal. Luckily, the former are rare. Besides the two just mentioned, others are described by Hohl, Braun, Earle (two cases), and Winckel.4 Hematomata along the genital canal may burst soon after their formation, with appalling hemorrhage, which may rapidly prove fatal. In cases of labial tumors the point of rupture is likely to be the boundary-line between the greater and lesser labia. A hematoma within the pelvis may open into the peritoneal cavity, with fatal hemorrhage. In one case under my observation a large hematoma formed between the layers of the broad ligament. Four hours later the posterior 1 One case reported by Dewees (" Diseases of Females," " Of Bloody Infiltra- tion in the Labia Pudendi "), and six by Madame Sasanoff ("Annales de Gyne- cologic," December, 1884). Four of these latter cases died. 2 " Trav. Obstet.," Paris, 1889, t. i, p. 449. 3 "System of Obstetric Med. and Surg.," Philadelphia, 1885. 4 " Lehrbuch," 1889. PUERPERAL HEMORRHAGES. 605 layer of the broad ligament ruptured, the bleeding became intra- peritoneal and unlimited, and the patient died before I reached her. After early rupture or primary incision of the tumor, the hemorrhage will almost surely be great, and secondary bleeding is apt to occur. This accident does not happen, as a rule, when the tumor is opened after bleeding into it has ceased. Winckel has thus summarized the terminations of puerperal hematoma: (1) Death by hemorrhage with or without previous rupture of the tumor ; (2) death following, suppuration of the sac and septicemia, most frequently after the sac has been opened ; (3) rupture of the tumor, with recovery; (4) rupture of the tumor, with a resulting fistula; (5) perfect recovery by absorp- tion of effused blood, without rupture of the sac. In fifty cases collected by Winckel from modern literature the tumor burst spontaneously in the first eight days in twenty-three. A hema- toma may be evacuated not only by escape of the contained blood externally, but by diffusion of its contents under the skin. Dill1 reports a case of large hematoma of the right labium, which burst and at the same time occasioned ecchymoses reach- ing to the nates and to the right knee, to the umbilicus, and even as high as the right axilla. Suppuration may occur in a blood- tumor that has not been ruptured at all, and the effused blood may be converted into a large accumulation of pus. As these abscesses are often in the neighborhood of the rectum, the pus often acquires a fecal odor, even without a communication with the bowel. A rectovaginal fistula may result if the hematoma breaks its way into the rectum and also opens anteriorly into the vagina. Suppuration is most to be feared after the blood-tumor is opened and its cavity is exposed to the contamination of the atmosphere and of the lochial discharge. Prognosis.—The formation of a hematoma during or after labor was formerly regarded as a more dangerous complication than it is considered to-day. Of Deneux's 62 cases, 22 died. Fatal cases have been reported by Cazeaux, Lubanski, Broers, Seulen, Josenhans, Hugenberger, Braun, and the author. The causes of death in these cases were hemorrhage (in two instances into the peritoneal cavity), septicemia, and typhoid fever (?). Blot col- lected 19 cases since Deneux's paper was published, with 5 deaths. Perret, in an analysis of 43 cases, found 17 deaths. Of II cases observed by Hugenberger,2 4 died. Girard,3 m an 1 " Dublin Jour. Med. Sci.," November, 1886. 2 "St. Petersburg med. Zeitung," 1865. 3 "Contribution a 1'etude des Thrombes de la Vulve et du Vagin dans leurs Rapports avec la Grossesse et 1'Accouchement," " These de Paris," 1874. 606 PATHOLOGY OF THE PUERPERIUM. analysis of 120 cases, found 24 deaths. Johnston and Sinclair1 report 7 cases during seven years' service in the Dublin Rotunda, with 2 deaths. Scanzoni met with 15 cases, 1 of which died. Winckel, among 50 cases, found only 6 deaths. Of the 6 cases in his personal experience, not one died. Barker reports 22 cases of his own, of which 2 died. Barnes2 reports 2 cases with a favorable issue ; Auvard,3 1 of cervical hematoma that disap- peared by absorption. Croom's 3 cases all recovered. Death from a puerperal hematoma at present should be rare, especially if the patient's general condition is good and her hygienic sur- roundings are satisfactory. Treatment.—If the hematoma is of moderate size, not larger than one's clenched fist, the main object of treatment is to secure absorption of the effused blood, and thus the disappearance of the tumor. It may, however, be necessary to remove an ob- struction to labor if the tumor develops before delivery ; to con- trol the hemorrhage either before or after rupture of the sac ; to treat the general symptoms of profuse bleeding ; to evacuate the contents of the sac when suppuration has occurred, and to pre- vent septic infection. To secure the disappearance of a hematoma by absorption cleanliness of the parts and rest are necessary. If the tumor is vaginal or cervical, frequent irrigation of the vagina is ad- visable. If the effusion is subcutaneous, cooling lotions and inunctions with carbolized oil will often prevent inflammation and rupture of the sac. If the tumor appears before or during labor, and offers an obstacle to the delivery of the child, it must be freely opened ; the contents, whether fluid or clotted blood, evacuated ; pressure exerted by a tampon of iodoform gauze, in order to check the hemorrhage ; while the extraction of the infant by forceps or after-version is hastened as much as pos- sible. To control the hemorrhage into the tissues before exter- nal rupture has occurred, pressure, cold, and the internal admin- istration of ergot may be tried. An ordinary tampon in the vagina is not admissible, for it would dam back the lochial secre- tion, and would become foul. Braun's colpeurynter, or a large Barnes' bag, distended with ice-water, is the best appliance, for it can be easily removed at frequent intervals to allow an anti- septic irrigation of the vagina. If it is possible to avoid it, the tumor should not be opened while it is increasing in size, for there may be profuse hemorrhage at the time and a secondary bleeding later. This does not occur, as a rule, when the tumor is incised after the effusion ceases, and yet there are two cases 1 Barker, loc. cit. 2 Loc. cit. 3 Loc. cit. NONINFECTIOUS IE IERS. 607 on record in which hemorrhage occurred from tumors opened one and three weeks after their formation.1 If the tumors are too large to be absorbed, or if there is threatened gangrene of their coverings, they should be opened. Hematomata may burst within the first few days after their formation, and there may be, in consequence of the rupture, an alarming hemorrhage. In such cases it is best to enlarge the opening ; to turn out the clots within the tumor ; to search for the bleeding vessels, which may be seen spurting from the walls, and to apply a ligature. If this is impossible, and bleeding still continues, the cavity may be firmly packed with iodoform gauze, firm external pressure being exerted by a large pad and a T- bandage. The styptic salts of iron should not be applied, for such a firm, dense clot is thus formed that it takes a long time for it to disintegrate, the woman meanwhile running a risk of septicemia. After the coverings of a hematoma are incised or ruptured, suppuration will commonly occur in the cavity ; septicemia must be avoided in such cases either by an iodoform tampon in the abscess-cavity often renewed, or else by frequently repeated antiseptic injections. Suppuration may occur before the tumor has been opened at all. In such cases the pus must be evacu- ated. The opening should not be delayed too long, especially in suppurating hematomata of the posterior vaginal wall, or fistulae may result. The general treatment for loss of blood is to be conducted in the ordinary manner when the indications call for it—hypodermatics of ether, brandy, and other stimulants ; hot animal broths internally ; "auto-infusion " by bandaging the limbs ; and subcutaneous or intravenous infusions of a normal salt solution. Noninfectious Fevers.—Fever in the puerperal state not due to infection may arise from emotion, from exposure to cold, from constipation, from reflex irritation of any kind, from cerebral disease, from eclampsia, from insolation, from syphilis, from the exacerbation or persistence of an acute or chronic disease con- tracted during or before pregnancy. Emotional Fever.—In these cases there is simply a nervous stimulation of or a disturbance of balance in the heat-controlling centers of the brain, occasioned by some profound psychical impression—as grief, anger, fear. The normal action of these brain-centers may be disturbed by some powerful emotion which profoundly affects the higher cerebral functions. Another theory of fever after emotions deserves some con- 1 Parvin's "Obstetrics," p. 502. 608 PATHOLOGY OF THE PUERPERIUM. sideration. It is possible that the profound mental action pro- duces a change in the composition of the blood or of the fluids in glands and muscles, which, it is well known, take a part in heat-production. It is possible that thus a thermogenic toxin is manufactured. There may, again, be an excitation or paralysis of the vasomotor nerves. That fever may appear in consequence of emotions, clin- ical evidence leaves no doubt. The cause of the fever being tran- sient, perhaps momentary, the elevated temperature quickly sinks to normal. It is not in every person that powerful emotion will be followed by an elevation of temperature to a noteworthy degree. There must, apparently, be predisposing causes in the nervous system of the individual. Emotional fever is most often met with in children, in hysterical girls,1 and in women after child-birth. Day of Disease ; 2 3 4 5 6 7 8 9 10 11 1. 2 13 14 tf 16 M £ M £ M £ M £ /W E to £ to £ M £ to\ £. to £ to £Kf \Zto £ to £ to £ to E 105° 104° 103° 102° 101° 100° 99° 98° V V V ri ;l; : A A A N ; : ■J V '. V V Y : i - 1 «^> . r T Fig. 458.—Chart of emotional fever from dread of an operation. In child-bed there is a curious irritability of the organism, a lack of control over the mental processes. The petulant child, easily swayed by and completely yielding to emotions, subject on slight provocation to convulsions, is a familiar picture ; and no one can overlook this same mental and nervous character in pregnancy and in the early part of the puerperal state. It is this condition of the nervous system, apparently, that predisposes to emotional fever. It is, therefore, not at all uncommon in the puerperium. Hunt's2 records of seventy-five cases, confined to women free from infection and inflammation, in which the temperature was 1 The case reported by Dr. Matomed is a famous example ; the temperature is said to have reached 1280 F. ("Lancet," 1881. vol. ii, p. 790). 2 "Normal Course of Puerperal Temperature," " Practitioner," London, 1888, p. 81. NONINFECTIOUS FEVERS. 609 taken twice a day in the month, gives three apparently typical ex- amples of fever from emotion. I have seen a number of examples of emotional fevers. Failure to receive an expected letter, fear of exposure in illegitimate pregnancy, the expected removal of the woman's infant to an asylum, dread of an operation, and a variety of mental disturbances have given rise in my experience to a high but transitory fever. Figure 458 shows the tempera- ture record of a typical case. There had been one operation for suppuration in the breast in a hospital ward. It was witnessed by two puerperal patients. One of these, a young girl, shortly after experienced pain in the breast. She at once conceived a morbid dread of an operation in her own case. The beginning elevation of temperature in the chart indicates the commence- Day of Disease /Z IB /4 7S 76 77 18 19 20 21 105° 104° 103° 102° 101° 100° 99° 98° M £ M £ to £ M £VU £ M £ iUp M £ M £ M £ l : f\ jl A \i \ 1 / \\ : : •\ 1; /: \ :' ■ ; r i \ 1 : \- \ Fig. 459.—Chart of fever case from exposure to cold. The patient left her bed twice against orders, in her bare feet and night-gown. Each time there was a rise of temperature, quickly subsiding. ment of engorgement and pain in the breast. This went on for a few days, when, after having lain awake all night brooding on the subject, the girl's temperature began to rise in the morning, finally reaching the height indicated on the chart. The only antipyretic employed was the emphatic assurance of the resident physician that there was not, and would not be, the slightest excuse for an incision in the breast. The patient's fears being allayed, her temperature quickly sank to normal, where it re- mained. Fever from Exposure to Cold.—In the sensitive condition of puerperae it is not uncommon to see a febrile reaction follow undue exposure. A careless nurse or attendant may be respon- 39 610 PA THOLOGY OF THE PUERPERIUM. sible for too low a temperature in the lying-in room, or for ill- regulated ventilation, or for insufficient or ill-arranged bed- clothing. A wilful patient may leave her bed too soon and expose herself, thinly clad, to cold (Fig. 459)- Feverfrom Constipation.—Schroeder1 says that" among the causes, aside from infection and local inflammations, which, with special frequency, produce fever in the puerperal state, overdis- tention of the intestines with fecal masses should be given a fore- most place." This statement is, I think, exaggerated. Every practitioner of obstetrics, however, will surely see examples of this sort of "puerperal fever" (Fig. 460). Day of Disease / 2 3 4 5 6 7 s 9 70 // 12. 13 105° 104° 103° 102° 101° 100° 99° 98° M E M E M £A 4£. ME ME M\ E M £ M\ EL M E A/ £A 4E M £ 1 I \ i '• I \ A A \ ^ ; r- ,ji 4 A '■ k t ■> J V J \ i ^» h ■/ ._ 7 i s \ - Fig. 462.—Fever followed by expulsion of tape-worm. * Tenia passed from bowel. state, apparently an acute mastitis. The pain, the redness of the skin, the swelling of the breasts, and the course of the tempera- ture indicated that suppuration had occurred. Consequently, a deep incision was made into the gland; there was free bleeding, but 61 2 PA THOLOG Y OF THE PUERPERIUM. not a drop of pus was found. Immediately after the incision, which relieved the engorgement of the breast and the tension of the skin, the temperature fell to normal. The focus of irritation may be anywhere in the body. A primipara was delivered under my care without difficulty of a healthy infant. During the early part of the puerperal state she complained of a constant and distressing headache; diarrhea came on, which resisted treatment, and the woman's mental state tended rapidly toward pronounced melancholia. There was fever, apparently of a septic character. On the ninth day the body of a tape-worm fourteen and one-half feet long was passed from the bowel, and shortly after- ward the temperature became nor- mal. The great elevation of tempera- ture which often follows perforation of the uterus into the peritoneal cavity, appearing, as it commonly does, immediately, should also be attributed more to an intense reflex irritation than to septicemia. The chart, figure 463, is from a case in which the placenta was abnormally adherent. Separation was accom- plished four hours after delivery by means of the fingers and a curet. Fig. 463.__Rise of tempera- Ulceration of a limited area in the ture following perforation of the placental site followed, which ended uterus' in perforation and death on the third day. High fever occasionally appears in consequence of an acute retrodisplacement of the puerperal uterus, sometimes as late as the fourth week. If the rise of temperature is simply due to irritation, it subsides within a few hours after the uterus is replaced. Fever in the Puerperal State from Cerebral Disease.— A puerpera might have a tumor in the brain or spinal cord, in- sular sclerosis, locomotor ataxia, or degenerative changes in the brain—all of which could give rise to elevations of temperature.x It is, however, to cerebral hemorrhages and embolism that one should usually look for an explanation of fever arising from brain disease, for these accidents are by no means rare in the puerperal state ; and if the hemorrhage or embolism affects certain regions, a rise of temperature, often to a great height, is almost sure to 1 W. Hale White, " The Theory of a Heat-center, from a Clinical Point of View," '■ Guy's Hospital Reports," 1884, p. 49. Day of Disease ' 1 z 3 * M EM E ML :_(%£ 108° ' \ 105° ' \ 104° ' J 103° ' 102° ' \ \ ! ! 101° -^- : ill ----10Q° i. NONINFECTIOUS FEVERS. 613 follow. A temperature of 108 ° in the axilla has been noted in a case of cerebral embolism following child-birth.x Fever with Eclampsia.—It is justifiable to put the fever of eclampsia among the non-infectious fevers of the puerperal state. Winckel,2 writing in 1878, said he had observed and had called attention to the fever accompanying eclampsia fifteen years before ; he was accordingly the first to refer to it. Bourne- ville and Budin published this fact as an original discovery in 1872. With each convulsion there is a notable rise of temperature, until, finally, the fever may run very high. Day of Disease 7 z 3 4 J 6 7 A 1E M £ M £ Ml r/vf EME K±£ 106° • 105°- "l>0 104° k h 103° £ W 102° '■ '•> 101° >i 100° -c A 99° Fig. 464.—Fever-chart of patient who died of eclampsia. Insolation.—Sun-stroke, or heat-stroke, is by no means an impossible accident to lying-in women in the torrid tempera- ture of the American summer. The only case, however, that I know of occurred at sea in a ship sailing from France to New Orleans.3 The cabin in which the woman was confined was hot and ill-ventilated. The temperature of the air was 93.40 F. A portion of the membranes was left behind, and the discharge was offensive, but there was no fever. On the fourth day, however, the temperature rose to 1040, and shortly 1 Neve, "A Case of Cerebral Embolism with Hyperpyrexia following Child- birth," "Lancet," 1884, ii, p. 103. 2 "Path. u. Therap. des Wochenbettes," 3. Aufl., 1878, S. 493. 3 Skinner, " Sur un Cas d'Hyperthermie post-puerperale," " Le Progres medicale," 1887, p. 269. 614 PA THOLOGY OF THE PUERPERIUM. after mounted to 109.40 in the rectum. The woman ultimately recovered. Syphilitic Fever.—Mewis,1 from an analysis of 167 cases of syphilis in lying-in women, came to the conclusion that the influence of the puerperal state upon the local lesions of the disease was a favorable one, but he called attention to a spe- cial tendency in syphilitic women to specific febrile action and to peri-uterine inflammations during that period. Fournier's discovery of a specific syphilitic fever naturally turned the attention of French writers and students to this matter, and 7 Z 3 4- 5 6 7 8 9 10 ;/ 11 105° 104° M P M * M \B M - M e M £ M £ M —/■ 1 s--- ;-- £ —*-—<-v----1 M £ to £ -----) ------1------1-i~. —/— ft \ /; \ M ^--\—i -V-< —V ---\ to £ 102° 101° 100° 09° 98° 97° ^ A \r — i i 1 % i f= 1---- 1---- \---- 1---- 1----- T I pi-------- /1 —/■—t-r / -J—l— -+—/■— -\-L— -+-/■---- il--- i -& ^ 1 1---; 1 A— V 4- 4n !— +- ----r — 4— -r A N z£ f =fl= h ----/-/ —. ^F *= ^ — 7T 4 4j EE —/— —■ 4* >■— / v 11 \ \f u -4 —\- ' \ 1 \1 —V- ■W ■f —f —^ Fig. 465.—Temperature-chart of syphilitic fever. there were four elaborate theses on the subject written in the years 1885-86 in Paris.2 It appears from these studies that the proportion of syph- ilitic fever to be looked for in women after child-birth is only a trifle over two per cent, of those women affected with the dis- ease. In my experience with syphilitic women in child-bed, the disease has complicated puerperal convalescence by the retention within the uterus of the hypertrophied deciduous membrane,3 which is so often seen as a result of syphilis by 1 " Zeitschr. f. Geburtsh. u. Gyn.," Bd. iv, H. i. 2 Combes, " Suites des Couches chez les Syphiiitiques," Paris, 1886. 3 See Kaltenbach on " Syphilitic Endometritis in Pregnancy and the Puerperal State," "Zeitschr. f. Geburtsh.," Bd. ii, S. 225. NON-INFECTIOUS FE VERS. 61 5 adherent placenta, by the development of pelvic exudates, and, as in one instance, by septic infection, which occurred in con- sequence of large ulcerated surfaces in the vagina that had developed during pregnancy. Persistence or Exacerbation of Febrile Affections in the Puerperal State.—A woman may acquire any of the acute or chronic fevers during pregnancy, which may persist in the puerperal state or take on new activity during that period. This is true of all the infectious diseases, but particularly so of phthisis. The effect of labor upon the course of phthisis has interested many observers. It has been asserted that the disease makes no progress, or, at least, is very much retarded in the puerperal state. There is a fictitious appearance of regained health in the woman by reason of the accumulation of fat to which pregnancy disposes. The laity, therefore, enter- Fig. 466.—Fever-chart of woman with advanced phthisis in pregnancy and the puerperal state. tain the idea that it is an advantage for the phthisical woman to become pregnant. No mistake could be more unfortunate. The drain and strain of the child-bearing processes are often accountable for the origin of phthisis in a woman disposed to tuberculosis, and, if the disease already exists, there is after delivery an exacerbation of the fever, an aggravation of the pulmonary symptom, and a rapid loss of strength and vitality, which shortens the patient's life by many months. It is the duty of a physician to advise the tuberculous subject against marriage or maternity. Acute Intercurrent Affections in the Puerperal State.— Any one of the acute diseases may fasten itself upon a woman after confinement. It acquires a special interest in this condition, for its course is often modified, its prognosis is commonly graver, and its diagnosis is more difficult. It is often difficult and occasionally impossible to distinguish certain diseases—as erysip- 6l6 PATHOLOGY OF THE PUERPERLUM. elas, diphtheria, malaria, scarlet fever, and typhoid fever, occurring during the lying-in period—from septic infection. Pneumonia.-—Pneumonia does not attack women so often as it does men, but it is more fatal in the former. Pregnancy and the puerperal state are grave complications of the disease. They increase the gravity of the symptoms and make the prognosis distinctly less favorable than under ordinary circumstances. Pneumonia more frequently attacks a woman during the nine months of pregnancy than during the six w7eeks of the puer- peral state, but the pneumonia of pregnancy often becomes a complication of the puerperal state, for very frequently the disease induces a premature expulsion of the ovum at the height of the attack and convalescence or death occurs in the lying-in period. In 43 cases of pneumonia in pregnancy collected by Ricau x there was premature expulsion of the fetus in 21. From these statistics it further appears that the likelihood of this accident is increased after the sixth month. In 28 of the 43 observations the women had not passed the sixth month of pregnancy; of this number 11 aborted. Of the other cases, however, 15 in number, in which the pregnancy was past six months, there was premature labor in 10 instances. The prognosis of pneumonia in pregnant women is grave. Of Ricau's 43 cases, 12 died : 5 before the sixth month ; 7 after it. The infants were expelled in 21 cases prematurely ; and of those which had reached sufficient development to exist outside the uterus the majority .died. Tarnier2 sums up the outlook for mother and child in the following way : The more advanced the pregnancy,the greater the probability of an expul- sion of the fetus, the graver the prognosis for mother and child. Treatment.—A discussion of the medical treatment of pneu- monia has no place here. A consideration of the obstetrical treatment of the disease when it attacks the pregnant woman is important and is best handled by the obstetrician. The question that will come before him for decision will be to induce labor or to avoid interference. Pregnancy complicates pneumonia by mechanically increasing the difficulty of respiration, by calling upon the heart for extra work, and by demanding unusual facilities for disposing of the waste-products of two organisms, part of which should be discharged through the lungs. It would seem, therefore, that the uterine cavity should be emptied for the mother's sake, more especially as the infant deserves but small consideration, being almost certainly doomed. But i" These de Paris," 1874. 2 Tarnier et Budin, " Traite de 1'Art des Accouchements," t. ii, Paris, 1886. INTERCURRENT DISEASES. 617 the evacuation of the uterus, the contraction of its walls, and great diminution of its blood-supply favor a determination of blood to other internal organs, among them the lungs. The exhausting discharges of the puerperal state, moreover, may fatally waste the patient's strength, while in her feeble and unresisting condition it is possible at least to have a general septic infection added to the pulmonary disease. Statistics cer- tainly do not speak in favor of artificially inducing abortion or premature labor. Matton x says that of 18 cases in which preg- nancy was interrupted 9 women died, while in 20 women who suffered from pneumonia without abortion but 1 succumbed. Tarnier justly remarks that in the former series the disease was probably more malignant, and that this fact accounted for the abortions as well as for the fatal issue in so large a proportion ; and of the 20 cases it was, perhaps, on account of a mild attack of the disease that none aborted and but 1 died. There are, however, 2 recorded cases in wrhich death occurred without the previous interruption of pregnancy. Chatelain's 2 statistics in- clude 39 cases ; in 10, abortion occurred ; in 9, premature labor was induced. Of the 19, 10 died, and of the remaining 20, 10 also died, showing that little was gained by the interruption of pregnancy. It must be remembered, too, that it requires con- siderable time and also a certain amount of operative interference to induce abortion or premature labor, and during the process the woman may die. On the other hand, it is an undoubted fact that, temporarily at least, the symptoms are often somewhat relieved after the expulsion.of the uterine contents. My experience embraces 4 cases of pneumonia in pregnancy and 3 in the puerperium. Of the 4 women attacked during pregnancy, all expelled their infants prematurely, 2 died, and 2 recovered. One of these women had double pneumonia. Of the 3 women wrho acquired the disease after labor, 1 died and 2 recovered. Of the 4 infants born in the midst of the disease, 3 died. Pleurisy may possibly complicate the puerperal state. It would be simply an intercurrent affection, to be treated on gen- eral principles. It does not influence the course of pregnancy, nor is it influenced by the woman's condition. The Exanthemata.—Scarlet Fever.—Although this disease in the puerperal state has attracted much attention and aroused extended discussion among medical writers, there are still several points in its relationship with the puerperium in dispute. It is ll* Jour, de Med. de Bruxelles," 1872, p. 412. 2 Ibid., 1870, t. 1, pp. 430, 5l6, and t. Ii, p. II. 618 PATHOLOG Y OF THE PUERPERIUM. not strange that there should be some confusion and difference of opinion in regard to scarlet fever in the puerpera, for its course is often much modified by the woman's condition ; it may be complicated by the coexistence of septic infection ; there may be, on the other hand, scarlatiniform rashes in the course of septi- cemia, although scarlatina may be excluded ; and, moreover, there may be, in certain cases, after infection with the poison of scarlatina, a train of pelvic symptoms indistinguishable from that which commonly follows the entrance into the body of septic micro-organisms. Frequency.—Scarlet fever is a rare complication of the puerperal state. Prior to 1876 Olshausen x collected 134 cases ; Winckel2 saw one in Rostock ; single cases are likewise reported by Pal- mer,3 Parvin,4 Busby,5 Harvey,6 Cummins,7 and the author. Braxton-Hicks 8 asserts that he has met with 37 cases (!), chiefly in consulting practice. Epidemics of scarlet fever among puer- perae are described by Boxall 9 and Meyer,10 in which, respec- tively, 16 and 18 women were attacked by the disease. In the discussion on Boxall's paper, several members of the London Obstetrical Society related individual experiences with the dis- ease. It can not be asserted that puerperae are peculiarly dis- posed to scarlet fever. Epidemics occur, it is true, in lying-in hospitals at long intervals, but the proportion of patients at- tacked is never very large. During the epidemic in the Ma- ternity Hospital of Copenhagen, described by Meyer, only about one per cent, of the lying-in patients acquired the disease. Box- all says that 40 women were exposed to the contagion of scarlet fever during an epidemic, without the slightest detriment to their health. During the years 1871-85 there were only 2 cases of scarlet fever, in the lying-in period, among the patients at the Copenhagen Maternity ; in six years but 3 cases of the kind were seen in the hospital for infectious diseases (Meyer). In a ten years' hospital service in the Philadelphia, Maternity, and Uni- versity Hospitals, I have seen but 2 cases of true scarlet fever in the puerperium. Infection and Incubation.—Women after child-birth may be 1 " Archiv f. Gyn.," Bd. ix, S. 169. 2 " Path. u. Therap. des Wochenbettes," 1878, p. 529. 3 "Cincinnati Lancet-Clinic," 1887, ix, 481. 4 "Amer. Jour. Med. Sci.," 1884, 179. s /bid., 1887, p. 394. 6 "Scarlet Fever and the Puerperal State," " N. V. Med. Record," 1886, xxx, 376. 7 " British Med. Jour.," 1884, i, 760. 8 "London Obst. Trans.," vol. xii, pp. 44-113. 9 Abstract from " London Obst. Trans." in "Amer. Jour, of Obstetrics," 1888, PP- 547, 553. 666. !o "Ueber Scharlach bei Wochnerinnen," " Zeit. f. Geburtsh.," Bd. xiv, S. 289. INTERCURRENT DISEASES. 61 infected with the poison of scarlet fever in the ordinary manner- through the throat—or through wounds in the genitalia The latter statement has been disputed, but the short period of incu- bation, the fact that the rash often begins at the vulva and spreads thence over the trunk, the common occurrence of pelvic inflam- mations, and the fact that the diphtheric patches usually seen in the throat of scarlet-fever patients are met with commonly in the vagina when the disease attacks a lying-in woman, while the throat is affected to a minor degree or entirely spared—all indi- cate the genitalia as the point of entrance for the specific matcries morbi. It is likely that the majority of women affected durin^ the puerperium are infected by actual contact with the disease germs on fingers or instruments inserted in the vagina • but it is quite possible that the poison of the disease may be drawn into the throat from the atmosphere or may be conveyed to the geni- talia by the same medium. Before the adoption of antiseptic measures in surgical practice it was well understood that the poi- son of scarlet fever might find entrance to the body through a solution of continuity in the skin and mucous membranes. Sir James Paget long ago pointed out that the wounded become more susceptible to scarlatina.1 The woman after child-birth is always a wounded person, and she also becomes more susceptible to attacks of the disease. This explains those cases which, ex- posed to the contagion during pregnancy, only manifest the symptoms of the disease after labor, the poison having lain dor- mant for varying lengths of time until its invasion of the body is facilitated by the wounds and abrasions which always attend parturition (Olshausen). This mode of entrance would also explain the short period of incubation when scarlet fever attacks a puerpera. Ordinarily, five to seven days intervene between the date of infection and the appearance of the first general symptoms. In the puerperal state, however, the time of incu- bation is shortened to twenty-four or forty-eight hours (Senn, Hervieux, Olshausen). In one of my cases the patient, two weeks before her confinement, had handled some old linen that had been used in a fatal case of scarlatina ten years before. She developed a violent and typical attack of scarlet fever forty-eight hours after her delivery. Olshausen 2 says that four-fifths of all puerperae attacked will manifest the first symptoms at some time in the first three days after labor; and this assertion has been supported by the major- ity of the cases reported since the appearance of his article. Symptoms and Diagnosis.—A frank case of scarlet fever in 1 See also Hoffa, Volkmann's " Samml. klin. Vortrage," No. 292. 2 Loc. cit. 620 PATHOLOGY OF THE PUERPERIUM. the puerperal state would be no more difficult to diagnosticate than under any other circumstances in the adult male or female. But "in rare instances the disease may assume a masked form in which the ordinary signs of scarlatina are absent, or so slight and evanescent as to escape observation," and "in some such cases the only manifestation of the illness may be found in signs usually referred to septic poisoning " (Boxall).x It is, more- over, a well-recognized fact that one of the manifestations or accompaniments of septicemia in occasional cases is the appear- ance of a scarlatiniform rash. And, again, there are reported, from time to time, erythematous eruptions in the puerperal state resembling, on the one hand, the rash of scarlet fever, and, on the other, the eruption sometimes associated with general sepsis,2 and yet apparently unconnected with either of these diseases. Finally, there may coexist in the same individual local inflammations about the pelvic organs of septic origin and a general infection of the whole organism with the poison of scarlet fever. It is obvious, therefore, that a definite diagnosis of scarlet fever in the puerperal state may be difficult or even impossible. The diffuse nature of the rash, followed by desquamation ; the characteristic appear- ance of the tongue ; the affection of the throat; the more exag- gerated diphtheroid inflammation of the vagina; the exposure to the contagion of the disease ; the occurrence of scarlatinous nephritis ; finally, the infection of those who come in contact with the patient and the subsequent outbreak in them of a typi- cal case of the disease,3 make the diagnosis certain. But there are cases in which the existence of the disease, with symptoms closely resembling sepsis, will be overlooked, or, if suspected, can only be inferred. The Peculiarities of Scarlet Fever in the Puerperal State.— Olshausen asserts that scarlet fever is modified in three ways when the disease appears during the puerperium ; it almost always appears in the first three days after labor ; the throat complica- tions are slight; the eruption appears quickly, is rapidly diffused over the body, and is apt to assume a dark-red color. Winckel states that convalescence is commonly tedious. A careful study of the published cases must convince any one that scarlet fever 1 Braxton-Hicks takes an extreme position in this connection. He says that among sixty-eight cases of puerperal diseases in his practice for which there was a demonstrable cause, thirty-seven were due to scarlet fever. This is, no doubt, an overestimate, and it has not met with general acceptance. Even Boxall's moderate statement, however, has a long list of names arrayed in opposition to it, but, to the writer's mind, the weight of evidence is distinctly in favor of his view. 2 This word is used, in default of a better, to designate,infection by the com- moner pyogenic micro-organisms. 3 See the cases reported by Palmer and Harvey, loc. cit. INTERCURRENT DISEASES. 621 exercises an unfavorable influence upon the puerperal state. The milk-secretion is often lessened, if not suppressed ; there is often some change in the lochia, denoting probably an exanthematous endometritis or a diphtheric inflammation of the vagina. In a number of the cases reported, fetid lochia is noted; in some a "peculiar odor" is described; the only change noticed may be an increase or a return of the lochia rubra. In a considerable proportion of all the cases it would appear that the discharges from the genitalia were unaffected. In 10 of the cases reported by Meyer rheumatic complications were observed. In 21 of the cases collected by Olshausen there was an evanescent tenderness over the uterus. The occur- rence of pelvic inflammation is reported in so large a propor- tion of the entire number of cases that one is forced to believe there must be something more than a coincidence to account for it. Of Meyer's cases, for instance, 6 presented evidence of peri- and parametritis. It is possible that the specific poison of scarlet fever is capable of causing a pelvic peritonitis or an in- flammation of the pelvic connective tissue when it enters the body through the wounds along the genital tract or finds en- trance to the peritoneal cavity through the tubes. Or, perhaps, there may be a " mixed infection," as happens in gonorrhea. Whatever the explanation, it would appear highly probable that pelvic inflammation may occur as a consequence of scarlatinous infection during or after labor. Diarrhea may develop early in the attack. It is an unfavorable sign. Of 21 women in Olshausen's series thus affected, 1 5 died. Prognosis.—If the attack is a frank one ; if the genitalia are not much involved ; if the pelvic tissues are not extensively in- flamed, the woman will probably recover. It would scarcely be correct, however, to assert that the prognosis of scarlet fever in the puerperal state is favorable! The death-rate among Ols- hausen's cases was 48 per cent. ; of those infected immediately after labor, 75 percent. Of Meyer's 18 cases, I died. The 3 cases observed by Martin all died. Of Braxton-Hicks' 37 patients, 27 died. Many of these, however, were not cases of scarlet fever, but were probably cases of puerperal infection with a septic erythema. Galabin 1 twice saw fatal peritonitis during desquamation. On the other hand, Hervieux had 7 cases which ended favorably. All of Boxall's cases recovered. Legendre 2 reports 23 cases without a death. The single examples reported by Palmer, Parvin, Busey, Harvey, and Cummins all ended in recovery. The two patients under my observation recovered. 1 Discussion on Boxall's paper, loc. cit. 2 See Parvin, loc. cit. 622 PATHOLOGY OF THE PUERPERIUM. In scarlet fever, as in all the contagious diseases of the puer- perium, the patient must be isolated and should not be allowed to nurse her child. Erythematous Rashes in the Puerperal State.—A rash some- what resembling the exanthem of scarlet fever will sometimes make its appearance on the skin of a puerpera, but a distinction can usually be made between the two. In the simple erythema there is apt to be a moderate and evanescent fever,x the pulse is rapid, and in most cases fetid lochia is noted,2 with some uterine or pelvic tenderness ; there is often intense itching and usually desquamation ; miliaria often make their appearance, especially on the abdomen under the binder, and there may be desqua- mation. The eruption is very likely the expression of a sep- tic infection, usually of a mild degree ; but occasionally ery- thema may be associated with the gravest forms of septicemia. Mackness explains the eruption by the supposition that some septic products are evacuated through the sweat-glands, irritat- ing the skin and producing a general hyperemia. His theory is supported by the fact that the rash is at first punctate, seeming to begin usually at the hair-bulbs, and soon after becoming diffuse. The belief in the septic nature of the eruption is shared by Winckel, Kaposi, Maygrier, Geneix, Farre, and many others. The superficial resemblance that this affection bears to scarlet fever has led many observers into error. Raymond 3 would have one believe that the eruption is the manifestation of an attenuated form of scarlet fever. With the same idea in mind Gueniot calls the rash scarlatinoid. It is likely that future investigation will confirm an opinion, already expressed, that there is an "infectious erythema" dependent upon the invasion of the body by a specific microbe, which, it is claimed, has been already isolated.4 Loviot 5 has reported an erythema recurring a number of times during a year after an attack of puerperal sepsis. Lipin- sky 6 also reports two cases of recurrent erythema in the puer- perium. Gaertig 7 reports an erythema recurring after three successive labors, twice with fever, the third time without. 1 Mackness, " Some Scarlatinous Rashes Occurring During the PuerDerium," " Edinb. Med. Jour.," August, 1888. 2 Mackness, loc. cit. ; MacDonald, " Edinb. Obst. Soc. Trans " i884-'85, x, 235; Charpent.er; Gueniot, "These," 1862; Poupon, " Erytheme scarlatiniform chez une Pemme recemment accouchee," "La France medicale," 1884, i, 41. 3 " These d'Aggregation." * Simon et Legrain, "Contribution a l'Etude de l'Erytheme infectieux," Ann. de Dermatol, et de Syphilog.," November, 1888. 5 " Annales de Gyn.," July, 1894. e » Centralbl. f. Gyn." 1894. 7 Ibid., p. 720. INTERCURRENT DISEASES. 623 Measles.—Pregnant women are rarely attacked by measles. The disease is even more rare in the puerperal state, owing to the shorter duration of the period. The measles of pregnancy, however, usually becomes a complication of the puerperium by inducing an expulsion of the ovum. Nine out of eleven cases of measles during pregnancy reported by Klotz x caused a pre- mature expulsion of the fetus. Occasionally, the disease first manifests itself in the puerperal state. Tarnier 2 describes an instance in his own experience. Measles in the child-bearing woman is a dangerous disease. There is a disposition to hemorrhage, and pneumonia is a frequent and a very dangerous complication.3 Small=pox.—Pregnancy and the puerperium increase the gravity of all the eruptive fevers. This is true of small-pox as of the rest. Luckily, the disease is a rare one under any circumstances in this country, and as a complication of the puerperal state it is of very exceptional occurrence. A case of rbtheln 4 during the puerperal state has been re- ported. I have also observed one case, mild in character, end- ing in recovery. Erysipelas.—The practical identity of the streptococcus ery- sipelatis and the streptococcus pyogenes explains why the germs of the disease, when introduced into wounds along the genital canal or into the uterus, are capable of generating a violent form of puerperal sepsis without manifesting externally the rash, which is commonly supposed to be distinctive of erysipelas. Goodell 5 said : " That there is a relation between the diseases of erysipelas and puerperal infection, I am satisfied." Dr. Goodell, in the course of his remarks, quoted the case of a physician who, while in attend- ance upon an erysipelatous patient, delivered seven women. Five of them died of puerperal fever without showing external evidence of the disease in a rash. Dr. Fordyce Barker,6 on the same occasion, said : " The intimate relation between puerperal fever and erysipelas I consider as firmly established as is any fact in medicine." He referred to the epidemic of black tongue in Connecticut, which he witnessed in the early part of his profes- sional career, and stated that every woman who was confined at 1 "Archiv f. Gyn.," Bd. xxix, S. 448. 2 Tarnier et Budin, " Path, de la Grossesse," p. 17. A good bibliography pre- cedes the chapter. 3 Two fatal cases are reported by Hulburt, "St Louis Courier of Medicine," 1887, xvii, p. 549- 4 Kite, " Boston Med. and Surg. Jour.," August 18, 1887. 5 Discussion on Dr. Campbell's paper, "Erysipelas in Child-bed without Puer- peral Peritonitis," "Trans. Amer. Gynec. Soc," vol. vi, 1881. 6 Ibid. 624 PATHOLOGY OF THE PUERPERLUM. that time in the region devastated by the epidemic had puerperal fever, and he thought every one of these women died. Dr. Barker also spoke of a physician who contracted a fatal case of erysipelas from a patient whom he attended in puerperal fever. Statistics gathered in Belgium show plainly the connection between outbreaks of puerperal fever and of erysipelas in certain districts.1 In an analysis of the Belgium health reports it was found that the number of localities where erysipelas and puer- peral affections were noted at the same time numbered 456, while there were only 154 districts in which puerperal affections were observed alone without accompanying outbreaks of erysip- elas. In discussing Dr. Boxall's paper on " Scarlet Fever in the Puerperal State,"2 Dr. Playfair said, "Twenty-five years ago a lying-in ward was established in King's College Hospital. The arrangement was disastrous, and was at length abandoned. During the existence of the ward there were outbreaks of ery- sipelas in the surgical quarter of the hospital and coincident epidemics of puerperal fever in that ward, but the lying-in patients had no symptoms of erysipelas ; which, on the other hand, was seen in some of their infants." A large number of cases might be cited in which contact with puerperal-fever patients originated an attack of erysipelas, or, on the other hand, in which puerperae exposed to the contagion of erysipelas devel- oped virulent forms of puerperal sepsis.3 Pneumonia is a frequent complication of puerperal erysipelas. During an epidemic that Winckel observed in 1880, six out of thirteen puerperae attacked manifested this complication. In relation to erysipelas, as to all the infectious fevers of the puerperium, it is important for the obstetrician to realize that if these diseases fasten themselves upon the woman after child-birth in the ordinary manner,—that is, erysipelas through a scratch in the skin, scarlet fever from the throat or lungs, and so on,—their course, symptoms, and treatment differ very little from the or- dinary manifestations and management of the respective diseases in an adult female ; but when any of these poisons enter the woman's system through wounds along the genital canal, the history is a very different one. The train of symptoms produced is, to a great extent, the same, no matter what the nature of the poison which has found entrance to the body. There may be the same endometritis, the same involvement of the uterine walls, of the lymphatics, of the blood-vessels, of the 1 "L'Erysipele et les Femmes en Couches," Jorisenne, "Archives de Tocol.," xv, 1888, p. 302. 2" Trans. London Obst. Soc," 1888. 3 Winckel, " Ueber das puerperale Erysipel," Separat Abdruck aus dem "Aerzt- lichen Intelligenz-Blatt," Miinchen, 1885. INTERCURRENT DISEASES. 625 connective tissue, and of the serous membranes after infection of the pelvic organs by any one of the numerous pathogenic micro-organisms. Winckel has seen, in all, 42 cases of ery- sipelas during pregnancy and the puerperal state ; 36 of these developed after the delivery of the infant; 6 occurred during pregnancy. Of the cases in pregnant women, not one had its origin in the genitalia. Of the 36 cases in the puerperal state, 28 began in the genitalia, 2 in the breast, and the remainder in the face and scalp. Winckel, from an extensive study of the subject, offers the following points of evidence as to the etiology of erysipelas in the puerperal state and its connection with puerperal sepsis : 1. By far the most frequent points of origin—in five-sevenths of all the cases—for puerperal erysipelas are the genitalia and nates. There are endemics in which not a single case of facial erysipelas appears. 2. Primiparae contract the disease three to four times as fre- quently as multiparae. 3. Puerperae with wounds upon the genitalia are particularly predisposed to the disease. 4. Those who have undergone difficult operative deliveries acquire the disease much more frequently than others. 5. The children of lying-in women with erysipelas remain, in my (Winckel's) experience, free from the disease. (Gusserow, in fourteen cases, saw the child infected twice ; in Goodell's expe- rience this happened once.) 6. The larger the number of women diseased in a puerperal- fever epidemic, the larger is also the number of erysipelatous cases. Frequency.—Erysipelas in the puerperal state manifested by a cutaneous eruption is very uncommon. Symptoms and Diagnosis.—If the erysipelas manifests its ex- istence by a cutaneous eruption, the symptoms are distinctive and the diagnosis is plain. If, on the contrary, the streptococci in- vade internal organs and tissues, it is impossible to differentiate the case from one of ordinary streptococcus infection. Prognosis.—If the case is one of frank erysipelas, starting from the breast or the face, the prognosis is relatively favorable. Among 14 cases of the kind described by Winckel there were only 2 deaths. Of the 28 cases in wrhich the erysipelas orig- inated about the vulva 12 ended fatally.1 1 It goes without saying that the puerperal state predisposes to attacks of ery- sipelas by furnishing so many points of entrance for the poison in the wounds of various degrees along the genital canal. It would seem, also, that the condition of the whole organism favored the occurrence of the disease. Doderlein (" Munch. med. Wochens.," xxv, iSSS) reports a case in which the poison lay latent for a year in a lymphatic gland and broke out into fresh activity after an abortion. 40 626 PATHOLOGY OF THE PUERPERIUM. Treatment.—The treatment of erysipelas of regions distant from the pelvic organs in the puerpera differs in no respect from the treatment of the disease under any circumstances, except that the greatest care must be exercised not to transfer the strepto- coccus infection to the genitalia, and not to allow the child to nurse from an infected breast. Puerperal Diphtheria.—If infection occurs in the throat, the disease is an accidental complication of the puerperal state. If the infection has occurred in the genitalia, a variety of puerperal sepsis ensues that is considered in another place. Puerperal Malaria.—Malaria is something more than an acute intercurrent affection of the puerperal state, for in some important particulars the condition of the woman's organism after labor modifies the disease. The liability to infection is increased after child-birth. This is a proposition which is now beyond dis- pute. It has long been recognized and will be verified by the experience of every observant physician. Bonfils,1 in a thesis, has collected 140 observations of malarial fever in child-bearing women and has carefully studied the articles on this subject written by Pitre, Aubinais, Duboue, Ritter, Dupuy, Bureau, Goth, Pasquali, Bompiani, Cuzzi, and Mangiagalli. As the result of his investigation Bonfils came to the following conclusions in regard to the influence of malaria upon the puerperal state and to the modifications exhibited by the disease in this condition : Malarial fever after child-birth predisposes to puerperal hemor- rhages. These occur apparently in consequence of the disturb- ances in blood-pressure which accompany the chills and fever. The lacteal secretion is suppressed during the exacerbation of fever, but appears again after the febrile stage ; it is, however, less abundant. Whether or not the milk can convey the specific poison of malaria from the mother to the nursing infant is a ques- tion which as yet remains undecided. The most striking phe- nomenon in the puerperal state of women already infected with malaria is the reawakening of malarial manifestations, probably by reason of the traumatism and the physical depression follow- ing child-birth. The third day after labor seems to be the usual time for the reappearance of the disease, probably because of the slight elevation of temperature and of the general excitement of the organism which accompanies the establishment of lactation. The fever preserves, during the puerperal state, a perfect periodic- ity, a characteristic which much facilitates the diagnosis. Spieg- elberg and Ritter, however, stand opposed to this doctrine. In their opinion regularity in the occurrence of fever is very rare 1 " Paludisme et Puerperalite," " Ann. de Gynec," 1886, xxvi 125. INTERCURRENT DISEASES. 62 J during the puerperium. In my experience the fever is at first usually continuous. As the patient is brought under the influ- ence of quinin the fever becomes intermittent and finally dis- appears. The puerperal state predisposes to grave forms of malarial intoxication. The conclusions of Bonfils, while they are in the main cor- rect, are not absolutely true. Exceptions will be met with to almost every one of his propositions. For instance, I have seen malarial fever in the puerperal state, proven by the dis- covery of Councilman's bodies, pursue the mildest possible course, with very slight and irregular fever, which was easily controlled by the administration of quinin in small doses. On the other hand, the very worst example of malarial infection Fig. 467.—Malaria in the puerperium yielding to quinin when intrauterine dis- infection had failed. with which I have ever had to deal broke out in the last month of pregnancy. The patient had already, during the previous eight months, had two attacks of malarial fever. Within a week or two of term, the disease again made its appearance in a very grave form. There were congestive chills, a temperature run- ning to 1040 and over, and finally profound unconsciousness. The fever was almost continuous in its type. In the midst of the disease labor came on, and after some difficulty the child was extracted by the breech. After delivery the symptoms be- came even more grave. It seemed that the woman's death was inevitable, but by the administration of seventy to eighty grains of quinin in the twenty-four hours for several days, the fever was conquered and the woman made a rapid recovery. PATHOLOGY OF THE PUERPERIUM. 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If it were true, as has been asserted, that the fever is always characterized by distinct periodicity, the difficulty would in great part disappear, but no one who has had much ex- perience can admit the truth of this assertion. The main dif- ficulty is to distinguish the fever of sepsis from that of malaria. In doubtful cases it is a good plan to administer large doses of quinin, and at the same time to disinfect thor- oughly the genital canal. If this plan is followed by imme- diate improvement, it is always difficult to say whether there was in reality malarial infection, or whether the improvement was brought about by the dis- infection of the parturient tract. The microscopic examination of the blood should clear up many a doubtful case. The whole subject of malarial fever in the puerperal state has been discredited by the tendency to conceal cases of puerperal in- fection under this name. The practitioner should always be upon his guard in this respect. While not so satisfactory to him, it is far safer to his patient to err in the opposite direction —to regard a doubtful case of fever during the puerperium as of septic and not of malarial ori- gin, unless the proof in support of the latter belief is convincing. Treatment.—In the majority of cases larger doses of quinin INTERCURRENT DISEASES. 629 are required than under other circumstances. Reference has been made to a case in which, on the average, seventy-five grains were administered in the twenty-four hours for several successive days. In another case under my observation, forty- five grains a day were given for a long time, with success in con- trolling the fever and with no ill effect upon the patient. Several times an attempt was made to reduce the dose to thirty grains, but the reduction in the quantity of the drug was always followed by the reappearance of the fever. It was at one time erroneously taught that quinin administered to a nursing woman had a dis- astrous effect upon her milk. Runge states definitely that quinin may be given without hesitation to nursing women. Even in very large doses it does not pass into the milk. My own experi- ence is in accord with this statement. Rheumatism and Arthritis.—Arthritis in the puerperal state is either a manifestation of septic infection, with a localiza- tion of the septic inflammation in a joint, or else, as a rheumatic arthritis, is simply an accidental intercurrent affection. Accord- ing to Celles,x Charcot, in his doctorate thesis, published in 1853, was the first to call attention to rheumatism in the child- bearing woman. During the following year, Simpson in Great Britain, and Virchow in Germany, in their works upon the puerperal state, mentioned articular rheumatism as one of its complications. The subject has since been studied by Peter, Loisin, Simon, Vaille, Braunberger, Boillereault, Tison, Quin- quaud, Lacassagne, Hanot, Pinard, Siredey, Charpentier, Alex- andre,2 Hamill,3 and others. The diagnosis between septic arthritis and simple acute rheumatism is not always easy. In the latter, during the puerperal state one sees all the character- istic symptoms of the affection, just as under any other ordinary circumstances. Inflammation of the joints following septic infection, on the other hand, presents certain peculiar signs. The joint affected is usually a large one, very often the knee ; the inflammation is not fugacious ; 4 it is exceedingly stubborn in its resistance to all treatment; the duration is usually pro- longed, and in many cases there follows a complete ankylosis of the joint. There may be very little evidence of general septic infection. The arthritis may make its appearance late in 1 Marcel Georges Celles, " Du Rhumatisme articulaire pendant l'etat puer- peral," "These de Paris," 1885. 2 For extensive bibliography see Celles, loc. cit.; Felix Barral, " Contribution a Etude du Rhumatisme puerperal," "These de Paris," 1885; Tarnier et Budin, " Traite de l'Art des Accouchements," t. ii, p. 270. 3 "Amer. Jour, of Obstetrics," 1888, p. 317. 4 There are, however, occasional exceptions to this rule (Barral, loc. cit.). 63O PATHOLOGY OF THE PUERPERIUM. the puerperal state. It may be accompanied by very moderate fever of an irregular type. It is more apt to appear in women who have had gonorrhea. In the worst cases of general septic infection the joints may be the seat of metastatic abscesses as well as other portions of the body; but in these cases the symptoms pointing to a general septic infection are so plain as to indicate at once the origin of the malady. There is one factor which sometimes adds to the difficulty of diagnosis between acute articular rheumatism and a septic arthritis. A metastasis has been witnessed from the joints to the peritoneum in a case of rheumatism during the puerperal state.1 Such an occurrence would indicate that the case was septic, and that the peritonitis and the joint disease had a common origin in a grave form of septic infection. Prognosis.—The average duration of the septic arthritis is Day of Disease 101 100° 99 98° 97° ME ME M EM EM EMEM EMEM M M,£ to£ fc& i 1 4 I A % fti/H B S ft m wm m Fig. 469.—Temperature-chart of a puerpera with fever and uterine tenderness, with no other symptoms of sepsis. Irrigation and curettage of the uterus had no effect upon the fever, which yielded immediately to the salicylate of sodium. There had been an attack of muscular rheumatism during pregnancy. about three months. Recovery is the rule, but with an ankylosed joint (sixteen times out of twenty-three (Tison)). In scrofulous subjects the affected joint may become the seat of a tuber- culous inflammation. Treatment.—General medication is of little use. The salicy- lates are of no value. Local treatment, in the shape of counter- irritation (iodin, blisters, cauterization), may hasten the cure. If the inflammation is acute, soothing lotions must be used. The joint at first should be immobilized, but later a cautious employment of massage and passive motion may prevent anky- losis. 1 Alsdorf, " Peritonitis as a Metastasis of Acute Articular Rheumatism in the Puerperal State," "Amer. Jour, of Obstetrics," xx, 1887, 1032. INTERCURRENT DISEASES. 63I Muscular rheumatism may complicate the puerperal state. If the disease affects the uterine muscle and is associated with much fever, the only means, practically, of distinguishing be- tween this affection and puerperal infection with septic inflamma- tion of the uterus is the therapeutic test—the administration of salicylate of sodium. Gonorrhea.—The frequency of gonorrheal infection in the puerperal state depends upon the class of society to which the women belong. In the lower classes, seen in dispensary prac- tice, it is very common. In the upper classes it is decidedly rare. The proportion of cases varies, too, in different localities. Noeggerath and Sanger x report that among 1930 gynecologi- cal cases during a single year, in private and polyclinic practice, 230 (twelve per cent.) owed their sufferings to gonorrheal infec- tion. Among 398 pregnant women, 100 had a purulent discharge, presumably from gonorrhea (twenty-six per cent.) ; forty of the children developed blennorrhagia. This estimate is too high to be correct as an average. The differential diagnosis between gonorrheal and puerperal infection is, according to Sanger, to be made by the following signs : The progress of the disease in the former instance is slower. It very rarely appears in the early part of the puer- peral state. It breaks out first about six or seven weeks after de- livery. The most violent cases observed by Sanger were acquired during the period of uterine involution. It is difficult to draw in all cases a sharp distinction between infection by gonococci and infection by the other pathogenic micro-organisms which can occasion local inflammation in the genital tract. On the one hand, there are many of the infectious bacteria which can cause a severe inflammation of the mucous membrane along the whole extent of the canal ; and, on the other hand, the poison of gonor- rhea can, without doubt, excite inflammation of the deeper tissues in this region, and is quite certain, if it spreads through the tubes, to light up a sharp attack of peritonitis. The diagnosis may be made with approximate certainty if the disease existed during pregnancy, or if a careful examination detects an inflammation of the urethra and of the vulvovaginal glands, or if it is possible to isolate the gonococcus. The consequences of gonorrhea in the puerperal state may be of the most serious nature. There is often a mixed infection, the gonococci preparing the way for streptococci or other pathogenic micro-organisms. The local inflammation, under any circumstances, may take on a very acute character, and may be accompanied by violent peritonitis. There 1 " Ueber die Beziehung der gonorrhoischen Infection zu Puerperalerkrankun- gen," " Wien. med. Blatter," 1886, S. 902. 632 PATHOLOGY OF THE PUERPERIUM. may be a rapid accumulation of pus in the tubes in the course of the disease during the puerperium, which, however, can occur just as well in the course of an ordinary septic endome- tritis after labor. Skin Diseases.—The diseases of the skin which make their appearance during the puerperal state, and are apparently de- pendent upon that condition for their origin, are often a manifes- tation of septic infection. This is certainly true of erythema. It would appear to be true also of cases of pemphigus, which rarely occur after delivery. This disease x usually breaks out on the third or fourth day of the puerperal state. It may or may not be associated with some rise of temperature. In one case the contents of the blebs had a distinctly fetid odor. The duration of the disease is protracted. It lasts, on the average, perhaps ten weeks. It would be well in such cases to adopt at once thorough disinfection of the genital canal, because in all likelihood the poison of the disease finds an entrance into the body by this channel. Any other form of treatment would seem to be of little avail. The woman's general condition may be weak, and she may need stimulants. The distressing itching or burning of the skin which sometimes accompanies the disease can be relieved by weak carbolic acid solution. Diastasis of the Abdominal Muscles in the Puerperal State. —If the uterus has been much distended during pregnancy, and if the abdominal muscles during labor have been called upon to exert an unusual amount of force, there may occur a wide separation of the recti muscles, leaving space between them for a hernia of the abdominal contents. Prochownick 2 has reported two interesting cases of the kind. There was suddenly developed during the puerperium sharp abdominal pain with nausea and vomiting. Careful examination excluded puerperal infection, and detected the protrusion of coils of intestine between the recti muscles. The hernia was easily reduced, and a recurrence was prevented by a compress and adhesive strips. In both instances the symptoms yielded at once to this treatment. The accident is not likely to be a common one among English-speaking people and in countries where the use of the abdominal binder after labor is a universal custom. Flatulent Distention of the Abdomen (Tympanites).— There occurs occasionally in the puerperal state an extreme 1 Croft, " A Case of Pemphigus Recurring after Four Consecutive Labors," "Lancet," London, 1887, ii, 858; Wood, "A Case of Postpartum Pemphigus," ibid., 1888, ii, 468. 2 " Die Diastase der Bauchmuskeln im Wochenbett," "Archiv f. Gyn.," xxvii, 419. INTERCURRENT DISEASES. 633 distention of the abdomen, due to the overdistention of the intestines with gas. The cause of the flatulence is a partial or complete paralysis of the muscular coat of the intestines without peritoneal inflammation. A firm binder, turpentine by the mouth, and asafetida by the bowel will suffice in cases of moderate degree. I have had a successful result in some veiy alarming cases by giving a grain of calomel every half hour until six grains were taken ; two hours after the last dose of calomel a quarter of a grain of elaterium, and two hours later an enema of an ounce of glycerin, a half ounce of turpentine, a half ounce of Epsom salts, and two ounces of water. Large doses of strychnin hypodermatically are necessary to the suc- cess of this treatment. In the worst cases the only remedy which affords relief is a puncture of the large intestine with a fine trocar. This procedure appears to be devoid of danger. It has long been applied in the treatment of animals, especially sheep, to relieve flatulent dyspepsia. It has also been adopted with good results in human beings.1 In one recorded instance the bowel was tapped twenty-eight times without bad result. On one occasion I saw a complete paralysis of the intestinal coats after a twin labor. The woman's abdomen was opened, and the small intestines punctured with a knife in a number of places. The punctures were carefully closed after giving vent to all the gas and feces that would escape. The relief was only temporary. The woman died on the following day. There are many other acute and chronic affections besides those already described which can complicate the puerperal state. They are, however, purely accidental complications, which neither produce a distinctive change in the course of the puerperium nor are themselves modified by the woman's condi- tion. As examples of the kind might be mentioned dysentery, intestinal parasites,2 appendicitis,3 miliary tuberculosis,4 acute pancreatitis,5 miliary fever, hepatic colic,6 and gangrene of the ileum,7 besides many more, the list of which will include almost all the pathological conditions to which the adult female is subject. 1 Priestley, " Note on Puncture of the Abdomen for Extreme Flatulent Dis- tention," "Lancet," London, 1887, i, 718. 2 "Indian Medical Gazette," xxii, 240. 3 Dearborn, " Vermiform Appendicitis and General Peritonitis Complicating the Puerperal Period." 4 " Centralbl. f. Gyn.," 1885, ix, 417. 5 Ibid., 1884, viii, 609. 6 " Ann. Soc. d'Hydrol. med. de Paris," 1887, 169. 1 " Frauen-Arzt," Berlin, 1886, i, 308. 634 PATHOLOGY OF THE PUERPERIUM. Diseases of the Urinary System.—The Urine.—Gassner1 was the first to point out that the excretion of urine after delivery was very much increased. Winckel comes to the following conclusions in regard to the quantity of urine excreted and to the modifications in its constituent parts during the puer- perium : During the first two days the increase in quantity is most marked. The fluid is clear and of a light-yellow color. The specific gravity is very low. The absolute quantity of urea, phosphates, and sulphates is somewhat diminished, but the amount of sodium chlorid is not altered. The urine during the progress of uterine involution gradually regains its normal quality. The average amount of urine passed in the first six days is 11,160 grams. The average specific gravity is 1010. The quantity passed upon each day averages as follows : The first day, 2025 c.c; the second day, 2271 c.c; the third day, 1735 c.c; the fourth day, 1772 c.c; the fifth day, 1832 c.c; and the sixth day, 1949 c.c. It is not at all rare to find albumin in the urine 2 shortly after delivery, but as it is only a temporary phenomenon, disappearing' within forty-eight hours, as a rule (Blot, Ingersley, Lantos), and seems to exercise no injurious influence upon the woman's condition, it may be regarded as practically a physiological occurrence. Maguire 3 compares the albuminuria of the puerperal state with the cyclical albuminuria met with under other circumstances, and says that very likely in both these conditions the precipitate with nitric acid and heat is globulin, and not serum albumin. The appearance of sugar in the urine after delivery is also a very common occurrence, which has been attributed to the ab- sorption of lactose from the mammary gland ; indeed, one ob- server declares that the quantity and quality of the milk may be judged by the amount of sugar in the urine.4 But, as a matter of fact, glycosuria is more common when the milk-secretion fails than when the supply is most abundant.5 Curiously enough, the amount of urea in the urine does seem to depend on the ex- cretion of milk ; the former increases with the increase of the 1 Winckel, "Pathol, u. Therap. des Wochenbettes," p. 11. 2 Examining the urine of 600 puerpera directly after delivery, Lantos found albuminuria in 59-33 Per cent. This is a more common occurrence by one-third in primipane than in multipara (" Beitrage zur Lehre von der Eklampsie und Albu- minuric," "Archiv f. Gyn.," Bd. xxxii, p. 365). 3 " Pathology of Puerperal Albuminuria," London "Lancet," Sept. 18, 1886. * Blot, " Comptes Rendus," xliii, p. 676. 5 Hofmeister, " Zeitschr. f. phys. Chemie," Bd. i, S. 703; Johannovsky, "Archiv f. Gyn.," Bd. xii, S. 448. A full bibliography on this subject may be found in Schroeder's "Geburtshulfe," 10. Aufl., p. 236. DISEASES OF THE URINARY SYSTEM 635 latter.x This statement would also seem to hold good of the phosphates and the sulphates, which increase with the urea and with the excretion of milk.2 The appearance of peptones in the urine of recently delivered women is quite constant. The following statements in regard to it appear to be justified : 3 1. Peptonuria is constant in the puerperal state. The quan- tity of peptones, however, in individual cases varies consider- ably. 2. The urine contains usually no peptone on the first day, but thereafter until the fourth day the quantity increases steadily, then begins to decrease, and disappears on the twelfth day. 3. The peptonuria is probably the result of the direct con- version of the uterine muscle into peptone. 4. After the delivery of macerated infants, one finds no pep- tone, or only a very small quantity. 5. Occasionally, peptone is found during the latter days of pregnancy. In these cases peptonuria can be demonstrated directly after birth and in the first day of the puerperium, but in lesser quantities than in other puerperae. 6. The difficulty of a labor and its length exercise no in- fluence upon the peptonuria. 7. The peptonuria stands in direct relation to the involution of the puerperal uterus. 8. The specific gravity of the urine is in direct relation with the quantity of peptone in it. 9. The peptones formed in the uterus behave in the blood like the digestion peptones, or like the peptones that are arti- ficially introduced into the circulation. 10. The quantity of the peptones in the urine is in direct ratio to the number of white blood-corpuscles in the blood of the individual puerpera. The lochia may also contain peptones, but independently of the peptonuria, and without influencing the quantity of peptones in the urine. A careful examination of the uterus and its lining membrane after delivery demonstrated that in the uterine muscle considerable quantities of peptones could be discovered, while in the lining membrane this substance could not be found.4 Fischel declared that he found peptones in one-quarter of all the 1 Grammatikati, " Ueber die Schwankungen der Stickstoff bestandtheile des Hams in den ersten Tagen des Wochenbettes," "Centralblatt f. Gyn.," 1884, p. 353. 2 Grammatikati, op. cit., p. 467. 3 Fischel, "Ueber puerperale Peptonurie," "Archiv f. Gyn.," 1884, xxiv, p. 400, and "Neue Untersuchungen iiber den Peptongehalt der Lochien nebst Be- merkungen iiber die Ursachen der puerperalen Peptonurie," ibid., 1885, xxvi, 120; Biagio, " La Peptonuria puerperale," " Ann. di Ostet.," 1887, ix, 202. 4 Fischel, loc. cit. 636 PA THOLOGY OF THE PUERPERIUM. cases of pregnancy examined. If the urine after labor contains albumin in considerable quantities and persistently, it is evidence of trouble in the kidneys. There are usually associated with persistent albuminuria other symptoms indicating kidney disease. One of these is acute pain, most often in the head, but sometimes referred to the epigastrium or to other regions of the body.1 There may be edema. There is found in the urine microscopical evidence of degenerative changes in the renal epithelium. Albu- minuric retinitis is not a very uncommon accompaniment of kidney disease in the puerperium, and may induce complete blindness, but it should be remembered that there may rarely occur a temporary blindness in the puerperal state independent altogether of kidney disease.2 It usually comes on shortly after delivery, and lasts for a few days. Typical examples have been reported by Brush and by Konigstein. The latter attributes the accident to a spasmodic condition of the retinal vessels traceable to a vasomotor disturbance. The loss of vision may follow severe hemorrhage or eclampsia, may be associated with albu- minuria, or may be the result of a septic panophthalmitis. Konigstein suggests, as a treatment for the temporary blindness due to a spasmodic action of the retinal vessels, the inhalation of amyl nitrite. The woman's nervous system exercises a pow- erful influence on the composition of the urine. Cameron 3 has reported an extraordinary case of high temperature and glyco- suria in the puerperal state, the result of nervous influences. The temperature rose during waking hours and fell during sleep, without corresponding variation in pulse. The glycosuria seemed to have direct connection with the nervous phenomena, and lasted only a short time. Hematuria, when seen in the puerperal state, has almost in- variably persisted from pregnancy. In these cases there are usu- ally bleeding hemorrhoids of the bladder, due to the mechanical interference with the pelvic circulation by the presence of the gravid womb. The blood disappears from the urine in a few days after delivery. In bad cases of septic infection of the vesical mucous membrane, as a result of injury with instruments, or as a consequence of vesicovaginal fistulae, the same symptom may appear, but the differential diagnosis is easy. Renal and vesical 1 Raven, "Note on Puerperal Albuminuria," "Lancet," London, 1888, ii, 715; Phillips, "Acute Epigastric Pain in the Puerperal Albuminuria," ibid., 1887, i, 676. 2 Brush, "A Case of Temporary Blindness following Child-birth," "Obstet. Gazette," vii, 1884 ; Konigstein, " Erblindung nach einer Geburt in Folge von Isch- aemia Retinae," "Wiener med. Presse," 1885, xxvi, 585. 3 " High Temperature and Glycosuria in the Puerperal State, the Result of Nervous Influences," "Montreal Med. Jour.," Jan., 1889. DISEASES OF THE URINARY SYSTEM. &37 calculi and malignant tumors of the kidney and bladder are pos- sible causes. The Kidneys.—Hervieux divides the diseases of the kidneys in the puerperal state under four heads : First, inflammatory nephritis ; second, metastatic nephritis ; third, evanescent albu- minuric nephritis; and fourth, subacute albuminuric nephritis. In the first stage of inflammatory nephritis one finds hyperemia and tumefaction of the organ. Very often this condition is associated with general septicemia. If the disease develops primarily in the puerperal state, it is very likely a manifesta- tion or an accompaniment of general septic infection, and will often be undetected in the midst of other complications present- ing more obvious and more alarming symptoms. An intense hyperemia of the kidney associated with septic infection may result in an apoplexy of the organ. Metastatic nephritis is, of course, the result of septic infection. In the evanescent albu- minuric nephritis the kidney is increased in size. Its surface is smooth; the fibrous tunic, thickened and injected, is easily stripped off The increase in the size of the organ is due prin- cipally to the tumefaction of the cortical substance. In the fourth variety of kidney diseases in the puerperal state the course is a more tedious one, and the disease may pass into chronic nephritis. Maguire asserts that the lesion most commonly found in cases of puerperal albuminuria is one of anemia of the kidney with fatty degeneration. Lantos,1 in the records of 39 post- mortem examinations of puerperae who had neither died from eclampsia nor nephritis, found in 15 cases the kidney described as "anemic," in 21 "pale," and only in 3 "congested." Among 16 women who had presented symptoms of kidney disease there were found twice acute parenchymatous nephritis, once acute hemorrhagic nephritis, nine times parenchymatous degeneration, and four times albuminoid degeneration. Incontinence of Urine.—There may be an involuntary escape of urine after labor in consequence of an overfilled bladder, of paresis in the sphincter muscle, and of a perforation communi- cating with the vagina and some portion of the urinary tract. The first cause, the overflow of retention, should always be sus- pected and looked for, as it is the most common. The treat- ment must vary with the cause of incontinence. The use of a catheter will remove the difficulty in cases under the first cate- gory. Cases of the second group are more difficult to deal with. The partially paralyzed muscle will, as a rule, regain its tone in a short time. It may be possible to hasten recovery in 1 Loc. cit. 638 PATHOLOGY OF THE PUERPERIUM. a chronic case by the administration of tonics, the use of local astringents, or, perhaps, by the application of electricity. The preventive treatment should never be neglected. These cases almost invariably follow delayed and difficult labors with head presentations. A timely interference, therefore, would save the woman the discomfort, and even danger, of a constant dribbling of urine over the external genitals.1 Cases of the third order should be managed by attempting to obtain a primary closure of the fistulous opening. This can be effected in some cases, if the fistula is not too large, by touch- ing its edges with a strong caustic-like nitric acid. Cystitis.—Cystitis is, unfortunately, a common occurrence in the puerperal state. It is due, in the vast majority of cases, to a careless, clumsy, or ignorant use of the catheter. The old plan of introducing a catheter under the bed-sheet is responsible for a large number of these cases. If physicians and nurses would catheterize a patient with an aseptic instrument, after careful cleansing of the vestibule and by the sense of sight, there would be very little risk indeed of infecting the bladder mucous membrane by the use of the catheter. A transitory inflamma- tion of the bladder may be due to long-continued pressure or to injury during birth, but such cases are rare. The cystitis is almost always a septic disease following the infection of the bladder mucous membrane.2 It is possible that micro-organ- isms may migrate from the vagina along the mucous membrane of the urethra to the bladder without the intervention of cathe- terization. In order that the micro-organisms, having gained access to the bladder, may bring about an inflammation of the vesical mucous membrane, it is necessary to have a condition of that tissue favorable to the invasion and to the growth of the bacteria. The invasion is much facilitated by a solution of con- tinuity in the mucous membrane. It is also favored by a re- duction in the vitality of the vesical epithelium, which follows prolonged pressure upon the bladder during labor, or is a con- sequence of the overdistention of the bladder-walls from pro- longed retention of urine. There is a disposition of the inflam- mation in many cases to spread rapidly toward the kidneys, so that after the bladder affection is cured the kidney disease re- mains. There may be intermissions for some length of time of apparent health between the infection of the bladder and the outbreak of disease in the pelvis of the kidney. The termination 1 Bechadergue-Lagreze, " Incontinence d'Urine sans Fistule consecutive a I'Accouchement," " These de Paris," 1886. 2 " Die ^Etiologie des puerperalen Blasenkatarrhs nach Beobachtung an Woch- nerinnen und Thierversuchen," "Centralblatt f. Gyn.," 1886, 443. DISEASES OF THE URINARY SYSTEM. 639 of cystitis after delivery is, in the vast majority of cases, favor- able. The inflammation may, however, persist for a long time, and may become, perhaps, an inveterate chronic affection. In the worst cases of septic cystitis the disease manifests most alarming symptoms and may end fatally.1 There is in some cases a thick, diphtheric infiltration of the mucous membrane, which is finally exfoliated and discharged by the urethra in thick masses. In other cases, again, the mucous membrane becomes gangrenous, and is finally expelled in frag- ments of varying size along with the urine. Pieces of the infil- trated mucous membrane lying loose within the bladder may obstruct the outflow of urine. In these extreme cases the urine is full of pus, blood, albumin, and renal tube-casts, and it very often has a horribly fetid odor. Treatment.—Every case of cystitis after labor should be treated energetically and without delay, for fear of a spread of the infection to the kidneys. A daily irrigation of the bladder by a quart or more of boric acid solution (gr. xv—5j), a milk diet, and boric acid by the mouth are usually sufficient, if ordered immediately, to stamp out the disease in its incipiency. Vaginal cystotomy is required in severe cases for drainage. Pyelonephritis.—An inflammation of the pelvis of the kidney may follow infection of the bladder by an extension of the disease along the ureters. This is true of the vast majority of cases, but in some instances the bladder disease may be of such a transient nature that it passes undetected, and the physician's attention is first attracted by the subsequent pyelonephritis. It is possible that the infection in a case of pyelonephritis may occur in the kidneys from the blood. The disease may also follow mechanical irritation from renal calculi. I have seen one case of pyelonephritis during the puerperal state which was associated with renal calculi. There was a sudden exacerba- tion of the disease some few days after labor, associated with a high fever and a suppression of urine. The attack passed off in the course of forty-eight hours, however, and the woman finally recovered. The treatment of pyelonephritis of septic origin consists in stimulation, support, the administration of bland diuretics, and irrigation of the bladder. Occasionally, it is necessary to incise the pelvis of the kidney by the lumbar route and to drain it for a while. The ureter is washed out from above downward, and finally the urine is allowed to take its natural course. I have seen this plan of treatment carried out twice with success. In two other cases the infection spread from the 1 Boldt, "Cystitis Suppurativa Exfoliata Puerperalis," " N. Y. Med. Record," 1885, ii, 497. 64O PATHOLOGY OF THE PUERPERIUM. kidney to the perirenal fat, producing perirenal abscesses, that were opened by lumbar incisions. The outcome of a pyelo- nephritis is dubious. A large proportion of the cases under my observation have died. The kidney after death was found to be either a large bag of pus or else was riddled with innumerable minute abscesses. Diseases of the Nervous System.—For the psychoses and the neuroses, see page 233. Lesions of Sacral Plexuses; Neuritis and Nerve Degeneration from Pressure During Labor.—These complications are usually seen in a justominor pelvis or in one with a slight projection of the promontory, which affords insufficient protection to the nerve- trunks on either side of it. Puerperal paralysis may result. Both limbs may suffer (paraplegia), or there may be unilateral paralysis, with atrophy and anesthesia. The leg or legs may be the seat of constant pain, and may be very hyperesthetic. Pressure upon the sciatic nerve or movement of the affected limb may cause agonizing pain, or there may be intense and persistent pain in the pelvis, unassociated with disease of the sexual organs. Pressure with the finger in the rectum upon the sacral plexus causes exquisite suffering. The same results may follow pressure from exudates or the involvement of the nerve-trunks in septic inflammations. Fixation and extension of the limb give the greatest relief at first. When the acute stage has subsided, massage, electricity, and passive movements hasten the restoration of the limb to usefulness. The prognosis is fairly good. There may be, directly after child-birth, neuritis of nerves distant from the genital region (the ulnar, for instance). Multiple neuritis in alcoholic subjects may develop after child-birth or during pregnancy. Laury x makes three divisions of puerperal neuritis—traumatic, septic inflammatory by extension, and infec- tious neuritis of distant nerves and of the spinal cord. Apoplexies of the Brain and Spinal Cord; Aphasia; Hemiplegia; Paraplegia.—There is a predisposition to apoplexies in the central nervous system during labor, especially in women whose vessels are diseased in consequence of insufficient kidney-excretion. Ascending Myelitis—I have seen an ascending myelitis first manifesting itself some two weeks after labor, the temperature having been previously normal, but becoming elevated as paralysis of the lower limbs appeared. The paralysis was pro- gressive, and the result fatal. At the postmortem examination no starting-point in a septic focus or apoplexy could be discovered. There were simply the signs of inflammation and "Archives de Tocol.," Nov. 1, 1893. ANOMALIES OF THE BREAST. 641 degeneration. It is an interesting inquiry whether this condition could have come from pressure upon the lumbosacral plexus and an ascending nerve-degeneration. Developmental Anomalies of the Breast.—Absence of Mammae.—Complete absence of both breasts is one of the rarest anomalies of development. Marandel, Lousier, and Froriep x each report a case of entire absence of one breast, the other being well developed. Imperfect development of the mammary glands is common. It is sometimes seen to an extreme degree in cases of infantile or absent sexual organs. Hypertrophy of the mammas is also rare. Labarraque2 collected twenty-six cases, of which only five were over twenty-six years of age. The breasts are usually asymmetri- cal. There is one case on record in which a single mammary gland weighed sixty-four pounds. Lacta- tion has been known to diminish a congenital hypertrophy of the breasts. An overgrown mammary gland, therefore, is not a contrain- dication to suckling the child. Supernumerary Breasts — PoIy= mastia.—Supernumerary breasts and nipples are more common than is generally supposed. Bruce found 60 instances in 3956 persons ex- amined (1.56 per cent.). Leichten- stern places the frequency at 1 in 500. Both observers declare that men present the anomaly about twice as frequently as women. In Fig. 470.—Hypertrophy of 400 women examined in one winter the breasts in a y°ung idiotic in my hospital services there was 1 s'r' case of polymastia. It is impossible to account for the accessory glands on the theory of rever- sion, as they occur with no regularity in situation, but may develop at odd places on the body. The most frequent position is on the pectoral surface below the true mamma and somewhat nearer the middle line ; but an accessory gland has been observed 1 "American System of Gynecology," vol. ii, 338. 2 "These de Paris," 1875. 41 642 PATHOLOGY OF THE PUERPERIUM. on the left shoulder over the prominence of the deltoid ; on the abdominal surface below the costal cartilages ; above the umbili- cus ; in the axilla ; in the groin ; on the dorsal surface ; on the labium majus ; on the buttock, and on the outer aspect of the left thigh. In cases reported by Edwards x and Handyside, and in some others, including one of the author's, heredity seems to have been a probable explanation for the development of the supernumerary mammae ; but in the vast majority of cases no hereditary influence can be traced. Ahlfeld 2 explains the presence of mammae on odd parts of the body by the theory that portions of the embryonal material Fig. 471.—Polymastia: nine breasts and nipples. entering into the composition of the mammary gland are carried to and implanted upon any portion of the exterior of the body by means of the amnion. The woman represented in figure 471 is remarkable for the almost unprecedented number of breasts and nipples that she possesses.3 She has nine mammae all told, and as many nipples, 1 " Medical News," March 6, 1886 (good bibliography). See also Goldberger (" Archiv f. Gyn.," xlix, H. 2, S. 272), who states that there are 262 cases recorded in literature. 2 " Missbildungen der Menschen." 3 Neugebauer has reported a case of polymastia with ten nipples. " Central- blatt f. Gyn.," 1886, No. 45. ANOMALIES OF THE BREAST. 643 every one of which secreted milk profusely. The two normal glands are very large. The nipple of the gland in the left axilla is not shown very plainly in the illustration on account of its situation, and it is not easy to see it in the woman herself, concealed as it is by the axillary hair, but when the correspond- ing gland in the axilla is compressed, a stream of milk may be projected several feet from the woman's body. As may be seen, the glands are arranged with some symme- try. There are five on the left and four on the right side. The woman is a negress, nineteen years old, and a IV-para. Her child was born prematurely. Her mother had an accessory Fig. 472.—Supernumerary nipple and small mammary gland upon right buttock. It was always possible during pregnancy to squeeze out a drop of milk (author's case). mamma on the abdomen that secreted milk during periods of lactation. Anatomical Anomalies of the Nipple.—The shape of the nipple may unfit it for nursing, predisposing to injury by the child's gums, to fissure and ulcerations (see Fig. 473), or making it a mechanical impossibility for the child to take hold, as in inverted nipples (Fig. 473). The nipples should always be examined during pregnancy. If they are inverted, a systematic attempt should be made during the last month to draw them out with a breast-pump. Should this attempt fail, a nipple-shield might enable the child to nurse. 644 PATHOLOGY OF THE PUERPERIUM. Abnormalities of the Breasts and Anomalies in the Milk Secretion.—Milk secretion begins usually forty-eight hours after delivery. Previous to this time a thin fluid can be squeezed from the breast, containing large cells, within which are contained many fat-globules. To this substance the name " colostrum " has been given, and these cells are called colostrum corpuscles. It is always difficult to estimate the exact quantity of milk secreted. The best way is to draw the milk with a breast-pump at regular intervals during the twenty-four hours ; but the breast-pump does not excite maternal emotion, and, therefore, it always draws a less quantity than would be furnished a suckling infant, for the breast Fig- 473-—Faulty development of the nipple. is in some degree an erectile organ, and even the sight of the child may be sufficient to produce a flow of milk. Allowing for these errors, there will be found, at the end of the seventh day, about fourteen ounces in the twenty-four hours. During the five preceding days the quantity is small and variable. By the end of the fourth week the quantity of milk secreted in the twenty- four hours reaches about two pints. From this time it increases gradually until the sixth or seventh month, when about three pints of milk can be drawn from the breast in twenty-four hours. After the eighth month the quantity of milk gradually decreases. A curious anomaly of milk secretion is its occurrence independent of the puerperal state, as in very old women or very young girls, ANOMALIES LN MILK SECRETION. 645 after operations upon the ovaries,1 at the menstrual period,2 or even in the adult male.3 The most important abnormalities of milk secretion may be grouped under two main headings—quantita- tive and qualitative. Deficient Secretion.—In its extreme degree this anomaly is known as "agalactia," complete absence of milk, which is exceedingly rare. Winckel, in an enormous experience, asserts that he has never seen an example—that there is always some little milk secretion, which may, however, pass undetected with- out close observation. There are a few recorded cases of complete absence of the breasts. Under such circumstances, of course, there would be after delivery complete agalactia, so that, although this condition is doubtless one of great rarity, its occur- rence is a possibility. Deficient milk secretion is by no means uncommon. There are many causes preventing normal activity in the mammary gland. Premature maternity, if the individual is not yet fully developed, may account for it. Advanced age is another cause assigned for deficient lactation. There is either an atrophy of the gland or an exhaustion of it by previous activity. The nearest approach to complete agalactia which I ever witnessed was in the case of a woman who had her first living child at the age of forty-three. She had been married at forty, and had had previously two children still-born. There was in this case so slight a manifestation of milk secretion that it might have passed undetected without a careful search. Perhaps the most frequent cause of insufficient milk secretion is lack of development in the glandular tissue, which may be hereditary, may depend upon the continuous pressure from the clothing, or may be associated with a defective development of the remainder of the body, especially of the genital organs. Altmann 4 has called attention to the hereditary form of atrophy in the mammary gland. In parts of Bavaria, where it has been the custom for centuries to nourish the children artificially, the mammary glands no longer secrete milk. In Munich, of the women who did not nurse their infants, fifty-eight per cent, were said to be physically unable to do so. Of the women who nursed their children, seventy per cent, had to resort to mixed feeding. In other parts of Germany, on the contrary, notably in Silesia, where the custom of suckling children has been care- 1 Penrose, " M. and S. Rep.," 1889, 326. 2 Sinety, " Traite de Gynec," p. 955. 3 "John Hunter's Notes," quoted by Barnes; Humboldt, " Reise in die vEqui- noctiale Gegenden des neuen Continents," Bd. ii, S. 40. 4 "Ueber die Inactivitatsatrophie der weiblichen Brustdriisen," Virchow's "Archiv," Bd. cxi, p. 318. 646 PATHOLOGY OF THE PUERPERIUM. fully preserved for many generations, it is rare to find mothers with an insufficient supply of milk. The ability of the breast to furnish milk does not necessarily depend upon its size, for in some cases a large organ is made up Fig. 474.—Mammary gland of a nullipara (from Silesia). X 32°- chiefly of connective tissue, while in another apparently ill-devel- oped the gland-tissue is abundant and the milk-supply ample. During pregnancy the glandular structure of the breasts takes on an active growth and development, while the connective tissue decreases to a marked degree. If lactation is not practised, Fig. 475-—Mammary gland of a nullipara (from Silesia). X 52- there begins at once an involution of the gland, a shrinkage of the epithelial structures, and a regrowth of connective tissue. If involution is allowed to occur after the birth of the first child, it is more difficult after subsequent deliveries to awaken the breast to functional activity. ANOMALIES IN MILK SECRETION. 647 The mammary secretion, at first sufficient, may at times be much diminished as the result of hemorrhages or of diarrhea in consequence of an acute febrile attack during lactation, or of inflammation within the gland itself. Serious organic diseases may also be a cause, and insufficient nourishment must be held accountable in some cases. During the siege of Paris an obser- vation of forty-three nursing women by Decaisne x proved that with imperfect nutrition the total quantity of the milk is much decreased. Almost one-third of these women lost their children through starvation. Emotions exert an extraordinary influence upon lactation. Those which are of gradual development and long continuance, as profound grief, tend to progressively dimin- ish the amount of milk. Emotions of sudden onset and short duration, as fright or anger, either totally stop the formation of Fig- 476-—Mammary gland of a nullipara (from Fig. 477.—Mammary Bavaria). X 52- gland of a nullipara (from Bavaria). X 32°- milk, or else so alter its constitution 'that it becomes a rank poison to the child. The return of menstruation will sometimes affect the quantity and quality of a woman's milk, but not nearly so often as is popularly supposed. Zweifel states positively that for the most part the return of the menses is without influence upon lactation. This statement is in accord with the experi- ence of Winckel, Joux, Tilt, Becquerel, Vernois, and my own. There are a few other rarer causes to which deficient mammary secretion has been ascribed. It has been said that the exit of the milk-ducts may be obstructed by an accumulation of epi- thelium recognized by a minute white, projecting, translucent vesicle upon the nipple at the opening of the obstructed duct. 1 " Des Modifications que subit le lait de femme pour suite d'une alimentation insuffisante ; observations recueillies pendant la siege de Paris," " Comptes Rend.," lxxiii, No. 2. 648 PATHOLOGY OF THE PUERPERIUM. Nasal, pharyngeal, or bronchial catarrhs are supposed to dimin- ish the quantity of milk. The mammary gland is described in some cases as torpid. A failure to furnish enough milk is as- cribed occasionally to the fact that the individual approaches the male type. The milk-supply is rarely abundant after premature delivery or the delivery of dead infants. It is an undoubted fact that extreme obesity interferes seriously, if it does not almost entirely prevent, a functional activity of the mammary gland. Treatment.—It is obvious that no single plan of treatment will increase a deficient milk-supply. It is also apparent that in the vast majority of cases the cause of the difficulty is beyond the influence of any treatment. One can not alter the age of the patient nor replace deficient glandular tissue. There are some cases, however, of insufficient secretion that will respond promptly to appropriate treatment. A scanty supply of milk dependent upon an insufficient diet is easily corrected. It should never be forgotten that when lactation is interrupted by an acute febrile attack nursing may be successfully resumed after convalescence is established, even though weeks and occasionally months have intervened. I have seen lactation begun and continued success- fully a month after a difficult Cesarean section attended with pro- fuse hemorrhage. In cases of general ill health or constitutional weakness, much may be effected by the administration of tonics and nutritious diet and change of air and scene. If the deficient secretion is dependent upon some emotion, the cause, if possible, should be removed. Electricity has been much vaunted as a remedy for insufficient lactation. It may be applicable in cases of torpidity of the mammary gland or in those cases in which lactation was not practised after the birth of the first infant, and in which, therefore, the mammary gland does not respond readily to the stimulus of-subsequent births. This remedy will, however, often prove ineffective and disappointing. There is no medicinal galactagogue of any value. If three meals a day of food suitable to the patient's condition, reinforced by four glasses of milk between meals and fluid extract of malt at meals, will not produce a sufficient flow of milk, the child must usually be artificially fed. Quantitative anomalies by excess in the milk secretion may take three forms. In women of a vigorous physique, well nourished, and of a full habit, the supply of milk is very apt to be in excess of the infant's needs—polygalactia. Lactation may be continued far beyond the usual time—hyperlactation. In the third variety the milk continues to flow from the breasts in varying quantities and for varying lengths of time after the child has been weaned —galactorrhea. ANOMALLES IN MILK SECRETLON. 649 Polygalactia.—This condition is exceedingly common. The treatment has been referred to on page 344. Its main features are compression and support of the breast by a mammary binder, the administration of laxatives, the regulation of the diet, and the evacuation of the superabundant quantity of secretion. Hyperlactation is more frequently met with among the poorer classes. Infants are nursed far longer than they should be, either from the fact that it is difficult to provide food for another mouth or because of the prevalent belief that lactation grants immunity from impregnation. Women have been known to nurse their children up to the second or third year. Some women and certain races do it with impunity. Spanish wet- nurses suckle three or four successive children in one family. Japanese women habitually nurse their children for five or six years. Hyperlactation, however, usually leads to serious results in the women who fall under the care of physicians in this and most civilized countries. The patient becomes exceedingly weak and presents all the symptoms of a serious constitutional disease. The quantity of blood is diminished—oligemia. The woman grows pale and thin ; there are loss of appetite, constant head- ache, pain in the back, indisposition to make any physical effort, and the whole nervous system is more or less seriously deranged. Cramps in the muscles of the neck and upper extremities occur frequently; they appear often during the day and last for vary- ing periods. The application of the child to the breast often originates an attack. There is especial danger in women of tuberculous tendencies of originating phthisis. The treatment of hyperlactation is simple and effective. The child must at once be weaned, and the mother's strength restored by a nutritious diet, tonic remedies, and, if possible, change of air. Galactorrhea.—By this term is meant a flow of milk from the breasts not necessarily excited by the suckling child, and com- monly continued long after the usual term of lactation. The quantity of milk excreted may vary from a few grams to seven liters in the twenty-four hours.x Usually, both breasts are in- volved ; sometimes the flow is confined to one side. The cause of the anomaly is unknown. It has been attributed to a relaxa- tion or paralysis of the circular muscular fibers surrounding the milk-ducts, but, as Winckel remarks, this, in the majority of cases, is an effect and not a cause. There is a case recorded, however, of galactorrhea in the left breast, associated with the left hemi- plegia occurring after child-birth.2 The affection is one com- 1 Winckel, " Path. u. Therap. des Wochenbettes," p. 440. 2 " Trans. London Obstet. Soc. for 1887," xxix. 650 PA THOLOGY OF THE PUERPERIUM. monly of long duration, extending often over years. There is a case reported in which, for thirty years, there was an uninterrupted flow of milk from the breasts of a woman who, at the time the report was made, had reached her forty-seventh year. Curiously enough, this long-continued drain upon the system had had no injurious effect upon the woman's health, which remained excel- lent. Another anomalous feature in the case was that the return of the catamenia increased for the time the discharge of milk.1 I have seen a woman who had had galactorrhea for eleven years after a miscarriage at the fifth month. Her health remained per- fectly good. The usual effect of a long-continued discharge of milk from the breasts is most unfavorable upon the individual's health. It is the same that any long-continued discharge pro- duces upon the constitution. The general debility from this cause is known as "tabes lactea." The same condition may be seen in extreme cases of polygalactia and in hyperlacta- tion. Treatment.—The most prominent feature in these cases is the stubborn resistance that they offer, as a rule, to treatment. There are two measures which can usually be depended upon to give relief—firm compression of the mammary gland and the administration internally of iodid of potassium. It should be remembered, however, that in many cases the milk secretion stops spontaneously with the return of menstruation,2 and that in a certain proportion of cases a treatment adapted to securing a discharge of blood from the uterus has been successful in cur- ing galactorrhea. Routh 3 advocates Simpson's plan of intro- ducing a piece of caustic within the uterus for securing this result. Abegg was successful in two instances in stopping the galactor- rhea by the use of warm douches, which brought about a return of the menses. Electricity has been recommended to secure the proper contraction of the sphincter muscles of the lactiferous ducts. The long-continued administration of ergot has been successful, and its use is rational. The experiments of Roehrig 4 have demonstrated that drugs which bring about an increased arterial pressure in the breasts promote milk secretion, while those which lower arterial tension tend to diminish or even abolish the function. Chloral wras shown to be peculiarly power- ful in diminishing the quantity of milk ; therefore, this drug is also worthy of a trial. Belladonna internally, or as a local ex- ternal application, is usually employed as a routine practice, but 1 Green, quoted by Gibbons, " A Case of Galactorrhea (unilateral)," ibid. 2 Gibbons' case; Abegg's cases; in two cases, under the care of Depaul, the galactorrhea was arrested by the recurrence of pregnancy. 3 Discussion on Gibbons' paper, loc. cit. * Quoted by Gibbons. ANOMALIES IN MILK SECRETION. 65I it is of doubtful utility. It has been declared that antipyrin, in 2 lA-grain doses, three times a day, will diminish milk secre- tion. x Qualitative Anomalies in the Milk.—The most important factor influencing the constitution of the milk is the diet. A fatty diet diminishes the quantity of milk. A vegetable diet diminishes the casein and fat, and increases the sugar. A diet rich in meat increases the fat and casein, but diminishes the sugar. A scanty diet diminishes all the solid constituents of the milk except the albumin. The commonest anomaly in the constitution of the milk, in my experience, is a deficiency of fat and an excess of casein. In one of my patients, in each of three confinements there has been a milk of only 0.8 per cent, fat and 3 per cent, albu- minoids. Usually this disordered condition of the milk can not be remedied. In a few instances, however, qualitative anomalies may be corrected by dietetic management. The effect of emotions upon the constitution of the milk has already been referred to. Baranger 2 quotes a good example : A nursing woman saw her husband threatened by a soldier armed with a saber. Directly afterward she gave suck to her child. It seized the nipple at first with avidity, then refused it, became violently convulsed, and died. Every practising physician has seen, at least to some degree, examples of the change produced in the milk by mental impressions. Becquerel and Vernois found that under the influence of emotion the milk of a woman contained more water, very much less fat, and somewhat more casein than was found in the mammary gland of the same individual under ordinary circumstances. Almost all acute febrile affections not only diminish the mammary secretion, but produce some change in its constitution and make it indigestible. This is most marked in the prodromal period. If a chill occurs, the lacteal secretion is suspended almost entirely for from twelve to twenty-four hours. The germs of some diseases pass from the mother's organism into her milk ; this is undoubtedly true of tuberculosis. It is probable that the germs of malaria find an exit from the body in this way. Septic micro-organisms may contaminate the milk from the breast, although the mammary gland itself is free from inflammation. Karlinski 3 has reported a fatal infection of the 1 "Bull. gen. de Therap.," June, 1888. 2 " Les Contre-indications et Obstacles a l'Allaitement maternal," "These de Paris," 1884. 3 " Zur ^Etiologie der Puerperal-Infektion der Neugeborenen," " Wien. med. Wochenschr.," 1888. 652 PA THOLOGY OF THE PUERPERLUM. new-born from the milk of a puerpera with septic fever. In the milk wrere found staphylococci. Women under the influence of mercurialism or saturnism excrete milk of abnormal quality, dependent, perhaps, as much upon the anemia associated with these conditions as upon the excretion of the drug itself. The influence of syphilis upon the constitution of the milk is not yet known. It has been asserted that there is no change in the milk of syphilitic women. Vernois and Becquerel, on the other hand, affirm that there are well- marked alterations in the relative proportions of the different in- gredients in the milk from syphilitic women. Under ordinary circumstances colostrum-corpuscles may be detected in human milk for the first eight or ten days after de- livery. There are certain conditions in which a return of these corpuscles may be noted. They reappear sometimes upon the return of menstruation, during acute mastitis, or in any other acute affection during lactation. Of twenty-three examinations made by Truman x to investigate this point, colostrum-corpuscles were found present in the following cases : In a primipara for four weeks after the birth of a premature infant; in a woman who was suckling her four-month-old baby ; in a non-pregnant woman whose infant, born twenty-six months before, had been weaned for ten months ; in a non-pregnant woman who had been married three and a half years ; ever since marriage, for a week before menstruation, the breast filled with milk, in which were colos- trum-corpuscles ; in a nursing woman who had never been able to use her right breast during lactation. Her last child was twelve months old. In the milk which could be squeezed out of the right breast colostrum-corpuscles were discovered. Another case was one of chronic ovaritis. Twenty-three months had elapsed since the last labor, and eleven since weaning. The milk which exuded from the breast contained colostrum-cor- puscles. In the breast of a woman fifty-six years old, which was removed for carcinoma, about a teaspoonful of milk was found, very rich in colostrum-corpuscles. This woman's young- est child was eight years old. In a case of galactorrhea which had persisted for four years these bodies were also discovered. The presence of colostrum-corpuscles in the milk is not a proof, therefore, of a recent delivery. Diseases of the Mammary Glands.—Areola.—The glands of Montgomery may become inflamed, and their infection may lead to mammary abscess. Treatment.—Infection of the areolae should be avoided by 1 British Med. Jour.," 1888, ii, p. 947. ANOMALLES IN MILK SECRETION. 653 Fig. 478.—Massage of the breasts (Dickinson). 654 PATHOLOGY OF THE PUERPERIUM. cleanliness. Each inflamed and suppurating gland should be opened, curetted, and its interior touched with strong bichlorid solution. Exaggerated pigmentation of the areolae often persists after pregnancy ; it fades away in the course of lactation or after the child has been weaned. Congestion and engorgement of the mammae occur in almost every case on the third day, when lactation is instituted. Treatment.—Excessive congestion may be avoided by admin- istering a saline purge on the evening of the second day. The breasts must be thoroughly evacuated at regular intervals by the child's mouth, reinforced, if necessary, by massage and a breast- pump. Hot fomentations may give great comfort; but if the congestion and pain persist, lead-water and laudanum is the best Fig. 479.—Breasts disfigured by exaggerated pigmentation of the areolae. application. A mammary binder is almost always a necessary part of the treatment. The pressure and support which it affords contribute more than any other single item in the management of these cases to prevent excessive congestion and engorgement. From the investigations of Honigmann x and Ringel,2 it appears that human milk contains normally the staphylococcus pyogenes albus, as well as the staphylococcus aureus. These micro-organisms wander in along the milk-ducts from the skin. They produce, usually, no ill results, unless the vitality of the epithelial cells is reduced by engorgement of the gland with milk 1 F. Honigmann, " Bakteriologische Untersuchungen ueber Frauenmilch," In- aug.-Diss., Breslau, 1893. 2 Ringel, "Ueber den Keimgehalt der Frauenmilch," " Miinchen. med. Wochenschr.," 1894, No. 27. ANOMALIES LN MILK SECRETION. 655 and blood, as in the "caked breast." They may then take an active part in the development of a mammary abscess, by attack- ing the epithelial cells of the milk-ducts, destroying them, and invading the surrounding connective tissue. Sore Nipples.—Excoriations and fissures of the nipples are due to the maceration and irritation to which they are subjected by the child's gums and mouth. Mammary abscess not infre- quently results from the entrance of streptococci or of other in- fectious bacteria through these fissures. Prophylactic Treatment.—During the latter months of preg- nancy the nipple should be washed twice a day, and should then be touched with a piece of clean absorbent cotton, saturated with a mixture of glycerol of tannin and water, equal parts. Alco- holic astringents should be avoided. It is necessary, of course, to keep the nipple clean during lactation, and to keep the skin Fig. 480.—Breast-pump. Fig. 481.—Nipple-shield. in a healthy condition by frequent applications of sweet-oil, until the nipple becomes accustomed to its functions. Curative Treatment.—The nipple should be carefully cleansed after each nursing, and one of the following remedies should be applied to it: An ointment composed of 3ij each of bismuth subnit. and castor oil ; tinct. benzoin comp., applied directly to the fissure. Iodoform, gr. x, to ung. zinci oxidi, Iss ; ichthyol, 3j ; lanolin, glycerin, each siss ; olive oil, 3iiss. The fissure may be touched with a ten-grain solution of nitrate of silver, or with the solid stick. A nipple-shield is almost always necessary. It must be perfectly clean, and should be kept immersed in cool water while not in use. In cases of supersensitive nipples, with- out abrasions or cracks, or if the latter are slight in degree, ex- tract of witch-hazel is an excellent remedy. I have occasionally seen nipples so exquisitely sensitive that the pressure of a night- gown or of the bed-clothes was unendurable, although there was 656 PATHOLOGY OF THE PUERPERIUM. no fissure, crack, abrasion, or inflammation. In such cases nerve- sedatives internally and cocain as a local application are neces- sary. Usually, the child must be weaned. Inflammations of the Breasts—Mastitis.—There may be an in- flammation of the subcutaneous connective tissue, of the mam- mary gland, of the deeper interstitial tissue, or of the parenchyma. A septic inflammation is rarely confined strictly to one of these localities. There is usually involvement of all the tissues in the gland. As in all puerperal infec- tions, the micro-organisms responsible for the inflam- mation may be of many pathogenic varieties. The constitutional symptoms of mammary infection are usu- ally slight, but may be very severe, even though the local inflammation appears to be moderate. Causes.—The first two classes, superficial and inter- stitial mastitis, are due to sepsis, the result of direct in- oculation. Parenchymatous inflammation need not al- ways be ascribed to this cause. Overactivity of the gland, engorgement with blood, and distention with milk (the so-called " caked breast") may be primarily responsible for the infec- tious inflammation by weak- ening the resisting power of the cells against microbic invasion. Treatment.—If the inflammation is parenchymatous and is due to oversecretion, the breast must be emptied with a pump or by massage (see Fig. 478), and must be supported by a binder. If the inflammation is confined to the connective tissue and sup- puration is threatened, lead-water and laudanum should be applied with a mammary binder. Suckling had best be intermitted if the inflammation continues and an abscess is threatened, as the irri- tation of nursing may increase the mammary congestion and the milk is apt to disagree with the child. It has rarely given rise Fig. 482.—Puerperal mastitis forming abscess: a, Group of acini melted to pus (Billroth). ANOMALLES LN MILK SECRETION. 657 to septic infection of the child's intestines by its contained micro- organisms. Mammary Abscess.—The pus may be located, superficially, in the gland-substance, or in the submammary connective tissue, as postmammary abscess. The symptoms of suppuration are uncertain. The reddened skin, the swelling and sensitiveness of the breast, and the fever may be due simply to intense congestion. Fluctuation is rarely detected until late, and should not be awaited. A dusky-red hue of the skin, and edema, with fever, are the most valuable signs of suppuration, and should indicate an immediate incision or incisions. Treatment.—A mammary abscess must be incised as soon as the physician is satisfied that there may be pus within the breast. It is much better to make an unnecessary incision than to allow the pus to burrow through the gland until the operation for the woman's relief becomes quite formidable. If the abscess is opened early, one incision commonly suffices. If the case is neglected, every pocket of pus must be opened and every sinus must be drained to secure a prompt and permanent cure. I have made as many as eighteen incisions in the two breasts, and have had half that number of drainage-tubes through the glands in a woman who had been ill for six weeks or more with mammary abscesses, in spite of a few Yig. 483.__Pigment of the ineffective and insufficient incisions areola following incisions (Rich- in the breasts, made from time to ardson)- time by her medical attendant. In incising a mammary abscess, the incisions, so far as possible, should radiate from the nipple, so that they run parallel with the lacteal ducts. Otherwise, a duct may be cut across and a lacteal fistula may result. The incision should, if possible, avoid the area of pigmentation, or should be confined wholly within it, as the pigmentation will follow the cut, disfiguring the breast (see Fig. 479). The abscess-cavities should be compressed, after being opened, by a firm mammary binder, and they should be irrigated with sterile water daily. In the case of a postmammary abscess, the whole breast is lifted off the chest, and there are no signs of suppuration within the gland itself. The systemic symptoms of this kind of mam- mary abscess are usually severe. 42 658 PATHOLOGY OF THE PUERPERLUM. Treatment.—The incision should be made beyond the per- iphery of the gland at the most dependent part as the woman lies on her back, and a counteropening must be made upon the opposite side. A drainage-tube is passed under the gland by a dressing-forceps, and the cavity is irrigated daily. A galactocele is a milk-tumor due to occlusion of one of the lactiferous ducts. It is usually of no pathological importance, unless it should, as rarely happens, reach a large size, when it must be tapped and drained. Other mammary tumors, especially adenomata, may take on a very rapid growth in pregnancy, and may become so engorged and painful when lactation begins that their removal is necessary. In one of my cases an adenoma grew during pregnancy from the size of a walnut to that of a cocoanut, and I was obliged to excise it on the third day of the puerperium. Relaxation of the Pelvic Joints.—The pelvic joints, after labor, may be the seat of inflammation, accompanied by serous exudation, and ending possibly in suppuration. In the case of the symphysis pubis, the abscess can easily be opened and drained. The prognosis, therefore, is good. In the other pelvic joints suppuration is commonly fatal. The pelvic joints may be ruptured by violence during labor. This accident is considered in connection with the forceps operation and injuries to the woman in labor. Finally, there may be, to a marked degree, relaxation of the pelvic joints, much exaggerated beyond that seen in almost every pregnant woman, and persisting for varying periods after delivery. The etiology is obscure. Abnormal motion in the pelvic bones has been seen in justomajor pelves. It has been noted after abortion. It may be traced to a large, hard fetal head which had stretched the joints. It occurs in justominor pelves rather frequently. It has been ascribed to obesity, to a cachectic condition, to sudden and powerful exertion in the latter months of pregnancy, to an unusually great circumference of the preg- nant uterus,1 and to previous disease or abnormality of the joint.2 The diagnosis is easy. There is difficult locomotion, unusual mobility in the joints, especially the symphysis pubis, and local- ized pain. The treatment should consist in the application of a firm binder about the hips. Tonic remedies are often required. In the course of a few weeks the joints usually become firm. Occasionally, the relaxation persists for months. 1 Winckel, "Geburtshulfe," p. 873. 2 Schauta, in Midler's " Handbuch," vol. ii. PUERPERAL SEPSLS. 659 CHAPTER II. Puerperal Sepsis* Historical.—The history of the acquisition of our knowledge of puerperal infection is distinctly modern. It had its earliest beginning about fifty years ago, and dates back in reality scarcely twenty-five years. Indeed, one may say that a true comprehen- sion of the causes and nature of puerperal sepsis has been ac- quired only within ten years, and that the past five years have contributed more information on this subject than all the pre- vious ages of medicine. Only a few years ago (1884) the late Fordyce Barker made the following statement: " And so, by the microscopical researches of Tigri, Davaine, Leplat and Jaillard, Burdon-Sanderson, Coze and Feltz, and others, the infusoria called bacteria were discovered and found to be a constituent of septicemic blood, and thus we have been furnished with another element of distinction between septicemia and pyemia. These bacteria, however, seem to be a product of changes effected in the blood by septic poisoning, rather than a cause of the morbid phenomena which appear in septicemia, for the experiments of Bergmann and others have demonstrated that, when these bacteria are alone introduced into the blood, they give rise to none of these phenomena, and are absolutely innocuous." The history of medical views on the septic fevers of the puerperium prior to the middle of the present century is a long record of error and ignorance. From the earliest beginning of medical literature to the present century, puerperal sepsis was ascribed to suppression of the lochia. This dogma held undis- puted sway until 1670, when Puzos advanced the theory that all puerperal fevers were due to a metastasis of milk, which flowed in the blood during pregnancy, and was normally attracted to the breasts after delivery, but which might be drawn to other organs or structures, especially the peritoneum, with disastrous results. This theory found support in the reports of a number of postmortem examinations, stating that milk had been dis- covered in the peritoneal cavity after deaths following childbirth. A little later English and German observers explained the puerperal infectious fevers by attributing them to inflammations of the womb and of the peritoneum, without accounting satis- factorily for the occurrence of these inflammations. Occasionally, one finds a reference to putrid fevers in the puerperium, a sug- gestion that putrefying animal matter may occasion disease in 660 PATHOLOGY OF THE PUERPERIUM. human bodies with which it comes in contact, an intimation of the contagiousness of puerperal fever ; but these were mere glimmerings of light that flickered out at once without illumi- nating the general ignorance. Credit, however, must be given to some of the English writers of the first half of the present century for insisting upon the contagiousness of puerperal fever. Three events laid the foundation of our present knowledge of puerperal sepsis : The publication of Oliver Wendell Holmes' paper on "The Contagiousness of Puerperal Fever," in 1843; the observations of Semmelweiss in the Vienna Hospital, 1846- '48 ; the publication of Sir James Y. Simpson's paper on "The Analogy between Puerperal and Surgical Fevers," in 1850. The first of these papers must always remain a classic in medical and English literature. It ended with these words : " I have no wish to express any harsh feeling with regard to the painful subject which has come before us. If there are any so far excited by the story of these dreadful events that they ask for some word of indignant remonstrance to show that science does not turn the hearts of its followers into ice or stone, let me remind them that such words have been uttered by those who speak with an authority I could not claim.1 It is as a lesson rather than as a reproach that I call up the memory of these irreparable errors and wrongs. No tongue can tell the heart-breaking calamity they have caused ; they have closed the eyes just opened upon a new world of love and happiness ; they have bowed the strength of manhood into the dust; they have cast the helplessness of infancy into the stranger's arms, or bequeathed it, with less cruelty, the death of its dying parent. There is no tone deep enough for regret, and no voice loud enough for warning. The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the seal of promised maternity is impressed upon her. The remorseless vengeance of the law, brought down upon its victim by a machinery as sure as destiny, is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly ! " 1 Dr. Blundell and Dr. Rigby, in the works already cited. PUERPERAL SEPSLS. 661 This unanswerable arraignment of the prevailing views in America in regard to puerperal sepsis, this magnificent appeal and clarion note of warning, fell upon deaf ears. The very men who should have first recognized its truth, who should have most heartily welcomed the revelation, opposed, with all their might, the new doctrine, because, forsooth, it ran counter to their teaching. At that time, in America, two men were so pre- eminent in obstetrics that they were practically without rivals, and autocratically dictated their views to a large number of un- questioning followers. These men were Hodge and Meigs, holding, respectively, the Chairs of Obstetrics in the University of Pennsylvania and in the Jefferson Medical College. Meigs directed against Holmes' teaching all the satire and ridicule of which his brilliant mind was capable, descending often to undignified abuse ; Hodge inveighed against it with a pon- derous invective. But in spite of this powerful opposition the doctrine of the contagiousness of puerperal fever made rapid headway, and gained from year to year an increasing number of converts in America and in England. Hodge's immediate successor, Dr. Penrose, taught it most impressively. In 1846 a young assistant in the Maternity Department of the General Hospital of Vienna, named Semmelweiss, was struck with the frightful mortality in one of the maternity wards of the General Hospital, while in a neighboring ward the death- rate was scarcely one-tenth as great. He discovered that in the first ward the women were attended by students who were in the habit of coming fresh from postmortem examinations in the Pathological Department to the bedsides of the parturient patients. In the second the women wrere attended solely by midwives. Semmelweiss conceived the idea that the students carried on their hands putrid products from the postmortem table to the lying-in women whom they examined, and that these products were responsible for the large number of fatal inflam- mations and fevers that followed the students' work. He con- sequently ordered that no student should examine a woman until he had washed his hands in chlorin-water. The results of his regulation were fairly startling, as is shown in the accompanying table : Confinements. Deaths. Per Cent. 1846,..........4010 459 11.4 1847,..........349° J76 5- 1848,..........3556 45 i-27 It should be stated that the rule compelling the students to wash their hands in an antiseptic solution was put into effect in the middle of the year 1847. 662 PATHOLOGY OF THE PUERPERIUM. Semmelweiss recognized the transcendent importance of his discovery. He foresaw something of the lives preserved, the homes kept from bereavement, the mothers saved to their chil- dren, the wives to their husbands, in millions of families ; the in- calculable diminution of human suffering which his discovery promised to the world ; but his was not the calm and confident soul of a Harvey, wise enough to know that the truth is mighty and shall prevail : sure that mankind must accept it some day, and content to bide his time. Semmelweiss' nature was not great enough for such patience. He fumed and fretted his life away in vain efforts to obtain recognition for his great princi- ple of chemical disinfection. He preached his new doctrine in season and out of season, endeavoring to impress it upon his immediate colleagues, and upon the medical societies and periodi- cal medical literature of the time in Europe. During the latter days of his professorship in Buda-Pesth he would even stop acquaintances upon the street to importune them with his views. But he got for his pains nothing but ridicule, contumely, opposi- tion, or indifference. He finally lost his mind entirely, from chagrin and disappointment, ending his life in a lunatic asylum in Vienna, where he died, strangely enough, from a septic wound on his finger, received during an operation performed just before his commitment to the asylum. More than twenty years after Semmelweiss' discovery, the mortality of many lying-in hospitals in Europe remained as high as ten per cent. Then came the brilliant work of Pasteur in the field of bacteriology, the acceptance of the germ theory in disease, the application of antisepsis to surgery by Lister, and the adoption of the system almost immediately by obstetricians. From that day to this there has been a steady and increasingly rapid acquisition of knowledge of the etiology of septic infection, and of its most successful preventive and curative treatment. It is to be hoped that the medical world of to-day and of the future can never again be deaf and blind to such an appeal as that of Holmes, or to such a demonstration as that of Semmel- weiss. Etiology.—It has become necessary to study the normal and abnormal microbic flora of the vagina in order to under- stand fully the etiology of puerperal infection, and to comprehend the safeguards that nature affords a woman against infection after labor. The effective study of the subject dates from Doderlein's monograph published in 1892.1 Before this time the presence 1 " Das Scheidensekret und seine Bedeutung fur das Puerperal-Fieber," Albert Doderlein, Leipsic, 1892. PUERPERAL SEPSLS. 663 of bacilli in vaginal secretions was noted by Hausmann, G6nner Bumm, Winter, and Steffeck. Gonner, in 1887, found in vagina! secretions many varieties of micro-organisms, mainly, however bacilli, which were extremely difficult to cultivate in the ordinary culture media. The cocci in the secretions, many of which could be cultivated with ease, were found to be non-pathogenic. Gonner concluded that the vaginal secretions contained no pathogenic bacteria. Bumm also failed to find pathogenic germs in the vagina. Winter believed that pathogenic germs were present in the vagina in a state of lessened or absent virulence. Doderlein examined the vaginal secretions of 195 pregnant women. In these examinations notice was taken of the micro- Fig. 484.—Vaginal secretion of an Fig. 485. — Vaginal secretion of a infant (Doderlein). virgin (Doderlein). scopical appearance and of the reaction of the secretions, and as the result of this preliminary examination the secretions were declared to be normal or abnormal. In the two conditions the bacteriological find was quite different. In the normal secretion, which was of whitish color, of the consistency of curdled milk un- mixed with mucus, containing epithelial cells and mucous bodies, moistened by an exudate from the vaginal mucous membrane and of an intensely acid reaction, there was found almost exclu- sively a certain kind of bacillus possessed of distinctive and characteristic qualities. No pathogenic germ was ever found by Doderlein in normal vaginal secretions, except a thrush-fungus which is capable, to a very limited extent, of producing suppura- tion and destruction of tissue when injected under the skin or 664 PATHOLOGY OF THE PUERPERLUM. into the eye of an animal. In the pathological abnormal secre- tion, which was yellowish or greenish in color, of the consistency of cream, weakly acid or alkaline in reaction, mixed with mucus, containing often bubbles of gas and secreted usually in very large quantities, the greatest variety of cocci and bacilli could be found. Of the 195 pregnant women, Doderlein found that 55.3 had normal and 44.6 had pathological secretions. Although a number of observers had found bacilli in the vaginal secretions before Doderlein, no one had so carefully studie'd their characteristics, functions, and cultivation ; so that they are properly called the vaginal bacilli of Doderlein. They are, according to him, anaerobic. They have no motion. They produce by their life-process an acid medium by forming lactic Fig. 486.—Normal secretion of a puer- Fig. 487.—Pathological secretion of a peral woman (Doderlein). puerperal woman (Doderlein). acid. They are frequently associated with a yeast-fungus (thirty-six per cent, in normal secretions only), which Doderlein believes to be identical with the thrush-fungus, Saccharomyces albicans. The vaginal bacilli are antagonistic to staphylococci, which within certain limits they have the power to destroy. This was shown by several experiments, among others by infecting the vagina of a virgin with staphylococcus cultures in large quanti- ties. Within four days the staphylococci had disappeared, and no bacteria remained within the vagina except the vaginal bacillus. Doderlein attributes the germicidal action of the normal vaginal secretion to the production of an acid environment by PUERPERAL SEPSLS. 665 the vaginal bacillus. He supports this view by the following facts : 1. That all pathological secretions swarming with sapro- phytes and with many pathogenic germs are weakly acid or alkaline. 2. That in a puerpera the vaginal bacillis disappears and in its place are found many kinds of saprophytes, the lochial discharge being alkaline. 3. That when the lochia ceases the saprophytes disappear, the vaginal bacillus reappears, and the vaginal secretion becomes again intensely acid. In only 8 out of the 195 cases examined were streptococci found, and in only 5 of these cases was it possible to demon- strate by inoculation experiments that the streptococci were virulent. In 2 cases the streptococcus possessed no virulence at all. These discoveries of Doderlein have not been universally accepted. His views have not gone unchallenged, and further interesting properties of the vaginal secretions have been pointed out by others, but we may safely acknowledge Doderlein's conclusions to be correct in the main, so far as they go, and that his discoveries constitute the most important advance in the knowledge of this subject achieved by a single individual. Following Doderlein's investigation there have appeared a number of exhaustive studies, the most important conclusions of which may be briefly summarized as follows : In series of examinations conducted by Burgubru, Williams, Stroganoff, and Burkhardt, in 12, 15, 9, and 16 cases respect- ively, streptococci were found in 1, 3, 2, and 5. Or, taking the sum-total of all these cases with Doderlein's, streptococci were found twenty-seven times in 542 women examined, showing that in only a small proportion of cases are dangerous pathogenic germs to be found in the vaginal secretions of pregnant women ; and accepting Doderlein's results as correct along with those of Winter, even of this small proportion of cases in which strep- tococci were found, a considerable proportion of the streptococci were non-virulent. Kronig,1 in about 200 examinations, found that the vagina in pregnant women, aside from the gonococcus and the thrush- fungus, contained no pathogenic micro-organisms. The strepto- coccus was not found in a single case. Adding these examina- tions to the former series, the proportion of cases in which the streptococcus may be found is, as appears, still further reduced. 1 " Deutsche med. Wochenschr.," 1894, Oct. 24, p. 819. 666 PATHOLOGY OF THE PUERPERIUM. Moreover, Kronig found, after inoculating the vagina with pure cultures of streptococcus, staphylococcus, and bacillus pyocy- aneus, that none of these micro-organisms could be discovered after eleven to twenty hours. Kronig attributes the germicidal properties of the vagina, which are demonstrated by these observations, mainly to the flow out- ward of the vaginal secretions, and not to any special microbe having its normal habitat in the vagina. According to this observer, acid, neutral, and alkaline secretions all have germi- cidal power. Further, Kronig found that if an hour after the infection of the vagina an antiseptic douche of lysol wTere admin- istered, not only were the infecting micro-organisms not de- stroyed by the douche, but also that it took the vaginal secretions from nineteen to thirty-six hours to destroy microbes that with- out the douche would disappear in from eleven to twenty hours. These results were confirmed by Menge,x in a study of the germicidal power of vaginal secretions in non-pregnant women, except that Menge occasionally did find streptococci in the vagina. From a number of observations and experiments this observer forms the following conclusions as to the causes of the germicidal power of vaginal secretions, putting them down in the order, as he believes, of their importance : The antagonism of the normal microbic flora of the vagina and of the pathogenic micro-organisms which may be deposited there by accident. The products of the life-process of the vaginal bacilli. The acidity of the secretions. The germicidal powers of the anatomical elements of the vagina. The leukocytosis which is provoked by chemotaxic action either of the vaginal discharges or of the infecting micro-organ- ism invading the vagina. The phagocytosis following leukocytosis. The absence of free oxygen in the vagina. Walthard2 has recently contributed valuable information from the bacteriological study of the vagina in ioo women ante et post partum. According to Walthard, the genital canal of women is di- vided practically into two parts—one infected, the other sterile. The former comprises the vestibule, the vagina, and lower por- tion of the cervical canal. The latter, the upper portion of the cervical canal, the uterine cavity, and the tubal canals. The 1 " Deutsche med. Wochenschr.," 1894, Oct. 24, p. 819. 2 "Archiv f. Gyn.," vol. xlviii, p. 201. PUERPERAL SEPSIS. 667 causes of this division of the canals, according to Walthard, are : 1. The plug of mucus stopping up the cervical canal, which, though not in itself germicidal, is deficient in albuminoids and fur- nishes no nutriment for micro-organisms. 2. The leukocytes, which are found in great numbers where the cervical secretion mixes with the vaginal secretion at the level of the external os. According to this observer, there are really three divisions of the genital canal: one, the lower, containing leukocytes and bacteria ; the next, containing only leukocytes, and the third, the upper, containing neither leukocytes nor bacteria. It is supposed that the outpour of leukocytes is due to a chemotaxic action excited by the mixture of cervical and vaginal discharges, and that the phagocytosis follows naturally the^leu- kocytosis. In the vaginal discharges Walthard found, both during preg- nancy and after delivery, pathogenic microbes, streptococci, staphylococci, gonococci, and the colon bacilli. The first- named were found in 27 out of the 100 women examined, but these streptococci had lost all virulence and had become veritable saprophytes. Inoculation experiments with them pro- duced no results—that is, if they were inserted in normal tissues ; but if a certain region of the animal's body was reduced in vitality, or if the condition of the animal's system was lowered in any way, the inoculation of these streptococci produced abscesses in which the micro-organisms rapidly regained all their original virulence until they became quite as deadly as the most dangerous of their kind. From his experiments and ob- servations, Walthard draws the following conclusions : The virulence of vaginal streptococci of a pregnant woman not examined for some time is equal to that of the streptococci that live upon other mucous membranes or in their secretions. In other words, the vaginal streptococci are not virulent, and behave as saprophytes upon healthy tissues ; but as in the case of the intestinal streptococci, the vaginal streptococci can become infectious when the resistance of the tissues with which they are in contact is diminished. The virulence that the vaginal strep- tococci attain under these circumstances is quite equal to that of the streptococci of puerperal infection. Stroganoff,1 from an examination of eleven pregnant women, supports Doderlein's assertion that the vaginal bacillus pro- duces by its development lactic acid, and shows that, while 1 "Monats. f. Geb. u. Gyn.," Bd. ii, p. 381. 668 PATHOLOGY OF THE PUERPERLUM. the vaginal secretions of the new-born are very weakly acid, they become more and more acid as bacteria develop in the vagina. He quotes experiments of Schlutter, showing that an acid medium retards the growth of the staphylococcus and is destructive to the streptococcus of erysipelas. He further shows, by experiments with culture media, that the vaginal bacillus pro- duces not only an acid medium, but also other products of its life-processes that retard or prevent the growth of the staphylo- cocci. In these experiments the vaginal bacillus was cultivated, and the culture then raised to a high temperature, so that the bacilli were destroyed. The culture was then inoculated with the staphylococcus pyogenes albus, with negative result. If the culture, in addition to being treated as described, was made alka- line, the staphylococci grew, but not so vigorously as upon the same culture medium in which the vaginal bacillus had not been grown. Stroganoff explains the sterility of the upper cervical canal and of the uterine cavity by the active germicidal properties of the cervical mucus, by the mechanical action of the flow of men- strual blood, by the same action of the descending placenta and membranes, and by that of the lochial discharge. Perhaps there should be added the germicidal effect of blood itself, which property it has been recently demonstrated that blood possesses, to a certain extent. Stroganoff announces the following conclusions from his study : One finds in the vagina of pregnant women always a quantity of micro-organisms. The prominent form in normal cases is the bacillus, but there are, in addition, usually other forms present. Micro-organisms which liquefy gelatin are met with comparatively seldom in normal cases, and then only in small numbers. A pathological condition of the vaginal mucous mem- brane alters the normal flora. The vaginal secretion of pregnant women is strongly acid in reaction. In addition to micro- organisms, one sees usually under the microscope epithelial cells and isolated white blood-corpuscles. The cervix contains nor- mally no micro-organisms. When these are present in that situation, their number is small. The reaction of the cervical secretion is alkaline. In not a single case were there organisms in the cervix which liquefied gelatin. The external os is usually the boundary between that portion of the genital canal which contains micro-organisms and that portion which does not. Vahle1 finds that for the first twenty-four hours the vaginal 1 "Zeitschr. f. Geb. u. Gyn.," Bd. xxxii, H. 3, v. PUERPERAL SEPSIS. 669 secretions of new-born infants are sterile. By the third day they always contain micro-organisms, and in a considerable pro- portion of cases the staphylococci pyogenes albus and aureus and a streptococcus. Stroganoff finds that within a few hours of birth the vagina becomes infected, and that in a certain proportion of cases the inoculation occurs in utero, or during the passage of the child's body through the vagina. This is most likely to occur in breech presentations. A great variety of micro-organisms may be found in the vagina of the newly born, including streptococci, diplo- cocci, staphylococci, etc. From this mass of facts, set down without any special order, confusing in its complexity and occasionally in its apparent contradictions, the practical physician may draw the following conclusions as to the etiology of puerperal sepsis : The vagina becomes infected almost immediately after birth. In a normal condition it contains no pathogenic bacteria. It has strong germicidal powers which serve to guard a woman against infec- tion. These powers depend upon the presence of a special bacillus, and upon the products of its life-processes ; upon the leukocytosis due to chemotaxic action ; upon phagocytosis; upon the germicidal powers, perhaps, of the anatomical elements of the vagina ; of the cervical mucus, and of the bloody dis- charge during menstruation and the puerperium. During and after labor, mechanical safeguards of the most effective kind are furnished against infection. These are : the discharge of the liquor amnii, washing the vagina out; the passage of the child's body, scrubbing the vagina out; the descent of the placenta and membranes, and the bloody dis- charge which follows. Moreover, should the vagina contain pathogenic bacteria, they are likely to be in a condition of diminished or absent viru- lence, in which they will not be productive of disease. Bearing these facts in mind, it is apparent that the common practice of relying upon simple vaginal douching for disinfecting the vagina before labor, or before some gynecological manceuver or operation, is faulty, not to say foolish. It has been clearly demonstrated that the injection of an antiseptic fluid into the vagina will not destroy pathogenic germs there, and will rob the woman, to a certain extent, of the safeguards that nature pro- vides for her against infection. If, therefore, under certain cir- cumstances, it is desirable to disinfect the vagina, mere douching should not be depended upon, but the vaginal mucous membrane should be thoroughly scrubbed out as well as douched, just as one would prepare the skin for an important surgical operation. 67.O PATHOLOGY OF THE PUERPERIUM. It is clear that these remarkable discoveries in regard to the micro-organisms normally present in the vagina do not, in the slightest degree, lessen the importance of antiseptic precautions on the part of medical or other attendants upon a patient in labor. The presence of these organisms in the vagina might possibly be used as an argument against the necessity for anti- septic precautions. For, it might be said, the vagina being already infected, it is unnecessary to observe such elaborate pre- cautions against infecting it still more. When one considers that the micro-organisms in the lower genital canal are not infectious at all in the vast majority of cases, and that when they are nature has diminished, in many an in- stance, their virulence, it must appear that it is incumbent upon any conscientious man not to insert into the vagina infecting bacteria which may, by their number and virulence, overcome all the safeguards that nature throws about women in this condition, and may, consequently, be the cause of a serious and fatal disease. The Pathogenic Microbes Capable of Producing Local In= flammation and General Systemic Infection when Introduced in the Genital Canal.—Doderlein found, in five cases of serious puerperal infection, the streptococcus pyogenes as the sole infect- ing agent. Czerniewski, in 53 cases of puerperal infection, found strepto- cocci in 49. In a histological and bacteriological examination of 16 cases of puerperal fever, Widal found streptococci in 14, bacilli in 2. Bumm, in an examination of 17 cases of puerperal infection, found streptococci in all—5 times as pure cultures, 12 times mingled with small numbers of staphylococci and of other germs. Thus, in a total of 91 cases, the streptococcus was found to be the infecting agent in 85, or 94 per cent. Following streptococci, but a long way behind as the cause of puerperal infection, are the pyogenic staphylococci, the colon bacillus, the gonococcus, the bacillus pyocyaneus, the bacillus foetidus, the pneumococcus, the Klebs-Loffler bacillus of diph- theria, the tetanus bacillus, and possibly any germ at all that, inserted into living tissues or deposited upon weakly resisting surfaces, is capable of causing local inflammation or general disease. In addition to specific septic micro-organisms, the saprophytes of. decomposition play an important role in the common form of puerperal sepsis, due to the absorption of toxins, or ptomains produced in the decomposition of dead animal matter, such as blood-clots, fragments of placenta, hyper- trophied decidua, within the womb. Dobbin1 has reported an 1 " Puerperal Sepsis due to Infection with the Bacillus Aerogenes Capsulatus," "Johns Hopkins Hospital Bulletin," No. 71, February, 1897. PUERPERAL SEPSIS. 671 interesting case of fatal puerperal infection, in which the bacillus aerogenes capsulatus (gas bacillus) was probably the infecting agent, or, at least, produced the toxins that fatally intoxicated the maternal organism, and, after death, developed the same emphysema in the maternal body which was found in the dead and macerated fetus at the time of delivery. This is the germ which is accountable for cases of physometra, or tympanites uteri. It develops by preference in dead bodies, and may not manifest its presence during life. It finds in the dead fetus within the womb a habitat most suitable for its development; it gives rise to a horribly fetid gas, and probably to virulent toxins. J. Whitridge Williams, of Baltimore, in an examination of forty patients, the cultures being taken from the ward cases whenever the temperature went to or above 101° F. and from the out-door cases when it reached 102 °, found— Streptococci in..................8 cases Staphylococci in................. 2 cases Colon bacilli in.................6 cases Strictly anaerobic bacteria in............4 cases Unidentified aerobic bacteria in . . . . .... 5 cases Bacteria were found in cover-glass examinations, all cul- tures being sterile, in...............4 cases Diphtheria bacilli in................I case Bacillus aerogenes capsulatus in.......... I case Typhoid bacilli in ............I case Malarial plasmodia in blood, cultures sterile, in . . . I case No bacteria on cover-glass, cultures sterile and blood negative, in.................II cases making a total of 44 cases, the difference between that num- ber and the 40 cases actually examined being due to the fact that there were mixed infections in several instances. The Manner in which Pathogenic Organisms Find an Entrance into the Genital Canal.—The majority of puerperal infections are traceable to the insertion of pathogenic germs by the examining finger or hand of the physician, who in the course of his daily work may have touched the dried sputum of diph- theria, the desquamated skin of scarlet fever, suppurating wounds, erysipelatous surfaces, and other virulent, infectious material ; so that at any time his hands may fairly reek with the most dangerous poisons that could possibly be brought in contact with the parturient and puerperal woman. Many hundred cases have been traced directly to the association of the physician with infectious diseases, and there is scarcely a surer way of avoiding puerperal infection than by abstention from vaginal examinations. Epidemics of puerperal fever in hospitals have been quickly stamped out by avoiding all internal examinations, and the best morbidity and mortality records ever known have been obtained 672 PATHOLOGY OF THE PUERPERIUM. recently in institutions in which vaginal examinations were eliminated as much as possible. The hands of the nurse or other attendants may be the agents that deposit bacteria in the vagina or upon the vulvar orifice. The implements used in and about the parturient canal, an atmosphere laden with dust or vitiated by foul hygienic conditions, and the water used to wash and douche the patient may each and all carry disease germs to the parturient woman and may introduce them into the genital canal. The bed-clothing, the personal clothing, the mattress, the vulvar pads, the material used to cleanse the vulva (rags, sponges, cotton, cloths), may each and all be sources of infec- tion. Putrescible material retained within the genital canal (espe- cially within the uterine cavity) will attract the innumerable and ubiquitous saprophytes and their spores, with which the purest atmosphere swarms. The development of these bodies in a situation most favorable to their growth and active propagation may easily result in a toxemia, if not in actual invasion of the body by pathogenic germs. Finally, a certain proportion of cases may be traced to auto- infection—that is, to pathogenic germs resident in the body, and not introduced from without during or after labor. These germs may have had a lodgment in the vagina, as has been demon- strated in the bacteriological studies of that canal recently made ; or they may have been contained in a limited area near the genital canal, as in an old pyosalpinx, whence they spread by rupture of the pus-sac during labor, or in which they are incited to new activity by the compression and consequent reduction of vitality of surrounding tissue. Or there may be, in the neigh- borhood of the uterus, tumors of low vitality and highly putrescible material, which, being reduced in resisting power by compression from the descending child, become infected by germs that ordinarily can not influence vigorous body-cells. Dermoid cysts and fibroid tumors are the best examples of these growths. It is claimed that even highly vitalized tissues like the pelvic muscles, especially the iliopsoas, may be so bruised and in- jured by the child's head that they slough and become gangre- nous. The iliac bone, too, has become carious after the bruising to which it was subjected in a prolonged forceps operation. The parturient woman may have been, before conception, the subject of an interstitial endometritis, caused by the presence in the endometrium of some pathogenic germ. This germ being lodged in the interstices of the uterine mucous membrane, and the woman becoming pregnant, there is contained in the uterine PUERPERAL SEPSLS. 673 cavity, even before labor, an efficient cause, perhaps, of virulent puerperal sepsis after delivery. Cases in which infection followed child-birth in this way have been recently reported by Gottschalk and Immerwahr.x The Behavior of Pathogenic Micro=organisms when Intro= duced into the Genital Canal or Deposited upon its Entrance. —The consequences of microbic invasion of the genital canal by pyogenic germs are variable in the extreme. If the bacteria enter wounds in or near the vaginal outlet, the result may be the same as in the infection of any wound in general surgery—that is to say, local inflammation, suppuration, and perhaps general sys- temic infection ; but the infectious inflammation of a vaginal wound is almost certain to spread upward, for the conditions are more favorable to microbic growth and to systemic invasion in the uterine cavity and in the tubal canals than in the lower portion of the genital tract. Hence it is that the vast majority of serious puerperal infections have their effective starting-point within the womb. For example, it has been found, in a strepto- coccic infection of the whole genital tract, that the micro- organisms were present in the vaginal mucous membrane alone, in the cervical mucous membrane, and in the tissues immedi- ately subjacent; in the endometrium, and deep within the uterine muscle, showing that they could easily penetrate the deeper tissues within the womb, while they were incapable of invading the tissues underlying the vaginal mucous membrane. In other words, the resisting power of the tissues under the mucous mem- brane is less the higher the micro-organisms are found in the genital canal.2 Septic infection of the genital tract results often in the forma- tion of false membranes. This is true of pure streptococcic infections, of mixed infections (streptococcus, bacillus fcetidus, bacillus pyocyaneus, the pyogenic staphylococci), and especially true, of course, of the rare cases of true diphtheria of the genital tract in which the Klebs-Loffler bacillus is found. The apparent false membrane in a septic endometritis may be due to a necrosis of the endometrium, clothing the uterine walls with a dirty, greenish-yellow covering. There is much yet to learn of the antagonisms and associations of pathogenic germs in puerperal infections. This much, however, may be asserted with confidence : the streptococcus is frequently associated with the pyogenic staphylococci, the bacillus fcetidus, the bacillus pyocyaneus, and the colon bacillus, though it is said to drive 1 "Ueber die im weiblichen Genitalcanale vorkommenden Bakterien in ihrer Beziehung zur Endometritis," "Archiv f. Gyn.," Bd. 1, H. 3. 2 Lahn, " Inaug.-Diss." Jarhresbericht, 1894. 43 674 PATHOLOGY OF THE PUERPERLUM. away or destroy the staphylococci after a time. These mixed infections are, in my experience, the most fatal. The gonococcus seems often to prepare the way for the strep- tococcus, which, in its turn, may destroy the gonococcus, con- quering the latter in a struggle for existence and remaining in sole possession of the field. The streptococcus appears often to prepare the way for the colon bacillus, which certainly wranders in frequently in the course of streptococcic infection. Streptococci, staphylococci, and the pyogenic bacilli have preeminently the power to penetrate the tissues of the uterus and to distribute themselves throughout the body. This is particularly true of the streptococci. Gonococci and the colon bacilli confine themselves most often to the endometrium. The former is the pathogenic agent in a large proportion of the cases of septic endometritis after labor. Both of these organisms, however, can penetrate the uterine muscle, and may be distributed by the lymph-channels or by the blood-vessels throughout the system. The putrefactive micro- organisms (saprophytes) are themselves anaerobic, and confine their activity mainly to the decomposition of the endometrium and of putrescible uterine contents, particularly a hypertrophied endometrium, which is practically cut off from its blood-supply by the contraction of the womb, and which is peculiarly liable to rapid decomposition. During the process of the putrefaction the saprophytes manufacture soluble and absorbable products (toxins) of a highly pathogenic nature, causing in many a case a fatal intoxication without actual microbic invasion of the body. Moreover, these same saprophytes occasionally attack blood-clots in the uterine sinuses, and may in them, by detach- ment of a thrombus, be swept into the general circulation and deposited as a septic embolus in different portions of the body, causing metastatic abscesses. Symptoms and Diagnosis of Puerperal Infection.—The symptoms of puerperal infection are local and general. The latter are : an elevated temperature, preceded perhaps by a chill; a rapid pulse, and profound physical depression, with the devel- opment in some cases of metastatic inflammations of any of the organs or tissues in the body. The tongue is coated ; the breath is heavy. There is a disinclination to take food. There may be intense thirst; nausea and vomiting are not uncommon, and a septic diarrhea appears in the worst cases. There may be blotches of a scarlatiniform eruption upon the skin. The local symptoms of septic infection are : a foul discharge, redness of the mucous membrane, spots of ulceration and false membrane formation along the lower genital canal, edema of the PUERPERAL SEPSIS. 675 vulva, and, possibly, pelvic peritonitis with an exudate. Or there may be other inflammatory affections of the generative organs, such as superficial catarrhal colpitis or ulcerative metritis, the symptoms of which will be described in their appropriate places. It is not likely that any case of puerperal sepsis will present all the symptoms just detailed. Elevation of temperature and rapid pulse alone after labor should be regarded as indicative of puer- peral infection if no other cause for them can be demonstrated. It is possible, indeed, to see elevation of temperature alone as a symptom of puerperal infection in the early part of the puer- perium, during which time the influences that normally reduce the pulse-rate are so active as to counteract the disposition to rapidity of pulse usually shown in septic infection. The slow pulse, however, will not continue long. At the end, usually, of thirty-six hours, rapid heart-action appears. It may be impossible to make a differential diagnosis between septic fever and some of the other causes of elevated temperature after labor. In these cases it is wise to treat the patient for puerperal sepsis by a thorough disinfection of the parturient tract, while at the same time the bowels are well evacuated and a full dose of quinin is administered to dispose of a possible intestinal toxemia, and to combat a possible malarial infection which in many parts of the country, especially in the spring and fall, is a not improbable event. A microscopic examination of the blood is advisable in a doubtful case, to discover the leukocytosis of sepsis or the protozoa of malaria. Any elevation of temperature after delivery calls for the most careful investigation. A vaginal examination should be made, both digitally and with the speculum, to detect the following con- ditions : Redness of the mucous membrane and edema of the vulva; false membranes and ulceration in the vagina ; arrested involution and fixation of the uterus ; bogginess and extreme tenderness of the uterine walls ; enlargement of the tubes ; en- largement, fixation, or displacement of the ovaries ; edema or exudate in the pelvic connective tissue, and thromboses in the pelvic veins. The abdomen should be carefully palpated for tenderness and exudate ; the character and odor of the lochia must be observed. In short, the woman's condition should be thoroughly studied to eliminate or to discover some other cause for fever than an infection of the birth-canal. Preventive Treatment of Puerperal Sepsis.—It is conveni- ent to deal separately with the several sources of puerperal infection in describing the preventive treatment. Atmosphere.—While the air is not so frequent a source of infection as it was thought to be in the beginning of the anti- 676 PATHOLOGY OF THE PUERPERLUM. septic era, it is undeniable that an atmosphere which is stag- nant, deprived of sunlight, impregnated with dust, tainted with foul odors and mephitic gases, may not only contain disease germs and spores in larger proportion than it should, but also has a most depressing effect upon an individual subjected to its influences, reducing the vitality and resisting power of that indi- vidual until there occurs, perhaps, microbic invasion of the system that would have been successfully resisted had the body- cells preserved their normal combative power against patho- genic bacteria. The lying-in room, therefore, should be sunny ; should be well ventilated—best by an open fire-place; and it should not possess a stationary wash-stand or any other connec- tion with the sewer; nor should it be too near the bath-room and water-closet. If there is a stationary wash-stand in the room, its outlet should be kept stopped, water should be allowed to stand in it, and the overflow holes should be plugged with small corks or putty. If the bath-room immediately adjoins the lying-in room, the door between should be stripped. If the room is heated by a hot-air furnace, the intake for the air and the sanitary condition of the cellar may need investiga- tion. The nurse should be cautioned not to leave trays of food, an unemptied bed-pan, or a commode in the room over night or for any length of time. An antiseptic vulvar pad should be worn during the continuance of the lochial discharge, so as to protect the genital orifice from contact with the atmosphere, and the materials of which this pad is composed, or, rather, the anti- septics with which it is impregnated, should be chosen with a view of keeping the bloody discharge from decomposing, should it soak through the pad, and thus be exposed to atmospheric contamination. The best materials for this purpose, in my ex- perience, are salicylated cotton and carbolized gauze. Water.—The water used for douches, if they are employed, or for washing the vulva and perineum, may be the source of fatal infection. All the water used about the puerpera should be boiled beforehand for at least half an hour. It is not suffi- cient to make a germicidic solution—as; for example, of corrosive sublimate—in the belief that all germs in the water are killed by the antiseptic employed. Tetanus bacilli will live for hours in a 1 : 4000 bichlorid of mercury solution, and the other antiseptics usually employed in obstetric practice—lysol, kresin, creolin— may be perfectly inert against many dangerous pathogenic germs during the time that usually intervenes between the preparation of an antiseptic solution and its use upon a patient. I have seen three women contract tetanus from intra-uterine douches of unboiled water (creolin, two per cent), during a time when the PUERPERAL SEPSIS. 677 water of Philadelphia was unusually turbid, in consequence of freshets in the Schuylkill Valley. The Patient.—The parturient and puerperal woman may be infected by disease germs carried upon her person, especially in the pubic region ; by her personal clothing, by the bed-clothing and mattress, by the vulvar pads and the pads upon which the buttocks rest, by the material used to wash the vulva and perineum, and by pathogenic bacteria lodged in the vaginal or uterine mucous membranes before labor or even prior to con- ception. To insure the greatest obtainable degree of personal cleanli- ness, the woman falling in labor should be given a full bath, special attention being paid to scrubbing the genital region most thoroughly with soap, hot water, and a soft, bristle brush or a wash-rag. After the bath, the woman should put on clean clothes throughout. The mattress on her bed should not be soiled by the discharges of previous labors, by urine, feces, or other putrescible matter. It should not have been used in any case of contagious or infectious disease, and it should be pro- tected by a rubber cloth that has been carefully scrubbed clean. The bed-clothing should be clean, the bed being freshly made up for the labor. The pads on which the buttocks rest during labor and afterward should be made of nursery cloth prepared in the way described in the directions to the nurse (boiled and dried). It is scarcely necessary to say that a pad when soiled should be thrown away and not used again. The vulvar pads should be made of carbolized gauze and salicylated cotton—the best materials for disinfecting a bloody discharge. The nurse should make them up with sterile hands as they are required, or if she makes a number at a time they should be wrapped in a clean towel and taken out for use with sterile hands. The material used to wipe off the genital orifice, the mouth of the urethra, and the perineum should be absorbent cotton soaked in a 1 : 1000 solution of sublimate for at least a half hour before its use. During the second stage of labor these pledgets of cotton are employed to wipe away feces as it emerges from the anus, always in the direction from before backward. Care must be exercised to remove blood and blood-clots from the vulva before putrefaction sets in. This is best done by placing the woman on a bed-pan, letting a stream of boiled water run over the parts, and, if necessary, using cotton to wipe them off. This should be done about six times in the twenty- four hours for the first four or five days. A careful examination should be made of every woman's vaginal discharges in the beginning of labor. If there is leukor- 678 PATHOLOGY OF THE PUERPERLUM. rhea, or any pathological condition of the vaginal secretions, the vagina should be thoroughly scrubbed with tincture of green soap, hot water, and pledgets of cotton, and should then be douched with a bichlorid of mercury solution, I : 2000, a little clear water being employed at the end of the douche to wash out any residual sublimate solution that might poison the patient or do harm to the infant's eyes in its descent through the birth-canal. It should be borne in mind, in the conduct of the labor, that excessive bruising, long-continued pressure of the maternal tissues, extensive injuries, all conduce to microbic invasion of the parts by reducing their vitality and by affording, through solu- tions of continuity, a ready entrance into the system. The proper conduct of labor, therefore, is an extremely important item in the preventive treatment of puerperal sepsis. Finally, in the management of the third stage of labor and of the early puerperium, the greatest care should be exercised to evacuate the uterine cavity of all putrescible matter and to secure, so far as possible, firm contraction of the womb, for the presence of dead foreign matter within the uterine cavity will almost surely attract saprophytes, and an imperfect involution of the womb will favor the direct invasion of the uterine sinuses and blood- channels by micro-organisms and the absorption of the products of microbic activity into the circulation and into the lymph- spaces. The Physician.—The physician should not carry infectious germs upon his person or clothing into the lying-in chamber, and he should be scrupulously careful not to insert pathogenic germs into the woman's vagina in the course of his examinations. If a general practitioner is in attendance upon infectious and contagious diseases, he should either give up obstetric practice entirely, or, if he can not do so, he should take a full bath and should change his clothing completely before attending a woman in labor. It is a wise precaution to carry in one's obstetric bag a long linen gown or a pair of duck trousers and a cheviot shirt. The change of clothing should be made in another room before seeing the patient at all, or, at any rate, before making an examination. In the preparation of his hands for an examination the method recommended by Furbringer is to be preferred. This consists of a ten minutes' scrubbing of the hands with a nail-brush, hot water, and tincture of green soap, followed by a most thorough scrubbing with alcohol, and this followed by immersion of the hands in a 1 : 1000 bichlorid of mercury solution for at least two minutes. The examining finger should then be anointed PUERPERAL SEPSIS. 679 with carbolized vaselin (five per cent.), and in making the exami- nation the vulvar orifice should be exposed by lifting up the upper buttock as the woman lies upon her side, so that the finger may be inserted directly into the vagina without becoming con- taminated by being swept over the skin near the anus or pubes while searching for the vulvar orifice. As every examination entails upon the woman some risk of infection, the examinations should be limited in number as much as possible. The best results ever obtained in obstetrical practice, as regards both mor- bidity and mortality, have been secured by an almost entire elimination of the vaginal examination, which has been replaced, in the practice of some enthusiasts, by abdominal palpation, and even by rectal examinations. It is unnecessary, however, and is, moreover, inadvisable to give up the vaginal examination altogether. Much may be learned by abdominal palpation, so that there is little necessary information to be gained by examining per vaginam, but there are conditions that can be learned in no other wray. A few vaginal examinations in the course of labor are therefore indispensable. No harm is done by these examinations if their number is restricted and sufficient care is exercised to secure perfect cleanliness of the examining hand and to conduct the examination in the way just described. The Nurse.—The nurse should adopt the same precautions in regard to personal cleanliness that have been recommended for the physician. She should not have come from a contagious or infectious case. She should put on fresh clothing throughout for attendance upon the obstetrical patient. She must take a full bath, scrubbing her hair and scalp wrell with soap and water, and rinsing her hair in a 1 : 1000 sublimate solution. Her hands should be carefully prepared according to the method pre- viously described before any manipulation of a patient's genital region or of her breasts. It would be her duty also, in the care of a puerpera, to enforce the sanitary and aseptic regulations already described under their appropriate heads. The Implements.—All implements to be used about the person of the parturient and puerperal woman should be boiled for at least five minutes. In the case of a few articles that might be injured by boiling water a bichlorid solution 1 : 1000 should be employed for their disinfection, a full half hour at least being allowed for the immersion, and the bichlorid solution being made up with boiled water. The Curative Treatment of Puerperal Infection.—The treat- ment of puerperal sepsis is both local and general. Locally, a thorough disinfection of the whole genital canal is called for in every case of puerperal infection. It may appear unnecessary, 680 PATHOLOGY OF THE PUERPERIUM. and may prove, on actual experience, to be even harmful, but no one can tell beforehand how necessary this procedure will be. In the vast majority of cases it will be productive of the greatest good. It is only occasionally useless, and very rarely actually harmful. It should, as already stated, invariably precede all other treatment for puerperal infection. The method of dis- infecting the genital canal may be described as follows : A double tenaculum, a large, dull curet, a placental forceps, and an intra-uterine catheter are boiled for fifteen minutes. The operator disinfects his hands and arms. The patient is placed in the dorsal posture across the bed, with her buttocks resting Day of Disease 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° M £ M £ tl f£ A IE M E M £ M £ M £ ME ME M E Md \ 5* J: V fc ,K ;1 f '• h % V f- i \ \ : : j : rr \ • I ; : :i \ \ i '• ': : [/- • V; As / -. V '. s * s J- '. ■ Fig. 488.—Temperature-chart of a case treated in vain by intra-uterine irrigation, but cured immediately by a curetment. on a rubber pad. The external genitalia and the vagina are scrubbed with tincture of green soap and pledgets of cotton ; the vagina is douched with a sublimate solution, 1 : 2000. The operator then seizes the anterior lip of the cervix with the tenac- ulum. An intra-uterine douche, sublimate solution 1:2000, at least a quart, is administered. Then with the curet and the placental forceps in turn the uterine walls are gone over thoroughly in all directions, six to twelve times, until nothing is brought away but bright blood. A second intra-uterine douche concludes the treatment. If the womb is flabby and large, with a tendency to flexion, so that the drainage of the uterine cavity is not good, it is advisable to pack the cavity with iodoform gauze. PUERPERAL SEPSLS. 68 I In addition to cleansing the uterine cavity in the manner described, the operator should take the opportunity of carefully inspecting the visible portion of the parturient tract; and if there are false membranes or areas of inflammation and localized infection on the cervix or in the vagina, these should be carefully treated—best by the application of a strong solution of nitrate of silver, a dram to the ounce. It may be necessary to repeat the intra-uterine douches several times—in fact, several times a day for many days ; in this case plain water only should be used. Nothing is gained whatever by the employment of strong chemical disinfectants, which can not always reach and destroy the infecting micro-organisms of the genital tract, but which do have a most depressing action upon the body-cells of the w^alls of that tract, reducing their resisting power against the invasion of attacking bacteria. It is rarely necessary to repeat the curetment or the use of the placental forceps. It may be advisable to provide drainage from the uterine cavity by the insertion of a strip of gauze to the fundus. This is only necessary, however, in those cases of flabby, relaxed wombs which fall forward on themselves in such a manner as to prevent the free exit of the lochial discharge. The general treatment is stimulating. The patient should have as much food of an easily digestible character, chiefly milk, as she can assimilate, and as much alcohol as she can consume without showing the physiological effects of it. Digitalis will be useful as long as the pulse is above 110. Strychnin may be combined with it in suitable cases. To tide the patient over emergencies, carbonate of ammonia in large doses, by the bowel, and nitroglycerin hypodermatically, may be required. Inhala- tions of oxygen may also be of service. Absolute rest and freedom from all disturbances, mental and physical, must be insisted upon, and the patient should be given the best nursing that the family can afford. The Serum =therapy of Puerperal Sepsis.—Stimulated by the success of this treatment in diphtheria and in a few other infec- tious diseases, an effort has been made to procure a serum that will be antagonistic to streptococci and antidotal to the products of their activity. Richet and Hericourtx suggested, some years ago, the use of serum taken from animals " vaccinated " with a septic micro- organism, in order to secure immunity in other animals. Many enthusiastic investigators have recently worked in the same field, especially in France; but Marmorek's work has com- 1 " Comptes rendus de l'Academie des Sciences," 1888, p. 690. 682 PATHOLOGY OF THE PUERPERIUM. manded more respect and attention than that of any other single worker ; and it will not be unfair, therefore, to judge the merits of serum-therapy of puerperal sepsis by the results achieved with Marmorek's products.1 There are two ways of immunizing animals. One is to take culture media with the microbes destroyed or removed, and containing only the toxins of streptococcic activity. The other is to inject the streptococci themselves into the animal which is to be made immune. The latter is much the more reliable method. Marmorek was able to immunize horses, asses, sheep, and mules by injecting exceedingly virulent streptococcic cultures in increasing doses during a period of six to ten months. Taking the serum from the animals at least four weeks after the subsi- dence of all the symptoms in the reaction following the last inoculation, he found that TqVo Part °f a guinea-pig's weight in serum was sufficient to protect it against ten times the dose of virulent streptococci, which would be fatal in animals unprotected. But he admits that there may be a streptococcic infection so virulent that no antidote is of avail, and also that if the anti- streptococcic serum is employed late after the primary infection, the progress of the septic inflammation can not be arrested. Moreover, the antistreptococcic serum has no antagonistic power over the other micro-organisms of puerperal sepsis ; so that the quite common cases of mixed infection in which the colon bacillus, the bacillus fcetidus, the bacillus pyocyaneus, and the pyogenic staphylococci are active may not be benefited in the least by the antistreptococcic serum. Marmorek reports 15 cases of streptococcic infection in puerperal women in which the serum was employed. In 7 of these there was a pure streptococcic infection. This series had no mortality. In 3 cases the colon bacillus was associated with the streptococci. All these women died. In 5 cases pathogenic staphylococci were associated with streptococci. In this number there were 2 deaths. Gaulard 2 reports two cases of puerperal fever treated by serum. One was apparently benefited. The other died, although the septic symptoms appeared to improve. While the tempera- ture was falling, the patient was seized with bilious vomiting and meteorism, the pulse remaining as before, about 120. The vomiting became uncontrollable; she became comatose, and 1 " Le Streptocoque et le serum Antistreptococcique," Alexandre Marmorek, " Annales de l'Institute Pasteur," t. ix, July, 1895, P- 593- 2 " Presse Medicale," Nov. 30, 1895. PUERPERAL SEPSLS. 683 £- rz^ died on the thirteenth day. Gaulard believes that the serum was the cause of the vomiting. He fears that too much serum was injected, for at the autopsy there was no sign of suppuration or of peritonitis. The question of maximum dose of the serum has yet to be determined. Bar and Tissierx have re- ported further experiences with the treatment of puerperal infec- tion by antistreptococcic serum. They report, in a preliminary announcement, the treatment of ten cases of streptococcic in- fection by the antistreptococcic serum. Of this number five died and five recovered. Those that ended in recovery were compara- tively light, and one wrould expect a good result in such cases from the older plans of treatment. They were, moreover, all treated with intra-uterine irrigations, which seems to have had more to do with their recovery than the serum injections. ±S Among the fatal cases was one that received the first serum injection three-quarters of an hour after labor, and another in which the patient died apparently from toxemia after the symptoms of the streptococcic infection had sub- sided. One can not avoid the thought, in reading the history of this case, that the serum was the cause of death rather than the original dis- ease. Its clinical features resem- bled closely those of Gaulard's fatal case. At a meeting of the Philadelphia Obstetrical Society 2 the mem- bers reported 7 cases of their own treated by serum, and a col- 1 " Faits pour servir a l'Histoire du traitement del'Infection puerperale par les serum antistreptococciques l'Obstretrique," i, March, 1896, p. 97. 2 "Am. Journ. Obstet.," 1897, vol. xxxv, pp. 625-650. 5S 2E ;£: •^ :s % 684 PATHOLOGY OF THE PUERPERIUM. lection was made of 21 others with 7 deaths, a mortality of 25 per cent. The judgment on the serum-therapy of streptococcic infec- tion must at present run as follows : It requires a long time and especially virulent inoculations to obtain a serum with antitoxic and germicidal properties. It should be prepared, therefore, with great care, and should be obtained from a thoroughly reliable source. There is a possibility that this serum may contain danger- ous toxins, and that the treatment may be more dangerous than the disease. There is a streptococcic infection so virulent that the antitoxin will be of no avail, no matter how strong it may be. There is an undeterminable time in streptococcic infections, when the serum will be used too late. The antistreptococcic serum has no antagonistic power over other pathogenic micro-organisms. It is not easy to determine during life whether the infection is pure or mixed, though the majority of puerperal infections are due to streptococci. Therefore, the use of the serum must be more or less empirical. Finally, the clinical results of the serum- therapy for puerperal infection have not been as yet at all en- couraging. The Treatment of Septic Infection by the Artificial Production of a Hyperleukocytosis.—A large and influential school of pathologists regard phagocytosis as the agency by which an infectious disease is spontaneously cured. It is logical, therefore, in those hold- ing this belief, to attempt the treatment of septic infection by stimulating the production of white blood-corpuscles that shall serve as phagocytes. There are several agents administered in- ternally that have leukocytotic powers, such as pilocarpin, albu- mose, and nuclein. The first, however, is not advisable in sepsis on account of its depressing action. Hofbauer,1 from Schauta's clinic in Vienna, reports the results of employing Horbaczewski's nuclein in seven cases of puerperal infection. The cures affected in some of these cases certainly warrant a further trial of the method. For two years I have administered nuclein routinely as part of the treatment of puer- peral sepsis, combined with local disinfection, stimulation, and support, and in suitable cases with operative treatment. To my mind, this plan of treatment gives.promise of practical results. The Treatment of Sepsis by Washing the Blood; Hypodermatocly - sis; Intravenous Injections of Saline Solutions.—A recent method attended with marked success in the hands of physicians on the Continent of Europe and in America. The best fluid for the 1"Centralbl. f. Gyn.," No. 17, 1896, p. 441. PUERPERAL SEPSLS. 685 purpose is o. 1 gm. CaCl, 0.75 gr. KCl, to 1000 c.c. normal salt solution.1 Injections of large amounts—more than two quarts— of this fluid into the bowel seems to give as good results as hypodermatoclysis and is much more convenient. The use of the modified normal salt solution is a valuable adjuvant to the other measures required in the treatment of puerperal sepsis. The Operative Treatment of Sepsis in the Child bearing Period.— Since the first performance by Tait of abdominal section for puru- lent peritonitis there has been an extremely important develop- ment, especially in the last decad, in the scope of pelvic and abdominal surgery for septic inflammations during the child- bearing period. Regarded at first as a procedure analogous to opening an abscess anywhere on the body, the whole abdominal cavity being looked upon as an abscess-cavity and the abdominal walls as its capsule, abdominal section for puerperal sepsis has become a generic term of wide significance, including hysterectomy, salpingo-oophorectomy, evacuation of abscesses in the peritoneal cavity and in the pelvic connective tissue, removal of gangrenous or infected neoplasms of or in the neighborhood of the parturient tract, and exploratory incisions. Indications for Abdominal Section in the Treatment of Puer- peral Sepsis.—It is more convenient to deal generically with the indications for abdominal section in the course of puerperal sepsis, for the operation is usually decided upon in practice without refer- ence to what may be required after the abdomen is opened, the prudent and experienced obstetric surgeon holding himself in readiness to perform any of the pelvic or abdominal operations detailed above that may be found necessary when the abdominal cavity is exposed to view and to touch. In order to properly decide the important and anxious question for or against celiotomy in the course of puerperal septic fever, the medical attendant must be familiar with the different forms of sepsis after labor, and should know which of them are most and which are least amenable to surgical treatment. In a general way, it may be stated that the opera- tion is demanded most frequently for localized suppurative peritonitis ; it may be indicated, and often is, for diffuse suppura- tive peritonitis ; for suppurative salpingitis and ovaritis ; for sup- purative metritis, if the inflammation extends outward toward 1 See experiments of W. H. Howell, in Boston, on frog's heart; modified Ringer fluid. "The Use of Intravenous Saline Injections for the Purpose of Washing the Blood," H. A. Hare, "Therapeutic Gazette," April 15, 1897. The technic of the injection is the same as for the injections required in the treatment of the acute anemia following severe hemorrhage. 686 PATHOLOGY OF THE PUERPERIUM. the peritoneal investment of the womb or into the connective tissue of the broad ligament; for abscesses in the pelvic con- nective tissue ; for infected abdominal or pelvic tumors. On the contrary, abdominal section is contraindicated or is not required in simple sapremia ; in septic endometritis of all forms—diph- theric,1 ulcerative, suppurative; in dissecting metritis, sloughing intra-uterine myomata, or in suppurative metritis with the abscess pointing into the uterine cavity ; in phlebitis, lymphangitis, and in direct infection of the blood-current. One is most likely to perform an unnecessary operation in diphtheric endometritis. The writer has thus erred several times. By the time that symptoms justify surgical intervention in this condition it is always too late. It is extremely difficult to lay down correct rules for the guidance of a physician in a situation involving so much responsibility, and of necessity so dependent upon many circum- stances, as that seeming to require a very serious surgical opera- tion in the midst of an adynamic fever with, very likely, profound depression, rapid pulse, high temperature—in short, with every- thing a surgeon least desires in the face of a major operation. First and foremost, then, the attendant should avoid the operative treatment of puerperal sepsis if possible, and should not seek an excuse for surgical intervention merely in the cardinal symptoms of septic infection—high temperature, rapid pulse, and general depression. He should demand some tangible evidence of those forms of sepsis that are amenable to surgical treatment. But the physician of to-day, while reluctant to operate upon a patient under the least favorable circumstances, and on his guard against unnecessary or harmful surgery, must be prepared, in the event of certain symptoms or complications, to operate with the least possible delay. Thus, on the very first appearance of symptoms that will justify the diagnosis of diffuse suppurative peritonitis, the abdo- men must be opened without a moment's more delay than is necessary for an aseptic operation. Even with the utmost promptness the operation will almost always be too late, for the inflammation extends so rapidly and at first insidiously that by the time a diagnosis is possible the progress of the disease can not be stayed. It must be admitted, however, that an occasional success is possible by timely surgical interference.2 1 By diphtheric endometritis is meant a dirty, grayish- or greenish-brown exudate on the endometrium, containing mixed micro-organisms, and not necessarily the Klebs-Loffler bacillus. For a report of one and the mention of four cases of true diphtheria of the genitalia see Williams, "Amer. Jour, of Obstet.," August, 1898. 2 Hirst, "A Diffuse, Unlimited, Suppurative Peritonitis in a Child-bearing Woman Cured by Abdominal Section," " Medical News," 1894. A unique case in my experience. Diphtheritic endometritis; hysterectomy (author's case) PUERPERAL SEPSLS. 687 Again, in the presence of exudate, adhesions, or unnatural enlargement of any pelvic structure, suppuration may be sus- pected if the physical signs do not improve and if the tempera- ture, pulse, and general condition indicate a continuance of septic inflammation. It is hardly necessary to state that if pus forms it must be reached and evacuated irrespective of its situation. Just how long to wait, however, is a question requiring experi- ence, good judgment, and a special study of each individual case for its correct answer. Enormous pelvic and abdominal exudates may disappear ; adhesions may melt away ; enlarged and inflamed tubes, ovaries, and uterus may resume their proper size, functions, and condition on the subsidence of the inflammation ; but in these favorable cases distinct signs of improvement manifest themselves in a few days, and the course of the disease is comparatively short. A mere protraction of septic symptoms is in itself suspicious, along zvith local signs of inflammation. Without the latter, the same general symptoms, sometimes lasting for months, indicate phle- bitis and infection of the blood-current. In this form of sepsis an operation can do no good and may do the greatest harm. In infected tumors in and near the genital tract the indication for operation should be plain and the decision easy. The pres- ence of the tumor should, of course, be known. On the first sign of inflammation in it, or in the event of an elevated temperature for which there is no good explanation, the tumor should be removed. Early operations in these cases have furnished the best results, delayed operations the reverse.1 In cystic tumors the likelihood of twisted pedicle should be remembered, and in every case of child-birth complicated by a newr growth the woman should be watched with extraordinary care to detect the first indication of trouble. An exploratory abdominal incision should be made, as a rule, only when it is desired to determine if a pelvic mass, presumably containing pus, is situated within or without the peritoneal cavity, and if the abscess had better be evacuated through the abdominal cavity or extraperitoneally. In the early period of experimentation with abdominal section for puerperal sepsis I have made exploratory incisions in obscure cases without any local symptoms of inflammation in the pelvis or the abdomen, and I have seen a number of such operations in the hands of others. None of these operations yielded information of value, 1 The most desperate cases, however, need not be despaired of. I have successfully removed a gangrenous ovarian cyst from a puerpera who was so weak that complete anesthesia was not attempted. The late Dr. Goodell had declined the operation as necessarily fatal. 688 PATHOLOGY OF THE PUERPERLUM. nor did they benefit the patients. Consequently, it is a safe rule not to open the abdomen of a puerpera for sepsis unless there are physical signs of inflammation in the abdomen or the pelvis. Following these general statements in regard to abdominal section for puerperal sepsis, it is now more convenient to describe in detail the different kinds of operations required for the various forms of intra-abdominal septic inflammations. Abdominal Section for Intraperitoneal Abscesses and Diffuse Suppurative Peritonitis.—The situation and extent of localized suppuration within the abdominal cavity vary greatly. A quarter of the abdominal cavity may be filled with pus, the huge abscess-cavity being thoroughly walled off by dense exudate from the rest of the abdominal cavity. A smaller accumulation of pus about the orifice of the tube is not uncommon. In one of my cases two or three abscesses the size of an orange were found in coils of intestine quite far removed from one another, and with- out apparent connection with the genital tract. In three cases abscesses were found between the fundus uteri and adjoining structures—the abdominal wall near the umbilicus in one, the caput coli in the second, and the sigmoid flexure in the third. In these cases infection had traveled through a sharply-defined area of uterine wall and had appeared in the same limits on its peritoneal investment. Exudate and adhesions immediately walled off the infected area, with the result of an encapsulated abscess between the uterine wall and the structure nearest to it at the time of inflammation. The treatment of these abscesses consists of their thorough evacuation, the cleansing of the cavity, and drainage. The cleansing may be effected by flushing with hot sterilized water, if the rest of the abdominal cavity can be guarded from contamination. In some cases the writer has avoided irrigation and in its place has thoroughly dried the cavi- ties with gauze with good results. For drainage, as a rule, sterile gauze will usually be found best. In certain cases of abscesses near the abdominal walls a rubber tube answers better than the gauze, and in deep-seated abscesses on the base and the back of broad ligaments vaginal drainage by means of gauze or rubber tube is much to be preferred. If the work during the operation is well done, there may be little or no subsequent dis- charge, and douching of the abscess-cavities during convalescence is uncalled for. Occasionally, however, if the abscess-cavity is very large and well isolated, daily douching with sterile hot water is an advantage. In diffuse suppurative peritonitis the remote chance of success depends greatly upon the earliest pos- sible operation, though there are many virulent cases in wThich PUERPERAL SEPSLS. 689 nothing could check the spread of the inflammation and the deadly effect of septic absorption. This is not the place to discuss the symptoms of diffuse sup- purative peritonitis, but one fact should be insisted upon from the operator's point of view. It is usually supposed that true diffuse suppurative peritonitis appears early after delivery ; it may, however, develop at any time. I have seen it as late as four weeks after confinement. The woman, who had been up and about for some time, lifted an older child down a few steps. The effort squeezed a few drops of pus out of one of the tubes. The abdomen was opened within twenty hours, but to no purpose. The technic of the operation is simple : A small incision is made, and the finger is rapidly swept about the pelvis and abdomen to determine the condition of the organs ; then the irrigating tube is passed into the cavity at the lowest angle of the wound, and is swept about in all directions, while the return-flow is provided for by two fingers of the left hand distending the sides of the wound, which by the fingers and the irrigating tube is kept gaping as though by a trivalve speculum. Gauze and glass-tube drainage into the pouch of Douglas and a gauze drain in the flanks is provided for, and the wound is left open, or, at most, drawn together by a stitch or two. Rapidity of operation and the smallest possible quantity of anesthetic are essential to success. Salpingo-oophorectomy for Puerperal Sepsis.—An acute pyo- salpinx in the puerperium is very rare. It is uncommon for acute septic infection after labor to travel by the tubes alone. Infection usually occurs in the uterine muscle, the veins, the lymphatics, or the connective tissue of the pelvis. When the track of the septic inflammation is confined to the mucous mem- brane of the genital tract, the pelvic peritoneum, in a case serious enough to demand operation during puerperal convalescence, becomes infected, inflamed, and suppuration quickly follows, so that the operation is usually performed for an intra-peritoneal pelvic abscess. The tube may be found somewhat swollen, inflamed, and containing a few drops of pus, and its removal is required; but the pyosalpinx is a subordinate feature in the pelvic inflammation. It is the more subacute case, not usually requiring operation in the conventional period of the puerperium, that results later in a typical uncomplicated pus-tube. Ovarian abscess is more common than pyosalpinx. The writer has seen the infection travel to the ovary, both by the tube and by the connective tissue or lymphatics of the broad ligament. In the latter case the whole ovary may be infiltrated with a thin seropus of a particularly virulent character, and, 44 69O PATHOLOGY OF THE PUERPERIUM. unfortunately, in excising the ovary the exposure of the infected pelvic connective tissue in the stump may lead to infection of the peritoneal cavity and to a diffuse suppurative peritonitis. The commonest indication for salpingo-oophorectomy is fur- nished by a pus-tube antedating conception. The strain of labor excites a fresh outbreak of inflammation or leads to its spread, and the persistence of septic symptoms with the physical signs'of pelvic inflammation justifies operative interference. In one exceedingly instructive case under my charge an operation was performed on a presumptive diagnosis of old pus-tubes, the diagnosis being based mainly upon the patient's history and the existence of serious septic symptoms, with tender- ness on abdominal palpation over the region of the tube and ovary. The uterus was much too high in the abdominal cavity to permit of a satisfactory pelvic examination of the uterine appendages. On opening the abdomen, a pyosalpinx was found. The patient recovered. There is often nothing peculiar in the technic of these opera- tions. They differ, usually, in no respect from similar operations upon non-puerperal patients. The question of removing the uterus along with the tubes will, however, arise rather more frequently than in the non-puerperal woman, on account of the infection of the endometrium or of persistent metrorrhagia. But in associated suppurative salpingitis, ovaritis, and infection of the connective tissue of the broad ligament, there is a modifi- cation of the ordinary technic, which is of vital importance. The tubes and ovaries should be excised, the blood-vessels of the broad ligaments tied separately; the cut edges of the broad ligament should be allowed to gape ; the whole pelvic cavity should be filled with gauze and drained by a glass tube placed just posterior to the uterus. The tube is sucked out by a syringe at the end of twenty-four hours. Twenty-four hours later the gauze is removed, the tube again sucked out and removed, and replaced by a rubber drainage-tube, through which the pelvis is washed out daily with sterile water. I have lately saved several cases of the most desperate character by this technic. Hysterectomy for Puerperal Sepsis.—The latest development in celiotomy for puerperal sepsis is the removal of all the pelvic organs and structures that can be removed when the septic inflammation or suppuration involves the uterine muscles and the broad ligaments. Every physician wrho has seen many cases of puerperal infection during operations or postmortem is aware that there are some in which the mere removal of infected tubes and ovaries or the evacuation of pelvic abscesses can not be PUERPERAL SEPSLS. 691 expected to save the patient. There would be left behind areas of infected and infiltrated broad ligaments that would commu- nicate infection to the peritoneal cavity, or there would remain foci of suppuration or infection in the uterine body that must surely spread to the peritoneum or must result in septic metas- tases. The only hope for the patient in such cases lies in the entire removal of all infected areas, leaving behind in the pelvis a healthy, non-infected stump. To effect this result the excision of the uterus, the broad ligaments, the tubes, and the ovaries is required. In addition to these cases there are others in which, if the tubes and ovaries must be excised, the uterus might be removed with advantage, on account of an infected endometrium or of persistent metrorrhagia. Figure 490 is an example of such a case. The young woman from whom the specimen was re- moved had a double pyosalpinx following a criminal abortion. For seven weeks she had been bleeding persistently, and at Fig. 490. —Hysterectomy for purulent salpingitis (author's case). intervals had a foul-smelling discharge. Although the body of the womb was healthy and the endometrium alone was inflamed and infected, it was obviously wiser to remove at once all source of the trouble rather than to excise the tubes and ovaries and then to treat separately at some trouble and risk an organ that had become entirely superfluous. The result justified the pro- cedure. There may also be such wide-spread suppuration and disintegration of the broad ligaments, along with tubal inflam- mation, that the complete removal of all the infected area is more easily accomplished, especially as regards the control of hemorrhage, by a hysterectomy. Figure 491 represents such a case. In this woman a pyosalpinx antedated conception. Labor excited fresh inflammation. The infection spread from the tube downward through the connective tissue of the broad ligament, resulting in a partial destruction of it, in a thick infiltration at its base, and in an abscess between its layers, closely hugging the 692 PA THOLOGY OF THE PUERPERLUM. whole of one side of the uterine body. It was obviously impos- sible to remove the infected area here without removing the womb as well. The operation, though undertaken under the most discouraging circumstances, was successful. There can be no doubt as to the necessity of hysterectomy Fig. 491.—Suppurative cellulitis of broad ligament; hysterectomy (author's case). in such a case as that represented in figure 492. There were abscesses in the uterine wall, directly under the peritoneal en- velope, about to break into the peritoneal cavity ; one, indeed, did rupture during the operation. There was a septic ulceration at the placental site so nearly perforating the uterine wall that by a Fig. 492.—Suppurative and ulcerative metritis, salpingitis ; hysterectomy (author's case). light touch during the operation the forefinger passed into the uterine cavity. There was also a pyosalpinx in this case that, judging by the history, antedated or was coincident with impreg- nation. The operation saved the patient. In another success- ful hysterectomy for puerperal sepsis, the author found the womb PUERPERAL SEPSIS. 693 completely ruptured at the fundus from tube to tube. The diag- nosis of the injury had not been made. The operation was undertaken some weeks after labor, for what was thought to be an intraperitoneal abscess. Areas of suppuration were dis- covered, but the greater bulk of the inflammatory mass was exudate wrhich had shut off the general peritoneal cavity from infection through the gaping uterine wound. Indications for the Operation.—The indications for hysterec- tomy during puerperal sepsis are furnished by the condition of the pelvic organs when they are exposed to sight and touch after the abdomen is opened. The four cases described above are the types calling for hysterectomy. It is not often possible to deter- mine upon hysterectomy before the abdomen is opened, but it should be remembered that in any abdominal section for puer- peral sepsis hysterectomy may be necessary. The careful ob- stetric surgeon, therefore, should be provided with the implements Fig. 493.—Suppurative ovaritis (rear view). required for amputation of the womb in every abdominal section for puerperal sepsis, and should be prepared to remove the womb for any one of the four indications described above, but should rest content with the least radical measure that promises his patient safety. The operation that is quickest done and shocks the patient least is most successful, provided, of course, that it is adequate. Technic of the Operation.—There are two points in which the technic of hysterectomy for puerperal sepsis may differ from the technic of the operation performed for other conditions. One of these points is the necessity often of doing pan-hysterectomy ; the other is the necessity often of tying the ligatures in a broad ligament much thickened by inflammatory exudate or by ligating the blood-vessels separately so as not to include an infected mass in the ligature. The author's preference is strongly for amputation of the uterus, leaving as little cervix as possible, and this he always does 694 PATHOLOGY OF THE PUERPERLUM. unless an examination of the cervix by a speculum shows septic ulceration or exudate upon it or in its canal. The reasons for this preference for amputation of the womb over pan-hyster- ectomy are that the former can be done more quickly, there is not the same anxiety about the cleanliness of the vagina, and the suture material is more certainly guarded from infection afterward. The thickened broad ligaments are often a source of serious embarrassment in placing and tying the ligatures around the uterine arteries. There is this difficulty to contend with in the majority of the operations. In two of my cases the inflamma- tory exudate within and below the ligature broke down into pus, but in both cases an incision in the posterior vaginal vault evacuated the pus and secured an immediate disappearance of somewhat alarming symptoms. In one case it was necessary to do this as late as four weeks after the hysterectomy. Vaginal hysterectomy is, in my opinion, usually unsuitable for cases of puerperal sepsis on account of the danger of clamping large masses of infiltrated and infected broad ligament. Exploratory Abdominal Section for Puerperal Sepsis.—An exploratory incision should be made only in cases of suspected extraperitoneal pelvic abscess, to confirm one's suspicion, to be certain that none of the pelvic organs, especially the tubes, are diseased, and to determine the best situation for the incision that shall evacuate the abscess-cavity without contaminating the peritoneal cavity. This rule of practice would exclude ex- ploratory abdominal section in cases with no physical signs of pelvic inflammation, but in which there is evident septic infec- tion of a nature difficult to determine. There are possible ex- ceptions to the rule, however, as in the case described on page 691, of suspected pyosalpinx without physical signs, owing to the high position of the recently emptied womb and of its appendages. Figure 494, drawn from life, represents a typical case requir- ing exploratory abdominal section. The woman had a miscar- riage some weeks before my first visit to her. She had lost over thirty pounds in weight, was bedridden, had night-sweats, high fever, profound prostration, and exacerbations of pain in the pelvis. On examination, the usual symptoms of extra- peritoneal pelvic exudate and suppuration were found on the right side. When the abdomen was opened, it was found that all the pelvic organs and the pelvic peritoneum were per- fectly healthy. There was a large collection of pus between the layers of the right broad ligament, giving to this structure a dome-shape. The tube and ovary running over the top of the PUERPERAL SEPSLS. 695 distended broad ligament were perfectly healthy and without a trace of adhesion or inflammation of any kind. With the abdo- men opened it was easy to locate the level of the anterior dupli- cation of the peritoneum. A mark was made on the skin an inch below this point, the abdominal wound was closed, an inci- sion was made in the groin, as shown in the drawing, and the pus washed out by douching. Sinuous tracts of suppuration were found by the finger running up the psoas muscle and down into the floor of the pelvis. Two drainage-tubes were inserted, one upward into the psoas muscle, the other downward into the pelvis. In the course of this woman's convalescence it was Fig. 494.—Exploratory abdominal section ; incision in groin for extraperitoneal abscess (author's case). found advisable to make a counteropening in the right lateral fornix of the vagina, and to pass a drainage-tube through from the opening in the groin to the vagina. In this way perfect drainage was established, and the patient made a good recovery. Cases of true extraperitoneal pelvic abscess due to puerperal infection, and without intraperitoneal inflammation, are rare. There are some gynecologists who deny their existence, but the writer has had four cases under his charge in which the diagnosis was established by abdominal section. 696 PATHOLOGY OF THE PUERPERIUM. The Morbid Anatomy and Clinical History, the Diagnosis and Treatment of the Different Forms of Infection and Septic Inflammation of the Genital Region After Labor.—The mani- festations of puerperal sepsis differ with the various infecting bacteria that are lodged in the genital tract or have invaded the system, but especially with the organs or structures that are involved in the septic inflammation. The terms, therefore, ■"puerperal infection," "puerperal sepsis," or "puerperal fever," are generic in significance and include in effect a number of dis- tinct diseases, widely different in their symptoms, their prognosis, and their requirements for treatment. The lesions of puerperal sepsis may be found in the mucous membrane of the genitalia from the vulva to the abdominal orifices of the tubes, in the mucous membrane of the bowel and of the urinary tract, the Fig. 495.—Streptococcus and staphylococcus infection of the endometrium: a, Necrotic layer of the endometrium; b, zone of inflammatory reaction; c, gland spaces ; d, blood-vessels; e, remnants of glandular epithelium (Bumm). parenchyma of the uterus, the pelvic connective tissue, the peri- toneum, the lymphatics, the veins, and in the parenchyma of the ovaries. Neighboring organs and tissues may be involved secondarily, as the bowels, ureters, and pelvic nerves, and tumors of the pelvis and abdomen, if they exist, may be the starting- point of septic infection and inflammation. Encolpitis, Endometritis, and Salpingitis.—These inflamma- tions are most often of the superficial suppurative variety, in which the prognosis is good, except in the case of the tubes, whence the inflammation may extend to the peritoneum, causing diffuse peritonitis or a circumscribed abscess near the fimbriated extremities, usually involving the ovary, or a pyosalpinx. The diphtheric inflammation of these membranes with an PUERPERAL SEPSIS. 697 exudate and necrosis of tissue is less common and much more dangerous. It may be localized in the vagina in the shape of ulcers near the orifice or extending up the wall to the cervix. It may be diffuse, occupying the whole interior of the uterus in the shape of a yellowish-green, foul-smelling exudate, in which streptococci, the bacillus pyocyaneus, the bacillus fcetidus, and the staphylococcus pyogenes albus may be found. In rare in- stances the Klebs-Loffler bacillus will be discovered in the pseudomembrane, showing that the case is one of true diphtheria, and the diphtheria of the vagina may be associated with diph- theria in the throat.1 If the diphtheric inflammation affects the lower portion of the vagina, there will be edema of the vulva in at least two-thirds of the cases. Diagnosis.—The diagnosis of these inflammations is made in the cases of vaginitis by inspection, in salpingitis by a combined examination, and in endometritis usually by the character of the lochia, or by inspection of the cervical canal, which may be lined with the same exudate that covers the endometrium. The diag- nosis between pseudodiphtheric membranes and true diphtheria can only be made by a bacteriological examination. It is most important that this should be done, for cases of true diphtheria should be isolated. The treatment of these inflammations consists in frequently repeated irrigations of the whole genital tract. The best mate- rial for this purpose is sterile water without any antiseptic agent, which latter will simply diminish the resisting power of the body-cells without destroying the micro-organisms that are the cause of the inflammation. In case of septic endometritis the systemic symptoms will be grave, and a supporting, stimu- lating treatment is required in addition to the local treatment. In salpingitis a celiotomy may be demanded. If the inflamma- tion is localized and the inflamed area accessible, it should be touched with a nitrate of silver solution, 5j-5j- Metritis and Cellulitis of Subcutaneous and Pelvic Connective Tissue; Septic Metritis.—As a later stage of septic endometritis, usually of the diphtheric variety, but possibly of the suppura- tive, all the structures of the womb may be involved—connective tissue, muscles, lymphatics, and often the veins, especially, how- ever, the first. In the process of the inflammation portions of the uterine muscle may be undermined by ulceration and may slough off (dissecting metritis). A limited area of uterine tissue may be involved, not larger in circumference, perhaps, than a 1 J. W. Williams, five cases, loc. cit., to which should be added one of my own, with diphtheria of the throat in the husband and true diphtheria of the vagina in the wife, demonstrated by bacteriological examination. 698 PATHOLOGY OF THE PUERPERIUM. dollar. The inflammation extends directly through the uterine wall, still confined within its original limits, until the peritoneal covering is reached. Here the inflammatory process is also strictly limited by the rapid development of adhesions which bind the womb to those structures in the peritoneal cavity near- est the diseased area. I have seen four examples in which the uterus was anchored to the caput coli, the anterior abdominal wall, and the sigmoid flexure. In these cases involution goes on imperfectly, of course, for the womb can not be normally re- duced in size, held as it is at a high level in the abdominal cavity by adhesions. There are, however, besides the fixation and arrested involution of the womb, no other local evidences of inflammation, excepting some tenderness on pressure. It is usually impossible to locate the intraperitoneal abscess, by abdominal palpation or combined examination, on account of its situation. The course of these cases is slow, but they are ultimately quite certain to be fatal, for an abscess commonly de- velops on the diseased area of uterine surface between the uterus and the structures attached to it, usually the bowel or omentum. A bacteriological examination of some of these cases has shown the presence in the uterine wall of pyogenic staphylococci. If the pelvic connective tissue is in- volved, it is at first edematous. The liquid is then absorbed, leaving a dense infiltrate, if there has been much cell- proliferation, or entirely disappearing if the cell-element is scanty. The infiltrate, if not too extensive, is likewise absorbed in about four-fifths of all cases. Occasionally, however, in about one-fifth of the cases an abscess results, which may be opened above Poupart's ligament, or through the vaginal vault without entering the peritoneal cavity, but which may rupture into the abdominal cavity, or may perforate the rectum, bladder, vagina, or uterus. In cases of cellulitis from diphtheric or erysipelatous inflam- mation the edema rapidly becomes seropurulent, in the former case the inflammation rapidly becoming diffuse, in the latter possibly being limited. Fig. 496. — Dissecting metritis. Specimen expelled by B. R---- at the New York Maternity Hospital on October 20,1883,the twenty- sixth day after confinement. This was the eighth case of the report published in the "New York Medical Rec- ord," vol. xxiv, p. 664 (Gar- rigues). (The figure is two- thirds natural size.) PUERPERAL SEPSLS. 699 Diagnosis.—The diagnosis of metritis is very difficult to make. The womb is large in size, the walls feel boggy, and the uterus is very sensitive to pressure ; but it is almost impos- sible to be positive that metritis exists unless one can feel an abscess in its walls by an intra-uterine examination, or unless the collection of pus breaks into the uterine cavity. If the abdomen must be opened for the septic infection, the condition of the womb is, of course, easily determined. Ab- scesses may be seen in its walls, and ulceration may so nearly perforate them that wiien the operator's finger is laid upon the peritoneal covering of the womb, it penetrates at once into the cavity. The diagnosis of pelvic cellulitis is usually easy to establish. The exudate and infiltration can be felt on a vaginal examination. It is usually, however, impossible to decide whether the inflam- mation is limited strictly to the pelvic connective tissue, or whether the pelvic peritoneum is also involved. If the exudate is situated only upon one side of the womb and does not involve Douglas' pouch, one has the right to suspect pelvic cellulitis without pelvic peritonitis, but in my experience it has always been necessary to open the abdomen before obtaining a positive answer to this question. Treatment.—Occasionally, septic metritis will end in recovery by the discharge of pus-collections into the uterine cavity, or by the resolution of inflammation. The worst cases of the kind, however, will demand the performance of hysterectomy. Cellu- litis will yield in the majority of cases to rest in bed, counter- irritation, poultices over the lower abdomen, and hot vaginal douches. If it fails to do so, an abdominal section should be performed, in order to be sure that the peritoneum is not in- volved. If the inflammation is found, after the abdomen is opened, to be confined strictly to the pelvic connective tissue, the abdominal wound should be closed, and the infected area, if it has suppurated, should be opened by an incision above Pou- part's ligament, or through the vaginal vault. Pelvic Peritonitis and Diffuse Peritonitis.—Pelvic peritonitis is the result of the extension from a suppurative or diphtheric endometritis, either through the tubes or by extension directly through the tissues of the womb, or it follows pelvic cellulitis, the germs penetrating the peritoneum between the endothelia or through the lymphatic interspaces. In an extension through the tubes or by the spread of a cellulitis the ovary is likely to be involved, and an ovarian abscess will develop. A leakage of lochial or catarrhal discharge through the abdominal orifice of the tubes is by no means uncommon. It is followed by a sharp 700 PATHOLOGY OF THE PUERPERIUM. localized peritonitis, though it is not certain that the discharge is always septic. It may be simply irritating. The infected or irritated region may be surrounded by large areas of peritoneal exudate, thrown out as a barrier against the spread of the offend- ing substances. A large section of the abdominal cavity, one- fourth or more, may be thus, as it were, solidified. On palpation, the abdominal contents feel hard as stone, with the muscles of the abdominal wall involuntarily fixed over them for protection, on account of great sensitiveness to pressure. Occasionally, the exudate communicates to the finger a sensation as though snow were being kneaded through a covering of some flexible material. The symptoms are not alarming, and the common termination of this kind of peritonitis is recovery. The exudate is absorbed, the tenderness disappears, the temperature sinks to normal, and no ill-effects are left behind ; but the exu- date may break down and encapsulated abscesses may thus be formed, opening into the bowel, into the bladder, through the abdominal walls at the umbilicus, or possibly Undergoing caseous changes. General peritonitis after labor may result from an exten- sion of pelvic peritonitis ; from infection through rents in the vaginal or uterine walls ; from the rupture of old pus-collections in the tubes or elsewhere in the pelvis ; from putrefaction of tumors in the pelvis, as of dermoids and fibroids ; from the transmission of infecting germs by the lymphatics, and from the extension of septic inflammation through the bladder-walls. If the suppurative peritonitis is not limited, the intestines are lightly glued together; are bathed in a thin pus, which lies in pools between their coils ; are covered with a yellowish exudate, which can be stripped off, leaving a raw, bleeding surface. There is a form of septic peritonitis so virulent and poisonous that no signs of inflammation accompany it, and the patient dies before pus or exudate can be formed {peritonitis lymphatica). The abdomen is found, after death, filled with a dirty fluid, composed of serum, some blood, and numberless micrococci. In all forms of septic peritonitis the coats of the intestines are paralyzed and tympanites is marked. Diagnosis.—The diagnosis of pelvic peritonitis is made by the general symptoms and by the local physical signs. There is fever of varying degrees, with accelerated pulse and general depression. There is marked tenderness over the lower ab- domen, and there is tympanitic distention of the abdomen. On making a vaginal examination exudate is found in Douglas' pouch and to the sides of the womb, which is firmly fixed. The PUERPERAL SEPSLS. 701 exudate is usually exquisitely sensitive to pressure. It is some- times firm and hard, and, again, may be soft and boggy. If the latter condition persists, it is indicative of suppuration. General peritonitis is usually sudden in its onset and very rapid in its course. It occurs ordinarily in the first few days of the puerperium. There is extreme distention of the abdomen ; a rapid, running, wiry pulse ; an extremely anxious, pinched expression of the face ; a peculiar grayish color of the skin, and, perhaps, high fever, agonizing pain, and possibly dullness on percussion at certain points in the abdominal cavity ; but the latter signs may be en- tirely absent. There may be absolutely no tenderness nor pain, no dullness, and very little fever. I have seen most malignant cases end fatally within forty-eight hours from the first appearance of symptoms, with a temperature never exceeding 100y° by the mouth, though the rectal temperature is often much higher. Day of Disease 103° 102° 101° 100° 99° M E M E M E M E M £ M E M £ ^ "* «* • Fig. 497.—Temperature-chart of diffuse purulent peritonitis. Treatment.—It is difficult to determine at first whether a pelvic peritonitis will end in suppuration or resolution. As the latter is always possible, the treatment should at first be expec- tant. Counterirritation and poultices may be used over the lower abdomen ; the bowels may be thoroughly drained by a strong purgative, so as to diminish intra-abdominal congestion and inflammation, and copious hot vaginal douches may be given. If the symptoms persist much beyond forty-eight hours in their original intensity under this form of treatment, suppuration has probably occurred, or must be expected. In such a case the abdomen should be opened. Abscesses, if they are found, must be evacuated and the cavities thoroughly cleaned, disinfected, and drained. Distended tubes and ovaries must be removed, and it may be necessary to perform hysterectomy. 702 PATHOLOGY OF THE PUERPERIUM. General, diffuse, suppurative peritonitis is almost invariably fatal, let the treatment be what it may. The only possible chance for such a case is in the earliest possible performance of an abdominal section with free irrigation of the abdominal cavity; but even though this be done within twelve hours of the onset of symptoms, it will almost invariably be of no avail. Once in a long while, however, a case of true diffuse suppurative peritonitis may be saved by a timely operation, as I know by personal experience. I am, therefore, in favor of surgical intervention in these cases, although the surgeon should protect himself by in- forming the family of the comparatively hopeless nature of the case. Uterine and Parauterine Phlebitis.—The veins of the uterus and of the surrounding connective tissue are prone to thrombosis by reason of the sluggish circulation, the pres- sure during pregnancy, and the altered con- stitution of the blood in a puerpera. The clots, when formed, may become directly infected, usually at the placental site. They may then become disintegrated and swept into the circulation, producing pyemia, or the veins may become infected from passing through a septic region. Then the walls are first involved, the blood clots, and per- haps thus opposes the further spread of the process. Or, more likely, the clot is in its turn infected, disintegrated, and carried into the larger venous trunks. In the course of the inflammation clots may become dis- lodged or vessel-walls may be perforated and a most serious hemorrhage may result. Repeated bleedings may occur at short or long intervals. This form of septic infection is least likely to produce peritonitis or local inflammation in the pelvis, but is most likely to produce pyemia. If infected emboli are swept into the circulation, they may find lodgment in many different parts of the body, producing abscesses in the abdominal viscera, the eyeballs, the brain or spinal cord, the lungs, the pleura, or in the subcutaneous con- nective tissue at any portion of the body-surface. I have seen, for example, the whole anterior portion of the left leg and the right forearm riddled with the abscesses of suppurative cellulitis in the course of a case of puerperal phlebitis. Fig. 498.—Clots in sinuses of uterine walls (from specimen in the Army Medical Museum, Washington, D. C). PUERPERAL SEPSIS. 703 *^ . *• ^ ■v>\5 iSfeft.*5*!®.- Fig. 499.—Section through the placental site of a puerpera who died on the eighth day from embolic pneumonia (thrombotic form of infection) : a, Necrotic de- cidua, with colonies of streptococci and saprophytes ; b, thrombus in a vein opening at the placental site ; c, zone of inflammatory reaction ; d, section of a uteroplacental artery ; e, muscular tissue ; f. continuation of the thrombus, b, in which colonies of streptococci are softening and breaking down the clot (Bumm). Fig. 500.—Section of the endometrium in phlebitis and septic thrombosis : a, Ne- crotic decidua; b, zone of inflammatory reaction ; c, muscular tissue (Bumm). 704 PATHOLOGY OF THE PUERPERIUM. The thrombosis in a puerpera is not always limited to the veins of the uterus and of the pelvis. I have observed, for example, a fatal case, death occurring on the seventeenth day postpartum, preceded by convulsions and coma. It was not known whether the woman had had fever after delivery. In the postmortem examination the longitudinal and lateral sinuses of the brain were found perfectly solid with thromboses. There had been a very severe postpartum hemorrhage, and there were evidences in and about the womb of septic phlebitis. Fig. 501.—Softened thrombus from the placental site in a case of pyemia: a, Uterine muscle ; b, vein wall infiltrated with cells, the endothelium becoming necro- tic ; c, the thrombus infiltrated with masses of streptococci and beginning to disinte- grate (Bumm). An almost constant accompaniment of uterine and pelvic phlebitis is phlegmasia alba dolens. Diagnosis.—The characteristic signs of uterine and pelvic phlebitis are: a high, irregular, and long-continued fever; profound depression and great rapidity of pulse, with an entire absence of all local symptoms of septic infection or of septic inflammation. The womb is normal in size, is freely movable, and involution goes on uninterruptedly. There is no tenderness, no tympany. Any interference with the uterus, as in an attempt to disinfect its cavity, will give rise to exacerbation of the fever and may cause a serious hemorrhage. The woman's face is apt to show a PUERPERAL SEPSLS. 705 dusky flush on one or both cheeks, and red splotches appear on other parts of the body, especially upon the chest. In the course of the disease evidences of pyemia may appear, and phlegmasia alba dolens will almost surely develop, either as the predominant symptom or as a mere incident in the course of the disease. Treatment.—The treatment of phlebitis should consist of a Day of Disease ** ^j <^ * S^w H *4 <5 H t': i. '■ l; « VO ^ ^T?3 ; ^ 4 ,]A <% ^ * 4 u . v*f' \/: Fig. 502.—Case of phlebitis in which there was a sharp rise of temperature after two attempts to disinfect the birth-canal. Fig- 503.—A case of phlebitis. Twice the temperature rose above 1070 ; this seemed to be the result of an intra-uterine douche following directly after it. Recovery. preliminary disinfection of the uterine cavity. In a perfectly typical case this will prove unnecessary or even harmful, but it is so difficult to determine whether there remains in the womb or not some infecting material, that the risk of doing the patient some damage should be incurred in order to escape the serious 45 706 PATHOLOGY OF THE PUERPERLUM. error of leaving in the womb material which, if not removed, may result in the patient's death. The successful treatment of the phlebitis itself will consist of absolute rest and stimulation. Enormous quantities of alcohol may be used with advantage, and as much food of an easily digested character should be administered as the patient can assimilate. The vast majority of these cases will end in recovery, but the disease may run a course of weeks or months. Phlegmasia Alba Dolens, or Milk=Ieg.—This condition receives its name from the appearance that the leg presents, and from the old idea that most of the inflammatory conditions of the puer- perium were due to a metastasis of milk. There are two distinct classes of cases of phlegmasia after delivery. In one there is an occlusion of the veins of the pelvis and of the lower extremities, interfering with the circulation and leading to an intense edema. The leg is enormously swollen ; the skin is tense, glistening, and milk-white in color. The swelling is so great that the skin does not at first pit on pressure. In the other class of cases there is a septic inflammation of the connective tissue of the pelvis and of the thigh, the infection spreading from the perineum or from the deeper pelvic fascia through some of the larger foramina of the pelvis. Cases of the first class—thrombotic phlegmasia—are much more common than those for the second—cellulitic phlegmasia. Thrombotic phlegmasia should be also divided into two classes. In one the thrombosis is primary, and is due to the pres- sure to which the blood-vessels are subjected during pregnancy, to extensions of thrombi from the uterine sinuses, to stagnation of the blood-current. In the other there is a septic inflammation of the blood-vessel wall, leading to secondary thrombosis. The clinical manifestations are quite distinct in the two kinds of cases ; in the first there is little fever and few systemic symp- toms ; in the second the fever is high and the systemic symp- toms grave, but one often sees the first pass into the second by an infection of the blood-clot. Symptoms.—Usually from the tenth to the thirtieth day1 there develops a heaviness and stiffness in the leg, with pain, especially in the calf of the leg, soon followed by swelling, beginning at the ankle and gradually ascending to the groin, if the phlegmasia is due to thrombosis of the veins ; or at Poupart's ligament or the buttocks, extending down the thigh, if the condition is due to a septic inflammation of the connective tissue. In the former case there is very likely to be tenderness along the course of the femoral vein, which may also be marked by a line of inflam- 1 Phlegmasia may antedate labor, and I have seen it make its appearance seven weeks after delivery. PUERPERAL SEPSLS. 707 matory redness. Other superficial veins may be likewise affected, and may appear as red streaks under the skin. The lymphatics may also be involved, and may be thickened and reddened. There is almost always slight fever, which usually precedes the swelling of the leg and disappears commonly long before the swelling subsides. There is also gastric and intestinal disturb- ance, with a foul tongue, loss of appetite, nausea, and vomiting. There is profound physical depression, sometimes with great restlessness and sleeplessness. There is often a dusky flush upon one or both cheeks. Phlegmasia is a very frequent complication of septic phlebitis, in which disease it may occur as a mere incident, the swelling of the leg appearing, perhaps, during the height of the septic fever, lasting a comparatively short time, and disappearing entirely long before the subsidence of the other symptoms of the septic infection. The left leg is more frequently affected than the right. Occasionally, one leg is involved after the other, and possibly they may both be swollen at the same time. Frequency.—Phlegmasia is a comparatively rare disease. There are many general practitioners in active practice who have not seen a case. I have in my possession the records of more than twenty-five cases that have occurred under my own obser- vation. The majority of general practitioners, therefore, may expect to encounter this condition once in a while. As already stated, the thrombotic variety of phlegmasia is very much more common than the cellulitic kind. Of my twenty-five cases, only one was of the latter sort. Causes.—The commonest cause of phlegmasia is a septic in- flammation of the blood-vessel walls, beginning at the placental site and extending through the pampiniform plexus down to the femoral vein, or upward through the spermatic vessels to the vena cava. In consequence of the inflammation of the vein-walls the blood clots in the vessel, and the clot extends even more rapidly than the inflammation of the vessel-walls. Occasionally, the thrombus is the primary occurrence. This is proven by those cases which develop before labor. In these instances the pressure of the pregnant womb upon the pelvic vessels, the stagnation of the blood-current, and the composition of the blood all conduce to the formation of extensive clots. But even if the primary occurrence is a thrombosis, the clot usually becomes infected in time ; so that almost every case of phleg- masia, some time in its course, is septic in its nature. It has been recently claimed by a German observer (Widal) that the throm- 708 PATHOLOGY OF THE PUERPERIUM. bus of the femoral vein after child-birth is to be explained by the presence of pathogenic micro-organisms in the blood, which fasten themselves upon the vein-wall in the region of Poupart's ligament, where the circulation is sluggish and stagnant, espe- cially when the woman first stands up, and is favorable, on this account, to the deposition of bacteria along the walls of the blood-vessel. This theory very likely has some truth in it. It would explain the occurrence of phlegmasia in the course of infectious diseases, such as typhoid fever and grip; and it would also explain the thrombosis of other vessels than those in the pelvis, as, for instance, of the sinuses in the brain. Prognosis.—The outlook in a case of phlegmasia is always somewhat doubtful ; the dangers are manifold. There may be pyemia from the detachment of a portion of an infected clot; abscesses may develop in the vessel itself, extending rapidly to surrounding structures until the thigh-muscles are dissected one from the other by an ulcerative process and the whole limb becomes infiltrated with a foul seropus. The circulation may be so interfered with that gangrene of the limb occurs, or the vena cava may be blocked up, practically cutting off the whole lower portion of the body from its blood-supply by preventing the return flow. Or, if there is only partial compensation for the obstructed circulation, there will be a chronic congestion of the limb, which will be permanently enlarged and stiffened, and will swell beyond its usual proportions if the woman is much upon her feet. The passive congestion, if long continued and exag- gerated in degree, may even result in the development of elephantiasis. Most to be feared of all is the detachment of a large portion of the thrombus and a consequent pulmonary embolism, with sudden death. The most favorable course in these cases is absorption of the thrombus and the restoration of the circulation through the obstructed blood-vessel. The next most favorable termination is a firm organization of the thrombus, the obliteration of the vein, and a satisfactory compensatory circulation by means of the gluteal vessels or through the epigastric veins. Treatment.—The most important features of the treatment may be outlined as follows : Order absolute quiet and rest flat upon the back in bed, in order to avoid embolism ; elevate the limb, in order to facilitate the return circulation as much as pos- sible ; wrap it in cotton, so as to alleviate the feeling of cold and numbness in it; and support the system by sufficient food and carefully regulated stimulus, as the disease is almost always asthenic in tendency. PUERPERAL SEPSLS. 709 When all symptoms have subsided, when the swelling has disappeared, and there is no longer the slightest tenderness along the course of the affected vein, the limb may be restored more quickly to usefulness by gentle friction and massage. The patient should not be allowed to leave her bed until about ten days after the complete subsidence of all symptoms, for fear of embolism, which is always possible until the clot has become absorbed or is firmly organized. In the cellulitic variety of phlegmasia the fever is much higher, the disease is more acute, and the inflammation more intense. There will be almost a certainty of suppuration in the connective tissue of the thigh. The first formation of pus should Fig. 504.—Hypertrophied and angiomatous mass of infected decidua at the placental site ; hysterectomy (author's case). be carefully watched for, so that the abscesses may be opened in time to avoid extensive burrowing. Extensive and multiple incisions may be required to evacuate the pus and to drain the diseased areas, even early in the course of the inflammation. Abscesses may also develop, in the phlebitic and thrombotic variety of phlegmasia, along the course of the femoral vein, in the popliteal space, or in the calf of the leg. Septicemia, Sapremia, or Putrid Absorption.—By these terms is meant the absorption into the system of ptomains or toxins generated by the putrefaction of hypertrophied decidua, shreds of membranes, blood-clots, pieces of placenta, or of the lochial discharge. This is, in my experience, one of the most common forms of 7IO PATHOLOGY OF THE PUERPERIUM. septic fever after child-birth. To produce it the germs of putre- faction—saprophytes—must gain access to the uterine cavity after labor, which they usually do if there is a pabulum in that situation on which they may feed. Occasionally, they are excluded from the uterine cavity entirely, in spite of the presence there of large * Fig. 505.—Putrid endometritis, sapremia : a, Layer of decidua with saprophytes; b, inflammatory reaction (Bumm). Fig. 506.—Section of figure 507, under greater power : a, Lymphatic vessels filled with streptococci; b, invasion of the muscle tissue by the micro-organisms, pro- ducing necrosis (Bumm). masses of putrescible material, as is proved by cases in which a fetal head remained in the uterus three months, a placenta seven months, without disadvantage to the patient. Sapremia is quite likely to appear late in the puerperium, when the woman begins to move about in bed or to get up, causing the vagina to gape PUERPERAL SEPSLS. J I I by the movements of her limbs, thus admitting air to the vagina and even to the uterine cavity. Of all the forms of septic trouble after child-birth, sapremia is the least dangerous and the easiest cured. It may, however, at Fig- 507.—Streptococcic infection of the decidua and lymphatics: a, Necrotic decidua; b, lymph-spaces; c, inflammatory reaction; d, lymph-channels, infected with streptococci; e, superficial layer of the uterine wall; /, peritoneal exudate, with streptococci on the peritoneal surface of the uterus (Bumm). any time develop into one of the forms previously noted, and should never be neglected. Symptoms.—Usually in the first three days after labor the temperature rises and the pulse is accelerated. The womb 712 PATHOLOGY OF THE PUERPERLUM. is found larger than it should be, and the lochial discharge has a foul odor. Often, however, sapremia may develop very late in the puerperium. There may be no foul odor whatever to the discharges, and the involution may appear to proceed naturally. Whenever there are general signs of septic intoxication after labor, without evidences of local inflammation extending to the uterine walls or beyond them, sapremia should be sus- pected. Treatment.—The treatment of this form of infection has been described in the general treatment of all forms of sepsis. It consists of the thorough disinfection of the parturient tract. The success of this treatment is, in the majority of cases, most gratifying. All symptoms, though most alarming, may dis- appear entirely within twenty-four hours. Septic Cystitis or Ureteritis; Pyelitis.—These inflammations may be of the superficial, suppurative variety, or they may be diphtheric with the formation of a pseudomembrane. In the latter case the exudate or membrane may extend from the bladder by the ureter to the pelvis of the kidney. There may be sloughing of the infected mucous membrane, putrefac- tion of the masses of membrane exfoliated, and extension of the inflammation through the bladder-walls to the peritoneum. The kidney may bear the brunt of the attack ; it may be riddled with abscesses, or converted into a large bag of pus. From contiguity with the liver on the right side, hepatic abscesses may also be found. Diagnosis.—The cystitis usually develops a few days after labor, with the ordinary signs of that affection—frequent and painful micturition, slight elevation of temperature, and tender- ness on pressure over the bladder. The symptoms may subside after a few days and the patient may appear to be in perfect health, but fever will return with added intensity, and all the symptoms of septic infection may appear to a most alarming degree. The urine contains large quantities of pus and mucus, and swarms with micro-organisms. There is very likely tender- ness on pressure over one or both kidneys, and there may be intense pain in the lumbar region. At this stage of the disease a stimulating treatment may enable the patient to survive the immediate attack, though she will probably be left with a chronic pyelitis that may impair her health for the rest of her life. She is, however, very likely indeed to die of the septic infection of the kidneys. Infection of the bladder should never be allowed to extend to the ureters and kidneys. On the first symptoms of vesical PUERPERAL SEPSLS. 713 irritation and inflammation after labor, the bladder should be energetically washed out and disinfected with a boric-acid solution, or possibly with a somewhat stronger antiseptic. This treatment usually stamps out the septic infection of the bladder mucous membrane in a few days, and there is no extension of the inflammation. Septic Proctitis.—This rare disease may occur in conse- quence of employing a badly infected syringe-nozle in the ad- ministration of an enema. It is only likely to occur in hos- pitals, and is extremely rare under any circumstances. I have seen one case. The inflammation may be of a superficial suppurative or catarrhal, or of a diphtheric character. The latter is almost certain to be fatal. The former may end in recovery. Degeneration and Putrefaction of Pelvic and Abdominal Tumors. —The cystic tumors of the pelvis and abdomen, usually ovarian cysts, show a disposition to twist upon their pedicles in the puerperium, and they may thus become gangrenous. Der- moid cysts are particularly likely to undergo degeneration. Solid tumors (fibroids), from the squeezing and bruising to which they are subjected in labor, and from their low vitality, are not unlikely to become gangrenous. The diagnosis of these cases is not difficult. The presence of the tumor should be recognized, and inflammation or degeneration in it must be sus- pected if the patient develops fever and the signs of sepsis after delivery. The treatment consists of the timely removal of the infected growths. If there is any elevation of temperature at all after delivery, the tumor should be removed at once, without waiting for indubitable evidence of degenerative changes in it. Tetanus.—This rare disease of the puerperium is due to an infection of the woman by the tetanus bacillus. This micro- organism may be conveyed to her by a dust-laden atmosphere, by actual contact with hands or implements that are infected with the germ, or by water that is muddy, containing a heavy sediment of soil. The proximity of the lying-in room to a stable was held accountable for the disease in one case. In Vinay's 106 cases the placenta was manually separated in 20, a tampon was inserted in 17. Heyse1 claims that a tetanus infection is always a mixed infection, and that the way must be prepared for the tetanus 1 " Ueber Tetanus Puerperalis," "Deutsche med. Wochenschr.," No. 14, p. 318, 1894. Other cases have been recently reported by Meinert, "Archiv f. Gyn.," Bd. xliv, p. 381; Maxwell, "Jour. Amer. Med. Association," xxxiii, p. 224; Irwin, " N. Y. Med. Jour.," p. 324, 1892. 714 PA THOLOGY OF THE PUERPERLUM. bacillus by a preceding pathogenic germ, causing a septic endo- metritis or some other pathological condition along the birth- canal. This theory is not supported by the three cases under my observation, in each one of which a most painstaking post- mortem examination, conducted by a skilled pathologist, failed to reveal any septic lesion of the birth-canal. The disease may break out at almost any time after confine- ment, but usually appears within the first two weeks.1 It runs a varying course, sometimes ending fatally within a few days, in other cases lasting a number of days or weeks before the symptoms become aggravated enough to permit of a diagnosis. The fever may be very high, may be quite moderate, or may be altogether absent until just before death. The prognosis is extremely grave; the mortality may be put at about 90 per cent.2 A curious mistake in the diagnosis of this disease has been brought to my notice on three separate occasions. In each of these cases occurring at quite long intervals of time, seen each by a different physician, the disease was taken for hysteria and was so treated for a number of days. The treatment consists of the administration of huge doses of the bromids and of chloral, with stimulants, and in a disin- fection of the birth-canal. If a reliable tetanus antitoxin could be procured, it might be advisable to try this remedy, though one of the cases treated with it in Philadelphia recently was appar- ently killed by the treatment rather than by the disease itself. Suppuration of the Pelvic Joints.—Any of the pelvic joints may suppurate by the extension of an infectious inflammation or by a metastatic infection. The symphysis is, however, most often affected, usually in consequence of some injury during labor, which lessens the resisting power of the joint. An early diagnosis of suppuration in this locality should be made, and as soon as the observer can convince himself that the joint contains pus it should be freely opened and thoroughly drained. The prognosis is fairly good. Ischiorectal Abscess.—Suppuration in the ischiorectal fossa may occur in consequence of injury to this region during labor. I have one patient in whom an ischiorectal abscess developed regularly after some four or five successive confinements. The 1 Vinay ("Du tetanos puerperal," "Archives de Tocol.," 1892, p. 791) col- lected 106 cases—47 after abortion, 59 after labor at term. After abortion the disease broke out in 21 cases during the first week ; in 16 during the second ; after labor in 19 cases during the first week; in 23 during the second. 2 Vinay found a mortality of 88.67 Per cent. In surgical cases the mortality has been 89.7 per cent. PUERPERAL SEPSIS. 715 diagnosis of the condition is easy, and its treatment consists of a free evacuation of the pus and in good drainage of the abscess- cavity. The Relation of Infectious Fevers to Puerperal Infection, especially of Erysipelas, Diphtheria, Scarlet Fever, and Malaria.—A woman after confinement is more susceptible to the infectious fevers than she is at other times. Her lowered vitality and perhaps the reception of the poisons of these diseases into the genital tract make the period of incubation shorter and the disease itself more Fig. 508.—Endometrium of a case of malignant internal erysipelas and septic perito- nitis : a, Necrotic decidua; b, muscular tissue (Bumm). violent in its manifestations and more fatal in its results. Thus, measles, a disease ordinarily of low mortality, becomes during the puerperium a deadly malady. It is therefore incumbent upon the practitioner of medicine to abstain from obstetrical work altogether, if possible, while in attendance upon cases of exanthematous fever or upon diph- theria. It is not sufficient for the physician to depend alone upon thorough disinfection of his hands and arms in such cases ; his hair, clothing, skin, and breath may convey the contagion to 7 16 PA THOLOG Y OF THE PUERPERIL'M. the puerpera, who will absorb it, perhaps, not only by the ordi- nary channels, as by the throat in diphtheria, but also by the genital tract as well. Thus, cases are reported in which a recently delivered woman had at the time diphtheric exudate containing the Klebs-Loffler bacillus upon the pharyngeal and upon the vaginal mucous membranes. If a physician can not escape the necessity of at- tending a woman in child-birth while in attendance upon conta- gious diseases, he should take a full bath, should change his clothing throughout, and should be as long as possible in the open air afterward before he sees his parturient patient. Erysipelas.—The connection of erysipelas with puerperal in- fection may be dismissed in a few words. Modern bacteriologi- cal research points to the identity of the streptococcus pyogenes and the streptococcus erysipelatis. The production of pus and internal inflammation or of an efflorescence upon the skin is simply a question of virulence and of situation. It is not surprising, '"vSV. . ■ '- .-" .-■'" """"■ -'-** - .7* ,...—. " ' _****t- Fig- 5°9-—Enlargement of a section of figure 508, showing streptococci. therefore, to hear of such experiences as those of Winckel, who has found germs in abscesses of the pelvis after labor that on inoculation produced erysipelas, and who has seen one of his nurses, after catheterizing a febrile patient, develop erysipelas of the face from a drop of the lochial discharge that splashed upon her nose. Other clinical facts are also easily explicable by the identity of the pyogenic and of the erysipelatous streptococci. In the course of puerperal infection, erysipelas may appear upon the labia and spread thence down the thighs or over the trunk. If the patient, on the contrary, contracts erysipelas in some portion of the body remote from the genitalia, as upon the breast or face, the disease may run its ordinary course without symptoms of infection of the genital tract and without great danger to life ; but if the infection spreads to the genitalia or has its origin there, the danger of death is great. Diphtheria.—The connection between diphtheria and epi- PUERPERAL SEPSIS. 717 demies of puerperal infection has been demonstrated beyond a doubt by a vast amount of clinical observation. To select a single example out of many : One of my young friends and former students lost two healthy women in a week from puer- peral sepsis while he was in attendance upon a child with diph- theria. He had never had a serious case of puerperal infection before, and he has not had one since. The Klebs-Loffler bacillus has been found in two cases of vaginal exudate under my notice in Philadelphia. As already stated, the mere disinfection of the physician's hands and arms is not enough to protect a woman against this malignant disease. Complete change of clothing, including the shoes ; a thorough soap and hot-water bath, with scrubbing of the hair, face, and exposed portions of the body ; brushing of the teeth, and gargling of the throat with an anti- septic wash, such as listerine, and a purification of the lungs by prolonged exposure in the open air, are precautions none too great or troublesome to clear one's conscience of the dreadful imputation of having destroyed the life that he is charged with preserving, if he must attend a woman in child-birth while he takes care of diphtheric patients. Scarlet Fever.—The connection between scarlet fever and puerperal sepsis is yet in doubt. Contrary to the opinion ex- pressed by some authorities, scarlet fever in the puerperium is rare. The comparatively frequent occurrence of septic erythe- mata has led many observers in the past to believe that scarlet fever is a common cause of septic infection after child-birth. The same rule obtains in the case of scarlet fever in the puer- perium that prevails in other infectious diseases during that period—namely, the woman is more susceptible to contagion, the period of incubation is shorter, and the disease is more dan- gerous than at other times. During pregnancy the woman is particularly resistant against the poison of scarlatina. She may carry about with her, while pregnant, the poison of the disease, and may only yield to it after child-birth. As going to prove that the poison of scarlatina finds an entrance into the body through the mucous membrane of the genital tract, it is inter- esting to observe that in the puerperium the rash is more marked upon the lower portion of the body, and that the throat symp- toms may be entirely absent or very slightly marked. Malaria.—The puerperal state excites almost surely a fresh outbreak of malaria that is latent in the system, even though it has been dormant for years. There is nothing to show that the woman is likely to contract the disease during the period of puerperal convalescence itself, but if she has ever had it in her 7 18 PA THOLOGY OF THE PUERPERLUM. past life, it will be practically certain to break out before she rises from bed. The differential diagnosis of malaria and sepsis may be very difficult to establish at first, but the past history of the patient, the microscopical examination of the blood, and the therapeutic test usually suffice to clear up all doubt within twenty-four hours. To be on the safe side in doubtful cases, it is wise to disinfect the genital tract, as well as to administer antimalarial treatment. PART VI. OBSTETRIC OPERATIONS. Induction of Abortion.—By the induction of abortion is meant the interruption of pregnancy before the viability of the child—that is, prior to the one hundred and eightieth day of pregnancy. Indications.—The induction of abortion should be undertaken with the same reluctance that one would commit justifiable homi- cide. If, in the course of pregnancy, some disease arises as a direct consequence of gestation, or if a woman suffering from disease is made much worse by the existence of pregnancy, and if the woman's life is distinctly endangered in consequence, it becomes then not only justifiable, but it is the physician's duty to terminate gestation, and thus to save one life, and that the more valuable of the two, instead of sacrificing both mother and fetus. The following conditions occasionally furnish a justifi- able indication for the induction of abortion : Pathological Vomiting.—When all the remedies for this con- dition have been conscientiously and carefully tried without avail, when rectal alimentation has been continued for a week or ten days without marked improvement in the woman's condition, and it is evident that she is in danger of death if her pregnancy continues, the induction of abortion for uncontrollable vomiting is justifiable. Albuminuria and Kidney Breakdown.—If ominous symptoms appear, such as progressive edema, persistent headache, steady or rapid increase in the amount of albumen, sudden diminution in the quantity of urine, casts in great number in the urine, and failing vision, in spite of careful dietetic and medicinal manage- ment, the induction of abortion is called for. Death of the Embryo or Fetus.—If it can be demonstrated that the embryo or fetus is dead within the uterus, its removal is desirable ; but it must be remembered that the signs of fetal death are difficult to elicit, and that a certain diagnosis can be 719 720 OBSTETRIC OPERATIONS. made only after an observation extending over some days or weeks, unless the membranes are ruptured and the fetal body has begun to putrefy. Certain Intra-uterine Diseases.—As pointed out in the sec- tion on Intra-uterine Diseases, acute hydramnios and cystic degeneration of the chorion villi may call for the induction of abortion. Uterine Hemorrhage.—Uterine hemorrhage, from placenta praevia or from the detachment of an abnormally situated pla- centa, may be so profuse or so long continued as to demand the evacuation of the womb early in pregnancy. Displacement of the Gravid Uterus.—Retroflexion, prolapse, and anteflexion of the gravid womb, resisting other treatment, and threatening to become incarcerated, call for the termination of gestation. Certain Nervous Diseases.—In the course of acute mania and melancholia, or in chorea, and possibly in general pruritus, the question of terminating pregnancy may be considered. Certain Blood Diseases.—If pernicious anemia or leukocy- themia arises in pregnancy or is made much worse by the advent of pregnancy, the question of terminating the woman's condition may arise for consideration. In any of these indications the question will be an anxious one, and should not be decided by the attending physician on his own responsibility, no matter what his experience or skill may be. There should invariably be a consultation, so that the responsibility may be shared and the operator may be free from criticism. Methods of Inducing Abortion.—Many plans have been advo- cated, but most of them have been found either too slow, too dangerous, or ineffectual. Such are the administration internally of ergot, rue, sabina, aloes, and of cotton-root; injections upon the cervix or between the membranes ; the insertion of inflated rubber bags in the vagina or in the uterus ; rapid or gradual dila- tation of the cervix ; perforation of the membranes ; injections of irritating substances, as Monsell's solution, into the womb ; and an electrical current. The method employed by myself with satisfaction in a num- ber of cases may be described as follows : The woman is ether- ized and placed in the dorsal position upon an operating table. The vagina and vulva are disinfected by tincture of green soap and hot water and absorbent cotton, and by a douche of corro- sive sublimate solution, I : iooo. The anterior lip of the cervix is fixed with a double tenaculum, and the cervical canal is dilated to the size of the thumb with Hegar's dilators or cautiously with INDUCTION OF PREMATURE LABOR. 721 branched dilators. An Emmet's curetment forceps is inserted into the womb, opened and shut in several directions so as to crush the ovum, and then withdrawn with whatever portion of the ovum or embryo that comes with it. It is impracticable to remove the whole ovum at once. An iodoform gauze tampon is then packed in the lower uterine segment and in the cervical canal, and a tampon of gauze or antiseptic wool is placed in the vagina. The tampons remain in place twenty-four hours. On their removal, if the remainder of the ovum is not yet discharged from the external os, the cervix, now much softened and easily stretched, is further dilated with larger bougies than were used before, and the uterine cavity is emptied of all its contents as after an ordinary abortion by the curet, the finger, and a pla- cental forceps (Emmet's curetment forceps). While the interruption of pregnancy before the one hundred and eightieth day is called the induction of abortion, the method just described is only practicable up to the fourth month. After that time abortion is induced in the same manner as premature labor. Induction of Premature Labor—In addition to the indications for the induction of abortion there are special indications for the premature interruption of pregnancy after the child has become viable. The most important of these is a contracted pelvis. The next in importance, perhaps, is placenta praevia. It may be necessary, in advanced phthisis, or in grave heart disease, to secure the mother's delivery before term, in order that the child may be born before the fatal termination of her disease, which is evidently close at hand. Labor at term, or shortly after, may be induced in a woman showing a disposition to prolongation of pregnancy. Last of all, in the rare cases of habitual death of the fetus just before term, it is advisable to induce labor before the period at which the child's death may be expected. Methods of Inducing Labor.—The following, founded upon Krause's 1 method, is the best plan for use in the vast majority of cases. The parturient tract is made aseptic by tincture of green soap, hot water, and pledgets of cotton, and by an anti- septic douche. An aseptic, stiff, silk or linen bougie (No. 17 French), which has been soaked for at least a half hour in a cold corrosive sublimate solution 1 : 1000, is thoroughly anointed with carbolized vaselin (5 per cent.). The patient is placed in the dorsal position across the bed, her feet resting on two chairs. The operator passes two fingers of his left hand into the vagina, inserting one or, if possible, both finger-tips 1 "Die kiinstliche Friihgeburt, monographisch dargestellt " von Albert Krause, Breslau, 1855. 46 722 OBSTETRIC OPERATIONS. into the cervical canal. The bougie is then passed along the groove between the two fingers until it enters the cervical canal and passes into the lower uterine segment posteriorly. It is then pushed further in until it has entirely disappeared within the uterus, with the exception of an inch or a little more that pro- trudes from the external os. An iodoform gauze tampon is then packed lightly in the vagina, to keep the bougie in place. Active and effective labor-pains will begin in from thirty minutes to thirty-six hours. In the majority of cases labor begins within twelve hours. If it has not begun at the end of that time, a second bougie should be inserted alongside the first. If, after twenty-four hours more, labor has not begun, the cervix should be artificially dilated with Barnes' bags, and, if necessary, the membranes should be ruptured, forceps may be applied to the head, or version may be performed and the child extracted by the feet. If the mother's condition demands immediate delivery, the best method is as follows : The cervical canal is dilated forcibly, the membranes ruptured, a forceps is applied, or version is per- formed and the child is extracted by the feet. The other plans proposed for the induction of labor have not been satisfactory. The injection of glycerin between the membranes, first proposed by Pelzer, and enthusiastically recom- mended for a time, has proved dangerous, and is, moreover, not to be depended upon. The use of dilatable bags in the lower uterine segment should also be condemned, as they are unre- liable and may burst. FORCEPS. Historical—Three years before the massacre of St. Barthol- omew, in 1569, there fled from France to England a Huguenot family named Chamberlen. The head of this family, named William, was a practising physician. He settled in South- ampton, and raised a large family of children, two of whom, both named Peter, took up the calling of their father, and became physicians, going up to London to practise their profession, where they achieved great success. The younger Peter was in continual conflict, however, with his brother practitioners, and was many times summoned for reprimand and punishment before the College of Physicians. On one of these occasions he was accused of boasting that "he and his brother and none others excelled in these subjects" (difficult labors). This was in the beginning of the seventeenth century (1616), and is the first record of that secret which remained in the Chamberlen family FORCEPS. 7?3 for more than three generations, which was the foundation of their boast that they alone could be regarded as skilled obstet- ricians, and which enabled them all to grow rich by the practice of their hidden method of dealing with difficult labors. But instead of being honored as the discoverers of one of the most important inventions of medicine, posterity has and must con- demn them that for their own gain they should have deprived the world of knowledge that might have saved hundreds of lives and have prevented untold suffering during the hundred years that the forceps remained a well-guarded secret in their family. The younger Dr. Peter Chamberlen had a son, also named Peter, who was a most remarkable character : a man of great, but ill-directed talents ; possessing some inventive genius ; an extensive traveler ; an accomplished linguist; obtaining the favor and friendship of the British royal family, and engaged during the greater part of his mature life in a most lucrative practice among the upper classes in London. It is to this man, who made such a mark in his time, that the invention of the forceps was formerly credited ; but there is no doubt, from evidence recently come to light, that he inherited the secret from his father, who, in his turn, obtained it from his elder brother, Peter Chamberlen, senior.1 The idea that the younger Peter invented the instrument was no doubt fostered by himself, for he was a man of intense egotism. Before his death he wrote his own epitaph, which began— " To tell his learning and his life to men Enough is said by, ' here lies Chamberlen.' " This Peter had a son, Hugh, wrho also studied medicine, and to whom his father disclosed the family secret of the Chamber- lens. This Hugh, who was extravagant, determined to make the most of his inheritance, and to part for a consideration with the secret that had remained in his family so long. He accord- ingly went to Paris and offered to acquaint Mauriceau with his secret method of dealing with difficult head presentations, which up to that time had been managed by tearing the child to pieces with sharp hooks. For this piece of information Chamberlen asked the enormous sum—for it was enormous in those days— of ten thousand dollars (ecus). Mauriceau took the matter under consideration, and, having one day a deformed dwarf in labor, Chamberlen was asked to test his method in the case. He did so, and failed completely, the patient dying from a rup- 1 " The Chamberlens," J. H. Aveling, London, 1882. 724 OBSTETRIC OPERATIONS. tured uterus, undelivered. This ended the negotiation for the sale of the secret in Paris. On his return to England Chamber- len translated and published Mauriceau's book, with a preface written by himself, in which he says : " My Father, Brothers, and my Self (tho none else in Europe as I know) have by God's Blessing and our Industry, attained to, and long practised a way to deliver Women in this Case without any Prejudice to them or their Infants." Hugh Chamberlen is next heard of in Amster- dam, whither he had fled from England on account of some financial difficulties. Here he had better fortune than in Paris, and succeeded in selling his secret to the College of Physicians of Amsterdam. This institution immediately induced the govern- ment to pass a law which forbade any one to practise medicine in the town who had not given satisfactory evidence of possess- ing the secret now owned by the college, and imparted to each aspirant for a medical degree who was able to pay for it. This went on until almost the middle of the eighteenth century, when two public- spirited citizens of Amsterdam, thinking it an outrage that a method for which such extravagant claims were made should re- main a secret, took a course in medicine, purchased the knowledge from the College of Physicians, and published it to the world. It was a single blade of the obstetric for- ceps. Before this time, however, certainly as early as 1725, the true secret had leaked out in England, and during the middle of the eighteenth century the forceps came to be widely known and quite generally used. There was for a long time much speculation as to the kind of instrument that the Cham- berlens really invented, and there were many, some years ago, who doubted that the invention had been the forceps at all. It was thought at one time to have been a forcing powder or a blunt hook. It was believed for a while that Jean Palfyn (1716) had first conceived the idea of an instrument which was developed later by others into the forceps. But these doubts have been set at rest. At Woodham, Mortimer Hall, in Essex, owned and occupied by Peter Chamberlen, junior, was discovered, in 1813, a chest in which were found the instruments shown in figure Fig. 510.—Smellie's straight forceps. An eighteenth century Eng- lish forceps, the blades wrapped with leather, thought to keep them from slipping. FORCEPS. 725 512.1 The Chamberlens were also the inventors of the vectis, or lever, an instrument no longer made, for a single blade of the obstetric forceps answers the purpose perfectly. Fig. 511.—Palfyn's forceps or " hands." Fig. 512.—The four forceps found in the Chamberlen chest. Fig. 513.—Chamberlen's vectis. The Chamberlen instrument had not been long known and employed before certain defects were noticed in it. It was found 1 It is obvious that the successive possessors of these instruments received all that were in existence in order to preserve the secret. The evolution of the forceps at the hands of the original inventor or of his descendants is easily seen in the illustrations. 726 OBSTETRIC OPERATIONS. difficult to introduce it, especially if the head was high up in the parturient tract. It was also found difficult to lock it, and the necessity of binding the handles together was found to be inconvenient. The first of these disadvantages, the difficulty of introduction, was soon discovered to be dependent upon the curve of the pelvic canal, and it was recognized that an instrument to be introduced into this curved canal should itself be curved to correspond with the direction of the canal. Almost simultaneously, in Eng- land and France, about 1750,x a pelvic curve was added to the forceps—in England by Smellie, in France by Levret. Each of these men, distinguished ob- stetricians of their time, added very important modifications to the forceps, which are worthy of careful attention, for the two instruments known as the for- ceps of Levret and the forceps of Smellie are the direct pro- genitors of the two types of for- ceps in use at the present time. The English forceps, as may be seen in figure 514, B, is small, short, and light. It has, as may be seen, the English lock ; the pelvic curve is inadequate, and to keep the instrument from slipping it was originally wrapped in leather ; but the in- strument had good points about it, which are found modified in the modern English forceps of Simpson. In the French forceps (Fig. 514, A), we find a heavy, long instrument, with powerful handles and closely approximated blades. The lock is the pin or French lock, which the French forceps carry at the present time. In this instrument, too, the pelvic curve is inadequate, but the forceps has certain advan- Fig. 514.—A, Levret's forceps with a pelvic curve ; B, Smellie's for- ceps with a pelvic curve. 1 Levret presented his forceps to the Academy of Surgery in 1747. Smellie first published a description of his in 1751, though he had invented the pelvic curve ten years before. FORCEPS. 727 tages, which, modified, may be found in many modern instru- ments. It was not long before the disadvantage of the inade- quate pelvic curve was appreciated, and soon after the time of Smellie and Levret this feature was improved, and a forceps with a better constructed pelvic curve came into use. It may be noticed that the handles of both the Levret and the Smellie for- ceps are rather difficult to grasp, if one desires to make a strong traction upon them. This disadvantage was overcome by Busch, a German, who was the first to add the cross-pieces or shoulders to the handles, which enable the operator to take a firm and convenient grip of the instrument. It is plain that both the French and English locks each possess some advantages and some disadvantages. The English lock is easy of adjustment, but is not very secure. The French lock is difficult to adjust, but when once fastened, is firm and Fig. 515.__A, French, B, English, and C, German locks. unyielding. Brunnighausen united the advantages of both these locks and did away with their disadvantages in the lock known as that of Brunnighausen, or the German lock (see Fig. 515). Almost every eminent practitioner of obstetrics for the last hundred years has added some modification of slight importance to the forceps ; so that the patterns, differing in a slight degree from one another, have been almost innumerable. There are two types of modern forceps, however, that merit description— that of Hodge in this country, and that of Simpson in Edin- burgh. They embody the best features of the two distinct classes that they represent. Hodge's forceps is the direct descendant of Levret's ; Simpson's, of Smellie's. The Hodge forceps has the advantage of taking an extremely firm grip upon the child's head, and of allowing great power in extraction and compression of the head. Its great disadvantage is that it may injure the child's head more easily than almost any other modern 728 OBSTETRIC OPERATIONS. instrument. Simpson's forceps—in my opinion, the best modern instrument for the ordinary case—has a cephalic curve so well constructed that it can scarcely injure the child's head, even when great force is used to extract it. The pelvic curve is sufficient, but is not so great as to embarrass the operator when the instru- ment is applied to the head low down in the pelvic cavity. The Fig. 516.—Hodge's forceps. Fig. 5J7-—Simpson's forceps. Fig. 518.—Davis' forceps. Fig. 519.—Small forceps, modified by the author for use at the vulvar orifice and pelvic outlet. blades are of such length that the instrument may be used with equal convenience at the superior strait or at the pelvic outlet. The lock is the English lock, which has the great advantage of easy adjustment; and the handles are provided with shoulders for two fingers, and with depressions along the handle for the FORCEPS. 729 remaining fingers and thumb of the hand, so that a firm and con- venient grasp can be taken of the instrument in use. Another modern instrument deserving description is the Davis forceps, very carefully constructed upon iron models of the fetal head. If this instrument is carefully adjusted to the sides of the normal child's head in the pelvis, it is no doubt pro- Fig. 520.—Showing the direction in which traction must be made by the handles, and the correspondence of the direction in traction upon the traction-handle and the direction in which the head must move. Fig. 521.—Hermann's forceps. vided with a better cephalic curve than any other forceps ; but if it should not be applied accurately to the sides of the head, it is capable of doing the child's head great damage. A very use- ful instrument also in the author's experience is a light, short forceps for use at the parturient outlet. As the mechanism of labor was better appreciated, and the forceps came into more general use in the latter part of the 73Q OBSTE TRIC OPERA TIONS. present century, it was realized that a certain amount of force was lost in the extraction of the child's head by the necessity of pulling the forceps in great part in the line of their handles. The angle at which this force met the direction it is desired to impose upon the head is shown in figure 520. This difficulty has been overcome by the axis-traction principle, first proposed and carried out by Hermann, but the introduction of which we owe to Tarnier, of Paris. Figure 522 shows the latest and best Fig. 522.—Tarnier's axis-traction forceps. To show the details, the hand is repre- sented in an improper position for traction; below is one of the traction rods. Fig- 523.—Poulet's forceps. axis-traction forceps.1 Figure 500 illustrates the coincidence of the line of traction with the direction in which the head must move. Many modifications of the axis-traction forceps have been made. The most useful on the score of economy and simplicity is Poulet's, who uses strong tapes passed through 1 Tarnier destroyed ninety-nine models before he accepted the one-hundredth as entirely satisfactory. FORCEPS. 731 eyelets in the forceps blades, and fastened to a handle bent at right angles. Uses and Functions of the Forceps___The main function of the forceps is that of a tractor, which is by far the most im- portant. Another function sometimes to be remembered is that of a rotator, as, for example, when a straight forceps is applied to the head in face presentation, with the idea of twisting the chin forward. In a difficult forceps operation the instrument some- times has the function of a lever ; the operator, swaying his arms a little from side to side, pulls down first one side of the head and then the other, in this way dislodging it from its impacted position. Last of all, least frequently to be employed, and most dangerous of all functions, the forceps may occasionally be regarded as a compressor; but the instrument is to be used for this purpose only in cases where there is a choice between com- pressing the head with the forceps and performing craniotomy, by the former action extracting a child that is almost certainly dead, but with one or two chances for life out of a hundred. Indications for the Application of the Forceps.—The for- ceps is an instrument designed mainly to reinforce the vis a tcrgo in labor. The most important indication for the use of the in- strument is found in actual and relative uterine or abdominal inertia. The expulsive force may be relatively too weak if the resistance is greater than normal ; hence the forceps is indicated in contracted pelves, rigidity of the soft parts, and overgrowth of the fetal body. It may be necessary, in any case of head presentation in labor, hastily to terminate the process. This is especially desirable if conditions exist threatening the child's safety, as premature detachment of the placenta, compression or prolapse of the cord, prolonged pressure on the fetal head, feebleness and slow action of the fetal heart, or sudden danger to the mother during the second stage of labor, as in eclampsia. There is a valuable indication of fetal condition during labor in the action of the fetal heart. In case of serious disturbance the heart-sounds first increase in rapidity, but soon become slower. If they sink to 100 and remain at that rate for any length of time, it is likely that the child will be born dead, and it is a good practical rule in obstetrics to apply the forceps and to deliver the child rapidly whenever the fetal heart-sounds sink to 100 and remain at that rate for a minute. It may be desirable to save the mother the muscular exertion necessary in the second stage of labor. This is particularly true if labor is complicated by some adynamic disease, as phthisis, typhoid fever, or pneumonia. It is most desirable to avoid all 732 OBSTETRIC OPERATIONS. muscular effort in the second stage of labor in valvular disease of the heart. Finally, labor may be obstructed by abnormal positions of the cephalic extremity, or by anomalies in the mechanism of labor, as, for example, in face presentations when the chin does not rotate forward, or in vertex presentations when the head is insufficiently or excessively flexed. A good rule of thumb to govern the obstetrical practitioner is to apply the forceps in head presentations whenever the presenting part remains stationary for two hours in the second stage of labor. It is quite as important to recognize the contraindications to the use of the forceps as it is to understand when the instrument is needed. The contraindications to the use of the forceps, ex- pressed dogmatically as rules of practice, are as follows : The forceps must not be applied unless the os is dilated. There are exceptions to this rule. When the maternal or fetal life is threatened, it may be permissible to apply forceps through a partially dilated os, as, for example, when rupture of the uterus is threatened. It may be necessary, in some cases of rigid cervix, to artificially dilate the os by applying forceps and pulling the head down upon the cervix. It is also necessary, in cases of valvular disease of the heart and in the adynamic fevers, to shorten labor as much as possible by applying forceps to the head through an undilated os and rapidly extracting the child. The forceps must not be applied until the head is engaged in the superior strait. This rule, too, admits of some excep- tions. It is rarely possible to fix the head in a contracted pelvis with forceps, when the powers of nature are insufficient to attain this end. It is also justifiable to apply the forceps to the head loose above the superior strait in cases of placenta praevia with the head presenting, and to bring it down as a tampon in the pelvic canal. The forceps must not be applied until the membranes have been ruptured. This rule admits of no exception. The forceps must not be used as tractors in impossible posi- tions and presentations, as, for example, face presentations with the chin posterior. The forceps must not be employed unless the head be of average size. If the fetal head is too large or too small, the instrument is apt to slip and to inflict dangerous injuries upon the maternal soft parts. The forceps must not be used when the disproportion be- tween the head and the pelvic canal is too great. In selecting an instrument, the author would recommend the beginner, if he must restrict himself to a single forceps, to pur- FORCEPS. 733 chase Simpson's. As soon as practicable, the Tarnier axis-trac- tion forceps should be added, and it is a great advantage to possess, in addition to these two instruments, a light short forceps for use at the pelvic outlet. Preparation for the Operation.—The patient's consent, or the consent of her husband or nearest relative, should always be first secured. An anesthetic renders the operation less difficult, and is to be recommended to beginners; but where it is pos- sible to deliver the woman in a short time,—say, half an hour or under,—and if the difficulty of extraction promises to be slight, the anesthetic may be dispensed with. The woman should be placed in the lithotomy position at the edge of the bed, with her feet resting upon two chairs or sup- ported by assistants. With the small forceps used at the pelvic outlet the lateral position need not be altered. The whole forceps should be immersed for from ten to fifteen minutes before use, in a pitcherful of boiling water, or, if it is practicable, should be boiled for the same length of time in a suitable instrument tray. Just before its insertion the whole blade, both outer and inner surfaces, should be smeared with carbolated vaselin. The Application of the Forceps.—In using the Simpson forceps, or any other with a non-detachable pin-lock, the left-hand blade is always inserted first. The left blade lies upon the left-hand side of the woman's pelvis, and is held in the left hand of the operator. The right-hand blade of the forceps lies upon the right-hand side of the pelvis when introduced in position on the child's head, and is held in the right hand of the operator. Assuming that the diagnosis of the presentation and of the position of the presenting part has been made, and that the vagina is rendered surgically clean, the successive steps in the application of the forceps-blades may be summarized as follows : Having introduced two fingers of the right hand into the vagina, the left blade, grasped at the lock by the left hand as a pen, is held perpendicularly to the woman's body, with the tip of the blade opposite the vulva. The tip of the blade is inserted in the vagina, and is pressed backward along the pelvic floor toward the sacrum. The blade is then rotated outward on its long axis to bring it in apposition with the posterior inclined plane of the pelvis, and to escape the promontory of the sacrum : the handle is depressed and the tip of the blade is thus elevated into the uterine cavity, the fingers of the right hand in the vagina guiding the blade and protecting the soft parts ; finally, the handle is carried to the left side in order to engage the tip of the blade over the curve of the child's head. The right-hand blade is in- troduced in a similar manner, substituting the right for the left, OBSTETRIC OPERATIONS. Fig. 524.—Introduction of the left blade: first step. ^"'6- 525-—Introduction of the left blade: rotation on its long axis. FORCEPS. 735 Fig. 526.—Insertion of the right blade, the left wrist being depressed to crowd the left blade out of the way. Fig. 527.—Both blades inserted, unrotated. 73& OBSTETRIC OPERATIONS. Fig. 528.—Rotation of a blade (the left). Fig- 529-—Both blades joined by the lock after the rotation of the right. FORCEPS. 737 Fig- 53°-—The grip on the forceps. Flg- 531-—The direction of the forceps-handles at the inferior strait (Hodge). 47 73* OBSTETRIC OPERATIONS. of course, in the foregoing description. As the blades lie after their insertion it is impossible to lock them, for both of them have ascended the posterior inclined plane of the pelvis, after being rotated outward on their long axes. It is necessary to bring one of them forward toward the region of the acetabulum, if the head lies in the oblique position, before the blades will lock. Obviously, the blade to be rotated forward within the pelvis differs with the different positions of the presenting part. In the left occipito-anterior position of a vertex presentation the right- Fig. 532.—The direction of the forceps-handles with the head at the superior strait. hand blade must be rotated forward, the left-hand blade lying as it was when first introduced. To rotate the right blade the handle is lightly supported by the fingers of the right hand, while the first two fingers of the left hand are inserted under the heel of the blade and gently pry it upward, outward, and then inward. If the operator finds it more convenient, he may reverse the hands. If there is difficulty in locking the blades, a depression of both handles toward the perineum often facilitates their conjunction. The handles being approximated and the blades joined, the operator takes the grip upon the instrument shown in figure 530. FORCEPS. 739 The forefinger of the right hand is kept extended against the child's scalp to detect the first inclination on the part of the in- strument to slip. Too great compression of the child's head may be avoided by placing a folded towel between the handles, and by using the slack of this towel to cover the shoulders of the forceps-handles, the operator will save his fingers from exces- sive fatigue and even bruising. The grip represented in figure 530, with pressure exerted downward, outward, and on the ends of the handles upward, enables the operator to impose upon the head a movement corresponding with the axis of the parturient canal. If traction were made directly outward by pulling straight upon the forceps-handles, much of the force would be lost by dragging the head against the symphysis pubis. In making traction, nature should be imitated as closely as possible, the intervals between one's efforts corresponding to the usual intervals between the pains, and the traction lasting for about a minute. In the intervals of rest the blades should be loosened, or even unlocked, to spare the fetal head from long- continued and uninterrupted compression. The force should be exerted by the muscles of the shoulders and arms. It is inad- visable to throw the weight of the trunk upon the forceps and it is absolutely inexcusable to utilize the muscles of the back and legs, plus the weight of the body, by bracing the feet against the bed while pulling upon the forceps. The tractive force should take a different direction as the head progresses along the par- turient tract. When the forceps is at rest, the direction of the handles is a good indication of the direction in which the next traction should be made ; as the head descends the birth-canal and appears at the vulvar orifice, distending the perineum, care should be exercised to moderate the tractive force, otherwise the head might be violently pulled out through, instead of over, the perineum. When the degree of distention is reached shown in figure 533, the grip on the forceps is changed. The handles are seized in the right hand, as shown in figure 533, the operator standing to one side of the patient. Instead, now, of making traction, the forceps-handles with each pain are lifted and carried up over the woman's abdomen, very little force being employed. The outspread fingers and thumb of the left hand push the head away from the perineum and guide it upward under the pubic arch. When the pain passes off, the forceps-handles are allowed to sink again. Finally, just before the head emerges, the grip on the instrument is again changed so that the handles may be almost laid on the woman's abdomen (Fig. 536). Used in this way there is no better safeguard for the integrity of the perineum than the obstetric forceps. 740 OBSTE TRIC OPERA TIONS. Fig. 533.—The extraction of the head from the vulvar orifice: first stage. Fig- 534-—-The extraction of the head from the vulvar orifice : second stage. FORCEPS. 741 Fig. 535.— The extraction of the head from the vulvar orifice: third stage. Fig. 536.—The extraction of the head from the vulvar orifice: fourth stage. 742 OBSTETRIC OPERATIONS. In the description of the application of the forceps it has been assumed that the head is in a normal oblique position of a vertex presentation and that the blades of the instrument are applied to the sides of the fetal head, where they do the least damage, and to the contour of which their cephalic curve has been adjusted. It often happens, however, that the head occu- pies an abnormal position, and the question arises whether the forceps shall be applied at the sides of the maternal pelvis, where the blades are not likely to injure the woman, or whether an attempt must be made to adjust the blades to the sides of the fetal head regardless of the additional risk to the mother. If, for example, the head is transverse, as it usually is when detained at the pelvic inlet in a contracted pelvis, one blade must lie behind the symphysis and the other in front of the promontory if they are to be placed at the sides of the fetal head. It is pos- sible to so adjust them, if one possesses manual dexterity and is skilled in the use of the forceps, but there is always a danger of perforating the posterior uterine wall in the attempt. It is better under these circumstances to place the blades obliquely, the posterior behind the promontory of the occiput, the anterior in front of the chin and mouth. By this adjustment the fetal head is not likely to be so badly damaged as if the forceps were applied directly over the face and the occiput, the anterior rota- tion of the latter is facilitated, and the woman is subjected to no extra risk. It is not infrequently necessary to apply the forceps to the head in a normally oblique position, but with the occiput directed posteriorly. As the head descends, anterior rotation should occur, and it is to be considered whether the grip of the instru- ment will interfere with the rotary movement of the head upon the pelvic floor. As a rule, it does not if the precaution is ob- served to disengage the blades completely from each other by unlocking them after each tractive effort. As soon as rotation is accomplished, the forceps-blades lie over the occiput and the face; they must, therefore, be rotated into their appropriate positions over the sides of the head, or, if it is difficult to do this, they should be withdrawn and reinserted. To give a concrete example : In a right occipitoposterior position of a vertex pres- entation the two blades of the forceps are inserted along the posterior walls of the pelvis to either side of the promontory; the right blade is then rotated forward until it lies under the right acetabulum. As the occiput rotates forward after encoun- tering the resistance of the pelvic floor, the long anteroposterior diameter of the head shifts from the right to the left oblique diameter of the maternal pelvis, bringing the forceps-blades FORCEPS. 743 directly over the face and the occipital protuberance. The left blade must, therefore, be rotated forward and the right backward, or, if it is difficult to rotate the blades, they must be withdrawn and reinserted as for a right occipito-anterior position of a vertex presentation. If the occiput rotates into the hollow of the sacrum, the head should be extracted from the vulvar orifice by the following manoeuver : The forceps-handles are raised gradually and inter- mittently until almost the largest diameters of the head have escaped ; then, instead of continuing the elevation, the left hand firmly supports the head through the perineum and the forceps- handles are depressed, turning the fetal face out from behind the symphysis. In this way the perineum and pelvic floor are some- what relieved of the tremendous strain imposed upon them in a persistent posterior position of the occiput. In applying the axis- traction forceps, the bars are closed against the blades, which are in- serted in the ordinary manner. After adjusting the blades to the sides of the child's head if possible, or in an oblique diameter of the pelvis, the blades are locked ; the pin-lock of Tarnier's instrument is screwed moderately tight; the con- necting bar between the handles is thrown across, locked, and screwed until the blades take a firm but not too forcible grip on the fetal head. The traction bars are then sprung loose at their lower end and the handle is adjusted to them and locked. Traction should be made in a line as nearly as possible coinciding with the axis of the pelvic inlet—namely, backward and downward. To do this even approximately the woman must be placed upon a bed or table with her buttocks projecting well beyond the edge and the axis-traction handle of the forceps must be pulled downward and backward as far as possible. To pro- tect the perineum from injury by the traction rods a Sims specu- lum should be held in place during the tractive efforts. Between the tractions the bar joining the handles should be unscrewed and thrown out of place and the pin-lock should be unscrewed, thus relieving the fetal head from continued pressure. As soon as the fetal head has descended well into the pelvic cavity the axis-trac- tion principle becomes unnecessary. The handle should, therefore, be removed, the bars fastened in their places by the blades, and Fig- 537-—Over-distention of the perineum in persistent occipito- posterior deliveries ; the nose rests under the pubic arch. The blades at this point should be depressed. 744 OBSTETRIC OPERATIONS. Fig. 538.—Axis-traction forceps; head at the superior strait. Fig. 539.—Axis-traction forceps; head in the pelvic cavity. EXTRACTION OF THE BREECH. 745 the forceps used as an ordinary instrument or else withdrawn and replaced by a Simpson forceps. Statistics as to the frequency of forceps operations have neither interest nor value. They vary enormously in different clinics, in different classes of society, and in the hands of different operators. The author is an advocate of the frequent use of forceps, believing that more harm arises from inordinate delay in labor to mother and infant than can be traced to the use of the instrument in careful and skilful hands. The mortality of a forceps operation, per se, should be nil. The most frightful damage, however, has been inflicted upon both mother and child by the unskilful and careless use of the instru- ment. The pelvic joints have been sprung apart by too forcible traction ; the lower uterine segment with an undilated os has been caught in the grip of the blades and has been cut through into the peritoneal cavity ; the posterior wall of the lower uterine segment has been perforated by the tip of one blade ; the child's scalp has been cut and a forceps- blade forced between its scalp and the skull ; in an attempt to apply forceps to the breech in the mistaken notion that it was the head, the tip of a forceps-blade has torn the perineum of a female infant into the rectum ; the vaginal vault has been perforated and the vaginal walls deeply cut, and frequently, indeed, is the perineum torn, often into the rectum, by a failure to elevate the handles sufficiently and to moderate the tractive force as the head is extracted from the vulvar orifice. EXTRACTION OF THE BREECH. Breech labors are normally slow and tedious. The indica- tions for interference are; delay for more than twenty-four hours, rapid and feeble pulse, signs of exhaustion, elevation of tempera- ture in the mother, and abnormally slow fetal heart-sounds. Methods of Extraction in the Order of their Efficiency.— Manual Method.—Seizing a foot by passing a hand into the uterus, extracting the leg up to the knee, thus decomposing the breech Fig. 540.—To bring down a foot when it is against the face, the knee may be bent by pressure in the popliteal space (modified from Farabeuf and Varnier). 746 OBSTE TRIC OPERA TIONS. Fig. 541.—Manual extraction of breech. Fig. 542.—Forceps on breech. Fig. 543.—Fillet on breech. Fig. 544.—Fillet carrier. EXTRACTION OF THE BREECH. Jtf presentation and affording a convenient handle to the fetus by which to control the subsequent progress of labor, is the best of all methods for extracting the breech, if it is practicable. Pinard's suggestion to push one thigh outward and backward, thus flex- ing the leg upon the thigh, will occasionally make it easier to grasp the foot. Another plan of manual extraction is to place the hand on the infant's back, so that the little and fore-fingers hook over the crest of the ilium, while the middle and third fingers are extended along the spine. This is not so good. For both manceuvers the patient must be anesthetized. Forceps.—If the breech is low in the pelvic canal, and it is impossible to pass the hand into the uterine cavity to seize a foot, it may be most convenient to apply forceps over the trochanters. By avoiding compression of the han- dles, and simply making traction by hooking one's fingers over the shoulders of the instrument, the breech may be extracted readily, with no danger to the child. Extraction by Fillet.— Each end of a strip of bandage about two inches wide may be passed be- Fig. 545.—The handle of a long forceps used tween the thigh and the as a blunt hook. abdomen and brought down in front of the external genitalia. If drawn tight, the loop of the bandage will be in contact with the child's sacrum. A very firm and convenient grip is thus taken upon the breech. The fillet is very difficult to apply with the fingers. A fillet-carrier, shown in figure 544, makes the application much easier. An anesthetic is required. This plan is excellent if the manual extrac- tion is impossible, or if it is considered inadvisable to use forceps. 748 OBSTETRIC OPERATIONS. Blunt Hook.—This instrument is passed between the thigh and the abdomen. It is an extremely dangerous instrument for the infant. It is very likely, indeed, to fracture the thigh or to perforate the groin. Its use, therefore, is not recommended, and is never resorted to by the author unless the child is dead. THE ARTIFICIAL DILATATION OF THE CERVICAL CANAL, It is necessary to dilate the os artificially in cases of rigidity of the cervix, or when it is desired to hasten labor for any purpose. The os may be dilated by Barnes' bags, by graduated bougies, by the fingers, by pulling the head down with forceps, by taking hold upon a foot or leg in a breech presentation, or by mul- tiple incisions. Hydrostatic Dilatation.—For this purpose rubber bags of a fiddle shape and of graduated sizes are most convenient (see Fig. 546). It is desirable to have the largest bag larger than that ordinarily sold in the shops—that is, four sizes, the largest one made specially. To insert one of these rubber bags, it is Fig. 546.—Barnes' bag. rolled upon itself, grasped in an Emmet curetting forceps, well smeared with carbolized vaselin, and passed into the cervical canal, so that the internal os corresponds with the constriction around its middle. The tube is then attached to the rectal nozle of a Davidson syringe, and the bag is distended with water. It is well to test the capacity of each bag outside the woman's body, to avoid overdistention and the danger of bursting. When the bag is filled, the rubber tube attached to it is clipped with a hemostat, which at the same time is made to grip the bed-sheet, so that the water is held in the bag, and the tube is supported firmly in order that it shall not drag t.he bag out of the cervical canal. Each of the progressively larger bags is inserted in the same manner, and allowed to remain in place from fifteen minutes to an hour, according to the time at one's disposal. As complete a dilatation of the os should be made as possible, unless haste is necessary. The pockets made upon the rubber bags are of very little use as an aid in their introduc- tion, unless one inserts a heavy instrument, like a closed Emmet AR TIFICIAL DLL A TA TLON OF THE CER VLCAL CANAL. 749 curetment forceps, in them. The ordinary uterine sound, which is often recommended for this purpose, is worthless. Graduated Bougies—The cervical canal may be dilated by inserting graduated bougies from the size of a small lead-pencil up to the size of one's wrist or forearm. This is a convenient and effective method, but it requires a number of bougies which will scarcely ever be carried about by any obstetrician, and it will, therefore, only be available in a well-equipped obstetrical hospital. In fifteen to twenty minutes by this plan the os may be almost fully dilated or sufficiently at least to permit the ex- traction of the child by the forceps if the head presents, or by drawing down a leg in a breech presentation. Fig 547.—Hegar's dilators or bougies. Manual Method—The best manual methods for the dilata- tion of the os are illustrated in figure 548. In Harris' method the fore-finger and thumb, -and then the other fingers of the hand, are successively inserted, the thumb and fingers being spread apart as widely as possible. In Edgar's method the dilatation is begun by branched dilators and is completed by the powerful action of the first two fingers of both hands. By this means very rapid dilatation of the os is possible, and it is most to be recommended in cases of greatest haste, in which it is only desired to secure enough dilatation to make the forcible extrac- tion of the child afterward possible. Forceps—If the os is already about the size of a dollar, and it becomes necessary to deliver the child rapidly, forceps may be applied to the head and strong traction made. The cervix will either stretch or tear, and it is thus possible to extract a child in a very few minutes when there is urgent need for rapid delivery. Multiple Incisions—This plan is an old one, but in its mod- ern most effective form, of incisions through the cervix to the vaginal vault, it was first proposed by Duhrssen.x It is to be recommended in cases in which there is need for the utmost rapidity in the extraction of the child. If the head presents, it is best to apply forceps to pull the head firmly down against 1 Wiener med. Presse, xxxi, 33. 750 OBSTETRIC OPERATIONS. the cervix, and then with scissors, or a blunt-pointed bistoury, to cut the cervix in one, two, or as many as four places, until the child can be dragged through the cervical canal. It will be necessary afterward to suture the incisions, which bleed pro- Fig. 548.—Method of performing rapid manual dilatation of the os uteri: 1, Position of fingers in the beginning of manual or digital dilatation of the cervix uteri, first position; 2, showing limit of dilatation in the first position ; 3, second position ; 4, showing limit of dilatation in the second position ; 5, third position ; 6, limit of dilatation in the third position; 7, fourth position ; 8, limit of dilatation in the fourth position ; 9, fifth position ; 10, sixth position (Harris). fusely for a time, at least. If the patient should be in a serious condition, it may be sufficient to place one suture in the upper angle of each incision. This will check the hemorrhage suffi- ciently, and promotes, occasionally, the entire repair of the injury. AR TIFICIAL DIE A TA TION OF THE CER VICAL CANAL. / 5 I Fig. 549.—Instrumental dilatation of parturient os, preparatory to further manual dilatation (Edgar). Fig. 550.-Digital dilatation of the parturient os. Os admits one finger. Vaginal and supravaginal portions of the cervix present (Edgar). 752 OBSTE TRLC OPERA TLONS. Fig. 551.—Bimanual dilatation of the parturient os. Os admits two fingers. Vaginal and supravaginal portions of the cervix present; commencing shortening of the cervical canal (Edgar). Fig- 552-—Bimanual dilatation of the parturient os. Os one-half dilated. Lateral position of the hands (Edgar). AR TIFICIAL DILA TA TION OF THE CER VICAL CANAL. 753 Fig. 553.—Bimanual dilatation of the parturient os. Os two-thirds dilated. Entire effacement of internal os (Edgar). Fig. 554.—Bimanual dilatation of the parturient os. External view, showing position of hands (Edgar). 48 754 OBSTETRIC OPERATIONS. VERSION. Version may be defined as an operation or manoeuver to change the position of the fetus in utero. The object of version is to change a transverse into a longitudinal presentation, and to change the presentation of one pole of the fetal ellipse into a presentation of the opposite pole. The changes in the position of the fetus are effected by four methods—postural treatment of the mother, external manipu- lation alone, internal manipulation alone, and a combination of internal and external manipulations. As the child is brought to present by the cephalic or pelvic presentation, the operation is called version by the head or version by the breech. If the foot is seized and is extracted in the operation of version, the operation is called podalic version. The operation of version is an old one. Hippocrates speaks of the difficulties encountered when a child lies crosswise in the uterus. He compares it to an olive lying crosswise in a bottle with a narrow neck. But Hippocrates believed that the infant could only be delivered if it presented head first, and therefore, in cross-positions of the fetus, if the effort to turn it with the head toward the maternal pelvis did not succeed, embryotomy was to be performed in the dreadful manner that was practised in those days—tearing the child to pieces with sharp hooks. Among the aboriginal tribes of Mexico a curious custom pre- vailed in cases of difficult labor. A woman was seized by the feet, suspended head downwards, and vigorously shaken. If the dystocia was due to a transverse position of the fetus in utero, this rough and unscientific treatment might, in a certain number of cases, be effective, and it was no doubt in consequence of a few successes that the custom had its origin. / In Japan, before the country had reached its present high stage of civilization, it was customary to apply massage to the abdomen of pregnant women, in order to straighten out a pos- sibly faulty position of the fetal ellipse. In many primitive races some form of version has been and is in vogue, handed down as a custom of ancient origin. Indications for Version.—The most important and the most frequent indication for version is found in a transverse posi- tion of the fetus in utero. In order to secure delivery, one or the other of the poles of the fetal ellipse must be substituted for the shoulder, which usually presents in a transverse position of the fetus. Contracted pelves are an indication for the performance of version, when it is thought that the child's head can be brought VERSION. 755 through the contracted pelvic canal more easily with the small end of the wedge coming first than last. If it is necessary to deliver the mother rapidly, in cases of sudden danger, when the head is presenting but not engaged, as in eclampsia, premature detach- ment of the placenta, rupture of the uterus, embolism, and death of the mother, podalic version furnishes the most rapid means of delivery. In malpositions of the head, as presentation of the ear, of one parietal bone, of a brow or face, it is better to sub- stitute for the unfavorable presentation of the head the more favorable presentation of the breech, which is secured by podalic version, or by version by the breech. In placenta praevia, if the head is presenting, version is indicated, in order to bring down the breech as an intrapelvic tampon upon the bleeding placental side. In prolapse of the umbilical cord, version is indicated if the cord can not be returned into the uterine cavity and kept there. Before undertaking the operation of version, it is quite as important to realize the contraindications to the operation as it is to recognize the indications. Version is positively contra- indicated if the presenting part is firmly engaged in the pelvic canal and has passed out of the external os ; also, if the con- traction-ring is so high that a rupture of the lower uterine seg- ment is threatened if version is attempted. While these are the only positive contraindications to the operation, the following conditions may make it difficult, dan- gerous, or quite impossible: an undilated and undilatable vagina; a similar condition of the cervix. These obstructions may usually be overcome under anesthesia, or they may be insuperable obstacles to the performance of version. It may be impossible to effect an entrance into the uterus, as when the liquor amnii has long been drained away and the uterus is firmly contracted, when the uterus is permanently contracted in what is called a tetanic spasm, when there is some obstruction on the part of the fetus, as hydrocephalus and spina bifida with a large meningocele, or if the presenting part is pressed firmly upon the superior strait. The last-named difficulties may be obviated by placing the woman in the knee-chest posture. Prolapse of the arm, at one time considered a serious ob- stacle to the performance of version, is no longer so. The phy- sician's hand can readily pass by the arm, and indeed it is some- times an advantage to pull the arm out of the external os before attempting version. It may be impossible to bring the feet down in podalic version after they are grasped. This difficulty may be overcome by 756 OBS TE TRIC OPERA 7 IONS. applying a fillet to the foot, and, while traction is made upon it, the other hand of the physician in the vagina pushes the shoulder upward and in the direction of the child's head. Certain conditions may interfere, also, with the manipulation of the external hand in combined and in podalic version, as an excessive amount of fat in the abdominal wall, or convulsions in eclampsia, epilepsy, chorea, and hysteria. On the other hand, the conditions most favorable for the operation are : a uterus dis- tended by liquor amnii, a dilated os, a uterine muscle that is not irritable, abdominal muscles that are flexible and thin, and a cervix well dilated or easily dilatable. Fig. 555.—Diagram of knee-elbow posture for internal version. The lower part of the hollow of the uterus is lifted out of the pelvis. Postural Version—In this method the woman is put in dif- ferent positions to influence the position of the child in utero by the force of gravity. For example, if the brow should present, the woman should be turned on that side toward which the fetal back looks, so that the breech may drop to that side, and thus bring the vertex to the center of the superior strait; or, if the head should be tightly fixed in the superior strait, the woman may be turned on that side toward which the face looks, in order to promote the flexion of the child's head, and thus favor a con- version of the brow presentation into one of the vertex. This is a simple, safe, and easy means of performing version, if it is practicable. It is usually, however, unsuccessful, and the physician must be prepared to resort to other plans when this fails. VERSION. 7S7 Version by External Manipulation—This method may be used before labor to convert a breech presentation into a presen- tation of the head, or to correct a transverse presentation. When the child has been brought into the position desired, by a series of stroking movements, pads and a binder should be ap- plied to prevent the return of the child to its original position. This method, while successful in a fair proportion of cases, requires often an expert's skill; a diagnosis of the position before labor has begun ; the preservation of the membranes ; thin, flexible uterine and abdominal walls, and non-irritable muscles. Combined Version—This method was first proposed by Busch, D'Outrepont, and by Dr. Wright, of Cincinnati, and was later advocated by Braxton Hicks, of London. The operation is performed as follows : The patient is placed in the lithotomy position and anesthetized. Externally, the hand nearest the fetal part to be acted upon by external manipulation seizes this part through the abdominal walls, the operator being seated facing the vulva. The internal hand pushes the presenting part up and to that side opposite the fetal part acted upon by the external hand. For example, in a shoulder presentation, with the face of the child turned forward and the head in the right iliac fossa, the physician seizes the head with his left hand, inserts the right hand in the vagina, and with two fingers of this hand passed into the uterine cavity pushes the child's left shoulder upward and toward the mother's left-hand side, while the head by external manipulation is pulled downward and toward the median line. In all shoulder presentations, version by the head should be preferred to version by the breech in the combined method, for this presentation is more favorable to the child, and the head is more readily brought to present at the superior strait, making the version easier and quicker of performance than if the breech were brought down. Podalic Version---This operation was known in the time of the Roman Empire, but was lost sight of until Ambrose Pare and his students revived it in the sixteenth century. The operation is performed as follows : Relaxation of the uterus and of the ab- dominal muscles is secured by an anesthetic. The lowest pos- sible position of the fetal feet is secured by turning the mother on that side toward which the feet point. That hand which, midway between pronation and supination, as the operator faces the woman's vulva, corresponds with its palmar surface to the abdomen of the child is inserted, in an aseptic condition, into the uterine cavity, until it meets the anterior foot. This foot is grasped by the first two fingers and the thumb, and is then ex- tracted until the knee appears at the vulva. 758 OBSTETRIC OPERATIONS. Fig. 556.—D'Outrepont's method of combined version, modified by Scanzoni. Fig. 557.—Combined version by the breech. Fig. 558.—Combined version, Wright's method. VERSION. 759 The advantages of resting content with the anterior foot, and drawing upon it alone without seeking for the other, are these : A further entrance into the uterus is unnecessary. It is easier to hold one foot than two. The other leg is folded up upon the abdomen, and thus secures a more thorough dilatation of the cervical canal. Finally, by pulling upon the anterior foot one is more likely to secure a sacro-anterior position of the breech. While making traction upon the foot, the version of the child is facilitated by external manipulation of the head (Fig. 562). It is-occasionally easier to seize a leg or the knee than the foot (Figs. 563, 564). In such a case time need not be wasted seek- Fig. 559.—Version in dorsoposterior Fig. 560.—Version in dorso-anter.or position. Traction in upper limbs (Fara- position, first stage of traction in lower beuf and Varnier). limb (Farabeuf and Varnier). ing for the foot. Combined version by the breech may precede or replace podalic version with great advantage, as first pointed out by Braxton Hicks, obviating the necessity of introducing the hand into the uterine cavity and enabling the operator easily to seize the knee or foot after it is brought near or into the supe- rior strait. As soon as the knee is born, the operation of podalic version is finished, and, unless there is some indication for immediate delivery, the anesthetic should be removed, the patient should be turned upon her back, and should be allowed to expel the child spontaneously until the umbilicus appears in view. This delay secures a more thorough dilatation of the cervical canal, 760 OBSTETRIC OPERATIONS. and produces a paretic condition of the circular muscle of the cervix. The advantages of this condition of the cervix are obvious when it comes to the extraction of the after-coming head. With an undilated cervical canal and a rigid cervical muscle, the neck is likely to be grasped in so firm a hold that all efforts to extract the head are unavailing until the child is asphyxiated. In rare cases rapid extraction may be indicated. Fig. 561.—The upper buttock is Fig. 562. — Assisting podalic version by moving downward and the lower shoul- external manipulation (Dickinson). der rising (Dickinson). If it is, the legs and trunk are pulled upon forcibly, as shown in fig- ures 565 and 566. The child's body being slippery, should usually be enveloped in a towel. When the child is born to the umbilicus the pressure upon the cord is great, and delay in the extraction of the infant beyond this point means an asphyxia so deep that it is unlikely the child will be revived. From this moment, there- VERSION. 761 fore, the attendant must put forth every effort possible to secure the most rapid delivery of the infant. This is effected by the \^ mm, , Fig. 563.—Seizing the leg instead of the foot. Fig- 564.—Seizing a knee instead of the foot. following methods : The arms, if extended alongside of the child's head, as they usually are after version, must be extracted in the following manner : locate the posterior arm by the 762 OBSTETRIC OPERATIONS. position of the trunk and shoulders. To deliver the right arm, grasp the legs with the left hand, the middle finger above the internal malleoli, the index and middle fingers above the external malleoli. Raise the child's body upward and outward over the mother's right thigh. This movement should be suffi- ciently forcible to bring the right shoulder well down in the pelvis. The first two fingers of the right hand, entering the vagina in contact with the right scapula, are passed along the posterior surface of the arm beyond the elbow, when the arm and forearm are pushed in front of the child's face as though the elbow-joint did not exist. The fingers are now hooked in the Fig. 565.—Method of seizing the Fig. 566.—Method of seizing both breech. feet. elbow-joint and pulled directly downward until the elbow appears at the vulva, the forearm being flexed by this movement upon the arm. The forearm is then easily delivered by extension. The left arm is brought down and delivered in the same manner, sub- stituting, of course, right for left. The right hand grasps the child's feet and lifts them over the mother's left thigh. The fingers of the left hand are inserted into the vagina past the elbow-joint. The arm is swrept forward over the face, as though it were a single piece without the elbow-joint. The elbow is then flexed, pulled downward, and the forearm extended at the vulvar orifice. Should the shoulders occupy a transverse posi- tion, either arm may be brought down and delivered first. After VERSION. 7^3 delivering the arms, the head may be extracted by one of the following methods, given in the order of their efficiency and safety : Wiegand's Method.—In this method the first three fingers of the supinated hand are inserted into the vagina, that hand being employed whose palm corresponds to the abdomen of the child. Over the forearm of this hand the child's body rests astride. The index-finger of the hand in the vagina is inserted in the child's mouth, care being exercised to avoid the eye-sockets. Fig. 567.—Delivery of the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim (Dickinson). Sufficient traction is exerted upon the lower jaw to secure and maintain flexion of the head. The disengaged hand now locates the head through the abdominal wall above the pubes, and delivery is accomplished by suprapubic pressure in the axis of the parturient canal, and by the elevation of the child's body toward the mother's abdomen. Mauriceau's Method.—One hand is inserted in the vagina, as described above, and one finger is placed in the child's mouth. The other hand is passed along the child's back until the middle finger rests upon the occipital protuberance. The index- and 764 OBSTETRIC OPERATIONS. ring-fingers are flexed over the clavicles, and traction is made by both hands at once, the force upon the jaw and the pressure upon the occipital protuberance keeping the head well flexed, Fig. 568.—Combined traction upon mouth and shoulders (Mauriceau). Fig. 569.—Second step of the Mauriceau method. while the traction upon the shoulders extracts the head in the direction of the parturient canal. As the head descends upon the pelvic floor, the child's body is carried upward toward the mother's abdomen. Properly directed suprapubic pressure by VERSION. 765 an assistant increases the efficiency of this method, and makes it, indeed, the most effective of all methods in extracting the after- coming head. Prague Method.—The child's ankles are grasped with the right hand pronated, the middle finger being placed between the legs just above the internal malleoli, the index- and ring-fingers above the external malleoli. The index-finger of the left hand is flexed over one clavicle, and the remaining fingers of the same hand over the other clavicle. Traction directly downward is now made with both hands until the perineum is well distended. F'g- 57°-—The method of Fig. 571.—The Prague method of extracting extracting the trunk. head. The right hand then loosens its hold upon the ankles, and again grasps them as described above, but approaching them at their anterior surface. The child's feet will now be in contact with the back of the right hand. The feet are then raised by a cir- cular movement toward the mother's abdomen, while the left hand as originally placed is used as a fulcrum, around which the head moves until it is finally forced out of the parturient outlet by this lever-like movement on the part of the child's body. Forceps.—An assistant should raise the child's body, sup- porting its arms and legs, and thus keeping them out of the way of the operator, who rapidly applies the blades to the sides of the y66 OBSTETRIC OPERATIONS. child's head. Traction is made in the direction of the axis of the parturient canal, and the head is finally delivered by lifting the handles of the forceps, the disengaged hand protecting the perineum as much as possible. Deventer's Method.—The child's body is seized as in the Prague method, but the arms are still alongside the child's head Fig. 572.—Deventer's method of extraction of the after-coming head and arms (Dickinson). and need not be extracted first. The body is pulled directly downward toward the ground, until the shoulders descend and press upon the pelvic floor. The child's body is then carried downward and backward under the woman's buttocks, the head being rolled out of the parturient outlet between the arms, which easily follow after. To do this the woman's buttocks must pro- ject well beyond the edge of the bed, and the child must be EMBRYOTOMY. 767 carried well under them. The operation is only possible under the most favorable conditions, and is not always to be relied upon. It has, however, the merits of simplicity and rapidity. EMBRYOTOMY. Embryotomy is a mutilating operation upon the fetus. The term is generic,and includes the following operations: Craniotomy, decapitation, evisceration, and amputation of the extremities. Craniotomy—In this operation the child's head is perforated, the contents evacuated, and the head thus diminished in size. The forcible extraction of the evacuated head is often also a part of the operation. The operation may be indicated upon a dead or upon a living child. In the former case the indications for the operation may be comparatively trivial. If the mother can be saved any additional risk or suffering by the rapid delivery of the mutilated child, craniotomy is not only justifiable, but advis- able. In case of prolapse of the umbilical cord, with a con- tracted pelvis, the commonest condition that calls for craniotomy upon a dead infant, it is far better to open the head and to deliver the child easily with a cranioclast, than to apply the forceps to the head at the superior strait and to subject the mother to the delay, pain, and danger of a prolonged forceps operation, when nothing is to be gained by it. Craniotomy upon the living child is only justifiable in excep- tional circumstances. To condemn this operation, however, unreservedly and without exception is a mistake. In cases of difficult labor, when the pelvis is contracted or the child over- grown, and the physician must make a choice between Cesa- rean section, symphysiotomy, or craniotomy, if he has no skill in surgical work and is unable to procure expert assistance, it is better, unquestionably, to sacrifice the child for the mother's sake, rather than to attempt a serious surgical operation, amid un- favorable surroundings, and performed by an unskilful operator whose mortality must be very great. Every attempt must be made to avoid the destruction of a living child, of course ; and if the operator feels himself pos- sessed of sufficient skill to attempt the more serious operations of Cesarean section and symphysiotomy with fair prospect of success, or if he can summon to his aid an expert obstetric or abdominal surgeon, he should not think of performing crani- otomy upon the living child. But under certain circumstances craniotomy upon a living infant is a justifiable operation, and one not to be unreservedly condemned. 768 OBSTETRIC OPERATIONS. The Instruments for the Operation—Embryotomy is the oldest operation of obstetrics and the instruments for performing it would make an interesting historical collection. The sharp hook or crotchet in its numerous forms had a place in the obstet- rician's armamentarium for many centuries. At the present day the operator may need for craniotomy a perforator, a head seizer A B Fig-573-—A, Sharp hook or crotchet ; B, Baudelocque's cephalotribe. or cranioclast, and a head crusher in its various forms of cephalo- tribe, basiotribe, or basilyst. Perforators.—The best perforator is Blot's. Smellie's perfora- tor or Hodge's scissors answer the purpose well enough, and in the absence of an instrument specially devised for the purpose, any long, sharp-pointed scissors serves admirably. Head Seizers or Cranioclasts.—This instrument was invented by Sir James Y. Simpson. It has been much improved by Carl EMBRYOTOMY. 769 -K. Fig- 574-—Smellie's perforator. F'g- 57S-—Blot's perforator. Fig- 576.—Oldest form of cranioclast. Fig- 577-—Simpson's cranioclast. Fig- 578.—Braun's cranioclast. Fig- 579-—Cranioclast modified by the author. 49 770 OBSTE TRIC OPERA TIONS. Fig. 580.—Hicks' cephalotribe. Fig- 581.—Tarnier's basiotribe. Fig. 582.—Tarnier's basiotribe (separate parts). Fig. 583.—The second blade of the basiotribe has crushed the sinciput. EMBRYOTOMY. 771 Braun and the author has added to the latter instrument a pelvic curve, which facilitates its application at the superior strait. The cranioclast is made with two blades : one for insertion inside the other outside, the skull. The handles are provided with a screw and nut to bring them close together, so as to give the blades a powerful grip upon the skull. Head Crushers or Cephalotribes.—The cephalotribe is the in- vention of the younger Baudelocque. It is simply a heavy, powerful forceps with the handles screwed together so as forci- bly to compress the skull between the blades. The best cephalo- tribe is Tarnier's basiotribe, which combines a perforator and a powerful head crusher. Other modern instruments for the extraction of the mutilated Fig. 584.—Perforation of the head begun : the right hand is grasping the handles of the instrument. The tips should not be separated until after they have entered the fontanel (Dickinson). head are Simpson's basilyst and Van Huevel's laminator. The latter is designed to saw off the face and the occipital protuber- ance. A wire ecraseur answers the purpose perfectly well, as was shown by Barnes. In addition to these instruments, the operator needs a heavy volsella forceps and a large metal catheter to break up the brain and to wash it out of the skull. The technic of the operation is as follows: The woman should be anesthetized not so much because the operation is painful or prolonged, but to spare her the sight of her mutilated infant. The patient is placed in the lithotomy position, and brought well to the edge of the bed or table on which she lies. 772 OBSTETRIC OPERATIONS. The vagina is scrubbed with tincture of green soap and hot water on pledgets of cotton. Following this, a douche of bichlorid solution, I : 4000, is given. The child's scalp is then seized by a strong volsella forceps, which is handed to an assistant, who pulls upon the instrument firmly, so as to fix the head at the superior strait. The operator then inserts two fingers of his left hand, made aseptic, and feels for a suture or a fontanel. The perforator is then inserted into the vagina, along the palmar surfaces of the fingers, and is plunged into the skull Fig. 585.—The head after delivery by the cranioclast. at a point upon which the finger-tips rest—that is, through a fontanel or a suture. When it has entered the skull the per- forator is twisted about in all directions, in order to break up the brain and is also opened in several different directions to enlarge the opening in the skull. The large catheter is next inserted and attached to a Davidson syringe. A column of water is injected into the cranial cavity, to wash out the remaining brain-substance. Next, if it is necessary, the size of the emptied head may be reduced with a cephalotribe. This is only called for in case of EMBRYOTOMY. 773 extreme pelvic contraction, or in the presence of some pelvic tumor seriously diminishing the capacity of the pelvic canal. In the vast majority of cases a cranioclast should be used instead of the cephalotribe. The internal branch of this instrument is inserted within the skull. The outer branch is next introduced in the same manner that one would insert a blade of the forceps. The two branches are then locked, and the handles are screwed firmly together, care being taken that the internal branch isinserted deeply within the cranial cavity, so that it shall get a firm grasp upon the skull. The child is now extracted in the same manner that one would extract the head with the forceps, except that the tractive efforts are made uninterruptedly and with greater Fig. 586.—Craniotomy on the after-coming head: one method of perforating (Dickinson). force. In certain cases it is sufficient simply to perforate the skull. This applies particularly to cases of hydrocephalus. The head being evacuated, the forces of nature will be sufficient to in- sure the child's delivery. If it is necessary to perforate the after- coming head, the perforator may be inserted behind the ear, in the lambdoid suture, under the chin, through the roof of the mouth, or, possibly, through the foramen magnum. In a case of hydrocephalus with breech presentation, should there be great difficulty in reaching the after-coming head, it is possible to evacuate the fluid by perforating the spinal column and passing a catheter through the spinal canal into the cranium. Decapitation.—The chief indication for decapitation is an impacted shoulder presentation, in which it is impossible to do 774 OBSTE TRIC OPERA TIONS. version, either on account of the inability to move the child or because of the risk of ruptured uterus owing to the enormously distended lower uterine segment. The instruments needed for Fig. 587.—Braun's hook. this operation are a Braun hook or a Ramsbotham sharp hook. The former is fastened firmly over the child's neck, when with two or three sharp turns of the wrist the neck is broken, and the soft structures may be pulled through with the hook alone, or may be severed with scis- sors. The Ramsbotham knife- edged hook is passed over the neck, and by a rocking motion is made to cut through all the tissues of the neck. In the absence of specially devised instruments for the purpose, a string may be car- ried over the neck and the child decapitated by a sawing movement with the string, the vagina and perineum being protected by a Sims speculum. Amputation and eviscera- tion are very rarely indicated. Some forms of monstrosities may possibly require these operations. A long-handled scissors is the best instrument for the purpose. SYMPHYSEOTOMY. The operation of symphyse- otomy is a division of the pubic joint, allowing a diastasis of the bones during labor, the child being extracted through the natural passage. The opera- tion was suggested for the first time in 1598, and was performed Fig. 588.—Decapitation with Braun's hook (Dickinson). S YMPHYSE 0 TOM Y 775 for the first time on a living woman in 1777 by Sigault in Paris. For a time symphyseotomy was in high favor, but the mortality that followed it, and the accidents which frequently marred its success, prejudiced the medical world against it, and it gradually died out. In 1866 the operation was revived in Italy, and from that time to 1886 it was performed 71 times with a death- rate of 25 per cent. The success achieved in the latter years of this period attracted the attention of the Parisian school of obstetricians. The operation was revived in its original home, and this revival was followed rapidly by its adoption throughout the civilized world. In the following three years there were 74 operations in the United States, with 10 maternal deaths and 18 infantile deaths. The mortality for America is about 12 per cent., but certain operators abroad have had as many as 20 cases in succession without a fatal result, and in Italy 54 symphy- seotomies have been performed with but 2 deaths. Even the best records for Cesarean section do not equal this, and, taking into consideration the statistics of both operations throughout the civilized world, it may be said that Cesarean section is about twice as dangerous to the mother as is symphyseotomy in the hands of a surgeon not specially trained. The expert abdominal surgeon, however, with a thorough aseptic technic should have a very low, and about an equal, mortality in both operations. An objection long urged against symphyseotomy, and one that retarded its general adoption, was that little space is gained by the separation of the pubic bones. But a careful study of the subject on the living woman and on cadavera has shown that the separation of the symphysis up to 7 cm. secures an increase in the anteroposterior, the transverse, and the diagonal diame- ters of the pelvis of 1.4 cm., 3.1 cm., and 3.5 cm., respectively. Clinical observation, moreover, has demonstrated its utility in pelves with a conjugate above 7 cm. This, in my opinion, should be the lowest limit for the operation. It is possible to achieve success with a conjugate as low as 6.5 cm., but in a pelvis so badly contracted symphyseotomy is more dangerous than Cesarean section, and it is possible that after the symphysis is severed it may be found necessary to deliver the child by craniotomy. The Indications for Symphyseotomy.—This operation should be the alternative of version in flat, contracted pelves. The woman with a conjugate diameter over seven centimeters should be al- lowed to remain in active labor twenty-four hours. If at the end of that time the head is not engaged, axis-traction forceps should be applied and an attempt made with the instrument to engage the head. If after some twenty minutes of intermittent traction with justifiable force the head is not engaged, a choice must J/6 OBSTETRIC OPERATIONS. be made between version and symphyseotomy. The former is almost always practicable with a conjugate over seven centi- meters, but the mortality of the infants is about thirty-three per cent. The latter practically insures a living child but is distinctly dangerous to the mother, especially if the operation must be performed in a private house, and in an emergency. The case should be laid before the woman or her husband, who should certainly have some voice in the decision. The only situations in practice in which version need not be considered as an alter- native to symphyseotomy are the firm impaction of the present- ing part in the superior strait, and labors obstructed by a gener- ally equally contracted pelvis and by a kyphotic pelvis. The Technic of the Operation.—This differs as one prefers the French or the Italian method. The latter, to my mind, is to be preferred. It is quite as easy as the direct incision, and it has Fig. 589.—Galbiati's knife for cutting the symphysis. Fig. 590.—Author's knife for cutting the subpubic ligament. the great advantages that the wound is more readily kept from infection after delivery and that injuries to the urethra and blad- der are more surely avoided. To perform the operation accord- ing to the Italian plan the technic is as follows : The abdomen and pubic region should be cleansed as though for an abdominal section. An incision is made just above the symphysis, about an inch long, through the skin, fat, and super- ficial fascia. The attachment of the recti muscles to the pubic bones is then severed by a transverse cut just sufficient to admit the fore-finger behind the symphysis. The fore-finger of the left hand is passed behind the symphysis and hooked under it, while an assistant inserts a metal catheter in the woman's urethra, holding it down and a little to one side, usually the woman's right. The curved or sickle-shaped knife S YMPHYSE O TOM Y. 777 of Galbiati is then seized firmly in the right hand and passed along the index-finger of the left hand until it glides under the symphysis. With an upward and forward rocking movement of the knife the symphysis is divided. It will almost invariably be found that this incision has failed to divide the subpubic ligament. To cut this, a smaller curved knife is inserted into the wound and passed under the ligament, which is then severed, from below upward, without difficulty. At this point in the operation there is usually a good deal of hemorrhage, which Fig. 591.—Subcutaneous section of the symphysis. occasionally is most alarming. It can be checked at once, how- ever, by packing the wound firmly with a strip of iodoform gauze. During this part of the operation two assistants hold the woman's thighs equally flexed and at an equal distance apart. Each assistant should also support the pelvis by firm pressure with a hand upon the trochanters. If the child's head is pre- senting, axis-traction forceps should be applied to it, and the head slowly and interruptedly extracted along the parturient canal, at each tractive effort the assistants being warned to exert 77% OBS TE TRIC OPE RA TIONS. firm lateral pressure upon the pelvis to prevent too great separa- tion of the pubic bones, which would endanger the integrity of the sacro-iliac joints. As soon as the child is born, the knees of the woman are brought together and the thighs are somewhat extended. The operator then cleanses his hands again, removes the gauze packing from the suprapubic wound, inserts a finger behind the symphysis to see that the bladder is not nipped between the pubic bones, and then sews together the abdominal wound with three or four silkworm-gut sutures. It is quite unnecessary to suture the pubic bones or the symphysis. A dressing of aseptic gauze, cotton, and adhesive strips is applied Fig. 592.—French method of performing symphyseotomy (direct incision). to the wound. A firm binder is placed about the hips, and the woman is put in bed straight upon her back, upon an even mattress, which should be firm enough not to allow of sagging where the woman lies upon it. It is an advantage to support the sides of the pelvis with sand-bags during the woman's con- valescence. These should be placed directly alongside the hips, extending at least to the knees. The after-care of a symphyseotomy is exceedingly trouble- some. The patient must usually be catheterized, and much care must be exercised to keep the vulva and the surrounding regions clean. This is best done by slipping a bed-pan under the CESAREAN SECTION. 779 woman's buttocks and rinsing off the external genitalia two or three times a day with a weak solution of bichlorid of mercury. A slip sheet should be placed over the sand-bags and under the woman's buttocks. The knees must be kept bound together, and the woman must lie quietly upon her back for at least three weeks. If it becomes necessary to disinfect the parturient canal during puerperal convalescence, the legs should be raised straight in the air, without separating them or without bending the knees. A bed-pan is then slipped under the woman's buttocks, and the physician can carry out curetment and intra-uterine douching with comparative convenience. In the French method of performing symphyseotomy an incision is made directly over the joint, which is then cut with an ordinary scalpel. It is asserted that synostosis of the symphysis occasionally complicates the operation. I suspect that in the majority of such cases the operator has missed the joint. In view of this possibility, however, a chain or a metacarpal saw should be among the instruments prepared for the operation. CESAREAN SECTION.1 When the escape of the child by the natural passage is impos- sible, it may be delivered by an abdominal and uterine incision. Cesarean section may be performed ante- and postmortem. Postmortem Cesarean Section.—If a pregnant woman near term dies suddenly, the abdomen and uterus may be cut open as quickly as possible, in order to deliver a living infant. It is said that the child has been extracted alive twenty minutes, three- quarters of an hour, and even two hours after the death of the mother, although it is almost inconceivable that this should be so. The child's death usually is synchronous with that of the mother, or follows a few moments afterward. In my opinion rapid version and extraction preceded by forcible dilatation of the cervix is a preferable method of delivery in a woman who has died suddenly during pregnancy, and, if possible, the operation should be completed before death has actually occurred. Thetis- sues of the dying woman offer no resistance to the forcible dilata- tion of the cervix, and the extraction of the child can be effected, as a rule, quite as quickly by version as by Cesarean section. Cesarean Section upon the Living Woman.—The first recorded Cesarean section upon a living subject was performed in Europe in the year 1610 2 ; but the operation is probably a much older 1 The name is not derived from Caesar, but from the Latin description of the operation, Cceso mains utero. 2 By Trautmann in Wittenberg. The patient lived twenty-five days. 780 OBSTETRIC OPERATIONS. one, and was in all likelihood known in certain primitive tribes and nations in remote antiquity. Until quite recent times the mortality of Cesarean section was so high that the operation was avoided at any cost. Among the procedures devised to avoid it was laparo-elytrotomy, an operation that is no longer justifiable. A few years ago in England the death-rate was more than 99 per cent. Throughout the civilized world the mortality was at least 50 per cent. With the improvement in the technic of abdominal surgery, and with the perfection of asepsis in such surgery, the statistics of Cesarean section have steadily improved, until at the present time it has been possible to collect 68 consecutive cases with a mortality of 5.8 per cent., and 27 cases with a mortality of 3.7 per cent.1 Under favorable circumstances and in the hands of skilful operators, the mortality of Cesarean section may be very low, perhaps below 5 per cent.; but in general practice the mortality of the operation remains high, and will probably continue so. In America the mortality, according to Harris' statistics, ranges from 30 to 40 per cent. Varieties of the Cesarean Section.—In 1876 Porro 2 modified the operation by successfully performing, in addition to the celio- hysterotomy, a hysterectomy—that is, a removal of the uterus. The stump was fixed in the abdominal wound, and treated extra- peritoneally. The improvement introduced by Porro reduced the mortality one-half by the prevention of leakage through the uterine wound into the abdominal cavity. The next improvement in the technic was introduced by Miiller, who advocated a long abdominal incision through which the womb was delivered before it was incised. This prevented the soiling of the peritoneal cavity by liquor amnii and blood. Miiller also advocated the application of an Esmarch tube around the cervix and broad ligaments to control hemorrhage, but this is a bad plan, as it predisposes to postpartum bleeding from relaxation of the womb, and is never really necessary. No con- striction of the cervix at all is required if the operation is done with sufficient rapidity. The most important modification of Cesarean section in recent times—or, at least, the modification that has attracted the most attention, and has apparently done most to improve the mor- tality of Cesarean section—was that introduced by Sanger.3 Sanger was the first to propose the careful and accurate closure of the uterine wound by a double layer of sutures. At first it 1 Leopold, " Ueber ioo Sectiones Cesarese," " Archiv f. Gyn.," Bd. lvi. 2 The amputation of the uterus after a Cesarean section was first proposed by Michaelis in 1809, and first carried out with a fatal result by Storer, of Boston, in 1868. 3 "Archiv f. Gyn.," Bd. xix. CESAREAN SECTION. 78 I was thought necessary to make a peritoneal flap by exsecting a portion of the uterine muscle below the peritoneum. But it was soon recognized that this was unnecessary, and the present prac- tice is to use simply a deep and superficial layer of sutures, sufficiently large in number to secure the accurate and firm clo- sure of the uterine wound. The superficial layer of sutures may be introduced after the manner of Lembert, but even this is not absolutely necessary ; if they are tied tightly and set closely enough, a single insertion of the needle on each side of the wound will insure the approximation and closure of the peritoneal cover- ing of the wound. Indications for Cesarean Section.—The indications for this operation are relative and absolute. By an absolute indication is meant some condition which admits of no other method of delivery. Examples are furnished in extreme degrees of pelvic contraction—in a flat pelvis, for instance, in which the true conjugate is less than six and a half centimeters. The highest grades of kyphosis, osteomalacia, spondylolisthesis, and Naegele's pelves also furnish absolute indications for Cesarean section, as do foreign growths obstruct- ing the pelvis, cicatricial contraction of the vagina, and carcinoma of the cervix and of the rectum. By a relative indication for Cesarean section is meant a con- dition that admits of some other method of delivery,—say, by symphyseotomy or by craniotomy,—but in wiiich the question arises whether Cesarean section will not give the best result for mother and child. In a case of this kind the decision is difficult, and should be left, in part at least, to the woman or to her hus- band. Ordinarily, the physician will be instructed to select the form of operation least dangerous to the woman. Examples of a relative indication for Cesarean section are found in flat pelves with a true conjugate above seven centimeters. Technic of the Porro Operation or Celiohysterectomy. — The most favorable time for a Cesarean section is about two weeks before term. It is not necessary to wait for the beginning of labor; in fact, it is better not to do so if the indication for the operation is absolute. A time of day convenient to the physi- cian should be selected, and all the preparations should be made for the operation as for any other abdominal section. Where the surroundings and the time permit of it, the following regulations, which govern the abdominal work of the author in general, should be carried out: Give the patient, on admission to the hospital, a full hot bath. Have her kept in bed from the time she enters the hospital until the operation is performed. Administer pill: strychnin, gr. fa ; 782 OBSTETRIC OPERATIONS. digitalis, gr. \; quinin, gr. 2 ;—t. i. d. before operation. Secure movements of bowels by two drams Rochelle salt every evening. Have the heart and lungs examined. Examine urine. Day before Operation.—Diet.—Gruel for breakfast, soup for dinner, milk-toast for supper, one glass of milk 10 a. m., 4 p. m., 9 P. M. Medicine.—Five p. m., afternoon before operation, ten grains sulphonal in half a glass of boiling water, cooled down to tempera- ture that permits of its being drunk, if patient is nervous and has been sleepless. Nine p. m., half an ounce of Epsom salt in a tumblerful of water. Evening before, first cleansing of the abdomen, as follows: Cleansing.—1. Sterilize the following articles for twenty minutes at 24001: soft bristle brush ; absorbent cotton ; one-half dozen towels ; gauze, unmedicated ; binder; long gown. 2. The physician, or, under his supervision, the nurse, who cleanses the abdomen must prepare his or her hands and arms as though about to operate—namely, remove rings ; scrub with brush, hot water, and tincture of green soap for ten minutes in three changes of sterile water; clean nails with sterile nail-file; scrub hands and arms with benzine and then with alcohol ; immerse hands and arms in bichlorid solution (1 : 1000) for two minutes. Then put on the gown. 3. The abdomen, from ensiform to symphysis, and from flank to flank, must be scrubbed thoroughly (for at least ten minutes) with soft bristle brush, tincture of green soap, and hot water, paying special attention to navel and to pubic regions. Wipe off a razor with cotton and alcohol. Shave the pubis, then scrub the whole abdomen again thoroughly with alcohol. Cover the abdomen with the sterile gauze, and put on the binder. Morning of the Operation.—Give cup of beef-tea at 7 a. m. Hands of nurse or the doctor cleansed, articles re-sterilized, same cleansing of abdomen repeated as described above, but, in addition, before alcohol scrubbing, scrub abdomen with benzine ; wring put a sterile towel in 1 : 1000 bichlorid solution, and cover the abdo- men with the towel; put over it a thick layer of sterile cotton ; apply binder. Catheterize the woman, just before anesthetiza- tion, with sterile glass catheter in aseptic manner. Give vaginal douche, 1 quart of 1 :4000 solution, followed by a little sterile water. If the bowels have not opened freely, give enema—a pint of soapsuds and one dram of turpentine. Instruments for Hysterectomy.—Two scalpels ; one straight blunt and one large pedicle-scissors; eight hemostats; four In the absence of an autoclave sterilizer, an Arnold steam sterilizer will do. CESAREAN SECTION. 783 curved large pedicle-clamps ; four Keen's hemostats ; one large and one small volsella forceps ; two right and two left aneurysm needles ; one right and one left sharp-pointed pedicle-needles ; four curved and two straight needles ; one tissue-forceps ; catgut; silk ; ten strands silkworm gut. Dressings, etc., for Abdominal Section.—Autoclave No. 1 ; ten towels ; one large binder; three pieces gauze ; three pieces cotton ; two six-inch gauze bandages ; two sheets ; three covers for tables ; three gowns ; three caps ; six brushes ; one bundle wooden toothpicks for nails ; one large cover for basket; silk ligatures ; tubes of catgut in absolute alcohol. Autoclave No. 2 ; three small white basins ; three small white pitchers ; one small nickel pan ; seven small gauze pads ; seven large gauze pads; one intestinal pad (sixteen inches square). The Operation.—With a large scalpel held firmly in the full hand, a free incision is made from two inches above the umbilicus to just above the symphysis. This incision may be carried en- tirely through the abdominal wall in its upper part, as the intes- tines are out of the way. The abdominal opening is enlarged with scissors downward as low as possible. An assistant makes the wound gape while the operator delivers the womb from the abdominal cavity. A sterile towel is next packed in the perito- neal cavity behind the uterus. The assistant then approximates the edges of the abdominal wound as closely as possible around and above the cervix, at the same time squeezing the latter with his outspread hands. With a few rapid but light strokes of the knife the operator makes an incision an inch in length through the uterine muscle, but not through the membranes, so as not to cut the child. Then, with one rapid movement of the left hand and arm, the uterine wall is torn down to the internal os, the mem- branes are ruptured, the placenta, if in the way, is detached and pushed aside, the child is seized by the most accessible part,— shoulder or leg,—is delivered, and, with the placenta still attached to it, is dropped into a sterile sheet spread out over the out- stretched arms of an assistant who stands directly at the opera- tor's left hand, and whose duty it is to revive the child, if asphyxiated, and to tie and cut the cord. Up to this point the operation rarely requires seventy-five seconds. Then follows an easy hysterectomy : the ligation of the ovarian arteries and of the arteries of the round ligaments ; the application of clamps ; the cutting of the broad ligaments ; the preparation of peritoneal flaps; amputation of the womb; the ligation of the uterine arteries ; and the oversewing of the stump, which is dropped. The abdominal wall may be closed by close-set, interrupted 7«4 OBSTETRIC OPERATIONS. stitches,—the easiest plan for a beginner,—or by a few through- and-through, interrupted silkworm-gut sutures, which simply serve to splint the wound—the peritoneum, the fascia, and the skin being united by separate running stitches of catgut. The technic of the Sanger operation is the same up to the point when the child and appendages have been extracted from the womb except that the uterine wall must not be torn but should be clean cut with scissors. Then, instead of amputating the uterus, the uterine wound is carefully brought together by three sets of sutures ; one interrupted, of fine silk, set about an inch apart, inserted under the peritoneum running across the lower part of the wound above the endometrium and emerging on the oppo- A B Fig. 593.—A, The interrupted sutures; B, the lower tier of the running catgut stitch. site side under the peritoneum ; the second, a running cat-gut stitch in two tiers, embracing the muscle only and ending oppo- site the point where it began, so that there is but one knot; the third, a running Lembert stitch of fine silk in the peritoneum, beginning above and running down, the needle being inclined upward at each insertion to allow for the pull downward of the suture when it is tightened (Figs. 593 and 594). Fritsch's proposition to make the incision across the fundus uteri from tube to tube, instead of in the anterior abdominal wall, is receiving a practical trial in Germany. There seems to be no decided advantage in it except that the uterine wound is as far as possible from the cervical canal, and, therefore, from subsequent CESAREAN SECTION. 785 contamination. But should leakage occur, the woman is de- prived of a safeguard to which she has often owed her life, namely, adhesions between the uterine and abdominal walls. The Choice of Celiohysterectomy or of Celiohysterotomy in a Case Requiring Cesarean Section.—The impression pre- vails that the classical conservative Cesarean section, or celio- hysterotomy, is a safer and better operation than the Porro- Cesarean section, or celiohysterectomy—the removal of the uterus after the extraction of the child. It is the general belief that hysterectomy should only be performed when a woman has been very long in labor and many futile attempts to extract the child had been made, probably infecting the endometrium ; if there Fig. 594.—A, The upper tier of the running catgut stitch ; B, the running Lembert stitch in the peritoneum. is uncontrollable hemorrhage from uterine atony ; in case of in- superable obstacle to drainage of the lochia, as a cancer of the cervix or a bony tumor of the pelvis ; or in the presence of a uterine tumor which could only be removed with the uterus. It is the author's conviction, however, that celiohysterectomy in a case requiring Cesarean section is the preferable operation, with a lower mortality and a greater freedom from complications not only in the puerperium, but in the patient's future existence. It is easy to understand the prejudice against the Porro operation and in favor of the classical Cesarean section, if one recalls the history of abdominal and uterine section for the ter- mination of insuperably obstructed labors. 50 786 OBSTETRIC OPERATIONS. During the first two hundred and sixty-six years in which Cesarean section was practised upon the living woman the mor- tality of the operation had been so frightful that any expedient to avoid it was thought justifiable. Induction of abortion for deformed pelvis, symphyseotomy, laparo-elytrotomy, each had its origin in a desire to escape the dangers of Cesarean section, while, for the same reason, much ingenuity was devoted to the improvement of the technic and to the invention of new instru- ments in the oldest obstetrical operation—embryotomy. Finally, in the spring of 1876, Edward Porro performed the first successful celiohysterectomy for obstructed labor. This method of operating so obviously avoided the most fatal dangers of the older plan that it was widely adopted, and in the hands of such men as Carl Braun, Breisky, Leopold, Krassowsky, Frank, Fehling, Tait, and Porro himself, the mortality of Cesarean sec- tion was reduced to less than half of what it had been. Scarcely, however, were these results beginning to be appreciated by the medical world at large when Sanger proposed the close and accurate suturing of the uterine wound, including the peritoneal covering. Coincident almost with the adoption of this great improvement in the operation there began the aseptic era in ab- dominal surgery and the appreciation of the common-sense rule that Cesarean section, when required at all, should not be post- poned until the patient is at the last gasp, after every other means of delivery had been tried in vain. By a combination of three factors—close suturing of the uter- ine wound, aseptic technic, and early operations—results were secured of such brilliancy as to throw the achievements of Porro and his followers completely in the shade. Meanwhile, however, Cesarean section by celiohysterectomy had undergone an evolu- tion from which attention was distracted by the glamour of the results following the Sanger operation. All gynecologists are familiar with the improvement in the technic of hysterectomy which has made the intraperitoneal treatment of the stump a much safer as well as a much more satisfactory method of oper- ating than the extraperitoneal fixation of the cervix formerly was. In the past six years a number of Cesarean sections followed by hysterectomy have been performed by the best and most modern technic—ligating the arteries of the broad ligament, dropping the cervix and sewing over it a peritoneal flap. It is too soon, however, to collect statistics of this operation and to compare its results with those of celiohysterotomy. There are disadvantages, moreover, in the mere statistical study of any sub- ject which the practical worker has often reason to appreciate. Without an array of figures, therefore, to support his statement, CESAREAN SECTION. 787 the author can say, from his own experience, that not only does it add nothing to the danger of a Cesarean section to remove the womb, but, on the contrary, it diminishes the risk of the operation, for it eliminates the possibility of postpartum hemorrhage and les- sens enormously the chance of puerperal infection. Certain com- plications in the puerperium also, as well as others at later periods in the individual's life, are surely avoided by a hysterectomy. These are: retention and decomposition of the lochial dis- charge, to which the undilated cervical canal does not give free vent if the operation is performed before labor ; adhesions be- tween the anterior uterine and abdominal walls ; persistent fistulse communicating with the uterine cavity ; rupture of the uterus in subsequent pregnancies and labors, and the necessity for repeated Cesarean sections if the woman is allowed to become pregnant again. In consideration of these incontrovertible facts it is clear that the statistics of the future, studied with discrimination, and tak- ing into account the woman's life-history, will demonstrate the superiority in results of the modern Porro operation over the conservative classical Cesarean section. Whatever one's predilection may be in favor of hysterotomy or hysterectomy, there are certain conditions in parturient women which forbid a freedom of choice and compel the selection of the latter operation. It is important, therefore, to learn the propor- tion of cases in which the Porro operation must be performed and a mere hysterotomy should not be relied upon. The author's experience in Cesarean section amounts to 20 operations, performed for the following indications : fibroid tumors, 2 ; dermoid cysts impacted in pelvis, 2 ; cancer of the cervix, 1 ; partial atresia of vagina, 1 ; contracted pelves, 14, of which there were 1 kyphotic pelvis, 1 obliquely contracted and flat, 1 transversely contracted, 11 flat rachitic. Out of this number it would have been absolutely necessary to perform a Porro operation in 11 cases. In 6 of the operations for con- tracted pelvis the patient had been in labor many hours. Futile attempts at delivery had been made with forceps, and in two in- stances by craniotomy. The uterus was already infected, and the birth-canal injured by slipping instruments or by the exercise of unjustifiable force in efforts at extraction. In one of the cases of impacted dermoids the woman had been in labor four days. The pelvic connective tissue and lower uterine segment were ex- traordinarily edematous, and the endometrium was almost black in color. In the two cases of fibroids attached to the lower uterine segment a hysterectomy was necessary to remove the tumors. In the cases of atresia of the vagina and of cancer 788 OBS TE TRIC OPERA TIONS. of the cervix it was obviously improper to leave the womb behind. If the author may judge by his experience alone, it appears that a Porro operation is required in practice a little more fre- quently than the so-called "conservative Cesarean section."1 It is fair to assume, therefore, that any physician who may be called upon to perform a Cesarean section should always be prepared for a hysterectomy as a part of a Cesarean section. Whether the uterus should be removed in the majority of cases depends upon one's viewpoint in regard to the justifiability of repeated pregnancies in women who can only be delivered by a Cesarean section. It is perfectly plain to the author's mind that a woman should not be condemned to the probability of a repeated Cesarean section unless she herself and her husband demanded it. This, however, is a remote contingency. In almost every case in which the subject is submitted to the patient or to her husband, the surgeon is urgently requested to prevent the possibility of another conception. Even if it were possible for the most skilful and experienced operator, dealing with patients in the most favorable condition and amid the best surroundings, to eliminate the dangers of Cesarean section, it would still be impossible to be certain that a woman would, on the next occasion, be so situated that she could command the best attention. Hence, Cesarean section is and will remain a dangerous procedure with a considerable mortality. Taking into account the unavoidable, though small, mortality of Cesarean section under the most favorable circumstances; considering, moreover, the impossibility of always securing the best circumstances in many cases, it seems perfectly clear that it is unjustifiable to subject a woman with an insuperably ob- structed pelvis to the dangers of subsequent pregnancies and of a repeated Cesarean section. Once this point is conceded, it is unnecessary to argue further for a hysterectomy. No one can contrast in actual practice the greater facility and rapidity with which a Porro operation can be done, the entire freedom from many of the risks of the puerperium after the removal of the uterus, the impossibility of many complications that are likely in the Sanger operation, without preferring the former to the latter operation. 1 Leopold in ioo Cesarean sections performed the Porro operation twenty-nine times {loc. cit.). PART VII. THE NEW-BORN INFANT. CHAPTER I. Physiology of the New-born Infant. Respiration.—There are two factors which explain the in- stitution of respiration : (i) External irritation, the result of a change of environment from a liquid medium, with a tempera- ture of 990 F., to the air, with a temperature of 700 F., causing a reflex action of all the muscles, including those of respiration. (2) The maternal supply of oxygen being cut off from the fetal blood as the placenta is separated or compressed, there is an accumulation of C02, the primary action of which is that of a stimulant to the respiratory apparatus and to the brain-centers governing respiration. The power of the latter factor is often shown during or before labor. Should anything diminish the supply of oxygen to the fetal blood, such as pressure upon the cord, there is an immediate effort to respire. If the membranes are unruptured, liquor amnii is sucked into the lungs. If the head is in the vagina, or if air is admitted to the uterus after rup- ture of the membranes, respiration may be begun long before birth, and the child has actually been heard to cry aloud within the womb {vagitus uterinus). The rate of respiration at birth is 44 to the minute, sinking shortly to 35. The weight at birth is about 7 y pounds. There is a steady increase of about 1 y pounds each month before and 1 pound after the fourth month. Weight, Month. Pounds. 7 16 8 17 9 18 10 19 II 20 12 21 789 Weight, Month. Pounds. 1 7-75 2 9-5 3 " 4 I2-5 790 THE NEW-BORN INFANT. There is normally a loss of 5 ^ ounces, on the average, during the first two to five days, which is usually made up by the end of the first week. Some children, however, gain steadily from birth. Digestion is accomplished by the digestive juices, except the diastatic ferment of the pancreas and of the salivary glands. It is partially dependent upon the bacteria normally present in the alimentary tract. A knowledge of the capacity of the stomach is important if one would avoid the common error of overfeed- ing a new-born infant. The capacity of the infant's stomach is, on the average, dur- ing the first week, 46 c.c; second week, 78 c.c; third and fourth weeks, 85 c.c; third month, 140 c.c; fifth month, 260 c.c; ninth month, 375 c.c. The greater the infant's weight, the greater the gastric capacity. One one-hundredth of the body-weight plus one gram each day is a fairly accurate formula for the expression of gastric capacity in the new-born. In a child of normal weight the capacity should be one ounce at birth and an increase of one ounce per month up to the sixth month, after which it is some- what less (Holt). The Position of Stomach.—Its axis is almost longitudinal, which in part explains the frequent regurgitation and vomiting of early infancy. It is placed high on the left side under the false ribs, so that it is influenced by the movement of the float- ing ribs in respiration. Excretions.—The urine is albuminous for the first few weeks. The quantity is difficult to estimate. It is always acid in reac- tion. The specific gravity is low, 1003-5. A trace of sugar is often found in breast-fed infants and in those fed upon an arti- ficial food containing sugar of milk. The urine is voided six to twenty times in twenty-four hours. It does not, as a rule, stain the diapers, and the mistake may thus be made of supposing none to have been voided. The movements from the bowels consists for the first forty- eight hours of meconium, a substance greenish-black in color, and consisting mainly of bile-salts and coloring matter. Later, the evacuations become light yellow, are not formed, are sour in smell, acid in reaction, and have a slightly fecal odor. The nor- mal frequency of evacuation is from three to four times in the twenty-four hours. The temperature is always slightly elevated directly after birth. It then sinks a little below normal. Its subsequent course is marked by considerable irregularity, with the variations usu- ally above 980. Comparatively slight causes produce high tem- peratures. PHYSIOLOG Y OF THE NE W-BORN INFANT. ygI The eyesight is always hypermetropic. The pulse beats from 125 to 160 in the minute. It should be counted by listening to the beat of the heart, and not by feeling the pulse, as in an older child or adult. The blood has a total bulk to the body-weight of 8 per cent.; there are six to seven millions red blood-corpuscles to the cubic millimeter; they are more spherical than in the older child, and do not tend to form rouleaux. Shadow corpuscles are abundant. White blood-corpuscles are more numerous, viscid, and deliques- cent than in the adult. There is a large amount of hemoglobin Fig. 595.—The circulation in the young embryo, before the atrophy of the umbilical vesicle. at birth compared with the mother's blood—120.2 percent, in the infant and 93.8 per cent, in the mother. At thirty-six to forty-eight hours after birth the percentage of hemoglobin is highest, and then begins to diminish.x The ordinary jaundice of the new-born infant is due to the superabundance of red blood- corpuscles which are destroyed in the liver, giving rise to an excess of bile-pigment. It is reasonable to suppose that it may also be in part hematogenic, the destruction of the red blood- corpuscles setting free a certain amount of coloring matter in the blood, which is directly absorbed by the tissue. 1 Cattaneo, " Diss. Inaug.," Basel, 1892. 792 THE NEW-BORN INFANT The heart exhibits a transition from the fetal to the infantile circulation by the closure of the foramen ovale, the obliteration of the ductus arteriosus, and the disappearance of the Eustachian valve (Figs. 595, 596). The umbilical cord, after twenty-four hours, shows a line of demarcation at its base. There is then a necrosis of the amniotic covering, a mummification of the mucous tissue, and a destruc- Fig. 596.—The circulation in the mature fetus before birth. tion of its vessels. The cord drops off about the fourth day. Its detachment is followed by the retraction of the granulating stump within the umbilical ring. Abnormalities in the Physiology of Premature Infants.— The two main deviations are low temperature—variations below 98 °—and inability to ingest and digest food. The management of premature infants consists in incubation and gavage. In the absence of a specially constructed incubator, PHYSIOLOGY OF THE NEW-BORN INFANT. 793 such as Tarnier's or Auvard's, one can be readily improvised with an ordinary infant's bath-tub, several layers of cotton-wool or lambs' wool, and a number of bottles filled with hot water. Gavage is the regular feeding of the infant with freshly drawn Fig. 597.—Modified Auvard incubator: v, Glass plate of the movable lid b ; H, ventilating tube containing small rotary fan; K, ventilating slide; M, hot-water cans ; O, slide closing hot-air chamber. Fig. 598.—Interior view of a modified Auvard incubator (Fig. 597). mother's milk through a small soft catheter passed into the stomach at each feeding. A more convenient and quite as effi- cient a plan is to draw the mother's milk with a breast-pump and to feed it to the child through a medicine dropper, a few drops being allowed to trickle into its mouth at a time. The ��-/:��/+/.�:0�:+/.9:./:+.�./��D 794 THE NEW-BORN INFANT. intervals between feedings should be an hour and the quantity administered should at first be no more than a dram. The child should not be bathed, but should receive, instead, a daily rub with warm oil. It should not be clothed, but should be buried in wool except its face. A diaper should be put under but not Fig. 599.—Auvard incubator or couveuse. Fig. 600.—Interior view of the Auvard incubator (Fig. 599). around the buttocks, and must be changed often enough to prevent chafing. The mortality of this treatment has so much improved the chances of a premature infant that at six months, according to Tarnier's statistics, 22 per cent, are saved ; at seven months, 38 PHYSIOLOGY OF THE NEW-BORN LNFANT. 79 5 per cent, are saved. Charles,1 from an analysis of 932 premature births, found that at six months 10 per cent, were saved ; at six and a half, 20 per cent. ; at seven, 40 per cent. ; at seven and a half, 75 per cent. Sclerema is a disease of premature infants, seen most often in lying-in hospitals. The most prominent symptom is a har- dening of the skin, beginning in the legs and spreading* over the body, usually sparing the breast and abdomen. Jaundice or a hemorrhagic tendency often accompanies it. The temperature is very low, remaining at or below 95°. The pathology of the disease is not well understood. It has been ascribed to edema. The most probable explanation is that the large excess of stearin and palmitin in the subcutaneous fat of infants solidifies when the temperature falls below normal. The condition is a grave one and is likely to be fatal. The treatment consists in incubation, stimulation, and support. The Management of the New-born Infant.—Clothing.—An infant should be clothed in winter as follows : A binder, of flannel or knit wool, twice around abdomen ; a knit shirt, diaper, knit shoes, and two skirts, the first flannel (in midsummer, linen), and finally its dress. The skirts should be supported from the shoulders by sleeves or tapes. Each skirt should be made with a body, and not with a band. A knit jacket may be worn over the dress. A light flannel shawl or cap is desirable to protect the child's head from cold, when it is lifted from its crib or carried to another room. As an infant urinates frequently, the diapers are changed about twenty to twenty-four times a day. The buttocks should be carefully dried and powdered with compound talcum, borated talcum, oxid of zinc and lycopodium, or rice-flour powder. Feeding.—Human Milk.—The secretion is established at the end of forty-eight hours. It derives its origin from an over- growth of epithelial cells lining the ducts of the mammary glands, their infiltration with fat, and subsequent rupture. The specific gravity is 1024-35, the reaction alkaline. Each minute fat- globule is surrounded by a pellicle of serum-albumin. Chemical Constitution. Meigs. Vogel. Gautrelet. Water..........87.163 89.5 88.1 Fat............4283 3-5 4-o Casein..........1.046 2.0 2.2 Sugar...........7.407 4-8 6.2 Ash ...........0.101 0.17 0.5 1 " Viabilite des nouveau nes a terme et avant terme," "Archives d'Obstet.," 1893, P- 412. 796 THE NEW-BORN INFANT. Fat.—This constituent of human milk is subject to wide variations in quantity under the influence of diet and general health. Under normal conditions, however, it stands quite con- stantly at four per cent. Proteids of Milk.—The proteids of milk are casein and lact- albumin. Casein.—Casein is, strictly speaking, the curd of milk, formed by a digestive ferment acting upon " caseinogen," a proteid analogous to fibrinogen, myosinogen. Caseinogen is a peculiar substance, neither an alkali-albumin nor a globulin, but occupy- ing a distinct position among proteids. Lactalbumin.—A proteid resembling closely serum-albumin, but somewhat different from it. It is present in small quantities —one-half of one per cent. When the milk is curdled, a new proteid appears in whey, called " whey -proteid," which is soluble and non-coagulable by heat. The sugar is lactose ; it is not strong in sweetening properties. The ash of human milk is made up mainly of potassium, sodium, calcium, and phosphoric acid. The quantity of milk at each nursing is difficult to determine. It maybe estimated by: (i) The infant's gain in weight after each feeding. This is not constant, varying from three to six ounces. (2) The capacity of the infant's stomach. (3) The quantity secreted in twenty-four hours, divided by the number of nursings. At the end of the seventh day the quantity in twenty- four hours is fourteen ounces ; at the end of the fourth week, two pints. If the mother can not nurse her child, the best substitute, theoretically, is a wet-nurse. The selection of a wet=nurse should be governed by the fol- lowing considerations : She should have milk of good quality, which is best judged by the appearance of her own child. She should, preferably, be a multipara, and of suitable age; her child should be, approximately, the same age as the one to be nursed ; her nipples should be well shaped ; and it is an ad- vantage to have made a chemical analysis of her milk. She should have an equable disposition and an absence of disagreeable qualities. Above all, she should not have syphilis. As a matter of fact, wet-nurses are so inconvenient and disagreeable in the average household, and the results of artificial feeding have so markedly improved, that the vast majority of children who are not nursed by their mothers are raised on the bottle. Artificial Feeding.—Asses' and goats' milk are more like PHYSIOLOGY OF THE NEW-BORN INFANT. Jgj human milk than is cows' milk, but, as they are not conveniently procurable, the last is universally used. To appreciate why so large a proportion of artificially fed children die annually, particu- larly in the hot summer months, it is sufficient to glance at the differences between cows' and human milk.x The most important differences may be briefly tabulated as follows : Gross Appearances.—Cows'—a dead white in color, and opaque. Human—often yellow; sometimes bluish. More translucent. Reaction.—Cows'—acid. H uman—alkaline. Specific Gravity.—Cows'—1030-35. Human—1024-35. Curd Comparison.—The coagulum produced by a digesting ferment, as rennet, is dense, tough, and digested with difficulty in cows' milk ; light, flocculent, and easily digested in human milk. This difference is due merely to the larger quantity of case- inogen in cows' milk, and to the acidity. Dilute cows' milk and make it alkaline, and the curd, on the addition of rennet, is as light and flocculent as in human milk. Chemical Comparison.—Cows' milk contains more casein and less sugar. Comparative Analyses. Meigs. Vogel. Lehman. Gautrelet. Human. Cows'. Human. Cows'. Human. Cows'. Water.....87.16 87.1 89.5 87.5 88.1 85.61 Fat......428 4-20 3.5 3-5 4-0 40 Casein.....1.04 3.25 2.0 3.5 2.2 3.5 Sugar.....7-40 5° 4-8 4-8 6.2 6.0 Ash......0.10 0.52 0.17 0.75 0.5 0.85 Histological Comparison.—It is asserted that the albuminous envelope surrounding the fat-globules is thicker and tougher in cows' milk. Colostrum-corpuscles are found in human milk, normally, up to the eighth or tenth day. They return under influences interfering with lactation, as heretofore described. Bacteriological Comparison.—Human milk comes from the breast practically sterile. Cows' milk in cities, particularly in hot weather, after twenty-four hours, swarms with all kinds of pathogenic and non-pathogenic micro-organisms and their pro- ducts, some of which are virulent toxins. Quantitative Comparison.—Human milk is furnished in quan- 1 According to official statements relating to the Russian foundling hospitals at St. Petersburg and Moscow, about 1,000,000 newly born children have been given over to them during the last hundred years, most of them illegitimate. Of this large number neTrly 800^000 have died in the first months or first ^^^^^ A well-known authority on statistics satirically calls it << chronischer Kindermord auf Staatskosten " (" chronic infanticide at the cost of the State ). 798 THE NEW-BORN INFANT. tity and at intervals suitable for the infant. Artificially fed children are often overfed. Preparation of an Artificial Food.—In making an artificial food with cows' milk as a basis, three factors must be borne in mind: the quantity required, the differences in chemical composition and reaction, and the microbic infection. The first may be regu- lated by the following table, based upon a study of the capacity of the infantile stomach : Number of Feedings in Twenty- four Hours. Amount of Food Total Amount Age. Interval. ,^"4-"™ at Each in Twenty- Feeding, four Hours. First week.......2 hrs. 10 I oz. 10 ozs. Second to fourth week. .2 " 9 1% ozs. 13^ " Second to third month . . 3 " 6 3 18 " Third to fourth month . . 3 " 6 4 " 24 " Fourth to fifth month . . 3 " 6 4~4/^ " 24-27 " Sixth month......3 " 6 5 " 30 " Eighth month.....3 " 6 6 " 36 " Tenth month......3 " 5 8 " 40 " The difference in chemical composition and reaction may be removed by diluting the whole to reduce the casein, adding cream and milk-sugar, and making alkaline. The microbic in- fection of cows' milk may be obviated by pasteurization.x The following formula accomplishes these purposes : Milk for one bottle.................4 drams Water (boiled)..................5 " Cream......................I dram Lime-water....................1 " Milk-sugar....................10 grains. To pasteurize the milk, six bottles should be made up for the ensuing twelve hours. Stopper the mouth of each bottle with dry, baked cotton ; put them in a receptacle with a lid ; pour boiling water around them to the level of the milk in the bottles ; put on the lid and let stand off the stove for thirty minutes. Set aside to cool and then put in a refrigerator. Apply a plain rubber nipple to the bottle before use. Warm it to blood heat in a warming cup before giving it to the child. Cleansing.—The infant should receive a daily bath in the middle of the day in the warmest part of the room. The tem- perature of the water should be not much over 900. The nurse, whose hands are commonly insensible to hot water, 1 By this term is meant the subjection of the milk to a temperature of i67°-l75°> which sterilizes it but does not impair its nutritive value as steam sterilization or boiling does. INJURIES TO THE INFANT DURING LABOR. should be required to use a bath thermometer. Castile-soap and a soft sponge should be used, and care must be exercised not to irritate the eyes. For the first week the child should be simply sponged on the nurse's lap. After that, if it is strong and vigorous, it may be immersed in the tub. Airing.—In summer the baby may be taken out after the second month ; in winter after the third month, for a short time, in the warmest part of the day. The resting place should be a crib, and not a cradle. CHAPTER II. Pathology of the New-born Infant. INJURIES TO THE INFANT DURING LABOR. {Classified According to the Seat of Lnjury.) Brain.—Injury to the brain is most frequently the result of the faulty use of forceps or of the violent extraction of the after- coming head. It may be a meningeal hemorrhage, varying in extent from the rupture of a small vessel and a slight extrava- sation of blood to the laceration of the longitudinal sinus and a fatal intracranial hemorrhage. If less in degree, the child may live to adult age, but is apt to show impaired physical or mental development. The brain-substance may be crushed. Injuries may be inflicted upon the brain not so grave, but affecting intel- lectual or physical centers, and the subsequent mental or physical development of the individual. There may be simply com- pression of the brain, causing perhaps asphyxia. Persistent priapism may be seen occasionally, as a result of injury to the brain or cord.1 Peripheral Nerves.—The facial and brachial plexuses are the peripheral nerves most frequently damaged. The majority of cases of facial hemiplegia are due to the faulty use of forceps. Recovery may be expected, usually in the course of a week. Should this fail to occur, the faradic current may be used with advantage. Facial palsies at birth are usually unilateral and transitory ; they may, however, be bilateral and permanent. The 1 In one of my cases priapism persisted for two weeks, much to the dismay of the mother, who feared it would be permanent. 8oo THE NEW-BORN INFANT. brachial palsies result from unskilled attempts at extracting the shoulders and arms, and are likely to be permanent. Skull.—Spoon=shaped depressions of parietal or frontal bones may be caused by a prominent promontory or by forceps. It has been suggested to elevate the depression by pneumatic trac- tion or by trephining. Fractures, if compound, require an aseptic dressing. Re- covery, even from so grave an injury, sometimes occurs. Fig. 601.— Spoon-shaped depression and fracture of a parietal bone (Winckel). Fig. 602.—Formation of caput succedaneum : 0. e., External os ; b, bladder; u, urethra ; v, vagina. Distortion of the head is very common, almost constant. Its variations in form are the result of the different presentations and positions. The deformity, even though very marked, disappears within the first three days (Figs. 603—608). Scalp.—Caput Succedaneum.—A serous infiltration of that portion of the presenting part corresponding to the external os. It disappears in two or three days, and requires no treatment. INJURIES TO THE INFANT DURING LABOR. 801 PI Fig. 603.—The undistorted head of a breech presentation (Schroeder). Fig. 604.—Right occipito-posterior position of the vertex (Schroeder). Fig. 605.—Normal vertex (Schroeder). Fig. 606.—Outline of head after de- livery, the brow presenting (Budin). Fig. 607.—Brow presentation (Schroeder). Fig. 608.—Face presentation (Schroeder). 51 802 THE NEW-BORN INFANT. Cephalhematoma is a more important condition, and is to be distinguished from a caput succedaneum. It occurs about once in two hundred cases. Usually two or three days after birth a swell- ing develops, rapidly increasing in size, possessing the physical signs of a cystic tumor, distinctly confined by the boundaries of one of the cranial bones. It may be bilateral. It may occupy the parietal and the occipital bones, and it may possibly develop Fig. 609.—Cephalhematoma. Fig. 610.—Cephalhematoma. Fig. 611.—Longitudinal section through a cephalhematoma: a, Dura mater; /;, cranium; c, pericranium; c/,c/, beginning hyperostosis ; e, scalp (Oavis). before birth. It is due to a subpericranial hemorrhage, which lifts the pericranium from the bone, irritates it, and stimulates it to bone-production, thus giving rise to a bony sensation at the lifted edges of the pericranium, and later to a peculiar crackling or crepitus over the surface of the tumor, due to the movement of the thin bone-plates on one another. Non-interference is the treatment, except when the hemorrhage is excessive or suppura- tion occurs. The former may be controlled by pressure and INJURIES TO THE INFANT DURING LABOR. 803 cold ; the latter requires incision and drainage, with strict asepsis. In spite of the greatest care, septic meningitis may develop. Contused and lacerated zoounds, usually the result of a forceps operation, are to be treated on general surgical prin- ciples. Sloughs.—The vitality of the scalp may be destroyed by for- ceps or by prolonged pressure from the pelvic bones, and sloughs may appear in the first few days after birth. They require the ordinary surgical treatment for the same condition any- where on the body. Face.—A caput succe- daneum may occupy the face if it presented in labor. The eyes and the mouth may be injured by careless examinations or by violent extraction of the after-com- ing head. The former may be injured by the forceps. The globes may be luxated to complete exophthalmos ; the recti muscles may be permanently paralyzed; there may be subconjunc- tival or palpebral ecchy- moses, edema of the lids, and temporary ptosis ; frac- ture in the roof of the orbit; exudation of blood into the anterior chamber. The cheeks, temples, and forehead may be bruised, crushed, or cut by forceps. Hematomata may develop in the cheeks within twenty-four hours of birth. The blood- tumors should be let alone, as in the case of a cephalhematoma. Neck.—There may be injury and thrombosis of the neck- muscles, with reactive inflammation, most frequently of the sternocleidomastoid, with the development of torticollis. This sort of wry-neck usually recovers without treatment. Fracture, Dislocation, or Decapitation.—The author has been told the details by eye-witnesses of three cases in which the head was pulled off after version. In each instance Cesarean section was done to extract the head. The women all died. Crani- Fig. 612.—Child in face presentation. 804 THE NEW-BORN INFANT. otomy should obviously have been the operation for the extrac- tion of the head. There is occasionally injury to the cervical spine and to the larynx and trachea, in consequence of the excessive twisting of the neck that occurs when the occiput turns forward from a posterior position and the shoulders do not follow the movement of the head. Limbs.—Fractures, which are usually a separation of diaph- ysis and epiphysis, require, in the case of the lower extremities, surgical fixation, extension, and a plaster bandage. In the case of the arms, fixation in the Velpeau position by a jacket with only one arm-hole, for the sound arm. Union is prompt. Frac- tures are usually the result of faulty management on the physi- cian's part, but they may be spontaneous. Avulsion of the Fig. 613.—Visceral hemorrhages into the kidney (author's case). limbs sometimes occurs in efforts to extract a premature or macerated fetus. Trunk.—Perforations of the groin and perineum may be due to the use of a blunt hook or a forceps applied to the breech. There may be rupture of some important viscus, like the spleen, liver, or lungs, with fatal hemorrhage into the peritoneal or pleural cavities, especially in syphilitic children; or. visceral hemorrhage may occur, as in the kidney, without actual rupture, but to a sufficient degree to abrogate the functions of the organ. Fracture of the clavicle in extracting the after-coming head may result in the puncture of the lung by the broken end of the bone and in fatal emphysema. The kidney, spleen, and liver have been ruptured in attempts to extract the breech. Subcapsular hemorrhages in these organs are observed quite frequently. In the pleura there are often ecchymotic spots in asphyxiated chil- INJURIES TO THE INFANT DURING LABOR. 805 dren, with minute but multiple extravasations in lungs and brain. The pleura may be lacerated, with a hematothorax as the result.x The body may remain distorted for some time as the result of a face presentation, and there may be ecchymoses upon the body if there is a presentation of the trunk. Fig. 614.—Child born in face presentation (Schroeder). Fig 615 —Back presentation. Fig. 616.—Fetus after a presentation of Disposition of the serosanguineous the back, shoulder, and elbow. Disposition ecchymosis (Budin). of serosanguineous ecchymosis (Budin). Bowel.__The large bowel may rupture from preexisting ulceration' or necrosis, usually at the sigmoid or other flexures. i"Ein Fale von traumatischen Hematothorax beim Neugeborenen," " Z. f. G u G " Bd xxx I und 2 ; Gebhard, p. 402. There was a rupture of an inter- costal vein and of the pleura in attempts to extract a breech and trunk. 8o6 THE NEW-BORN INFANT. Asphyxia.—Asphyxia of the new-born child results in con- sequence of an insufficient supply of oxygen to the blood. To understand its causes it is necessary to review the Physiology of the Institution of Respiration.—The sudden changes in the environment of the fetus (from a liquid medium at 990 to the air at Jo°) produces an exaggerated stimulation of all the muscles to reflex action, including the muscles of respira- tion. Placental respiration is, moreover, abolished, and the accumulated CO., primarih' stimulates, but finally paralyzes, the respiratory center. The causes of asphyxia are : First, intra-uterine. Under this head come— Fetal inspiration. Any interference with placental respiration, paralyzing the brain-centers, as premature detachment of placenta; coiling, compression, or prolapse of the cord ; diminution of the caliber of the umbilical vessels, as from syphilitic periphlebitis ; excess- ive and prolonged uterine contraction. Prolonged pressure on the fetal brain by the pelvis or by for- ceps, paralyzing the brain-centers. Grave systemic diseases of the mother, and accidents, includ- ing hemorrhage, uterine or pulmonary. Anomalies or diseases of the fetus, preventing the entrance of air into the respiratory tract, or preventing the proper distribu- tion of blood from right ventricle to the lungs, as a patulous fora- men ovale or atresia of the pulmonary artery. Second, extra-uterine causes, as— Placing the infant after birth in a position unfavorable for respiration. Precipitate labor. Interference with the access of air to respiratory passages, as by a caul, unruptured membranes, or maternal discharges. Asphyxia neonatorum is divided into two stages : i. Asphyxia Livida.—In this stage there is an accumula- tion of C02 in the blood, yet the circulation continues and the reflexes are preserved. The prognosis of this stage is favorable. 2. Asphyxia Pallida.—This is an advanced stage of the for- mer, characterized by weakness of the heart, slowing of its pulsa- tions, and the abolition of the reflexes. The prognosis of this stage is naturally unfavorable. Treatment.—If possible, asphyxia should be prevented by removing the possible causes during labor. The treatment of the condition after labor consists of: i. Extraction of mucus from the throat and fauces by hold- ing the child by the feet and cleaning the mouth with a finger. INJURIES TO THE INFANT DURING LABOR. 807 2. The application of exaggerated stimuli to respiration, as slapping of the buttocks, vigorous rubbing of the back and chest; immersing the body in warm water, and pouring ice-water on the epigastrium ; applying electricity, if practicable, preferably in the shape of a faradic current, one pole being placed on the epigastrium and the other applied on the sternum, flanks, and thighs. The electric brush is most efficacious. In the pallid variety only the most powerful of these stimuli are useful. 3. Artificial respiration is induced by one or all of several methods. Sylvester's is not to be recommended because the pectoral muscles of the infant are too weak to inflate the chest when pulled upon by the manipulation of the arms. Fig. 617.—Schultze's method of artificial respiration: A, Inspiration; B, expiration. Marshall Hall's method, modified to suit the requirements of the new-born infant by suspending it in a towel, and thus rolling it from side to side, is sometimes useful. Schultze's method is one of the best. The infant should be wrapped in a towel to protect it from being chilled, should be held as shown in figure 617, and should be swung between the physician's knees and over his shoulder ; after practising the swinging movements fifteen to twenty times, the child should be immersed for a few seconds in warm water to raise its tem- perature, when the movements may be repeated. Mouth-to-mouth insufflation ranks with Schultze's method, or is superior to it. The exit of air from the lungs should be 8o8 THE NEW-BORN INFANT. facilitated by placing the infant's neck over a mug or cup with the head extended, and after inflating the lungs flexing the head and compressing the chest. The nose should not be held to prevent the escape of air, as is sometimes advised. The physi- cian draws a full breath and through a clean towel spread over the child's face blows the first part of the expired air into the child's mouth. The open nostrils serve as safety-valves. The air-vesicles of the lungs are not so likely to be damaged. Catheterization of the larynx with a soft catheter and direct inflation of the lungs is only advisable if there is tumefaction of the neck or some other mechanical interference with the entrance of air into the larynx. Great care must be exercised not to injure the posterior wall of the trachea nor to catheterize the esophagus. As a last resort, tracheotomy and catheterization through the wound may be required. It is only required in most exceptional cases.x Risks Attending Artificial Respiration.—Injuries, as apo- plexies ; Schultze's method may injure the spine ; hemorrhagic effusions in the pleurae and lungs ; rupture of the air-vesicles in insufflation ; the trachea and larynx may be injured ; the lung may be punctured if the clavicle is broken. After=treatment of Asphyxia Neonatorum.—A child deeply asphyxiated and revived with difficulty will, more likely than not, die within forty-eight hours of birth. It should be carefully watched, therefore, for at least two days, in order to detect rapid respiration, feeble heart-action, and evidence of intracranial dis- turbance. It is a good practice to administer routinely to such children five drops of brandy and a drop of tincture of digitalis in hot water, every four or every two hours, to keep them swathed in cotton-wool, and possibly to surround them with hot-water bottles or bags, if their vitality is low. DISEASES OF THE NEW-BORN INFANT. Diseases of the Lungs.—Atelectasis.—The causes are not known. Sometimes it may be due to obstruction of the air- passages, as by an enlarged thymus, a clot of blood, curd of milk, etc. The diagnosis is usually not made during life. Dullness on percussion might be detected on one side if the atelectasis were 1 I was obliged to resort to this treatment in a case of face presentation with such distortion of the neck that mouth-to-mouth insufflation and catheterization of the larynx were impossible. The child was kept alive for an hour, but would make no attempt at respiration. DISEASES OF THE NEW-BORN INFANT 809 unilateral. The respiration is accelerated and imperfect. There is an absence of fever. The symptoms are present at birth. Pathological Anatomy.—One lung is found shriveled up, is not crepitant, and sinks when placed in water. The prognosis is necessarily grave. Treatment.—If the diagnosis is made, gentle insufflation of the lung with a catheter might be attempted. Syphilis of the Lung.—The diagnosis may be made by a his- tory of syphilis in the parents, by the signs of fetal syphilis, together with the cyanosis and physical signs of pneumonia. The temperature is very low, suggesting the use of an incu- bator. Treatment, however, is of no avail, the child usually dying within twenty-four to thirty-six hours. Pathological Anatomy.—An enormous overgrowth of connec- tive tissue is found, compressing the blood-vessels and diminish- ing the capacity of the air-vesicles. As some air has entered the lung, a cut-off portion never sinks, but does not float buoyantly. The "white pneumonia" of syphilitic infants is rare. It is the result of proliferation, desquamation, and fatty degeneration of the epithelial cells in the lungs, giving the latter a white appearance, and distending them so that the thoracic cavity is well filled out and the lungs bear the imprint of the ribs. Respiration is impossible. Septic infection of the lungs is rare. It is the result of inspi- ration of septic matter from the vagina or from the decomposition of inspired blood-clots or vaginal discharges. Tuberculosis may be caused by mouth-to-mouth insufflation on the part of a tuberculous person. Pneumonia of the new-born is usually caused by the inspiration of maternal discharges, resulting from intra-uterine respiratory efforts when asphyxia is threatened. Pneumonia arising from this cause develops about twenty- four hours after birth, in a child apparently healthy, the tempera- ture at this time beginning to rise and the respiration growing more rapid. Cough, although a variable symptom, is occasion- ally incessant. The child is restless, refuses the nipple, is cyanotic, at times gasps for breath, and there may be dullness over one or both lungs. The diagnosis can not always be made by the physical signs ; only a small patch may be involved. There is usually a history of dystocia. When a new-born infant has a high temperature, septic infection or pneumonia should be suspected as the most probable causes of the fever. The prognosis is grave. The treatment should consist of stimulation—gr. y to y carbonate of ammonium in 3SS-3J mucilage of acacia every four 8 IO THE NE W-BORN IN FA NT. hours if it does not irritate the stomach. Tincture of digitalis, in drop doses, should be given every two or four hours. A mustard-bath once, twice, or thrice daily x is an extremely im- portant item in the treatment. A cotton jacket should be applied. The mother's milk should be drawn from the breast and fed to the infant from a medicine dropper in small quantities every two hours ; a few drops of brandy may be added to it. The pathological anatomy shows the features of catarrhal pneumonia. A cut-off portion of the inflamed lung usually sinks in water. Pulmonary apoplexy is a rare accident in young infants, the result of severe straining in crying or coughing. There is hemoptysis, the quantity of blood lost usually not being very great, though it stains the front of the dress and alarms the child's caretaker exceedingly. The prognosis is favorable. Syphilis of New=born Infant.—Symptoms.—The child is often ill-developed and ill-nourished, but the characteristic signs of the disease do not usually appear before four or six weeks. In the order of their diagnostic value these signs are : Coryza syphilitica. The discharge from the nose is irri- tating to the upper lip, and frequently produces crusts and even ulceration. Maculopapular syphilide ; roseola, especially marked on the heels ; cutaneous papules and mucous tubercles ; rhagades oris et ani; pemphigus ; cutaneous ulcers ; paronychiae ; pseudo- paralyses of extremities, due to infirm connection between diaph- ysis and epiphysis, or to painful periostitis which inhibits motion ; hemorrhagic diathesis; bone diseases; fever; disease of the testicles, which are enlarged from the overgrowth of connective tissue. Treatment.—The best results are obtained from the internal use of calomel with chalk or soda, y1^ of a grain given twice a day, gradually increasing the dose. Should vomiting or diarrhea occur, mercurial inunctions must be employed, rubbing a piece of mercurial ointment as large as the end of the little finger on the child's abdominal binder every other day. This treatment should be kept up intermittently for months, being replaced from time to time by tonics, as drop doses of syrupus ferri iodidi. The child's food requires careful attention. Prognosis.—If the child is well nourished by its mother or by a wet-nurse, the prognosis is very good, so long as some impor- 1 The bath is made as follows: Three large pitcherfuls of water at loo0 P\, and a tablespoonful of mustard; allow the child to remain in the bath for five minutes, or until the temperature of the latter falls to 950, when the infant should be removed and wrapped, undressed, in a warmed blanket, in which it remains for a half hour. DISEASES OF THE NEW-BORN INFANT. 8 I I tant internal organ is not seriously affected. In artificially fed children the prognosis is unfavorable. The wet-nurse is liable to be infected, and she should not be ignorant of her danger. Mastitis.—Four days after birth the breasts in both sexes contain colostrum, which has disappeared by the twentieth day. During this period there may occur in the breast of the child pathological processes like those in the breast of the puerpera. The breasts may enlarge and become painful ; the skin over them may be an angry red ; the secretion maybe much increased, so that the milk runs out in a stream, and even a mammary ab- scess may develop. Treatment.—The nurse must avoid squeezing the glands. Cooling lotions should be applied, and the skin should be oiled, to relieve tension. If suppuration occurs, the abscess should be incised without delay, as there is always a tendency for the pus to burrow inward toward the pleura. Specific or Essential Fevers.—Exanthemata.—The infant may exhibit the exanthem at birth or may contract the disease subsequently. The treatment is the same as under other cir- cumstances. Septic Infection.—Infection occurs through the umbilicus. The most important treatment is the preventive (see Diseases of Umbilicus). The infection usually occurs in the first two weeks of life, but the symptoms may appear as late as the fourth week. The Treatment of Certain Congenital Deformities.—Hare= lip.—This deformity may prevent suckling ; if so, an immediate plastic operation is indicated, which may be undertaken in the first few hours of life. The operation for cleft=palate is too serious to be undertaken during early infancy. A rubber flap over the nipple of the bottle may enable the child to suck. It can not nurse from the breast. Supernumerary digits should be ligated and cut off. If they are mere fleshy appendages, a thread may be tied around their base, and they may be left to fall off. In a tongue=tie the frenum should be snipped superficially with blunt-pointed scissors, and then torn with the fingers to the floor of the mouth. The child's head is placed between the knees of the operator ; the two first fingers of the left hand are inserted on either side of the frenum, to hold the mouth open and to protect the tongue from injury. Umbilical Hernia.—There are two varieties of this deformity. In one, a knuckle of intestine covered by skin projects from the navel. This degree of deformity is common, occurring in two per cent, of infants. It is treated by a convex button, cork, or hard-rubber compress on a strip of adhesive plaster, which 8l2 THE NEW-BORN INFANT. encircles two-thirds of the child's body. This improvised truss is renewed from time to time, and should be worn six months. In the second variety there is an exomphalic condition, due to defective development, the intestines protruding from the umbili- cus covered only by amnion. An immediate plastic operation is indicated even if the mass of protruding intestines is as large as an apple. The results of this operation have been excellent. Spina bifida is to be distinguished from the less serious con- ditions—fibroma, myxoma, or lipoma of buttocks—and from parasitic teratomata. In spina bifida a hardened patch is found at the prominence of the tumor, due to the attachment at that point of the cauda equina. Treatment.—Lay the tumor open, dissect out the sac, make traction upon the latter, when the cauda equina will retreat into the canal ; ligate with catgut the pedicle formed, and accurately close up the wound with buried catgut sutures, with strict asep- sis. The prognosis is not good. If the child survives the opera- tion, it is not unlikely to die of hydrocephalus. Imperforate Rectum.—The anus and rectum should be exam- ined immediately after birth in all cases. To avoid the danger of fecal accumulation, inguinal or lumbar colotomy should be performed. In simple cases with merely a transverse septum between the anus and the rectum, a cruciform incision over the imperforate anus is sufficient to open the rectum. The mucous membrane of the bowel is then stitched to the skin of the anus. Technic of Inguinal Colotomy for Atresia Ani.—Make an in- cision above and parallel with Poupart's ligament on the left side ; deliver the distended sigmoid flexure ; put two stitches through it, one on each side of the bowel, the threads running parallel with one another and with the long axis of the bowel, the two ends of each stitch entering and emerging from the bowel-wall about a quarter of an inch apart; incise the bowel between the two stitches, pulling it well down below the abdom- inal wound, to guard the peritoneal cavity from contamination, as meconium and gas make their escape. Making the wound in the bowel gape by pulling upon the ligatures through its wall, a few interrupted sutures are passed through the bowel at the site of the opening and the abdominal wall, fastening the two together. Finally, the edges of the abdominal and bowel wound are whipped together with a continuous catgut stitch, to prevent hemorrhage from the former. An anesthetic is not absolutely necessary. I have seen the infant nursing contentedly from its mother's breast five minutes after such an operation. Later, the rectum may be probed from above to determine the depth of the incision necessary to reach it from the anus. Plate h. Gonorrhea of the mouth in the new-born (Rosinski). DISEASES OF THE NEW-BORN INFANT. 813 Nasal Catarrh (Snuffles).—Causes.—When the disease is not syphilitic, it is due, usually, to faulty clothing or to drafts of air. The crib should be protected, and the child should wear a thin lawn cap until its head is covered by a growth of hair. Diseases of the Mouth.—Aphthae are rounded, pearl-colored vesicles seen in the mouth and on the lips. Washing the mouth daily with a clean linen towel will prevent them. Boric acid, gr. v-x to the ounce, as a wash, is curative. In true thrush there is a coalescence of white spots, with an areola of reddened mucous membrane. The disease is often seen in hospital practice, or in infants whose hygienic surroundings are bad. It is due to the presence of a parasite, the saccharo- myces albicans. Treatment.—Boric acid, gr. xvj-xx to gj of honey. One-half of a dram of this mixture is put in the mouth three or four times a day. The associated symptoms of malnutrition, diarrhea, and vomiting indicate attention to hygienic surroundings, to the general health of the child, and to its diet. In gonorrheal stomatitis there is violent inflammation of the oral mucous membrane, due to the presence of gonococci. Cleanliness and mild disinfection of the mouth with boric acid solution will effect a cure. The disease is rare. I have seen but one case in all my hospital services. Sublingual cysts are probably the result of the occlusion of the duct of a submaxillary gland. The cyst appears in the first few days after birth, and may reach such a size as to displace the tongue and to interfere with sucking. The treatment consists of puncture of the cyst, which does not return. Colic, Diarrhea, Constipation.—Colic always indicates a careful attention to diet. Medicinally, gr. j of pepsin may be given in 3J of hot water, with a few drops of brandy or gin. Milk of asafetida, gtt. xx—xl, or soda-mint, 3J, may be used, and a spice- plaster may be applied to the abdomen. Diarrhea indicates almost always some error in the diet. Frequent serous movements, draining the child's strength and demanding a remedy, may be checked with the following : U . Acid, sulphuric, aromat., Tinct. opii camph.,...........aa gtt. iv. One dose, not to be repeated. Constipation.—In simple cases a dose of castor oil (3J), the soap-stick, a glycerin suppository or injection (gtt. xv-xx in %j of water) suffice, or the following may be used : U. Calcined magnesia, Sugar of milk, . of each 7^ grains. 814 THE NEW-BORN INFANT. P'or chronic constipation the daily injection of warm soap- suds (f§ij) by a soft-bulb rubber ear-syringe is least harmful. Medicinally, the treatment may consist of a piece of flake manna in each bottle of artificially fed children ; the administra- tion of ten drops of the syrup of figs, with two to four drops of the fluid extract of cascara ; a pinch of salt in the bottles ; the addi- tion of Mellin's food, and daily abdominal massage ; the addition to each bottle of milk of two to four grains phosphate of soda ; an increase in the proportion of cream ; Tarrant's Seltzer Aperient (ten grs.) in the milk ; a little milk of magnesia, added to one or more bottles or given in water to a nursing baby. Intussusception.—In a case in the University Maternity, the child died forty-eight hours after birth. The symptoms began in the first twenty-four hours ; the child passed blood and mucus by the bowel, developed high fever, and vomited incessantly. Postmortem examination showed the intussusception in the ileum ; the bowel above was much distended ; below, inflamed and very dark in color for a couple of inches. Skin Diseases.—Gum, a sort of acne, is due to the irritation of the skin by the atmosphere and the clothing. It is exceed- ingly common. Treatment.—Cleanliness, proper clothing, and some simple ointment, perhaps as a salve to the mother's anxiety as much as to the infant's skin. Furuncles are likely to be small and numerous. The condi- tion is an exaggeration of gum, with enlargement and suppura- tion of the pimples. The diet and hygienic surroundings should be investigated. The small boils may be washed twice daily with a solution of boric acid, gr. xv, and resorcin, gr. iij-f^j, and boric acid ointment, 3J-5J, ung. aq. rosae, may be applied. The boils may be opened with a needle when they come to a head. Simple acute pemphigus is very rare. From the second day to the fourth, fifth, or sixth week, vesicles the size of a pea to a quarter- or half-dollar appear indifferently over the whole body, except the soles of the feet and the palms of the hands. The disease lasts from twelve to fourteen days, without manifestation of constitutional disturbance. It is contagious, and may be carried by the nurse or be com- municated to a mother or nurse. It disappears without treat- ment. The specific micro-organism, it is claimed, has been dis- covered. Syphilitic pemphigus usually begins in utero, and the child is born with the vesicles upon it, the soles of the feet and the palms of the hands being most often affected. The disease is associated DISEASES OF THE NEW-BORN INFANT. 815 with marked evidence of malnutrition and constitutional disturb- ance, and yields only to specific treatment. Ophthalmia Neonatorum.—Symptoms.—True ophthalmia is the result of the infection of the conjunctivae by gonococci. Usually after twenty-four to forty-eight hours the eyelids are edematous and puffed out, and between them there appears a seropurulent discharge, which soon becomes, greenish-yellow pus. When the lids are separated, the conjunctivae are seen to be red and velvet-like in appearance, and later the cornea may lose its epithelium, become glazed, ulcerate, and be perforated. Treatment, Prophylactic.—The best preventive treatment is the Crede method. As soon as the head is born, warm water is dropped in the eyes. When the deliver}- is completed, the eyes are again cleansed with warm water, followed by one or two drops of a ten-grain solution of nitrate of silver to the ounce, which is then washed out with salt solution. Curative.—The eyes are cleansed every hour, day and night, with a concentrated solution of boric acid. Cold compresses are kept upon the lids. Morning and evening a drop of nitrate of silver, twenty grains to the ounce, may be dropped in the eye, followed by irrigation with salt solution. If only one eye be affected, the other should be carefully bandaged with a pledget of lint to protect it. A drop of a weak solution of atropia is occasionally required. If possible, the case should be placed under the care of an oculist. The author invariably refuses to accept the responsibility of treating such a case. The mouth, the nose, and the ears of a new-born infant may be the seat of inflammation from gonorrheal infection. There is frequently a subacute conjunctivitis after birth, often affecting one eye alone, and yielding to the mildest treat- ment, or disappearing spontaneously. The inexperienced phy- sician not infrequently mistakes this innocuous inflammation for ophthalmia, and by the injudicious energy of his treatment con- verts a mild into a very severe conjunctivitis. I have seen per- manent opacity of the cornese from the unnecessary use of nitrate of silver in such a case. The severest possible inflamma- tion, ending in total blindness, has resulted from the injection of sublimate solution in the vagina during labor, the corrosive sub- limate gaining access to the child's eyes and causing inflammation and perforation of the cornese. Hemophilia is an inherited pathological disposition to bleed from apparently normal or slightly injured surfaces. The manner of transmission is peculiar ; it is always through the mother to male children, who do not transmit it. The female children show no evidence of the disease, but transmit it. The cause is not 8i6 THE NEW-BORN INFANT. known, and it manifests itself throughout life. Treatment is of no avail. It should be remembered that a hemorrhagic diathesis is sometimes due to syphilis, and in such cases specific treatment is of value. I have seen a hemophilic infant bleed to death from its conjunctivae, incessantly weeping tears of blood, and another lose its life from hemorrhage following a superficial abrasion under the tongue. Icterus.—There are two classes of cases : In the first the jaundice is slight in degree. The face and breast only are affected. This grade of jaundice is very com- mon, the majority of children manifesting it. The cause is said to be hepatogenic. The very small com- mon biliary duct fails to empty into the bowel the excess of bile produced by the liver. The discoloration disappears a few days after birth, and the condition usually requires no treatment. Fractional doses of calomel may be given if the child's digestion is impaired, or if the jaundice is deeper than common. In the second variety the whole body is jaundiced. The urine and feces are discolored, and may contain blood. This variety is decidedly rare, and is a manifestation of grave systemic derangement, usually general septic infection. Causes.—This kind of jaundice is said also to be, as a rule, hepatogenic. It is seen in Buhl's and Winckel's disease, in atresia of the bile-duct, and in polycystic disease of the liver. In streptococcic infection of the blood-current producing disinte- gration of the blood, the jaundice, I believe, is in part hemato- genic, resulting from a disintegration of the blood-corpuscles. The prognosis of the malignant variety is extremely grave. The result is almost invariably fatal. Cyanosis was once thought to be synonymous with congeni- tal heart disease. The laity still regard a "blue baby" as one with a defective heart. The causes of cyanosis, in the order of their frequency, are : pneumonia (often syphilitic), premature birth, asphyxia, atelec- tasis, degeneration of the blood, malformation of the heart and blood-vessels, interference with the function of the nerves of respiration, malformation of the respiratory tract, congenital pleurisy, and partial occlusion of the trachea. Congenital heart affections may result from intra-uterine endocarditis, as stenosis of the right and left auriculoventricular orifices, stenosis of the aortic and pulmonary orifices, and insuffi- ciency of the valves. Or they may be the result of defective development, as patency of the foramen ovale, atresia of the pulmonary artery, stenosis of the conus arteriosus, and defects in the ventricular septum. DISEASES OF THE NEW-BORN INFANT. 817 A child with congenital heart disease must be managed with extraordinary care. Exposure to cold is particularly danger- ous, as there is a tendency to pulmonary congestion and pneu- monia. Artificial heat may be necessary ; malnutrition must be combated; heart tonics may be required. The prognosis is relatively favorable. Compensation may often be secured in apparently the most unfavorable cases. Diseases of Umbilicus.—Septic Infection.—The ulcer on an infected umbilicus is covered with a grayish, diphtheritic mem- brane, has a reddened areola, and the local inflammation leads to general infection. An acute, high fever in a new-born infant suggests septic infection or pneumonia. The latter may be sep- tic. The so-called Buhl's and Winckel's diseases, with fatty degeneration of the organs, icterus, cyanosis, and hemoglob- inuria, are merely the result of streptococcic infection of the blood-current. Treatment, Prophylactic.—The ulcer should be exposed at the daily bath, cleansed with soap and water, and dressed with sali- cylic acid, 1 part; starch, 5 parts. An aseptic ligature should always be used to ligate the cord at birth, and the daily dressing of the cord with fresh salicylated cotton should be carefully carried out with clean hands until the cord drops off. Curative Treatment.—The ulcer should be touched with a solution of bichlorid of mercury, 1 : 500, or with nitrate of silver solution, %j-f$j. It should be thoroughly irrigated and dusted with salicylic acid and starch, and covered with salicylated cotton. Umbilical fungus is usually an overgrowth of granulation tissue. It projects in a mass like a strawberry from the navel. It should be cauterized with a solid stick of nitrate of silver, whereupon it promptly melts away. In about one-fifth of the cases cauterization fails, the tumor is more solid in feel, and is found, on microscopic investigation, to be the remains of the om- phalic duct. This kind of umbilical fungus is called an entero- teratoma. It should be ligated and cut off. The stump of the cord may persist, unchanged, almost indefinitely, covered with an angry, red layer of granulation cells, or a spur of well-organized connective tissue may project from the umbilicus. In such cases there is a small supply of blood to the cord in spite of the liga- ture. The projecting mass must be cut off. I have been obliged to amputate the persistent stump of a cord on the sixteenth day. Omphalitis is a peculiar inflammation of the umbilicus and surrounding structures, in which the abdomen becomes conical in shape ; the skin and subcutaneous connective tissue are hard, red, and infiltrated. It is always septic in origin. It requires dis- 52 8i8 THE NEW-BORN INFANT. infection of the umbilicus, poultices, and early incisions, with stimulants and supporting treatment. A later stage of the in- flammation is gangrene. The prognosis is very grave. It is difficult to avert general systemic infection. Inflammation of the umbilical vessels is always due to septic infection, and invariably leads to systemic infection, which is commonly fatal. Hemorrhage from the Umbilicus (Omphalorrhagia).—The bleed- ing may come from the cord or from the umbilical ulcer. It may be primary, from careless ligation of the cord ; or second- ary, after the cord drops off. The vessels of the cord close from the placental end inward, and the hypogastric arteries may be patulous after the cord drops off, when increased blood-pressure or handling the ulcer may bring on hemorrhage. The mortality of this accident is computed at seventy-six to eighty-three per cent. Treatment.—In primary hemorrhage the cord must be promptly re-ligated. In bleeding from the umbilical stump, if the bleeding vessels are seen, they should be ligated. Usually, it is impossible to isolate the bleeding vessels. In such cases the hemorrhage may be controlled by Monsel's solution and pressure by liquid plaster-of-Paris poured into the navel, where it "sets," or by successive layers of powdered bismuth, with gauze and collodion. As a last resort, the abdominal wall around the navel should be transfixed with harelip pins or ordi- nary large-sized needles, and a figure-of-eight ligature should be applied under them. If there is sufficient stump of the cord left, it should be drawn out and transfixed with two pins or needles and ligated below them. I was able to check a hemorrhage in this way several days after the cord had dropped off. If this is impossible, one pin may suffice ; it should transfix the abdominal wall just below the umbilicus, so as to occlude the hypogastric arteries. Before inserting the pin the abdominal walls should be compressed and rolled between ■ the thumb and forefinger to get rid of coils of intestines. Should the hemorrhage continue, it can be controlled by a pin above the umbilicus to occlude the umbilical vein. Tetanus of the new=born is the result of the entrance of tetanus bacilli through the umbilicus. The disease in temperate climates occurs almost exclusively in hospitals. It is usually fatal, the death-rate being over ninety per cent. The treatment should always include an immediate and a thorough disinfection of the navel. Melena, or gastrointestinal hemorrhage, is an extravasa- tion of blood into the stomach and intestines, occurring most DISEASES OF THE NEW-BORN INFANT. 819 often in the first few hours of life. Duodenal ulcer, some con- genital defect increasing intra-abdominal blood-pressure, intus- susception, or hemophilia may be the cause. The child may vomit bright, unaltered blood, or the vomit ma)- be "coffee- grounds " in character. The blood from the bowel is black in color, and is mixed with meconium, hence the name melena. It is to be carefully distinguished from the vomiting of blood derived from a fissured nipple in the mother and ingested with the milk. In melena the infant shows unmistakable symptoms of internal hemorrhage. Treatment.—Gallic acid, gr. ij, may be given every hour. I'ig. 618.—Atresia of the ureter : A, Kidney ; B, ureter ; C, bladder (author's case in University Maternity). Ergotin hypodermatically, an ice-bag to the abdomen, and hot bottles to the flanks and thighs. Stimulation may be required. The mortality, in spite of intelligent and energetic treatment, is fifty per cent. Bloody discharge from the genitalia of female children is not very rare. It shows an activity of the sexual organs anal- ogous to the breast changes in the new-born. The condition is not dangerous, and requires no treatment. The blood comes 820 THE NEW-BORN INFANT. from the uterus, like the menstrual discharges—in fact, the dis- charge is a true menstruation, as has been demonstrated in postmortem examinations of infants who died from intercurrent affections. It appears three or four days after birth, and lasts only a few days. Sudden death of apparently healthy children is an accident not infrequently demanding an explanation by the attending physician. Among the causes may be found overlying by the mother, accidentally or intentionally. I have seen five cases. In one of the reports of the Registrar-general of England, there was a record of 1500 cases, the majority occurring on Saturday night! Diseases.—Most commonly pneumonias, apoplexies, more rarely perforation or intussusception of the bowels, rupture of a large viscus, or any of the diseases previously described, which had not been detected during life. Occlusion of the trachea by an enlarged thymus or by curds of milk. Congenital deformities of important internal organs, as atresia of the ureter. Medication of the New=born.—In administering medicine to a newly born infant, the physician should remember its peculiar intolerance of opium and its tolerance of some other remedies. The following are some of the drugs and their doses re- quired in the first four weeks of life : Opium, only as paregoric, from two to five drops in one dose, not repeated; mercury, always as calomel, fa to \ gr. ; castor oil, 15 gtt. to 3j ; nitrate of silver, eV to To Sr- ; pepsin, gr. j-ij ; gallic acid, gr. ss-ij, etc. INDEX. Abdomen, appearance of, in pregnancy, changes in size and shape of, in preg- nancy, 192 palpation of, in pregnancy, 200 Abdominal binder in postpartum hem- orrhage, 539 muscles, contraction of, in labor, 306 diastasis of, in labor, 570 in puerperal state, 632 pad after labor, 313 palpation, diagnosis of position of fetus by, 351 in labor, 350 in pregnancy, 200 pregnancy, 259 clinical history of, 265 death of fetus in, 271 symptoms of, 278 section, exploratory, for puerperal sep- sis, 694 for interstitial pregnancy, 281 for tubal pregnancy, 279 in puerperal sepsis, 685 tumors, putrefaction of, 713 walls, change in, in pregnancy, 186 Abortion, 243 after-treatment of, 257 appearance of ovum after, 248 causes of, 243 clinical history of, 247 phenomena of, 248 diagnosis of, 251 duration of, 248 frequency of, 247 from abnormal positions of the uterus, 246 from alterations of the maternal blood, 246 from anemia, 176 from cholera, 161 from chronic endometritis, 176 metritis, 176 poisoning of mother, 177 from coughing, 245 from diffuse hyperplasia of decidual endometrium, 144 8 Abortion from emphysema of lungs, 239 from heart disease, 236 from injuries of mother, 242 from irritable uterus, 243 from maternal diabetes, 177 from metritis, 215 from overdistention of uterus, 247 from placenta praevia, 530 from prolapse of uterus, 246 from retroflexion of uterus, 246 from typhoid fever, 161 from vomiting, 245 hemorrhage in, 248 in cholemic convulsions, 246 in chorea, 245 in eclampsia, 245 in epilepsy, 245 in hydramnios, 247 in hysterical convulsions, 246 in multiple pregnancy, 247 in retrodisplacement of the pregnant uterus, 212 induction of, 719 indications for, 719 in nephritis, 229 in pneumonia, 617 methods of, 72° inevitable, diagnosis of, 251 treatment of, 255 missed, 258 pain in, 248 prognosis of, 253 threatened, diagnosis of, 251 treatment of, 254 treatment of, 254 tubal, 272 Abscess, ischiorectal, 714 mammary, 657 in pregnancy, 221 of Bertholin's gland, obstruction of labor by, 490 postmammary, 657 suburethral, in pregnancy, 217 Acanthopelys, 453 Accessory corpuscle of spermatozoon, 65 Accidental hemorrhage, 534. See Hem- orrhage 21 822 INDEX. Accouchement force in eclampsia, 581 Acetabulum, fracture of, 457 Acetonuria in pregnancy, 231 After-birth. See Placenta After-coming head, delivery of, by for- ceps, 765 Deventer's method, 766 Mauriceau's method, 763 Prague's method, 765 Wiegand's method, 763 After-pains, 328 Agalactia, 645 Albuminuria an indication for inducing abortion, 719 from death of fetus, 174 in pregnancy, 227, 232 Alimentary canal, diseases of, in preg- nancy, 221 Allantois, 132 Amnion, abnormalities of, 95 secretion of, 95 adhesive inflammation of, 101 anatomy of, 93 cysts of, 102 development of, 92 dropsy of, 96 Amniotic bands, formation of, ici fluid. See Liquor amnii Amniotitis, 98 Amputation of fetal parts to effect deliv- ery, 774 Amputations, intra-uterine, 166 Anasarca, 512 of fetus, 165 Anemia, abortion from, 126 pernicious, in pregnancy, 238 puerperal, 588 Anesthetics in labor, 303 Aneurysm in pregnancy, 238 Ankylosis in fetus, 166 of pelvic joints, 459 Annular placenta, 120 Anteflexion of the gravid uterus, 210 Anteroposterior diameter of pelvic inlet, measurement of, 411 of pelvic outlet, measurement of, 423 of pelvis, 22 Ante-uterine hematocele, 273 Anus vaginalis, obstruction of labor by, 489 vestibularis, obstruction of labor by, 489 Aphthae of new-born, 813 Apoplexies in pregnancy, 232 in puerperal state, 640 pulmonary, of new-born, 810 Appendicitis in pregnancy, 226 Appetite in puerperal state, 332 Arbor vitae of uterus, 46 Areola of pregnancy, 194 Armamentarium for labor, 299 Arms, delivery of, after podalic version, 761, 762 Arthritis in puerperal state, 629 Articular rheumatism of fetus, 162 Artificial dilatation of the cervical canal, 748 feeding of infant, 796 food, preparation of. 798 respiration of new-born infant, 807 Schultze's method, 807 Ash of human milk, 796 Asphyxia livida, 806 neonatorum. 806 after-treatment of, 808 causes of, 806 treatment of, 806 of new-born child, 806 pallida, 806 Asthma in pregnancy, 239 Atelectasis of new born infant, 80S Atresia ani of new-born, treatment of, 812 of vagina, obstruction of labor by, 489 Atrophy of deciduae, 150 Auscultation, diagnosis of position of fetus by, 352 in diagnosis of pregnancy, 202 Auto-infection in puerperal sepsis, 672 Auvard incubator, 793 Avortement instantane, 248 Avulsion of limbs of child in labor, 804 Axis-traction forceps, 730 application of, 743 Baby-clothes, 347 Baby's basket, 348 Bacillus aerogenes capsulatus in puer- peral sepsis, 671 fcetidus in puerperal sepsis, 670 pyocyaneus in puerperal sepsis, 670 Bacteria, passage of, from mother to fetus, 156 Bacteriology of the vagina, 662-673 Bag of waters, 292 Ballottement, 202 Bandl, ring of, 183, 354, 544 Barnes' bags for artificial dilatation of cervical canal, 748 in inertia uteri, 404 in placenta praevia, 533 in treatment of hematoma, 606 Bartholin's glands, 45 abscess of, obstruction of labor by, 490 Basiotribe, Tarnier's, 770, 771 Baudelocque's diameter, 411 method of cephalic version, 376 Binder, mammary, 346 obstetrical, 313 Bladder, changes in, in pregnancy, 186 diseases of, in pregnancy, 230 INDEX. 823 Bladder, irritability of, in pregnancy, 230 Blastomeres, 72 Blindness in pregnancy, 234 Blood, changes in, in pregnancy, 186 clots, retention of, puerperal hemor- rhage from, 599 diseases of, in pregnancy, 238 in new-born infant, 791 tumor. See Hematoma -vessels, diseases of, in pregnancy, 237 _ of pelvic organs, 32 of uterus, changes in, in pregnancy, 181 Bloody discharge from genitalia of new- born female children, 819 Blot's perforator, 768, 769 Blunt hook, 748 Body-cavity, 73 Body of Rosenmuller, 42 Boric acid in aphthae of new-born, 813 in cystitis, 639 in thrush of new-born, 813 Bougies, graduated, for dilating cervical canal, 749 Hegar's, 749 Bowels in puerperal state, 343 movements of, in new-born infant, 79° of child, injury of, in labor, 805 Brachial palsy from injury during labor, 800 Brain, congestion of, in pregnancy, 232 diseases of, in pregnancy, 232 injury to, during labor, 799 Braun's cranioclast, 769 hook, 774 Breast-pump, 655 Breasts. See also Mammary glands absence of, 641 areola of, in pregnancy, 194 hypertrophy of, 641 inflammation of, 656 in pregnancy, 194 sensations in, in pregnancy, 193 striae of, in pregnancy, 194 supernumerary, 641 Breech, extraction of, 745 by blunt hook, 748 by fillet, 747 by forceps, 747 manual method of, 745 presentation, 381. See Presentation, breech Brim of pelvis, 17 Broad-ligament pregnancy, 261 Bronchial catarrh in pregnancy, 239 Brow presentation, 378. See Presenta- tion Brown atrophy of myocardium in preg- nancy, 237 Bruit, uterine, 203 Buhl's disease, 817 Bulbs of vestibule, 45 Caked breast, 655 Calcareous degeneration of placenta, 124 of umbilical cord, 138 Calculi, vesical, complication of labor by, 505 in pregnancy, 231 Calculus, renal, in pregnancy, 230 Canals of Gartner, 41 Cancer, syncytial, 129 Caput succedaneum, 800 in flat pelvis, 426 in justominor pelvis, 431 Carcinoma of cervix uteri, obstruction of labor by, 498 of uterus a cause of puerperal hemor- rhage, 600 syncytiale, 129 Cardiac nerve-storms, 240 Caries of pelvis, 459 of teeth in pregnancy, 221 Carunculae myrtiformes, 45, 208 enlarged, obstruction of labor by, 491 Carus, curve of, 24 Casein of milk, 796 Catarrhal endometritis, 147 Catheterization in puerperal state, 342 Celiohysterectomy, 781 and celiohysterotomy, choice of, 785 Cellular hypertrophy of placental villi, 120 Celom, 72 Centers of ossification as signs of matu- rity of fetus, 86 Cephalhematoma, 802 Cephalic presentation. See Presenta- tion version. See Version Cephalotribe, Hick's, 770 Cephalotribes, 771 Cervical canal, artificial dilatation of, 748 by Barnes' bags, 748 by forceps. 749 by graduated bougies, 749 by manual method, 749 by multiple incisions, 749 pregnancy of Rokitansky, 151 Cervicitis in pregnancy, 216 Cervix uteri, alterations in, in pregnancy, 185 atresia of, obstruction of labor by, 485 carcinoma of, obstruction of labor by, 498 cicatricial contraction of, obstruction of labor by, 486 circular detachment of, in labor, 553 dilatation of, artificial, 748 824 INDEX. Cervix uteri, diseases of, in pregnancy, 216 displacement of, obstruction of labor by, 498 injuries to, in labor, 552 rigidity of, obstruction of labor by, 486 Cesarean section, 779 indications for, 781 in labor with contracted pelvis, 483, 484 Porro's method. 780, 781 postmortem, 779 Sanger's method, 780, 784 varieties of, 782 Cessation of menstruation as a sign of pregnancy, 191 Chamberlen's vectis, 725 Child, new-born. See Newborn infant Chloasmata of pregnancy, 194, 242 Chloral in eclampsia, 580 in galactorrhea, 650 in inertia uteri, 404 in rigidity of cervix uteri, 486 Chloroform in eclampsia, 578 in labor, 304 Cholemic convulsions, abortion in, 246 Cholera of fetus, 161 Chorea, abortion from, 245 in pregnancy, 233 treatment of, 233 Chorion, chronic inflammation of, 112 description of, 104 development of, 103 diseases of, 104 false, 103 fibromyxomatous degeneration of, 112 frondosum, 104 laeve, 104 Chorionic villi, 103 cystic degeneration of, 104. See Cystic degeneration dropsy of, 105 Chronic poisoning of mother, effect of, upon fetus, 177 Chyluria in pregnancy, 231 Circular vein of placenta, 118 Circulation of fetal blood, 82 Circulatory apparatus, alterations in, in puerperal state, 329 diseases of, in pregnancy, 236 system, changes in, in pregnancy, 186 Cleft-palate of new-born, 811 Clitoris, 45 Cloaca, 39, 42 Clothing of new-born infant, 795 Cocain for hemorrhoids, 226 in pernicious vomiting, 224 Coccyx, fracture of, in labor, 569 Coffee-grounds vomit in melena neona- torum, 819 Coitus, time when most likely to result in conception, 69 Colic of new-born, 813 Colon bacillus in puerperal sepsis, 670, 674 Colostrum, 335, 644 Colpohyperplasia cystica in pregnancy, 217 Combined examination in pregnancy, 201 version, 757 D'Outrepont's method of, 758 Wright's method of, 758 Compact layer of uterine decidua, 140 Compound presentation, 516. See Pre- sentation Conception, average date of, after mar- riage, 70 time when most likely to occur, 69 Congenital cystic elephantiasis, 165 deformities, treatment of, 811 Congestion of brain in pregnancy, 232 Conglutinatio orificii uteri externi, 485 Conjugate diameter, false, of spondylo- listhesic pelvis, 464 of pelvis, diagonal, measurement of, 413 by manual method, 414 external, measurement of, 411 true, measurement of, 413, 414 Conjunctivitis of new-born, 815 Connective tissue of pelvis, 28 of uterus, alterations in, in preg- nancy, 181 Constipation in pregnancy, 187, 188 treatment of, 225 of new-born, 813 Contracted pelves, version in, 754 pelvis, flat, 431 generally, 429. See Pelvis, justo- minor obliquely, 434 transversely, 438. See Pelvis, con- tracted Contraction-ring, 183, 354, 544 Convulsions, 576. See also Eclampsia Cord, umbilical, 132. See Umbilical cord late ligation of, 317 ligation of, 318 prolapse of, 573 reposition of, 574 rupture of, 575 Cords, coiling of, in twin labor, 520 Corpus luteum, 62 of menstruation, 62 of pregnancy, 63 Cotyledons of placenta, 118 Coughing, abortion from, 245 Cows' milk compared to human, 797 composition of, 797 Coxalgic pelvis, 475 Cranioclast, 768, 769 INDEX. 825 Cranioclast, Braun's, 769 Hirst's, 769 Simpson's, 769 Craniopagus, 507 Craniotomy, 767 instruments for, 768 technic of, 771 Crede's method of expressing placenta, 3*5. 396 of preventing ophthalmia neonato rum, 815 Curve of Carus, 24 Cyanosis of new-born, 816 Cystic degeneration of chorion villi. 104 clinical history and diagnosis of, 109 etiology and frequency of, 110 pathological anatomy of, 107 treatment of, in endometritis, 148 Cystitis in pregnancy, 231 in puerperal state, 638 septic, in puerperal sepsis, 712 Cystocele, obstruction of labor by, 505 Cysts of amnion, 102 of placenta, 129 of umbilical cord, 138 ovarian, complication of labor by, 502 Davis forceps, 729 Death of fetus, causes of, in fetus itself, 178 referable to father, 178 detection of, 173 diagnosis of, 206 effect of, upon mother, 172 habitual, 175 in utero, 172 of mother, effect of, upon fetus, 171, 572 sudden,in labor, 571 Decapitation, 773 Decidua, diffuse hyperplasia of, 144 epichorial, 140 ovular, 140 placental, 140 reflexa, 139, 140 serotina, 139 uterine, 140 compact layer of, 140 glandular layer of, 143 spongy layer of, 143 vera, 139, 140 Deciduae, 139 acute inflammation of, 149 atrophy of, 150 diseases of, 144 Decidual cells of Friedlander, 140 endometritis, exanthematous, 149 hemorrhagic, 146 Decidual endometrium, diffuse hyper- plasia of, 144 fragments, retention of, after labor, 592 Deciduoma malignum, 129 Deciduosarcoma, 129 Deformities of pelvis, 407. See Pelvis Delirium of fever in pregnant women, 235 temporary, of labor, 235 tremens distinguished from puerperal insanity, 235 Delivery of placenta, 314 postmortem, 573 Descent sta^e of labor, 293 Determination of sex, 87 Deutoplasm ot ovum, 60 Deventer's method of delivering after- coming head, 766 Diabetes, maternal, effect of, upon fetus, mellitus in pregnancy, 232 Diagnosis of life or death of fetus, 205 Diagonal conjugate, measurement of, 413 manual method of, 414 Diameter of pelvis, anteroposterior, of outlet, measurement of, 423 Baudelocque's, 411 diagonal conjugate, measurement of, 413 by manual method, 414 external conjugate, measurement of, 411 transverse, measurement of, 420 of outlet, measurement of, 422 true conjugate, measurement of, 4I3,4H Diameters of fetal head, normal, 86 of pelvis, 22 Diarrhea in pregnancy, treatment of, 225 Diastasis of abdominal muscles in puer- peral state, 632 Dicephalus, 507 birth of, 509, 511, 512 Diet in puerperal state, 340 regulation of, in pregnancy, 189 Diffuse peritonitis in puerperal sepsis, 698 Digestion in new-born infant, 790 Digestive tract, changes in, in pregnancy 187 Dilatation stage of labor, 293 Dilators, Hegar's, 749 Dimensions of fetal head, 86 Diphtheria in puerperal state, 626 relation of, to puerperal sepsis, 716 Diprosopus, craniotomy for, 513 Dipygus, 508 parasiticus, 508 Direction of presenting part, anomalies of, 365 Discus proligerus, 60 Dissecting metritis in puerperal sepsis, 697 DEN. 826 IN_ Distortion of head during labor, 800 Doderlein, vaginal bacilli of, 664 Double promontory, 424 vagina, 450 D'Outrepont's method of combined ver- sion, 758 Dropsy of amnion, 96 of chorion villi, 105 Dry labor, 533 Ductus arteriosus, 83 omphalicus, 133 venosus, 82 Dullness on percussion of abdomen in pregnancy, 203 Duration of pregnancy, estimation of, 204 Dwarf pelvis, 429, 430 Dystocia, 401 due to disease, 576 Dysuria in retroflexion of pregnant uterus, 211 Eclampsia, 576 abortion in, 245 accouchement force in, 581 anesthetization in, 578 caffein in, 580 catharsis in, 579 causes of, 576 chloral in, 580 chloroform in, 578 diaphoresis in, 579 differential diagnosis of, 577 during labor, 581 effect of, on fetus, 171 frequency of, 577 hot-air bath in, 579 morphin in, 579 nitrate of amyl in, 580 obstetrical treatment of, 581 oxygen in. 580 prognosis of, 578 symptoms of, 577 treatment of, 578 venesection in, 579 veratrum viride in, 580 wet pack in, 579 Ectoderm, 72 Ectopic pregnancy, 259. See Extra- titerine pregnancy Eczema of nipples in pregnancy, 221 Edema of genitals after labor, 590 of glottis in pregnancy, 239 of placenta, 120 of vulva in pregnancy, 218 Edgar's method of dilating os uteri, 749 Effective conjugate diameter of spondy- lolisthesic pelvis, 464 Egg-cords. 59 Elephantiasis, congenital cystic, 165 Embolism of pulmonary artery in labor, 571 pulmonary, in pregnancy, 239 Embryo, development of, 74 in first month, 74 in second month, 78 in third month, 79 Embryonal area, 72 Embryotomy, 767 Emotion as a cause of puerperal hemor- rhage, 599 death from, in labor, 572 Emotional fever in puerperal state, 607 Emotions, maternal, influence of, upon fetus, 169 Emphysema in pregnancy, 239 subcutaneous, in labor, 57° Encolpitis in puerperal sepsis, 696 Endocervicitis in pregnancy, 216 Endochorion, 104 Endometritis, catarrhal, 147 chronic, as a cause of death of fetus, 176 cystic, 148 decidua polyposa or tuberosa, 146 decidualis, 124 exanthematous decidual, 149 hemorrhagic decidual, 149 in puerperal sepsis, 696 microbic decidual, 150 placentaris gummosa, 124 polypoid, 146 purulent decidual, 150 Endometrium, decidual, diffuse hyper- plasia of, 144 hyperplastic inflammation of, 144 involution of, 324 Entoderm, 72 Epichorial decidua, 140 Epilepsy, abortion in, 245 in pregnancy. 233 Episiotomy, 308 Epistaxis in parturition, 238 in pregnancy, 238 Epoophoron, 42 Erysipelas in puerperal state, 623 of fetus, 159 relation of, to puerperal sepsis, 716 Erythematous rashes in puerperal state, 622 Evisceration, 774 Evolution, spontaneous, 394 Exanthemata of new-born, 811 Exanthematous decidual endometritis, 149 Exochorion, 104 Exostoses of pelvis, 453 Expulsion, forces of, 354 stage of labor, 293 Expulsive force of labor, excessive power of, 406 Extension ot fetal head, anomalies of, 365 INDEX. 827 Extension of fetal head in face presenta- tions, 372 in labor, 360 External conjugate, measurement of, 411 genitals, development of, 42 Extramedian engagement of head, 428 Extra-uterine pregnancy, 259 advanced, 281 changes in uterus and vagina in, 261 classification of, 259 clinical history of, 260 diagnosis of, 278 etiology of, 260 frequency of, 259 prognosis of, 278 symptoms of, 274 terminations of, 267 treatment of, 279 Eyesight in new-born infant, 791 Face, appearance of, in pregnancy, 194 injuries ol, during labor, 803 presentations, 370. See Presentation, face Fallopian tubes, anatomy of, 50 False corpus luteum, 63 Fat of human milk, 796 Fatty degeneration of heart in pregnancy, 237 of placenta, 121 Feeding of new-born infant, 795 artificial, 796 Female pronucleus, 69 sexual organs, development of. 39 Femora, luxation of, effect on pelvis of, Fertilization of ovum, 69 Fetal head, dimensions of, 86 structure of. 356 movements, auscultation of, 204 in pregnancy, 193 palpation of, 201 pelvis, 432 syphilis, 151 diagnosis of, 153 manifestations of, 152 prognosis of, 153 treatment of, 155 Wegner's sign of, 154 traumatism, 167 Fetation, multiple, 89 abortion in, 91 acardia in, 91 fetus papyraceus in, 91 frequency of, 89 hydramnios in, 91 placenta in, 90 Fetus, accidents to, 573 alterations in maternal blood that are fatal to, 176 Fetus, anasarca of, 165 ankyloses in, 166 articular rheumatism of, 162 cause of death of, in itself, 178 cholera of, 161 circulation of blood in, 82 conditions of uterus which interfere with development of, 175 death of, diagnosis of, 205 effect of, upon mother, 172 from causes referable to father, 178 in utero, 172 development of, 74 in eighth month, 81 in fifth month, 80 in first month, 74 in fourth month, 79 in ninth month, 81 in second month, 78 in seventh month, 80 in sixth month, 80 in tenth month, 81 in third month, 79 diagnosis of life or death of, 205 diseases of, 151 effect of chronic diseases of mother upon, 177 of chronic poisoning of mother upon, 178 of death of mother upon, 171, 572 of eclampsia upon, 171 of excess of urea in maternal blood upon, 177 of maternal diabetes upon, 177 of maternal nephritis upon, 177 erysipelas of, 159 fractures of the bones of, in utero, 166 habitual death of, 175 diagnosis of cause of, 179 preventive treatment of, 180 infectious diseases of, other than syph- ilis, 156 influence of icterus gravidarum upon, 170 of maternal emotions upon, 169 of maternal fever upon, 168 intestinal invagination in, 166 luxations in 166 malaria of, 160 malformations of, obstruction of labor by, 5°9 mature, 85 general appearance of, 87 length of, 86 weight of, 85 measles of, 158 non-infectious diseases of, 162 overgrowth of, obstruction of labor by, 505 papvraceus, 91 rachitis of, 163 828 INDEX. Fetus, recurrent fever of, 162 scarlatina of, 159 septicemia of, 161 sex of, diagnosis of, 208 signs of maturity of, 85 syphilis of, 151 syphilitic infection of. 151 temperature of, in utero, 84 traumatism of, 167 tuberculosis of, 160 tumors of, obstruction of labor by, 512 typhoid fever of, 161 variola of, 158 yellow fever of, 162 Fever in puerperal state, emotional, 607 from cerebral disease, 612 from constipation, 610 from exposure to cold, 609 from reflex irritation, 610 non-infectious, 607 syphilitic, 614 with eclampsia, 613 maternal, influence of, upon fetus, K>8 Fibrofatty degeneration of placenta, 121 Fibroid of uterus, obstruction of labor by, 498 Fibroids in puerperal state, 599 Fibromata of uterus in pregnancy, 215 Fibromyxomatous degeneration of cho- rion, 112 Fibrous degeneration of placenta, 121 Fillet-carrier. 746, 747 extraction of breech by, 747 Fimbriae of oviduct, 53 Finger nails, loosening of, in pregnancy, 242 Flat pelvis, non-rachitic, 431 rachitic pelvis, 441 Flexion of fetal head, 360 abnormalities of, 364 Food-yolk of ovum, 60 Foramen ovale, 83 Forceps, 722 application of, 733 axis-traction, application of, 743 Davis', 729 dilatation of cervical canal by, 749 Hirst's, 728 historical sketch of, 722 Hodge's, 727 in after-coming head, 765 in breech presentation, 747 in labor with contracted pelvis, 482 in occipitoposterior positions, 742 in transverse positions of head, 742 indications for application of, 731 introduction of, 733 Levret's, 726 locking of, 738 mortality from, 745 Palfyn's, 725 position for, 733 Forceps, Poulet's axis-traction, 730 preparations for application of, 733 Simpson's, 728 Smellie's, 726 sterilization of, 733 Tarnier's axis-traction, 730 traction on, 739 uses and functions of, 731 Forces of expulsion, 354 of labor, anomalies of, 401 of resistance, 354 Fossa navicularis, 44 Fourchet, 44 Fracture of limbs of child during labor, 804 of pelvis, 456 of skull during labor, 800 Fractures in utero, 166 Friedlander, decidual cells of, 140 Fundus uteri, height of, as an indication of duration of pregnancy, 205 Funic souffle, 203 Funis. See Cord, umbilical Funnel-shaped pelvis, 432 Furuncles of new-born, 814 Galactocele, (158 Galactorrhea, 649 Galbiati's knife, 776 Gangrene of vulva, obstruction of labor by, 491 Gartner, canals of, 41 Gastro-intestinal hemorrhage in new- born, 818 Gavage of premature infants, 793 Gelatin of Wharton, 132 Generative organs, nerves of, 32 Genital cord, 40 eminence, 42 Genitalia, diseases of, 210 Genitals, external, development of, 42 internal, development of, 39 Germinal spot of ovum, 60 vesicle of ovum, 60 Germ-yolk of ovum, 60 Gestation. See Pregnancy Gingivitis in pregnancy, 221 Glands of clitoris. 45 of Montgomery, 334 Gland-space, 59 Glandular layer of uterine decidua, 143 Glottis, edema of, in pregnancy, 239 Glycosuria in pregnancy, 232 Goiter in pregnancy, 237 Gonococcus-infection in pregnancy, 217 in puerperal sepsis, 670, 674 Gonorrhea in puerperal state, 631 Gonorrheal stomatitis of new-born, 813 Goodell's rule of pregnancy, 201 Graafian follicles, 55 development of, 59 INDEX. 829 Graafian follicles, rupture of, 60 Graduated bougies, dilatation of cervical canal by, 749 Graves' disease in pregnancy, 237 Gravid uterus. See Pregnant uterus Gum of new-born, 814 Habitual death of fetus, 175 diagnosis of cause of, 179 preventive treatment of, 180 Harelip, treatment of, 811 Harris-Dickinson pelvimeter, 410 Harris' method of dilating os uteri, 749 Head, fetal, effects of flat pelvis upon, 426-428 extramedian engagement of, 428 structure of, 356 Hearing, disturbances of, in pregnancy, 234 . Heart affections of new-born, 816 changes in, in pregnancy, 186 disease in labor, 583 in pregnancy, 236 failure, death from, in labor, 571 muscle, diseases of, in pregnancy, 237 of new-born infant, 792 sounds, fetal, in pregnancy, ausculta- tion of, 203 Hegar's bougies or dilators, 749 sign of pregnancy, 201 Hematocele, ante-uterine, 273 from tubal pregnancy, 273 retro-uterine, 274 Hematoma from ruptured tubal preg- nancy, 273 of vagina, obstruction of labor by, 488 polypoid, of uterus, 146 puerperal, 601 clinical history of, 603 diagnosis of, 603 etiology of, 602 prognosis of, 605 situation of, 601 size and form of, 602 treatment of, 606 rupture of, causing death in labor, 571 Hematuria in pregnancy, 232 in puerperal state, 636 Hemophilia of new-born, 815 Hemoptysis in pregnancy, 240 Hemorrhage, accidental, 534 complicating labor, 525 from laceration of cervix, 552 from umbilicus, 818 gastro-intestinal, in new-born, 818 in placenta praevia, 529 in third stage of labor, prevention of, 312 placental, 127 postpartum, 537 abdominal binder in, 539 auto-infusion in, 542 Hemorrhage, postpartum, causes of, 537 compression of uterus in, 540 diagnosis of, 538 electricity in, 540 ergot in, 539 intravenous injection of salt solution in, 542 Monsel's solution in, 540 morphin in, 542 rectal injection of salt solution in 541 symptoms of, 538 tampon in, 540 transfusion of blood in, 542 treatment of, 538 vinegar in, 539 puerperal, 590 from carcinoma of uterus, 600 from dislodgements of thrombi, 598 from displacements of uterus, 595 from emotional causes, 599 from fibroids, 599 from hematomata, 601 from pelvic engorgement, 600 from relaxation of uterus, 599 from retained placenta and mem- branes, 590 from retention of blood-clots, 599 from wounds of genital tract, 600 unavoidable, 525 Hemorrhagic decidual endometritis, 149 Hemorrhoids in pregnancy, 226 vesical, in pregnancy, 231 Hemothorax of child from injury in labor, 805 Hernia of pregnant uterus, obstruction of labor by, 492, 493 umbilical, 137 of new-born, 811 vaginal, obstruction of labor by, 503 Hernial protrusion of pregnant uterus. 215 Herpes gestationis in pregnancy, 241 Hick's cephalotribe, 770 Hirst's cranioclast, 769 forceps, 728 knife for cutting subpubic ligament, 776 pelvimeter, 418 Hodge's forceps, 727 scissors, 768 Holoblastic ovum, 60 Hook, blunt, 748 Braun's, 774 Ramsbotham's, 774 Human milk as food, 795 compared with cows' milk, 797 constitution of, 795 Hydatidiform mole, 105 Hydramnion, 96 Hydramnios, 96 acute, 96 differentiation of, from ascites, 100 830 INDEX. Hydramnios, differentiation of, from ovarian cyst, loo from twin pregnancy, loo etiology of, 96 from both fetal and maternal sources, 99 from excessive excretion of fetal urine, 98 from fetal skin, 98 from the amnion itself, 98 of fetal origin, 97 of maternal origin, 96 symptoms and diagnosis of, 99 treatment of, 100 Hydrencephalocele, 510 obstruction of labor by, 512 Hydrocephalus, 513 diagnosis of, 513 treatment of, 5*4 Hydronephrosis in pregnancy, 230 Hydrorrhea gravidarum, 283 Hydrostatic dilatation of cervical canal, 748 Hymen, 45 unruptured, obstruction of labor by, 489 Hyperemesis gravidarum. See Vomit- ing, pei'nicious Hyperlactation, 649 Hypodermatoclysis in puerperal sepsis, 685 Hysterectomy for puerperal sepsis, 690 Hysteria in pregnancy, 234 Hysterical convulsions, abortion in, 246 Icterus gravidarum, influence of, upon fetus, 170 of new-born, 816 Iliopsoas muscle, 25 Imperforate rectum of child, 812 Impetigo herpetiformis, 241 Impregnation, changes in ovum follow- ing, 72 time when most likely to occur, 69 Incarceration of pregnant uterus, 211 treatment of, 213 Incontinence of urine in pregnancy, 231 Incubation, 792 Incubator, Auvard, 793 Indigestion in pregnancy, 225 Induction of abortion, 719. See Abor- tion Inertia uteri, 401 diagnosis of, 403 etiology of, 401 treatment of, 404 Infant,new-born. See New-born infant Infundibulopelvic ligament, 55 Inguinal colotomy for atresia ani of new- born, 812 Injuries of child-birth, repair of, 589 Injuries to infant during labor, 799 Inlet of pelvis, 17 Insanity in pregnancy, 234 Insemination, 64 Insertio velamentosa, 137 Insolation in puerperal state, 613 Insufflation in asphyxia neonatorum, 807 Internal cell-membrane of ovum, 60 Interstitial invagination in fetus, 166 placentitis, 121 pregnancy, 259 abdominal section for, 281 clinical history of, 264 symptoms of, 277 terminations of, 271 Intraperitoneal abscess, abdominal sec- tion for, 688 Intrauterine amputations, 166 Intussusception of new-born, 814 Inversion of uterus in labor, 563. See Uterus, inversion of Involution of uterus, 320, 331, 340 abnormalities of, 584 adnexa in, 325 changes in blood-vessels in, 323 in muscle-fibers in, 321-323 endometrium in, 324 ergot for, 340 Irritable uterus as a cause of abortion, 243 Ischiopagus parasiticus, 5°7 Ischiopubiotomy in obliquely contracted pelvis, 438 Ischiorectal abscess, 714 Janiceps, 508 Jaundice in pregnancy, 226 of new-born. 816 Jorisenne's sign of pregnancy, 187 Justomajor pelvis, 439 Justominor pelvis, 429. See Pelvis Juvenile pelvis, 429 Karyokinesis in ovum, 60 Kidney, dislocation of, in pregnancy, 230 of pregnancy, 226 differential diagnosis from nephritis, 228 etiology of, 227 frequency and course of, 227 pathology of, 227 symptoms of, 227 treatment of, 227 Kidneys, diseases of, in pregnancy, 226 in puerperal state, 637 Klebs-Loffler bacillus in puerperal sepsis, 670 Knots of umbilical cord, false, 133,136 true, 136 INDEX. 831 Kyesteinic pellicle, 187 Kyphoscoliosis, pelvis of, 473 Kyphosis, 465 Kyphotic pelvis, 465. See Pelvis, ky- photic Labor, injuries to face during, 803 to infant during, 799 to neck of fetus during, 803 to peripheral nerves during, 799 to scalp during, 800 to trunk of child during, 804 inversion of uterus in, 563 labia in, 294 lacerations of perineum in, 306 treatment of, 558 of vagina in, 554 of vestibule in, 555 of vulva in, 555 liquor amnii in, 305 management of, 298 of, when obstructed by contracted pelvis, 480 manner in which uterine muscle acts on fetal body, 355 mechanism of, 350 abnormalities in, 364 expulsion of trunk in, 364 forces involved in, 354 in breech presentation. 381 in brow presentation, 378 in face presentations, 372 in flat pelvis, 424 in funnel-shaped pelvis, 433 in justominor pelvis, 431 in kyphotic pelvis, 468 in obliquely contracted pelvis, 436 in occipitoposterior positions, 366 in osteomalacic pelvis, 453 in rachitic pelvis, 447 in right occipito-anterior position,366 in shoulder presentation, 393 in third stage, 395 abnormalities of, 396 in vertex presentation, 357 normal, 358 accommodation of fetal head in, 358 anterior rotation of occiput in, 361 descent of head in, 360 dilatation of lower segment and of cervical canal in, 360 external rotation in, 364 propulsion and extension of head in,361 restitution in, 361 when occiput rotates into hollow of sacrum, 367 missed, 188 obstruction of, by abnormal condition about rectum, 505 by abnormalities of fetal membranes, 523 by abscess of Bartholin's gland, 490 by anus vestibularis or vaginalis, 489 by atresia of cervix uteri, 485 of vagina, 489 by calculi in bladder, 505 Labia majora, 44 minora, 44 puncture of, for edema of vulva, 219 Labor, 285 abdominal palpation in, 350 action and appearance of woman in, 291 anesthetics in, 303 armamentarium for, 299 bed in, 302 caput succedaneum in, 800 causes of, 286-288 chloroform in, 304 circular detachment of cervix uteri in, . .553 clinical phenomena of, 291 complicated by accidents and diseases, 525 by heart disease, 583 by hemorrhage, 525 by pneumonia, 582 by typhoid fever, 582 contraction of uterus after, method of securing, 312 contractions of uterine muscle in, 291 decapitation of fetus during, 803 definition of, 286 descent of uterus in, 288, 289 diagnosis of, 288 diastasis of abdominal muscles in, 570 distortion of head during, 800 dry, 523 duration of, 290 eclampsia during, 581 embolism of pulmonary artery in, 571 ether in, 304 examination of patient in, 300 expulsive forces of, excessive power of, 406 first stage of, 293 anesthetics in, 303 management of, 301 pain in, 302 forces involved in, 354 of, anomalies of, 401 fracture of coccyx in, 569 of limbs of child during, 804 of pelvic bones in, 569 of skull during, 800 heart failure in, 571 induction of, in placenta praevia, 532 injuries of, repair of, 589 to bowel of child during, 805 to brain during, 799 to cervix uteri in, 552 832 INDEX. Labor, obstruction of, by carcinoma of cervix uteri, 498 by cicatrices of vagina, 488 by cicatricial contraction of cervix uteri, 486 by closure of vagina, 487 by congenital anomalies of uterus, 484 narrowness of vagina, 491 by cystocele, 505 by displacement of the cervix uteri, 498 by double uterus, 484 by edema of vulva, 490 by enlarged carunculae myrtiformes, 491 by former fixation of uterus, 493 by gangrene of vulva, 491 by hematomata of vagina, 488 by hernia of pregnant uterus, 492, 493 by hydrencephalocele, 512 by hydrocephalus, 513 by large fetal head, 509 by malformations of fetus, 509 by ovarian cysts, 502 by overgrowth of fetus, 505 by placenta praevia, 525. See Pla- centa prcevia by premature ossification of cra- nium, 509 by prolapse of uterus, 495 by rectocele, 505 by rigidity of cervix uteri, 486 by sacculation of uterus, 495 by septa of vagina, 488 by tumors of fetus, 512 of vagina and vulva, 489 by twins, 518 by unruptured hymen, 489 by uterine displacements, 491 fibroid, 498 polypi, 501 by vaginal enterocele, 503 by vaginismus, 491 by varicose veins, 491 by Wormian bones, 509 pains of, 289 pathology of, 401 preliminary preparations for, 298 premature, care of child after, 792 induction of, 721 in overgrowth of fetus, 506 preparations for, 298-300 prevention of hemorrhage in third stage of, 312 profound emotion in, 572 pulse in, 329 resistant forces of, excess of, 407 rupture of hematoma in, 571 of respiratory tract in, 57° of sacroiliac joints in, 569 Labor, rupture of symphysis pubis in, 569 of uterus in, 543. See Uterus, rup- ture of second stage of, 293 clinical features of, 306 shock in, 571, 582 signs of, 288 sloughs of scalp from injury during, 803 stage of descent in, 293 of dilatation in, 293 of expulsion in, 293 stages of, 293 subcutaneous emphysema in, 570 sudden death during, 571 syncope in, 571 temperature in, 298 third stage of, 293, 314 mechanism of. 395 twin, 518 coiling of cords in, 520 mechanism of, 520 placenta in, 521 presentations in, 518 prognosis of, 522 uterine contractions in, 291 vulva in, 294 Laceration of perineum in labor, 306 preventive treatment of, 308 Lactalbumin of human milk, 796 Lactose, 796 Langhans' cells, 114 Lanugo, 80 Laparo-elytrotomy, 780 Larynx, diseases of the, in pregnancy, 238 Late ligation of cord, 317 Lateral displacement of pregnant uterus, 214 Lateroflexion of the pregnant uterus, 214 Lateroposition of the pregnant uterus, 214 Lateroversion of the pregnant uterus, 214 Length of mature fetus, 86 Leukemia in pregnancy, 238 Leukorrhea in pregnancy, 193 vaginal, in pregnancy, 216 Levator ani, importance of, 26 Levret's forceps, 726 Ligamentous structure of pelvis, 27 Limbs of fetus, fracture of, during labor, 804 Linea nigra, 199 Lipuria in pregnancy, 231 Liquor amnii, 93 abnormalities of, 101 complicating labor, 523 secretion of, 95 composition of, 94 INDEX. 833 Liquor amnii, deficiency of, 95 escape of, in labor, 305 excessive quantity of, 96 origin of, 94 putrefaction of, 101 folliculi, 59 Lithopedion, 175 Liver, degeneration of, in pregnancy, 226 L. O. A, 353 explanation of frequency of, 353 Lochia, 326 alba, 326 rubra, 326 serosa, 326 Lohlein's method of measuring trans- verse diameter of pelvic inlet, 420 Longings in pregnancy, 187 L. O. P., 353. Lordosis, pelvis of, 473 Lowenhardt's method of estimating dura- tion of pregnancy, 205 Lungs in puerperal state, 332 of new-born infant, diseases of, 808 septic infection of, 809 Luxation of femora, effect of, on pelvis, 477 Luxations of fetus, 166 Lymphangioma of fetus, obstruction of labor by, 512 Lymphatic ducts of pelvic organs, 32 Lymphatics of uterus in pregnancy, 182 Malaria in puerperal state, 626 of fetus, 160 relation of, to puerperal sepsis, 717 Male pronucleus, 69 Mammae, absence of, 641 congestion and engorgement of, 654 hypertrophy of, 641 supernumerary, 641 Mammary abscess, 657 in pregnancy, 221 binder, 346 changes in puerperal state, 333 glands, diseases of, 652 management of, in puerperal state, 344 structure of, 333 tumors, 658 in pregnancy, 221 Manual method of dilating os uteri, 749 of extracting breech, 745 Marginal insertion of cord, 136 Marshall Hall's method of artificial respi- ration, 807 Martin's pelvimeter, 410 Masculine pelvis, 429 Mastitis, 656 of new-born, 811 Maternal blood, alterations in, that are fatal to fetus, 176 53 Maternal emotions, influence of, upon fetus, 169 fever, influence of, upon fetus, 168 Maturation of ovum, 60 Mature fetus, 85 appearance of, 87 dimensions of head of, 86 length of, 86 weight of, 85 Mauriceau's method of delivering after- coming head, 763 Measles in fetus, 158 in pregnancy, 240 in puerperal state, 623 Mechanism of labor, 350. See also Labor, mechanism of forces involved in, 354 normal, 358 of various positions, 357 presentations, 357 Melancholia in pregnancy, 187 Melena of new-born, 818 Membrana decidua vera, 139 granulosa of Graafian follicle, 59 reflexa, 139 serotina, 139 Membranes, fetal, abnormalities of, com- plication of labor by, 523 retention of, puerperal hemorrhage from, 590 Menstrual flow, character of, 58 duration of, 58 quantity of, 58 molimina, 58 Menstruation, 56 and ovulation, connection between, 63 cessation of, 59 as a sign of pregnancy, 191 in extra-uterine pregnancy, 275 time of onset of, 57 Mesoderm, 72 Mesonephros, 42 Metritis, chronic, as a cause of abortion, 176 dissecting, in puerperal sepsis, 697 in pregnancy, 215 treatment of, 215 septic, in puerperal fever, 697 Micro-organisms, behavior of, in genital canal, 673 capable of producing puerperal sepsis, 670 manner of entrance of, into genital canal, 671 passage of, from mother to fetus, 156, 157 Miliary tuberculosis in pregnancy, 239 Milk, colostrum-corpuscles in, 652 cows', constitution of, 797 effect of emotions on, 647, 651 human, as food, 795 constitution of, 795 834 INDEX. Milk, qualitative anomalies in, 651 quantity of, 336 secretion of, 644 defective treatment of, 648 deficient, 645 excessive, 648 uterine, 114 Milk-leg in puerperal sepsis, 706 Miscarriage, 243, 258. See also Abor- tion Missed abortion, 258 labor, 188 Mole, hydatidiform, 105 Moles, tubal, 271 Molimina, menstrual, 58 Mons Veneris. 43 Montgomery's glands, inflammation of, 652 prominence of, in pregnancy, 194 Morning sickness, 187 Morula, 72 Mother, chronic diseases of, effect of, upon fetus, 177 conditions of, which injuriously affect fetus, 168 death of, effect of, upon fetus, 171 directions for, 347 effect of death of fetus upon, 172 Mouth-to-mouth insufflation in asphyxia neonatorum, 807 Mucous plug, 186 Mulberry mass, 72 Miillerian ducts, 39, 40 Multiple births, 518. See Labor, twin fetation, 89. See Fetation incisions, dilatation of os uteri by, 749 pregnancy. See Fetation, multiple Murphy breast-binder, 346 Muscle-fibers of uterus, alterations in, in pregnancy, 181 Muscles of pelvis, 25 Myelitis, ascending, in puerperal state, 640 Myocardium, brown atrophy of, in preg- nancy, 237 Myometrium, rheumatism of, in preg- nancy, 215 Myxoma fibrosum placentae, 112 of fetus, obstruction of labor by, 512 Myxomatous degeneration of placenta, 123 Naboth, glands or follicles of, 46 Naegele's method of estimating duration of pregnancy, 204 pelvis, 434. See Pelvis, contracted, obliquely Nasal catarrh of new-born, 813 Nausea and vomiting in pregnancy, 187, 192 Neck, injuries of, during labor, 803 Necrosis of pelvis, 459 Nephritis, differential diagnosis of, from kidney of pregnancy, 228 in pregnancy, 227 treatment of, 228 maternal, effect of, upon fetus, 177 Nerves of generative organs, 32 of uterus, changes in, in pregnancy, 182 Nervous system, changes in, in preg- nancy, 187 diseases of, in pregnancy, 232 Neuralgia in pregnancy, 187, 233 Neuritis in puerperal state, 640 Neuroses of pregnancy, 233 New-born infant, 789 airing of, 799 aphthae of, 813 artificial feeding of, 796 respiration of. 807 asphyxia of, 806 atelectasis of, 808 atresia ani in, 812 bathing of, 798 blood in, 791 bloody discharge from female genitalia of, 819 capacity of stomach of, 790 care of, 316, 346 directions to nurse for, 348 cephalhematoma of, 802 cleft-palate of, 811 clothing of. 795 colic of, 813 conjunctivitis of, 815 constipation in, 813 cyanosis of, S16 deformities of, treatment of, 811 digestion in, 790 diseases of, 808 lungs of, 808 exanthemata of, 811 eyesight in, 791 feeding of, 795 furuncles in, 814 gastro-intestinal hemorrhage in, 818 general appearance of, 87 gonorrheal stomatitis of, 813 harelip of, 811 heart of, 792 affections of, 816 hemophilia of, 815 hemorrhage from umbilicus in, 818 icterus of, 816 inflammation of umbilical vessels in, 818 injuries to. during labor, 79° intussusception in, 814 jaundice of, 816 management of, 795 mastitis of, 811 INDEX. 835 New-born infant, medication of, 820 melena of, 818 movements of bowels in, 790 nasal catarrh of. 813 omphalitis in, 817 ophthalmia of, 815 pathology of, 790 pemphigus of, 814 syphilitic, 814 physiology of, 789 pneumonia of, 809 position of stomach in, 790 pulmonary apoplexy of, 810 pulse in, 791 respiration of, 789 physiology of, 806 septic infection of lungs of, 809 of umbilicus of, 817 septicemia of, 811 skin diseases of, 814 sublingual cysts of, 813 sudden death of, 820 syphilis of, 810 of lungs of, 809 temperature of, 790 tetanus of, 818 thrush of, 813 tuberculosis of, 809 umbilical cord in, 792 fungus in, 817 hernia in, 811 urine in. 790 weight of, 789 wet-nurse for, 796 white pneumonia of, 809 Nipples, anomalies of, 643 care of, 189 eczema of, in pregnancy, 221 sore, 655 Nipple-shield, 655 Nose, affections of, in pregnancy, 238 Nurse, directions for, 348 Nymphae, 44 Oblique diameters of pelvis, 22 pelvis, 434. See Pelvis, contracted, obliquely Obstetric examination in labor, 300 Obstetrical binder, 313 Obturator membranes, 27 Occipito-anterior position, 353 mechanism of labor in, 357 right, mechanism of, 366 Occipitoposterior position, 353 diagnosis of, 366 mechanism of labor in, 366 prognosis of, 369 treatment of, 369 Oligohydramnios, 95 Omphalitis of new-born, 817 Omphalorrhagia, 818 Ophthalmia neonatorum, 815 Os uteri, artificial dilatation of, 748. See Cervical canal, dilatation of Osiander's pelvimeter, 410 Ossification of cranium, premature, ob- struction of labor by, 509 Osteomalacia of pregnancy, 240 Osteomalacic pelvis, 450 Osteophytes in pregnancy, 187 Ostium abdominale of oviduct, 53 internum of oviduct, 53 Outlet of pelvis, 17 Ovarian arteries, 32 pregnancy, 259 clinical history of, 265 operation for, 281 terminations of, 271 Ovario-abdominal pregnancy, 259 Ovariopelvic ligament, 55 Ovariotomy for ovarian cyst complicating pregnancy. 502 Ovary, anatomy of, 54 cysts of, complication of labor by, 502 development of, 40 germinal epithelium of, 59 Oviducts, anatomy of, 50 Ovular decidua, 140 Ovulation, 59 and menstruation, connection between, 63 Ovule and spermatic particle, meeting- place of, 68 Ovum, changes in, following impregna- tion, 72 deutoplasm of, 60 discharge of, from ovary, 61 fertilization of, 69 germinal spot of, 60 vesicle of, 60 internal cell membrane of, 60 maturation of, 60 a cause of labor, 287 migration of, to uterine cavity, 62 polar globules of, 60 premature expulsion of, 243. See Abortion protoplasm of, 60 transmigration of, 62 vitelline membrane of, 60 yolk of, 60 zona pellucida of, 60 Pain in extra-uterine pregnancy, 274 Pains in labor, 289, 291 Palfyn's forceps, 725 Palpation, abdominal, in labor, 350 Paralyses, spinal, in pregnancy, 233 Paralysis in puerperal state, 640 Para-uterine phlebitis in puerperal sepsis, 702 Parovarium, 40, 42 836 INDEX. Parturition, epistaxis in, 238 Pelvic bones, fracture of, in labor, 569 cavity, measurement cf capacity of, 422 direction, 24 engorgement a cause of puerperal hemorrhage, 600 joints, ankylosis of, 459 changes in, in pregnancy, 186 loosening of and pain in, in preg- nancy, 220 relaxation of, 459 after labor, 658 suppuration of, 714 lymphatic glands, 32 organs, sensations in,in pregnancy, 193 peritonitis in puerperal fever, 699 position, 22 shape, 20 size, 22 tumors, putrefaction of, 713 Pelvimeter, 409, 410 Harris-Dickinson's, 410 Hirst's, 418 Martin's, 410 Osiander's, 410 Pelvimetry, 409 Skutsch's method of, 422 Pelvis, anatomy of, 17 obstetrically considered, 20 anomalies of. See Pelvis, deformities of blood-vessels of organs of, 32 brim of, 17 caries of, 459 cavity of, measurement of capacity of, 422 connective tissue of, 28 contracted, Cesarean section in, 483, 484 forceps in, 482 generally, 429. See Pelvis, justo- minor induction of premature labor in, 480 management of labor in, 480 obliquely, 434 characteristics of, 434 diagnosis of, 436 etiology of, 435 influence of, on labor, 436 prognosis of, 437 treatment of, 437 symphyseotomy in, 483 transversely, 438 version in, 482, 754 coxalgic. 475 deformed, frequency of, 407 deformities of, 407 classification of, 408 description of, 423 diagnosis of, 409 deformity of, from absence of both lower extremities, 479 Pelvis, deformity of, from absence of one lower extremity, 479 from clubfoot. 480 development, of, 24 diameters of, 22 direction of, 24 dwarf, 429, 430 effect of luxation of femora upon, 477 exostoses of, 453 fetal, 432 flat, non-rachitic, 431 rachitic, 441 simple, 423 diagnosis of, 424 etiology of, 424 influence of, upon labor, 424 fracture of, 456 funnel-shaped, 432 inclination of, 22 inferior strait of, 17 inlet of, 17, 18 justomajor, 439 justominor, 429 characteristics of, 429 etiology of, 430 influence of, on labor, 431 juvenile, 429 kyphoscoliotic, 473 kyphotic, 465 characteristics of, 466 diagnosis of, 471 frequency of, 472 influence of, on labor, 468 prognosis of, 472 treatment of, 470 ligamentous structures of, 27 lordosic, 473 lymphatic ducts of organs of, 32 masculine, 429 muscles of, 25 Naegele's, 434. See Pelvis, contracted obliquely nana, 429 nerves of organs of, 32 obliquely contracted, 434 obtecta, 468 osteomalacic, 450 diagnosis of, 452 influence of, upon labor, 453 treatment of, 453 outlet of, 17 plana, 423 position of, 22 pseudo-osteomalacic, 444 rachitic, 440 characteristics of, 440 diagnosis of, 445 flat, 441 influence of, on labor, 447 Robert's, 438. See Pelvis, contracted, transversely scoliotic, 472 INDEX. 837 Pelvis, shape of, 20 simple flat, 423 sitz, 479 size of, 22 soft tissues of, 25 spinosa, 453 split, 439 spondylolisthesic, 460 characteristics of, 460 diagnosis of, 462 etiology of, 462 influence of, upon labor, 464 treatment of, 465 superior strait of, 17 true, 17 tumors of, 453 undeveloped, 432 Pemphigus of new-born, 814 syphilitic, 814 Pendulous belly, obstruction of labor by, 492 Peptonuria from death of fetus, 174 in pregnancy, 231 in puerperal state, 635 Perforator, Blot's, 768, 769 Smellie's, 768, 769 Perineum, laceration of, in labor, 306 treatment of, 558 supporting of, 308-310 Periodicity a cause of labor, 287 Peripheral nerves, injury to, during labor, 799 Peritoneal covering of uterus, changes of, in pregnancy, 181 Peritonitis, diffuse, in puerperal sepsis, 699 suppurative, abdominal section for, 688 lymphatica in puerperal sepsis, 700 pelvic, in puerperal fever, 699 Peri-uterine adhesions in pregnancy, 220 inflammations in pregnancy, 220 Pernicious anemia in pregnancy, 238 vomiting, 222. See Vomiting Pfliiger's theory of menstruation, 56 Phlebitis, para-uterine, in puerperal sep- sis, 702 uterine, in puerperal sepsis, 702 Phlegmasia alba dolens in puerperal sep- sis, 706 Phthisis in puerperal state, 615 placental. 123 pulmonalis in pregnancy, 239 Physical disturbances in pregnancy, 234 Pigmentation, exaggerated, in pregnancy, 242 of areolae, exaggerated, 654 Placenta, 112 adhesion of, 397 diagnosis of, 398 prognosis of, 399 treatment of, 398 Placenta, anatomy of, 117 annular, 120 anomalies of, 119 of number of, 119 of position of, 119 of shape of, 119 of size of, 119 of weight of, 119 calcareous degeneration of, 124 circular vein of, 118 cotyledons of, 118 cysts of, 129 delivery of, 314 in twin labor, 521 detachment of, premature, 534 causes of, 535 diagnosis of, 535 prognosis of, 536 symptoms of, 535 treatment of, 536 development of, 112 duplex, 120 edema of, 120 expression of, Crede's method of, 396 expulsion of, mechanism of, 395 fatty degeneration of, 121 fibrofatty degeneration of, 121 fibrous degeneration of, 121 functions of, 118 hemorrhages of, 127 hernia of, through muscular coat of uterus, 390. manner of separation of, 297 membranacea, 104, 119 multiloba, 120 myxomatous degeneration of, 123 praevia, 525 abortion in, 530 clinical history of, 528 diagnosis of, 530 etiology of, 527 frequency of, 525 hemorrhage in, 529 history of, 525 induction of labor in, 532 prognosis of, 534 symptoms of, 53° tampon in, 533 varieties of, 527 retained, a cause of puerperal hemor- rhage, 590 retention of, 396, 524 in double uterus, 485 syphilis of, 124 tripartita, 120 tumors of, 129 villi of, 112 cellular hypertrophy of, 121 Placentae succenturiatae, 120 Placental decidua, 140 hemorrhages, 127 phthisis, 123 838 IN Placental polypus, 146 syphilis, 124 villi, cellular hypertrophy of, 121 Placentitis, 128 interstitial, 121 Plane of pelvic contraction, 21 expansion, 21 Plethora, maternal, effect of, on fetus, 176 Pleurisy in pregnancy, 240 in puerperal state, 617 Pneumococcus in puerperal sepsis, 670 Pneumonia, complication of labor by, 582 in pregnancy. 239 in puerperal state, 616 of new-born infant, 809 Podalic version, 757 Poisoning, chronic, effect of, upon mother, 177 Polar bodies or globules, 60 Polygalactia, 649 Polyhydramnion, 96 Polymastia, 641 Polypi, uterine, obstruction of labor by, 5oi Polypoid endometritis, 146 hematoma of uterus, 146 Polypus, placental, 146 Polyuria in pregnancy, 231 P- O. P.,353 explanation of frequency of, 353 Porro's method of Cesarean section, 780, 781 Position, definition of, 350 occipito-anterior, 353 occipitoposterior, 353. See Occipito- posterior position of fetus, diagnosis of, by abdominal palpation, 351 by auscultation, 352 Positions, mechanism of, 357 Postmammary abscess, 657 Postmortem Cesarean section, 779 delivery, 573 Postpartum hemorrhage, 537. See Hem- orrhage Postural version, 756 Posture, Walcher, 483, 484 Pott's disease in pregnancy, 240 Poulet's axis-traction forceps, 730 Prague method of delivering after-coming head, 765 Pregnancy, 17 abdomen in, 192, 195 abdominal, 259. See Abdominal preg- nancy accidents of, 242 acetonuria in, 231 albuminuria in, 227, 232 aneurysms in, 238 anomalies of urine in, 231 IX. Pregnancy, anteflexion of uterus in, 210 appendicitis in, 226 areola in, 194 asthma in, 239 auscultatory sounds of, 202 blindness in, 234 blood in, 186 breasts in, 193, 194 broad ligament in, 261 bronchial catarrh in, 239 caries of teeth in, 221 cervical, of Rokitansky, 150 cervicitis in, 216 cessation of menstruation in, 191 changes in abdomen in, 192 in abdominal walls in, 186 in bladder in, 186 in blood in, 186 in breasts in, 194 in cervix in, 185 in circulatory system in, 186 in digestive tract in, 187 in heart in, 186 in nervous system in, 187 in pelvic joints in, 186 in rectum in, 186 in respiratory apparatus in, 188 in several bodily systems in, 186 in urine in, 187 in uterus in, 181 in vagina in, 186 in vulva in, 186 in weight in, 187 chloasmata of, 194 chorea in, 233 chyluria in, 231 colpohyperplasia cystica in, 217 combined, examination in, 201 congestion of brain in, 232 constipation in, 187, 188 treatment of, 225 cystitis in, 231 degeneration of liver in, 226 diabetes mellitus in, 232 diagnosis of, 189-210 diarrhea in, treatment of, 225 diet in, 189 diminution of urine in, 231 diseases of alimentary canal in, 221 of blood in, 238 of blood-vessels in, 237 of brain in, 232 of cervix in, 216 of larynx in, 238 of nervous system in, 232 of respiratory apparatus in, 238 of spinal cord in, 233 of vagina in, 216 of vulva in, 217 dislocation of kidney in, 230 displacements of uterus in, 210 disturbances of hearing of, 234 ■ INDEX. 839 Pregnancy, disturbances of vision in, 234 dullness on percussion in, 203 duration of, estimation of, 204 ectopic, 259. See Pregnancy, extra- uterine eczema of nipples in, 221 edema of vulva in, 218 emphysema in, 239 endocerviciiis in, 216 epilepsy in, 233 epistaxis in, 238 exaggerated pigmentation in, 242 extra-uterine, 259 face of woman in, 194 fetal heart-sounds in, 203 movements in, 193 palpation of, 201 fibromata of uterus in, 215 funic souffle in, 203 general changes in, 186 gingivitis in, 221 glycosuria in, 232 goiter in, 237 Graves' disease in, 237 heart disease in, 236 hematuria in, 232 hemoptysis in, 240 hemorrhoids in, 226 hernial protrusion of uterus in, 215 hydronephrosis in, 230 hysteria in, 234 incarceration of uterus in, 211 incontinence of urine in, 231 indigestion in, 225 infection with gonococcus in, 217 in horn of uterus bicornis or unicornis, 282 injuries of, 242 insanity in, 234 interstitial, 259. See Interstitial preg- nancy jaundice in, 226 kidney of, 226 kyesteinic pellicle in, 187 lateral displacements of uterus in, 214 lateroflexion of uterus in, 214 lateroposition of uterus in, 214 lateroversion of uterus in, 214 leukemia in, 238 leukorrhea in, 193 linea nigra in, 199 lipuria in, 231 longings in, 187 loosening of and pain in pelvic joints in, 220 of finger-nails in, 242 mammary abscess in, 221 tumors in, 227 management of, 188 measles in. 240 melancholia in, 187 metritis in, 215 Pregnancy, miliary tuberculosis in, 239 morning sickness in, 187 multiple. See Fetation, multiple nausea and vomiting in, 187, 192 nephritis in, 227 nervous system in, 187 neuralgias in, 187, 233 neuroses of, 233 osteomalacia of. 240 osteophytes in, 187 ovarian, 259. See Ovarian preg- nancy ovario-abdominal, 259 palpation of abdomen in, 200 peptonuria in, 231 peri-uterine adhesions in, 220 inflammations in, 220 pernicious anemia in, 238 vomiting in, 222 phthisis pulmonalis in, 239 physiology of, 181 pleurisy in, 240 pneumonia in, 239 polypoid hypertrophies of vaginal mu- cous membrane in, 217 polyuria in, 231 Pott's disease in, 240 prior, diagnosis of, 208 prolapse of uterus in, 214 prolongation of, 188 pruritus in, 241 vulvae in, 218, 241 ptyalism in, 192, 222 pulmonary embolism in, 239 tuberculosis in, 239 purpura haemorrhagica in, 238 pyelitis in, 230 quickening in, 193 renal calculus in, 230 tumors in, 230 respiratory apparatus in, 188 retroflexion of uterus in, 211. See Re- troversion retroversion of uterus in, 211 salivation in, 192 signs of, 191 objective, 193 on auscultation, 202 on inspection, 194 on sense of touch, 200 subjective, 191 skin diseases in, 241 spurious, 209 striae, mammary, in, 104 suburethral abscess in, 217 surgical operations in, 242 syphilis in, 240 tetany in, 234 toothache in, 221 torsion of uterus in, 215 tubal. See Tubal pregnancy tubo-abdominal, 259, 273 84O INi Pregnancy, tubo-ovarian, 259. See also lubo-ovarian pregnancy tubo-uterine, 259 typhoid fever in, 240 umbilicus in, 199 urine in, 187 uterine bruit in, 203 utero-abdominal, 260 vagina in, 200 vaginal leukorrhea in, 216 varices of labia majora in, 218 of vagina in, 217 varicose veins in, 237 vegetations of vulva in, 218 vesical calculi in, 231 hemorrhoids in, 231 vomiting in, 187, 192 pernicious, 222 vulva in, 200 weight in, 187 Pregnant uterus, alterations in, 181 anteflexion of, 210 displacements of, 210 hernial protrusion of, 215 incarceration of, 211 lateral displacements of, 214 lateroflexion of, 214 lateroposition of, 214 lateroversion of, 214 prolapse of, 214 relation of, to intestines, 184 retroflexion or retroversion of, 211. See Retroflexion torsion of, 215 Premature infants, abnormalities in phy- siology of, 792 gavage of, 793 management of, 792 sclerema of, 795 labor, induction of, 721 in contracted pelvis, 480 in overgrowth of fetus, 506 Presentation, breech, abnormalities in mechanism of, 387 blunt hook in, 748 causes of, 381 diagnosis of, 381 extraction of, 745 by fillet, 747 by manual method, 745 forceps in, 747 frequency of, 381 mechanism of, 381 prognosis of, 386 treatment of, 387 brow, 378 diagnosis of, 378 frequency of, 378 mechanism of, 378 prognosis of, 378 treatment of, 378 cephalic, explanation of frequency of, 352 Presentation, compound, 5J6 treatment of, 517 definition of, 350 diagnosis of, by abdominal palpation, 351 by auscultation, 352 by vaginal examination, 352 face, 370 abnormalities in mechanism of, 372 causes of, 371 diagnosis of, 370 frequency of, 370 mechanism of, 372 prognosis of, 374 treatment of, 374 mechanism of, 357 of greater fontanel, 379 shoulder, 388 causes of. 393 diagnosis of, 388 mechanism of, 393 treatment of, 395 version in, 395 transverse, 388 varieties of, 357 vertex, 357 diagnosis of, 357 explanation of frequency of, 353 mechanism of labor in, 357 positions of, 353 Priapism from injury to brain during labor, 799 Primitive streak, 72 Proctitis, septic, in puerperal sepsis, 713 Prolapse of pregnant uterus, 214 of umbilical cord, 573 of uterus, complication of labor by, 495 Promontory, double, 424 Pronucleus, female, 89 male, 69 Prosopothoracopagus, 508 Proteids of milk, 796 Protoplasm of ovum, 60 Pruritus in pregnancy, 241 vulvae in pregnancy, 218, 241 Pseudocyesis, 209 Pseudo-osteomalacic pelvis, 444 Ptyalism in pregnancy, 192, 222 Pubes, fracture of, 457 Puerperal anemia, 588 fever. See Puerperal sepsis hematoma, 601. See Hematoma hemorrhage, 59°- See Hemorrhage, puerperal infection. See Puerperal sepsis insanity, 234 sepsis, 659 abdominal section in, 685 atmosphere in, 675 bacteriology of, 662-673 behavior of micro-organisms in gen- ital canal, 673 INDEX. 84I Puerperal sepsis, care of patient in, 677 clinical history of, 696 diagnosis of, 674 diffuse peritonitis in, 699 dissecting metritis in, 697 encolpitis in, 696 endometritis in, 696 etiology of, 662 exploratory abdominal section in, 694 forms of, 696 hypodermatoclysis in, 684 hysterectomy for, 690 microbes of, manner in which they find entrance, 671 that produce, 670 milk-leg in, 706 morbid anatomy of, 696 operative treatment of, 685 pelvic peritonitis in, 699 phlegmasia alba dolens in, 706 precautions in regard to implements, 679 on part of nurse in, 679 physician in, 679 preventive treatment of, 675 physician in, 678 proctitis, 713 putrefaction of pelvic and abdominal tumors in, 713 pyelitis in, 712 relation of diphtheria to, 716 of erysipelas to, 716 of infectious fevers to, 715 of scarlet fever to, 717 salpingitis in, 696 salpingo-oophorectomy for, 689 sapremia in, 709 septic cystitis iii, 712 metritis in, 697 septicemia in, 709 serum-therapy of, 681 symptoms of, 674 tetanus in, 713 treatment of, 679 by artificial hyperleukocytosis, 684 by washing the blood, 684 preventive, 675 ureteritis in, 712 uterine phlebitis in, 702 water in, 676 state, 319 acute intercurrent affections of, 615 after-pains in, 328 alterations in circulatory apparatus in, 329 anemia in, 588 apoplexies in, 640 appetite in, 332 arthritis in, 296 ascending myelitis in, 640 Puerperal state, bowels in, 342 breasts, care of, in, 344 care of child in, 346 catheter in, 342 change in urinary system in, 330 cystitis in, 638 diagnosis of, 336 diastasis of abdominal muscles in, 632 diet in, 340 diphtheria in, 626 directions to nurse for, 349 edema of genitals in, 590 erysipelas in, 623 erythematous rashes in, 622 fever in, emotional, 607 from cerebral disease, 612 from constipation, 610 from exposure to cold, 609 from reflex irritation, 610 non-infectious, 607 syphilitic, 614 with eclampsia, 613 fibroids in, 599 gonorrhea in, 631 hematoma in, 601. See Hematoma hematuria in, 636 incontinence of urine in, 637 insolation in, 613 involution of uterus in, 320 kidneys in, 637 lesions of sacral plexus in, 640 lochia in, 326 malaria in, 626 mammary abscess in, 657 changes in, 333 glands in, care of, 344 management of, 337 mastitis in, 656 measles in, 623 neuritis in, 640 nursing in, 349 paralysis in, 640 pathology of, 584 peptonuria in, 635 phthisis in, 615 physician's visits during, 337 pleurisy in, 617 pneumonia in, 616 pulse in, 329 pyelonephritis in, 639 rest and quiet in, 338 rheumatism in, 629 muscular, 631 scarlet fever in, 617 secretion of milk in, 644 skin diseases in, 632 small-pox in, 623 sun-stroke in, 613 sweat-glands in, 332 temperature in, 333 thirst in, 332 842 INDEX. Puerperal state, tympanites in, 632 urination in, 342 urine in, 634 visits of friends in, 339 weight, loss of, in, 2,1s Puerperium. See Puerperal state Pulmonary apoplexy of new-born, 810 embolism in pregnancy, 239 Pulse during labor, 329 in new-born infant, 791 in puerperal state, 329 Puncture of labia for edema of vulva, 219 Purpura haemorrhagica in pregnancy, 238 Putrefaction of pelvic and abdominal tumors, 713 Putrid absorption in puerperal sepsis, 709 Pyelitis in pregnancy, 230 in puerperal sepsis, 712 Pyelonephritis in puerperal state, 639 Pyopagus, birth of, 511 Quickening, 80, 193 value of, in estimating duration of pregnancy, 205 Rachitic pelvis, 440. See Pelvis, ra- chitic Rachitis of fetus, 163 Ramsbotham hook, 774 Rectocele, obstruction of labor by, 505 Rectum, abnormal conditions of, obstruc- tion of labor by, 505 changes in, in pregnancy, 186 imperforate, of child, treatment of, 812 Recurrent fever of fetus, 162 Relaxation of pelvic joints, 460 Renal calculus in pregnancy, 230 tumors in pregnancy, 230 Resistance, forces of, 354 Resistant forces of labor, excess in, 407 Respiration of new-born infant, 789 physiology of, 806 Respiratory apparatus, changes in, in pregnancy, 188 diseases of, in pregnancy, 238 tract, rupture of, in labor, 570 Restitution, anomalies of, 365 in face presentation, 372 in vertex presentation, 361 Retention of placenta, 396 of urine in puerperal state, 342 Retroflexion of pregnant uterus, progno- sis of, 212 symptoms of, 211 terminations of, 212 treatment of, 212 when uterus is incarcerated, 213 Retro-uterine hematocele, 274 Retroversion of pregnant uterus, 211 Rheumatism, articular, of fetus, 162 in puerperal state, 629 muscular, in puerperal state, 631 of myometrium in pregnancy, 215 Ring of Bandl, 183, 354, 544 R. 0. A., 353 Robert pelvis, 438. See Pelvis, con- tracted, transversely Rosenmuller, body of, 42 Rotation, external, anomalies of, 365 in face presentation, 372 of fetal head, 364 of fetal head, 361 anomalies of, 365 of occiput in face presentation, 372 in occipitoposterior position, 366 abnormalities of, 367 Rupture of membranes, artificial, 305 of umbilical cord, 575 of uterus, 543. See Uterus, rupture of Sacculation of uterus, 212 obstruction of labor by, 495 Sacral plexus, lesions of, in puerperal state, 640 Sacrococcygeal joint, ankylosis of, 459 fracture of, in labor, 569 Sacroiliac joint, rupture of, in labor, 569 synostosis of, 459 Sacrosciatic ligaments, 27 Sacrum, fracture of, 457 Saddle-shaped back, 462 Salivation in pregnancy, 192 Salpingitis in puerperal fever, 696 Salpingo-oophorectomy for puerperal sep- sis, 689 Sanger method of Cesarean section, 780, 784 Sapremia in puerperal sepsis, 709 Scalp, injury of, during labor, 800 Scarlatina of fetus, 159 Scarlet fever in puerperal state, 617 frequency of, 618 infection and incubation of, 618 peculiarities of, 620 prognosis of, 621 symptoms and diagnosis of, 619 of fetus, 159 relation of, to puerperal sepsis, 717 Schatz's method of cephalic version, 376 Schultze's method of artificial respira- tion. 807 Sclerema of premature infants, 795 Scoliosis, 472 Scoliotic pelvis, 472. See Pelvis, scoli- otic Seminal fluid, description of, 64 mechanism of ejaculation of, 66 of reception of within genital canal of female, 67 granule of spermatozoon, 65 INDEX. 843 Septic infection of lungs of new-born in- fant, 809 of umbilicus of new-born, 817 Septicemia in puerperal sepsis, 709 of fetus, 161 of new born infant, 811 Serum-therapy in puerperal sepsis, 681 Sex, determination of, 87 of fetus, diagnosis of, 208 Shock, death from, in labor, 571 in labor, 582 Shoulder presentation, 388. See Presen- tation Shoulders, descent, rotation, and birth of, 364 Show, 290 Signs of pregnancy, 191 ascertained by auscultation, 202 by inspection, 194 by sense of touch, 200 objective, 193 subjective, 191 Simple flat pelvis, 423 Simpson's cranioclast, 769 forceps, 728 Sitz-pelvis, 479 Skin diseases in pregnancy, 241 in puerperal state, 632 of new-born, 814 Skull, fracture of, during labor, 800 injury to, during labor 800 Skutsch's method of pelvimetry, 421, 422 Sloughs of scalp of infant from injury during labor, 803 Small-pox in puerperal state, 623 Smellie's forceps, 726 perforator, 768. 769 Snuffles, 813 Somatopleure, 73 Souffle, funic, 203 Spermatic particles in semen, first appear- ance of, 65 Spermatozoa, 64 meeting-place of, with ovule, 68 power of motion of, 65 time of disappearance of, from semen of old men 66 vitality of, 65 Spina bifida, treatment of, 812 Spinal cord, inflammation of, in preg- nancy, 233 paralyses in pregnancy, 233 Splanchnopleure, 73 Split pelvis, 439 Spondylizema, 465 Spondylolisthesis, 460 Spondylolisthetic pelvis, 460. See Pelvis, spon dylolistketic Spongy layer of uterine decidua, 143 Spontaneous evolution, 394 version, 394 Spurious pregnancy, 209 Staphylococci in puerperal sepsis, 670 Stein's instrument for measuring conju- gate, 413 Stethoscope, use of, in diagnosing preg- nancy, 204 Still-births, repeated, diagnosis of causes of, 179 Still-born children, habit of giving birth to, 179 Stomach, capacity of, in new-born infant, 790 position of, in new-born infant, 790 Streptococcus pyogenes in puerperal sep- sis, 670, 673 Striae, mammary, 194 Subinvolution, 585 causes of, 585 diagnosis of, 586 treatment of, 587 Sublingual cysts in new-born, 813 Suburethral abscess in pregnancy, 217 Sugar of human milk, 796 Sun-stroke in puerperal state, 613 Superinvolution, 584 Supernumerary digits, treatment of, 811 Suppuration of pelvic joints, 7*4 Supravaginal portion of uterus, 47 Surgical operations in pregnancy, 243 " Sway " back, 462 Sweat-glands in puerperal state, 332 Symphyseotomy, 774 by French method, 779 by Italian method, 776 indications for, 775 in labor with contracted pelvis, 483 technic of, 776 Symphysis pubis, rupture of, in labor, 569 synostosis of, 459 Syncephalus, craniotomy for, 513 Syncope after labor, 571 Syncytial cancer, 129 Syncytium, 112, 114 Synostosis of pelvic joints, 459 Syphilis, fetal, 151 diagnosis of, 153 manifestations of, 152 prognosis of. 153 treatment of, 155 Wegner's sign of, 154 in pregnancy, 240 of lungs of new-born infant, 809 of new-born infant, 810 placental, 124 Syphilitic fever in puerperal state, 614 Tarnier's axis-traction forceps, 730 basiotribe, 770, 771 sign of inevitable abortion, 252 Teeth, caries of, in pregnancy, 221 844 INDEX. Temperature of fetus in utero, 84 of new-born infant, 790 Teratoma of fetus, obstruction of labor by, 511, 512 Tetanus bacillus in puerperal sepsis, 670 in puerperal sepsis, 713 of new-born, 818 Tetany in pregnancy, 234 Theca folliculi, 59 Third stage of labor, 314 mechanism of, 395 Thirst after delivery, 332 Thoracopagus, birth of, 511, 512 Thrombi, displacement of, as a cause of puerperal hemorrhage, 598 Thrombosis of pulmonary artery in labor, 571 Thrush of the new-born infant, 813 Tongue-tie, treatment of, 811 Toothache in pregnancy, 221 Torsion of pregnant uterus, 215 Transmigration of ovum, 62 Transverse diameter of pelvis, 22 measurement of, 420 pelvic outlet, measurement of, 422 presentation, 388. See Presentation Transversely contracted pelvis, 438. See Pelvis, contracted Traumatism, fetal, 167 True conjugate, measurement of, 413,414 corpus luteum, 63 Trunk of child, injuries of, during labor, 804 Tubal abortion, 272 moles, 271 pregnancy, abdominal section for, 279 atrophy of sac in, 267 clinical history of, 261 pathology of. 261 rupture of sac of, 267 vaginal section for, 281 varieties of, 259 Tuberculosis of fetus, 160 of new-born infant, 809 pulmonary, in pregnancy, 239 Tubo-abdominal pregnancy, 259, 273 Tubo-ovarian ligament, 53 pregnancy, 259 clinical history of, 265 Tubo-uterine pregnancy, 259 terminations of, 271 Tumors of fetus, obstruction of labor by, 512 of genital canal, obstruction of labor by, 498 of pelvis, 453 of placenta, 129 of umbilical cord, 138 of vagina and vulva, obstruction of labor by, 489 Tunica fibrosa of Graafian follicle, 59 media of Bischoff, 93 Tunica propria of Graafian follicle, 59 Twin labor, 518. See Labor Tympanites in puerperal state, 632 Typhoid fever in pregnancy, 240 labor complicated by, 582 of fetus, 161 Umbilical cord, 132 anomalies of, 134 calcareous degeneration of, 138 coiling of, around fetus, 136 cysts of, 138 description of, 133 development of, 132 exaggerated twisting of, 134 false knots of, 133, 136 hernia into, 137 in new-born infant, 792 marginal insertion of, 136 short, complicating labor, 523 true knots of, 135 tumors of, 138 velamentous insertion of, 137 fungus in new-born, 817 hernia, 137 of new-born, 811 vesicle, 132 vessels, 133 inflammation of, 818 rupture of, 135 stenosis of, 135 varices of, 135 Umbilicus, changes of, in pregnancy, 199 hemorrhage from, 818 inflammation of, 817 of new-born, septic infection of, 817 Unavoidable hemorrhage, 525 Undeveloped pelvis, 432 Urea, excess of, in maternal blood, effect of upon fetus, 177 Ureteritis in puerperal sepsis, 712 Urinary apparatus, diseases of, in preg- nancy, 226 system, changes in, in puerperal state, 330 Urination in puerperal state, 342 Urine, anomalies of, in pregnancy, 231 changes in, in pregnancy, 187 diminution of, in pregnancy, 231 examination of, in pregnancy, 188 excessive secretion of, a cause of hy- dramnios, 98 incontinence of, in pregnancy, 231 in puerperal state, 637 in new-born infant, 790 in puerperal state, 634 of mother after death of fetus, 174 retention of, after labor, 330 Urogenital sinus, 39, 40, 42 Uterine adnexa, involution of, 325 artery, 32 LNDEX. 845 Uterine bruit, 203 contractions in labor, 291 decidua, 140 compact layer of, 140 glandular layer of, 143 spongy layer of, 143 milk, 114 muscle, contraction of, in labor, 291 deficient power of, 401. See also Inertia uteri diseases of, 215 in pregnancy, 215 manner in which, acts on fetal body, 355 phlebitis in puerperal sepsis, 702 segment, lower, 354 upper, 354 Utero-abdominal pregnancy, 260 clinical history of, 265 Utero-ovarian ligament, 55 Uterus, alterations of, in pregnancy, 181 anatomy of, 46 at full term, 182 bicornis duplex, 49 pregnancy in one horn of, 282 unicollis, 49 biforis, 487 blood-vessels of, in pregnancy, 181 carcinoma of, a cause of puerperal hemorrhage, 600 changes in form, position, and relations of, in pregnancy, 183 in volume, capacity, and weight of, in pregnancy, 183 conditions of, which interfere with de- velopment of fetus, 175 congenital anomalies of, obstruction of labor by, 484 connective tissue of, in pregnancy, 181 contraction of, after labor, method of securing, 312 cordiformis, 49 deformities of, 49 descent of, in labor, 288, 289 development of, 41 didelphus, 49 displacement of, anterior, obstruction of labor by, 492 as a cause of puerperal hemorrhage, 595 lateral, obstruction of labor by, 494 obstruction of labor by, 491 double, obstruction of labor by, 484 fibroid of, obstruction of labor by, 498 fibromata of, in pregnancy, 215 fixation of, obstruction of labor by, 493 hernia of, obstruction of labor by, 492, 493 incudiformis, 49 inversion of, causes of, 565 in labor, 563 symptoms of, 566 Uterus, inversion of, treatment of, 567,568 involution of, 320. See also Involu- tion of uterus abnormalities of, 584 irritable, as a cause of abortion, 243 lymphatics of, in pregnancy, 182 muscle-fibers of, in pregnancy, 181 nerves of, in pregnancy, 182 overdistention of, a cause of labor, 287 peritoneal covering of, in pregnancy, 181 polypi of, obstruction of labor by, 501 pregnant, anteflexion of, 210 displacements of, 210 hernial protrusion of, 215 incarceration of, 211 lateral displacements of, 214 lateroflexion of, 214 lateroposition of, 214 lateroversion of, 214 prolapse of, 214 relation of, to intestines, 184 retroflexion or retroversion of, 211. See Retroflexion torsion of, 215 prolapse of, complication of labor by, 495 relaxation of, as a cause of puerperal hemorrhage, 599 rupture of, 543 causes of, 543 clinical history of, 548 diagnosis of, 548 differentiation of, from accidental hemorrhage, 549 frequency of, 543 in pregnancy, 242 morbid anatomy of, 545 prognosis of, 550 symptoms of, 548 treatment of, 55 * sacculation of, 212 obstruction of labor by, 495 semipartitus, 49 subinvolution of, 585. See Subinvo- lution subseptus, 49 superinvolution of, 584 unicornis, 50 pregnancy in horn of, 282 Vagina, alteration in, in pregnancy, 186 anatomy of, 45 appearance of, in pregnancy, 200 atresia of, obstruction of labor by, 489 cicatrices of, obstruction of labor by, 488 closure of, obstruction of labor by, 487 congenital narrowness of, obstruction of labor by, 491 development of, 41 846 INDEX. Vagina, diseases of, in pregnancy, 216 double, 50 hematomata of, obstruction of labor by, 488 laceration of, in labor, 554 microbic flora of, 662-673 micro-organisms of, 662-673 polypoid hypertrophies of, in preg- nancy, 217 septa of, obstruction of labor by, 489 tumors of, obstruction of labor by, 489 varices of, in pregnancy, 217 Vaginal enterocele, obstruction of labor by, 5°3 examination for diagnosis of present- ing part, 352 leukorrhea in pregnancy, 216 portion of uterus, 47 secretions, germicidal power of, 663- 670 section for tubal pregnancy, 281 Vaginismus, obstruction of labor by, 491 Vagitus uterinus, 789 Van Huevel's method of treating fetal hydrocephalus, 514 Varices of labia majora in pregnancy, 218 of vagina in pregnancy, 217 Varicose veins in pregnancy, 237 rupture of, 242 obstruction of labor by, 491 Variola of fetus, 158 Vegetations of vulva in pregnancy, 218 Velamentous insertion of cord, 137 Vernix caseosa, 80 Version, 754 by external manipulation, 757 cephalic, Baudelocque's method of, 376 Schatz's method of, 376 combined, 757 D'Outrepont's method of, 758 Wright's method of, 758 contraindications to, 755 in breech presentation, 387 in contracted pelves, 754 in labor with contracted pelvis, 482 in shoulder presentation, 395 indications for, 754 podalic, 757 postural, 756 spontaneous, 394 Vertex presentation. See Presentation Vesical calculi in pregnancy, 231 hemorrhoids in pregnancy, 231 Vestibule, 45 bulbs of, 45 lacerations of, in labor, 555 Villi of chorion, 103 cystic degeneration of, 104. See Cystic degeneration dropsy of, 105 of placenta, 112 cellular hypertrophy of, 121 Vision, disturbances of, in pregnancy, 234 Vitelline membrane, 60 Vomiting, abortion from, 245 as an indication for inducing abortion, 719 in pregnancy, 187, 192 pernicious, 222 causes of, 222 diagnosis of, 222 mortality from, 225 treatment of. 223 gynecological, 224 hygienic, 223 medicinal, 224 obstetrical, 225 Vulva, alterations in, in pregnancy, 186 appearance of, in pregnancy, 200 diseases of, in pregnancy, 217 edema of, in pregnancy, 218 obstruction of labor by, 490 gangrene of, obstruction of labor by, 491 in labor, 306 lacerations of, in labor, 555 pruritus of, in pregnancy, 218 vegetations of, in pregnancy, 218 Vulvovaginal glands, 45 Walcher posture, 483, 484 Wegner's sign of fetal syphilis, 154 Weight, changes of, in pregnancy, 187 loss of, after labor, 333 of mature fetus, 85 of new-born infant, 789 Wet-nurse, selection of, 796 Wharton, gelatin of, 132 White pneumonia of new-born infants, 809 Wiegand's method of delivering after- coming head, 763 treatment of placenta praevia, 533 Winckel's disease, 817 Wolffian body, 40, 41, 42 ducts, 39, 40 Womb. See Uterus Wormian bone, obstruction of labor by, 509 Wright's method of combined version, 758 Xiphopagus, 508 birth of, 511 Yellow fever of fetus, 162 Yolk of ovum, 60 Zona pellucida of ovum, 60 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W; B* SAUNDERS, No. 925 WALNUT STREET, PHILADELPHIA. Arranged Alphabetically and Classified under Subjects. 'TtHE books advertised in this Catalogue as being sold by subscription are usually to be * obtained from traveling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States; but any book will be sent by the publisher to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following ways: A post-office money order, an express money order, a bank check, and in a registered letter. 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" It is practical from beginning to end. Its descriptions of conditions, its recommen- dations for treatment, and above all the necessary technique of different operations, are clearly and admirably presented. . . . It is well up to the most advanced views of the day, and embodies all the essential points of advanced American gynecology. It is destined to make and hold a place in gynecological literature which will be peculiarly its own."— Medical Record, New York. AN AMERICAN TEXT-BOOK OF LEGAL MEDICINE AND TOXI- COLOGY. Edited by Frederick Peterson, M. D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York;'Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York; and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, and Toxicology in Rush Medical College, Chicago. In Preparation. AN AMERICAN TEXT-BOOK OF OBSTETRICS. By 15 Eminent American Obstetricians. Edited by Richard C. Nor- ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome imperial octavo volume of over 1000 pages, with nearly 900 beautiful colored and half-tone illustrations. Cloth, #7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription. " Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that I have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers."—Alexander J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. " This is the most sumptuously illustrated work on midwifery that has yet appeared. In the number, the excellence, and the beauty of production of the illustrations it far surpasses every other book upon the subject. This feature alone makes it a work which no medical library should omit to purchase."—British Medical Journal. " As an authority, as a book of reference, as a ' working book ' for the student or prac- titioner, we commend it because we believe there is no better."—American Journal of tht Medical Sciences. Illustrated Catalogue of the "American Text-Books n sent free upon application. Medical Publications of W. B. Saunders. 5 AN AMERICAN TEXT-BOOK OF. PATHOLOGY. Edited by John Guiteras, M.D., Professor of General Pathology and of Morbid Anatomy in the University of Pennsylvania; and David Riesman, M.D., Demonstrator of Pathological Histology in the University of Pennsylvania. In Preparation. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. By 10 of the Leading Physiologists of America. Edited by William H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- kins University, Baltimore, Md. One handsome imperial octavo volume of 1052 pages. Illustrated. Cloth, #6.00 net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. " We can commend it most heartily, not only to all students of physiology, but to every physician and pathologist, as a valuable and comprehensive work of reference, written by men who are of eminent authority in their own special subjects."—London Lancet. " To the practitioner of medicine and to the advanced student this volume constitutes, we believe, the best exposition of the present status of the science of physiology in the English language."—American Journal of the Medical Sciences. AN AMERICAN TEXT-BOOK OF SURGERY. Second Edition. By 13 Eminent Professors of Surgery. Edited by William W. Keen, M.D., LL.D., and J. William White, M.D., Ph.D. Handsome imperial octavo volume of 1250 pages, with 500 wood-cuts in the text, and 39 colored and half-tone plates. Thoroughly revised and enlarged, with a section devoted to " The Use of the Rontgen Rays in Surgery." Cloth, $7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Sub- scription. " Personally, I should not mind it being called THE Text-Book (instead of A Text- Book) , for I know of no single volume which contains so readable and complete an account of the science and art of Surgery as this does."—Edmund Owen, F.R.C.S., Member of the Board of Examiners of the Royal College of Surgeons, England. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. AN AMERICAN TEXT-BOOK OF THE THEORY AND PRACTICE OF MEDICINE. By 12 Distinguished American Practitioners. Edited by William Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- cine and of Clinical Medicine in the University of Pennsylvania. Two handsome imperial octavo volumes of about 1000 pages each. Illus- trated. Prices per volume : Cloth, #5.00 net; Sheep or Half Morocco, #6.00 net. Sold by Subscription. " I am quite sure it will commend itself both to practitioners and students of medicine, and become one of our most popular text-books."—Alfred Loomis, M.D., LL.D., Pro- fessor of Pathology and Practice of Medicine, University of the City of New \ork. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second and last volume leads us to modify that verdict and to say that the completed work is in our opinion the best of its kind it has ever been our fortune to see. — New York Medical Journal. ___________________ Illustrated Catalogue of the "American Text-Books" sent free upon application. 6 Medical Publications of W. B. Saunders. AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. A Yearly Digest of Scientific Progress and Authoritative Opinion in all branches of Medicine and Surgery, drawn from journals, monographs, and text-books of the leading American and Foreign authors and investigators. Collected and arranged, with critical editorial com- ments, by eminent American specialists and teachers, under the general editorial charge of George M. Gould, M.D. One handsome imperial octavo volume of about 1200 pages. Uniform in style, size, and general make-up with the "American Text-Book" Series. Cloth, 56.50 net; Half Morocco, #7.50 net. Sold by Subscription. " It is difficult to know which to admire most—the research and industry of the distin- guished band of experts whom Dr. Gould has enlisted in the service of the Year-Book, or the wealth and abundance of the contributions to every department of science that have been deemed worthy of analysis. . . . It is much more than a mere compilation of abstracts, for, as each section is entrusted to experienced and able contributors, the reader has the advantage of certain critical commentaries and expositions . . . proceeding from writers fully qualified to perform these tasks. . . . It is emphatically a book which should find a place in every medical library, and is in several respects more useful than the famous 'Jahrbucher' of Germany."—London Lancet. ANDERS' PRACTICE OF MEDICINE. Second Edition. A Text-Book of the Practice of Medicine. By James M. Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, 55.50 net; Sheep or Half Morocco, $6.50 net. " It is an excellent book,—concise, comprehensive, thorough, and up to date. It is a credit to you ; but, more than that, it is a credit to the profession of Philadelphia—to us." James C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson Medical College, Philadelphia. " I consider Dr. Anders' book not only the best late work on Medical Practice, but by far the best that has ever been published. It is concise, systematic, thorough, and fully up to date in everything. I consider it a great credit to both the author and the publisher."— A. C. Cowferthwaite, President of the Illinois Homeopathic Medical Association. ASHTON'S OBSTETRICS. Fourth Edition, Revised. Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00; interleaved for notes, 51.25. [See Saunders'' Question-Compends, page 21.] " Embodies the whole subject in a nut-shell. We cordially recommend it to our read- ers."—Chicago Medical Times. BALL'S BACTERIOLOGY. Third Edition, Revised. Essentials of Bacteriology ; a Concise and Systematic Introduction to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 pages; 82 illustrations, some in colors, and 5 plates. Cloth, 51.00; interleaved for notes, 51.25. [See Saunders'' Question-Compends, page 21.] '' The student or practitioner can readily obtain a knowledge of the subject from a perusal of this book. The illustrations are clear and satisfactory."—Medical Record, New York. Medical Publications of W. B. Saunders. 7 BASTIN'S BOTANY. Laboratory Exercises in Botany. By Edson S. Bastin, M.A., late Professor of Materia Medica and Botany, Philadelphia College of Pharmacy. Octavo volume of 536 pages, with 87 plates. Cloth, 52.50. "It is unquestionably the best text-book on the subject that has yet appeared. The work is eminently a practical one. We regard the issuance of this book as an important event in the history of pharmaceutical teaching in this country, and predict for it an unquali- fied success."—Alumni Report to the Philadelphia College of Pharmacy. "There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation."—American Journal of Pharmacy. BECK'S SURGICAL ASEPSIS. A Manual of Surgical Asepsis. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and the New York German Poliklinik, etc. 306 pages; 65 text-illustrations, and 12 full-page plates. Cloth, 51.25 net. " An excellent exposition of the ' very latest' in the treatment of wounds as practised by leading German and American surgeons."—Birmingham (Eng.) Medical Review. "This little volume can be recommended to any who are desirous of learning the details of asepsis in surgery, for it will serve as a trustworthy guide."—London Lancet. BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERATIONS. Obstetric Accidents, Emergencies, and Operations. By L. Ch. Boisliniere, M.D., late Emeritus Professor of Obstetrics, St. Louis Medical College. 381 pages, handsomely illustrated. Cloth, 52.00 net. " It is clearly and concisely written, and is evidently the work of a teacher and practi- tioner of large experience."—British Medical Journal. " A manual so useful to the student or the general practitioner has not been brought to our notice in a long time. The field embraced in the title is covered in a terse, interesting way."— Yale Medical Journal. BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. Essentials of Medical Physics. By Fred J. Brockway, M.D., Assistant Demonstrator of Anatomy in the College of Physicians and Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. Cloth, 51.00 net; interleaved for notes, 5I-25 net- [See Saunders' Question-Compends, page 21.] " The student who is well versed in these pages will certainly prove qualified to com. prehend with ease and pleasure the great majority of questions involving physical principles likely to be met with in his medical studies."—American Practitioner and News. "We know of no manual that affords the medical student a better or more concise exposition of physics, and the book may be commended as a most satisfactory presentation of those essentials that are requisite in a course in medicine."—New York Medical Journal. " It contains all that one need know on the subject, is well written, and is copiously illustrated."—Medical Record, New York. BURR ON NERVOUS DISEASES. A Manual of Nervous Diseases. By Charles W. Burr, M.D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia; Pathologist to the Orthopedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to St. Joseph's Hospital, etc. In Preparation. 8 Medical Publications of W. B. Saunders. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- MACOLOGY. Second Edition, Revised. A Text-Book of Materia Medica, Therapeutics, and Pharma- cology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 860 pages, illustrated. Cloth, 54-oo net; Sheep, 55-°° net- " Taken as a whole, the book may fairly be considered as one of the most satisfactory of any single-volume works on materia medica in the market,"—Journal of the American Medical Association. "The work is executed in a clear, concise, and practical manner, and should meet with a hearty endorsement from the students of our up-to-date colleges. The book will be found a valuable work of reference for the practitioner."—American Medico-Surgical Bulletin. CASSELBERRY ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By W. E. Casselberry, Pro- fessor of Laryngology and Rhinology in the Northwestern University Medical School, Chicago. In Preparation. CERNA ON THE NEWER REMEDIES. Second Edition, Revised. Notes on the Newer Remedies, their Therapeutic Applications and Modes of Administration. By David Cerna, M.D., Ph.D., formerly Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania; Demonstrator of Physiology in the Medical Department of the University of Texas. Rewritten and greatly enlarged. Post-octavo, 253 pages. Cloth, 51.25. " The appearance of this new edition of Dr. Cerna's very valuable work shows that it is properly appreciated. The book ought to be in the possession of every practising physi- cian."—New York Medical Journal. CHAPIN ON INSANITY. A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physi- cian-Superintendent of the Willard State Hospital, New York; Hon- orary Member of the Medico-Psychological Society of Great Britain, of the Society of Mental Medicine of Belgium. i2mo, 234 pages, illustrated. Cloth, 5T-25 net- The author has given, in a condensed and concise form, a compendium of Diseases of the Mind, for the convenient use and aid of physicians and students. The work will also prove valuable to members of the legal profession and to those who, in their relations to the insane and to those supposed to be insane, often desire to acquire some practical knowledge of insanity presented in a form that may be understood by the non-professional reader. CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. Second Edition, Revised. Medical Jurisprudence and Toxicology. By Henry C. Chapman, M.D., Professor of Institutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, 51.50 net. "The best book of its class for the undergraduate that we know of."—New York Medical Times. Medical Publications of W. B. Saunders. 9 CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence in the North- western University Medical School, Chicago ; and Frederick Peter- son, M.D., Clinical Professor of Mental Diseases in the Woman's Medical College, New York; Chief of Clinic, Nervous Department, College of Physicians and Surgeons, New York. In Press. CLARKSON'S HISTOLOGY. A Text-Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, 56.00 net. " The work must be considered a valuable addition to the list of available text-books, and is to be highly recommended."—New York Medical Journal. '' This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students."— Chicago Medical Recorder. "The volume is a most valuable addition to the armamentarium of the teacher."— Brooklyn Medical Journal. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, 51.50. COHEN AND ESHNER'S DIAGNOSIS. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 382 pages; 55 illustrations. Cloth, 51.50 net. [See Saunders1 Question- Compends, page 21.] "We can heartily commend the book to all those who contemplate purchasing a t- "I shall value very highly the copy of Penrose's 'Diseases of Women' received. I have already recommended it to my class as THE BEST book."—Howard A. Kelly, Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. " The book is to be commended without reserve, not only to the student but to the general practitioner who wishes to have the latest and best modes of treatment explained with absolute clearness."—Therapeutic Gazette. Medical Publications of W. B. Saunders. 19 POWELL'S DISEASES OF CHILDREN. Second Edition. Essentials of Diseases of Children. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of Children in the Hospital of the University of Pennsylvania. Crown octavo, 222 pages. Cloth, $1.00; interleaved for notes, 51.25. [See Saunders' Question-Compends, page 21.] "Contains the gist of all the best works in the department to which it relates."— American Practitioner and Neivs. PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. Pictorial Atlas of Skin Diseases and Syphilitic Affections (American Edition). Translation from the French. Edited by J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex Hospital, London. Photo-lithochromes from the famous models in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- cuts and text. In 12 Parts. Price per Part, 53.00. Complete in one volume, Half Morocco binding, 54°-°° net- " I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology."—Stephen Mackenzie, M.D. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit."—New York Medical Journal. PYE'S BANDAGING. Elementary Bandaging and Surgical Dressing. With Direc- tions concerning the Immediate Treatment of Cases of Emergency. For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers, 75 cents net. " The directions are clear and the illustrations are good."—London Lancet. " The author writes well, the diagrams are clear, and the book itself is small and port- able, although the paper and type are good."—British Medical Journal. RAYMOND'S PHYSIOLOGY. A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital; Director of Physiology in the Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the text, and 4 full-page colored plates. Cloth, 51.25 net. " Extremely well gotten up, and the illustrations have been selected with care. The text is fully abreast with modern physiology."—British Medical Journal. RONTGEN RAYS. Archives of the Rontgen Ray (Formerly Archives of Clinical Skiagraphy). Edited by Sydney Rowland, M.A., M.R.C.S., and W. S. Hedley, M.D., M.R.C.S. A series of collotype illustrations, with descriptive text, illustrating the applications of the new photo- graphy to Medicine and Surgery. Price per Part, 51.00. Now ready: Vol. L, Parts I. to IV.; Vol. II., Parts I., II. StaAnQaatucUmftiM BuntuisM ftmiOLOCT RAAnlMJV, ►AUNDERS' Question Compends Arranged in Question and Answer Form. nr1HE MOST COMPLETE AND BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature .... with Students and Practitioners in every City of the United States and Canada. ^ OVER \ 65,000 COPIES SOLD. -