v-^ $ e=^ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NLN DDSfllDfl7 3 J jo Aavaan ivnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NLM005810873 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY 3NOia3w jo Aavaan ivnouvn snidiqsw jo Aavaan ivnouvn snidiqsw jo Aavi NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY iNioiasw jo Aavaan ivnouvn 3nidiq3w jo Aavaan ivnouvn 3nidio3w jo Aavt JATIONAl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY NiDiasw jo Aavaan ivnouvn snidiosw jo Aavaan ivnouvn 3noio3w jo Aavs IATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY ^l /^BbiM^l /^iM\l /*• A MANUAL OBSTETRICS. 7^£ /^j? A MANUAL OBSTETRICS. BY S A. F. A. KING, M.D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN IN THE MEDICAL DEPARTMENT OF THE COLUMBIAN UNIVERSITY, WASHINGTON, D. C, AND IN THE UNIVERSITY OF VERMONT, ETC. ETC. f, A^"> *-J^A_ WITH FIFTY-EIGHT ILLUSTRATION^. PHILADELPHIA: HENRY C. LEA'S SON & CO 1882. K 5 2 »■„ W2Z Entered according to Act of Congress, in the year 1882, by HENRY C. LEA'S SON & CO., in the Office of the Librarian of Congress. All rights reserved. COLLINS, PRINTER. DESIGNED IN PARTICULAR FOR MY OWN STUDENTS IN THE MEDICAL CLASSES OF THE COLUMBIAN UNIVERSITY, WASHINGTON, D. C, AND THE UNIVERSITY OF VERMONT, TO THEM fflfa g0flft IS AFFECTIONATELY DEDICATED, WITH THE EARNEST HOPE IT MAY BE OF SERVICE TO THEM, AND WITH THE BEST WISHES OF THE AUTHOR. 1* PREFACE. The chief purpose of this book is to present, in an easily intelligible form, such an outline of the rudiments and essentials of Obstetric Science as may constitute a good groundwork for the student at the beginning of his obstetric studies ; and one by which it is hoped he will be the better prepared to understand and assimilate the extensive know- ledge and classical descriptions contained in larger and more elaborate text-books. Confessedly, in great part, a compilation from these, it is upon the more recent treatises of Leishman, Play fair, and Lusk that I have most largely depended, as authorities, in dealing with matters that are still unsettled, and it is with pleasure I acknowledge my in- debtedness to these authors. Whatever value the work may possess as a book of refer- ence for the practitioner, I cannot but hope it may prove of service to those whose onerous duties allow but little leisure for consulting larger works, and who simply desire to refresh their minds upon the more essential points of ob- stetric practice. viii PREFACE. It will be observed I have ventured to anglicize the terms "ante-partum" and "post-partum" into, respectively, " ante- partal" and" post-partal." If this be considered an error, or an unwarrantable assumption, I can only plead guilty, and await sentence from my confreres. For many of the illustrations—the plates of which were placed at my disposal by the publisliers—I am indebted to the works of Meigs, Leishman, and Playfair; for others, which will be found only in this work, my grateful acknow- ledgments are cordially extended to my friend and former pupil, Dr. William Nicholson, of this city. A. F. A. K. 726 Thirteenth Street, Washington, D. C, May, 1882. CONTENTS. CHAPTER I. INTRODUCTION. The Pelvis—Sacrum, Coccyx, and Innominate Bone—Planes and Inclined Planes — Sacro-sciatic Ligaments — Articulations of Pelvis — The Parturient Canal — Cams's Curve — Mobility of Pelvic Joints—Measurements of the Pelvis—Diameters of the Straits and Cavity—Muscular Appendages of the Pelvis—The Pelvic Floor and Perineum. pp. 24 to 39 CHAPTER II. THE FOiTAL HEAD. Compressibility, Shape, Sutures, Foiitanelles, Regions, Diameters, and Measurements. pp. 39 to 43 CHAPTER III. THE EXTERNAL GENERATIVE ORGANS. Mons Veneris, Labia Majora, Labia Minora, Fossa Navicularis, Clitoris, Vestibule, Urethra, Hymen, and Carunculae Myrti- fornies. pp. 43 to 46 CHAPTER IV. INTERNAL GENERATIVE ORGANS. Vagina, Uterus (its Structure, Ligaments, Arteries, Veins, Lym- phatics, Nerves, and Functions), Fallopian Tubes, and Ovaries —The Graafian Follicle and its Contents—Corpus Luteum— The Parovarium—Mammary Glands. pp. 46 to 57 X CONTENTS. CHAPTER V. MENSTRUATION. Cause, Symptoms, and accompanying Changes in Uterine Mu- cous Membrane—Destiny of the Ovule—Signs of Puberty- Quantity and Source of Menstrual Flow—Vicarious Menstrua- tion—Periodicity and Normal Suspension of Menses. pp. 57 to 61 CHAPTER VI. FECUNDATION. The Spermatic Fluid—Changes in Ovule after Impregnation— Blasto-dermic Membranes—Vitelline Membrane—Amnion— Allantois—Chorion—The Decidua Vera, Reflexa, and Serotina —Placenta—Umbilical Cord—Nutrition of Foetus—Fcetal Cir- culation : Changes in Circulation after birth. . pp. 61 to 69 CHAPTER VII. THE SIGNS OF PREGNANCY. Classification—Early Diagnosis of Pregnancy—Positive Signs : The Fcetal Heart Sounds, Quickening, Ballottement, Uterine Murmur, and Intermittent Uterine Contractions — Doubtful Signs : Suppression of Menses, Breast Signs, Morning Sick- ness, Morbid Longings, Changes in Abdomen, Softening and Enlargement of Os and Cervix Uteri, Violet Color of Vagina, Kiestein, Pigmentary Deposit in Skin, Mental and Emotional Signs—Differential Diagnosis of Pregnancy—Order of Exami- nation in Suspected Pregnancy. pp. 69 to 84 CHAPTER VIII. THE DISEASES OF PREGNANCY. Classification—Salivation—Toothache and Dental Caries—Exces- sive Vomiting — Constipation — Diarrhoea — Albuminuria — Bright's Disease—Uraemia—Convulsions—Irritable Bladder— Incontinence of Urine—Uterine Displacements—Leucorrhcea— CONTENTS. xi Pruritus Vulva?—Painful Mammas—Palpitation—Syncope— Varicose Veins—Anaemia and Plethora—Cough and Dyspnoea —Nervous Diseases pp. 84 to 98 CHAPTER IX. ABORTION. Definition, Frequency, Causes, Period, Symptoms, Prognosis, Diagnosis, and Treatment. pp. 98 to 102 CHAPTER X. EXTRA-UTERINE PREGNANCY. Varieties—Tubal Pregnancy : its Causes, Symptoms, Diagnosis, and Treatment—Ovarian and Interstitial Varieties—Abdominal Pregnancy : its Diagnosis and Treatment—Hydatiform Preg. nancy—Moles : True and False. pp. 102 to 107 CHAPTER XI. LABOR. Mode of Foretelling Date of—Causes and Forces of—Labor-pains —The " Bag of Waters"—Stages of Labor—Symptoms—Phe- nomena of the Several Stages—Duration and Management of Labor—Preparation for Emergencies—Examination of Female : Verbal, Abdominal, and Vaginal—Purposes of latter—Arrange- ment of Bed and Night-dress—Rupture of Bag of Waters— Attendants—Pinching of Os Uteri against Pubes—Attention to Perineum—Birth of the Head—Tying the Cord—Delivery of Placenta—The Binder—Attentions to New-born Child—Dress- ing Stump of Navel String. pp. 107 to 122 CHAPTER XII. MANAGEMENT OF MOTHER AND CHILD AFTER DELIVERY. The Lochial Discharge—After-pains—Suckling the Child—The Infant's Bowels and Urine—The Mother's Bowels and Urine— Her Diet—Milk Fever—Sore Nipples—Sunken Nipples—Ex- Xll CONTENTS. cess of Milk — Deficient Milk — Artificial Feeding —Infantile Jaundice—Sore Navel—Secondary Hemorrhage from Navel- Time of getting up after Delivery. pp. 122 to 128 CHAPTER XIII. MECHANISM OF LABOR IN HEAD PRESENTATIONS. Posture of Child in Uterus—Four "Positions" of Head " Pre- sentations"—Mechanism in Left Occipito-Anterior Position— Flexion—Descent—Rotation—Extension—Restitution—Mech- anism of other Positions—Diagnosis of Position—Prognosis and Treatment in Occipito-Anterior Positions, and in Occipito- Posterior ones. PP- 128 to 141 CHAPTER XIV. FACE PRESENTATIONS. Causes, Frequency, and Positions of— Mechanism in Men to- Anterior Positions: Extension, Descent, Rotation, Flexion, and Restitution—Mechanism in Mento-Posterior Positions— Cause of Arrest after Posterior Rotation of Chin—Diagnosis, Prognosis, and Treatment of Face Cases—Brow Presentations. pp. 141 to 150 CHAPTER XV. BREECH PRESENTATIONS. Positions of—Mechanism in Sacro-Anterior Positions—Mechanism in Sacro-Posterior Positions—Knee and Footling Presentations -—Diagnosis of Breech, Knee, and Foot—Prognosis and Treat- ment of Breech Cases — Delivery of After-coming Head— Difficulty in Breech Cases. pp. 150 to 162 CHAPTER XVI. TRANSVERSE PRESENTATIONS. Positions and Mechanism of—Spontaneous Version—Spontaneous Evolution—Causes and Diagnosis of Transverse Cases—Diag- CONTENTS. Xlll nosis of Shoulder and Elbow, and of One Shoulder from the Other—Prognosis and Treatment. pp. 162 to 167 CHAPTER XVII. VERSION. Cephalic and Podalic—Methods of Operating: by External, Bi- polar, and Internal Manipulation—Version in Head Presenta- tions—Version in Transverse Presentations—Where to find the Feet—Prolapse of the Arm—Difficulties of Version. pp. 167 to 176 CHAPTER XVIII. INSTRUMENTS. The Fillet, Blunt-hook, Vectis, and Forceps—Long and Short Forceps—Action of Forceps—Cases in which they are used— The "High" and "Low" Operation—Conditions Essential to Safety—Application of Forceps at Inferior Strait after Anterior Rotation of Occiput—Oscillatory Movement—Application at Inferior Strait after Posterior Rotation—Application before Rotation—Application in Pelvic Cavity—The "High" Opera- tion—Tarnier's Forceps—Dangers of Forceps Operations— Forceps in Face Presentations—Forceps to the After-coming Head in Breech Cases. pp 176 to 190 CHAPTER XIX. CUTTING OPERATIONS UPON THE MOTHER. Symphysiotomy—Caesarian Section: Prognosis and Dangers, of Method of Operating, After-treatment—Laparotomy—Laparo- Elytrotomy—Porro's Operation. pp. 191 to 195 CHAPTER XX. MUTILATING OPERATIONS UPON THE CHILD. Craniotomy — Embryotomy — Perforation — Smellie's Scissors — Excerebration—Cephalotripsy—The Cranioclast—Cephalotribe —Craniotomy Forceps—Crotchet—Evisceration—Decapitation. pp. 195 to 202 2 XIV CONTENTS. CHAPTER XXI. PELVIC DEFORMITIES. Symmetrically Enlarged Pelvis—Symmetrically Contracted Pelvis —The Juvenile Pelvis—The Masculine Pelvis—The Pelvis of Rickets — The Malacosteon Pelvis — Oblique Deformity of Naegele—The " Roberts Pelvis"—The Spondylolithetic Pelvis — The Kyphotic Pelvis — Deformity from Hip-Dislocation, Exostosis, etc.—Symptoms of Deformity—Pelvimetry : Inter- nal and External—Diagnosis of Varieties—Dangers of Deformed Pelves—Modifications in Mechanism of Labor—Methods of As- sisting Delivery in Pelvic Deformity. pp. 202 to 212 CHAPTER XXII. INDUCTION OF PREMATURE LABOR. Cases proper for—Objects of—Its Employment in Pelvic De- formity—Methods of Inducing Labor before Child is Viable— Best Method when Child is Viable — Other Methods: the Vaginal Douche, Cohen's Method, Vaginal Tampon, Sponge- tent, Ergot, etc.—Treatment of Premature Infants. pp. 212 to 216 CHAPTER XXIII. PLACENTA PIM.VIA. Hemorrhage before Delivery—Causes, Consequences, Symptoms, Diagnosis, and Prognosis of Placenta Praevia — Treatment: before and after Viability of Child—Delivery—Version or For- ceps—Tampon—Dilators—Ergot—Rupture of Membranes— Barnes's Partial Digital Separation of Placenta—Simpson's Method—Treatment after Delivery—Hemorrhage before Labor without Placenta Prajvia : its Symptoms, Prognosis, and Treat- ment, pp. 216 to 221 CHAPTER XXIV. POST-PARTAL HEMORRHAGE. "Flooding"—Its Causes, Prevention, Symptoms, and Treatment —Preventive Measures—Remedies to arrest flow—Removal of CONTENTS. XV Placenta and Blood-clots — Manipulation of Uterus — Lemon- juice, vinegar, ice, hot water, and styptic iron applied to Ute- rine Cavity—Compression of* Aorta—No Tampon—Remedies for Syncope—Retained Placenta—Hour-glass Contraction of Uterus—Spasm of the Os—Treatment of—Large size of Pla- centa, pp. 221 to 228 CHAPTER XXV. INVERSION OF UTERUS. Varieties (or degrees), Causes, Symptoms, Prognosis, Danger, Diagnosis from Polypus, and Treatment. pp. 228 to 230 CHAPTER XXVI. RUPTURE OF UTERUS. Causes, Symptoms, Prognosis, and Treatment—Laceration of Cervix Uteri—Laceration of Vagina and Vulva—Thrombus of Vulva—Rupture of Perineum—Loosening of Pelvic Articula- tions, pp. 230 to 237 CHAPTER XXVII. MULTIPLE PREGNANCY. Twin, Triplet, Quadruplet, and Quintuplet Births—Arrangement of Placentae in Twins—Diagnosis and Prognosis of Plural Preg- nancy—Treatment of Twin Labors—Treatment of "Locked Twins"—Hydrocephalus: its Diagnosis, Prognosis, and Treat- ment — Encephalocele — Ascites, Tympanites — Distension of Bladder—Large size of Child—Premature Ossification of Cra- nium, pp. 238 to 245 CHAPTER XXVIII. TEDIOUS LABOR. Causes, Prognosis, Symptoms, Diagnosis, and Treatment—Swell- ing of Anterior Lip of Uterus—Rigid Os Uteri—Rigidity of Perineum—Mode of Delivery in Tedious Labor—Powerless Labor—Precipitate Labor: its Causes, Symptoms, and Treat- ment, pp. 245 to 253 xvi CONTENTS. CHAPTER XXIX. DIFFICULT LABOR. Obstruction by Maternal Soft Parts — Imperforate Hymen — Atresia and (Edema of Vulva—Atresia of Vagina—Cystocele— Rectocele—Impacted Feces—Vesical Calculus—Vaginismus— Growths in Vaginal Walls—Hernia—Occlusion of Os Uteri— Atresia of Cervix Uteri—Cancer of Cervix—Ante-partal Hour- glass Contraction of Uterine Body—Polypus—Fibroid and Ovarian Tumors. pp. 253 to 259 CHAPTER XXX. PROLAPSE OF FUNIS. Causes, Prognosis, Diagnosis, and Treatment—Postural Treat- ment—Repositors—Short and Coiled Funis : Symptoms and Treatment—Knots in the Cord. pp. 259 to 265 CHAPTER XXXI. ANAESTHETICS IN MIDWIFERY. General use of — Chloroform — Sulphuric Ether — Hydrate of Chloral: use of in labor, eclampsia, mania, etc.—Ergot: dan- gers, and contra-indications to use of—Quinia as an Oxytocic. pp. 265 to 269 CHAPTER XXXII. PUERPERAL ECLAMPSIA (CONVULSIONS) DURING LABOR. Symptoms and Clinical History—Varieties—Prognosis and Treat- ment, pp. 269 to 272 CHAPTER XXXIH. PUERPERAL SEPTICEMIA. Septic and Non-septic Puerperal Inflammation—(Child-bed Fever — Puerperal Fever) —Varieties of Inflammation — Causes — Prognosis — Post-mortem Appearances — Symptoms of Septi- CONTENTS. xvii ca?mia, of Metritis, of Vaginitis, of Peritonitis, of Phlebitis, of Cellulitis, etc.—Treatment: Antisepsis, Food, Anti-pyretics, Opiates, Arterial Sedatives, Cold, Blood-letting, Purgatives, Prophylaxis. pp. 272 to 282 CHAPTER XXXIV. CENTRAL VENOUS THROMBOSIS (HEART-CLOT). Causes — Post-mortem Appearances — Symptoms, Prognosis, Diagnosis, and Treatment — Peripheral Venous Thrombosis ("Milk Leg," "Phlegmasia Dolens")—Causes and Pathology —Symptoms, Prognosis, Local and General Treatment—Arte- rial Thrombosis and Embolism—Symptoms and Treatment. pp. 283 to 287 CHAPTER XXXV. PUERPERAL MANIA. Insanity of Gestation, Lactation, and the Puerperal State—Causes —Symptoms of each Variety—Prognosis as to Life and Mental Restoration—Treatment. pp. 287 to 291 CHAPTER XXXVI. INFLAMMATION OF BREASTS. Varieties — Causes — Symptoms — Treatment W eaning—W et-nurses. CHAPTER XXXVII. OBSTETRIC JURISPRUDENCE. Unusual Prolongation of Pregnancy—Short Pregnancies with Living Children—Appearances of Foetus at Different Periods of Gestation—Suspected Conjugal Infidelity—Moles—Diag- nosis of Pregnancy—Signs of Recent Abortion—Signs of Re- cent Delivery at Term—Unconscious Delivery—Feigned De- livery—Criminal Abortion—Medicinal Oxytocics—Mode of Examination after Instrumental Methods — Infanticide — In- spection of Child's Body—Duration of Survival after Birth— — Lactation and pp. 291 to 296 XV111 CONTENTS. Evidence of Live Birth—Static Test—Hydro-static Test— Value of Respiration as Evidence of Live Birth—Evidence from Circulatory Organs and Stomach—Natural Causes of Death in New-born Children—Violent Causes, Accidental and Criminal—Strangulation—Medical Evidence of Rape—Marks of Violence on Genitals and Body—Examination of Clothing— Venereal Disease—Signs of Virginity—Pregnancy resulting from Rape—Impotence. pp. 297 to 317 LIST OF ILLUSTRATIONS. 13. 14. 15. 16. 17. 18- 24. 25. 26. 27. 28- 34. 35. 36. 37. 38. 39. 40, Pelvis : Superior Strait and its Diameters . Do. Inferior Strait and its Diameters Axis of Parturient Canal ..... Foetal Head and its Diameters .... Relation of Ovary with Uterus and Fallopian Tube Graafian Follicle and its contents (Diagrammatic) 12. Six " Positions" of Head ("Vertex") " Presenta tion" ........ Influence of Flexion in Permitting Descent (Diagram matic) ........ Occiput at Inferior Strait after Anterior Rotation Upward Extension of Occiput .... Restitution (External Rotation) .... Downward Extension after Posterior Rotation 23. Six "Positions" of Face "Presentation" Influence of Extension in Permitting Descent Anterior Rotation of Chin ..... Delivery by Upward Flexion of Chin Arrest of Mechanism after Posterior Rotation of Chin 33. Six "Positions" of Breech "Presentation" Rotation and Delivery of Hips . Rotation and Delivery of Shoulders . Anterior Rotation of Occiput..... Posterior Rotation of Occiput and Delivery by Flexion Posterior Rotation of Occiput and Delivery by Exten- sion ......... Extraction of Head in Breech Cases . . . . 41. Two " Positions" of Right Shoulder " Presentation" PAQB 27 30 33 ■42 53 54 130 132 134 135 136 137 142 144 145 145 147 150, 151 . 153 . 154 . 155 156 157 160 163 XX LTST OF ILLUSTRATIONS. FIG PAGE 42, 43. Two " Positions" of Left Shoulder "Presentation' ' 163 44. Bi-polar Version (first step) .... . 169 45. Bi-polar Version (second step) .... . 170 46. Bi-polar Version (third step) .... 171 47. Podalic Version, grasping the Feet 173 48. Podalic Version, turning the Child 174 49. Short Forceps (Denman's) ..... 178 50. Long Forceps (Hodge's) ..... 179 51. Use of Forceps at Outlet. Introduction of first Blade 182 52. Introduction of Second Blade .... 183 53. Lifting Handles (of Forceps) to follow Extension 184 54. Tarnier's Forceps ...... 188 55. The Cephalotribe ...... 198 56. The Cranioclast ........ 199 57. The Craniotomy Forceps ...... 199 58. Pelvimetry with the Finger . 207 OBSTETRICS. CHAPTER I. INTRODUCTION--THE PELVIS. Obstetrics is the science and art of midwifery. Its object is " the management of woman and her offspring during pregnancy, labor, and the puerperal state." In its wider scope it embraces a knowledge of the slructure and functions of the reproductive organs and of their relations to the general system. The Pelvis—The word " pelvis" means basin. It is a strong framework of bones, in which the reproductive organs are contained, and to which they are attached, and its cavity contributes to form a canal through which the child must pass during parturition. It is composed of the right and left innominate bones, sacrum, and coccyx. The Sacrum and Coccyx__The following anatomical features of the sacrum are of obstetrical importance:— First, its promontory—the central, projecting, anterior border of the superior surface {or base) of the bone. From this promontory the antero-posterior diameter of the brim of the pelvic basin is measured, and a material reduction in its distance from the symphysis pubis, directly opposite, consti- tutes the most common variety of pelvic deformity. The rounded convexity of the promontoric border is important, for it causes the globular head of the child to glide off, during labor, to one or other side of the median line, where there is more room for it to pass, as will be explained hereafter. Second. The anterior concave surfuee, or u hollow'''' of the sacrum. It contributes to give amplitude and curvature to 3 26 THE PELVIS. the pelvic canal. It is in conformity with the supra-infral curvature of the sacrum that the long obstetrical forceps are made with what is called their " sacral curve." Material increase or decrease in the degree of sacral curvature con- stitutes deformity, and may render labor mechanically dif- ficult or impossible. Rarely, bony tumors (exostoses) spring from the anterior surface of the sacrum and obstruct delivery. This surface of the bone is pierced by the anterior sacral foramina, which give exit to the anterior sacral nerves. Pressure of the child's head upon these nerves may produce severe cramp in the lower limbs during delivery. Third. Each lateral surface of the sacrum presents a rough, ear-shaped area—the auricular, articular surface,— covered with cartilage, which joins a similar shaped surface on the iliac bone, constituting the sacro-iliac synchondrosis. The posterior ends of the oblique diameters of the pelvic brim terminate at the sacro-iliac synchondroses. Fourth. The apex, or inferior extremity of the sacrum presents a transversely oval facet, covered with cartilage, for articulation with a corresponding oval surface upon the coccyx. This sacro-coccygeal articulation is a perfect hinge- joint, furnished with a synovial membrane, and is movable ; that is, the child's head during its passage out of the pelvis forces the coccyx backwards, so as to leave more room be- tween its tip and the symphysis pubis. In women past the prime of life this joint becomes anchylosed, the coccyx re- fuses to yield before the advancing head, and hence difficult labor. Fifth. It is of the utmost importance to remember that the vertical measurement of the sacrum and coccyx, in the median line, i. e., from the centre of the sacral promontory above, to the tip of the coccyx below—the line of measure- ment being a tangent of the sacro-coccygeal curve—is four inches and a half in length (4^); exactly three times as long as the vertical depth of the symphysis pubis, which is one inch and a half (1-^). The Innominate Bone__The internal aspect of the bone only requires study. There we find a prominent line or ridge beginning at the sacro-iliac synchondrosis, a little below the level of the sacral promontory, and extending ob- liquely forwards, slightly downwards, and at the same time THE INNOMINATE BONE. 27 describing a somewhat semicircular curve inwards towards the median line, where it eventually joins its fellow of the opposite side at the symphysis, pubis; this line is the linea- i/io-pcctinea of anatomists. It forms, with the sacral pro- montory, and two short ridges crossing the wings of the sacrum between the promontory and sacro-iliac synchondro- ses, a sort of cordiform outline, which is, in fact, the brim of the pelvic basin, or, technically, the superior strait of the pelvis. To recapitulate : the entire contour of the supe- rior strait may be thus described : beginning in the median line at the centre of the sacral promontory, it passes out- wards across one lateral half of the promontory until reach- ing the wing of the sacrum, then across the wing outwards, forwards, and slightly downwards, until reaching the sacro- iliac synchondrosis, then it traverses the ilium and pubis, as just described, along the linea-ilio-peetinea, until arriving at the symphysis pubis, and so on back, over the opposite side, until again reaching the centre of the sacral promontory from whence it started. (See Fig. 1.) 1. Antero-posterior (conjugate). 2. Bis-iliac (transverse). 3. Oblique. The " false" pelvis, so called, is all that portion of the pelvis situated above the superior strait, and is made up chiefly by the wings, crests, and spinous processes of the iliac bones. Its bony wall is deficient in front; hence it is, of course, an imperfect or "false" basin. 28 THE PELVIS. The "true" pelvis is all that portion of the basin situated below the brim. It is a little wider in every direction than the brim itself, while the false pelvis is a great deal wider ; the brim is, therefore, a somewhat narrowed bony ring or aperture between these two ; hence the term " strait" is given it. In the cavity of the pelvis we find on each side the prom- inent spine (spinous process) of the ischium and the inclined planes of the ischium. The ischial spinous process projects from the posterior border of the body of the bone, about mid- way down between the highest border of the great sciatic notch above and the lowest margin of the tuberosity of the ischium below. Its tip points at once downwards, back- wards, and inwards towards the median line, and extending from it forwards and upwards towards the upper margin of the acetabulum is an indistinct ridge of bone. Now the smooth, slanting internal surface of the ischium in front of and below this indistinct ridge is called the anterior inclined plane of the ischium, or the anterior inclined plane of the pelvis—no matter which. Note, however, its direction : it slants downwards, forwards, and inwards towards the me- dian line ; so that a rounded body like the foetal head, com- ing down from above and impinging upon it, would glide at once lower down, move forwards, and also inwards towards the pubic symphysis. Hence it is instrumental in producing what is called " anterior rotation" of the occiput in the mechanism of labor. Of course there is an " inclined plane" of this sort on both sides of the pelvis, called respectively the right and left anterior inclined planes. The posterior inclined planes of the pelvis are rather diffi- cult to cfefine, but we may map them out as follows : Draw a line on the inner surface of the pelvic cavity from the spinous process of the ischium to the ileo-pectineal eminence (in most pelves an indistinct ridge may be observed along this line). The drawn line divides the anterior from the posterior inclined plane. But as there is only a small re- maining surface of the ischium behind the dividing line to form the posterior plane, it is evident that, in the living woman, this plane is completed by the sacro-sciatic liga- ments and the muscular structures, etc., that fill up and cover the sacro-sciatic foramina. In a dried pelvis, there- THE GREAT SACRO-SCIATIC FORAMEN. 29 fore, especially when divested of its sacro-sciatic ligaments, it is possible to see only a very small part of the posterior inclined plane, viz., that part where it begins on the back of the dividing line just mentioned. Its continuance or exten- sion downwards and backwards to the median line of the hollow of the sacrum can only be seen when the muscles and ligaments are intact; and of which, in fact, the larger por- tion of the posterior inclined plane is made up. The posterior inclined plane causes the presenting part of the child impinging upon it to rotate downwards, backwards, and inwards towards the median line of the sacrum. Of course there is a posterior inclined plane on each side— right and left. Complete ossification of the pelvic bone does not take place till about twenty years of age, which affords a proba- ble explanation why labor is generally more easy during the early part of adult life than later. The bones yield a little, and, after labor is over, the pelvis probably retains to some extent the size and shape acquired by the first early delivery, so as to render subsequent labors more easy. After thirty years of age the sacro-coccygeal joint may become firmly anchylosed and ossified so as to prevent yield- ing of the coccyx before the pressure of the child's head, thus adding another obstacle to delivery. The Sacko-sciatic Ligaments__The greater sacro- sciatic ligament (sometimes called the " posterior" one) arises from the posterior inferior spinous process of the ilium, the lower part of the lateral margin of the sacrum, and from the coccyx : it is inserted into the tuberosity of the ischium. The lesser (or "anterior") sacro-sciatic ligament arises from the lateral margin of the sacrum and coccyx, and is inserted into the spinous process of the ischium. These ligaments convert the great sciatic notch into the great sciatic foramen,and the lesser sciatic notch into the lesser sciatic foramen. The Great Sacro-sciatic Foramen transmits the piriformis muscle, the gluteal vessels and nerve, the ischi- atic vessels and nerves, the internal pudic vessels and nerve, and the nerve to the obturator internus muscle. Through the lesser foramen pass the tendon of the obtu- 3* 30 THE PELVIS. rator internus muscle, its nerve, and the pudic vessels and nerve. The Obturator or Thyroid Foramen is situated in the antero-lateral part of the pelvic wall, between the pubis and ischium. Sometimes called the " foramen ovale." It is bridged over by a strong membranous web of ligamentous tissue, called the obturator membrane, from the inner and outer surfaces of which arise, respectively, the internal and external obturator muscles. The obturator vessels and nerve pass through an aperture in the upper margin of the obturator membrane. The Pubic Arch is formed by the two descending rami of the pubes, and (in the female) its inner smooth surface, lined at its central upper part by the sub-pubic ligament, is of such shape and dimension as to be absolutely in unison with, and adapted to admit the passage of, the sides and base of the occipital pole of the fcetal head, as we shall see in describing the mechanism of labor in vertex presentations. The Inferior Strait or " Outlet" of the Pelvis. —The dried bony pelvis, divested of its muscular appen- dages, is a basin without a bottom. The opening where the bottom ought to be is the inferior strait or outlet. Its con- PLANES OF THE PELVIS. 31 tour may be described, in particular, as follows: beginning at the summit of the pubic arch, in the median line of the body, it passes downwards and backwards along the inner margin of the descending ramus of the pubes and the ramus of the ischium until reaching the tuberosity of the ischium, then along the great sacro-sciatic ligament to the side of the sacrum and coccyx, and tip of the latter bone; then back along the opposite side of the pelvis to the point of starting at the pubic arch. (See Fig. 2.) Articulations of the Pelvis :— First. The hinge-joint of the base of the coccyx with the apex of the sacrum (the sacro-coccygeal articulation). Second. The junction of the auricular-shaped articular sur- face on the side of the sacrum, with a similar shaped surface upon the opposing ilium, the articular surface on both bones covered by a plate of cartilage. This is the sacro-iliac syn- chondrosis. Third. The symphysis pubis, formed by the apposition of the two bodies or horizontal rami of the pubic bones in the median line. The articular surfaces are roughened by a series of nipple-shaped projections which dip into the layers of car- tilage that cover them. Fourth. The lumbosacral articulation, where the infe- rior aspect of the body of the last lumbar vertebra rests upon the base of the sacrum. Two layers of intervertebral car- tilage (one on each bone) intervene. They are much thicker in front than behind, which, of course, tilts the sacrum back- wards, and contributes to form the promontory. Fifth. The hip-joint, but with regard to this we need only remember the position of the acetabulum in relation to the pelvic brim ; it is situated near the antero-lateral part of the brim's circumference, in fact, nearly obliquely opposite the sacro-iliac synchondrosis of the other side, which is, of course, placed in the posterolateral part of the pelvic cir- cumference. Planes of the Pelvis__The inclined planes of the ischium, sometimes called inclined planes of the pelvis, already studied, have nothing whatever to do with the planes of the brim, outlet, and pelvic cavity, now to be con- 32 the pelvis. sidered. Let it be distinctly understood that the "planes" and " inclined" planes are different things. If we fill an ordinary basin with water, and float upon the surface a disk of paper whose circumference shall accurately fit the rim of the basin, the surface of the paper disk would represent the plane of the brim of that particular basin ; in like manner a disk of paper placed in the superior strait of the pelvis so that its circumference accurately fits the con- tour of the pelvic brim, would represent on its surface the "plane of the superior strait," or brim, of the pelvic basin. A disk of paper, similarly placed, in the outlet or inferior strait, would represent on its surface the "plane of the infe- rior strait," or outlet, of the pelvis. The surfaces of other disks placed at intermediate depths between the superior and inferior straits (such as might be imitated in the earthen basin by its different degrees of fulness), would constitute planes of the pelvic cavity, which latter might of course be multiplied in number indefinitely. The axis of the plane of the superior strait is an imag- inary line passing through the centre of the plane, at right angles to its surface, just as an axle-tree passes at right an- gles through the centre of a cart-wheel's disk. Owing to the anterior inclination of the pelvis, when the woman stands erect, the brim is, as it were, tilted up behind, so that the plane rests at an angle of about G0° with the horizon. Hence, therefore, its axis, instead of being ver- tical, is so disposed as nearly to agree with a line drawn from the umbilicus to the coccyx. The plane of the outlet is more nearly horizontal than that of the superior strait, but it is still elevated posteriorly, so that a line drawn from the tip of the coccyx to the high- est point of the pubic arch will meet the horizon at an angle of about 11°, which, however, is subject to variation, inas- much as the pressing back of the coccyx during labor also presses its tip downwards to some extent, which, of course, renders the angle more acute. The axis of the plane of the inferior strait nearly agrees with a line drawn from the sacral promontory to the anterior verge of the anus. The axes of the planes of the pelvic cavity are lines drawn through the centres of the planes at right angles to their surface. The axes of a great number of such planes, placed end to end, would form an imperfectly circular curve, or at planes of the pelvis. 33 least a polyhedral segment of an imperfect circle, which would represent the real axis of the pelvic canal. Such a curve was described by Carus, and known as Carus' curve, by placing one leg of a pair of compasses on the middle of the posterior edge of the symphysis pubis (in a bisected pelvis), Fig. 3. the other leg of the compass having its point placed midway between the pubis and sacrum, and being moved so as to describe a line from the superior to the inferior strait. But the true axis of the pelvic canal is not so geometrically per- fect a circular curve as to admit of being drawn in this 34 the pelvis. manner ; it is more nearly the segment of an irregular para- bola. (See Fig. 3, p. 33.) The pelvic canal in the living female does not really ter- minate at the inferior strait. In so far as its osseous walls are concerned it does, but the muscles and soft parts below form a continuation of the canal, and when these are stretched during parturition, the posterior wall of the lower, muscular part of the canal, viz., from the coccyx to the mouth of the vagina, measures quite as much as does the upper bony part, viz., from the coccyx to the sacral promon- tory. The anterior wall of the muscular part of the pas- sage, corresponding with the pubis of the bony part, is of course deficient, and necessarily so, or the child could never be extruded in delivery. (See Fig. 3, p. 33.) The female pelvis differs from that of the male exactly in those particulars which render it better adapted to facilitate parturition, notably (first), in being altogether wider in every direction, which gives more room for the child to pass; and (second), in being altogether shallower, which lessens the distance through which the child has to be pro- pelled; and (third), the bones are thinner and smoother. In the female pelvis the pubic arch is broader and rounder, the hollow of the sacrum is less curved (especially as regards its three upper segments, which are almost straight), the ob- turator foramen is more triangular in shape, the sacral pro- montory, ischial spinous processes, and tip of the coccyx are less prominent (so that they encroach to a less degree upon the cavity of the pelvic canal), and the sacro-sciatic notches are more spacious than in the male. Changes taking place in the Female Pelvis towards the end of Pregnancy__The inter-articular cartilages become thicker ; the ligaments softer and some- what relaxed; synovial fluid is formed more plentifully in the articulations; and the joints become, to an exceedingly limited extent, movable, so as to be capable of yielding a very little, if necessary to permit the passage of the child. Proof that the Joints actually yield during Labor is inferred not only from the fact of its occurrence in the lower animals (in the guinea-pig the symphysis pubis separates an inch, so that the sacro-iliac synchondrosis plays diameters of the superior strait. 35 the part of a hinge-joint ; and in the cow the sacrum sinks down between the innominate bones so as to push them wider apart), but also from the circumstances than in women dying during labor, separation of the bones has been observed post mortem ; and in certain cases where the physiological loosen- ing of the articulations has been pathologically exaggerated, locomotion has been interfered with, and the pubic symphy- sis found separated an inch or more. Measurements of the Pelvis__The object of measur- ing the pelvis is to compare the length of its diameters with the diameters of the child that passes through it ; without this it would be impossible to understand the mechanism of labor, or to render suitable assistance in cases of difficult delivery. The size of the pelvis is not the same in all women. It differs in different races of mankind, and in different indi- viduals of the same race. There is no reason why the pelves of any two women should be more exactly alike than the length of their feet or the features of their faces. There are no means by which we can measure with preci- sion (say within one-fifth or even one-fourth of an inch) the diameters of the pelvis in a living female : our measurements under such circumstances can only approximate the truth. Neither are there any means by which Ave can measure any more accurately the diameter of a child's head before it is born ; we can scarcely do better than guess even its ap- proximate measurements. Hence there is no practical use in trying to define and teach the measurements of the average female pelvis with that extreme precision (down to the smaller fractions of an inch) attempted in many obstetric text-books. It compli- cates the matter without any special object; an approximate precision is all that is requisite—all that is possible. Diameters of the Superior Strait (see Fig. 1, p. 27). First. The antero-posterior (sacro-pubic, " conjugate"), extending from the middle of the sacral promontory to the top of the symphysis pubis. Second. The transverse (bis-iliac), extending across the widest part of the strait, from the centre of one lateral mar- gin of the brim to the other. 36 the pelvis. Third. The right oblique, extending from the right sacro- iliac synchondrosis' to the left acetabulum (or left ilio-pecti- neal eminence, which is nearly the same thing). Fourth. The left oblique, extending from the left sacro- iliac synchondrosis to the right acetabulum. Diameters of the Inferior Strait. (Fig. 2, p. 30.) First. The antero-posterior (coccy-pubic, called also " con- jugate"), extending from the tip of the coccyx to the lower end of the symphysis pubis. Second. The transverse (bis-ischiatic), extending across the outlet from one tuberosity of the ischium to the other. Third. The oblique (of which, of course, there are two ; right and left, as at the brim), extending from about the mid- dle of* the lower border of the great sacro-sciatic ligament of one side to the thickened portion of bone where the descend- ing ramus of the pubis joins the ascending ramus of the ischium, or thereabouts, on the other. Diameters of the Pelvic Cavity. First. The antero-posterior (conjugate), extending from the centre of the symphysis pubis to the centre of the hollow of the sacrum. Second. The transverse, extending across from a point nearly opposite the lower edge of the acetabulum on one side to a corresponding point upon the other. Third. The oblique (of which there are two, right and left), extending from the centre of the great sacro-sciatic foramen on one side, to the obturator foramen on the other. (The diameters of the cavity are not so important as those of the brim and outlet.) The Average Approximate Length of the diameters of the pelvic canal in the living woman are as follows:— Antero-posterior of the brim or superior strait . 4 inches. Transverse of the brim in the living female . . 4 inches. (The transverse is 5 inches in the dried pelvis, owing to removal of the psoas magnus muscle, which takes \ inch space on each side in the recent pelvis.) 1 The oblique are sometimes called right and left according to the acetabulum they touch, instead of from the sacro-iliac synchondrosis as in the text. muscular appendages of the pelvis. 37 Obliques of the brim (right and left alike) . 4^ or 5 inches. Antero-posterior of the outlet or inferior strait............4^ or 5 inches. Transverse of the outlet......4 inches. Obliques of the outlet (right and left alike) 4 inches. Antero-posterior of the cavity .... 5 inches. Transverse of the cavity......5 inches. Obliques of the cavity (right and left alike) 5 inches. The most important fact developed by these measurements is, that Hie brim is longest in its oblique diameters, while the outlet is longest in its antero-posterior measurement, which explains the necessity of what is called " rotation" in the mechanism of labor. In addition to these measurements of the pelvis, it is necessary to remember the depth of its walls : thus the depth of the anterior wall, i. e., from the top to the bottom of the symphysis pubis, is 1^ inches; while the depth of the pos- terior wall, from the sacral promontory to the tip of the coccyx (the line being a tangent of the sacro-coccygeal curve), is just three times as long, viz. 4^ inches. The depth of the lateral wall is not of much importance ; it is about 3^ inches. In measuring the pelvis of the living female, externally, for the detection of deformity, it is necessary to remember the following:— 1. Between the widest part of the iliac crests . 10^ inches. 2. Between the anterior superior spinous pro- cesses of the ilia........9^ inches. 3. Between the front of the symphysis pubis and the spinous process ol the upper bone of the sacrum.........1\ inches. In this last measurement a deduction of 3^ inches must be allowed for the soft parts, which would then leave 4 inches—the normal conjugate diameter of the brim, as we have already seen. Muscular Appendages of the Pelvis—Above the brim the muscles of the abdominal walls complete the wall of the " false" pelvis, where its bony wall is deficient in front, and they form the abdominal cavity, roofed above by 4 38 THE PELVIS. the diaphragm, which agrees somewhat in shape with the full- term gravid uterus, so that by the contraction of the abdomi- nal muscles and diaphragm during the pains of labor the womb is tightly embraced by them, and assisted in its ex- pulsion of the child. At the brim we find the psoas magnus, which, arising from the side of the last dorsal and from the sides of all.the lumbar vertebrae, passes down and crosses the brim, where it takes up half an inch of space at each end of the transverse diameter of the superior strait, to be inserted, with the conjoined tendon of the iliacus internus muscle, into the lesser trochanter of the femur.1 The action of these two muscles is to flex the thigh upon the pelvis and rotate the femur outwards, and as this is the posture usually assumed by the parturient female, the muscles are prevented from being stretched taut, and thus thereby occupy less space at the brim and offer less obstruction to the passage of the child. Muscles forming the Floor of the Pelvis, and making a Bottom to the Basin__The pelvic floor is composed of two incomplete muscular layers, the upper layer being formed by the levator ani and ischio-coccygeus muscles. The levator ani, roughly speaking, arises from the inner surface of the sides of the. "true" pelvis, and passing downwards joins its fellow of the opposite side in the median line of the perineum, inserting some of its fibres into the anal and vaginal sphincter muscles. The ischio-coccygeus (called also simply "coccygeus") is a long, narrow, triangu- lar slip, situated parallel with and posterior to the levator ani, closing in a little space which the latter muscle, as it were, failed to cover. It arises by its apex from the ischial spinous process, and is inserted into the side of the coccyx. The muscles forming the lower layer of the pelvic floor are the sphincter ani, the sphincter vagince, and the trans- versus perinei. The two sphincter muscles blend their fibres together like the middle of a figure 8, while the anal end of the 8 is attached to the coccyx, and its vaginal end to the body and corpora cavernosa of the clitoris, which last, in turn, are attached to the rami of the pubes. The transversus 1 Leishman inadvertently attributes this reduction of the trans- verse diameter to " the iliacus muscle.'1'' (Obstetrics, Amer. ed., 1873, p. 43.) the fcetal head. 39 perinei arises from the ascending ramus of the ischium, and is inserted into the side of the sphincter vaginas muscle. Besides these two sets of muscles the floor of the pelvis is rendered complete by various layers of cellular, elastic, ligamentous, and aponeurotic tissues, fascia, fat, skin, etc. Besides their motor function these muscles, together with the pyriformis (not yet mentioned), which arises chiefly from and covers the hollow of the sacrum, provide a sort of muscular upholstery to the interior of the pelvis, by which its bony lines and prominences are cushioned over, so as to prevent injury to the soft parts from pressure during the pas- sage of the child, while the infant itself receives-the same protection. CHAPTER II. THE FCETAL HEAD. The head of the feet us requires special study, because, from its size and incompressibility, it is the most difficult part of the child to deliver; when the head is born, the rest of the labor is usually completed in a few minutes. The child's head, however, is not absolutely incompressible. Its bony wall is elastic to a certain extent in all parts except the base. The conservative utility in this arrangement is that moderate pressure on the upper part of the fcetal brain from external compression of the cranium is not dangerous to life, but pressure upon the base of the brain and medulla oblongata would be fatal. While it is not true that the short transverse diameter of the child's head, viz., from one parietal protuberance to the other, is less than the transverse diameter of the trunk, viz., from one acromion process of the scapula to the other, still the bones and muscles of the arms, shoulders, and trunk are so mobile and compressible that, when they are jammed into the pelvis, the said bis-acromial diameter is capable of being easily reduced to a less width than the transverse diameter of the skull; hence the head, though apparently not, practically is wider than across the shoulders. 40 THE FCETAL HEAD. Shape of the Fcetal Head.—This does not correspond perfectly to any geometrical figure, but it will best suit our purpose to consider it ovoid or egg-shaped—the chin corre- sponding to the small end of the egg, the occiput to the large end, and the widest transverse circumference (over the parietal protuberances) to the equator. One aspect of the ovoid, viz., its base, is considerably flattened, and so are the sides of the head, but to a less extent. The fcetal cranial bones are imperfectly ossified (and are therefore elastic) ; their sutural borders are surmounted by a rim of cartilage and are not united, and the several bones (except those of the base), being only held in apposition by the dura mater, pericranium, and skin, can be pressed closer together, or even made to overlap each other, during partu- rition. The posterior borders of the parietal bones especially nearly always overlap the anterior borders of the occiput. Sutures of the Cranium__They are :— First. The coronal suture (or fronto-parietal), passing between the posterior border of the frontal bone and the anterior borders of the two parietals. It goes over the arch of the cranium from one temporal bone to the other. Second. The sagittal suture (or biparietal), running along and between the superior borders of the two parietal bones and extending from the superior point of the occiput to the os frontis. It must be noted, however, that, in the foetus, the two halves of the frontal bone have not yet united; they are divided by what is called the bi-frontal suture almost to the root of the nose, and by some writers this bi-frontal suture is regarded as a continuation of the sagittal. Third. The lambdoidal suture (or occipitoparietal), run- ning between the anterior, or rather antero-lateral, borders of the occiput and the posterior borders of the parietals, and extending from near the mastoid process of one temporal bone to that of the other. The foiitanelles are spaces left in the skull at points where the angles of two or more bones meet. They are due to deficient ossification, and are explained by the general prin- ciple that ossification, beginning near the centre of a bone and extending towards its circumference, reaches the angles last because they are generally furthest from the centre. There are six fontanelles, but only two of them are of ob- REGIONS OF THE FCETAL SKULL. 41 stetric importance. These are the anterior (or fronto- parietal) fontanelle and the posterior (or occipito-parietal) one. The shape of the anterior one may be approximately de- scribed by drawing lines between the four points of a cruci- fix ; it is a four-sided figure, two of whose sides are equal —geometrically a trapezoid—the long acute angle being formed by deficient ossification in the posterior superior angles of the two halves of the frontal bone, and the short obtuse angle by deficient ossification in the anterior superior angles of the parietal bones. Its situation is where the coronal suture crosses the sagittal. In size it is a consider- able membranous space, easily recognized by the finger, and often by the eye, and through it the motion of pulsation in the cerebral arteries may be both seen and felt. It is not completely closed till one or two years after birth. Remem- ber particularly that the long point of this fontanelle points towards the forehead and nose ; the short one towards the occiput. The posterior fontanelle is much smaller in size, being simply a triangular depression situated at the point where the sagittal suture meets the lambdoidal; radiating from it are three sutural arms, viz., the sagittal suture and the two arms of the lambdoidal. It closes a few months after birth. The other four fontanelles, two on each side, are placed at the inferior angles of the parietal bones. They are unim- portant. Regions of the Fcetal Skull__One of the most im- portant is the vertex. Literally this means the highest part or "crown" of the head (sometimes called "sinciput" and " bregma") ; but when in midwifery we speak of a " vertex presentation," we refer to a more posterior region of the skull, which I have already compared to the larger rounded extremity of an egg, and which has (I think very properly) been termed by some writers the " obstetrical vertex ;" it may be defined as a circular space wdiose centre is the apex of the posterior fontanelle, and the circumference of which passes over the occipital protuberance. Other regions of the fcetal head have been described, but they are not of great importance, viz., the "base" or flat- 4* 42 THE FCETAL HEAD. tened surface directed towards the neck, and the facial, frontal, and lateral regions, which explain themselves. Diameters of the Child's Head, and their Approximate Average Length. (Fig. 4.) The occipito-mental, extending from the point of the chin to the superior angle of the occiput The occipito-frontal, extending from the centre of the forehead to a point on the median line of the occiput a little above its protuberance . The biparietal, passing transversely from one parietal protuberance to the other .... The cervico-bregmatic (called also "trachelo- bregmatic"), passing vertically from the pos- terior angle of the anterior fontanelle to the anterior margin of the foramen magnum . The fronto-mental, going from the top of the forehead to the end of the chin..... 1-2. Occipito-frontal. 3-4. Occipito-mental. 5-6. Cervico-bregmatic (or vertical). 7-8. Fronto-mental. Several other cranial diameters are given in some of the text-books, and the number might be indefinitely multiplied, but the above are all that require to be remembered.1 1 It should be noted that the head may be pressed out of its natural shape ("moulded") during delivery, and the direction of b\ inches. A\ inches. ?>\ inches. 3^ inches. 3^ inches. THE EXTERNAL ORGANS OF GENERATION. 43 One other measurement (of great importance when con- sidering the mechanism of face presentations) may be added, viz., the sterno-mental length of the child's neck when the chin is removed as far as possible from the sternum ; it is 1^ inches—exactly the same as the depth of the symphysis pubis. CHAPTER III. THE EXTERNAL ORGANS OF GENERATION. The structures generally included in the external genera- tive organs of the female are : The mons veneris, labia ma- jora, labia minora (nymphaj), clitoris, vestibule, urethra and its meatus, the fossa navicularis, hymen, and carunculae myrtiformes. The term " vulva" is generally used to ex- press all of the genital structures just mentioned, except the mons veneris. The term " pudenda." has a similar mean- ing. The Mons Veneris (mont deVenus) is a cushion of adi- pose, cellular, and fibrous tissue, situated upon the front of the symphysis and horizontal rami of the pubes. Its thick- ness varies with the obesity of the individual, and its promi- nence differs according to the degree of projection of the such distortion will vary with the kind of presentation, and conse- quently the cranial diameters will vary accordingly. Again, let it be remembered that the object of measuring any particular diameter is to get the dimension of the head in that one direction, and, while authorities constantly differ as to the exact points on the skull at which the extremities of their diameters are to be placed, the practical principle in measuring crania may be illustrated thus : occipito-mental diameter starts at the point of the chin, and ends at some opposite point on the median line of the occiput furthest removed from the point of starting; the occipito- frontal starts at the most anteriorly projecting part of the median line of the forehead, and ends at a point on the median line of the occ\p\\t furthest removed from the point of starting; and so of the other diameters. 44 THE EXTERNAL ORGANS OF GENERATION. pubes. After puberty it is covered with hair, and is abun- dantly supplied with sweat and sebaceous glands. Its func- tion is not positively known. It possibly serves the purpose of a brow, in preventing irritating secretions from the skin trickling into the vulvar fissure. The Labia Majora, called also " Labia Externa" and " Labia Pudexdi," are the lips of the genital fissure, placed side by side in an antero-posterior direction. They begin at the lower part of the mons veneris (as if by a bifur- cation of that structure), which is their thickest part, and pass at first downwards, then horizontally backwards, be- coming thinner in their course, and join each other at a point about one inch in front of the anus. Their point of junction in front is called the anterior commissure, and their point of apposition1 behind, the posterior commissure. Like the lips of the mouth, they are covered internally with a layer of mucous membrane containing mucus folli- cles, and externally with integument which contains hair follicles and sebaceous glands. Between those layers the substance of the labia is composed of superficial fascia, con- nective, adipose, and elastic tissue, together with some smooth muscular fibres which are arranged in the form of a little sac (continuous above with the external inguinal ring) con- sidered to be analogous with the dartos of the scrotum. The sac contains fat and cellular tissue, some terminal fibres from the round ligament of the uterus, and is occasionally the seat of hernia. The Fossa Navicularis__Just before the labia come together posteriorly, they are united by a transverse fold of mucous membrane (which somewhat resembles the web of skin between the thumb and finger) called the fourchette (or fraenulum pudendi), and the little depressed space be- tween this and the posterior commissure is the fossa navicu- 1 This is the description of the posterior commissure generally given, but Dr. Matthews Duncan has conclusively shown that the labia do not unite posteriorly at an angle, but running close to each other, the vulvar fissure terminates in a sort of horizontal "gut- ter" continuous with the perineum ; hence I have applied the term "apposition" instead of "junction" to the posterior union. THE HYMEN. 45 fan's. It is generally obliterated after labor by rupture of the fourchette. The Labia Minora, or Nymphs, are thick double folds of mucous membrane, about one inch and a half long, which begin by gradually projecting from the inner surface of the labia majora, midway between the two commissures. They then pass forwards until reaching the clitoris, when they split horizontally into two folds. The upper folds pass above the clitoris, and joining in the median line, contribute to form the prepuce of that organ, while the lower ones join underneath, forming its frcenum. The nymphae are covered with tessellated epithelium ; they contain connective and muscular tissue, vascular papilla?, and sebaceous glands. They are very vascular; also erectile, and secrete an odor- ous sebaceous mucus which lubricates their surface and pre- vents adhesive union. Their function is not certainly known. The Clitoris is a small erectile tubercle placed just in- side the vulvar fissure, half an inch below the anterior com- missure. It is composed of two corpora cavernosa, two crura, and a glans, like the penis, but lias no corpus spon- giosum or urethral canal. It has two erector muscles, is abundantly supplied with vessels and nerves, and constitutes the principal seat of sexual sensation in the female. It is secured to the pubis by a suspensory ligament. The vestibule is a triangular surface of mucous membrane, whose base is the anterior margin of the vaginal orifice ; its apex terminates at the clitoris, and its two sides are bounded by the nymphae. It is of little importance except as a guide for finding the meatus urinarius, placed near its lower margin. The female urethra is one inch and a half in length; is larger than that of the male, and more easily dilatable ; it begins at the meatus, which is situated immediately below the rim of the pubic arch, and passes backwards, curving a little upwards to the neck of the bladder. It is composed of a mucous, muscular, and vascular coat. The Hymen is a crescentic-shaped fold of mucous mem- brane whose convex border is attached to, and continuous with, the posterior wall of the vaginal orifice, just inside 46 internal organs of generation. the fourchette. Its sides then run upwards to terminate in the horns of the crescent, which last are united by its ante- rior concave border. It varies in form in different women. Sometimes the horns of the crescent, instead of coming to a point, are continued as a narrow band to the anterior vagi- nal wall, where the ends join each other, leaving a circular or oval opening in the centre. Occasionally it covers the orifice of the vagina entirely (" imperforate hymen"), or it may present a number of very small openings (" cribriform hymen") It also varies in thickness and strength. It is usually ruptured by the first act of coitus, though not al- ways, and may be torn by other causes, so that it is by no means so sure a sign of " virginity" as was formerly sup- posed. Moreover, it is sometimes absent altogether. The Myrtiform Caruncles (Caruncul^e Myrti- formes)__Formerly these were said to be shrivelled pro- jecting remains of the ruptured hymen ; in reality, they are vascular membranous prominences, placed immediately be- hind the hymen, and quite independent of it. They are not always present. CHAPTER IV. INTERNAL organs of generation. The Internal Organs of Generation are the vagina, uterus, Fallopian tubes, and ovaries. The Vagina is a mucous canal extending from the vulva to the uterus, hence sometimes called the " vulvo-uterine canal." It is made up of a mucous lining (covered with pavement epithelium), continuous with that of the vulva and uterus. Outside the mucous coat is a thin muscular layer, continuous with the uterine muscles, whose fibres run, some longitu- dinally, some in a circular direction, and others obliquely. The muscular coat becomes thicker during pregnancy. It THE vagina. 47 is extremely vascular, its vessels being so disposed as to con stitute an erectile tissue especially towards the vulva. Cel- lular and fibrous tissues also enter into the composition of the vaginal wall. Underneath the epithelium of the mucous membrane are a large number of vascular papilla;. Along the median line of the anterior and posterior vaginal walls there is a vertical ridge in the mucous membrane (the "anterior and posterior columns" of the vagina), and diverging from these laterally the mucous coat is thrown into transverse folds which admit of dilatation of the canal during labor. Its posterior wail is about three and a half inches long, its anterior wall about three inches. Its diameter is a little above an inch. At rest, the anterior and posterior walls are in contact with each other. With regard to the exact situation and direction of the vagina, the descriptions and illustrative plates of anatomists differ widely. Roughly speaking, according to Leishman, " it lies in the axis of the pelvis, but its axis is placed anterior to the pelvic outlet, so that its lower portion is curved for- ward." Its attachments to adjoining organs are as follows : the posterior wall is connected by its middle three-ffths with the rectum, the united walls constituting the recto-vaginal sep- tum ; its lower fifth is separated from the rectum, and is in contact with the perineal body ; while its upper fifth is in contact with the fold of peritoneum which descends behind the womb to form Douglas' cul-de-sac. Its anterior wall is united by connective tissue with the posterior walls of the bladder and urethra, constituting, respectively, the vesico- vaginal and urethro-vaginal septa. The upper extremity of the vaginal cylinder surrounds and is attached to the neck of the uterus. On each side of the orifice of the vagina, inclosed in a thin layer of fibrous tissue, under the labia majora, is a spongy oblong mass of small convoluted veins, which, when dis- tended during sexual excitement, assumes, in its entirety, the form of a filled leech, or of a diminutive banana. These are called the bulbi vestibuli, sometimes the vaginal bulbs. Their veins are continuous with those of the clitoris and vagina. Immediately beneath and behind the posterior round ex 48 internal organs of GENERATION. tremity of the bulb is placed, on each side, the vulvo-vaginal gland (analogue of Cowper's gland in the male, and variously called the gland of Huguier and of Bartholini). It is a conglomerate gland, varying in size from a horse-bean to an almond, and secretes, during sexual excitement, an ex- ceedingly viscid mucus, which is discharged from the orifice of the gland-duct into the fossa navicularis. The vagina is abundantly supplied with nerves, especially towards its orifice, where it is endowed with a peculiar sen- sibility. Its arterial supply is derived from the uterine and hypogastric arteries, and its numerous venous plexuses ter- minate in the hypogastric veins. The Uterus is a thick-walled hollow organ, in the form of a truncated cone, slightly flattened antero-posteriorly, situated in the middle of the pelvic cavity, its upper end being a little below the plane of the superior strait. The bladder is in front of it; the rectum behind, and the vagina below it. The small intestines rest upon it from above. It has three coats: (1) a serous coat (peritoneum) on the out- side ; (2) a muscular coat, which gives thickness and so- lidity to the uterine walls, and is composed of non-striated muscular fibres arranged in layers, having different direc- tions, circularly, longitudinally, and spirally, which are closely adherent to and decussate with each other; (3) a mucous lining continuous with that of the vagina and Fallo- pian tubes, and covered with ciliated columnar epithelium. That portion of the neck of the uterus which projects into the top of the vagina is covered, externally, with pavement epithelium. This last joins the columnar epithelium of the interior of the uterus just within the external os uteri. In length (counting the thickness of its upper wall) it is (roughly) about 3 inches ; its width, transversely across its widest upper part, is l£ inches ; and its greatest antero-poste- rior thickness 1 inch. At the end of pregnancy it attains the size of a foot or more in length, and 8 or 10 inches transversely. It is divided by anatomists into fundus, body, and neck. The fundus is all that rounded portion placed above a hori- zontal line drawn through the angles where the Fallopian tubes open into the womb; the body is all that portion be- tween the fundus and the neck; and the neck is all that part BROAD LIGAMENTS OF THE UTERUS. 49 below a line drawn horizontally through the organ at the level of the internal os uteri. Its cavity is divided into the cavity of the body and the cavity of the neck. That of the body is triangular and flattened antero-posteriorly; it has three openings, those of the two Fallopian tubes above, and that of the os internum below. The cavity of the neck is barrel-shaped or fusiform, and comparatively narrow ; it is constricted above by the in- ternal os that separates it from the cavity of the body, and grows narrow again at its termination in the external os uteri. Microscopic Structure of the Uterine Mucous Membrane___It is composed of mucous follicles (" utricular glands") placed perpendicular to the internal surface of the womb. Their mouths open into the uterine cavity, and they terminate by rounded bulbous extremities (some of which are bifurcated) upon the muscular eoat. The follicles are lined with columnar epithelium; and some idea may be formed of their size (^ of a line in diameter) by remem- bering that there are about ten thousand of them in the mucous membrane of the cavity of the neck alone. Broad Ligaments of the Uterus—These are simply folds of peritoneum covering the external surface of the womb. Let us imagine a line drawn across the outside of the top of the fundus and prolonged transversely until it reaches the sides of the pelvis- Beginning at this imagi- nary line a broad layer of peritoneum passes down over the anterior wall of the womb to the level of a point midway between the internal and external os, when it turns up and is reflected over the posterior wall of the bladder: this is the anterior broad ligament. A similar fold passes down over the posterior wall of the womb, going low enough to cover the upper one-fifth of the posterior vaginal wall (as already explained), when it turns up and is reflected over the anterior wall of the rectum : this is the posterior broad ligament. Thus the uterus, with (and between) its two broad ligaments, forms a sort of transverse partition to the pelvic cavity; the bladder, urethra, etc., being in the front compartment, and the rectum in the back one. The lateral borders of this double ligamentous curtain are attached to the sides of the pelvis. 5 50 internal organs of generation. Other Ligaments of the Uterus. First. The round ligaments, which are ftovo-muscular cords, \\ inches long. They begin near the superior angles of the womb, and pass between the two folds of the broad ligaments, successively outwards, forwards, and then in- wards, to the internal inguinal ring, and through the inguinal canal, their terminal fibres being lost in the mons veneris and labia majora. Second. The vesico-uterine ligaments : semilunar-shaped folds of peritoneum passing from the lower part of the body of the uterus to the fundus of the bladder. Third. The utero-sacral ligaments : crescentic-shaped folds of peritoneum passing from the lower part of the body of the uterus to be inserted into the third and fourth sacral vertebrae. Fourth. There is still another short cord, containing many smooth muscular fibres, extending from near the upper angle of the uterus to the inner extremity of the ovary. It is about one inch in length, and is called the utero-ovarian ligament—sometimes the " ligament of the ovary." All the ligaments of the uterus contain some muscular tissue, and its quantity is increased during pregnancy. Arteries of the Womb—The ovarian arteries (given off from the abdominal aorta) supply the fundus ; and the uterine arteries (coming from the internal iliacs) supply the body and neck. The branches of these arteries, in the ute- rine walls, are remarkable for their numerous anastomoses and spiral course (hence called "curling arteries of the ute- rus"). The latter quality provides for their longitudinal extension during pregnancy. Veins of the Uterus—These begin by small branches continuous with the fine plexus of capillaries, into which the uterine arteries divide in the internal lining of the or«an, and, inosculating freely with each other, unite to form larger veins (always without valves) in the substance of the uterine wall, from whence they eventually pass out towards the folds of broad ligament, where, joining the ovarian and vaginal veins, a remarkable venous network is formed, known as the "pampiniform plexus." Its blood is finally received by the internal iliac vein. fallopian tubes. 51 Lymphatics__The womb is abundantly supplied with lymphatics, and its lymphatic vesstds terminate in the pelvic and lumbar glands. Nerves—The nervous supply of the uterus is received chiefly from the sympathetic system, viz., from the hypogas- tric, renal, spermatic, and aortic plexuses. Whether it receives branches from the cerebro-spinal system remains questionable, though it is generally supposed that filaments from the third and fourth sacral nerves go to the cervix. Functions of the Uterus__It is the source of the menstrual discharge ; it receives spermatic fluid from the male, and the germ cell—whether impregnated or not— from the female ; it provides a place for the foetus during its development, and is the source of its nutritive supply ; and it contracts at full term to expel the child. During gestation all the tissues of the uterus undergo a decided physiological hypertrophy. After delivery they go through a sort of gradual physiological atrophy— back again to what they were before conception. The enlarged muscles especially undergo fatty degeneration and absorption—called " involution," in contradistinction to " evolution" or development. The process of involution requires a month or six weeks for its completion, sometimes longer. Fai.i.opiax Tubes.—Given off from the uterus, at each of its superior angles, is a tube whose canal is continuous with the uterine cavity. These are the Fallopian tubes (sometimes called " oviducts"). Each tube is about four inches long; near the uterus its diameter (Sjth of an inch) will just admit a bristle, but in- creases in size in its course from the womb towards the free distal end of the tube, where it is as large as a goose-quill. The tube passes from the uterus in a somewhat tortuous course, between the folds and along the upper margin of the broad ligament, towards the side of the pelvis, and termi- nates in a dilated, trumpet-shaped extremity, the free margin of which is, as it were, flayed out into a number of fringe- like processes called " fimbria? ;" one of these, longer than 52 internal organs of generation. the rest, is attached to the outer extremity of the ovary. Some of the fringed processes are continued as thin, leaf- like, longitudinal folds of mucous membrane into the dilated end of the tube. Like the uterus, the Fallopian tubes are composed of three coats : 1. A serous (peritoneal) coat on the outside ; 2. A muscular coat composed of two layers, viz., circular fibres (internally) and longitudinal ones (externally) ; 3. A mucous coat continuous with that of the uterus, and lined with cili- ated columnar epithelium. At the distal end of the tube the mucous coat is continuous with the peritoneum, and furnishes the only instance in the body where a serous and mucous membrane are thus joined. Functions of the Fallopian Tube__It conveys spermatic fluid from the uterus to the ovary, and conducts the germ-cell from the ovary to the uterus. When the ovule (germ-cell) is discharged from the ovary, the fimbriae of the tube, acting as prehensile lips, grasp the germ and force it into the trumpet-shaped mouth, from whence it is, by the peristaltic motion of the tube, as it were, swallowed into the uterus ; this transmission of the germ is also assisted by the cilia of the epithelium which wave towards the womb. The Ovaries__They are two in number (rarely three), and are placed one on each side of the womb in the posterior layer of the broad ligament, behind and below the Fallopian tube. The folds of broad ligament form for the ovary a sort of mesentery, and between its two layers the vessels and nerves pass to the organ. The ovary is connected to the trumpet-shaped end of the Fallopian tube by a single fimbria, and to the uterus by the fibro-muscular " ligament of the ovary," already described. Its anterior margin is attached to the broad ligament. It is one inch and a half in length, three-quarters of an inch wide, and one-third of an inch thick. Weight, from one to two drachms. It is an elon- gated, oval-shaped body, flattened from above downwards, and hence said to be "almond-shaped." Its function is ovulation, that is to say: the production, development, ma- turation, and discharge of ovules. Hence the ovaries are said to be the essential organs of generation in the female, as the testicles are in the male. (Fig. 5 shows relations of ovary STRUCTURE OF THE OVARY. 53 with uterus and Fallopian tube. A triangular bit of ovarian stroma, showing ovum magnified, is seen in Fig. 6.) Fig. 5. Relation of ovary with uterus and Fallopian tube. Structure of the Ovary--Anatomists generally describe it as being covered on the outside by a layer of peritoneum, but the microscopists have lately informed us that this external covering is not true peritoneum, but a layer of columnar epithelium peculiar to the ovary. Which- ever is right, immediately underneath this layer is a thick coat of white fibrous tissue, the tunica albuginea. Inside this last we find the solid substance of the ovarian body (the kernel of the ovarian nut, so to speak) called " stroma." It is composed, for the most [tart, of fibrous and muscular tissue, and is highly vascular. Dotted about in different parts of the stroma are little round cavities, called " Graafian jollicles." The wall of these globular follicular cavities is made up of the stroma substance itself, being in fact com- posed of a condensed layer of the stroma's connective or fibrous tissue, and is therefore sometimes called " tunica fibrosa." It is immediately surrounded on all parts of its 04 INTERNAL ORGANS OF GENERATION. periphery with an elaborate network of capillary bloodvessels. Fitting close inside and completely filling the "Graafian follicle" is the " Graafian vesicle" or "ovisac," sometimes Fig. 6. ' 8 9 10 n Triangular bit of ovarian stroma cut from ovary. Magnified to show Graafian follicle and ovule.—1. Epithelial covering of ovary. 2. Tunica albuginea (fibrous). 3, 3. Different parts of stroma. 4. Graafian follicle (tunica fibrosa). 5. Graafian vesicle or ovisac. 6,6. Tunica granulosa. 7. Liquor folliculi. 8. Vitelline membrane or zona pellucida. 9. Granular vitellus or yolk. 10. Germinal vesicle. 11. Germinal spot. termed, in contradistinction to the tunica fibrosa, the "tunica propria." Loosely adherent to the inside of the ovisac all around, is a granular layer of epithelial cells, the " tunica granulosa." Inside this is the " liquor folliculi (or fluid contents of the ovisac), in which floats the human egg, or ovule. It is only a yolk ; there is no white to it, so that the next membrane we have to encounter is the yolk membrane, technically the vitelline membrane, or zona pellucida, con- taining the " vitellus" or yolk. Imbedded in the substance of the yolk is the "germinal vesicle," and inside that, the "germinal spot." Besides the tunica granulosa covering the inside of the ovisac, a reflected layer of it is disposed all THE CORPUS LUTEUM. 00 around the outside of the vitelline membrane. At birth it is said each human ovary really contains about 30,000 Graa- fian follicles, with their contents, but only the few that are approaching maturity are large enough to be seen with the naked eye. The way in which the ovule (egg, germ-cell, but not called o\um until impregnated) gets out of the ovary is as follows: As the Graafian follicle reaches maturity, it approaches the surface, and begins to cause a protuberance (like a little boil) upon the outside of the ovary. Eventually, the peritoneal (or epithelial) external coat, the tunica albu- ginea, the wall of the Graafian follicle (tunica fibrosa), and the wall of the Graafian vesicle (or ovisac), all burst at the same point, and out comes the vitelline membrane, safe and whole, with its contents, and clinging around it is a loose irregular mass of the " tunica granulosa," now to be called the " pro/igerous disk." At the moment of rupture of the follicle, the ovule is re- ceived by the Fallopian tube and conveyed to the uterus. The Corpus Luteum__After discharge of the ovule, together with the liquor folliculi, and that part of the tunica granulosa clinging to the ovule (called then the proligerous disc), the emptied, deserted ovisac fills up with a clot of blood, and the remaining ovisac itself undergoes a curious hypertrophic thickening, becomes highly convoluted, and later on undergoes fatty atrophy which gives it a yellow color, and eventually the follicle and its contents shrivel and contract into an insignificant cicatrix or dimple. The yellow color of the fatty ovisac has caused the site of the discharged ovule to be called " corpus luteum." Corpora lutea are of two kinds, "true" and "false." If the ovule is impreg- nated, a true corpus luteum is developed ; if impregnation has not taken place, there results a false corpus luteum. The special (chief) differences between the two are as fol- lows : 1st. The false corpus luteum increases in size for three weeks only, the true one continues to grow for about five months. 2d. After three weeks the false corpus luteum de- clines rapidly in size, and is reduced to a cicatricial dimple at the end of two months ; while the true one, having grown so large as to occupy the greater part of the ovary by the fourth or fifth month, remains about of the same size during the fifth and sixth months, then gradually declines during the 56 INTERNAL ORGANS OF GENERATION. seventh, eighth, and ninth months, but it is not reduced to an insignificant cicatrix until one or two months after de- livery. 3d. A true corpus luteum is single ; a false one will be accompanied (either in the same or the opposite ovary) by the visibly evident remains of its predecessor. 4th. The cicatrix resulting from a true corpus luteum is more distinctly stellate than the cicatrix of a false one. The Parovarium ^sometimes called the "organ of Kosen- miiller").—It is the remains of the Wolffian body of foetal life, and corresponds to the epididymis of the male. Placed in the posterior fold of the broad ligament, where it may be seen by holding up the latter and looking through it by transmitted light, it consists of from ten to twenty tortuous tubes arranged in a pyramidal form (like the ribs of a fan), the base of the pyramid being towards the Fallopian tube;, its apex lost on the surface of the ovary. No excretory duct; function unknown. The Mammary Glands, whose function it is to secrete milk for the sustenance of the child after birth, properly be- long to the reproductive system. In shape, each gland is a flat, very flat, hemisphere, its base resting upon the pectoralis major muscle, between the third and sixth ribs. By cutting a large orange transversely through its equator each half would give an approximate idea of the shape of the gland, and on the cut surface will be seen radiating trabecular, be- tween which the pulp of the fruit is placed, that fairly resem- ble the radiating trabecular of fibrous tissue, fifteen or twenty in number, between which the so-called " lobes" of the secre- ting substance of the mammary gland are contained, and which are continuous with the circumferential fibrous capsule of the organ. The lobes are made up of lobules, and the lobules of terminal culs-de-sac (acini) lined with columnar epithelium. F^ach acinus empties its secretion (the milk being formed by desquamation, fatty degeneration, and rup- ture of the epithelial cells), through a little duct, which unites with others to form a larger duct for the lobule, and the lobular ducts unite to terminate in a still larger duct for each lobe, termed the galactophorous duct. The galacto- phorous ducts, fifteen or twenty in number, one for each lobe, converge towards the nipple, becoming widely dilated menstruation. 0/ as they approach it, but narrowing again as they actually enter it. Viewing the breast externally, we see the apex of the mammary projection surmounted by a pink disk of skin called the areola. From the centre of the areola projects the nipple, and beneath the disk is a circular band of muscu- lar fibres, which, in contracting, assists the expulsion of milk. The mammary glands receive their blood supply from the internal mammary and intercostal arteries. Their nerves are derived from the intercostal and thoracic branches of the brachial plexus. They are also abundantly supplied with lymphatic vessels, which open into the axillary glands. CHAPTER V. MENSTRUATION AND OVULATION. Menstruation is a monthly hemorrhage from the uterine cavity. It is called " catamenial discharge," " menses," and " men- strual flow," or in common parlance the " monthly sickness," the "flowers" the "turns," the "courses," the "periods;" or the woman is said to be " unwell." We have already defined ovulation to be the development and maturation of ovules in, and their discharge from, the ovary. What relation has this process to menstruation? About the time when an ovule is ripe and soon to be dis- charged, the reproductive organs, especially the ovaries and uterus, receive an extra amount of blood—they become physi- ologically congested in anticipation of impregnation taking place (for the menstrual period is really analogous with the period of " heat" or " rut" (" ceslruation") in other animals); but in the absence of impregnation the extra blood-supply, which was designed to prepare the organs for the reception and development of an impregnated germ, fails of its natural purpose, and is discharged in the form of menstruation. 58 menstruation and ovulation. Menstruation is therefore dependent upon, and more or less coincident with ovulation—this is the " ovulatory theory" of menstruation so-called. Objections have been urged against this theory. First. It is said the menses have recurred after removal of both ovaries. (Answer. This is extremely ex- ceptional ; the removal may have been incomplete ; there is sometimes a third ovary; the spayed women used as guards to the harems of Central Asia do not menstruate.) Second. It is alleged that women do not allow coitus, and become impregnated at the menstrual periods, but always between the periods, from which it is inferred ovulation is not coinci- dent with menstruation. (Answer. The human female, like other animals, is really more liable to impregnation when cohabiting near the menstrual period, and the same greater liability probably obtains at the period, did not the flow prevent cohabitation ; moreover, the union of the germ cell with the spermatic fluid of the male may take place at the ovulatory period from the survival of spermatozoa intro- duced by coitus a week or more before ovulation ; the ovule also may remain after being discharged from the ovary, and be impregnated a week or more after menstruation.) Third. It is stated that ovules are discharged from the ovary with- out any accompanying menstrual flow. (Answer. This may be admitted and explained without fatally conflicting with the theory. It is, however, exceptional.) On the whole, the ovulatory theory of menstruation is the best yet pro- pounded, and must be received, at least for the present. Changes in the Uterine Mucous Membrane at the Menstrual Epochs—Just before the flow the mem- brane becomes much thicker, congested,and thrown into shal- low folds. Then it undergoes disintegration by fatty degene- ration, and is thrown off with the blood that flows from the opened capillary bloodvessels. There exists some discrepancy of opinion as to how muchoi' the mucous membrane is thrown off every month, but no doubt exists as to the fact of its becoming physiologically hypertrophied just before the men- ses, and of its undergoing a certain degree of fatty atrophy and degeneration during and immediately after the period. Shortly after menstruation, a new mucous membrane is already in course of preparation. symptoms of menstruation. 59 What becomes of the Ovule?—When not impreg- nated, it is lost and discharged with the menstrual flow ; either before or after its disintegration. It is too small to be seen. The vitelline membrane is a mere cell, T^ of an inch in diameter; and its contained germinal vesicle meas- uses 7i'w of an inch ; the germinal spot about ^nW- The " vesicle" is the nucleus of the cell; the " spot" its nucleolus ; the entire egg simply a mass of protoplasm. Menstruation begins at about fourteen or fifteen years of age—the "age of puberty" so called. This period is pre- ceded and attended by what are called the signs of puberty. They consist in the development of womanly beauties, physi- ologically designed to attract the male ; enlargement and growth of hair upon the mons veneris and labia majora; en- largement and increased rotundity of the hips and breasts; the vulvar fissure is drawn downwards and backwards, so that in the erect posture no part of it is visible anteriorly as it is in children ; striking changes also occur in the inclina- tions and emotional susceptibilities of the female. Circumstances modify the age at which the first menstrua- tion takes place: thus, the menses appear earlier in hot cli- mates, but the difference between the hottest and coldest climates is only about three years ; the influence of race, which remains potent in spite of climatic changes; occupa- tion and mode of life: luxury, stimulants, indolence, hot rooms, pruriency of thought, etc., render the woman pre- cocious, while opposite conditions retard the menses ; general robustness of constitution and vigorous health promote the development of menstruation, and it is delayed by feeble- ness and debility. On the other hand, a very tall woman with large bones and muscles will require more time to complete her growth, and hence the reproductive functions will be belated. Symptoms of Menstruation, not always present, are lassitude and depression of spirits, headache, backache, chilliness, weight in hypogastrium and perineum, nausea, neuralgia, hysteria, perhaps slight febrile excitement. They vary in kind and degree in different individuals, and are generally relieved by the flow. The first few periods are apt to be irregular in their recurrence, and the discharge is slight in quantity and composed of mucus with but little blood. 60 menstruation and ovulation. The quantity of discharge, when the function has become regularly " established," is from one to eight ounces, the average being about five ounces. The duration of the period is from one to eight days, the average being five days, hence average daily quantity during the period, one ounce. The menstrual blood does not coagulate, owing to admix- ture with vaginal mucus which contains acetic acid. If the flow is very profuse, coagulation will occur, because the action of the vaginal mucus is then insufficient to prevent it. Mucus of any kind, in sufficient quantity, will prevent coagulation. The discharge also differs at different parts of the period. Towards the beginning and end of the epoch it contains more mucus and less blood; at the middle of the period vice versa. Source of the pZow___That the flow comes from the uterine cavity is absolutely proved by the following facts : it is found there, post mortem, in those who die during menstruation; it is seen to issue from the os externum uteri in cases of procidentia of the organ ; it has been seen oozing from the uterine mucous membrane in cases of inversion of the womb ; and when there is mechanical obstruction of the os uteri the menses do not appear, but accumulate and distend the uterine cavity. Vicarious Menstruation__This is a flow of blood from some other organ recurring at the monthly periods, and taking the place of menstruation. It may occur from the hemorrhoidal vessels, the lungs, the skin, the nails, the mammary glands, ulcerated surfaces, and many other parts. Periodicity—The monthly recurrence of menstruation is accounted for only in so far as ovulation explains it. The interval sometimes varies from the typical twenty-eight days, but it is then, strangely, some multiple of a week. Normal Suspension of Menstruation__It is tem- porarily suspended during pregnancy and lactation, and ceases permanently after the so-called " change of life" at about forty-five or fifty years of age. Numerous exceptions must be r.oted to each of these statements. fecundation and nutrition of the ovum. 61 CHAPTER VI. fecundation and nutrition of the ovum. Fecundation (or Impregnation) is the union of the germ-cell (ovule) with the spermatic fluid of the male. The spermatic fluid (sperm, semen, seminal fluid) is a whitish viscid fluid secreted by the genital glands of the male. Floating about in it are millions of ciliated epithe- lial cells, called spermatozoa (spermatozoids). When intro- duced into the womb during coitus, this fluid comes in con- tact with the germ-cell, and the spermatozoa get into the ovule by penetrating the vitelline membrane. The union may take place either in the womb, Fallopian tubes, or ovary, probably most often in the ovary. The natural receptacle for the semen (receptaculum seminis), in the act of coition, is the cavity of the uterus, whither it is conducted by the five or six successive ejaculatory jets, on the part of the male organ, and the five or six successive suctional aspirations on the part of the os and cervix uteri, that occur, when the orgasm is complete in both sexes, simultaneously. It after- wards goes on through the Fallopian tubes to the ovaries. Changes taking place in the Germ-cell after Feci ndatiox___First, it should be remembered the germi- nal vesicle and germinal spot disappear before the cell leaves the ovary, so that we have nothing left to deal with in this description but the simple vitelline membrane with its con- tained granular vitellus. Then begins division of the vitel- line mass (not of the vitelline membrane) into two halves, in each of which appears a nucleus. The halves divide into quarters, the quarters into eighths, these into sixteenths, and so this dichotomous subdivision continues, the resulting parts each developing a nucleus, until eventually a great number of minute cells result, which soon arrange themselves, close to each other like bricks in a wall, upon the inner surface of the vitelline membrane. The cells thus in close 6 62 fecundation and nutrition of the ovum. apposition with each other constitute a membrane, the "blasto-dermic membrane." Later, this splits into two, viz., the "external blasto-dermic" and the "internal blasto- dermic" membranes. From the former of these are developed the bones, skin, muscles, serous membranes, and nervous system of the foetus (in fact the organs of " animal life"), and from the latter the mucous and glandular organs (in fact the nutritive organs, or those of " vegetative life." Between the two layers of blasto-dermic membrane just mentioned a third one, the " middle blasto-dermic membrane," is subse- quently developed. From this the circulatory organs are evolved. These three layers of blasto-dermic membrane are called technically, and respectively in the order above de- scribed, epiblast (ext.), hypoblast (int.), mesoblast (middle). The vitelline membrane still surrounds and encloses all of these. Next, an oval-shaped patch, or area, begins to appear in the epiblast, of a somewhat darker color owing to closer aggregation of its cells, called the area germinativa. Its central portion is lighter and more transparent than the rest —it is the area pellucida. Along the longitudinal axis of this last, a streak or furrow appears : the primitive trace. The sides of the furrow increase in height, lamince dorsales or dorsal plates, thus deepening the " trace," and arching over, join each other, and so convert the furrow into a canal. This becomes afterwards the spinal canal in which the spinal cord rests. From the origin of the dorsal plates there pro- ceed also two others in an anterior direction, which converge and join each other to form the cavity of the abdomen, the lamince abdominales or abdominal plates. These in their growth do not project far enough to embrace all of the em- bryonic globe, but come together half way over, as it were, so as to indent the elastic vitelline and internal blasto-der- mic membranes, and thus leave part of it (the globe) pro- truding (like a sort of hernial sac) outside the abdominal walls; the thus excluded part is called the " umbilical vesi- cle" (Note.—The umbilical vesicle has nothing to do with the future umbilical vessels; they are formed in a different manner from the root of the allantois). A network of blood- vessels surrounds the umbilical vesicle to carry on absorption of its contained vitellus, derived from the omphalo-mesen- teric artery and vein, which in turn spring from that por- CHANGE8 IN THE GERM-CELL. 63 tion of the middle blasto-dermic membrane which surrounds the vesicle. The point of constriction between the cavity of the abdomen and that of the umbilical vesicle becomes more and more narrowed by the nearer approach of the two ab- dominal plates towards each other until only a small canal remains (the vitelline duct), which, later, becomes still nar- rower and also longer by the absorption of the contents of the vesicle and (apparently) the stretching of its stalk or neck. WTiile the changes thus far described have been progress- ing in the external blasto-dermic membrane, others have taken place in the internal one. It has become narrowed, elongated, and convoluted,\so as to form a rudimentary in- testinal canal. A little later, there springs from the external blasto-der- mic membrane another structure, called the amnion. The amnion is developed as follows : A sort of hollow pouch, fold, or duplication of the epiblast projects near the caudal end of the foetus, and another one like it near the cephalic end. They bend over towards the back of the foetus (which has now become curved and convex externally) until they meet and touch each other. In the mean time they have spread and widened laterally so that the dorsal aspect of the fuctal body is now completely enclosed by this double hemispherical fold of amniotic membrane. Where the two meeting folds touch each other, the double septum so formed breaks down and melts away along its centre, while the contiguous edges of the two meeting layers join each other ; thus a free space is made between the former hollow cavities of the two approaching folds, while the union of the two inner layers has formed the internal amnion, and that of the two outer layers the external amnion, which are thus sepa- rate from each other. The external peripheral surface of the outer amniotic layer comes in contact with the vitelline membrane, and these two weld or amalgamate together to form a single membrane, while the internal layer of the amnion becomes distended with fluid (liquor amnii), and, growing larger and larger during pregnancy, fills the womb, and constitutes one of the membranous strata composing the " bag of waters" that bursts in labor. 64 FECUNDATION AND NUTRITION OF THE OVUM. The Allantois and Chorion__The allantois begins as a membranous vascular pouch springing from, and con- tinuous with the lower part of the intestinal mucous membrane. It follows inside the space of the hollow amniotic pouch, and, like it, widens, spreads laterally, and eventually its two pro- gressively extending margins meet and join each other, so that the foetal body is now enclosed completely in a layer of allan- tois, which, from the nature of its place of origin, is of course situated between the internal and external layers of the amnion. The root or neck of this allantoic membrane becomes, and in fact already is in a rudimentary form, the umbilical cord or navel string. Later on, the two opposing folds or walls of the allantois unite to form one layer, and this last comes in contact with the inner concave surface of the external amnion and amalgamates with it. Thus the external amnion has the vitelline membrane on the out- side of it, and the allantois on the inside. The three amal- gamated together, as they now are, compose a single mem- brane which receives henceforth the name of " chorion." The chorion afterwards becomes covered externally with projecting villi, not unlike those of the adult small intestine, each of which, later on, receives a capillary vascular loop derived from what were originally the vessels of the allan- tois. The villi of the chorion, covered with epithelium ex- ternally, and containing the bloodvessels in their central axes, grow longer and branch out at their distal extremities, this process being more complete and complicated in that part of the chorion which is to participate in forming the future placenta. The projecting, dangling villi of the chorion (often termed its " shaggy coat") give the ovum, when examined post mortem, the appearance of a little bunch of wet, whitish, gelatinous moss. After eight weeks the villi over a greater part of the chorion disappear—this part is said to become bald—while about one-third of the surface retains its villi, and the latter become developed more and more, to form, as we shall see presently, the placenta.1 1 Since the amnion, as thus far explained, seenis only to en- velop the dorsal aspect of the foetus, some further explanation is necessary to understand how the whole body of the child eventually floats by its navel string in an amniotic hag that completely sur- rounds it. The body of the fetus is still a little oblong mass, changes in uterine mucous membrane. 65 Changes in Uterine Mucous Membrane. Forma- tion of Decidua, etc__The increased vascularity, hyper- trophic thickening and shallow folding of the uterine mucous membrane, which, we have seen, begin, preparatory to ovula- tion, at each menstrual period, progress, after the stimulus of impregnation, with a sort of almost paroxysmal rapidity. The membrane becomes extremely thick, vascular, and deeply convoluted (except near the orifices of the Fallopian tubes and os internum), so as to obliterate, or rather fill, the cavity of the womb. The hypertrophied mucous mem- brane thus formed on all sides of the uterine cavity is called the decidua vera. When the ovum1 first enters the womb it lodges between two of the folds of the decidua vera, and, imparting an extra stimulus to those portions of this membrane immediately surrounding it, they grow up all round the ovum, and, being reflected over it, meet and join together, thus, as it were, burying the little germ in a circular grave of mucous mem- brane, the arched covering of which is the decidua reflexa. That part of the decidua vera which lies between the ovum and the uterine wall (the bottom of our imaginary grave) is the decidua serotina,. This becomes greatly thickened, and constitutes the bed into which the rootlets of the chorial villi penetrate to form the future placenta. To recapitulate all the membranes with which the foetus is now covered, and beginning with the one nearest the fuMal body and proceeding outwards, they are :— 1. The inner layer of the amnion, in future simply called "The Amnion," for the outer amniotic layer, as we have curved so that its two ends look somewhat towards each other, but with no legs or arms as yet. Now the inner layer of the elastic amnion becomes more and more distended with fluid, and the ends of the sac yielding to this distension, gradually swell towards each other, as if rolled along the anterior surface of the foetal body un- til they meet on the abdomen, with nothing but the umbilical cord between them. Thus the cord is covered on its outside with a layer of amnion. The wide rounded ends of the amnion that thus meet over the abdomen have one surface in contact with the skin of the foetal body, the line of which, viewed in section, follows the abdom- inal surface till reaching the umbilical cord, then it goes along the cord till reaching the chorion, where it is of course continuous with the reflected layer already covering the dorsal aspect of the foetus. 1 The ovule is called ovum only after impregnation. 6* 66 fecundation and nutrition of the ovum. seen, has los"t its identity in becoming amalgamated with the allantois and vitelline membrane to form 2. The Chorion. 3. The Decidua Reflexa__These three membranes persist until delivery, constituting the bag of waters. In the progressive development of pregnancy, the external surface of the amnion comes in contact with the internal surface of the chorion ; the external surface of the chorion in contact with the internal surface of the decidua reflexa ; the exter- nal surface of the decidua reflexa in contact with the decidua vera, covering the remaining parts of the uterine walls. The Placenta__The placenta at full term is a soft spongy mass, irregularly saucer-shaped, seven or eight inches in diameter, three-quarters of an inch thick near the centre, and from one-eighth to one-fourth of an inch at the edge; average weight, twenty ounces. It varies much in all these particulars. It begins to be formed about the end of the second month of gestation, and attains its essential characteristics in a few weeks more. The exact mode of its development, its minute structure, and the precise relation of its bloodvessels with those of the foetal vessels in the chorial villi, are matters regarding which there still remains great uncertainty. It may be sufficient for practical purposes to understand the following leading matters of fact about which there is no doubt, viz. : 1. The chorial villi, with their loops of bloodvessels, penetrate, like the roots of a tree, the thick decidua serotina. 2. The de- cidua serotina is also penetrated from its uterine surface by bloodvessels continuous with the curling arteries of the uterine wall. 3. At first the external coats of the villi and the mucous coat of the decidua serotina intervene between these two sets of bloodvessels, but later on these intervening soft structures are absorbed, and then the bloodvessels of the chorial villi (foetal vessels) come directly in contact with the bloodvessels of the decidua serotina (maternal vessels). 4. Wherever this contact occurs, the coat of the maternal vessels unites with the coat of the fcetal vessels to form one membrane, and this last, growing very thin, still always remains as a membranous septum between the maternal and foetal blood, and through it all the interchanges of matter nutrition of the fcetus. 67 between mother and child take place.1 5. The two bloods never mix. On the contrary, the blood sent to the villi by foetal arteries returns by foetal veins, and that sent to the placenta by maternal arteries returns by maternal veins. 6. The two sets of bloodvessels do not come in contact with each other along any definite straight line, but at first the capillary loops, and later their branches, decussate "with each other (like the surfaces of two apposed cogged wheels) ; and still later, the two sets of branching vessels are con- fusedly united and irregularly interlaced and entangled with each other in a " most admired disorder," too complicated for brief description ; yet while the vessels tangle and ad- here, the bloods never mix. The whole substance of the placenta is eventually made up of these two sets of vessels and their contents. The Umbilical Cord (navel-string, funis)___At first it is the root of the allantois, or that portion of the allantois extending from the body of the foetus to the chorion. Later it remains the connecting link between the abdomen (navel) of the fbet us and the placenta. It contains two arteries which are continuations of the fcetal hypogastric arteries, and one vein—the latter without valves. The umbilical arteries, at first straight, become, later, twisted round the vein. The vessels are embedded in the so-called gelatin of Wharton, and the cord is covered externally by a layer of the chorion and amnion. Nutrition of Fcetus at Different Periods of Pregnancy. 1. At first it absorbs nourishment simply through the vitelline membrane. 2. The vitellus is absorbed and carried into the body of the foetus by the branches of the omphalo- mesenteric vessels. 3. The chorial villi absorb nutriment which is conveyed to the foetus by bloodvessels springing from the vascular allantois: 4. When a larger number of the villi have disappeared, the remaining (one-third) of the chorial tufts develop into the placenta. 1 The coalescence of the maternal placental vessels, by absorp- tion of their apposing walls, to form larger vessels ("placental sinuses") is still a matter of doubt. 68 FECUNDATION AND NUTRITION OF THE OVUM. Functions of the Placenta—It not only affords nutriment to the child, but is also its respiratory organ. The umbilical arteries carry blue (venous) blood to the placenta, where carbonic acid gas is given off to the maternal blood and oxygen taken in from it, so that the umbilical vein brings back arterial (red) blood to the foetus. The placenta is also an organ of excretion for the infant. Hence compression and obstruction of the cord kills the child. Fcetal Circulation___The umbilical vein after entering the umbilicus sends two branches to the liver, while its main trunk (the ductus venosus) empties directly into the ascend- ing vena cava. The blood returned from the placenta by the umbilical vein goes, therefore, part of it to the liver, whence it is returned by the hepatic veins into the ascend- ing vena cava just above the entrance of the ductus venosus to join the current from this latter vessel. The blood from the lower extremities of the foetus comes up through the vena cava and thus mixes with thereturned blood from the placenta. The ascending vena cava pours its blood into the right auricle of the heart, where it is directed by the Eustachian valve through the foramen ovale into the left auricle. From the left auricle it goes to the left ventricle ; from the left ventricle to the aorta. The great bulk of this aortic stream parses through the large arterial branches of the aortic arch to the head and upper extremities. From these the blood returns by the descending vena cava to the right auricle ; from thence through the tricuspid valve it passes into the right ventricle ; and then it enters the beginning of the pul- monary artery, but the two branches of the pulmonary artery going to the lungs cannot receive this column of blood before respiration is established, so that there is a special blood duct (the^Mc^s arteriosus) provided for carrying the stream from the trunk of the pulmonary artery into the descending aorta, from whence part goes to the lower extremities, to come back by the ascending cava, while the larger portion passes along the umbilical arteries to the placenta. The umbilical arteries are continuations of the hypogastric arteries given off from the internal iliacs. Changes taking place in the Circulation after Birth—There is no longer any current of blood through THE SIGNS OF PREGNANCY. 69 the umbilical vessels. The navel-string dries up and falls off. The umbilical arteries inside the abdomen remain per- manent in a part of their course, constituting the superior vesical arteries. The ductus venosus and ductus arteriosus no longer admit blood, but shrivel up into fibrous cords. The foramen ovale closes, so that there is no longer any passage from one auricle to the other, and when the lungs are expanded by respiration, the pulmonary arteries receive the blood which before went through the ductus arteriosus, and convey it to the lungs. CHAPTER VII. THE SIGNS OF PREGNANCY. The signs of pregnancy require particular and careful study, for several reasons :— (1) Because unskilled persons very often, and the most skillful physicians sometimes, make mistakes in stating that pregnancy exists when it does not, or vice versa. (2) The question of pregnancy may involve character, as in unmarried females. (3) It may involve the legal rights of offspring. (4) It determines medical, surgical, and obstetrical pro- cedures often of the gravest import. (5) It concerns the reputation of the physician. Classification of Signs.—They have been divided into presumptive, probable, and positive, according to the degree of reliance to be placed in them as evidence of preg- nancy. They have also been called rational, or such as are evident to the sensations of the patient; and physical, such as become apparent to the educated physician by physical examination. Probably the most practically useful method is to divide them into those that are certain and those that are not: hence, first, Positive signs; second, Doubtful signs. The duration of pregnancy in the human female is forty weeks, or two hundred and eighty days ; or ten months, /. e. ten lunar months. But it may be best to discard the term 70 THE SIGNS OF PREGNANCY. " month" altogether, inasmuch as an additional word is re- quired to indicate whether it means a lunar or calendar month. How Early During this Period is it usually pos- sible TO MAKE A POSITIVE DIAGNOSIS OF PREGNANCY IN Doubtful Cases where Important Interests are In- volved?—It cannot be far from true to assert that scarcely half the physicians in the world (to draw the line roughly) are sufficiently skilful to make a positive diagnosis in such cases before the pregnancy is nearly half over. Even the most skillful can hardly obtain absolutely positive signs dur- ing the first sixteen weeks. Positive Signs—There are only three signs that are absolutely positive, viz.:— 1. The foetal heart sound. 2. Quickening or active motions of the child. 3. Ballottement or passive locomotion of the child. Two others, though not so valuable, are usually classed with the positive signs, viz. :— 4. The uterine murmur. 5. Intermittent contractions of the uterus. The Foetal Heart Sound__The pulsation of the heart can seldom be heard before the twentieth week (the middle of pregnancy). A practised, skillful ear may recognize it two or three weeks earlier. As pregnancy advances the sound gets louder and more easy of recognition, resembling that made by the ticking of a watch heard through a feather pillow. A good imitation of it may be produced by pressing the palm of one hand strongly against the ear, while on the back or cubital border of it, a series of gentle touches, in quick succession, are made with the tip of the middle finger of the other hand, previously moistened with saliva. Owing to the flexed posture of the child the sound is trans- mitted through its back, which is in closer contact with the uterine wall than are the other parts of the infant's thorax. The back of the child usually lies against the lower part of the uterine wall on the left side. We listen for the sound, therefore, on the abdomen of the mother about the middle of a line drawn from the umbilicus to the centre of Poupart's ligament on the left side, or the region thereabouts. Failing quickening. 71 to hear the sound there, the same region on the right side may be examined, and, if again failing, the whole surface of the abdomen may be explored. In auscultation of the abdomen a stethoscope is used (the double one preferred), or the ear alone, one thin layer of clothing covering the surface in the latter method for the sake of delicacy. Selection determined by the custom or judgment of the practitioner. The patient must lie upon the back, and the room be kept quiet. Failure to hear the heart sounds during the latter months does not positively negative the existence of pregnancy, for the child may be dead; or the heart sounds may be very feeble ; or thick tumors, etc., may intervene between the uterine and abdominal walls, interfering with the transmis- sion of the sound ; or the auscultator's ear or skill may be at fault. The frequency of the foetal heart sound bears no relation with that of the mother's heart. They are independent of each other. The foetal heart beats from one hundred and thirty to one hundred and fifty times a minute. It is gen- erally a little less frequent in large children than in small ones. Very large children are usually males. Hence, at- tempts have been made to determine the sex before birth by the heart sounds, but little reliance can be placed in the method. It is barely possible to mistake the sound of the mother's heart for that of a child in utero, as when, ex. gr., the mother's heart, from fever or other causes, attains the same frequency as that of the infant; but this mistake could be avoided by noting if the mother's pulse beat simultaneously with the abdominal sounds. When the sounds of the pulsations of the foetal heart are distinctly heard, while the womb is found too small to con- tain a foetus of sufficient size to yield a heart sound, and especially if the womb is but little larger than an unimpreg- nated one, it indicates extra-uterine fcetation. Quickening__This term originated from the erroneous supposition that the child became " quick," or alive, only after it began to move. It simply means active muscular motions of the child's limbs or body. The period at which foetal movements may be first recognized varies very much ; 72 THE SIGNS OF PREGNANCY. but to make a practical statement, and one easy of recollec- tion, we may say about the middle of pregnancy. Then, and after then, an obstetrician of ordinary skill may feel the motions of the child, but the mother may be cognizant of certain sensations in the abdomen (described as "flutter- ing," " pulsating," " creeping," etc.), which she calls " feel- ing life" as early as the sixteenth or eighteenth week. Oc- casionally in examining the abdomen the physician, at this early period, or even before, may feel or hear with the stethoscope certain motions, which he supposes are foetal movements, but these are not reliable. In examining the female for foetal motions she may be either standing, sitting, or lying upon her back with the thighs flexed so as to relax the walls of the abdomen. One hand is then pressed with gentle firmness upon the abdom- inal wall and uterus, and kept there for some minutes. Should the motions not be felt, pressure or gentle taps may be made with the other hand upon other parts of the abdom- inal surface. Dipping the hand in cold water before placing it on the abdomen will sometimes excite foetal movements. When violent, the motions produce distortions and pro- jections of the abdominal wall, that may be seen as well as felt. Failure to recognize these movements does not negative the existence of pregnancy; the child may be dead, or it may retain life and vigor and yet fail to move, even during the physician's examination. Contractile muscular motions in the abdominal, uterine, or intestinal walls; the movement of gas in the intestinal canal; and the pulsations of aneurisms and large arteries, may, it is just possible, be mistaken for foetal movements by the inexperienced. Ballottement—Passive Locomotion of the Foztus —is a sudden locomotion of the child in the uterine cavity, produced and felt by the physician. Method of Examination—The woman is placed in a position which will make the child settle, by gravitation, towards that part of the uterus wdiere the examining finger is to be applied per vaginam. The best plan is to let her sit THE UTERINE MURMUR. 73 on the edge of a low bed and then lean back against pillows, so as to be midway between sitting and lying. The finger is now introduced and placed in front of the cervix close to its junction with the body of the womb. The other hand steadies the fundus uteri. A sudden upward, jerking, but not violent, motion, is now executed by the examining fin- ger, which will cause the foetus to bound slowly upwards to the fundus, and as it comes back again the finger will feel it knock against the neck (so to speak) of the uterine bottle in which it floats. The manipulation may be repeated several times to insure certainty. The position may be changed to a lying or standing one, and the finger put behind the cervix uteri, if the first examination is not satisfactory. If the abdominal walls are thin, external ballottement may be performed. The woman lies on her side, the abdomen slightly over the edge of the bed, and with a hand on each side of the womb the operator endeavors to move the foetus up and down for the purpose already indicated. Ballottement may be recognized earlier than any other of the positive signs, viz., from about the fourteenth or fifteenth week, and until within six or eight weeks of full term. Towards the end of pregnancy the child so nearly fills the uterine cavity that it cannot be moved about. In multiple pregnancies, or where there is deficiency of the liquor amnii, the sign is unavailable for the same reason. The child may also be immovable when it is lying crossways in the womb. Again, the operator may lack skill and acute tactile sensibility. During the first part of pregnancy the child is too light in weight to be felt with the finger through the uterine wall. A calculus in the bladder, and exaggerated flexion of the uterus, are the only conditions likely to produce results, on examination, resembling ballottement. The Uterine Murmur—This has been called placental murmur—placental souffle, or bruit placentaire—because it was thought to be produced by blood rushing through the " placental sinuses ;" uterine souffle or murmur, on the sup- position of its being caused in the same way in the sinuses of the uterine wall; abdominal souffle, because it was believed to occur from pressure of the gravid womb upon the large vessels of the abdomen. It has also been referred to blood- changes, like those occurring in profound anemia; and it is 7 74 THE SIGNS OF PREGNANCY. said a somewhat similar sound has been produced by pres- sure of the stethoscope upon the epigastric artery in the abdominal wall. These theories are still unsettled. The one most generally received is that which refers the sound to the uterine blood- channels. The murmur has been heard after complete delivery of the placenta; and there is no substantial proof of its production in the vessels of the abdomen. The most striking peculiarities of the uterine murmur are as follows :— 1. It is a maternal sound synchronous with the mother's pulse; 2. It is remarkably capricious or coquettish in char- acter, changing often in tone, pitch, intensity, duration, and location, even while we listen, or it may be absent and again return ; 3. It becomes stronger at the beginning of a labor- pain, ceases altogether at the acme of the pain, returns loud again as the pain goes off, and after that, resumes the char- acter it had before the pain began. It is most usually recognized near the lower part of the abdomen, and necessarily so when first audible, because the womb does not yet extend high up in the abdominal cavity. Towards the end of pregnancy it may be heard, of course, higher up. It cannot generally be recognized before the sixteenth week, except by ears exceptionally acute and skilled. It remains afterwards till full term, unless tempo- rarily absent as before explained. It is not an absolutely positive sign of pregnancy because a sound resembling it may be heard in large fibroid tumors of the uterus, ovarian tumors, and other conditions. Intermittent Uterine Contractions.—From about the twelfth week of pregnancy (when the womb has grown sufficiently large to be felt by the hand through the abdominal wall), until its termination, the uterus is constantly contract- ing at intervals of a few minutes. If the hand steadily grasp the fundus uteri and remain so doing for from five to ten or fifteen minutes, it will feel the womb hardening (by contrac- tion) and relaxing again at intervals, in a very characteristic manner. Though a valuable sign, from the early period at which it may be recognized, it is not an absolutely positive one, because the uterus may contract in a similar manner in its efforts to expel blood-clots, polypi, retained menses, fibroid SUPPRESSION OF MENSES. 75 tumors, and other products not connected with pregnancy. It is of great diagnostic value, however, as a corroborative sign when considered in relation with the history of the case. In addition to the positive signs thus far considered, other sounds, audible by auscultation, have been detected during pregnancy, but they are of no diagnostic or practical value. Thus there have been heard a murmur or souffle in the um- bilical cord when it is coiled or pressed upon ; sounds pro- duced by movements of the child in the liquor amnii; and others due to movement of gases resulting from decomposi- tion of the amniotic fluid. Doubtful Signs of Pregnancy__These are difficult to define numerically, but for convenience of recollection, we may enumerate five that are easy of recognition, and five others that are somewhat less so. Each of these ten signs, however, includes a variety of phenomena. They are as follows :— First Five. 1. Suppression of the menses. 2. Changes in the breasts and nipples. 3. Morning sickness. 4. Morbid longings and dyspepsia. 5. Changes in the size and shape of the abdomen. Second Five. 6. Softening and enlargement of os and cervix uteri. 7. Violet color of vagina. 8. Kiestein in the urine. 9. Pigmentary deposits in the skin. 10. Mental and Emotional phenomena. Besides these there are a few residual odds and ends by which the list of gestation signals may be completed. 1. Suppression of Menses__Menstruation is suppressed during pregnancy, because what would have been menstrual blood in the absence of impregnation is now appropriated to the development of the ovum and reproductive organs. There is no ovulation during pregnancy. Suppression of the menses is a very doubtful sign, because, exceptionally, 76 THE SIGNS OF PREGNANCY. menstruation (and even ovulation) may occur during gesta- tion. Cases are seen, very rarely, in which menstruation occurs only during pregnancy. Suppression of the menses may take place from cold, mental emotion, and many causes other than pregnancy. Again, the sign may be unavailable in cases where impregnation occurs at puberty, before the menstrual function is established ; or during lactation, when it is absent; or in women whose menses are wanting from anemia or debility. When menstruation occurs during pregnancy, it seldom recurs every month throughout the whole period; more fre- quently it ceases after the first three or four months. In the latter case the flow is supposed to come from that portion of the decidua vera with which the expanding decidua reflexa has not yet come in contact. After the contact named takes place, there is no further menstruation. 2. Changes in the Breasts and Nipples__The mammary glands become firmer, larger, more movable; their blue veins more easily visible ; and sensations of weight, pricking, tingling, etc., in them, may be noticed by the pa- tient. There are also a few light-colored silvery lines radi- ating over the projecting breasts. The nipples become enlarged somewhat, and more dis- tinctly prominent, or erect; and a sero-lactescent fluid ooz- ing from them, dries into branny scales upon their surface. The areola, or disk, surrounding the nipple, gradually be- comes darker in color, varying with the complexion of the individual, from the lightest brown tint to black. Upon its surface are seen ten, twelve, or more enlarged follicles, which project one-sixteenth or one-eighth of an inch. They vary in size. On the white sk'm just outside, but immediately surround- ing the colored disk, the secondary areola subsequently ap- pears. It consists of round, unelevated spots, of a lighter color than the surface on which they rest; hence they are said to resemble spots " produced by drops of water falling upon a tinted surface, and discharging the color." There is one complete row of them placed close together round the dark areola, and other scattering ones a little further off, that are less distinct. Secretion of Milk—In a woman who has never been p regnant before, this is considered a very valuable corrobo- MORNING SICKNESS. rative sign. Milk, in exceptional instances, runs from the breast weeks before delivery, and a drop of lactescent fluid may be squeezed from the nipple as early as the twelfth week of gestation in some cases. The dates at which these several breast signs appear, are as follows : The secondary areola does not become visible till the twentieth or twenty-fourth week ; the silvery lines do not appear till near the end of pregnancy ; and nearly all the other signs on these parts commence from the eighth to the twelfth week, and then become more pronounced as pregnancy goes on. What degree of certainty can be attached to the breast signs'?—They are totally unreliable, taken alone. In con- junction with other early signs they may lead us to suspect the existence of pregnancy, but such a suspicion should not be crystallized into an expressed opinion until more positive signs appear. Their absence does not negative pregnancy. Conditions resembling them may occur from uterine or ovarian diseases independent of gestation. Many of them continue a long time after delivery, and might thus be erro- neously attributed to a supposed succeeding pregnancy. Confusion of this sort arises when pregnancy is suspected during lactation, or after a concealed or unknown abortion. The secretion of milk has been produced artificially, not only in females, but even in males. In primiparous women, the occurrence of the secondary areola, or the secretion of milk, or the fact of our being able to force a drop of lactescent fluid from the nipple, de- serves great consideration, but in multipara?, they must be taken cum grano salis. Suppression of the milk secretion in nursing women, is of considerable value as a corrobora- tive sign. 3. Morning Sickness.—This consists in nausea, which mayor may not be accompanied with vomiting, on first rising in the morning, or it may take place at or after the morning meal. It usually begins about the fourth or fifth week, and lasts until the end of the sixteenth, or later. Sometimes it comes on a few days after impregnation, and continues throughout pregnancy. It is a sympathetic disturbance, most likely due to a de- 7* 78 THE SIGNS OF PREGNANCY. gree of congestion of the uterus beyond the physiological limit, and for which it is, to some extent, a natural correc- tive. Sexual excitement after conception is probably a fac- tor in its production. It justifies the suspicion of pregnancy only when it occurs and persists without any other special cause, and in a woman who is otherwise healthy and well. 4. Morbid Longings and Dyspepsia.—Some pregnant women have an unusual desire for sour apples and other acid fruits, or drinks, and salads prepared with vinegar, etc., or there may be a liking for substances still more unpalatable, such as chalk, ashes, lime, charcoal, clay, and slate pencil; even putrid meats and spiders have composed a part of the chosen menu. Occasionally there is entire loss of appetite, or a disgust for particular substances. Heartburn, pyrosis, flatulence, and unpleasant eructations are of common occurrence. These dyspeptic symptoms and morbid longings begin about the same time, and have about the same diagnostic value as morning sickness, and their duration is equally un- certain. 5. Changes in the Size and Shape of the Abdomen. __During the first eight weeks of pregnancy the abdomen is really flatter than before, and presents no increase in size. This is due to sinking down of the uterus, which pulls the bladder down a little, and the bladder, in turn, by means of the urachus, draws the umbilicus inwards, so that the navel and its immediately surrounding abdominal surface appear drawn in instead of prominent. Hence the oft-quoted French proverb : " Ventre plat, enfant il y a." " In a belly that is flat, There's a child—be sure of that." But you cannot be sure of it. By the twelfth week the fundus uteri begins to peep above the brim of the pelvis, where it can be felt with the hand over the pubes. The navel is still sunken. At the sixteenth week the fundus has risen about two inches above the symphysis pubis. The navel is no longer unusually sunken. So the vertical enlargement progresses at the rate of about ENLARGEMENT OF THE ABDOMEN. 79 one and a half to two inches every four weeks, until the fundus, at the thirty-eighth week, almost touches the ensi- form cartilage. During the last eight weeks the umbilicus protrudes beyond the surface. About two weeks before delivery the womb sinks down a little, the abdomen becomes less protuberant at its upper part, and appears smaller in size. This is generally ascribed to relaxation of the pelvic ligaments and soft parts. AVe may more easily remember the position of the fundus at different stages of pregnancy by dividing the whole term into thirds, as follows :— At the end of the^rsUhird the fundus rises a little above the pubes—say it is at the pubes. At the end of the second third it reaches the navel. At the end of the third third it reaches the ensiform car- tilage, allowing for sinking during the last week or two. By subdividing the intermediate spaces into thirds and allowing one-third of fundal rise for each four weeks, we shall attain approximate precision sufficient for practical purposes, for there are great differences in different cases. The principal characteristics by which enlargement of the abdomen from pregnancy may be distinguished from other kinds of abdominal swelling, are as follows : The pregnant womb is usually symmetrical in shape ; it is longer vertically than transversely; its contour is smooth and even; it pos- sesses a peculiar stiff elastic consistency and may be felt to contract under palpation. By careful firm pressure it may also be felt to contain a movable solid body—the foetus. It is not easy to distinguish these peculiarities by palpation of the abdomen. The sense of touch must first be educated by long practice, and even then, in doubtful cases, the history, origin, duration, and accompanying symptoms of the en- largement must be fully studied before we can attach to them much diagnostic importance. Fibroid and other tumors of the uterus ; cystic and other tumors of the ovary ; distension of the womb from retained menses; accumulations of fluids or gases; obesity; pseu- docyesis ; enlargement of liver, spleen, and other of the abdominal viscera, etc., may lead to enlargement of the abdomen simulating pregnancy. The history and duration of the swelling, together with accompanying symptoms, should prevent its being mistaken for gestation. 80 THE SIGNS OF PREGNANCY. 6. Softening and Enlargement of Os and Cervix Uteri__In making a digital examination per vaginam, the differences to be noted between a virgin uterus, and an impregnated one, are very characteristic ; but between the impregnated and unimpregnated uterus of a woman who has already borne children, the differences are less marked. Scarcely any change takes place during the first i'ew weeks of pregnancy, other than the alteration of position in the womb already noted, together with increased weight and consequent diminished mobility of the organ. The chief characteristic of the virgin cervix uteri is firm- ness of consistency. Very soon after impregnation it begins to soften and enlarge circumferentially. The lips of the os externum become wider, and puffy to the touch, and the fissure of the os becomes rounder and larger. The softening begins at the outside (vaginal surface) and lowest part of the cervix and gradually extends upwards and inwards until the com- pact nodule of the virgin cervix is converted into a soft elastic projection, whose length is apparently shortened by increase of width and diminished resistance to the examin- ing finger. These changes begin soon after conception, but scarcely become easy of recognition till about the fifth or sixth week. In sixteen weeks the lips of the os are softened; in twenty weeks half the cervix is soft, and the whole of it has under- gone the same change when the " term" is within a month of completion. After one child the cervix never goes back to its pristine virgin firmness, nor does it recover the perfect smoothness of surface and smallness of the external os characteristic of the virgin uterus. Again, during a first pregnancy the os will not admit the tip end of a finger, during a subsequent one it generally will. The diagnostic value of softening and enlargement of the cervix uteri, is only relative : their absence would generally negative advanced pregnancy; but as they may occur from other causes, the affirmative evidence they furnish is not reliable. 7. Violet or Dusky Color of Vaginal Mucous Mem- brane—By Jacquemin (wdio first discovered this sign in examining the prostitutes of Paris) and others, it has been considered to furnish positive evidence of pregnancy, espe- PIGMENTARY DEPOSITS IN THE SKIN. 81 cially during the early months. This is an error. The dis- coloration is due to venous congestion, and conditions closely resembling it may occur from uterine or vaginal congestion independent of pregnancy ; as it can only be observed by inspection, it is not always available. 8. Kiestein in the Urine.—When the urine of a preg- nant woman is kept for some days (it may require weeks) at a temperature of about 70° F., a flocculent woolly-look- ing cloud begins to form in the centre of the liquid, which gradually rises to the surface, like a pellicle of grease on cold broth ; and, later, the film breaks up and falls to the bottom of the vessel. This is kiestein. It occurs from the eighth week to the thirty-second, or thereabouts, and then disappears. It is mostly made up of the triple phosphates so often seen in decomposed urine, and is of little diagnostic, value inasmuch as it occurs in the urine of men and non-pregnant females. 9. Pigmentary Deposits in the Skin__Besides dark- ening of the areola of the nipple, before mentioned, there is occasionally a brown areolous blush round the umbilicus, which may extend along the median line to the pubes. It varies with the complexion of the patient. In rare instances the color covers the whole abdomen, and cases are recorded of its spreading over the entire body. It is of little value for diagnostic purposes. 10. Mental and Emotional Phenomena__A marked change of temper in the female, as from amiability to pee- vishness, from cheerfulness to melancholy, etc., or exactly opposite changes, may occur. In some women the moral sense is depraved, or elevated ; and intellectual power may be modified in degree. These signs are only of corroborative use for diagnosis. They are generally more apparent to the household than to the physician. The following additional signs may be noted : Toothache or facial neuralgia, or actual caries of the teeth, during suc- cessive pregnancies; salivation without mercury; a ten- dency to syncope in women not disposed to faint when unimpregnated. Some women date impregnation, and often correctly, from unusual gratification during a particular act of coition. 82 THE SIGNS OF PREGNANCY. The introduction of a clinical thermometer into the cervix uteri is said to indicate an elevation of temperature (1° or 2°) when pregnancy exists. None of these indications are reliable. Differential Diagnosis of Pregnancy. From Ova- rian Tumors__In ovarian tumors (cystic degeneration of the ovary) the positive signs of pregnancy are absent; men- struation generally continues ; there is fluctuation ; history of tumor shows it to be of longer duration than pregnancy, and to have begun on one side of the abdomen ; cervix uteri not softened; womb not enlarged, and can be moved with- out moving tumor; or, when tumor rolled to one side by abdominal palpation, cervix uteri does not participate in movement, as demonstrated per vaginam. Exceptions to be borne in mind, e. g__ Pregnancy and ovarian tumor may coexist. Diagnosis difficult, especially when associated with dropsy of amnion (excess of liquor amnii). In the latter, fluctuation is more superficial; cervix uteri enlarged and softened ; womb does move with movement of tumor. Before operating for ova- rian tumor in any case of doubt as to existence of pregnancy, the womb may be measured by uterine sound, or the os di- lated to admit examination by finger; or aspiration of fluid and its subsequent examination resorted to. Amniotic fluid contains— Ovarian fluid contains— Epithelial cells. Epithelial cells. Oil globules. Oil globules. Albumen, but no paral- Granular, non-nucleated bumen or metalbumen. ovarian cells, which Meconium (?). become transparent, but Urinary salts (?). not larger, by acetic Sp. gr. 1005-1010. acid. Reaction alkakine. Paralbumen. Usually clear and limpid. Metalbumen.1 Albumen. Cholesterine. Sp. gr. 1018-1024. Is sticky and tenacious. 1 Tests for paralbumen and metalbumen : see Thomas on " Dis- eases of Women," pp. 667-668. DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 83 From Fibroid Tumors oj Uterus. (Fibrous Tumors, Fibromata)—In uterine fibroids, tumor is (comparatively) harder and more inelastic; it is unsymmetrical and nodular in outline ; of much slower growth than pregnant womb ; is accompanied with profuse menstruation ; cervix not softened, but may be unevenly enlarged. Positive signs of pregnancy absent. Rarely fibroids may coexist with pregnancy. Diagnosis: by physical signs of pregnancy, and results of time. Labor will come on, and may terminate naturally, provided tumor does not obstruct pelvis. From Distension of Uterus due to Retained Menses___In retention of menses there is history of pain at the menstrual periods ; uterine tumor grows by sudden enlargement at each period with some decline in size afterwards. Vaginal exami- nation reveals mechanical obstruction, either in vagina or uterus, preventing egress of menses—this may be congenital, or acquired as result of inflammation, adhesion, etc. The breast signs and positive signs of pregnancy are absent. From Obesity___In enlargement of abdomen from fat, other parts of the body are enlarged ; belly is soft and doughy to touch, and without any central (uterine) tumor. The positive signs of pregnancy and most of the signs about the breasts, etc., are absent. The cervix uteri remains small and unsoftened. From Abdominal Dropsy. (Ascites.)—In dropsy there is distinct fluctuation and no uterine tumor. Resonance on percussion of abdomen changes its boundary line (horizon- tally), by changing position of female, owing to floating of intestines ; cervix uteri unchanged ; physical signs of preg- nancy absent. From Amenorrhcea associated with Congestive Enlarge- ment of Cervix Uteri___This is accompanied with symptoms of uterine inflammation ; backache ; pains in the hips, abdo- men, etc.; weight in perineum; difficulty in walking; and, on examination, the cervix uteri is tender to the touch. Time will (dear up doubt. If pregnancy exist, enlargement of the body of the womb will soon declare it. From Pseudocyesis.—This means " false " or " spurious pregnancy." Women who want to be pregnant, and single women having reason to fear pregnancy, are apt to imagine themselves enceinte when they are not. 84 THE DISEASES OF PREGNANCY. It occurs most often near the "change of life," when ces- sation of the menses, obesity, and various sympathetic phe- nomena appear to lend color to the false impression. There are hysteria, and involuntary projection and contraction of the abdominal walls, simulating the enlarged womb and fcetal movements. Diagnosis: anaesthesia by ether at once disperses the ab- dominal signs, and vaginal examination reveals an unchanged cervix uteri and an empty, unenlarged womb. In examining the female for suspected pregnancy, the order of sequence in the several steps of the examination should be as follows :— 1. Oral examination as to history, symptoms, and dura- tion of case. 2. Examination of mammary glands. 3. Examination and auscultation of abdomen. 4. Vaginal examination. CHAPTER VIII. the diseases of pregnancy. The diseases incident to pregnancy are numerous and varied. Let it be remembered that most of them are due either, 1st, to sympathy, other organs being disturbed in conse- quence of the tremendous changes going on in the reproduct- ive system ; or, 2d, to pressure—the mechanical pressure of the gravid uterus upon neighboring parts. Sympathetic dis- turbances predominate during the earlier months, mechani- cal disturbances during the later ones. The opposite blood conditions of anemia, and plethora, also play an important role in determining the character and treatment of these diseases. Again, generally speaking, the nervous system is more susceptible to impressions during pregnancy than at other times. Finally, some of the pathological conditions to be studied are simply exaggerations of the physiological phenomena ordinarily numbered with the usual signs of pregnancy. dental caries and toothache. 85 Classification—No classification of these diseases yet devised is perfect: all are arbitrary. For convenience sake we may group the several affections to be considered (con- fining the list to those actually due to pregnancy) as fol- lows :— 1. Diseases of the Digestive Organs:— a. Salivary glands. c. Stomach. b. Teeth. d. Intestines. 2. Diseases of the Urinary Organs:— a. Kidneys. b. Bladder. 3. Diseases of the Reproductive Organs :— a. Uterus. c. Vulva. b. Vagina. d. Mammae. 4. Diseases of the Circulatory Organs :— a. Heart. c. Blood changes. b. Aeins. 5. Diseases of the Respiratory Organs. 6. Diseases of the Nervous System. Salivation of Pregnancy. Symptoms__A constant dribbling of saliva, day and night, but no sore gums, loose teeth, or offensive breath, as in mercurial salivation. Occurs usually during the early months, but may continue during the whole of pregnancy. It varies greatly in duration as well as in degree. Prognosis is doubtful as to cure before delivery, but no serious consequences need be apprehended farther than anxiety and annoyance. Cause__It is one of the sympathetic affections. The sympathy between the salivary glands, and generative system is well known from the phenomena of mumps, coition, etc. Treatment__By gentle saline laxatives, which divert the excessive secretion to the intestinal glands, and by as- tringent mouth washes of tannin, alum, or sulphate of zinc. Counter-irritation by tincture of iodine or small blisters externally, over the parotids. No treatment is reliable. Dental Caries and Toothache.—That pregnancy actually causes the teeth to decay is a wide-spread belief among physicians as well as laymen : hence the proverb, "for every child a tooth." It has been ascribed to acidity of the oral secretion from dyspepsia, but, quite as likely it is due 8 86 THE DISEASES OF PREGNANCY. to mal-nutrition of the teeth from certain constituents of their composition having been appropriated to nutrition of the embryo. Treatment.—In recommending operative procedures upon carious teeth during pregnancy, the degree of " nervousness" or emotional susceptibility of the patient, and the severity of the required operation, should enable the physician to judge whether the mental shock or physical suffering to be incurred would be likely to bring on abortion. Conclusion accord- ingly. In case no operative procedure is agreed to, a dose of morphia may be administered hypodermically for immediate relief of the pain, to be followed by anodynes, and quinine in full doses, thus :— $. Quinae sulph. gr. xxx; Morph. sulph. gr. ss ; Extr. belladonnse, gr. iss ; Acid, sulph. aromat. q. s. ft. pil. vj. Sig.—Take one every four houi-s. Anodyne liniments and warm applications externally. Neuralgia of the face (tic douloureux) requires the same remedies. Derangements of the Stomach ; Excessive Vom- iting. Symptoms__Exaggeration of ordinary " morning sickness." Vomiting increased in severity, duration, and frequency. May come on at all times, day and night. Ejected matters contain, successively, food, clear mucus, and regurgitated bile. May be severe pain in stomach from con- tinued retching. Apt to continue weeks or even months in spite of treatment, then follow : constitutional symptoms, fever, emaciation, restlessness, exhaustion, and, later, fetid breath; dry, brown tongue; feeble and frequent pulse; night sweats and insomnia. Still later, in the worst eases, vomiting stops (from exhaustion of reflex power of spinal cord), and nervous symptoms appear, viz., delirium, stupor, coma, and rarely, very rarely, death. Prognosis—Cases apparently hopeless sometimes " turn a corner," as it were, and end in recovery when it is least expected. The symptoms may stop from sudden mental emotion, or the occurrence of spontaneous abortion; or, again, DERANGEMENTS OF THE STOMACH. 87 a new medicine, or some special article of food or drink may succeed, after many others have failed. Treatment—The remedies are " legion." When some fail others must be tried. What will cure one case may be futile in another. Diet—.Total abstinence from food or drink may be tried for a whole day, or even two or more complete days—a mode of treatment easy of application early, not so later, when the patient is exhausted. Liquid diet, in small quantities frequently repeated, in preference to solids, the order of selection as follows :— Milk. Iced milk. Meat soups ; either Beef, ^ Chicken, >■ carefully freed from grease. Mutton. ) Well-cooked farinaceous liquids. Barley-water. Arrowroot. Rice-water. Corn-starch, etc. Should these fail, and the patient avow a desire for bacon and cabbage, pork and beans, onions, green apples, horse- radish, mustard, or any other apparently unsuitable article, give it to her as an experiment, and put the slops aside. Ice-cream, cracked ice, ice-water, and water-ices may do good service. Wake the patient at midnight, or in the early morning hours, and give her (previously prepared) toast and coffee, or an egg, then quickly put out the lights and leave her alone to sleep again. Food thus given may be retained when it would be rejected at other times. Scraped beef, lean and raw, spread on very thin bread, is worthy of trial. Medicinal Remedies___Of the various medicines used it is impossible to say wdiich will suit any one case. For convenience of recollection they may be arranged into groups, as follows :— \.' Purgatives___A brisk cathartic pill, or laxative ene- mata, until bowels are freely open (especially if there has 88 THE DISEASES OF PREGNANCY. been previous constipation), will " work wonders" in reliev- ing emesis. 2. Reflex Sedatives and Anodynes. Vf. Potass, bromid. gr.x-xx, in some aromatic water, three times a day.. R. Chloral, hydrat. gr. v (a small dose), given in solution, every two hours. R. Pulv. opii, gr. j, given in a single pill with as little fluid as possible. Not to be repeated. Should the stomach reject all these, R. Potass, bromid. 5j, or fy. Chloral, hydrat. gr. xx, or ty.. Tinct. opii, f3ss, may be administered in a nutritive vehicle per anum. Morphia given either hypodermically, or endermically (sprinkled on a blistered surface). Anodyne plasters and liniments applied over the epigas- trium ; also counter-irritants,e.g., mustard,cantharidal collo- dion, or blisters of Spanish fly. 3. Alkalies___Especially suited to cases of acid stomach, heartburn, etc. Give aq. calcis ^ss with ,3jss of milk and repeat every fifteen minutes ; or Vichy water ; or magnesia with milk ; or the aromatic spirits of ammonia (dose xx drops) in 3j of some aromatic water. 4. Acids---Lemon-juice, orange-juice, or the acid, sul- phuric, aromatic, (dose x-xx drops) in sj of water. Citric acid (syrup, acidicitrici, U. S. P.) f Jss. Carbonic acid (gas), as in soda water, or the effervescing draught of the U. S. P., etc. One or two drops of the dilute hydrocyanic acid may be added to the latter. 5. Aromatic Bitter Tonics___Tinct. cardamom, co., or tinct. gentian, co., or tinct. cinchon. co., or tinct. rhei dulc. (dose of each about 5j), or the infusion of calumba with aro- matic sulphuric acid. 6. Intoxicating Drinks—Champagne ad libitum. French brandy, sherry, whiskey, kirschwasser. Either may be tried in sufficient quantities to produce slight intoxication. To be resorted to only after a trial of less objectionable methods of treatment. DERANGEMENTS OF THE INTESTINE. 89 7. Unclassified Remedies___Given empirically :— Bismuth subnitrate, dose grs. x-xx. Salicine, grs. v-x. Potass, iodid. gr. v. Oxalate of cerium, grs. v. to x. Vinum ipecac, gtt. j every hour. Creasote, gtt. ij, in aq. calcis Jss. Phosphate of lime, gr. xv-xx, in water, three times a day. Tinct. iodinii comp. gtt. x-xv, diluted. Fowler's solution of arsenic, gtt. j three times a day. Still other, non-medicinal remedies maybe necessary, as the restoration of a displaced uterus; a small venesection for relief of plethora ; dilatation of the external os uteri with the finger has sometimes produced immediate relief; or the application of Chapman's ice-bag to the cervical vertebrae for ten or fifteen minutes, three times a day. Should all means of relief fail and constitutional symptoms of a grave character arise, the last resort may be adopted, viz., the induction of abortion or premature labor ; but the cases requiring it are very rare, and it is not to be employed without a consultation of two or more physicians. Derangements of the Intestine.—Constipation is very common. Less often diarrhoea occurs. Constipation is a sympathetic affection during the early months, and due to pressure of the enlarged womb during the latter ones. Treatment.—During the early months mild saline laxa- tives, taken largely diluted before breakfast. After their action instruct the patient to visit the closet daily at a regu- lar hour, and use gentle massage of the abdomen while there. Oat-meal porridge, and brown bread, bran bread, or corn- meal bread, to be used instead of white flour bread. Cool water to be drank every morning before breakfast, and again the last thing at night. Grocer's figs, dates, prunes, or tama- rinds at night before drinking the water. During the later months when masses of scybala are liable to accumulate, castor oil with tinct. opii may be given, and injections (daily if required, at a regular hour) of soap and water. Should stronger medicines be necessary, either early or late, manna may be given, or extract of colocynth with ex- tract of belladonna, or an occasional blue pill with soap and assafoetida. 8* 90 THE DISEASES OF PREGNANCY. Impacted fecal masses sometimes require removal by mechanical means. Diarrhcea___If it has been preceded by constipation, and the evacuations contain but little fecal matter, and consist chiefly of mucus, give a gentle laxative of castor oil and laudanum, or a dose of solution of citrate of magnesia to cleanse the bowel. After being sure that no accumulation in the bowel re- mains, and in cases where none originally existed, give vege- table astringents with opiates, ex. gr. the tinctures of kino, catechu, or krameria (dose of either 3j), with tinct. opii gtt. x, in ^ss °f mist, creta, three times a day. Or pills con- taining acetate of lead, opium, and ipecac may be prescribed, or syrup of rhubarb with bicarbonate of soda. In addition enjoin muscular rest and the recumbent pos- ture ; mustard, followed by warm cataplasms to the abdomen, and milk diet with well-cooked rice-flour, arrowroot, or corn- starch, etc. The occurrence of diarrhoea during pregnancy must not be neglected. Unless checked it may lead to abortion or pre- mature delivery. It should be treated with great care, especially if accompanied with tenesmus or other signs of enteritis. Diseases of Kidneys and Bladder. Albuminuria. —It occurs, varying in degree, in about twenty per cent, of pregnant women. It may exist when slight in degree, and especially if only during the later months, without any marked ill health or without being suspected unless the urine be tested ; but in other cases where the quantity of albumen is great, and begins to appear early in the pregnancy, the prognosis may be of the gravest character. Causes—Pathologists are not fully agreed upon its etiol- ogy. One of the factors in its production is undoubtedly pressure of the gravid womb impeding the return of blood from the kidneys though the renal veins ; hence its greater frequency of occurrence in primiparae whose unrelaxed ab- dominal walls tend to keep the womb more firmly pressed upon those vessels. Congestion of the kidneys produced by exposure to cold and sudden suppression of perspiration albuminuria. 91 during pregnancy may be the beginning of it, especially if the patient has previously suffered from renal disease. It is supposed to occur from an excess of albumen in the blood of the pregnant female, but this is not a settled point. Bright's disease of the kidneys is one of the dangers to be feared. It may or may not occur. Diagnosis---By finding, with the microscope, tube-casts in the urine: their presence indicates Bright's disease. Al- bumen is detected by boiling the urine, which coagulates the albumen, as does also nitric acid ; but heat will give a pre- cipitate resembling that of albumen if phosphates are present, this, however, is immediately re-dissolved by nitric acid. Should albumen appear early and in sufficient quantity to constitute a serious case, the following symptoms may be successively anticipated:— Anasarca, beginning usually in the lower limbs, but if the kidneys are seriously implicated dropsical puffiness of the face and hands may occur first; the dropsy may extend to the serous cavities. Albumen, tube-casts, and blood in the urine, which is high- colored and diminished in quantity. Nervous Symptoms: Headache, nausea, and vomiting, derangements of special senses, impaired sight, hearing, etc. These are due to the beginning of uremic poisoning. The kidneys fail in their function and urea begins to accumulate and poison the nerve-centres, this terminates in Uremic Convulsions (spasms, eclampsia) ; stupor, going on to complete coma, perhaps death. Premature Delivery may occur, or, if the case should reach full term, convulsions may be looked for during labor. After delivery the convulsions may cease and the patient recover ; or, after partial recovery, the patient may die later from chronic Bright's disease. Prognosis___Conditions rendering labor difficult; the abundant occurrence of tube-casts and extensive dropsy, especially of the face and hands early in pregnancy ; together with indications of uremia,—all augur unfavorably. The late appearance of symptoms, dropsy confined to the lower extremities, uremic symptoms not impending, and the probabilities of an easy labor augur less danger, especially if the albumen is small in quantity and tube-casts are wanting. 92 THE DISEASES OF PREGNANCY. Treatment___Purgatives, to produce watery stools and thus promote excretion from the bowels to relieve the dis- abled kidneys. Give pulv. jalap, co. 3SS (tne compound contains two-thirds cream of tartar (potass, bitarfrate), and one-third powdered jalap). Repeat if necessary, and keep up a free action of the bowels with salines given daily, espe- cially potass, bitart. ^ss-^j a day. Lessen congestion of the kidneys and promote their secre- tion by extensive dry cupping with tumbler glasses, or large cups, over the loins, followed by the application of sinapisms to the same part, and then hot poultices constantly applied. Diuretics: Preferably potass, bitart. with infusion of digi- talis, or the acetate of potass, with colchicum. Promote the secretion from the skin by the warm water or vapor bath, or the hot wet pack, and diaphoretic drinks or medicines, as spts. mindererus, or jaborandi. Beware of indigestible or solid food. A milk diet is best of any. The treatment must be modified according as the patient is anemic or plethoric. If anemic give iron—the tinct. fe. chlo. with tr. digitalis—or the tartrate of iron and potassa with cream of tartar in solution. If plethoric, wet cupping over kidneys or bloodletting by venesection carefully, and abstemious diet. Under the supposition that retained urea breaks up into carbonate of ammonia, benzoic acid has been given with a view to produce an innocuous benzoate of ammonia. It is of doubtful efficacy. Dose, five to ten grains, three or four times a day in solution. Should the symptoms grow worse in spite of treatment, and involvement of the nervous centres be indicated by dis- ordered senses, convulsions, tic., premature delivery, if it do not take place spontaneously (which is not unusual), may be induced by catheterism of the uterus, tents and dilators. (See Chapter XII.) v Convulsions occurring during labor—whether the latter be premature or otherwise—and whether spontaneous or in- duced, call for speedy delivery and the administration of chloral, morphia, bromide of potassium, anaesthetics, etc., as set down in Chapter XXXII. Forceps or version may be required. INCONTINENCE OF URINE. 93 Bladder—Irritability of the organ is indicated by fre- quent desire to micturate. It occurs as a sympathetic af- fection during the early months, causing distress and some- times disturbing rest at night. Treatment---Bland mucilaginous drinks (flaxseed tea, etc.), infusions of buchu, uva ursi, or triticum repens, combined (if the urine is over-acid) with potass, bicarb, or liq. potassae. Balsam copaiba and tinct. belladonnas internally may be tried. Anodynes, preferably in the form of suppositories of mor- phia or atropia. Irritation of the bladder may occur later from pressure of the gravid uterus. The symptom is exaggerated by uterine displacements, by cross positions of the foetus, and by con- genital hydrocephalus increasing the size of the child's head. There are frequent and painful acts of micturition. Inability to fully empty the bladder, or complete retention may occur. Treatment—Be sure in the first place that the bladder is completely emptied. If in doubt, use a male elastic catheter, and repeat it as often as may be necessary. Re- store the womb, if displaced. The knee-elbow position may enable the patient to empty the bladder. If the child is cross-ways in the womb, correct the mal-position by exter- nal manipulation. (See External Version in Cross Presen- tations, chap. xvii.). A wide bandage round the abdomen will sometimes afford relief by supporting the uterus, and pushing it back and away from the bladder. Be sure to keep the bowels free from fecal accumulation, so as to leave more room in the pelvis for the uterus and bladder. Incontinence of Urine__The urine dribbles away in elderly women who have had many children. Treatment: the abdominal belt, tinct. cantharidis gtt. iij-v in Jj of flaxseed tea, three times daily. Frequent ablutions and simple ointments are required to prevent or relieve excoria- tions of the skin. Small and frequent discharges of urine are often associated with over-distension of the bladder and paralysis of its walls. When this is suspected, examine for bladder tumor above pubes and use catheter. 94 THE DISEASES OF PREGNANCY. Affections of the Reproductive Organs. Pro- lapsus Uteri (falling of the womb) during Preg- nancy__It usually rights itself when the womb rises dur- ing the third or fourth months, but failing in this, the condition may become serious from the growing uterus getting jammed between the bony walls of the pelvis and pressing upon the bladder and rectum, or leading to abortion. Treatment___Rest in the recumbent posture, with the hips elevated on pillows, pushing up the uterus by gentle manipulation, and, if imperatively necessary to keep it there, pessaries. Continue treatment until uterus gets large enough to remain above the pelvic brim. Should impaction occur and obstruct discharge of rectum or bladder, the in- duction of abortion may become a necessary resort to save the woman's life. Retroversion of Uterus__The fundus of the organ falls over backwards, while the cervix is tilted upwards and forwards, towards or over the pubes. Symptoms___Pain in the back, numbness or pricking or unsteadiness in the lower limbs, and difficult or very painful defecation and micturition. The diagnosis is made on finding the fundal tumor in its malposition by a digital examination per vaginam, while the os and neck are tilted high up towards pubes. Prognosis.—Usually favorable from gradual spontaneous replacement as the womb increases in size, but serious or fatal consequences may arise from impaction of the growing organ (as in prolapsus) if it is not replaced during the earlier months. Treatment must not be delayed. Empty the bladder by a male elastic catheter. If this is impossible, aspirate the bladder. Empty the rectum. Place the woman in the knee-elbow position, and restore the organ by gentle digital pressure either by vagina or rectum, or both conjointly. Should manipulation fail, make gentle prolonged pressure by distending a soft rubber bag in the vagina, or a Barnes dilator in the rectum, and keep them there for hours. Should all means fail to get the fundus above the sacral promontory, abortion or premature delivery may be required to save the woman's life. PRURITUS VULVAE. 95 Anteversion of Uterus—Since the anterior pelvic wall is only one-third as deep as the posterior one, there is far less difficulty in the fundus uteri getting above the brim when it is displaced anteriorly (anteversion) than when re- troversion occurs. It occurs chiefly in deformed women, (pelvic deformity) or in cases of ventral hernia, or in those whose abdominal walls have become relaxed and pendulous from frequent child-bearing. Treatment—Rest on the back ; abdominal support to the flabby belly by a wide bandage ; and a catheter (male elastic always during pregnancy) if necessary to empty the bladder. Leucorrhosa, or " Whites."—It consists of an exces- sive discharge of mucus from the vaginal canal. It is lia- ble to irritate the vulva and produce itching and excoriation. Condylomata may exist, or granular papillary projections constituting granular vaginitis. Generally the disease is simply a hyper-secretion, due to congestion of the vaginal wall or cervix uteri. Treatment—Avoid the use of injections for fear of pro- ducing abortion. Frequent tepid emollient ablutions are indispensable for cleanliness, and to prevent excoriation, etc. Laxatives to correct constipation. If the discharge is sufficiently profuse to require moderating by astringents, use vaginal suppositories of tannin, alum, etc. Pruritus Vulvae__Intense itching of the vulva is of frequent occurrence during pregnancy. There is an irre- sistible desire to rub the parts, sometimes even during sleep, which may lead to excoriation, scabbing, ulceration, etc. Itching may extend over thighs, abdomen, and other parts of the body. Treatment.—Frequent tepid emollient ablutions. Dust the vulva afterwards with starch powder four parts, to pulv. camphor one part; or powdered zinci oxid. Other reme- dies are : a solution of corrosive sublimate gr. ij, to water 3j ; solution of soda? borat. 3J, to water one pint; infusion of tobacco 3SS- l° water one pint; application of essence of peppermint with a camel-hair brush. If ulcers exist, re- move scabs by warm poultices, then apply nitrate of silver gr. xx, to water 5J, to be followed by calomel ointment (3J of calomel to 5J of lard or simple ointment). 96 THE DISEASES OF PREGNANCY. Painful Mammary Glands—Breasts are the seat of pain of a neuralgic character, due to rapid development. In plethoric women, relief may be obtained by the derivative effect of saline laxatives. In anemic, sensitive, nervous women, give iron, quinine, wine, and good food. In either case, application of belladonna ointment, or the tincture sprinkled on a bread poultice, or anodyne liniments of olive oil, camphor, and laudanum, will afford relief. Palpitation of the Heart may occur either sympa- thetically during the early months, or later from encroach- ment of the enlarged uterus pushing up the diaphragm, and embarrassing the heart's action. Treatment__The sympathetic trouble is usually associ- ated with nervous debility due to anemia, and therefore re- quires iron, quinine, good diet, including raw onions, and a little wine. A plaster of belladonna over the cardiac region. Direct relief may be obtained temporarily, by assafoetida, hyoscyamus, and other antispasmodics. The opposite state of plethora may exist, when rest, laxa- tives, low diet, and, perhaps, bloodletting will be required. For the mechanical embarrassment of the later months, little can be done further than palliation by antispasmodics and attention to the general health and excretory functions, but the patient may be consoled with the assurance of relief when the womb sinks down prior to delivery. Temporary ease may be attained by belladonna plasters over the prae- cordium. Syncope, or Fainting—The attacks may recur several times a day. The pulse is feeble, pupils dilated, conscious- ness partly lost, and there may be hysterical phenomena. Treatment---Recumbency with the head low, the ap- plication of ammonia to the nostrils, and diffusible stimu- lants, valerian, etc., during the attacks. In the intervals, iron, food, and bitter tonics. Bromide of potassium gr. xx. three times a day. Vartcose Veins—The pressure of the uterus upon the large venous trunks causes distension and varicose dilatation of the venous branches below them. Hence, 'jedema and nervous diseases. varicose veins of the legs, hemorrhoids, dilatation, and rup- ture (thrombus) of the veins of the vagina, vulva, etc. Treatment—Rest in the recumbent position, support of the uterus by abdominal bandages, support of the veins of the leg by elastic stockings, or well applied roller bandages. Hemorrhoids require, in addition, laxatives to correct con- stipation, cool water enemas before stool, and the avoidance of all straining efforts. Cold ablutions to the fundament followed by astringent ointments, e. g., ung. galbae and ung. stramonii aa 3j. In thrombus of the vagina, small ones may be left to na- ture for absorption to take place. In larger ones, causing pressure on surrounding parts, or threatening rupture, the only treatment is free incision and careful removal of the contained clots, with precautions as to the recurrence of bleeding, cleanliness of the parts, etc. The prognosis in such cases is doubtful. Blood Diseases of Precnancy__The exact blood changes of pregnancy are still unsettled. Practically, it may be sufficient to bear in mind the two conditions of anemia and plethora, the treatment for both of which has already been repeatedly indicated. Cough and Dyspnoea__Occurring during the early months, as nervous or sympathetic troubles, they require anodyne and palliative remedies, counter-irritation, antispas- modics, etc. During the later months, when they are due to pressure of the uterus, the same remedies may be em- ployed, but with little assurance of success until relief is obtained by sinking of the womb before delivery. Nervous Diseases__Exaggerations of the mental and emotional phenomena already referred to as signs of pregnancy may occur. They lead us to apprehend insanity. The time of their most frequent occurrence is from the third to the seventh month. Treatment consists in the pi*omotion of sleep by bromides and chloral hydrate; laxatives; moderate exercise, cheer- ful society, and change of scene; together with attention to diet, and the proper digestion and assimilation of food. 9 98 abortion. Chorea during pregnancy occurs chiefly in those who have previously suffered from the disease. It is a serious com- plication, one-third of the cases being fatal, sometimes end- ing in insanity, premature delivery, and death. Treatment by arsenic, iron, the bromides, etc., as in other cases not associated with gestation. Induction of premature labor as last resort. Paralysis (hemiplegia, paraplegia, facial palsy, or paral- ysis of the organs of special sense) occasionally occurs. Determine by urinary analysis whether or not the symp- toms are due to urcemia. If they are, the question of in- ducing premature labor must be considered. There is no further treatment other than the usual remedies for paralysis unconnected with gestation. CHAPTER IX. ABORTION. Abortion is delivery of the foetus before it is viable, i. e. before the end of the twenty-eighth week. Between this time and full term, discharge of the ovum is called "prema- ture labor." No other division of the subject is necessary. Exceptionally the child is viable before the twenty-eighth week, even a month or two earlier. Such cases are rare. Frequency—About one out of every twelve pregnancies ends in abortion, and 90 per cent of child-bearing women abort once or more during their lives. Causes—The predisposing causes may refer to either mother, father, or child. Death of the child from any cause, either from disease of the placenta or membranes, or obstruction in the umbilical cord, or inherited syphilis, or the eruptive fevers. (It is known that the fcetus may be attacked with these last.) On the part of the mother, constitutional syphilis is a potent cause. The occurrence of acute inflammation of the thoracic prognosis. 99 or abdominal viscera; the exanthematous fevers ; plethora ; anemia; albuminuria; excessive vomiting; constipation; pla- centa praevia; diseases and displacements of the uterus; multiple pregnancy; chronic lead-poisoning; chronic ergot- ism from ergoted rye-bread ; the. precocious, or very late occurrence of pregnancy ; the abortion-habit. On the part of the father, precocity, senility, syphilis, de- bauchery, and debility may lead to it. Exciting Causes__Mechanical violence, as blows, falls, violent exertion, the concussion of railroad accidents, exces- sive venery, ssa-bathing, irritation of the mammae, tooth- pulling, etc.; or emotional violence, as excessive fear, joy, grief, anxiety, anger, etc. Many abortions no doubt occur from the wilful adminis- tration of drastic emmenagogue medicines, and from inten- tional disturbance of the ovum with instruments. Period of Occurrence__It occurs most frequently during the second and third months, though, quite possibly, many abortions during the first month are never recognized. Symptoms__Pain, intermittent in character and due to uterine contractions ; and hemorrhage, due to partial separa- tion of the ovum form the uterine wall. Chilliness, nervousness, anorexia, ennui, flighty pains in the back and abdomen may occur some days before "labor- pains" and bleeding, but they are not of great importance from their infrequency. Pain and bleeding having occurred, the diagnosis is ren- dered positive by vaginal examination revealing partial or complete dilatation of the os uteri, and presentation in it of the bag of waters, umbilical cord, or body of the foetus. The membranes may or may not be ruptured. Prognosis__Abortions often consume more time than full-term labors, owing to the long and narrow cervix uteri, and, as yet, imperfect development of the uterine muscles. The secundines are often retained hours and days after dis- charge of the foetus. With proper treatment abortion is seldom fatal; it is less dangerous than full-term delivery, as regards the chances for life, but is far more likely to leave chronic uterine disease, and great debility from hemorrhage. 100 abortion. Diagnosis of Abortion from Returning Menstru- ation___In menstruation bleeding generally relieves the pain ; not so in abortion. Menstruation occurs at the period ; abortion not necessarily so. The digital examination clears up doubt. In abortion thyre may be a history of violence or some other cause for the symptoms. The treatment of abortion will differ much according as we design to prevent, or, on the other hand, hasten delivery. If the hemorrhage is only slight in degree, and the pains feeble, if the os uteri is not much dilated, and the membranes are not broken, we strive to continue the pregnancy ; if opposite conditions prevail, we cannot do so, but must hasten delivery to put the woman in safety. Treatment to Prevent a Threatened Abortion when the Symptoms are Slight___Absolute rest in the recumbent posture, in a cool room with light bed clothing. Mental and emotional quiet. Cooling drinks, avoidance of all stimulants. Opium to arrest uterine contraction and check hemorrhage. Astringents—lead, alum, the mineral acids —may be added if the bleeding continue. Never use ergot or the tampon ; and the application of cold cloths to prevent hemorrhage is of doubtful utility : it rather augments4 uterine contraction. Remove any known cause of the symptoms. Treatment when the Abortion is Inevitable___In the majority of cases the delivery may be left to complete itself by the natural powers, unless the hemorrhage is excessive, when our main and sure reliance is upon the tampon, which (1) stops hemorrhage, (2) promotes uterine contraction, and (3) secures complete separation of the ovum from the uterus by causing blood to accumulate between the womb and foetal membranes. The tampon is a vaginal plug, consisting of a soft smooth sponge, or pledgets of cotton-wool smeared with glycerine, each attached to a string, and passed into the vagina (preferably through a speculum) until the canal is filled from the os uteri to the vulva. A T bandage may be necessary over the latter to prevent expulsion of the plug by the vagina. The bladder should have been previously emptied, for the tampon may interfere with micturition. A prepared sponge tent placed in the cervix uteri may precede TREATMENT. 101 the tampon and ass:st dilatation, if necessary. The plug must not remain in the vagina longer than twelve hours— better not more than six or eight. If the woman be very weak from hemorrhage, a second one should be in readiness before the old plug is removed. The bladder must again be emptied, by the catheter if required. It is not always necessary to repeat the tampon. The ovum may be found in the vagina, the os contracted, and' the bleeding stopped. Remove the foetus (with the mem- branes and placenta if they are entire), and no further pro- ceeding is necessary besides ablution of the parts. If the hemorrhage is not sufficient to require the tampon, ergot may be given, cold cloths may now be applied to the vulva and hypogastrium ; we may be able to expedite de- livery by careful manipulation, when the os is dilated and the ovum protruding through it. It is best not to break the membranes if they are still intact. It is very common for the foetus to be expelled leaving the placenta and membranes in utero. When this occurs the cord may be cut or broken, (no ligature is necessary), the foetus removed, and the case treated by tampon, ergot, cold, etc., just as before the fcetus was expelled. By passing a finger into the uterus we may be able to hook down the placenta, or placental forceps may be employed, but they probably do as much harm as good. The retained secun- dines may sometimes be promptly expelled by the action of a brisk purgative, the woman, if she is not too feeble, assum- ing a sitting posture during its operation. A mild emetic (ipecac.) acts in the same way. In order to be sure when everything has come away, all the discharges, from the very beginning, must be preserved for examination by the physi- cian. So long as any part of the secundines is retained, there is danger of hemorrhage, and of septicaemia from putre- faction of the retained placenta, but occasionally it will be retained for weeks or even months without any bad symp- toms. It is never safe to leave it. Should there be offen- sive discharges from the vagina (indicating decomposition), the vagina must be freely washed out two or three times a day with a weak solution of carbolic acid f'3ij to water Oj, as a preventive of septic infection, but when septicaemic symptoms, such as chills, fever, vomiting, etc., are present, the carbolized fluid, in small quantity (3j-ij)> must be care- 9* 102 EXTRA-UTERINE PREGNANCY. fully injected into the uterus, through a double canula, so as to insure its immediate return. If the os is closed, it should be dilated with tents before the intra-uterine injection. The after-treatment of abortion must be continued rest, as after a full-term labor. In women who have aborted once or more, and who are likely to establish in this way the " abortion habit," we should enjoin abstinence from coitus for a year or more; removal of all suspected causes of the accident; when pregnancy again occurs, insist on perfect rest in bed for a week or ten days, at times corresponding to the menstrual epochs. After conception, coitus must be forbidden during gestation. CHAPTER X. EXTRA-UTERINE PREGNANCY, ETC. EXTRA-UTERINE GESTATION (EXTRA-UTERINE FcETA- tion)__Development of the ovum outside the uterine cavity. Varieties—The ovum may lodge in the Fallopian tube (tubal pregnancy) ; or it may drop into the cavity of the peritoneum (abdominal pregnancy) ; or it may stay in the ovary after the Graafian vesicle has ruptured (ovarian preg- nancy) ; or it may develop in the substance of the uterine wall (interstitial pregnancy). There are a number of other rare subvarieties. Tubal pregnancy is the most common variety, but all forms of extra-uterine fcetation are rare. Causes---Spasm, paralysis, stricture, doubling of or pressure upon the tube, etc. etc., causing obstruction of its canal. It is rare before thirty years of age. Prognosis—All forms of extra-uterine pregnancy are extremely dangerous ; the tubal variety most fatal of any. Diagnosis—As the cases usually terminate (a few ex- ceptions have been recently reported) by rupture of the tube TUBAL PREGNANCY. 103 and death before the end of the fourth month, the condition is often unsuspected before symptoms of approaching rupture begin. The early rational signs of pregnancy exist, but the physi- cal or positive signs are absent. On examination, a tumor may be felt on one side, usually in the iliac region. There may be slight pain occasionally in the same. The womb is slightly enlarged ; but nothing actually wrong may be suspected till premonitory symptoms of approaching rupture begin. They are: severe colicky pains referred to the tumor, and the appearance of a bloody, shreddy discharge from the uterus. Symptoms of Rupture—Severe and sudden abdominal pain, with intense collapse, from internal hemorrhage. Swelling and doughiness of the abdomen from accumulating clotted blood. The results are : death from collapse; or, surviving longer, death from peritonitis ; or, recovering from this, the cyst, now formed of organized lymph, inflames and suppurates, the abscess discharging externally or into some neighboring cavity, together with fragments of the fcetus. Death from septicaemia or exhaustion may result. Finally, the re-encysted ovum may remain, without any inflamma- tion, become partially absorbed, leaving a calcareous, inor- ganic remnant (lithopasdion) which may give no further trouble during a long life. Treatment before Rupture of the Tube.—Kill the ovum to stop its further growth, by (1) aspiration of the liquor amnii ; or (2) by injecting morphia into the amniotic sac or body of the foetus; or (3) by electric shocks conveyed through it—one pole of a battery being passed into rectum till in apposition with tumor, the other on the abdomen. Treatment after Rupture___Rest; compression of ab- dominal aorta; application of ice over abdomen to lessen bleeding ; and opium to relieve pain and insure absolute rest. Under this treatment there is a bare chance the hem- orrhage may stop and the fcetus become re-encysted by a wall of organized inflammatory exudation, and so remain harmless, or be discharged later by abscess and bursting of the cyst, either externally or into some neighboring viscus. The only other alternative is laparotomy — opening the abdominal cavity by incision and removing entire cyst and 104 EXTRA-UTERINE PREGNANCY. tube, after ligating its pedicle, as in ovariotomy. The foetus is taken out and all effused blood sponged from the abdomi- nal cavity. The operation to be performed under Listerism. Removal of the cyst, fcetus, etc., through an incision made by cautery knife in the top of the vagina has been suggested. Uncertainty of diagnosis, and the dislike to operate upon women almost at the door of death, has been the great barrier to the performance of these operations. Ovarian and Interstitial Extra-uterine Gesta- tion___The symptoms, results, and treatment of these varieties are, in the main, not essentially different from those of tubal cases. Abdominal Extra-uterine Gestation__The ovum in these cases is in the cavity of the peritoneum ; its growth is not curtailed by any resisting muscular wall. The preg- nancy may therefore go to the full term. Diagnosis—Nothing special occurs during early part of pregnancy, except that the uterus does not enlarge corre- spondingly with the duration of gestation. Attacks of pain in the abdomen may occur, due to localized peritonitis. Later, the movements of the child may be more easily felt, and the sounds of the fcetal heart more distinctly heard than in a normal pregnancy. Small size of uterus precludes pos- sibility of its containing the fcetus. Treatment—Do nothing before full term ; then, however, either " primary laparotomy" may be performed, with a view to save the child, or, the child being dead, the case may be allowed to remain without interference, until smyptoms arise requiring " secondary laparotomy." Difference of opinion exists as to which course is best, but the balance of evidence is in favor of the secondary operation. Symptoms of labor (labor pains) come on at " term " as in an ordinary pregnancy. Soon afterwards the child dies. It and the amniotic fluid may shrink and be absorbed, leaving a "litho- paedion "—a most favorable result; or inflammation, abscess, and ulceration of the cyst-wall take place, with discharge of foetus, piecemeal, through fistulous openings into neighboring cavities. During these processes, female is liable to exhaus- tion from continued discharges, and to septicaemia. Hence, "secondary laparotomy" is proper course to pursue after HYDATIFORM PREGNANCY AND MOLES. 105 child is dead and symptoms leave no hope of absorption and formation of lithopaedion. Hydatiform Pregnancy and Moles. Hydatiform Pregnancy—The foetus dies early, dissolves and disappears, and then the villi of the chorion—the bulbous ends of their branches—become distended with fluid into little sacs or cysts of different sizes, which continue to increase in number till the uterus is filled. Technically the disease is cystic (or dropsical) degeneration of the chorial villi. The cysts hang by long, narrow pedicles like diminutive elastic pears, or dangle from each other, suggesting a resemblance to ser- pents' eggs. Viewed en masse they look like a bunch of grapes. Causes—It has been ascribed to constitutional syphilis ; morbid changes in the decidua; early death of the fcetus, etc., but the question is yet unsettled. It has been called hydatiform pregnancy from a crude resemblance to, and a former erroneous supposition that the cysts were identical with, true hydatids (entozoa, acephalo- cysts) such as occur in the liver and other organs (possibly in the uterus), but which have nothing to do with impreg- nation, or an ovum. Remnants, or repeated new developements of the growth, may appear months or even years after impregnation. In women separated from their husbands, unpleasant complica- tions might thus arise, and the case assume medico-legal im- portance. Diagnosis of true Hydatids from Hydatiform Pregnancy___ In true hydatids the cysts develop, some inside of others, and the echinococci heads and booklets may be seen with the microscope. This microscopic appearance is wanting in hy- datiform pregnancy, in which, also, we have seen the cysts hang by stalks and increase by a sort of budding process— not inside each other. Syniptoms of Hydatiform Pregnancy___The early signs of pregnancy follow impregnation as usual; but there are no positive or physical signs, for the child dies before the tenth week—often much sooner. Then follows extreme rapidity of uterine enlargement. At six months it is as large as a full-term pregnancy. The womb is unsymmetrical in shape ; it is doughy or boggy to the touch, and no fcetus 106 EXTRA-UTERINE PREGNANCY. can be felt in it.. Overdistension, between the fourth and sixth months, leads to contraction of the womb, accompanied with gushes of transparent watery fluid, from crushing and bursting of cysts. Hemorrhage—severe hemorrhage—may also occur. Diagnosis is confirmed by finding characteristic cysts in the discharges, or the mass may have been previously felt in the os uteri. Prognosis___Generally favorable. The chief danger is hemorrhage. Treatment___Empty the uterus and secure its contraction as soon as safely practicable. Give ergot. Open the os uteri, if necessary, with a Barnes's or other dilator, and with the fingers, or hand in the uterus, carefully extract the mass. Beware of rupturing the uterine wall : it may be very thin. While the os is dilating, a tampon may be necessary to check hemorrhage. Instead of using the hand, the mass may be broken up with male metal catheter and left to be expelled by uterine contraction, especially when os is undilated. Moles are masses of some sort, developed in and expelled from the uterus. If the growth results from impregnation it is called a " true" mole, if it occurs independent of im- pregnation it is a "false " mole. True moles. The hydatiform pregnancy just described is a true mole. Another form—the "fleshy mole "—occurs after early death of the fcetus, from a sort of developmental metamorphosis of the fcetal membranes, mingled with semi- organized blood clots, so as to form a more or less solid non- descript fleshy mass. Chorial villi may generally be discov- ered in it with the microscope. Portions of the foetal membranes, or of the placenta, may be left after abortion, and develop into true moles. False moles. An intra-uterine polypus, or fibroid tumor, or retained coagula of menstrual blood, or a desquamative cast of mucous membrane from the uterine cavity (mem- branous dysmenorrhcea), may be expelled from the womb, with pains and bleeding, resembling those of abortion or labor. Examination of the mass, its history, and absence of chorial villi, will be sufficient to indicate a correct diag- CAUSE OF LABOR AT FULL TERM. 1<>7 nosis and shield the female, if unmarried, from any unde- served suspicions. A desquamative cast from the vagina may occasionally occur. These are. so-called, false moles ; they seldom attain any considerable size. Treatment consists in securing their com- plete expulsion, by ergot and manipulation, with use of tam- pon to control hemorrhage should it be excessive. CHAPTER XI. LABOR. Labor is the act of delivery or childbirth—parturition. The period after impregnation at which it takes place is ten lunar months or thereabouts (280 days). Children may be born alive earlier, as already explained, and, exceptionally, the pregnancy may last as long as eleven and even twelve months. The possibility of these latter cases becomes im- portant considered in a medico-legal point of view. For predicting the date of delivery in a given case there are several methods. The best is that of Naegele, to wit: (1), Ascertain the day on which the last menstruation ceased; (2), count back three calendar months; (3), add seven days. For example: Menstruation ceased January 1st, count back three months, i. e., to October 1st, add seven days, which brings us to October 8th,—the probable day of delivery. If, during a leap year, the pregnancy includes February, six days instead of seven should be added, after counting back the three months. Cause of Labor at Full Term.—A number of fac- tors combine to provoke uterine contraction, chief among which may be mentioned gradual distension of the uterus near the end of pregnancy (not before), from the organ having reached the physiological limit of its growth, while the bulk of its contents still continues to increase. Increased muscular irritability of the uterine walls, and 108 LABOR. exaggerated reflex excitability of the spinal cord probably occur towards the end of pregnancy, so that the uterus is excited to contract more readily; while the stimuli to con- traction, viz.: distension, motions of the child, stretching of the uterine ligaments, pressure of the womb on contiguous parts from its own weight, and compression of it by sur- rounding peritoneal and muscular layers, are all exaggerated. When the presenting part of the fcetus distends and presses upon the neck of the uterus, contractions are excited, (just as the bladder and rectum contract when their contents press upon and distend their respective necks), but, in labor, this is after the beginning, hence, irritation of the sphincter (os uteri) cannot be considered the primum mobile of uterine contraction. Forces by avhich the Child is Expelled.—The main force is that of uterine contraction, which derives its power chiefly by reflex motor influence from the spinal cord; the secondary or "accessory" force, is contraction of the abdominal muscles and diaphragm. Uterine contraction is entirely involuntary, that of the abdominal muscles may be assisted by voluntary effort in the act of straining. Labor Pains__A labor pain is a contraction of the uterus lasting for a little time, and then followed by an in- terval of relaxation or rest. In the beginning of labor the pains are short in duration (a minute or less); feeble in degree; the intervals are long (half an hour or more), and there is no contraction of the abdominal muscles, or straining effort. As labor progresses, in the natural order of things, the pains gradually increase in duration, strength, and the amount of straining effort, and the intervals between them become shorter, up to the moment of delivery. The early pains are called "cutting" or "grinding" pains, from the accompanying sensations experienced by the woman ; and the later ones " bearing-down" pains, from the distressing tenesmus or straining by which they are attended. In cases where there is no mal-proportion between the size of the head and pelvis, and other things are perfectly normal, there are still two great sphinctorial gateways which offer a certain amount of obstruction to the passage of the child, and the resistance of which must be overcome before delivery PREMONITORY SYMPTOMS OF LABOR. 109 can take place; these are: (first), the mouth of the uterus; (second), the mouth of the vagina. The "Bag of Waters.".—A natural arrangement is provided for the dilatation and opening of the resisting os uteri, by the gradual forcing into, and protrusion through it, of the most depending part of the amniotic sac, or "bag of waters." During labor pains, the contracting circular layers of uterine muscles compress the "bag" on all sides, circumferentially, thus tending to make it bulge out at the only point of escape (the os uteri); while the longitudinal muscular layers in the uterine wall shorten the womb, and thus tend to pull back, or retract, the ring of the os from off the bulging end of the protruding bag. The bag, being soft, smooth, and elastic, can more completely fit and more easily dilate the os uteri, than any part of the fcetus, hence the importance of not breaking it during the early part of the labor. The weight of the contained liquor amnii probably assists dilatation, the female not being confined to a recum- bent posture. The bag of waters also protects the body of fcetus, placenta, and umbilical cord from the direct pressure of the uterine wall; and it allows the womb to maintain its symmetrical shape, thus lessening interference with the uterine and pla- cental circulation. Labor is divided into Three Stages__The first stage begins with the commencement of labor, and ends when the os uteri is completely dilated. The second stage immediately follows the first, and ends when the child is born. The third includes the time occupied by the separation and expulsion of the placenta; it ends with safe contraction of the now empty uterus. Premonitory Symptoms of Labor__Sinking of the uterus, with consequent relief to cough, dyspnoea, palpitation, etc., as previously explained (pp. 96, 97). Increased frequency of evacuations from bowels and bladder from pressure on them of the now sunken uterus. Commencing and progres- sive obliteration of the neck of the uterus. Occurrence of a viscid mucous discharge from the vagina (originating, how- 10 110 LABOR. ever, chiefly in the cervix uteri) which may be tinged with blood ; it is called "the show." This last lubricates the soft parts and prepares them for dilatation. Intermittent pain in the womb, due to feeble contractions, may occur a few clays before the actual commencement of labor—sometimes weeks before. Sioxs and Symptoms of Actual Labor.—The char- acteristic signs are : 1. Labor pains; 2. Commencing dila- tation of the os uteri ; 3. Presence, or increase if previously existing, of muco-sanguineous discharge—the " show ;" 4. Commencing descent into, or protrusion through the os uteri, of the bag of waters ; 5. Rupture of the bag and dis- charge of liquor amnii. Phenomena of the First Stage—Feebleness and infrequency of the first " cutting" pains. Suffering during them is referred chiefly to the back. The woman walks about, if not prohibited from doing so ; is restless, despond- ent, perhaps slightly irritable from discontent at progress being slow. As dilatation of the os uteri progresses, the pains become " bearing-down" in character, and the pain in the back in- creases in severity. Nausea and vomiting occur during further dilatation, and probably assist it by producing relax- ation. When dilatation is near completion, slight " shud- ders" or even severe rigors occur, but without any fever. Full dilatation of the os uteri is usually announced by rup- ture of the bag of waters during a pain and an audible gush of liquor amnii.1 On vaginal examination we find simply progressive dilatation of the os uteri and protrusion of the bag of waters. The presenting part of the child may be felt through the unbroken sac. The duration of the first stage varies much in different cases ; it is nearly always much longer than the other two stages combined. It is, indeed, a common observation that a longer time is required for the os uteri to dilate as large as a silver dollar than for all sub- sequent parts of the labor together. The first stage is usually longer in primiparous women, and still more so in primipara? 1 By some authors, rupture of the bag defines the end of the first stage of labor ; it may, however, precede dilatation. PHENOMENA OF THE THIRD STAGE. Ill over thirty years of age. An os uteri that is soft, thick, and elastic, dilates more readily than a hard, thin, rigid one. Premature rupture of the bag of waters greatly impedes dilatation. Phenomena of the Second Stage___Tremendous increase in the frequency, strength, duration, and expulsive or bearing-down character of the pains. Nevertheless they are more contentedly borne, from (supposed) consciousness of progress on the part of the female. The head of the child may now be felt descending into and beginning to protrude through the os uteri. It eventually slips through the os into the vagina, accompanied with renewed flow of some remaining liquor amnii. There may be a momentary pause in the suffering, and the woman may exclaim, " Something is come !" The head now pressing upon sensitive nerves in the vagina, elicits still more reflex motor power from the spinal cord, and the pains are still longer, stronger, more frequent, and expulsive. The corrugated scalp of the child, swollen and (edematous (constituting the caput succedaneum), suc- cessively approaches, touches, and begins to distend the vulva and perineum. The anus is dilated and everted, fecal matter is forced out, the perineum is stretched more and more until its anterior border is almost as thin as paper, and at last, in a climax of suffering approaching frenzy, the equator of the head slips through the second sphinctorial gateway (the os vagina?), and the head is born. A moment or minute of rest may follow, and then, with one or two more pains, the body of the child is expelled, and the second stage of labor is over. The duration of the second stage largely depends upon the dilatability of the perineum. In a natural case, other things being equal, a soft, thick, elastic, perineum, with abundant mucous discharge, in a young and multiparous woman, will dilate sooner than when opposite conditions prevail. Phenomena of the Third Stage__By the time the child is fully expelled the placenta is separated from the uterine wall and lying loose in the now contracted uterine cavity. The womb may be felt as a hard, irregularly-glob- ular ball above the pubis. There may be an interval of one- 112 LABOR. quarter or one-half of an hour's rest from pains, if the case is left entirely alone. Then, sooner or later, gentle pains again come on, the placenta is doubled vertically, the fcetal surface of one-half in apposition with that of the other, and the organ protruded endways into the vagina, from whence it is, by other slight pains, finally expelled, together with some blood, remains of liquor amnii, membranes, etc. The womb now contracts into a distinctly globular, hard mass, no bigger than a cricket ball, thus effectually closing the uterine bloodvessels and preventing hemorrhage, which last is fur- ther stopped by coagulation of blood in the mouths of the open blood-channels. Thus ends the third stage of labor. The average duration of labor in natural cases is about ten hours. It may be over in one or two hours, or last twenty-four or longer without any bad consequences. Management of Labor. Preparatory Treatment. —In anticipation of approaching labor precautions against constipation, by mild laxatives (castor oil, manna, rhubarb), may be necessary to prevent fecal accumulation in lower bowel. Moderate exercise, as far as practicable in the open air, and cheerful social surroundings, to mitigate despon- dency. Physical and mental excitement must be avoided. Ascertain if urine is voided freely, if not use male elastic catheter. Preparation for Emergencies__On being called to labor case, the physician should attend without delay, and take with him always the following articles :— 1. A pair of obstetric forceps. 2. Fluid extract of ergot, t^j. 3. Hypodermic syringe. 4. Magendie's solution of morphia, f3j. 5. Liq. ferri persulphatis, fgss. 6. Needles, needle-holder, and sutures. 7. Male elastic catheter. 8. Davidson's syringe. 9. Sulphuric ether Oss. This last, being bulky, may be omitted, if it can be obtained within easy distance of the patient. Physicians do not generally carry all these things, and EXAMINATION OF THE PATIENT. 113 probably never will until compelled so to do, as they should be, by law. Most of the articles may be seldom wanted, but emergencies known to be probable should be anticipated. Examination of the Patient__First. Verbal exami- nation, in as gentle and pleasant a manner as possible, into the child-bearing history of the patient, as to number (if any) of previous labors ; their character, duration, and com- plications (especially as to flooding after delivery). Symp- toms during present pregnancy, if not already ascertained. Has it reached full term? Present symptoms of labor? Pains—their frequency, severity, character, and duration ? Character of the flow ? Has the bag of waters broken ? Second. Abdominal examination, to ascertain, by palpa- tion, the size and shape of gravid uterus. In cross pre- sentation, the shape of the abdomen may lead us to antici- pate it and enjoin additional care in making examination per vaginam. Multiple pregnancies, coexisting tumors, amniotic dropsy, etc., may be thus discovered or suspected, in the same manner. Third. Vaginal examination. To the young practitioner who may experience some embarrassment with his first vagi- nal examination, the following suggestions may be of service. In labor cases it is not necessary to obtain verbal consent of the patient before instituting the examination. Proceed (the woman being in bed), without hesitation as if consent had already been obtained. Having been sent for to attend her is a sufficient guarantee of this. If anything is to be said on the subject, some such remark as, " Well, we'll see how you are getting on,"—suiting the action to the word— will be amply sufficient; or a simple inquiry as to the con- venience of soap, water, and towel may be enough to intro- duce the subject and indicate one's purpose. The less said the better. Proceed, without hesitation, just as in feeling the pulse. Should the woman cry, demur, and declare she cannot submit to the examination, proceed just the same, meanwhile addressing to her any kind word of encourage- ment that may serve to lessen fear or embarrassment. Noth- ing but physical resistance on the part of the female should induce the physician to give up the examination. This will seldom occur; when it does there is nothing to do but with- 10* 114 LABOR. draw from the case, or the announcement of this intention will generally remedy the difficulty. Should the patient be dressed and sitting up, she must be requested to go to her room and lie down in order that the examination may be made. Instruct the nurse to place her near the edge of the right side of the bed, that the right hand may be conveniently used. The physician to be notified when she is ready. Position of the Woman.—On the back, with the knees flexed, is the obstetric position most common in the United States. Some practitioners prefer the English posi- tion, the woman lying on the left side, near the right edge of the bed, with her knees drawn up. Itroduction of the Finger.—Anoint the right index finger, with lard, oil, or vaseline. Fold it in towards the palm arid shield it with the thumb and next finger from { greasing the bed clothing (which must be previously loosened or untucked), while reaching the vulva. Pass the hand un- der—never over—the thigh, the knees having been previ- ously flexed ; separate the labia, and introduce finger rather towards posterior than anterior commissure, with care to avoid inverting any hair. The index finger will reach higher in the vagina if the remaining fingers are (not doubled into the palm, but) stretched out over the perineum so that the posterior commissure fits into the deepest part of the space between the index and middle fingers. The perineum may be thus pushed in, or lifted somewhat upwards and in- wards, when there is any difficulty in reaching the os uteri. Purposes of Vaginal Examination__By this exam- ination we learn— 1. The condition of the vagina and vaginal orifice as re- gards their patency and freedom from obstruction to the pas- sage of the child ; also their temperature, sensibility (freedom from tenderness), and moisture. 2. Corroboration of the existence of pregnancy if not previously ascertained by physical proof. 3. Condition of the os uteri—its degree of dilatation, thickness, consistency, and elasticity. ( 4. If labor has actually begun. PURPOSES OF VAGINAL EXAMINATION. 115 5. To wdiat stage it has progressed. 6. AVhether the bag of waters has ruptured. '7. What the presentation1 is. 8. The condition of the pelvis, whether normal or de- formed. 9. The state of bladder and rectum as to distension with their respective contents. AVhen accustomed, by practice, to the examination of nor- mal vaginas, pelves, etc., the existence of any abnormality is readily appreciated by the finger without any particular attention being given to each of the details just enumerated. In commencing practice, much more care is necessary to avoid overlooking existing departures from the natural state. In learning the degree to which the os uteri is dilated, it is the size of the circular rim (or lips) of the external os that we wish to ascertain. Without care the finger may be passed through a small os uteri and swept round a consider- able surface of the presenting part or amniotic sac, thus conveying an impression that the os is dilated when it is not. Finding a small, hard, easily movable uterus, per vaginam, at once negatives the existence of advanced preg- nancy, unless it should happen to be an extra-uterine case. A pregnant woman may imagine herself in labor when she is not, owing to the occurrence of "false pains." These, on vaginal examination, are found to be ?««accompanied with hardening and contraction of the os and cervix uteri at the beginning of a pain. A " true " labor pain does begin with contraction and hardening of the cervix—the contraction begins below and goes up. False pains further differ from true ones, in being irregular in their recurrence and not progressive in strength, duration, and frequency. False pains produce uneasiness in the fundus, true ones in the lumbar and sacral regions. A false pain is a transient spasmodic contraction of fundus only, and is not attended with greater prominence of bag of waters, as is the case with true pains. False pains are generally produced by some source of reflex irritation in the intestinal canal, and are usually relieved by a laxative, an opiate being given after its 1 The term "presentation" has not yet been defined. It means that part of the child which " presents " at the os uteri or supe- rior strait. 116 LABOR. action. The diagnosis of a head presentation may be made out even before the os is dilated. The hard, smooth, globe of the head may be recognized through the wall of the uterine cervix. There is nothing else like it. Generally the os will admit a finger, when the cranium, if not too high up, may be readily felt, covered by the membranes. It is not always easy to ascertain whether the membranes have ruptured. Statements of woman or nurse are not reliable. If there is a layer of liquor amnii between the head and membranes, the space and fluid may be readily recognized by gentle pressure with finger between the pains. Not so when the membranes closely embrace the head. Then feel- ing the child's hair, and corrugation of the scalp during a pain, show the bag has broken. The membranes, on the contrary, become smooth and tense during a pain, possibly wrinkled a little in the intervals. Opinion as to Time of Delivery__After one exami- nation only, no opinion as to the duration of labor can be confidently formed, certainly none should be expressed. Having felt the head, we may say, "everything is right," and encourage the female not to despond. After a second examination in twenty or thirty minutes, we may form, but should not express, an approximate idea as to time of delivery, by degree (if any) of progressive dilatation that may have taken place. Preparation of the Woman's Bed__Let it be any- thing rather than a feather bed—a firm mattress is best. Place it so as to be approachable on both sides. Cover it with a sheet. Place upon this, at a point where the woman's hips will rest, a piece of rubber (or other water-proof) cloth, four feet square. Upon this cloth lay an old blanket, doubled three or four times, until it is somewhat less in size than the rubber. Cover all over with a second sheet, the top border of which must be " turned down" a foot or two below the pillow. Upon this second sheet the woman lies. Pillows, and a third sheet, with quilt, etc., for covering, may be put on as usual. When labor is over, the rubber cloth, with its soddened blanket and soiled sheet (No. 2), may be easily dragged off NUMBER OF ATTENDANTS. 117 at the foot of the bed, leaving the patient resting upon the dry sheet first placed over the mattress. Arrangement of the Night-Dress__Its skirt should be rolled up to the level of the armpits or a little lower, so as lo be out of the way of vaginal discharges, while a thin petticoat, or light flannel skirt, covers the parts below the waist. When labor is over, the soiled skirt may be readily removed over the feet, without lifting the patient, and the dry night-gown then pulled down from above. Is it Necessary to Keep the Patient in Bed dur- ing the First Stage?—No. Let her sit, walk, or change her position as she desires, until the bag of waters is about to break, when recumbency is desirable to prevent washing down of the umbilical cord by the gush of liquor amnii, and for other reasons. Rupture of the Bag ok Waters__Just before rupture the female should be told what is going to happen, to prevent alarm, especially if she is a primipara, and an extra cloth or piece of blanket may be placed under her to soak up the bulk of the flow. Just after rupture, a vaginal examination should be made to ascertain more surely the presentation, and that no change has taken place in it, and the sutures and fontanelles may now be felt, and the " position"1 of the head made out. The extra cloth may be removed at once. Number of Attendants__It is not desirable for the physician to remain in the lying-in room during the first stage of labor. After having seen that every preparation has been made, and having expressed a willingness to be called at any time the woman may desire, let him retire to some other apartment. One nurse is necessary, and an additional attendant or relative not objectionable, but no others. The husband may be present or not, as the wife prefers. 1 "Position," in obstetrics, means the positional relation exist- ing between a given point on the presenting part, and certain fixed points on the pelvis. There are several "positions" to each "presentation," as will be explained hereafter. 118 LABOR. Precautions during Early Stage—If the rectum is loaded, administer an enema of soap and water to empty it. See that the bladder empties itself. If not, use a catheter. Protect the female from a glare of light, whether by day or night. Keep the temperature of the room at 65° or '< 0° F., if practicable. Instruct the patient not to strain or bear down during the first stage : it does no good, and tires her. Pinching of the Anterior Lip of the Os Uteri.— As the head passes out of the uterus into the vagina, the lower margin of the os uteri slips up out of reach of the fin- ger, but sometimes the anterior lip of the os gets pinched between the child's head and pubic bones so that it cannot slip up. It may then become greatly swollen, congested, and oedematous. Treatment: push it up with the ends of two fingers between the pains and hold it there till the next pain forces the head below it.1 The Perineum may require attention to prevent rup- ture. There is no fear of laceration as long as the anterior border of it maintains any considerable thickness and is not fully on the stretch during the pains. Hence, no "support" is necessary, and nothing is required but to watch the pro- gress of the head (now easily touched inside the vulva), and ascertain when the perineum does become thin and tightly drawn out over the advancing head, and when there is dan- ger of laceration, especially if the labor progresses rapidly Treatment: ask the woman not to bear down any more than she can help; impede the too rapid progress of the head by pressing it with the finger ; relax the perineum by hooking a finger in the anus and pulling it towards the vagina (Goodell); or, by placing the palm of the hand over the anus, so that the distended globe of the perineum rests between the out- stretched thumb and fingers, then, during the pains, gently 1 The author considers it probable that this accident is produced, in part, by a too rigid adherence to the horizontal posture during labor, which tilts the fundus uteri towards the spine, and the os forwards towards the pubes ; whereas, if a kneeling, sitting, or squatting posture could be adopted, the fundus would be thrown forwards, and the os directed more centrally and in a line with the pelvic axis. This, however, requires proof. MANAGEMENT OF THE NAVEL-STRING. 119 lift or push the perineal margin upwards and forwards towards the pubes (Playfair). Birth of the Head—When the head is expelled, feel with the finger if the. umbilical cord encircle the child's neck. If so, draw down the cord from whichever direction it will most freely come, and pass the loop of it thus formed over the head. See that nothing impedes the further free motion of the head. Keep one hand on the womb, and, by gentle pressure follow down its decreasing size, so as to assist its contraction and prevent hemorrhage. Support the head in the other hand, and, as another pain or two expels the shoulders and body, gently lift it in a direction continuous with the axis of the pelvic curve, i. e., slightly upwards. No traction is necessary generally; and though the child's face begin to get bluish, there is no necessity for haste, nor fear of suffocation, even though delayed several minutes, which it larely will be, before complete expulsion. After expulsion of the child, cleanse its nostrils and mouth from mucus, etc., and see that it breathes. If it does not, slap the buttocks (not roughly), rub the spine, dash a little cold water in the face or on the chest, which will generally suffice in an ordinary case. When respiration is established, let the infant rest on the bed between the thighs of the mother, pre- ferably on its right side or back, avoiding contact with dis- charges, while the navel-string is attended to. No haste is necessary in tying and cutting the cord; unless relaxation of the uterus, flooding, or some other condition of the mother, requires immediate attention from the physician. Management of the Navel-String__Ligatures— previously prepared by taking three or four feet of strong undyed thread, doubling and redoubling it, twisting it into a string and tying a knot at each end—should be in readiness. Cut the cord with scissors, one and one-half inches from the umbilicus. Pinch the stump of the cord near its root with the thumb and finger of one hand, and with those of the other squeeze out of its distal extremity, by a sort of milking process (" stripping"), any excess of Wharton's gelatin, and tie it near the end tightly, but not tight enough to wound the bloodvessels. If the end bleeds, put on another ligature just above the first one. There is no necessity for 120 LABOR. putting a ligature upon the placental end of the funis, unless twins are suspected, when it should be done. Ascertain the sex of the infant; examine it for deformi- ties or malformations ; give it to the nurse, who holds a warm flannel or blanket for its reception ; and caution her to let no strong light glare in its face, and to get no soap in its eyes. Delivery of the Placenta.—The child having been disposed of, place a hand upon the fundus uteri. If it be found symmetrical in shape, and as small in size as a cricket ball, the placenta is probably resting loose in the vagina. If it be larger than this, and not so symmetrically globular in shape, the placenta is most likely still in the womb, or half in and half out. In this latter case manipulate the fundus and make pressure upon it to excite contraction, meanwhile asking the woman to bear down when she feels the pain begin. Should there be any bleeding, the fundus may be grasped firmly by the hand, and the placenta liter- ally squeezed out of the uterus into the vagina, after the manner of Crede. It is well always to give a teaspoonful of fid. ext. of ergot immediately after the child is born or a few (15) minutes before, when we are certain the child will be born so soon—to insure contraction of the womb and expulsion of the placenta. When the placenta has passed entirely through the os uteri into the vagina, it is easily ex- tracted by hooking into it one or two fingers and making traction. When it is only half way through the os, the index and middle fingers are passed up to it, following the cord for a guide, and the organ being grasped between the finger ends, it is made to bulge completely through the os by directing traction backward towards the sacrum, the other hand compressing the fundus, and the woman being told to bear down. Never, under any circumstances, make traction on the cord. It tends to pull the placenta flatwajrs (like a button in a button-hole) thus obstructing its egress, and might, if the placenta were still adherent, invert the womb. As soon as the organ has passed the vulvar orifice, hold it there, close up, and with both hands twist it round and round, always in one direction, and the membranes will thus be twisted into a sort of rope, which gradually gets longer and narrower until terminating in a mere string which finally slips from ATTENTIONS TO NEW-BORN CHILD. 121 the vagina, and delivery is complete. If this twisting de- vice be not adopted, a part of the membranes is likely to remain, and becoming entangled with clots of blood, cause after-pains, and come away, foetid, days afterwards, not with- out alarm to the patient. After delivery the placenta should be inspected to see that no part has been torn off and left behind, and then deposited in the vessel held by the nurse for its reception. Once more feeling the fundus uteri to re-assure himself that the womb is well contracted, the physician may leave the room while the nurse removes the soddened blankets, etc., and cleanses the female, getting her ready for the "bin- der," which is then to be applied by the physician himself. Before it is put on, the perineum should be examined for laceration (by ocular inspection if any doubt exist), and if any be found, one or two silver sutures should be put in to draw the raw surfaces together ; they may be removed in a week (see chapter xxvi.). The Binder is an abdominal bandage designed to sup- port the stretched walls of the abdomen, and compress the uterus so as to prevent its relaxation and consequent hemor- rhage. It gives the female comfort, and prevents syncope. It scarcely improves her figure as was once supposed. It may be made of strong unbleached cotton or jean, and must be wide enough to reach from below the projecting tro- chanters (otherwise it will slip up) nearly to the ensiform cartilage ; and long enough to go once around the body and overlap enough for fastening with strong " safety-pins." Let there be no creases under the back. Pin it, from above downwards, where the ends meet in front of the abdomen, as tight as may be comfortable. A warm napkin is then placed, by the nurse, under the perineum and vulva to receive the discharges, and the woman let alone to rest. Attentions to New-born Child—The nurse anoints it with olive oil, and then washes it with mild soap and water, to remove the vernix caseosa—an accumulation of whitish sebaceous matter—from the skin, especially plentiful about folds and creases. It is most abundant in over-long pregnancies. 11 122 MOTHER AND CHILD AFTER DELIVERY. Dressing the Stump of the Cord—It is an old cus- tom, still prevailing, to draw the stump of the funis through a hole made in the centre of a bit of greased rag, then fold the borders of the rag over, and after laying it upon the ab- domen with the end downwards, place one or two belly-bands round the child to keep it in place. This old-fashioned custom is not by any means a good one. It is inconvenient, as well as uncomfortable and inju- rious to the child. If there be no defective developement of the abdominal walls, the infant needs no artificial support by belly-bands, and the cord is better left without any dressing at all except a little raw cotton (borated, or mildly carbol- ized) to absorb its moisture and prevent sticking to the cloth- ing. The stump falls off in about five days. CHAPTER XII. management of mother and child after delivery. The condition of being in " child-bed," whether during or shortly after parturition, is known as the " Puerperal State." (From "puer," a child, and "parere," to bring forth.) Hence, certain diseases following labor are called "puerperal" fever, "puerperal" peritonitis, etc. These more serious puerperal affections—not of frequent occurrence—will be reserved for a future chapter. At present, only the more trivial and common accompani- ments of lying-in will be considered. The Lochia—Lochial Discharge__It is a discharge from the uterus following labor, consisting during the first two or three days of blood, mixed with mucus and remnants of decidua. The red (blood) color gradually changes to a yellowish or pale green tint, and the flow is thinner and less in quantity. It continues to diminish in quantity, consis- tency, and color, becoming at last serous or watery, ceasing altogether in two or three weeks, varying in different cases. SUCKLTNG THE CHILD. 123 Treatment—Generally none further than the application of napkins (by the nurse) for its reception, and cleanliness. Should it be prematurely suppressed, as may occur from cold, mental emotion, etc., warm poultices may be applied to the hypogastrium and vulva, and a warm foot-bath given, to promote its return. If these be insufficient, and there are headache and other symptoms resembling suppressed men- struation, give gentle saline laxative, and a diaphoretic (liq. ammon. acetat. ^ss every two hours). The lochial discharge often has a disagreeable odor, but this, unless excessive, or distinctly putrescent indicating re- tention of decomposing blood-clots, requires no treatment. If it is putrescent, use tepid antiseptic vaginal injections twice daily. After-Pains___These are painful contractions of the uterus following delivery, for three or four days. Often caused by retained blood-clots or membranes, owing to uterus having been imperfectly contracted after expulsion of placenta. Seldom occur in primiparaa. Treatment___Digital removal of clot if it can be felt lodged in the os uteri. Ergot to secure firm uterine contraction and expulsion of any retained secundines, and anodynes to re- lieve pain. A laxative enema, the woman sitting up during its action (there being no contra-indication to this proceed- ing, from previous hemorrhage or weakness) will often empty the uterus and secure its firm contraction, relieving after- pains. Subsequently a morphia suppository should be given, if required. Relief often follows warm poultices (preferably of hops) to the hypogastrium. After-pains are sometimes due to neuralgia of the womb. The organ is tender to the touch, but there is no general tenderness of abdomen, and no fever. Treatment : quiniaa sulph. gr. x-xv. They also occur from reflex irritation every time the child is put to the breast. Time and patience will relieve this. To lessen suffering give potass, bromide gr. xx; also, anodyne liniments to breasts. Suckling the Child.—The infant may be put to the breast as soon as it is washed, dressed, and ready for the mother, provided she is not over-tired. If she is, let her 124 MOTHER AND CHILD AFTER DELIVERY. rest for an hour or two. The child may nurse about every four hours, during the first day or two, before the flow of milk begins. After then, more frequently, every two hours, except from IIP. M. to 5 A. M. when the mother should be allowed continuous sleep. The flow of milk is not usually established until the sec- ond or third day after delivery. During these first days there is, however, a little imperfectly formed yellowish milk, known as the "colostrum," which is enough for the infant without the addition of any artificial food, and acts upon it as a laxative to remove the " meconium," or native contents of the intestinal canal, consisting of unabsorbed bile, mucus, etc. Laxatives for the Infant—If the child's bowels fail to move spontaneously, which is rare, a little " pinch " of brown sugar dissolved in a teaspoonful of water may be given ; or half a teaspoonful of olive oil. Before giving any laxative it must be known that the child is not suffering from imperforate anus. If the mother is constipated, laxatives given to her will re-appear in the milk, and operate on the child. The Infant's Urine.—If upon inquiry the child is reported not to have passed urine during the first day after delivery, examine the urethra and meatus for congenital de- formity ; feel, above the pubes, whether its bladder is dis- tended, and ascertain that the urine has not been voided in the bath unawares. If the bladder is full, a sprinkle of cool water on the hypogastrium, or a teaspoonful internally, or a warm bath, may answer. A very small elastic catheter may, very rarely, be required. The Mother's Bowels—Laxatives during the first two or three days after labor are not necessary, if the bowels were freely open before delivery. Otherwise an enema of castor oil with soap and water should be administered, or a dose of rhubarb (pil. rhei comp. no. ij-iij). The Mother's Urine—The urine may be wholly or partially retained from swelling of the urethra, or want of contraction and loss of sensibility in the bladder. Relieve SORE NIPPLES. 125 by the catheter three times a day until the parts resume their normal function. Ergot internally stimulates cystic contraction. Hot applications (sponges) to the pubes, or laving the vulva with warm water, may afford relief. The Mother's Diet__The " toast-and-tea " starvation system after delivery is injurious and obsolete. Give any easily digestible food—soft-boiled eggs, milk, meat-soups, bread, potatoes—but in moderate quantity, avoiding solid meats until after the milk secretion has become established. Milk Fever is a transient, slight, febrile excitement, preceded by chilliness, attending the establishment of the milk secretion. It scarcely requires treatment, and is far less frequent and less severe now than when the toast-and- tea diet system prevailed. Occasionally, in debilitated women, a distinct rigor, high fever, and sweating occur; but only once—the patient is well next day. Sore Nipples. " Chapped Nipples."—The apex and sides of the nipples are affected with fissures like a chapped lip. There are great pain and some bleeding during suck- ling ; pain on touching nipple ; fissures visible on inspec- tion ; in severe cases, fever. The agony of suckling may lead to accumulation of milk, followed by inflammation and abcess of the breast. Treatment___Preventive: Caution the woman against flattening her nipples by pressure of corsets. Harden them during later weeks of pregnancy by frequent applications of alum, or tannin, and brandy, carefully avoiding sufficient mechanical irritation to produce premature contraction of the uterus. Curative: While nursing, use a nipple-shield—one with a hard base and rubber mouthpiece. Cleanse the part after- wards, with tepid water, and apply tannin and glycerine aa 3'U- 1 'ie compound tincture of benzoin, applied with a brush, leaves a film over the erosion, lessens pain, and pro- motes healing. Each fissure may be touched twice daily with solution of argent, nitras gr. xx, to water 3j, by means of a very fine camel-hair pencil. Wet the fissures only, not the whole nipple, with the silver solution. Prof. Barker 11* 126 MOTHER AND CHILD AFTER DELIVERY. strongly recommends nitrate of lead gr. x-xx to an ounce of simple ointment, both as a preventive and curative agent. Many other remedies have been employed. For slighter and more superficial irritations of the nipple, without ulcers or fissures, cleanse and dry them after each act of suckling, and dust with powdered oxide of zinc, or gum Arabic. Another plan is to keep them moistened with a rag wet with Goulard's extract 3'j» to water Oj, carefully wash- ing it off before nursing the child. Sunken Nipples.—The nipple is too flat, short, or sunken for the mouth of the child to grasp. The infant attempts to nurse, fails, and turns away crying. Treatment: Flold the child in readiness while the nipple is first drawn out by the mouth or fingers of an adult, or breast pump, and then apply it promptly. Another plan : Hold over the nipple the mouth of an empty glass bottle whose contained air has been previously rarified by heat, till the air cools, and the nipple is drawn up into the neck of the bottle. Then remove it and apply the child immediately. Excessive Flow of Milk__The breasts overflow, or become tender, hard, and distended from accumulation of milk. Danger of inflammation and abscess, if not relieved. Treatment: Restrict the woman's diet to dry food, as far as possible; abstinence from fluids. Laxatives, preferably salines, to produce watery stools and reduce the fluids of the blood. Diaphoretics (liq. ammon. acetat. Jjss every two hours) to produce watery secretion from the skin. Locally, R. ext. belladonnas 5j? liniment, camphor. 3j. M. Sig. Apply to breasts with gentle friction of the hand. Large doses of potass, iodid. (gr. xx three times a day), with rigid enforcement of dry, abstemious diet, and moderate, continued compression of the breasts with adhesive plasters, will soon entirely stop the secretion of milk, as may be neces- sary when the child dies, or the mother is not able to nurse. Deficient Milk-Flow—When due to anemia, debility, or hemorrhage, build up the patient with iron, quinia, bitter tonics, and nutritious fluid diet, especially milk; as a direct galactogogue use fomentations of the leaves of the castor-oil SECONDARY HEMORRHAGE FROM UMBILICUS. 127 plant1 to the breasts, or a teaspoonful of the fluid extract may be taken three times a day. Artificial Feeding—If the mother cannot nurse her infant, it must be nourished by a wet-nurse. When none can be obtained, give cows' milk one part (by measure), to two parts of water, adding a small lump of white sugar, or, preferably, the sugar of milk 3ij, to each pint of the mixture ; the proportion of milk to be increased with age. When this food disagrees, and the child passes lumps of undigested curd, use limewater, instead of ordinary water, or give one grain of potass, bicarb, in each fluidounce of the mixture. Infantile Jaundice. (Icterus Neonatorum.)—A com- mon affection during the first week of infant life. Symptoms: Yellow skin and conjunctivae; high-colored urine; light- colored stools. Causes: (Not well understood.) The tight application of belly-bands, restricting the respiratory mo- tions of the abdominal walls and diaphragm, upon which the portal circulation chiefly depends, is probably a factor in the production of the disease. Treatment: Nothing further than the removal of belly-bands may be necessary in slight cases. It soon goes away. In severe cases, with constipation, give calomel one-sixth of a grain, with one grain of white sugar, in powder, three times a day, for one or two days, followed by a teaspoonful of olive or castor oil. Sore Navel__An ulcer, usually with sprouting, flabby granulations, remains after falling off of stump of funis. Usually caused by friction and pressure of bandages, etc., used in dressing the cord. Treatment: Remove all dress- ings, and dust ulcer with a pinch of calomel, or touch it with crystal of cupri sulphas or argent, nit. Secondary Hemorrhage from the Umbilicus__A dangerous and often fatal bleeding from the navel, coming on days, and even weeks, after delivery, and recurring (sometimes) again and again, in spite of styptics, ligatures, the actual cautery, and other means that must be promptly tried for its relief. 1 Preferably the white variety ; the red is said to be emmenagogue. 128 labor in head presentations. how long should the mother keep her bed after Labor?—The popular, conventional rule is nine days. It is a custom without reason. Some strong, vigorous women, with healthy and well-contracted uteri, might get up sooner; others require a much longer period. PiVerything depends upon the character and complications of the labor, the strength of the female, and the condition of her uterus. Too early getting up, while the womb is large and heavy, and its natural supports relaxed from the stretching of pregnancy and labor, endangers uterine displacements, congestion, and subinvolution. It is better to err on the safe side, by making the lying-in too long, than to risk too early rising. CHAPTER XIII. MECHANISM OF LABOR IN HEAD PRESENTATIONS. By the mechanism of labor we understand the opera- tion of the mechanical forces, and the execution of the mechanical movements, necessary to secure the passage of the child through, and its exit from the pelvic (or rather, parturient) canal. In studying it there are six presentations to be considered, viz.:— 1. Head presentations. 4. Knee presentations. 2. Face " 5. Feet " 3. Breech " 6. Transverse " Posture of Child in Uterus__The position of the child in utero is very much that of an adult, when trying to keep warm in a cold bed before going to sleep, viz.: the spine curved forward, the face bowed towards the chest, the thighs flexed upon the abdomen, the legs towards the thighs, and the arms flexed and folded across the breast. The child, in utero, thus flexed, and folded, is more compact and occupies less space than it could do in any other posture : its whole frame approaches the ovoid form of the uterine cavity in which it reposes. HEAD PRESENTATIONS. 129 Now, when either end of this foetal ovoid presents, other things being normal, delivery is mechanically possible. When it presents crossways, delivery is impossible. Hence, presentations of the head, face, breech, knees, and feet, may be considered natural presentations ; while transverse pre- sentations are preternatural. Sometimes head and face pre- sentations are called " cephalic " presentations, because the cephalic (or brain) end of the ovoid presents ; while breech, knee, and footling presentations are termed " pelvic " pre- sentations, because the pelvic or caudal end of the ovoid comes first. The long spinal column must come one end first—either head or tail. Head Presentations—Cases in which the head pre- sents at the os uteri or pelvic brim. The Four " Positions" of Head Presentations__ By the term "position" as applied in the mechanism of labor, we mean the positional relation existing between a given point on the presenting part, and certain other given points upon the pelvis. In head presentations the occiput is the given point on the presenting part, and the given points on the pelvis are the two acetabula, and the two sacro-iliac synchondroses. Thus the Jour positions of a head presen- tation are :— 1. Occiput to left acetabulum (left occipitoanterior).1 2. Occiput to right acetabulum (right occipitoanterior). 3. Occiput to left sacro-iliac synchondrosis (left occipito- posterior). 4. Occiput to right sacro iliac synchondrosis (right occi- pito-posterior). Very rarely the occiput points directly in front, to the symphysis pubis, or directly behind, to the sacral promon- tory, thus making two more positions (six in all). But these two may be left out. They usually become converted into one of the other four at the beginning of labor. The order of greatest frequency of the four positions is as follows :— First. Occiput to left acetabulum, L. O. A.2 • 1 So called because the occiput is pointing to the left and forwards. The same plan of nomenclature is applied to the other positions. 2 L. 0. A., Left Occipitoanterior; L. 0. P., Left Occipito-Poste- rior, etc. 130 LABOR IN HEAD PRESENTATIONS. Fig. 7. Fig. 8. Exceptional Figs. 7, 8, 9, 10, 11, and 12 represent the six positions of the occiput. LEFT OCCIPITO-ANTERIOR POSITION 131 Second. Occiput to right sacro-iliac synchondrosis, R. 0. P. Third. Occiput to right acetabulum, R. 0. A. Fourth. Occiput to left sacro-iliac synchondrosis, L. O. P. This order of frequency is worth remembering, but to call the positions first, second, third, and fourth is worse than useless and had better be omitted. (If the student is not already familiar with the terms and measurements given in describing the pelvis (chap, i.) and fcetal head (chap, ii.), he should review them before at- tempting to learn the mechanism of labor. In the following description it is designed only to give the main principles of the mechanism, leaving exceptional occurrences and slight deviations and obliquities, of no great practical value, en- tirely out. A simple outline sketch had better be learned first. The finer tints and shades of variation can be put in afterwards. Mixture is confusion.) Stages of Mechanism in Head Presentations.— These are—1. Flexion ; 2. Descent; 3. Rotation; 4. Exten- sion ; 5. Restitution or external rotation. Mechanism in Left Occipitoanterior Position (Occiput to Left Acetabulum).—1. Flexion. It must be remembered the foetal head is (roughly) egg-shaped, and measures from the big end of it to the little end (from the occiput to the chin) 5^ inches. While the occipital pole of the head is at the left acetabulum, the chin-pole must be somewhere towards the right sacro-iliac synchondrosis, and a line drawn between these two pelvic points is one of the ob- lique diameters of the brim, and measures 4^ inches. Is a head diameter of 51.- inches, then, trying to pass a pelvic diameter of 4^? No; the bowed attitude of the child's head in utero, already mentioned, keeps its chin-pole tilted up towards the uterine cavity and the occipital pole tilted down towards the os uteri and pelvis, so that the forehead instead of the chin is really at the right sacro-iliac syhchon- drosis, and it is, therefore, the occipito-frontal diameter of the head (4^ inches in length) that is apparently trying to go through the oblique pelvic diameter of 4^. But this would be too tight a fit. The chin must be tilted yet more decidedly towards the sternum of the child, and the occiput 132 LABOR IN HEAD PRESENTATIONS. be made to dip more decidedly towards the entrance of the pelvis, in order that the oval-shaped head may enter the brim more or less endways. This is Flexion—so called because the child's neck is flexed, and the chin pressed against the sternum. Fig. 13 shows, diagram matically, the effect of flexion in permitting descent. In the upper head, Influence of flexion in permitting descent. unflexed, it is seen the 5£ inch occipito-mental diameter cannot enter the 4^ inch diameter of the brim (represented by the ring at the lower part of the figure). The middle head is flexed sufficiently to descend. The lower head shows an LEFT OCCIPITO-ANTERIOR POSITION. 133 impossible degree of flexion—impossible when the head is attached to the neck—and undesirable, as it would permit the head almost to drop through the pelvis. The lines and numerals represent inches. What causes flexion ? The force of uterine contraction is transmitted through the body of the child to its head by means of the spinal column, but the cervical end of the spine, where it joins the cranium, is not in the centre of the base of the skull, midway between the two poles, but is nearer the occipital pole, this last, therefore, bears the brunt of uterine force and is made to dip down lower than the other pole. Moreover the two poles meeting equal resist- ance from the circle of the os uteri and pelvic brim, the resisting force exerted upon the chin or frontal pole will be more effective because it is acting on the end of a longer lever than that applied to the occiput, hence the chin and forehead are tilted upwards. While the long (occipito-frontal) diameter of the head is more or less parallel with one oblique diameter of the pelvic brim, the transverse or bi-parietal diameter (3^ inches) occu- pies the other oblique (4|). Hence there is plenty of room for that to pass. The bi-parietal diameter is also about on a level with the plane of the superior strait, owing to the fundus uteri being so tilted forwards as to bring the uterine axis in a line with the axis of the plane of the brim. 2. Descent—The head having been tilted endways by flexion, it enters, occiput first, the pelvic brim, and descends into the pelvic cavity. It goes on down (the occiput still towards the left acetabulum and forehead towards the right sacro-iliac synchondrosis) until reaching the pelvic floor (the bottom of the basin). (Note. While flexion and descent are thus described as separate processes, and while the former is necessary to the latter, it must not be supposed that flexion is complete before descent begins; on the contrary they go on simultaneously, each increment of flexion being accompanied with an incre- ment of descent). 3. Rotation—The head having descended to the pelvic floor, its occipito-frontal diameter (4^) now occupies the oblique diameter of the inferior strait, which, however, measures only four inches. It cannot go on. Something must occur to bring the long diameter of the head parallel 134 LABOR IN HEAD PRESENTATIONS. with the antero-posterior diameter of the outlet, which we know measures 4| inches, or even 5 when the coccyx is pushed back. This is accomplished by rotation. Near the end of its " descent" the occiput strikes the slanting surface of bone in front of the ischial spine—the so-called left ante- rior inclined plane—and gliding downwards, forwards, and inwards towards the median line, it reaches the symphysis pubis, while the forehead, rotating downwards, backwards, and inwards towards the median line (along the right pos- Fig. 14. Occiput at inferior strait after rotation. terior inclined plane), reaches the centre of the sacrum. Thus the ovoid head has come to occupy a position agreeing with the longest (antero-posterior) diameter of the outlet, and the occipital pole is almost ready to escape, endways, through the inferior strait. (See Fig. 14.) 4. Extension—The head now stretches the perineum and soft parts into a kind of gutter, which constitutes the fleshy continuation of the parturient canal. The occiput descends below the symphysis pubis and passes on between the pubic rami, until the biparietal equator of the head fits into the pubic arch. The back of the child's neck meanwhile fits square against the posterior surface of the pubic symphysis ; and resting there immovably, the force of uterine contraction is expended upon the chin pole of the head, hence, as soon as the resistance of the soft parts permits the occiput to begin to escape, the chin is released from its condition of flexion, and extension is said to have begun. Finally the forehead slips by the projecting coccyx, the parietal equator of the head emerges from the vaginal orifice, and the LEFT OCCIPITO-ANTERIOR POSITION. 135 immediate retraction of the elastic perineum over, succes- sively, forehead, nose, mouth and chin, causes the occiput to rise up outside and in front of the pubes towards the mons veneris. Thus delivery takes place by the head de- scribing a circular movement round the fixed centre of the pubic arch—a movement exactly the reverse of flexion, viz. extension. (See Fig. 15.) (Remember the direction of Fig. 15. extension in this L. O. A. position is such as to make the occipital pole go upwards and forwards towards the mons veneris. In the R. O. P. and L. O. P. position, we shall see this is sometimes reversed.) 5. Restitution (External Rotation)___The head, after being completely born by extension, hangs out of the vagina, the chin dropping towards the anus, the vaginal orifice encircles the neck. The head next twists, or rotates, in such a manner as to bring its occiput towards the mother's left thigh—the thigh corresponding to the acetabulum at which it originally presented. The purpose of this manoeuvre is to facilitate delivery of the shoulders. Their longest diameter is, of course, the bisacromial—from one acromion process to the other. This diameter entered the brim and descended into the cavity of the pelvis parallel with the oblique pelvic diameter extending from the right acetabulum to the left sacro-iliac synchondrosis. But having reached the inferior strait, the bisacrominal diameter must rotate 136 LABOR IN HEAD PRESENTATIONS. from its oblique direction in the pelvis to the antero-posterior one. Hence the right shoulder glides along the right anterior inclined plane to the pubes ; the left one, along the left pos- terior inclined plane to the sacrum. This rotation of the shoulders inside the pelvis, causes rotation of the head out- side of it. The shoulder at the pubes usually fixes itself there, while the other one, at the perineum, swings round, describing a circular movement (as the occiput did), and comes out first. (See Fig. 16.) Fig. 16. Restitution. When the shoulders are delivered, the rest of the body usually slips out at once, without any special mechanism. Mechanism of R.O. A. Position—Occiput to Right Acetabulum. 1. Flexion, by which the chin tilts up, and the occiput down, so as to get the long diameter of the head more or less endways to the pelvic brim. 2. Descent, by which the head descends, occiput first, through the brim, into the cavity, down to the inclined planes of pelvic floor. 3. Rotation, by which occiput glides along right anterior inclined plane, downwards, forwards, and inwards to sym- RIGHT 0CCIP1T0-P0STERI0R POSITION. 137 physis pubis ; and forehead glides along left posterior inclined plane to middle of sacrum. 4. Extension, by which occiput escapes under pubic arch and rises up, outside, towards mons veneris, while forehead, nose, mouth, and chin successively escape at perineum. 5. Restitution (external rotation), by which occiput turns towards mother's right thigh (the thigh corresponding to acetabulum at which it originally presented), in consequence of shoulders rotating upon inclined planes—left shoulder to pubes, right to coccyx, the latter one generally escapes first. Delivery of the body. Thus we have described the two anterior positions of the occiput: L. O. A. and R. O. A. Next come the two posterior ones. Mechanism of R. O. P. Position (Occiput to Right Sacro-iliac Synchondrosis) :— 1. Flexion, and 2. Descent, as in anterior positions of the occiput. 3. Rotation—In the large majority of cases (96 per cent.), the occiput rotates all the way round to the symphysis pu- Fig. 17. Extension after posterior rotation. bis. In doing so it passes the right acetabulum, but it no sooner reaches this point than it becomes practically, and in reality, a risarian section, then turn out the uterus, secure the cervix and remove the organ before extracting the child, the latter being extracted immediately afterwards. In this way hemorrhage into the peritoneal cavity is avoided. There are other modifications of the operation, but experience has not yet demonstrated which course is best. So far, of 71 operations, 30 of the women recovered ; 41 died. (Lusk.) CHAPTER XX. mutilating operations upon the child. The object of these operations is to reduce the size of the child, or divide it in pieces, so that delivery—otherwise im- practicable—may be accomplished. Operating upon the head is called " craniotomy," upon the body " embryotomy." Since the term " embryotomy" literally means cutting the embryo, it is sometimes loosely used synonymously with "craniotomy." The conditions requiring mutilation are chiefly mal-pro- portion between the size of the child and pelvis, or other mechanical obstacles to delivery. Many cases in which 196 mutilating operations upon the child. craniotomy is adopted as a last resort have already been referred to. The several craniotomy operations are: 1. Perforation; 2. Excerebration ; 3. Cephalotripsy ; together with a number of minor operative procedures and instrumental manipula- tions that have not received definite names. Perforation—" Cephalotomy," consists in perforat- ing the skull and breaking up the brain. Various " perfora- tors" (" pierce-cranes") have been devised, most of them modifications of " Smeliie's scissors." The instrument con- sists, in brief, of a scissors with long handles and short blades, the terminal inch of the latter forming a triangle whose apex is the point, and at the base of which is an elevated margin, or projecting shoulder-stops, to prevent a too deep penetration. Unlike ordinary scissors the outside border only of the blades is sharp. Carefully guarded and guided by the fingers while entering the vagina, the point of the blades is made to penetrate the skull, as nearly as pos- sible at right angles to its surface to prevent glancing off, until further penetration is arrested by the shoulder-stops. The handles are then manipulated so as to open the blades, the outer edges of the latter thus making an incision in the cranium. After withdrawing the reclosed blade-points from the skull—not from the vagina—the instrument is twisted one-fourth of a circle and again applied as before so as to make a crucial incision. It is then pushed more deeply into the cranial cavity and turned about in all directions to break up the brain and its membranes, care being taken, if the child be alive, to kill it at once, by breaking up the medulla oblongata. The points to be preferred for penetra- tion are, in head presentations, the parietal bone; in face cases the frontal bone, orbits, or roof of the mouth ; and in retained head following breech presentations, the base of the occiput, behind the ear, or, if the chin can be pulled down, the roof of the mouth as in face cases. Avoid sutures and fontanelles: if these are penetrated the bones afterwards overlap each other and close the opening. Modern perfora- tors have been constructed on the principle of the trephine. A round hole is cut in the cranium through which the brain may come out, but the scissors are best when it is desired to break up the bones afterwards. cephalotripsy. 197 Contraction of the uterus together with resistance of the pelvic walls, after perforation, may cause the brain to ooze out and sufficiently reduce the size of the head to admit of its passage through the pelvis; generally, however, further artificial aid is necessary. Excerebration (Decerebration) is the next step after perforation. It means removal of the brain. This is done by a scoop or spoon passed in through the opening, or a strong stream of water may be injected with an ordinary Davidson's syringe and the cerebral mass washed out. When collapse of the head after these measures is still not sufficient for delivery, compression and traction may be made by forceps or by the omphalotribe. Cephalotripsy consists in crushing the skull with the cephalotribe, an instrument composed of two thick, narrow, solid blades, which are applied singly (like forceps), and after being locked are made to approach each other by means of a screw running transversely through the handles, so that powerful compression is made upon the skull, and its bones crushed, or, without crushing, the instrument may simply be used for compression and traction after perforation (Fig. 55, p. 198). In cases where the cranium cannot be delivered at all in its entirety, it must be broken up and removed piece- meal with the cranioclast or craniotomy forceps. The cranioclast, Fig. 56, p. 199, is a strong solid pair of for- ceps, with small, duckbill-shaped blades, serrated on their op- posing surfaces. One blade goes inside the skull (through the perforation previously made), the other outside, but under- neath the scalp. They are introduced separately and lock like forceps. When applied, the inside blade, wdiich is smaller than the other and has no fenestra, apposes its con- vex serrated surface against the concavity of the cranium, while the outside one—larger, and having a fenestra against which the other may press—rests its concave serrated sur-r face upon the convex exterior of the skull. When the handles are brought together after locking, the blades grasp the intervening bone, like the jaws of a crocodile, when it may be wrenched off by a twist of the wrist, and removed. Thus, a bit at a time, the whole vault of the cranium may be brought away. 17* 198 mutilating operations upon the child. The cranioclast may also be used as a tractor, when, after perforation, it is attempted to extract the skull in its entirety. Fig. 55. Cephalotribe. The craniotomy forceps, Fig. 57, differ from the cranio- clast in being smaller, and in having their blades perma- nently joined at the lock, like ordinary tooth-forceps. The inner surfaces of the blades are serrated : some are straight, others bent at right angles. They are used to grasp, twist off, and extract pieces of bone, the point of one blade ^oin«» cephalotripsy. 199 into the skull, that of the other outside of it, but under the scalp, this last having been previously loosened from its attachment to the bones. Fie. 56. Fie. 57. Cranioclast. Craniotomy forceps. In all these operations the greatest care is necessary to avoid lacerating the soft parts while withdrawing sharp bony fragments. The vaginal wall must be pushed aside by the fingers, or, better, a large cylindrical, or a Sim's speculum used, and the operation conducted under the guidance of sight instead of touch. The crotchet is a steel rod, the end of which, flattened into a sharp triangular point, is bent round, at an acute angle, to form a hook. It is passed into the cranium through the foramen magnum, or through a perforation made in some solid part of the base1 of the skull, and its point made to penetrate the bone from within outwards, so as to get a hold by which traction can be made. A finger end is placed outside, opposite the point of the hook, to prevent lacera- tion in case the instrument slips, or tears out. The "guard- crotchet" has a second solid blade (attached to the other by 200 mutilating operations upon the child. a " lock"), the end of which takes the place of the finger in fitting over the hook to prevent injury. However constructed the crotchet is a formidable contrivance, and since fearful laceration will often occur, despite all " guards" and care, is now seldom used. When the chief part of the cranial vault has been re- moved, by the cranioclast, etc., extraction of the remaining base of the skull, which is too solid to be broken up, may be facilitated by inserting a blunt hook in the orbit, or getting a firm hold on the forehead with craniotomy forceps, and then, by making downward and backward traction, bring- ing down the face. The symphysis of the lower jaw is next divided, and its two halves pushed aside or removed, when the remaining portion of the face, from the alveolar border of the upper jaw to the root of the nose—only measuring 11 inches—may be made to enter the pelvis, and the base of the skull extracted. Generally speaking, a pelvis sufficiently large to allow ex- traction of the head by craniotomy, will permit the body to pass without mutilation. It may be necessary, however, to pull on the neck until a blunt hook can be passed into the axilla, by which the shoulders—first one, then the other— may be drawn out. Exceptionally it may be required to perform Embryotomy__This embraces two operations, viz., evisceration and decapitation. Evisceration (Exvisceration — Exenteration —) means opening the thoracic and abdominal cavities (one or both), and taking out their viscera. It may, though very rarely (as just explained), be neces- sary in extracting the body after craniotomy, or when there is some abnormal enlargement, or monstrosity, on the part of the child. It is resorted to more frequently in impacted transverse presentation, arrested " spontaneous evolution," etc. Operation—The thorax is penetrated near the axilla, by curved scissors or the pierce-crane, and the thoracic organs broken up and removed, either by instruments, or, if prac- ticable, by the fingers. Through the same opening the diaphragm may be perforated and the abdominal viscera decapitation. 201 removed. The same care is necessary as in craniotomy to avoid lacerating the vagina with splinters of bone. When evisceration is performed subsequent to craniotomy, the body may be afterwards drawn out by a blunt hook in the axilla, as above directed. In impacted transverse presentations the eviscerated body may be delivered in one of three ways, viz.: 1, by traction on the arm and shoulder; 2, by passing a blunt hook to the groin and pulling down the breech; 3, by grasping the feet and delivering by podalic version. Which mode is to be selected must be left to the judgment of the obstetrician, much depending upon the position of the child, its size, and the shape and dimensions of the pelvis. Decapitation—separating the head from the body—is required in impacted shoulder presentations, or arrested "spontaneous evolution," when the child is jammed tight in the pelvis and cannot be moved up or down. Operation___Get down an arm for traction, pass a blunt hook round the neck, and while it is held as low down as possible, nibble through the vertebrae and soft parts with a blunt-pointed pair of scissors. Cut everything, so that the hook or finger may be passed through the incision to ascer- tain that the head and body are completely separated. Another device is that of a blunt hook, whose inner con- cave surface is made sharp. The hook having been passed over the neck, the latter is separated by rocking the handle of the instrument up and down while traction is made. Keep a finger on the end of the hook, and reduce the trac- tion force when severance is near completion, to prevent injury from sudden release of the instrument. Other contrivances consist of chains, wires, and strings passed round the neck, and through along, double canula, to protect the vagina, while by a sawing to-and-fro movement the neck is severed. After decapitation, the head is pushed up out of the way and the body delivered first, by traction on the arm, eviscera- tion, etc. The remaining head is then extracted by forceps, or, if required, by craniotomy. In attempting the latter operation upon a decapitated head, extra care is necessary to prevent slipping of the perforator. An assistant steadies 202 PELVIC deformities. the uterus by firm abdominal pressure to keep the head from revolving while the instrument is being used. Finally, in all mutilating operations upon the child when it is alive, the chances of a successful cutting operation upon the mother for its safe removal should first receive considera- tion. In deciding which course to adopt, the value of the mother's life must be allowed the pre-eminence. CHAPTER XXI. PELVIC DEFORMITIES. A general study of pelvic deformity is necessary, in order that we may learn to ascertain—at least approxi- mately—the degree and kind of malformation existing in a given case. A knowledge of the degree of deformity indi- cates whether delivery by the natural passages is or is not practicable, and determines the mode of assistance by ope- rative measures. A knowledge of the kind of malformation, derived chiefly from examination of specimens in museums, indicates what diameters are most likely to be altered in length, and what parts of the pelvis—brim, cavity, or outlet —are chiefly affected, thus determining necessary modifica- tions in the mechanism of labor, and indicating the time and manner of rendering assistance. By far the most frequent variety of deformity is that in which there is shortening of the conjugate (antero-posterior) diameter of the brim, and while slight variations in size and shape are almost endless in number, twelve distinct types may be enumerated, each of which will now be considered. 1. The Symmetrically Enlarged Pelvis (Pelvis iEQUARiLiTER Justo-ma.ior)—Shape natural; size, in all directions, increased. A congenital condition. Labor is apt to be unnaturally rapid, with consequent liability to inertia of the uterus and post-partal hemorrhage, and there is increased tendency to uterine displacements. Treatment: confine the woman to the recumbent posture as soon as labor THE PELVIS OF RICKETS. 203 begins ; rupture the membranes early, before the os is di- lated, and enjoin resistance to bearing-down efforts, that labor may be prolonged. Extra care to secure uterine con- traction during third stage of labor. 2. The Symmetrically Contracted Pelvis (Pelvis ^Equabiliter Justo-minor)__Shape natural; size, in all directions, lessened. A congenital variation. Labor diffi- cult, or impossible, according to degree of contraction. Oc- curring in dwarfs, children may sometimes be born without difficulty. 3. The Juvenile Pelvis__Shape resembles the pelvis of infancy and childhood. It is an arrest of development. Transverse measurements relatively shorter than the conju- gate, owing to narrowness of sacrum. Sides of pelvis un- naturally straight; pubic arch narrow ; and ischia too near together. Labor difficult, or impossible pro re nata. In precocious mothers time may remedy the deformity. 4. The Masculine Pelvis—sometimes called "funnel- shaped." It is deep and narrow, resembling that of a male, the narrowness increasing from above downwards; hence obstruction to labor, most marked towards the outlet. The pelvic bones are thick and solid, a condition thought to be produced by laborious muscular work only suitable for men. 5. The Pelvis of Rickets (Rachitis)__Sub-varieties numerous. The typical rachitic pelvis is the most common, and hence most important of all deformities. Obstruction to labor chiefly at the brim, by shortening of conjugate diameter, Transverse diameter may be either long, short, or normal. Rickets occurs in early life. The child, from muscular weakness, etc., fails to walk, hence long continu- ance in sitting posture forces promontory of sacrum forwards and downwards towards pubic symphysis. If the child does walk, counter-pressure of thigh bones in acetabula forces in the sides of the pelvis, and then transverse diameter is also shortened. Cavity of pelvis not generally contracted, a sit- ting posture rather tending to squeeze the ischial bones apart. The outlet may be lessened by sharp inward curva- ture of sacral apex towards pubes. 204 pelvic deformities. Exceptionally the symphysis pubis is drawn (by contrac- tion of recti muscles ?) towards the sacral promontory, pro- ducing so-called figure-of-8 pelvis, and, rarely, the sacrum may lack curvature, thus lessening size of pelvic cavity. The rickety pelvis is a most prolific cause of difficult labor. The degree of obstruction may require mutilation of the child, or even necessitate cutting operations upon the mother. (For general rule in selecting the mode of opera- tion, see p. 211.) 6. The Malacosteon Pelvis, resulting from osteo- malacia—a uniform softening of the bones occurring in adult life. It may come on in women who have previously borne children without difficulty. Its progress being gradual, the patient is able to walk about, hence pressure of thigh bones in acetabula pushes in the sides of the pelvis, shortening the transverse diameter. Anterior border of pelvic brim has a spout-shaped or beaked appearance. Exceptionally, and in very bad cases, the oblique and conjugate diameters may be also contracted. Osteo-malacia is about four hundred times less frequent than rickets. The last resorts of craniotomy or Caesarian section may be required for delivery. Sometimes the softened bones yield, and admit the passage of the child by other methods. 7. The Oblique Deformity of Naegele.—The sacro- iliac synchondrosis of one side is anchylosed, the corre- sponding wing of the sacrum atrophied, or imperfectly developed, so that the acetabulum of this side approaches the healthy sacro-iliac synchondrosis of the other, shortening the oblique diameter between these two points. The other oblique diameter, starting from the diseased sacro-iliac synchondrosis, is lengthened, owing to the symphysis pubis and acetabulum of the healthy side being forced out of place towards the sound side of the median line. This variety of deformity is comparatively rare. 8. The " Roberts Pelvis"—a double oblique deformity. Both sacro-iliac synchondroses anchylosed, and both wings of the sacrum absent or undeveloped. The brim is oblon°; pelvic sides more or less parallel with each other; ischia pressed towards each other, and sides of pubic arch nearly ORDINARY SYMPTOMS. 205 parallel. Transverse diameter universally shortened, at brim, cavity, and outlet. Obstruction very great, requiring Casarian section. It is really the oblique deformity of Naegele occurring on both sides, and is extremely rare. 9. The Spondylolithetic Pelvis, due to forward and downward dislocation of the lumbar end of the spinal column from its proper place of support on the base of the sacrum. It produces marked contraction of conjugate diameter of the brim, and, owing to sacral promontory being forced some- what backward, the apex of sacrum may be tilted forward, thus lessening conjugate diameter of outlet. Degree of obstruction very great, sometimes requiring last resorts in operating. 10. The Kyphotic Pelvis, due to backward curvature of the spinal column near its lower end. The sacral pro- montory is absent or drawn backwards out of reach, thus lengthening conjugate diameter of brim, but contracting its transverse measurement. The apex of sacrum is tilted forwards, and the two ischia and two sides of pubic arch approach each other, so that all the diameters of the outlet, and some of the cavity, are diminished. Obstruction chiefly at the inferior strait. 11. Deformity from Hip Dislocation occurs in hip- joint disease. Head of femur presses on innominate bone and pushes in side of pelvis, thus shortening transverse diameter of the brim. The inferior parts of the innominate bone are tilted outwards, hence capacity of outlet increased. 12. Deformity from Exostosis, etc.—Bony and osteo- sarcomatous tumors growing from pelvic bones—most often from front of sacrum—project into pelvic cavity and pro- duce obstruction. Bony projections also occur from callus resulting from fracture of the bones. The ischial spines are sometimes too long and encroach upon the pelvic canal. Ordinary Symptoms of Pelvic Deformity without Reference to any Special Case__Previous history of difficult labors, and of the diseases or accidents by which pelvic deformity is produced. Early recognition of quick- 18 206 pelvic deformities. ening by the patient (third month). Pendulous belly. Increased obliquity and mobility of the pregnant womb. Greater liability to mal-presentations and to presentation and prolapse of the funis. During labor the finger can be more easily introduced between the lips of the os uteri and bag of waters. Os uteri movable from side to side. Pre- senting part high up, or out of reach, when brim contracted. Pains intense without proportionate progress in descent of presenting part. Later " arrest" of the head (it descends no farther), or " impaction" (when it cannot be moved, either up or down). Caput succedaneum unusually large, its gradual swelling may be mistaken for progress in descent. Additional Symptoms in Special Cases.—In Rickets: " bow-legs," curved spine, and other deformities of the skeleton, with history of rachitis in early life. In osteo-malacia (malacosteon) : probable history of pre- vious labor without difficulty, the disease beginning soon after a delivery. Symptoms of osteo-malacia are : pains in bones of pelvis and lower limbs; bones tender on pressure, especially over symphysis pubis. They are also pliable, yielding to manual pressure during labor. Old-standing cases of hip disease with dislocation of femur, present pre- vious history of coxalgia. The diagnosis in the above cases must be confirmed, and in the other varieties made out almost entirely, by measuring the pelvis. (Pelvimetry). Pelvimetry may be accomplished both by internal and external measurements. The best pelvimeter (pelvis-mea- surer) is the hand. To measure conjugate dian^ter of the brim, pass index finger under pubic arch and rest its point against sacral pro- montory,1 Fig. 58. (It is not possible to touch the promon- tory in a normal pelvis.) With a finger nail of the other hand, make a mark on the examining finger where it touches the pubic arch. AVithdraw the finger and measure (with a rule) from the mark to its tip. From this measurement deduct half an inch, and the remaining length gives the con- jugate diameter of the brim. The half inch is subtracted 1 Take care not to mistake the (sometimes prominent) junction of first and second sacral vertebrae for the real promontory. PELVIMETRY. 207 because the length as measured from the promontory to the under surface of the pubic symphysis is half an inch longer than from the promontory to the upper surface of the pubic joint, the latter being the brim measurement it is desired to ascertain. During this examination the woman should lie on the back with the hips elevated. Fig. 58. Pelvimetry with the finger. Another method : patient lies on her left side, near the edge of the bed. Fkherize if necessary to prevent pain. Introduce entire hand into vagina, and dispose it flat-ways with the little finger towards symphysis pubis and the index finger against sacral promontory. Learn how many fingers 208 PELVIC DEFORMITIES. can thus be simultaneously introduced between the two points. The breadth of four fingers, in a hand of average size, is about two and three-quarter inches. The fingers in- troduced may be afterwards measured by a rule. Of the numerous instrumental pelvimeters for internal use, those of Dr. Lumley Earle and Dr. Greenhalgh are probably the best; but they can scarcely be used during labor when most often needed, and give no better results than the hand under any circumstances. The transverse and oblique diameters of the brim can only be roughly estimated. External Pelvimetry__The pelvimeter of Baude- locque is generally used. It is a pair of circular callipers, a scale near the hinge indicating the space between the open ends when applied. To measure conjugate diameter of brim, the woman lying on her side, place one point of the instrument upon the upper edge of pubic symphysis, and the other opposite sacral promontory, i. e., over the depression just below spinous process of last lumbar vertebra. Normally this should measure 7^ inches. Deducting 3^ for thickness of bones and soft parts, leaves 4 inches—the normal length of the brim's conjugate diameter. The degree of reduction in this measurement, allowing for individual variation from obesity, etc., will give, approximately, the amount of pelvic contraction, but a limited reliance only can be placed upon this method without other corroborative evidence of de- formity. Two other external measurements are useful, viz., (1) be- tween the two anterior superior spinous processes of the ilia (normally 9J? inches) ; and (2) between the most laterally- projecting points on the two crests of the ilia (normally 10^ inches). When both measurements are reduced, it indi- cates a uniformly contracted pelvis. When the inter-crestal measurement is normal, or only a little diminished, while the inter-spinous one is increased, it indicates a pelvis with conjugate contraction of the brim, but otherwise normal. When both measurements are decidedly diminished, while the inter-spinous one exceeds the inter-crestal, other diam- eters are contracted besides the conjugate. dangers of pelvic deformity. 209 Diagnosis of the Oblique Deformity of Xaegele. —Lameness, from inequality in the height of the hips. If two plumb-lines are let fall, one from the centre of the sacrum, the other from the symphysis pubis (the patient standing erect), the pubic one will deviate towards the healthy side. Measuring from the spinous process of the last lumbar vertebra to the anterior and posterior spinous processes of the ilia, will show a reduction of half an inch or more on the diseased side. Anatomical features of the de- formity, already described, to be further made out by vaginal examination. Diagnosis of the Kyphotic Pelvis__Mensuration reveals marked narrowing of space between tuberosities of the ischia; between ischial spinous processes ; and between sides of pubic arch. Space between anterior superior spinous processes of ilia decidedly increased. Absence of sacral promontory and other anatomical characters revealed by vaginal touch. Diagnosis of Spondylolithetic Pelvis___Figure pe- culiar : thorax normal; abdomen short and sunken between crests of ilia, the latter widely separated. Aortic pulsations felt through posterior vaginal wall. History of violent pains in sacrum at puberty (i-1). Vaginal examination reveals dis- location at sacro-lumbar articulation. Diagnosis of " Roberts Pelvis."—Owing to narrow- ness of sacrum, the spaces between the two iliac crests, between the two iliac spines, between the two trochanters, and be- tween the two ischial tuberosities, are all reduced. The two posterior superior iliac spinous processes, especially, approach each other. Diagnosis of Masculine Pelvis.—Mensuration dem- onstrates diminished width between pubic rami, and between ischial tuberosities, etc. No obstruction to labor at supe- rior strait; head arrested in pelvic cavity. Dangers of Pelvic Deformity__Tediouslabor; shock ; exhaustion, and inertia of uterus from prolonged contractile efforts. Inflammation, ulceration, and sloughing of mater- 18* 210 PELVIC DEFORMITIES. nal soft parts from contusion and prolonged pressure. Child's life jeopardized by prolapsed funis ; by continued and exag- gerated compression of cranium, especially against sacral promontory. Operative measures for delivery may necessi- tate destruction of infant. Modifications in Mechanism of Labor when Con- jugate Diameter of Brim only is Contracted__ Flexion is imperfect, so that anterior fontanelle is lower than posterior one. The bi-temporal diameter of the head (3j inches) therefore occupies contracted conjugate of brim. Sagittal suture lies across the pelvis, in transverse diameter, but inclined towards the sacrum. During " descent," one parietal bone impinges against, and is depressed by, the sacral promontory. Sagittal suture now comes nearer to symphysis pubis. Occipital pole of head is then depressed, and made to descend through the contracted brim, by flexion becoming more complete. This done, the chief difficulty is over, and labor is finished in the usual way. Modifications in Mechanism of Labor when Pel- I vis is uniformly Contracted__Flexion is unusually complete, so that occipital pole of occipito-mental diameter points almost vertically down at right angles to plane of su- perior strait. Thus descent begins, and, if the narrowing is not too great, the bi-parietal equator of the skull, followed by the forehead, eventually passes the brim, and the remainder of the mechanism follows the usual course. When the eon- traction is very great, the head becomes " impacted," fixed fast, like a wedge, between pelvic walls, necessitating em- bryotomy. Methods of Assisting Delivery in Pelvic Defor- mity—In a certain number of cases, where the pelvis is only slightly contracted, delivery may be accomplished by forceps. When the contraction is a little too decided for delivery by forceps, it may still be possible to deliver a living child by podalic version. Should the deformity be so great as to preclude the pos- sibility of delivery either by forceps or turning, yet not suf- ficient to exclude extraction by craniotomy, the two alter- METHODS OF ASSISTING DELIVERY. 211 natives of a cutting operation upon the mother, or mutilation of the child, may be considered. Should the child be dead, mutilation of it would of course be selected. If it still live, and there is reason to suppose it has not suffered from delay or futile attempts to extract it in other ways, so as to en- danger its life if promptly delivered without further injury, a cutting operation on the mother might be chosen for ex- traction. The woman and her relatives must be consulted in this selection ; and whether the condition of the patient is such as to give substantial hope of her surviving the operation must be duly considered. In the worst cases of pelvic deformity, when the contrac- tion is so extreme that there is not even room to deliver by craniotomy, cephalotripsy, or any other of the craniotomy operations, without subjecting the female to greater danger (from injury of the soft parts) than would be incurred by a cutting operation upon the abdomen, the Caesarian section, or some other of the cutting operations upon the mother, must be selected as the only resort, whether the child be dead or alive. The modes of delivery proper in different degrees of pelvic contraction may be succinctly stated as follows:— When conjugate diameter of The proper mode of delivery is brim measures Between 4 and 3£ inches, Forceps. Between 3^ and 2f " Podalic version. Between 2£ and If " Craniotomy, or, if child alive, Caesarian section (?). Below If inches, Caesarian section, always. The above rules must be admitted, in practice, only with considerable qualification. Much will depend upon the size of the child's head, as estimated approximately by vaginal examination and the duration of pregnancy, the size being generally smaller or larger according as the pregnancy has been, respectively, short or long. A head too large for delivery by forceps through a conju- gate diameter of 3^ inches, may be delivered by version through a diameter of 3 inches, especially when manual pressure from above is judiciously employed. A Tain, while it is seldom possible to deliver a live child 212 THE INDUCTION of PREMATURE labor. by version (without fatal injury) through a diameter of 2f inches, a dead one may, nevertheless, be extracted, and should it then be impossible to draw out the after-coming head, this may still be delivered by craniotomy. Still further : the possibility of extracting by craniotomy through a conjugate diameter of If or thereabouts, will much depend upon the coexisting length of the transverse diameter ; this last should be at least 3 inches, to allow room for the use of necessary instruments and manipulations. When, in cases of pelvic deformity, one or more children have been destroyed by craniotomy, the birth of a living child may still be possible by the induction of premature labor, which is considered in the next chapter. CHAPTER XXII. THE INDUCTION OF PREMATURE LABOR. By the end of the 28th week of pregnancy the child is sufficiently developed to be capable of extra-uterine life. Delivery between the 28th week and full term is called " premature labor:" before the 28th week, "abortion." Cases in which it is Proper to Induce Preaiature Labor__1. In pelvic deformity where there is sufficient space for a seven-months' child to be delivered without in- jury. The object is twofold: (a) to save the child's life by obviating the necessity for craniotomy; (b) to spare the mother the dangers of craniotomy, Caesarian section, or other operations that might be required if the pregnancy went to full term. 2. In cases where, in previous labors, the head of the child at full term has been prematurely ossified, or unusually large, so that labor has been difficult and danger- ous, even though the pelvis were normal. The period of deliv- ery need only be two or three weeks before " term" in these cases. 3. In cases where the children of previous preg- nancies have died in utero during the later weeks of gestation PREMATURE LABOR IN PELVIC DEFORMITY. 213 from disease (fatty, calcareous, or amyloid degeneration, etc.) of the placenta. 4. In conditions where the continuance of pregnancy seriously endangers the mother's life, such as : excessive vomiting; albuminuria; uraamic convulsions, or paralysis; chorea; mania; organic disease of the heart, lungs, liver, bloodvessels, etc., threatening fatal disturbance of the respiration, circulation, and other vital functions; irreducible displacements of uterus; placenta praevia wdth hemorrhage ; and in dangerous pressure upon neighboring organs from overdistension of uterus, due to dropsy of amnion, tumors, multiple pregnancy, etc. Induction of Premature Labor in Pelvic De- formity—The degree of conjugate contraction of the pelvis, in which it is proper to induce premature delivery, when it is designed to save the child's life, is practically limited to between 2^ and 3^ inches. A child, at the end of the seventh lunar month (28th week), may be delivered alive through a conjugate diameter of 2^ (possibly 24J inches. One at the end of the eighth lunar month (32d week) through 3 inches. One at the end of the ninth lunar month (36th week) through 3^ inches. When the measurement is over 3^ inches, the labor may be left till full term (40th week). Owing to difficulty of determining exact size of the head and pelvis, the more precise rules given in text-books are practically useless. The selection of any week, intermediate of the periods above noted, must be left to the judgment of the obstetrician and decided by the circumstances of each case. When the conjugate diameter measures less than 2-J (or 24J inches, abortion should be induced as soon as possible after the diagnosis of pregnancy is certain. If, however, the female (being childless, or for other reasons) prefers to risk the dangers of a cutting abdominal operation, and there are no special circumstances rendering such a course peculiarly inadvisable, the case may be allowed to go to term, and the child then extracted promptly by section through the abdo- men. 214 the induction of premature labor. Methods of Inducing Labor Early in Pregnancy before the Child is Viable__Rupture the amniotic sac by introducing a sound into uterine cavity and turning it about therein, until the liquor amnii escapes. This method is never to be adopted later, when it is designed to save the child's life, for discharge of "waters" subjects soft and im- mature fcetus to fatal compression from contracting walls of uterus ; it also renders version (which may be necessary for delivery) difficult. Another method: Introduce carbolized sponge or sea-tan- gle-tent into cervix to dilate the os, and provoke uterine contraction. This method secures preservation of the bag of waters which aids subsequent dilatation of os and cervix uteri, and favors discharge of entire ovum, membranes, pla- centa, and fcetus—all at one time. Best Method of Inducing Premature Labor when it is Designed to Save the Child's Life—Pass into the uterus, between its wall and the fcetal membranes,—with great care and gentleness, to avoid rupture of sac and dis- turbance of placenta—a male elastic catheter or bougie, to a length of 6 or 8 inches within the os. Let it remain there (kept in place, if necessary, by a sponge placed in the vagina) as a foreign body to invoke uterine contraction. If, in twenty-four hours, no effect be produced (which rarely hap- pens) take it out, and again introduce it in a somewhat dif- ferent direction, and leave it as before. Uterine contractions eventually occur, when the instrument is removed, and if the pains increase in strength, the case may be left to nature. If the contractions are only feeble and do not increase in strength and frequency, accelerate both them, and dilatation of the os, by introducing elastic dilators (Barnes's water- bags, etc.), first a small one, afterwards larger sizes, into the cervix. No other measures will generally be required. If, when the os is well dilated with the larger bags, uterine con- traction is still delayed, the membranes may be ruptured. Other Methods—The Vaginal Douche__Place the woman upon a bed, her hips near the edge of it and resting on a rubber cloth, in which is arranged a gutter to guide the returning fluid into a vessel on the floor. By means of a THE SPONGE TENT. 215 fountain-syringe, Davidson's syringe, or a rubber tube con- nected with an elevated vessel, direct a stream of warm water against the cervix uteri, continuously, for fifteen minutes, three times a day, at intervals of six hours. The nozzle of the syringe must go against the neck, never into the month of the womb. Temperature of the water about 100° F. From four to twelve, or more, injections may be necessary. The woman need not keep her bed before labor begins. A modification of the vaginal injection is known as Cohen's Method—This consists in passing an elastic catheter between the membranes and uterine walls, and injecting warm water, slowly, in quantity of seven or eight ounces, into the uterus, preferably near the fundus, until the patient feels some distension. Labor comes on much more certainly and rapidly than after the vaginal douche ; but, both these methods have caused sudden death of the female, and Dr. Barnes, with whom many other practitioners agree, avows " that the douche, whether vaginal or intra-uterine, ought to be absolutely condemned as a means of inducing labor." Cohen's method has, however, been highly recom- mended even recently. Yet as we have a safer one, which has just been described, this risk is needless. The Vaginal Tampon—Distending the vagina with a tampon, or rubber bag blown up with air or water through a stopcock (the colpeurynter of Braun), is another means of exciting uterine contraction, and a comparatively harmless one when carefully used, but withal painful, and uncertain in efficacy. The Sponge Tent was formerly used to induce labor by mechanically dilating the cervix uteri. It is now seldom resorted to except, where the os is very small, as a prelimi- nary to the introduction of Barnes's elastic dilators, pre- viously mentioned. The use of ergot and other oxytocics ; the injection of carbonic acid gas into the vagina; separation of the mem- branes from the uterine wall by means of the finger or the uterine sound; the induction of uterine contraction by electricity, galvanism, abdominal frictions, irritation of the mammary glands, have in turn all been resorted to for 216 PLACENTA PREVIA. bringing on premature labor, but cannot now be recom- mended. Whatever method is used, the main purpose of the opera- tion, viz., that of saving the child's life, must be kept con- stantly in view, and since delay after rupture of the mem- branes, if prolonged, is likely to destroy the child, it should be delivered either by forceps or version as soon as dilata- tion of the os uteri and other existing conditions render such a proceeding safely practicable. Treatment of Premature Infants after Birth.— The two great desiderata are warmth and food, to which a third might be added, viz., rest. Lay the child upon a mass of, and cover it over with, cotton wool. Keep it near the fire, protected from changes of temperature. Handle it carefully in washing, the water used being as warm as 100° F. The mother's milk, given wdth a spoon if the child is too feeble to suck, must be administered at frequent inter- vals, and without a long fast during the night. CHAPTER XXIII. PLACENTA PREVIA--HEMORRHAGE BEFORE AND DURING LABOR. Placenta Previa consists in implantation of the pla- centa abnormally near to, or more or less over, the internal os uteri. There are three varieties : (1) The border of the placental disk may be near the margin of the os without overlapping it, hence called "marginal;" (2) the placenta may be partially, or, (3) completely, over tbe os internum ; hence, respectively, "partial" or " complete" cases. Causes___Not certainly known. Probable explanations are: displacement of ovum from its normal position and lodgment lower down, as after arrest of threatened abortion ; abnormally low position of orifices of Fallopian tubes ; large relaxed uteri of multiparous women, in which folds of de- cidua vera do not retain ovule near fundus when it first PLACENTA PRiEVIA. 217 enters the womb ; hence the undoubted greater frequency of placenta praevia in multiparas. Consequences of Placenta Prcevia___1. Liability to prema- ture delivery; 2. Tendency to mal-presentation ; 3. Fearful hemorrhage, generally coming on during the last twelve weeks of pregnancy, or when labor begins; the bleeding being earlier and greater according to the greater degree of placental encroachment over the os; in the marginal cases sometimes not until " term," in complete ones, exception- ally, before the last twelve weeks. Symptoms and Diagnosis___Before labor sets in, placenta prawia is generally unsuspected until the sudden occurrence of hemorrhage, which begins without any known cause, sometimes even at night during sleep. It may stop and again recur. The quantity varies with the amount of pla- cental separation (which always precedes the bleeding). First attacks usually moderate; exceptionally, quarts of blood are lost, and death follows one or two recurrences; such cases are usually " complete" ones. During labor the bleeding begins"early with commencing dilatation of the os. It may, in marginal cases, be arrested by rupture of membranes and consequent compression of bleeding surface by the presenting head. Labor pains usually feeble, and dilatation slow. To these symptoms must be added those clue to blood loss : syncope, restlessness, feeble pulse, cold extremities, etc. In fatal cases convulsions often precede death. The diagnosis—clearly suspected from history and symp- toms—is confirmed by vaginal examination, the irregularly- granular spongy texture of the placenta being easily recog- nized by the finger passed into the os. In some primiparae passing the finger to or through the internal os may be diffi- cult or impossible; then, however, one side of the lower segment of the uterus may be felt, through the vagina, to be boggy, soft, and enlarged where the placenta is attached; and the pulsation of arteries may be felt in it. A stethoscope applied to cervix may reveal loud placental murmur. The sign ballottement is obscured. Prognosis___Extremely grave. Statistical estimates give maternal mortality from 25 to 30 and even 40 per cent. As statistics cover a long period of time, necessarily so from placenta praevia not occurring more frequently than once in 19 218 PLACENTA PREVIA. 500 or 1000 labors, there is reason to hope that the above rate of mortality has been reduced by recent improvements in treatment. The outlook is worse in proportion to the degree in which placenta overlaps the os. Two out of three children are born dead, and still others succumb soon after birth. Treatment___The main principle of treatment is delivery; there is no safety for the woman until the uterus is emptied. * It was formerly the custom, and still is by some obstetricians, when hemorrhage occurs before the twenty-eighth week of pregnancy, to wait, using only palliative measures to check hemorrhage, until the period of viability, before attempting to deliver. This is wrong and always unsafe. The child will seldom be saved by temporizing, and the mother often dies wth the recurrence of hemorrhage, the bleeding coming on suddenly, as it is apt to do, in the absence of the physician. The best rule is to deliver as soon as practicable after the i first occurrence of hemorrhage whether the child is viable or not. The usual mode of delivery is podalic version, preferably by external manipulation and subsequent traction of the feet; in a few cases forceps may be employed. But version and the application of forceps are impossible before sufficient i dilatation of the os and cervix uteri; therefore, while waiting for and to expedite this latter, and at same time prevent a' fatal hemorrhage, the several means at our command are: Vaginal Tampon, Uterine Dilators, Ergot, Rupture oj Membranes, and Partial Digital Separation of Placenta, the selection of one or more of these means to depend upon the kind of case under treatment as defined below. In cases where the uterine neck is long and narrow and the os small, put a sponge tent in the cervix and pack vagina with tampon. Ergot and rupture of the membranes are not advisable thus early. Retention of liquor amnii promotes dilatation of os and keeps uterine cavity full so as to prevent backing up of blood into it. An abdominal binder supports the womb and promotes contraction of its walls. In five or six hours, or in three or four if the pains are strong enough to lend hope that dilatation of the os is progressing rapidly, remove tampon (a second one having been previously pre- pared), and, if dilatation is still inconsiderable, change the sponge tent for a Barnes's elastic dilator and reapply vaginal PLACENTA PREVIA. 219 tampon. Should bleeding have been controlled and no other conditions enforce urgent haste, this treatment may be continued until the os will admit version or forceps. Under opposite circumstances, or when dilatation of the os and cervix were at first considerable, the membranes may be ruptured early (before anything like complete dilatation), with the hope that compression of the presenting head against bleeding surface, especially in " marginal" and " par- tial" cases, will arrest hemorrhage. This may be promoted by ergot and abdominal pressure over the fundus. In trans- verse presentations—not infrequently associated with placenta pnevia—version by external manipulation should be accom- plished, before the membranes are ruptured, or ergot given, pelvic version being of course preferred to cephalic. Partial Digital Separation of the Placenta consists in passing the hand into the vagina, and one or two fingers as far as they will reach into the uterus. The fingers, then insinuated between the placenta and the uterine wall, are swept round in a circle so as to complete the separation of that part of the placenta attached near the cervix, and whose incomplete detachment keeps the bleeding vessels open. It is often followed by retraction of the cervix and cessation of the hemorrhage, and is especially serviceable when the pla- centa is placed entirely over the os. Rapid expansion of the cervix with Barnes's dilators and deli very by version should follow. It must be noted that version may be performed in cases of placenta pnevia when there is less dilatation of the os than would be necessary in other cases, the tissues of the cervix being usually more relaxed and dilatable. In " par- tial" and " marginal" cases the hand is passed in through the segment of the os not covered by the placenta, and in " complete" cases one margin of the placenta must be loosened to make way for the hand, the wrist and forearm subsequently acting as a plug to stop bleeding. The prac- tice formerly recommended, of plunging the hand through the middle of a centrally implanted placenta in performing version, has for good reasons been abandoned. Simpson's method of treating placenta praevia consisted in completely separating and extracting the placenta, trust- ing to powerful uterine contraction for subsequent rapid delivery of the child, a trust so seldom realized in practice 220 PLACENTA PREVIA. that Simpson's plan is a thing of the past, and altogether given up. No precise rules can be laid down for the exact treatment of placenta prasvia in every case. The main difficulties, dangers, and principles of management having been learned and the several methods of treatment enumerated, the rest must depend upon the judgment, skill, and self-possession of the accoucheur. After delivery ergot must be given, and for several days, to prevent post-partal hemorrhage ; and a 2 per cent, solution of carbolic acid should be injected into the vagina twice a day to prevent septic infection. Hemorrhage before Delivery, but without Pla- centa Previa.—Partial separation of the placenta, with hemorrhage, may occur during the latter months of preg- nancy, or after labor has begun, when the organ is normally situated. It may result from blows, falls, or other mechani- cal violence; pathological degeneration of the placenta or utero-placental junction, profound anemia, albuminuria, and multiparity with frequent child-bearing are probable pre- disposing causes. Seldom occurs in primiparae. Symptoms___Flow of blood from the uterus; pure blood when it comes from between uterine wall and unbroken membranes; blood mixed with liquor amnii when the mem- branes are broken. Hemorrhage (coupled with alarming syncope, collapse, etc.) may, however, take place inside the womb without appearing externally, as, ex. gr., when the presenting head sufficiently plugs the os uteri; when effused blood accumulates between uterine wall and middle part of the placenta, the placental circumference remaining unseparated ; when the blood flows into the amniotic sac through a rupture of the membranes near the placenta ; and when it accumulates between the womb and membranes near the fundus. Other symptoms are : excessive pain, like flatulent colic, distension and irregular bulging of the uterine wall; labor pains may be absent altogether, or, if present, are irregular, feeble, and inefficient. The collapse, pain, etc., occurring during labor, have been mistaken for rupture of the uterus. The latter, however, will be accompanied with recession, or mobility of the presenting part, and escape of the child, POST-PARTAL HEMORRHAGE. 221 wholly or partially, into the abdominal cavity. Rupture is usually preceded by violent uterine contractions. Prognosis___Extremely grave, especially in concealed cases where the diagnosis is (or may be) uncertain, and efficient treatment postponed. The maternal death rate is, roughly, about 50 per cent., the infant mortality 95 per cent. Luckily the accident is not a common occurrence, though it is per- haps sometimes undiscovered. Treatment___Stimulate uterine contraction by every known means. Rupture the membranes at once; give ergot, ergo- tine hypodermically; apply uterine compression by firm abdominal binder. If os is dilated, deliver by version, or, if during labor the head is low enough, by forceps. If the os is not dilated, dilate it with Barnes's bags, until sufficiently open to admit of version, extraction of the child being assisted by manual abdominal pressure. CHAPTER XXIV. POST-PARTAL HEMORRHAGE--" FLOODING." Hemorrhage after delivery of the child, and either before or after delivery of the placenta, is a most dangerous complication, sometimes causing death in a few minutes, especially when unprepared for, and irresolutely managed. Hence necessity of fixed principles and decided remedies, used without hesitation, in the hour of need. Dr. Gooch well said: "No physician should have the assurance and hardihood to cross the threshold of a lying-in chamber who is not thoroughly conversant with the remedies for flooding." It consists of bleeding from the open mouths of uterine blood- channels from which the placenta has, wholly or in part, been separated. Causes___Correctly appreciating the causes of flooding permits prevention, which is better than cure. Excluding, for the present, the rarer cases in which bleeding occurs from laceration of the uterus, vagina, and vulva, the one condition, 19* 222 POST-PARTAL HEMORRHAGE. above all others, that leads to flooding is deficient uterine contraction,—sometimes a total want of it,—inertia uteri. Why should the womb remain inert after the child is born? Its muscular walls may be worn out by a long labor; or partially paralyzed (like an over-full bladder) from previous over distent ion due to amniotic dropsy, or plural pregnancy, etc. Too rapid labor, as by injudicious haste in artificial delivery, or from abnormally enlarged pelvis, especially when preceded by overdistension of the womb, produces it. The uterine muscular walls may be congenitally deficient in development (as in precocious mothers), or malformed, or bound down on the outside by peritonitic adhesions, or texturally degenerated from previous inflammation, or nu- merous and quickly successive labors, as in elderly women. Weak uterine muscles may occur from general weakness of the female, due to constitutional disease, severe previous illness, exhausting discharges, heat of climate, etc. Distension of bladder or rectum causes sympathetic uterine inertia, as may also violent mental emotion. Retention of placenta,—whether from morbid adhesion, large size of the organ, or irregular ("hour-glass") contrac- tion of the womb, mechanically prevents close contractile approximation of the uterine walls. In the case of morbid placental adhesion, the partially separated blood-channels are kept open and cannot retract to prevent bleeding, as they normally should do. Those who have flooded in previous labors are apt to flood again. This is observed in plethoric women, subject to profuse menstruation, and is further explicable by exist- ence of conditions as to pelvis, womb, etc., previously men- tioned, which are permanent and irremovable. Further causes are : conditions which interfere with for- mation of, or which tend to move and displace, coagula in the mouths of the bleeding vessels. The blood changes of profound albuminuria, and wasting diseases, possibly the so-called "hemorrhagic diathesis," may retard formation of coagula; and formed or half-formed clots may be displaced by strong arterial tension and pulsation, or by the patient suddenly rising, " sneezing, coughing, laughing, vomiting, etc." (Lusk.) On the whole the one main cause is deficient uterine con- POST-PARTAL HEMORRHAGE. 223 traction. When a contracted womb continues to bleed, there is probably laceration. Symptoms—Gushing of blood from the vagina, either immediately or some time after birth of child, or still later after delivery of placenta. Quantity variable : moderate or fatal—a trickle or a flood. Absence, partial or complete, of hard uterine globe on hypogastric palpation. The womb may be soft and greatly enlarged from accumulation of blood in its cavity, with little or no external flow (" concealed hemorrhage"). In either case there are symptoms of blood- loss : deathly pallor; cold extremities; feeble, frequent, thready or imperceptible pulse ; gaping, restlessness, dys- pncea, and hunger for air; thirst and even hunger for food. In the worst cases syncope, loss of vision, convulsions, death. Treatment. Preventive and Preparatory Measures.— The necessity of guarding against relaxation of the uterus and promoting uterine contraction during the third, and near the end of the second stage of labor—by manual pressure and ergot—has already been insisted upon as a precaution in every case. Prof. Lusk in his recently published work advises every obstetrician to prepare for flooding during second stage of labor—whether it is likely to occur or not—by pro- viding beforehand a good working Davidson syringe, ice, brandy, ether, perchloride of iron, morphia, a hypodermic syringe ready filled with aqueous fluid extract of ergot, basins of hot and of cold water, a bed-pan, carbolic acid, ergot, etc., all placed within easy reach of the bedside, a preparation neither tedious or troublesome, but wdiich may save a life.1 When the hemorrhage occurs, inject a drachm of fluid ex- tract of ergot, or two grains of ergotine in a drachm of water, into the outside of the thigh. Let an attendant give another dose by the mouth. Then pass one hand, without delay, into the uterine cavity, while the other compresses and manipulates (by kneading and friction) the fundus to pro- 1 It is hoped the recommendations of Dr. Lusk may contribute to lessen the frequency of the appalling deaths from flooding, many of which may be attributable to lack of previous preparation. It has long been the author's opinion, as already expressed on a former page, that some such preparation should be required of phy- sicians by legal enactment. 224 POST-PARTAL HEMORRHAGE. voke contraction. If the placenta is undelivered it must be removed at once, either by grasping and squeezing the fundus firmly by the outside hand; or the hand inside grasps the placenta bodily, having previously separated any remaining adhesions, and gently withdraws it, the hand outside mean- while compressing the uterus with sufficient firmness to squeeze its anterior and posterior walls together. If the placenta is delivered before the flooding, and large blood clots occupy the cavity, these must be fearlessly removed, and the obstetrician's hand take their place; at the same time a piece of ice, as large as an egg, may be passed in with the hand and moved about over the surface of the uterine cavity. A special mode of grasping the uterus— bimanual manipulation—maybe tried as follows : press the finger ends of the outside hand deep in between the umbili- cus and fundal tumor, so that the latter resting in the palm may be pushed down and forwards against the pubes, while the other hand (or two fingers of it), passed high up along the posterior vaginal wall, presses the lower segment of the womb—in fact, its cervix—forward towards the symphysis pubis, thus by a sort of temporary anteflexion the canal of the neck is closed and no blood can come out, while the pressure above prevents enlargement of cavity and accumu- lation within. It also stimulates contraction. A rolled, gashed lemon, or a small sponge filled with vinegar, passed into the womb, and squeezed so that their respective juices come in contact with uterine walls, are also efficient stimuli to contraction. And another good one is irrigation of the uterine cavity with hot water (110°- 120° F.) by means of a Davidson syringe, care being taken that the instrument is completely emptied of air before being used ; a bed-pan receives the returning water. In every case the child, whether washed or not, may be put to the breast, by an assistant, in the hope that suction of the nipples will produce reflex uterine contraction. Contraction may sometimes be induced by rolling a piece of ice on the abdomen over the fundus at intervals, or pour- ing cold water from a height upon it, or flaying it with a wet towel, or injecting ice water into the rectum, or vagina, or even into the uterus; this last, however, is not so good as the hot water previously mentioned. Should all means thus far referred to fail, the last resorts POST-PARTAL HEMORRHAGE 225 are : injecting the uterine cavity, or swabbing it by a sponge probang, with liq. ferri perchlorid. (or liq. fe. persulph.) one part, to five parts of water. This constringes the mouths of the bleeding vessels, coagulates the blood in them, and stimu- lates uterine contraction. The remedy is not without danger to life, but is justifiable when other means have failed. Tinc- ture of iodine, one part to three of water, has been used in the same manner. Compression of the abdominal aorta has been employed with good result as a temporary measure in urgent cases. It cuts off the blood supply to the flooding uterus, stimulates uterine contraction, and lessens risk of fatal syncope by keeping blood in the brain that would otherwise flow down- wards. Under no circumstances should a vaginal tampon be used. It would cause the uncontracted empty womb to fill up with blood, thus converting an external hemorrhage into an in- ternal, " concealed" one, and enlarging instead of diminish- ing the uterine cavity. In all cases it should be ascertained that inertia of the womb is not kept up by a full bladder or rectum. To restore the circulation after hemorrhage has ceased, or to prevent impending fatal syncope during its continuance, stimulants, nutrients, and opiates are required. A drachm of brandy, whiskey, or sulphuric ether may be given hypodermically and repeated at required intervals, morphia hypodermically to promote cerebral congestion, and tinc- ture of opium and brandy internally in full doses, to- gether with strong beef essence, milk, etc., at short inter- vals. If vomiting occur, opiate, stimulating and nutrient enemata, or hypodermic injections, may be used to the tem- porary exclusion of mouth feeding. Admit plenty of fresh air from open windows. Remove all pillows to keep the head low, and elevate the foot of the bed, thus promoting gravitation of blood to the brain and medulla. The head must not be raised from its dependent position, to give food or medicine, nor for any other purpose, for fear of syncope and fatal heart-clot, until reaction has taken place. Compression of the brachial and femoral arteries,—or binding the four extremities with Esmarch's bandages—like aortic compression—may keep enough blood in the brain, 226 POST-PARTAL HEMORRHAGE. temporarily, to prevent death, while stimulants get time tO actl r r- , > Transfusion of blood ; intravenous injection of fresh cow a milk, and of saline solution, are last resorts when other remedies fail. Milk, as advised by Prof. Thomas, is most available. Half a pint may be passed into a vein in the arm, by means of an elevated funnel from which depends a tube surmounted at its lower end by a small canula for penetrating the opened vein. The tube and canula must contain no bubble of air. After reaction has been established the woman wall suffer, perhaps for several days, with neuralgic headache and pho-' tophobia, due to cerebral anemia, hence iron, quinine, and nutritious diet will be required. Morbid Retention of the Placenta, from causes other than inertia uteri, has been referred to as an additional factor in the production of post-partal hemorrhage. It is commonly due to morbid adhesion of the placenta to the uterine wall, in consequence of placentitis, or inflammation of the utero-placental junction, having taken place during pregnancy ; or there may have been chronic inflammation of the lining of the womb (endo-metritis), with hyperplasia of connective tissue, before impregnation. Abnormal placen- tal adhesion is often associated with, and is indeed a cause of irregular, "hour-glass" contraction of the uterus, which consists in a spasmodic contraction of some of the circular muscular fibres of the womb near its middle, the placenta being retained above the constriction, through which last the umbilical cord may be traced up from the os externum. Spasmodic Contraction of the Os is another con- dition by which delivery of the placenta may be delayed. Treatment__Spasm of the os, and spasm of the circular fibres higher up, may both be overcome by steady continu- ous pressure with the hand, the finger ends being approxi- mated into a cone, or one finger put in at a time until all have entered, when the hand may be gradually forced through the constriction, counter-pressure being always made by the other hand upon the fundus. The placenta is then, if not adherent, simply grasped by the hand and gently withdrawn during a contraction of the uterus, aid being afforded by post-partal hemorrhage. 227 pressure on the fundus, and by ergot. If the organ is adherent, the morbid adhesion must be broken up and the placenta completely separated before withdrawal is attempted. A finger—one or two—must be insinuated between the uterus and placenta at some point already partially separated, or, if no partial separation exist, at a point where the placental border is thick, and then passed to and fro, transversely through the utero-placental junction, acting like a sort of blunt " paper-knife," until separation is complete. Another mode is to find, or make, a margin of separation as before, and then peel up the placenta with the finger ends, rolling the separated portion towards the hand-palm upon the surface of the still adherent part, as one might lift up the edge of a buckwheat cake and roll it upon itself until it were turned completely over and separated from the plate on which it lay. Strong fibrous, or fibro-cartilaginous, rarely, even partially ossified bands, may require to be pinched in two between the thumb nail and index finger. Great care is necessary to avoid peeling up an oblique layer of uterine muscular fibre, which might split deeper and deeper until leading the finger ends through the uterine wall into the peritoneal cavity. Should such a splitting begin, leave it alone, and recommence the separation at some other point on the placental margin. It is sometimes only possible to get the placenta away in pieces. These should be afterwards put together and examined to indicate what remnants are left behind. It may be quite impracticable to get out every bit, but small remnants, or thin layers too firmly adherent for removal, do not distend the womb enough to create hemor- rhage from their bulk, and the subsequent danger of septi- caemia from their decomposition may be obviated by inject- ing warm (2 per cent.) carbolized water into the uterus, twice daily, until everything has come away. In cases where the placenta is retained from its unusually large size, hook down one edge of it with the fingers to insure its presenting endways instead of flat like a button buttoned in a button-hole, and then make downward and backioard traction—aided by ergot and abdominal pressure— to draw it through the os uteri. To make the backward traction referred to, dig one or two fingers into the substance of the placenta, if it cannot be grasped firmly enough by the finger ends, and manipulate as if attempting to push it 228 inversion of the uterus. towards the sacrum. A part of the organ having thus been made to bulge out of the os, release the fingers and hook them into the placenta again, higher up, and so on until it has entirely passed into the vagina. Introducing the hand into the vagina for extraction of the placenta is sometimes sufficiently painful to cause objection and resistance on the part of the female, the vulvar orifice being tender, or perhaps more or less lacerated. A little firmness of purpose, sometimes lacking in the young practi- tioner, coupled with moral encouragement of the woman, and gentleness of manipulation, will remedy the difficulty. CHAPTER XXV. INVERSION of the uterus. The womb may be inverted in various degrees, from a simple indentation of the fundus, to its being turned com- pletely " wrong side outwards," and hanging in the vagina. It usually begins by " depression" of the fundus, the top of the uterus being indented like the bottom of an old fashioned black bottle; this may go on until the fundus reaches and begins to protrude through the os into the vagina ("partial inversion"), or the protruding part may come through more and more until the whole organ is turned inside-out (" com- plete inversion"). Occasionally inversion begins at the neck, the fundus being then inverted last. Causes—Under any circumstances inversion of the uterus is rare, but it is usually the result of mismanagement—trac- tion on the cord, or upon an unseparated adherent placenta, during the third stage of labor, especially when the womb is not well contracted. Other causes are: an actually short umbilical cord, or one that is practically short from coiling round the child; sudden delivery, particularly while stand- ing, and when the uterus is over-distended and relaxed ; violent straining, or coughing efforts after child-birth ; forci- ble and injudicious pressure upon the fundus from above, inversion of the uterus. 229 whether by the hand, or heavy compresses. In short a relaxed womb may be inverted either by pressure from above, or by traction from below. A very few cases have occurred after abortion, and in unimpregnated uteri with polypi whose pedicles were at- tached near the fundus, but these last belong to gynaecology. Symptoms___Hemorrhage, faintness, shock, pain, vesical and rectal tenesmus. Abdominal palpation reveals " depres- sion" of fundus, and bimanual examination, in " partial" and " complete" inversion, demonstrates respectively partial or complete absence of uterus from its normal position in the pelvis. Vaginal examination discovers uterine tumor occu- pying the vagina, together with the placenta, if this last has not been previously delivered. A fibrous polypus, the only thing liable to be confounded with an inverted womb, may be diagnosticated from the uterus by its complete insensibility, its total want of contrac- tion when handled, and by following its pedicle through the os uteri up into the uninverted uterine cavity, which last may, in any case of doubt, be demonstrated with the uterine sound. Feeling the fundal tumor of the womb in its proper position, through the abdominal wall, shows the organ is not inverted. Uterine inversion is hardly likely to be mistaken for polypus, except when the organ remains inverted for months (sometimes for years) after labor, becoming reduced in size by involution ; such cases are called " chronic inver- sion," and properly belong to gynaecology. The prognosis of uterine inversion during labor is always serious. The great immediate danger is profuse hemorrhage, the more profuse when associated with inertia uteri, and perhaps some spasm of the os. Much depends upon the early reduction of the inversion. Every minute adds to both danger and difficulty. Exceptionally the placenta may be sufficiently adherent to prevent great hemorrhage. Treatment___" Depression" of the fundus, and " partial" inversion may be readily reduced, by passing the hand into the womb and pushing out the indented portion, while the organ is then stimulated to contract. When inversion is "complete," reduction may still be easy, if attempted at once, but not so after delay. If the placenta be still wholly or in great part adherent, it should be attempted to push it back with the uterus, the closed fist 20 230 rupture of the uterus, vagina, etc. being pressed against the dependent fundus on which the placenta forms a cushion, while counter pressure is made with the other hand over the abdomen. When the bulk of the placenta interferes with reduction, and when it is already in great part detached from the womb, its separation may be completed before pushing back the fundus. When constric- tion of the os, and other causes, have produced swelling and congestion of the inverted uterine body, the latter must be compressed between the two hands steadily for a few moments to reduce its bulk before reduction is attempted. Should spasmodic constriction of the os render reduction impossible even by steady, firm pressure, anaesthesia may be resorted to, to relax the spasm. After reduction, the hand must not be withdrawn from the uterine cavity, until the organ has been made to contract, and the placenta, if pushed back with the womb, must then be separated and withdrawn as in other cases. When the dependent inverted fundus refuses to yield readily to manual pressure, one or both of the angles of the womb, where the Fallopian tubes enter, may be first indented in the operation of reduction. CHAPTER XXVI. rupture of the uterus, vagina, etc. Rupture of the Uterus may occur in any direction, transversely, longitudinally, or both ; in any position, fun- dus, body, or neck, most frequently towards the last; and in various degrees, that is through the muscular wall without rupture of the peritoneum, or through both peritoneal and muscular coats. Causes—Strong uterine contraction coupled with me- chanical ^ impediment to passage of child _ conditions existing in transverse presentations, pelvic deformity, or contraction, and with large size of the fcetus, especially of the fcetal head, as in hydrocephalus. The powerful contrac- tions produced by a too early and injudicious use of ergot. RUPTURE OF THE UTERUS, VAGINA, ETC. 231 Multiparity, and thinning of the uterine walls due to fre- quent child-bearing, are predisposing causes. Anteflexion, anteversion, cervical obstruction, and lateral obliquity of the uterus, constitute other instances of mechanical hindrance to labor liable to be attended with rupture. The womb may be ruptured by violent and unskilful manipulations during version and forceps operations. Inflammatory changes in the uterine tissues, due to prolonged pressure between the fcetus and pelvic walls, conduce to rupture—even ulceration and gangrene may occur. Rupture may occur also from blows, falls, and other mechanical injury. Symptoms—Although rupture generally occurs suddenly, and without warning, the existence of conditions mentioned under the head of " causes" ought to be sufficient to indicate danger of the accident. In certain cases of mechanical ob- struction to delivery, where the cervix uteri is tremendously stretched, and powerful contractions draw the fundus and body of the uterus, as it were, upwards, and off the child when the latter refuses to descend, the line or furrow of division between the thickened body of the uterus, and the thin distended neck, may be felt through the abdominal walls by palpation. Action and reaction are equal and in opposite directions, hence, during powerful uterine contraction, if the child will not descend, the body and fundus of the womb wdll ascend, thus the round ligaments of the uterus are put upon the stretch, and can sometimes be felt as tense cords by abdominal palpation. Such conditions indicate danger of rupture, and may be set down as premonitory symptoms. When rupture actually occurs, the typical symptoms are a sudden sharp pain in the womb (caused by its tearing), often accompanied by a snapping noise audible at some distance from the patient; sudden and simultaneous cessation of labor pains (a bursted uterus can no longer perform its func- tion of contraction) ; violent shock and collapse indicated by pallor, feeble and frequent pulse, cold extremities, fainting, hurried respiration, vomiting, etc. (usually due to hemor- rhage into the peritoneal cavity). On vaginal examination, the presenting part of the child is found to have receded from its former situation, owing to partial or complete escape of the fcetus through the rent into the abdominal cavity, where, by abdominal palpation, it may be felt as an irregular shaped tumor, more or less distinct from another tumor 232 RUPTURE OF THE UTERUS, VAGINA, ETC. formed by the partially contracted uterus. Blood may or may not escape from the vagina. A loop of intestine may prolapse through the rent and be found by vaginal exami- nation. The foregoing array of symptoms would leave no room for doubt in diagnosis. But when rupture takes place more gradually or is incomplete, and not accompanied by even partial escape of the child into the abdominal cavity, the symptoms are less decided. There may be no recession of tlie presenting part, no sudden excruciating pain, and uterine contraction may continue. Here the diagnosis is necessarily obscure. But there is usually bleeding into the peritoneal cavity, hence symptoms of collapse, a feeble and frequent pulse, etc., coming on more or less suddenly and otherwise unaccounted for. In a gradually progressive rupture, labor pains may continue, and force the child gradually through the enlarging rent. Accumulating blood may sometimes be felt as a doughy mass through the abdominal wall. Prognosis—It must be understood that rupture (lacera- tion) of the vaginal portion of the cervix uteri, may, and frequently does, occur during labor without any necessary immediate danger to life; but in these the tearing does not involve the peritoneum and escape of blood, etc., into the abdominal cavity. Rupture involving any portion of the womb above the vaginal part of the cervix is a different affair. The prognosis is here most grave. Death may ensue rapidly, either from profound shock, or hemorrhage into the peritoneum, or, sur- viving these dangers, fatal peritonitis and septicaemia may shortly follow. The maternal mortality much depends upon the severity of the case, the extent of rupture, and the treat- ment adopted. Formerly it was stated only one out of six cases survive, but by the timely performance of laparotomy the results have become so much more favorable that over half the women are saved. The fcetal mortality is still greater, survival of the child being a rare exception. Treatment—Before the occurrence of rupture, but when existing conditions indicate an evident liability to the acci- dent, every means of prevention must be adopted. Though good may be done in certain cases by the rectification of mal- presentations, uterine obliquities and flexions, still the main prophylactic resort is delivery, either by forceps, version, RUTTURE OF THE UTERUS, VAGINA, ETC. 233 craniotomy, or whatever other method the circumstances of the case require or will admit. Whatever method is adopted, extra care is necessary to avoid violence of manipulation, particularly when version is attempted. The thin distended lower segment of the womb may be easily ruptured even by moderately violent manipulations, and in cases where the child is dead, craniotomy and embryotomy should be resorted to, by preference, notwithstanding sufficient amplitude of the pelvis to admit of version being performed. After rupture has occurred, especially if it be at all ex- tensive, whatever is to be done had best be done quickly. There must be no delay. The results of modern practice and the weight of professional opinions have of late strongly tended to the conclusion that laparotomy (cutting through the abdominal wall and taking out the child, blood-clots, etc., through the incision) should be at once performed in all cases of extensive uterine rupture. Such a rule, how- ever, has not yet been finally adopted. The child should certainly be delivered, without delay, in all cases. This rule is invariable. The mode of its removal is the difficult point to be decided in a special case. In this decision but little value must be accorded to the life of the child. It will generally die. Should craniotomy or cepha- lotripsy, therefore, appear to afford the speediest method of delivery, they may be employed, even though the child still live, and though it were possible, with a little more delay, to extract it by version or forceps. Delivery, however, through the natural passages must not be attempted by any operation, when the child has entirely, or in a great mea- sure, escaped through the rupture into the cavity of the abdomen. Then laparotomy is, without question, the only resort.1 When, on the other hand, the child has not escaped ; when the os uteri is dilated and the head presents; and when there is no mechanical obstacle to rapid delivery by forceps, this instrument may be applied. If necessary, and the proper instruments are attainable without delay, perfo- ration of the skull may precede forceps. In other cases, when the child still remains in the womb, but delivery by 1 For the mode of its performance, see " Cutting Operations upon the Mother," chapter xix. 20* 234 RUPTURE OF THE UTERUS, VAGINA, ETC. forceps is not likely to be rapidly successful, the main resort is version by the feet. Even when part of the child has escaped into the abdomen, provided it be not too great a part, version may still be performed. The utmost care is necessary to avoid enlarging the rupture and pulling down a loop of intestine, and when the child is delivered, extreme caution is required in delivering the placenta. The rup- tured womb will not expel this last spontaneously. The hand must be passed into the uterus for its withdrawal, as in other cases. If the placenta has escaped through the rent (which is unusual when the child has not done so), , traction may be made on the cord to bring it near, or into the tear, so that the hand in the uterus may get hold of it without the necessity of passing the hand through the rent into the abdominal cavity. Subsequent Treatment___Stimulants to counteract shock . and collapse from hemorrhage. Opiates to relieve pain. A drainage tube passed into the uterus, and penetrating half an inch through the rupture, its lower end stitched with silk to the posterior commissure of the vulva, and covered with antiseptic cotton, has recently been recommended to promote ( discharge of retained septic fluids. After two or three days, when inflammatory adhesions have sufficiently closed any communicating channel between the uterine and peritoneal cavities, antiseptic solutions of carbolic acid (two per cent.) may be used for irrigating the cavity of the womb and pre- venting septic infection. Rupture (laceration) of the Vaginal Portion of the Cervix Uteri—Slight superficial lacerations are very common, and often unrecognized. Even considerable ones pass unnoticed by the obstetrician more frequently than they would if properly sought for, as they should be after labor is over. Occasionally they extend up to the utero-vaginal junction, or into the vaginal wall. Sometimes transverse in direction (though generally longitudinal) ; pieces of the os may hang downwards in the vagina, and rarely an entire ring of the vaginal cervix may be separated. Causes—Distension by the presenting part of the child during labor ; rough manipulations during version, forceps, and other operations ; incarceration of the anterior lip of the 1 os between the head and pelvis. THROMBUS OF THE VULVA. 235 Tissue changes preventing dilatation of the os, and primi- parity, especially in elderly women, are predisposing causes. Symptoms—Hemorrhage, more or less profuse, according to extent of laceration, the latter to be diagnosticated by digital examination, or, if necessary, by ocular inspection with speculum. Treatment.—Slight lacerations get well rapidly without treatment. In more severe ones hemorrhage may be con- trolled by application of solution of persulphate or perchlo- ride of iron on cotton plugs. Recently the practice of uniting extensive lacerations with silver sutures has been adopted with good results ; it prevents the subsequent oc- currence of congestion, inflammation, and hypertrophy, etc., of the cervix, which may require restoration of the lacera- tion by sutures, etc., months or years afterwards. Carbolized injections into the vagina for a few days after labor when laceration exists, should always be employed to prevent absorption of septic matter by the raw surfaces. Lacerations of the Vagina itself, or of the Va- ginal Orifice are recognized by digital examination or inspection. Extensive ones should be united by silver sutures at once. Small ones require only antiseptic clean- liness, and remedies for hemorrhage, should any occur. Rupture of the Tissues of the Vulva—of their inner tissues and bloodvessels—without any necessary lacera- tion of skin or mucous membrane—may occur either during or after labor. Blood is immediately extravasated, causing the labium to swell rapidly, and constituting Thrombus of the Vulva__A tumor—bluish in color, elastic or fluctuating, accompanied by sharp pain, usually on one side—forms rapidly, sometimes of sufficient size to mechanically prevent delivery. It may burst and lead to profuse or even fatal external hemorrhage. Extravasation may extend upward outside the vaginal wall to the uterus, or even to the cellular tissue of the iliac fossa, or behind the peritoneum to the kidneys. The Prognosis is variable according to the extent of the injury and extravasation. Death may result from hemor- rhage, or from decomposition of retained clots and septi- 236 RUPTURE OF THE UTERUS, VAGINA, ETC. caemia. In many cases, of moderate extent, absorption of the effused blood and recovery take place. Treatment__During labor, delivery should be hastened, preferably by forceps, and this early—before the thrombus has had time to grow very large. If its size prevent delivery the tumor must be incised, the clots turned out, subsequent hemorrhage controlled by compression, or pledgets of cotton containing solution of perchloride of iron, and delivery by forceps rapidly completed. After labor, when the thrombus has been opened, artificially or otherwise, styptics and com- pression may still be required to prevent further bleeding. If delivery has been completed without opening the tumor, it must be left alone for absorption to take place. Should suppuration occur, as sometimes happens in a few days, the part must be incised to give exit to pus and clots, and anti- septic treatment of the wound adopted to prevent septic infection. In all cases absolute rest in the recumbent pos- ture and the avoidance of straining efforts of every kind are indispensable, to prevent recurrence of hemorrhage. The bleeding (or extravasation) may also be controlled by vaginal hydrostatic pressure, an elastic rubber bag, or Barnes's dilator, filled with ice water being introduced into the vaginal canal, for a few hours subsequent to delivery. Carbolized washes to be used after its removal. Rupture of the Perineum—Causes and mode of pre- vention of this accident during labor, have already been considered. (See chapter xi.) Every woman ought to be carefully examined after de- livery, and preferably by inspection of the parts, to ascertain if perineal laceration exist. Slight fissures of the posterior commissure, or of the four- chette in primiparae, usually heal of themselves without treatment. Extra antiseptic cleanliness is, however, ad- visable. Even tears of apparently considerable size shrink almost to nothing when the tissues have recovered from the distension of parturition as they do in a short time. The extent of rupture may be either seen or made out by passing a finger into the rectum and thumb into the vagina* so as to hold the remaining recto-vaginal septum between the two. Extensive lacerations often involve the sphincter ani and posterior vaginal wall. LOOSENING OF THE PELVIC ARTICULATIONS. 237 Treatment.—Unless the laceration is quite insignificant, the sum total of treatment consists in bringing the freshly lacerated surfaces together by silver sutures immediately after labor. This is to be done whether the sphincter ani be torn or not. In fact the more extensive the laceration, the more necessity and greater advisability of stitching up the rent. In slight cases one -suture alone may be sufficient. The operation is not' very painful immediately after delivery. Anaesthesia seldom required, unless the rent be very exten- sive, when ether may be cautiously administered. The sutures should remain in situ one week, the patient mean- while being confined to the recumbent posture, her knees loosely tied together to prevent stretching of the perineum by their separation. Opium may be required to relieve pain ; saline laxatives to keep the bowels soluble ; and a catheter twice daily to empty bladder. Carbolized vaginal washes twice a day, and extreme cleanliness. Loosening of the Pelvic Articulations—of the pubic symphysis and sacro-iliac synchondroses—occasionally occurs, either from pathological changes in the joints, or from great violence during forceps and other modes of artificial delivery, or both conditions exist together. The symptoms are, at the time, pain and increased mobility of the articula- tions, demonstrated by grasping the two iliac bones near the anterior extremities of their crests, one in each hand, and moving them slightly to and fro, transversely, in opposite directions. Later symptoms are pain on locomotion, and movement of the lower limbs, relieved by rest and support of the pelvic walls by a wide circular bandage around the pelvis, which constitute the proper treatment, and must be continued until reunion of the parts has taken place. A strong towel or leather belt must be applied so that it em- braces the pubic, symphysis, without pressing upon the iliac crests. Recovery usually results. 238 multiple pregnancy, etc. CHAPTER XXVII. MULTIPLE PREGNANCY--HYDROCEPHALUS AND OTHER ENLARGEMENTS OF THE CHILD. The simultaneous existence of two or more fcetuses in the womb is termed " multiple" or " plural" pregnancy. The number of ova may be too, three, four, or five, named, respectively, twins, triplets, quadruplets, and quintuplets. Reported cases of more than five are not well authenticated. Twins occur once in about seventy-five cases ; triplets once in about five thousand ; quadruplets and quintuplets are ex- tremely rare. Plural pregnancies are produced by two or more ovules entering the uterus and becoming impregnated about the same time. One ovule may come from each ovary, or two from the same ovary. In the latter case both ovules may come from one Graafian follicle, or each from a separate one. Again, one ovule may contain two germs, like a double-yolked egg from the fowd. These several modes of origin explain the observed variation in the arrangement of the placentae and fcetal membranes in different cases. Gen- erally each ovum (in twin cases) has its own sac of amnion and chorion, which comes in contact with that of the other as growth advances; but the two sacs do not amalgamate: they remain separate till birth. In these there are two placentae, usually separate from each other, though they may be near together, or partially united. In other cases each ovum has its own amnion, but both are contained in one chorion. In these the two placentae are fused together, or the two um- bilical cords may be united before reaching the placenta. Rarely both foetuses are contained in one amnion, as well as in one chorion. Here again the placentae are united in one mass. Two ova contained in one chorion are of the same sex. The fact that the vessels of the two placentae and of the MULTIPLE PREGNANCY, ETC. 239 two cords may inosculate with each other (but which cannot be made out before delivery), leads to an important modi- fication of the management of labor in twin cases, to be mentioned presently. The growth of the embryos in twin cases is seldom ex- actly equal, and sometimes the difference is very great, one child appearing fully developed, while the other remains very small. One foetus may die and be thrown off prema- turely, while the other remains till full term ; or the little dead one may still remain in utero, and come away at full term with the live one. These variations are due to con- ditions favoring the nutrition and circulation of one foetus at the expense of the other, such as folds or compression of the cord and compression of the placenta. When the two fcetal circulations inosculate in the cord or placenta, one fcetus having a stronger heart than the other would favor its better nutrition and development. Occasionally one child remains for days and even weeks after the birth of the first one before it is delivered, and thus completes its development. Such cases are best ex- plained by the existence of a double uterus. Plural births generally occur a little before full term, the degree of pre-maturity increasing with the number of foe- tuses. In twins only a few weeks may be wanting of the usual period ; quintuplets are always abortions ; the others are intermediate. Diagnosis.—The certain diagnosis of twins before one child is born is seldom practicable. The following data are, however, sufficient to make a diagnosis probable, and in a few cases, when they are all available, a positive decision may be reached : Large size and irregular shape of the uterus ; feeling the numerous parts of the foetuses, especially two fcetal heads, through the abdominal wall ; exaggeration of the signs of pregnancy, especially such as are due to pressure of the gravid uterus ; recognition of foetal motions at different parts of the abdomen ; impossibility of ballotte- ment; recognition by auscultation of two fcetal heart sounds, not synchronous with each other, heard loudest at two dif- ferent points of the abdominal surface, and becoming feeble or inaudible between those points. After one child is born, the existence of a second is readily made out by the still large size of the womb ; by feeling the 240 MULTIPLE PREGNANCY, ETC. child through its wall over the abdomen; and, by a vaginal examination, recognizing the bag of waters and presenting part of the second infant. Women who have borne twins once are likely to do so again. The tendency to plural births is also hereditary in some cases. Prognosis.—Delivery of the first child usually tedious from inadequate labor pains, due to over-distension of the uterus, and from force of uterine contraction being neces- sarily diffused through bodies of both children, instead of being concentrated upon the presenting one. Delay is greater when first child presents by the breech, especially so in delivery of the after-coming head. Prolongation of labor, large size of placental wound, and over-distension of womb predispose to inertia uteri and post-partal hemorrhage. Mai presentations are more frequent than in single births. In about half the cases both children present by the head; in one-third of the cases, one head and one breech ; in one- ninth both by the breech ; and in one-tenth, either one or (rarely) both children present transversely. Excluding the complication of mal-presentation, the oc- currence of twins, with proper management, need not pre- clude a favorable prognosis in the great majority of cases. Treatment—Tie the placental end of the cord when one child is born, to prevent possible hemorrhage from the second child owing to inosculation of vessels between the two cords or placentae. Let the placenta alone until after delivery of second child, unless it be spontaneously expelled before then, when it may be carefully removed. The alleged danger of mental shock from telling the fe- male she is to have a second child, is seldom serious, espe- cially when she is told its delivery will be short and easy. After one child is born there usually succeeds an interval of rest from labor-pains for fifteen minutes, sometimes for half an hour or an hour, when contractions again come on, and the second child is easily expelled, the parts having been thoroughly dilated, and the second child being usually smaller than the first. During the interval, when rest is advisable for recuperation of the (perhaps exhausted) uterus, examination must be made to ascertain the presentation, and correct it if transverse. After an hour, or before then if the uterus is not exhausted MULTIPLE PREGNANCY, ETC. 241 by previous prolonged effort, the membranes, if intact, may be ruptured, ergot given, and the womb manipulated through the abdomen, to produce contractions. In case of hemorrhage, convulsions, feebleness of the fcetal heart, or any condition rendering immediate delivery necessary, forceps may be applied if the head has descended into the pelvis, and version if it has not. In either case, extract the child slowly, so as not to leave an empty relaxed womb, every means being taken to secure simultaneous uterine contraction. When both children are delivered, extra care is necessary to overcome inertia and prevent post-partal hemorrhage. Treatment of Locked Twins___When both children are contained in one amniotic sac, or when, there being two sacs, both have ruptured early in labor, both children may present and enter the pelvis together, and thus getting " locked," prevent delivery. When both heads present at the brim, one may be pushed out of the way by combined internal and external manipu- lation, and forceps then applied to the other to bring it down into the strait and cavity of the pelvis. When both heads have passed the brim, push back the second one, and apply forceps to the first (the lower) one. Should this be impracticable from the heads having des- cended too far, the lower head, and then the other, may be successively delivered by forceps. F^xceptionally craniotomy is required. The same mode of treatment may be necessary when one head, having entered the pelvic cavity, is arrested by the jamming of the thorax against the second head either at or above the pelvic brim. When the first child presents by the breech and is delivered as far as the head, the latter may remain above the brim, owing to the head of the second child having descended into the pelvic cavity, the head of each child resting against the neck of the other, so as to lock or lap the chins together and prevent further progress. Diagnosis of the exact arrangement of the complication having been made by the hand in the vagina, several differ- ent methods of delivery are available, selection of either being a matter of judgment determined by the peculiarities of each case. As a rule, the life of the child whose breech is delivered will be enfeebled or lost by compression of its 21 242 MULTIPLE PREGNANCY, ETC. funis, or it may be already extinct. Hence in selection of operative measures superior value should be allotted the second child. The head of the second child may, possibly, be pushed up out of the way for the other to pass. The second head may (?) be delivered by forceps, while the first remains, but not without difficulty and great danger to both children. The head of the first child may be punctured, or even decapitated, so as to allow extraction by forceps of the second one, the body of the first (when decapitation has been performed) being, of course, previously removed ; its head coming after the other child is born. This last method probably affords the best chance for the second child. Most frequently both are lost. When the lives of both are ex- tinct before delivery, there still remains another resort, viz : that of puncturing the second head and delivering it by forceps or cephalotribe past the body of the lower child. In cases of conjoined twins—double monsters—when the natural powers are insufficient for delivery, version by the feet—and possibly subsequent mutilation—afford the best means of relief. Most such cases are, however, delivered spontaneously. Hydrocephalus—distension of the skull from accumu- lation of effused serum—constitutes a dangerous impediment to delivery, leading to rupture of the uterus, or dangerous inflammation and sloughing of the mother's soft parts from their prolonged compression during a tedious labor. When slight in degree, labor may, however, terminate spontane- ously without danger. In extreme cases the child's head is as large as that of an adult. Diagnosis—Difficult early in labor. Strong pains, con- joined with a (known) normal pelvis, but without expected descent of the head, should excite suspicion and induce a careful examination. Owing to unusual large size of fcetal head, the child's body is higher up, hence sounds of foetal heart heard level with, or even above the umbilicus. When head arrested above superior strait, pass the whole hand into vagina (under ether, if necessary from pain) and feel the head. Its large size, wide and perhaps fluctuating fonta- nelles and sutures are sufficiently characteristic. The head is less convex, and feels more like a flat lid over the pelvic brim, than a globular mass. The sutures and foiitanelles MULTIPLE PREGNANCY, ETC. 243 become tense during a pain. The cranial bones are less resistant to the finger An enlarged posterior fontanelle is very significant. The prominent forehead and superciliary ridges contrast with the comparatively small face of the child. The previous birth of a hydrocephalic infant, and comparatively feeble fcetal movements, are corroborative circumstances. In breech presentations (they occur one out of five in hydrocephalic cases), the diagnosis is still more doubtful. Nothing wrong is suspected, usually, until the body is born; then there is delay, an unusual resistance—a sort of elastic, resilient resistance—on making traction upon the body. The body may be well nourished, but frequently is small and emaciated. The uterine tumor is of larger size than usual above the pubes owing to its containing the distended cra- nium. Prognosis___The chief dangers to the mother are uterine rupture ; exhaustion ; laceration, contusion, etc., of soft parts, with subsequent ulcerations and fistulae;—all preventable, in great measure, by timely assistance of obstetrician. The child generally dies, either before, during, or shortly after delivery. Exceptions possible. Treatment___In head presentations, aspirate, or tap skull to lessen its size, when this is absolutely required. Cases of moderate enlargement may be delivered spontaneously, but it is better not to risk mother by delay, for the sake of a child whose survival, at best, is extremely dubious. After puncture, and reduction of size of head, it may be possible to extract by forceps—but they are nearly sure to slip off during traction if the head is very large. Then either the cephalotribe or cranioclast might be used ; but the better and more usual plan is to turn and deliver by the feet. In breech presentations, puncture of the skull may be made behind the ear, or through the occiput, or through the orbit, or roof of the mouth ; or the spinal canal may be opened and a wire or metal catheter, etc., passed through it to the brain, and the fluid thus drawn off. Excephalocele__Associated with, though at other times independent of, congenital hydrocephalus, may be an accumulation of cephalic fluid outside the cranium under- neath the scalp, forming a tumor, insignificant in size or as 214 MULTIPLE PREGNANCY, ETC large as a foetal head, whose cavity may, or may not com- municate with that of the cranium. It is attached to the head by a pedicle and constitutes a so-called encephalocele. Fortunately such tumors are most often attached either to the frontal or occipital pole of the foetal head, and hence are less liable to interfere mechanically with delivery than when placed elsewhere. The bones of the cranium are also usually softer and more yielding. Puncture of the sac and evacua- tion of its fluid will remedy any mechanical interference with delivery that may arise. Ascites, Tympanites, Distension of the Urinary Bladder, Hydrothorax, Hydronephrosis, and various other pathological enlargements on the part of the child, may occasionally lead to difficult labor and require operative interference. They are extremely difficult to diagnosticate befor'e delivery. The diagnosis chiefly rests upon the ex- clusion of more common causes of mechanical obstruction, and (in the case of gaseous or liquid distension of cavities, etc.), on the springy, resilient resistance recognizable when traction is made on the presenting or extruded fcetal parts. Liquid or gaseous accumulations are to be relieved by care- ful puncture, preferably by aspiration, if the child be living. Forceps, version, and exceptionally embryotomy, may after- wards be required. Large Size of the Child. Premature Ossifica- tion of the Cranial Bones.—In over-long pregnancies (those of 10|> 11, or 12 lunar months) the child is apt to be far above the usual size and weight. Instead of weigh- ing seven or eight pounds (the average), it may reach twelve, fifteen, or even more, and though the increase is distributed over the whole body, the degree of cranial enlargement espe- cially may considerably impede delivery, and a certain amount of difficulty may even attend extraction of the shoulders and body. In carefully measuring the cranium of a child weigh- ing thirteen and a half pounds, immediately after birth, I found all of its diameters nearly an inch above the average length. Such infants are usually males. In well formed and good sized pelves delivery may be accomplished by forceps or version. In very extreme cases craniotomy may become a possible necessity. In delivery of the body, trac- TEDIOUS labor. 245 tion and manual aid in furthering the normal mechanism of labor will usually suffice. Premature Ossification of the Cranium sufficient to interfere with moulding of the head, thus producing dys- tocia (difficult labor), is very rare. Diagnosis by complete closure of the fontanelles and un- yielding resistance of the bones to pressure of examining finger. Treatment__Forceps, if required: possibly perforation of the skull. CHAPTER XXVIII. TEDIOUS LABOR—POWERLESS LABOR--PRECIPITATE LABOR. Tedious Labor (called also " Lingering," " Tardy," " Protracted," and " Prolonged)."—These terms refer to time, but the duration of labor varies so widely within the limits of normality, that it alone is not sufficient to indi- cate the technical and practical meaning of " tedious" de- liveries. Certain other phenomena, mentioned below under the head of "Symptoms," are necessary, before any case can be set down in this category. Causes__The very numerous conditions liable to produce tedious labor may be broadly comprised in two lists: 1st. Conditions rendering the natural forces of labor deficient; 2d. Mechanical impediments to delivery. Both kinds of conditions may, and necessarily often do, coexist. The main force by which the child is naturally expelled is that of uterine contraction. This may be impaired in various degrees by exhaustion of the muscular walls of the uterus from prolonged effort; by over-distension of the womb from hydramnion, plural pregnancy, etc.; by precocious or advanced age at the time of delivery; by violent mental emotion; by distension of the urinary bladder, and of the /-rectum ; by obliquities and displacements of the uterus ; by 21* 216 tedious labor. thinning of the uterine walls from frequent and quickly re- peated labors, or from fatty or other degeneration of the uterine tissues ; by general debility or feebleness on the part of the female,1 whether resulting from previous disease, enervating habits of life, heat of climate, or exhaustion from hemorrhage, or want of sleep during a prolonged first stage of labor. Loss of power in the uterus also occurs occasion- ally as the result of uraemia; and morbid adhesion between the decidua and uterine walls is set down as another cause. The secondary forces of labor, viz., contraction of the ab- dominal walls and diaphragm, may be impaired by abdom- inal distension, as from dropsy, ovarian and other tumors, etc.; or by diseases of the respiratory organs (asthma, bron- chitis, etc.), which interfere with the woman inspiring and holding in a long breath during the act of bearing down. The mechanical impediments to delivery, from which tedious labor may result, are almost numberless, embracing, of course, every kind and degree of obstruction, such as smallness, deformity, and abnormal growths of the pelvis ; resistance, rigidity, deformity, and abnormal growths of the maternal soft parts; and abnormal size, presentation, position, etc., of the child. Practically the larger number of tedious labor cases are due to partial or complete inertia, or exhaustion of the mus- cular uterine walls, coming on as the result of prolonged effort, due to coexistence of some mechanical impediment to delivery. Prognosis and Dangers of Tedious Labor___The first stage of labor, before rupture of the membranes, may be greatly prolonged, even for several days, without any neces- sarily serious consequences to either mother or child. Ex- ceptions, however, occur. Before rupture the waters act as a cushion between womb and child, thus protecting both from injurious pressure. Pressure upon the funis, and ob- struction to the placental circulation, such as may occur when the womb is long contracted, round, and in close con- tact with the child, are also obviated. 1 The womb derives its motor power, in great part, from the (so to speak) electric engine of the spinal cord, but the evolution of nerve-force, when the patient is enfeebled by general debility, loss of blood, etc., is necessarily defective. tedious labor. 247 During the second stage, when the womb does contract powerfully and in close contact with the infant; when the placental circulation, therefore, is, or may be, partially in- terfered with ; and when the soft parts of the mother, both the uterus and other parts below, are necessarily subjected to great pressure, the results of prolongation of the labor become far more serious. Swelling, oedema, inflammation, with subse- quent sloughing and fistula? may occur; the child may die from continued compression of its skull, cord, or placenta; and general symptoms of exhaustion and collapse take place, from which the woman, if not promptly delivered, may die on the spot, or succumb afterwards from post-partal hemor- rhage, puerperal inflammation, septicaemia, etc., etc. Every case, therefore, of actual or impending tedious labor should excite apprehension for the woman's safety, increasing in degree according to the extent to which the symptoms have progressed, and the estimated difficulty of prompt delivery. With timely assistance safety may often be assured, while delay may render recovery impossible. Symptoms___These, be it noted once for all, usually begin moderately, but increase in varying degrees of rapidity with delay. They are: increased frequency and feebleness of the pulse; heat and dryness of skin; coated and. dry tongue; persistent nausea and vomiting; in fact, some fever. Increasing feebleness, instead of normal increasing strength, of the labor pains, which are also irregular in their°recurrence, with shortening of their duration and lengthening of the intervals between them. The woman is restless, despondent, irritable, apparently wilful. Moral en- couragement no longer serves to revive her hopes and renew her good spirits. The examining finger easily recognizes increased heat, lack of moisture, swelling, and perhaps ten- derness of the vulva or vagina. There is no advance of the presenting parts. Things are at a stand-still, and soon retrograde from bad to worse if relief is not at hand. The pains°stop altogether; pulse very frequent and feeble (110- 120 or more); dry, brown tongue; slight incoherence or muttering delirium ; husky voice ; anxious expression ; face dusky, and eyes apparently sunken. Uterus tender on ab- dominal palpation, and vaginal symptoms just cited are in- creased. Such symptoms are of extreme gravity. One other symptom deserves special notice, viz., though 248 tedious labor. the pains are feeble or quite absent, the womb is spasmod- ically contracted round the child, and remains so continu- ously,—it is a rigid tonic contraction that has been called, not inaptly, " uterine tetanus." Diagnosis___The combination of symptoms just stated, even in their early and slighter manifestations, especially when coupled with prolonged duration and lack of progress in the labor, and evident causes of mechanical hindrance to delivery, can leave no possible room for doubt. Other con- ditions leading to cessation of labor pains, frequent and feeble pulse, collapse, etc., such as, e. g., rupture of the womb and hemorrhage, have a different history, and the symptoms are sudden instead of gradual in their approach. Treatment—The main element of treatment is to treat the case early, before the symptoms have progressed beyond recovery. The indications are, in the beginning, to correct or remove existing causes of uterine inertia, and existing mechanical impediments to delivery. When manual or instrumental delivery is required, the operation should be begun, if practicable, before, or at least as soon as, the symp- toms of tedious labor begin. In every case ascertain that the bladder and rectum are empty. If they are not, a catheter and purgative enemata must be used. Excessive distension of the womb from dropsy of the amnion, requires evacuation of the fluid by rupture of the membranes. Distension from twins : delivery by forceps or version. The effect of violent mental emotion can scarcely be ame- liorated else than by moral persuasion, quiet rest, and per- haps a composing dose of valerian (elix. valerianat. ammon. gtt. xx.), or some other anodyne. Uterine feebleness from sleeplessness due to a prolonged first stage of labor, requires a full dose of morphia (gr. ^), or of chloral hydrate (gr. xx.). Lateral obliquities of the uterus may be corrected by a finger hooked into the os, while pressure is made in the right direction upon the fundus. The woman should lie on the side opposite that to which the fundus is directed, so that the latter falls straight by its own weight. Unusual resistance of " tough membranes," or adhesion of rigidity of the perineum. 249 the decidua to the uterine wall, must be remedied respectively, by rupture of the sac, or by breaking up the adhesions with a finger or flexible catheter. A feeble, debilitated woman must have food (milk is best), and a moderate quantity of wine or alcoholic stimulant, given cautiously in small quantities at short intervals. Obstructions due to the mother's soft parts are as fol- lows :— Swelling and OEdema of the Anterior Lip of the womb, from its getting pinched between the head and pubic symphysis. It must be pushed up with the finger ends, and held there for several successive pains, until the head slips by it. If much swollen and appearing at the vulva, as may occasionally occur, pushing it up is impracticable. Deliver the child by forceps, or by whatever method may be neces- sary, without delay. Rigidity of the Os Uteri : is either spasmodic or or- ganic. The former occurs in highly nervous and emotional primiparae most frequently; or may be due to premature rup- ture of the membranes. Treatment.-—When the membranes are intact, time and patience usually remedy the difficulty, but in these cases, as in others where the membranes have ruptured, dilatation is greatly expedited by full doses of chloral hydrate, gr. xv., repeated every twenty minutes till two or three doses are taken. An emetic of ipecacuanha (gr. xx.) will often relax the os. Warm vaginal douches for half an hour at a time, and stretching the contracted ring by the finger will assist. In organic rigidity, due to development of fibrous tissue from previous chronic inflammation, nicking the border of the os, with scissors or a bistoury, to the depth of ^th of an inch, at two or three different points, may be necessary when other measures fail. When the constriction is at the inter- nal os, use Barnes's dilators. Rigidity of the Perineum__Very rarely organic, cica- tricial hardening of the perineum may require incisions, to be afterwards closed by sutures ; but in far the larger num- ber of cases, delivery by forceps, and without incision or lace- 250 tedious labor. ration, is the proper treatment, the rigidity not being due to constricting tissue changes. Other more rare conditions of the soft parts of the mother obstructing labor will be considered in a future chapter. The mechanical impediments to delivery on the part of the child and pelvis, are, of course, to be treated in accord- ance with the general principles of operative midwifery. Thus far we have referred chiefly to removing or obviating the causes of tedious labor—in fact its prophylactic treat- ment. When tedious labor has actually set in, or has consider- ably progressed, the main point is delivery as soon as possi- ble ; the mode of delivery being, in the larger number of cases, forceps. While true that in a certain number of cases delivery would, in clue time, spontaneously occur after some hours' further delay, provided the uterine inertia and general exhaustion were not excessive and there existed no absolute mechanical obstacle to delivery, experience has, neverthe- less, amply proven that the required additional delay is not to be depended on, while delivery by forceps may be safely and often quite easily performed. The old maxim, "Med- dlesome midwifery is bad," has become obsolete. Though delivery might in time spontaneously occur, the chances of final and rapid recovery, after labor, are far less than when forceps are applied without delay. Besides forceps, three other remedies are available, viz., manual pressure upon the uterus through the abdominal wall, ergot, and quinia. Manual pressure is simply a substitute for uterine contrac- tion. It may be used to reinforce feeble pains, or replace absent ones ; and must imitate them, especially as regards intermittance, duration, and force, as nearly as possible. Complete expulsion of the child, by pressure properly ap- plied, has even been accomplished when the pains were en- tirely absent. It is applied thus : the patient lying on the back, spread the palms of the hands out over the sides and fundus of the womb, and when a pain begins, make firm pressure, while it lasts, downwards and backwards, in a line with the axis of the plane of the superior strait. Lessen, and then stop pressing, as the pain goes off. If there are no pains, imitate them as nearly as possible. If the woman lie upon her side, one hand only can be used (the left, if she lie PRECIPITATE labor. 251 on the left side, the right, if on the right) to make pressure on the fundus, while the other guards the progress of the presenting part per vaginam. Manual pressure must not be employed, of course, when the uterus is very tender on pressure, nor when it is spasmodic- ally contracted round the child, nor when there is any mechanical impediment to delivery. Ergot, given to expedite labor, is at best a dangerous remedy to both mother and child. Given in the usual dose of 15 or 20 grains of the powder, or as many minims of the fluid extract, it is apt to produce tetanic rigidity, and even rupture of the uterus, besides injuring or killing the child by compression. It certainly must not be given wdth a view to overcome mechanical obstruction, of whatever degree, and whether in the hard or soft parts. If resorted to at all in tedious labor, a close of 1 or 2 grains given every twenty minutes, to reinforce feeble pains, is its only safe application ; excepting, of course, the conventional full dose, fifteen min- utes before delivery (when we are assured the child will be born in that time), to promote contraction during the third stage of labor, and thus prevent post-partal hemorrhage —a precaution doubly necessary after uterine exhaustion from protracted delivery. Sulphate of quinia, in fifteen-grain doses, has of late been used as a substitute for ergot in stimulating uterine contrac- tion during labor. It is not accompanied or followed by any unpleasant consequences, and is decided in its good effects. Powerless Labor practically means nothing more or less than the last stage of tedious labor, just previously de- scribed. The powers of the woman and of her uterus are completely exhausted. Such cases should never be permitted to occur; and scarcely ever would if "tedious" cases were promptly delivered before they become too far advanced, as above recommended. (See Tedious Labor, pages 248-250.) Precipitate Labor is one in wdiich the child is deliv- ered with unusual rapidity. It is of comparatively infrequent occurrence. The infant may be expelled unexpectedly, while the woman is standing or walking, and, as sometimes unpleasantly happens, in public places ; or while she is at stool. The child may be injured by falling from the mother 252 tedious labor. —such cases sometimes leading to undeserved suspicions of infanticide. The umbilical cord may be ruptured in its con- tinuity, or torn out at its junction with the navel, but the bloodvessels usually contract and prevent hemorrhage. The child may be born in its unbroken membranes, and drowned in the liquor amnii. Numerous alleged dangers to the mother may result from precipitate labor, but" their occur- rence is, on the whole, exceptional. These are : inertia and post-partal hemorrhage from sudden emptying of the womb ; inversion of the uterus; syncope from abrupt reduction of abdominal distension; rupture of the uterus, laceration of its cervix, and of the perineum, or vagina ; procidentia of the womb. Causes—Unusually large size of the pelvis (pelvis aequabi- liter justo-major). Unusual laxity and diminished resistance of the soft parts. Excessive force and frequency of the pains, and of reflex contraction of the abdominal walls and dia- phragm, generally due to peculiar temperament or nervous excitability of the woman. Symptoms—The pains come on with little or no warn- ing, and are bearing down in character from the beginning, quickly succeeding each other, and rapidly progressing to an almost tornadal intensity. In a large pelvis, or wdien the child is very small, labor may be terminated in a few minutes, without any necessarily over-violent pains. Violent pains and a large pelvis may, however, coexist. The child may be born during sleep, the woman dreaming she had colic. Intensity of suffering, on the other hand, may produce tran- sient mania. Treatment: should be preventive in women who have previously had precipitate labor. It is liable to recur—cer- tainly so when the pelvis is over large. The woman should keep her room during the last week of pregnancy, and go to bed on the first indication of labor pains, a competent nurse having been previously provided. During labor, anaesthesia constitutes the readiest means of lessening undue violence of the pains. Opium internally; morphia given hypodermically, or by rectal suppositories, when there is time for them to act. Tepid enemata, to wash out the bowel, and an abdominal bandage, have a soothing influence to some extent. The woman must avoid bearing down, as far as possible, by crying out, instead of holding in atresia of vaginal canal. 253 her breath during a pain ; and everything likely to increase uterine contraction must be avoided. Procidentia may re- quire a T-bandage over the vulva, an aperture being made in it through which the child may be born. CHAPTER XXIX. DIFFICULT LABOR FROM THE MORE RARE FORMS OF OBSTRUCTION IN MATERNAL ORGANS. Imperforate Hymen__An absolutely imperforate hymen would prevent impregnation ; an apparently imperforate one may contain a small, undiscovered opening, large enough to admit entrance of spermatozoids, and may thus afterwards constitute an obstruction to delivery. The organ maybe perforated with a visible round opening (hymen annularis), or with several small apertures (hymen cribiformis). Diagnosis: by impossibility of introducing finger, and by subsequent inspection of parts. Previous history of partial retention of menses. Treatment___Incision may rarely be required. Atresia of the Vulva: maybe partial or complete, resulting from inflammatory adhesion ; healing of ulcerated surfaces following traumatic injury; or inflammation attend- ing exanthemata ; former labors, etc. It may be congenital. Diagnosis: by inspection. Treatment___Obstruction usually overcome by spontaneous dilatation during labor. Artificial dilatation by tents, or Barnes's dilators, or careful incision along median line, while labia are stretched laterally, may be necessary. (Edema of Vulva : when excessive may require nume- rous small punctures for its relief. Atresia of Vaginal Canal : may be congenital or acquired: partial or complete. Non-congenital cases are due to inflammatory adhesions following injury of former 22 254 DIFFICULT LABOR. deliveries, pessaries, and other traumatic causes ; or to in- flammation of exanthemata and other constitutional diseases. Considerable surfaces may be adhered, or constricting cica- tricial bands only exist. Diagnosis: by digital examination, or ocular inspection through speculum. Treatment: artificial dilatation by elastic water bags, tents, etc. Dissection through obstructing tissue with finger, or finger-nail, during labor pains, gradually executed, with care not3 to penetrate vesico- or recto-vaginal walls. Shallow vertical incisions—longitudinal scarifications—for cicatricial bands; and careful vertical incision of central septum of adherence in bi-lateral union, may be required. Finally, forceps delivery, to prevent prolonged compression of parts by fcetal head. Cystocele—Prolapse of Vesico-vaginal wall— may be due to, or associated with, retention of urine and vesical distension. The prolapsed wall presents a tense, fluctuating tumor, more or less occluding the vagina; it may be forced down by advancing head, or even ruptured. Symptoms and Diagnosis—Known existence of cystocele before or during pregnancy. History of urinary retention. During labor: intense pain; vesical tenesmus and dysuria. May be mistaken for bag of waters ; diagnosticate by feeling presenting part above and behind cystocelic tumor, and by reduction in size of tumor by catheterism. Diagnosis from hydrocephalic head by same means, and by recognition of enlarged sutures, fontanelles, etc., of cranium. Treatment: catheterism, which is difficult, and may be impossible, requiring puncture or aspiration through vesico- vaginal septum. Push back or hold up the prolapsed wall during pains, till the head slips by it. Forceps. Rectocele — Prolapse of Recto-vaginal avall—is produced, much in the same manner, by distension of rectum by faecal contents, and pushing down of projecting recto- vaginal pouch by advancing foetus. Diagnosis: by putty-like consistence of tumor, and inden- tation of its contents by digital pressure through recto-vaginal wall, or examination per anum. occlusion of EXTERNAL OS UTERI. 255 Treatment—Remove faecal accumulation by emollient enemata, or scoop out hard masses with spoon-handle or finger. Push back prolapsed wall, while head passes by it. Forceps. (?) Impacted F.eces, without rectocele, maybe sufficient to obstruct delivery. Treatment the same as above described. Prophylaxis by laxatives during pregnancy. Vesical Calculus—Stone in the Bladder : when of considerable size may, very rarely, obstruct labor, and lead to cystocele, or vesico-vaginal fistula, from compression of vesico-vaginal wall between calculus and foetal head. Diagnosis : (from exostosis, etc.) by mobility of calculus, felt per vaginam, between the pains, as a hard tumor behind and sometimes above the pubes, and by sounding bladder. Treatment__Lift the stone above the pelvic brim by digital palpation per vaginam. If this be impracticable, crush it, or extract through rapidly dilated "urethra. If these are too tedious, perform vaginal lithotomy through neck of bladder. Vesical calculus recognized during pregnancy should be re- moved before labor. Vaginismus (spasmodic contraction of the vaginal ori- fice or canal); Cystic, Fibrous, and Cancerous Growths Developed in Vaginal Walls ; and Her- nial Protrusions of large or small intestine and omentum, usually in Douglas's cul-de-sac, may, very rarely, lead to sufficient obstruction to require operative assistance before delivery can take place. Intestinal hernia, from liability to strangulation and incarceration, is a serious complication. It should be reduced by manipulation or posture, and de- livery must be expedited. Occlusion of External Os Uteri.—The lips of the os are either completely closed from former adhesive inflam- mation, or an observed or unobserved opening may exist, of so small a size as to constitute practical occlusion so far as delivery is concerned. The adhesion may have followed traumatism of the parts from instruments used in producing abortion, or cauterizations, lacerations, ulcers, etc. < 256 difficult labor. Symptoms and Diagnosis___Absence of the os on palpation and even on inspection by speculum. A circular dimple may be recognized where the opening ought to be. The cervix and internal os are widely distended, perhaps by the advancing head, their tissues being so thin as to necessitate care not to mistake them for the fcetal membranes; the recognition of their continuity with the vaginal wall would prevent the mistake. In uterine lateral obliquities and ex- aggerated ante- or retro-version, an existing os uteri may be tilted out of reach of the finger in ordinary vaginal exami- nation, the os only being discovered by passing the whole hand through the vulva, and thoroughly exploring every part of the vaginal roof. When occlusion really exists, there is danger of rupture of the uterus, as well as of " tedious" labor, if relief is not afforded. Treatment—Make an opening where the os ought to be. Having found the circular dimple above stated, it may, if the obstructing septum be thin, be penetrated by pressure of the finger or finger-nail during the pains. Under other cir- cumstances a small crucial incision must be made, preferably with a guarded bistoury, over the same spot, or when no dimple can be discovered, over the most dependent point of the dis- tended cervix. Tents and elastic bags may be necessary to complete dilatation if it fail to take place spontaneously. In a few cases, where no trace of the os could be discovered, Caesarian section has been successfully performed. Atresia of Uterine Cervix (within the external os) and Hypertrophic Elongation of it, the latter generally associated with prolapsus, may require operative interfer- ence. Atresia requires either vertical shallow incisions or gradual mechanical dilatation by sponge tents and water-bag dilators. In hypertrophic elongation of neck, dilatation alone is usually sufficient. Cancer of the Cervix Uteri__When only involving the lower portion of the cervical canal, the diseased tissues will often yield enough to admit delivery. When extending higher up, the cancerous growth, by its size and want of elasticity, either prevents passage of child, or ruptures with severe hemorrhage. polypus of the uterus. 257 Prognosis—Of course most grave. Treatment.—-Incision of cervix, with application of per- chloride of iron to stop bleeding. Perforation maybe after- wards necessary, if circumstances demand immediate de- livery. Another plan, certainly preferable so far as the child is concerned, and, in bad cases, not adverse to the mother's interest, is to perform Caesarian section as soon as labor begins. Masses of the cancerous growth may some- times be broken away with the hand, making a sufficient opening to admit version. Constriction of the Uterine Body—Ante-partum Hour-glass Contraction of the Uterus—is a circular, semi-circular, or falciform constriction of the body of the uterus, either at the internal os, or at some point between it and the fundus. It constitutes a most serious obstacle to delivery, but is rare. The constriction probably due to cicatricial bands, like those observed in vagina and cervix, associated or not with spasm of circular fibres. The child may be held so firmly by the constriction as to resist even violent efforts to deliver by forceps or version. Diagnosis.—Very difficult. The furrow across the out- side of the womb may possibly be felt by abdominal palpa- tion ; the inner constriction only by passing the hand into the uterus, when it may be felt to resemble "a sharp metallic ring." It is not relaxed by anaesthesia. Treatment. — Forceps do not succeed; even version may fail, or be attended with rupture, owing to the violence neces- sary to be used. Version, however, may succeed in some cases. Future experience will, probably, demonstrate the advisability of early Caesarian section. Polypus of the Uterus—pediculated fibrous tumors— hanging in the parturient canal, may be of sufficient size to obstruct labor. Diagnosis: by their mobility—if not impacted—insensi- bility, pediculation, etc. Small ones might, without care, be mistaken for swollen scrotum of breech presentation. Treatment: Push the tumor up, out of the way, above superior strait, and retain -it there till head takes precedence in descent. When the pedicle is easily reached, remove the 22* 258 difficult labor. growth by ecraseur or scissors. Some break off during labor, and come away of themselves. Some are sufficiently compressible as not to prevent delivery. Fibroid Tumors of the Uterus—not pediculated__ whether subserous, submucous, or interstitial, may or may not obstruct delivery, according to their size and position. If high up, above the superior strait, they produce no ob- struction, but may render pains inefficient from asymmetrical uterine contraction, and predispose to ante- and post-partal hemorrhage, as well as to abnormal presentation and posi- tion of the child. Situated below the brim, in the lower seg- ment of the womb, they necessarily obstruct labor, and may be large enough to nearly fill the pelvic cavity. Diagnosis : by history of the tumor, its slow growth and attendant symptoms before pregnancy, and by its firmness, want of fluctuation, etc. Treatment: in all cases extra precaution against occur- rence of post-partal haemorrhage. Application of styptic iron solutions generally necessary to arrest it. Tumors below the brim, even in apparently very unpromising cases, may be pushed up above it, by persistent pressure with the hand or closed fist, the patient being anaesthetized. The knee- elbow position may facilitate success. Surgical interference, enucleation of the tumor, or its removal with 'ecraseur, when the base is not too large, may be advisable. The only other alternatives in bad cases are Caesarian section and cranio- tomy. In lesser degrees of obstruction forceps may suffice. Ovarian Tumors, whether solid or cystic, occupying the pelvic cavity, usually between vagina and rectum, may obstruct delivery. Even small ones (if cystic) may burst from pressure, which last may also lead to subsequent serious inflammation. Diagnosis: by rectal and vaginal examination ; by fluc- tuation, and by aspiration and examination of fluid contents. Treatment: Push tumor above pelvic brim. This may be impossible, from its adhesions and large size, or incarceration below presenting part. Then puncture cyst, from vaginal wall, during a pain. Should puncture fail to remedy the difficulty, from tumor being solid or multilocular, forceps, PROLAPSE OF FUNIS. 259 version, or craniotomy may be selected, according to degree of existing obstruction. When there is not space enough for body of child to pass, deliver by Caesarian section. Ovariotomy during pregnancy has been suggested. CHAPTER XXX. PROLAPSE OF FUNIS—SHORT OR COILED FUNIS. Prolapse of Funis__A loop of the umbilical cord hangs down alongside of, or below, the presenting part of the child. Before rupture of the membranes it is called by some writers "presentation" of the funis; after rupture, when the loop falls down into the vagina, "prolapse,"—a distinction of no great value, at least as regards nomen- clature. Causes.—Conditions in which the presenting part of the child does not completely fill, or block up, the ring of the os uteri and pelvic brim, viz. : pelvic contraction or deformity ; transverse, footing, knee, breech, and face presentations. It may occur, in ordinary head presentations, as well as under the circumstances just stated, from unusual length of the cord ; insertion of placenta near the os uteri ; excess of liquor amnii ; and gush of amniotic fluid, when membranes rupture at the height of a labor pain, and in multiple preg- nancy. Head presentation complicated with that of a hand or foot, or with both, especially favor prolapse of cord. From the far greater relative number of head presentations there are more cases of prolapsed funis associated with them than with presentations of other parts. But, in a given equal number of each presentation, prolapse of the cord will be found least frequently with head cases, as and for the reason before stated. Thus Scanzoni's figures are :— Funis presents once in 304 head cases. " " " 32 face cases. " " " 21 pelvic cases. " " "12 transverse cases. Prognosis___Not unfavorable to the mother, except in so 260 PROLAPSE OF FUNIS. far as may result from emotional disturbance and subsequent breast troubles, from child being born dead. As regards the child, it is a most serious complication. About 50 per cent, die owing to compression of funis during delivery. The dangers are less in proportion to the greater length of time that the membranes are ww-ruptured, and when the presentation and other conditions are favorable to rapid delivery after their rupture. Hence breech presentations, which admit of speedy extraction, are comparatively favor- able. The breech, moreover, is softer and smaller than the head, hence there is less fear of fatal pressure on funis. Transverse cases do not necessarily involve pressure of cord, and are less dangerous than head presentations in this re- spect. A large pelvis is favorable, unfavorable conditions are primiparity (owing to length of labor from resistance of soft parts), contracted pelvis, low placental insertion, and early rupture of membranes. Diagnosis may be attended with some difficulty before membranes rupture, the finger having to feel the cord through them, or through the thinned uterine wall. It feels a soft, compressible, and movable body, in wdiich pulsations, syn- chronous with the fcetal heart, may be recognized. Pressure of cord, during a pain, may temporarily interrupt pulsa- tions. Pulsations in vaginal or uterine wall are synchro- nous with mother's pulse. Confounding fingers or toes of child with funis is avoided by remembering their harder consistency, number, and by absence of recognizable pulsa- tion in them. In cases of uterine rupture a prolapsed coil of small intestine has been mistaken for funis. The attached mesentery, and want of pulsation in the intestine, are suffi- ciently diagnostic with ordinary care. When the mem- branes have ruptured, or the presenting cord has prolapsed into the vagina, there can scarcely be any mistake. Umbili- cal pulsation, of course, shows child to be alive, but the funial pulse may cease some time before the infant dies, hence auscultate before death is assumed to have oc- curred. Treatment—Preserve the membranes from rupture as long as possible. The cord is safer from pressure, when bag of waters is intact, than it can be made by any ope- rative treatment after membranes rupture. One exception noted below. PROLAPSE OF FUNIS. 261 Postural Treatment—Before membranes rupture, place the woman upon her side—upon the side opposite that upon which the cord lies—and elevate the pelvis upon pillows, while the head and chest rest low. The cord may thus gravi- tate towards fundus uteri during early part of labor. The knee-chest or knee-elbow positions are more effective, but difficult to maintain for any considerable time. They should be resorted to at intervals during early stage, the woman afterwards resuming her lateral position as above stated. Later on, when the os is sufficiently dilated for the head to pass, the woman may be placed, temporarily, in a decided knee-elbow posture, when, if the cord slip back, the mem- branes are to be ruptured, and manual pressure applied ex- ternally to produce engagement of the head, which last fills the opening, and prevents re-prolapse, the woman subse- quently resuming and maintaining her latero-prone position. Should posture alone not suffice to cause the cord to slip back, let tlie membranes reihain intact. When, finally, they rupture, artificial reposition of the cord must be attempted. There are several methods of ope- rating, all of them being more likely to succeed when the woman is placed in the knee-chest position. The hand may be carefully passed into the womb with the loop of cord protected in its palm, until the loop is carried above the equator of the head to the back of the child's neck, the fundus uteri being meanwhile supported with the other hand, and the head gently pushed aside wdien the inner hand passes along side of it. When this proceeding is inadvisable, or impossible from the head having descended too low, two or three fingers may be used to push up the loop, and hold it above the equator of the head until the latter is forced down by a succeeding pain, when the fingers are withdrawn. Repeat during several successive pains, if necessary. In lieu of the hand or fingers, various repositors have been devised. A tape and styletted male elastic catheter answer as well as any of them. A piece of tape three or four feet long is doubled, end to end, and passed into the catheter so that the tape loop can be drawn out an inch or two through the eye of the instrument. The stylet is also passed in, and its extremity made to project from the eye of the catheter. The loop of tape is next passed round the loop of cord, and hooked over the projecting end of the stylet, 262 PROLAPSE OF FUNIS. which last is pushed back into the eye, and shoved up quite to the closed end of the catheter. The two ends of the tape may now be gently drawn upon, until the loop loosely holds the cord in contact with the instrument. The prolapsed funis is then pushed up into the uterus by the catheter until it is quite above the presenting part of the child, when, by withdrawing the stylet, the cord is released. The catheter and tape may be left in till labor is over. A flat piece of whalebone, having an eye near one end, through which a loop of tape may be threaded, has been also employed in a somewhat similar manner, and, after reposition, left in till the completion of labor. Braun's and Robertson's reposi- tors, described in the books, are modified applications of the same principle. Retention of a replaced funis has been secured by attaching to the cord a collapsed elastic bag or pessary, having a tube by which it may be inflated, after in- troduction into the uterine cavity. When reposition fails, as it is "often wont to do, the next element of treatment, generally speaking, is speedy delivery; or, when circumstances render this impracticable it may be attempted to place the cord where it will receive a minimum amount of pressure. Thus when the occiput is placed at one of the acetabula, the loop of cord should be put near the sacro-iliac synchondrosis of the same side. In breech pre- sentations put it near the sacro-iliac synchondrosis which corresponds to the antero-posterior diameter of the breech. Speedy delivery may be secured by forceps, when the os is dilated and the head sufficiently low. When forceps are not available, the next alternative is version by the feet, preferably by external, or by combined external and internal manipulation, and subsequent rapid extraction. The dangers of version, especially when the conditions for its easy and safe performance are not present, should, in the interests of the mother, be earnestly consid- ered before the operation is agreed upon. It should be also ascertained that pressure upon the cord has not already so far injured the child as to render its chances of survival, after version, insufficient to justify any risk to the mother that may be incurred by the operation. In face presentations, when operative interference is de- cided upon to save the child's life, an early resort to version SHORT AND COILED FUNIS. 263 is the best—that is, when other methods of relieving the cord from pressure have failed. In breech cases, the extremities should be brought down, and the child rapidly extracted by the methods already stated. (See Breech Presentations^ pp. 160, 161.) Footlings the same. In cases of prolapsed funis, associated with contracted pelvis or with transverse presentations, the treatment required for these complications, in theinterest of the mother, must take precedence of that solely relating to the interests of the child. When prolapsed funis is associated, in head presentations, with coincident prolapse of a hand, the prolapsed extremity should be replaced with the funis, and the head made to descend and fill up the space so as to prevent reprolapse. Care must be taken not to displace the head and thus pro- duce transverse presentation : it is best prevented by abdo- minal pressure during the proceeding. When a foot presents with the cord and head, or when foot, hand, head, and cord all present at once, it will usually be best to draw down the foot, while the head, cord, etc., are pushed up, thus producing version by the feet. Such presentations are technically known as " complicated" or "complex" ones ; and are also so called when the cord does not prolapse. When the pelvis is large, prolapse of a hand alongside of the head may still admit of spontaneous de- livery, or forceps may be applied if the extremity cannot be replaced, and progress is much impeded by the complication.1 When the child is dead, prolapse of the cord requires no interference. In all cases where hope of life remains, pre- pare beforehand for resuscitation, by providing hot and cold water, brandy, electricity, etc. Short and Coiled Funis.—Actual shortness of the cord (cases have been seen as short as two inches), or arti- ficial shortening, by its being coiled round the neck, body, or other parts of the child, very rarely, offer considerable me- chanical obstruction to delivery, and more frequently a slight prolongation of the second stage of labor results. Very long cords of even six or eight feet in length (such have been 1 These " complex" presentations will not reqtiire further sepa- rate consideration in this work. 264 prolapse of funis. observed) may be practically short, from coiling. From stretching of a short or coiled cord during labor there may result, though very rarely, inversion of the uterus; pre- mature separation of the placenta and hemorrhage ; rupture of the funis or interference with' its circulation, and death of the infant. • Symptoms___Before extrusion of the child's head, the diagnosis of a shortened funis is not always easy. The fol- lowing symptoms may be present: A peculiar pain, or sore- ness, felt during uterine contraction, usually high up at the supposed placental site, which is described by multipara} as being different from the suffering produced by ordinary labor pains. Later on there is partial arrest of labor pains, espe- cially of bearing-down efforts; and retardation in descent of presenting part with elastic retraction of it, between the pains, to a greater degree than can be accounted for by re- sistance of maternal soft parts. Blood may be discharged before birth owing to partial separation of placenta, and when there are no coexisting lacerations of cervix, etc., to explain it. Depression of placental site, during pains, felt through abdominal wall.(?) An unusually persistent desire on the part of the woman to sit up, not occasioned by fulness of bladder or rectum. A finger passed high up may touch an existing coil. Treatment—None is required in the large majority of cases, other than release of a coil round the neck after the head is born. The coil is loosened by drawing it down to form a loop, which is then passed over the occiput. Harmless or at least remediable coils of this sort occur once in about every five labors. When the cord is too short to admit of release in this way, cut it, and deliver at once to prevent the child bleeding and suffocating. When labor is unduly retarded from a short cord before the head is born, let the woman assume a sitting or kneeling posture upon the bed, and lean forward during the pains! The whole womb is thus pushed down and tension of the cord relaxed, while the head, if its rotation have not previously taken place, will rotate and so be prevented from retract- ing between the pains, thus affording the succeeding uterine contractions a better chance of completing delivery. Should forceps be used in such cases, owing to symptoms of tedious labor, care must be taken not to invert the womb. A cord ANESTHETICS—CHLOROFORM. 265 that is very short may require division, in utero, before the head can be safely extracted. Such cases are extremely rare. Knots in the cord do not impede delivery. CHAPTER XXXI. ANAESTHETICS : CHLOROFORM, ETHER, CHLORAL. ERGOT, QUININE. Anaesthetics are used in obstetrics to lessen suffering produced by labor pains; to lessen the pain attending cer- tain obstetric operations ; to relax the uterus when its rigid contraction interferes with version; to promote dilatation of the os uteri : to reduce excessive nervous excitement which may interfere with progress of early stage of labor ; to relieve eclampsic convulsions, and mania. The practice of giving anaesthetics in all cases of labor to lessen pain, has been warmly advocated in certain quarters, but is not, on the whole, advisable. Complete anaesthesia from chloroform, or ether, undoubt- edly lessens the force of uterine contraction, and thus retards labor, as well as predisposing to post-partal hemorrhage. Hydrate of chloral, on the contrary, may be given in suffi- cient quantity to produce relief from suffering without mate- rially interfering with uterine contraction. Chloroform, when given to lessen the agony of labor pains, as it often is in Europe, though much less frequently in the United States, is usually administered when labor is pretty well advanced—when the os uteri is well dilated, the head descending, and the pains are propulsive. A few drops are placed upon a handkerchief, and held near, not close to, the mouth, at the beginning of a pain, the inhalation being continued till the pain passes its acme, when it is at once stopped. Pure air should be breathed during the intervals. Complete insensibility is not desired ; the woman should re- main sufficiently conscious to converse. During the early stage of labor chloroform should certainly not be given merely 23 266 ANESTHETICS, ERGOT, ETC. to lessen pain. A mixture of one-third absolute alcohol with two-thirds chloroform is less objectionable than chloro- form alone. All the uses to which chloroform may be applied in obstetrics may be attained by ether or chloral.1 Ether (Sulphuric ether) may be safely given during the second stage of ordinary labors at the beginning of each pain, and during its continuance, and should be so given, to lessen suffering when the agony is severe and the patient particularly sensitive ; but complete anaesthesia and insensi- bility are not advisable, from fear of post-partal hemorrhage, against the occurrence of wdiich a double vigilance is always necessary when anaesthetics have been used. Ether is not so liable to retard labor from lessening the force of uterine contraction as chloroform, but it is not entirely free from this liability. It is objectionable during the early stage of labor. Ether is inflammable, and hence requires care in using it at night. During obstetrical operations requiring anaesthetics, anaes- thesia should be complete : if it is only partial the patient is liable to toss about without any control. In delivering with forceps, under anaesthesia, extra care is necessary to avoid pinching the soft tissues, of uterus and vagina, in the grasp of the blades, since the patient, being insensible, cannot indicate, by her complaints, the occurrence of such a mishap. Strong contractions of the uterus, rendering version ex- tremely difficult and dangerous—or perhaps impossible—are at once relaxed by complete anaesthesia. The child having been turned, it should not be at once extracted until the womb, has, at least in part, resumed its contractile efforts, so as to lessen the danger of hemorrhage. Anaesthetics are contra-indicated, of course, by organic pulmonary and cardiac diseases. When ether is given for puerperal eclampsia it should be administered just before the beginning of each returning paroxysm in time to prevent the seizure. Chloral (Hydrate of Chloral) will probably, in great 1 The author never uses, nor does he, on his own account, advise chloroform in obstetric practice. Ether and chloral are safer, and answer every purpose. ERGOT. 267 measure, take the place of chloroform and ether in obstetric practice, except when severe operations are required. Under its influence tlie woman may sleep during labor without any great suffering, being only awoke by the recurrence of pains, the agony of which is not tben acute. It is especially valua- ble, as already indicated, wdien the os uteri is thin, rigid, and difficult to dilate, in fact, during the early stage of labor, when ether and chloroform are inadmissible. Cliloral does not diminish uterine contraction. It, indeed, lessens the fre- quency of the pains, but at the same time renders them stronger and more efficient; calms nervous excitement, and promotes dilatation of the os. Fifteen grains may be given in a little water or syrup of orange-peel, every twenty minutes, until two, three, or (possibly) four doses are taken, according to the degree of somnolence produced. More than a drachm during the whole labor seldom required. Serious and even fatal symptoms have resulted from too large doses. In puerperal eclampsia chloral is a most valuable remedy, both during and after labor. Large doses of twenty or thirty grains may be taken ; or twice this quantity may be given at once, by enema, and repeated in a few hours if the spasms recur. As a sleep-producer in puerperal mania chloral is better than opium, hyoscyamus or any other narcotic. It may be combined, to advantage, with bromide of potassium (xv to xxx grains of each). Ergot (SecaleCornutum—Ergot of Rye—Spurred Rye), though by no means allied, in its action, with anaesthetics, may be here considered, as one of the obstetri- cian's special medicaments. Its effect on the uterus is ex- actly opposite to that of ether and chloroform, with which, indeed, it is sometimes administered as a sort of antidote to their relaxing effect upon the uterine muscles. When given in ordinary full doses (xx-xxx grains of the powder, or xx-xxx minims of the fluid extract, or 5j of the tincture or wine) ergot produces, in the course of ten or fif- teen minutes, strong contractions of the uterus, which, when the drug is repeated so as to obtain its full effect, become persistent and continuous as well as powerful. This tonic and unremitting persistence of the contractions constitutes one of the chief drawbacks and dangers of ergot. If the 268 anesthetics, ergot, etc. child is still tinborn, continuous pressure upon the cord, ob- struction to the utero-placental circulation, and consequent injury or death of the fcetus may result, unless speedy de- livery take place. Injury to the uterine wall from continu- ous pressure, or actual rupture of it may result, wdien there exists any mechanical resistance to delivery. Hence the following contraindications to the use of ergot may be posi- tively affirmed : pelvic deformity; malproportion between the size of the child and pelvis ; transverse and other mal- presentations or positions of the fcetus; undilated os uteri; resisting, rigid perineum. It is not to be used, even in the absence of these conditions, during the first stage of labor or when the head is high up near the superior strait. During the second stage of labor its use is extremely questionable, unless there be evidence that the child will be born by the time or soon after it begins to act. When powerful contractions are produced by ergot—as may happen from its injudicious administration by nurses and others—and the labor is not rapidly completed, forceps should be applied to relieve the child from danger—a proceeding all the more imperatively needed if auscultation reveal irregularity or feebleness of the fcetal heart. On the whole it is a safe rule to abstain from giving ergot at all before the child is born, except in threatened post-partal inertia of the uterus, when its admin- istration may just precede delivery of the infant; or in reten- tion of the after-coming head in breech presentations as already explained. Its administration in certain cases of placenta praevia is generally recommended, as well as in accidental hemorrhage from separation of a normally placed placenta, but, if the child is to be saved, delivery must be expedited by every possible or practicable means. Ergot was formerly used to induce premature labor, but has now been abandoned for better and less dangerous methods. The chief use of ergot in midwifery is to secure persistent uterine contraction after birth of child. It thus prevents hemorrhage, and lessens tendency to after-pains. The pla- centa should be removed by " expression" or manual extrac- tion after ergot is given, in time to prevent its being retained by spasmodic contraction of the womb—hour-glass contrac- tion—which ergot is liable to produce if the°placenta re- main undelivered. puerperal eclampsia. 269 Quinine (Quinia Sulph.), though not yet generally used in labor cases to reinforce feeble uterine contraction, has been proven of sufficient efficacy in this respect to war- rant the hope that it may form a safe substitute for ergot during the first and second stages of labor. Dose, x-xv grains every three hours. Its efficacy in relieving after- pains has been previously mentioned. CHAPTER XXXII. puerperal eclampsia during labor. Puerperal Eclampsia, associated with premature de- livery, due to uraemia, from albuminuria and renal congestion or inflammation during pregnancy, have been already dis- cussed in so far as their etiology, symptoms, and prophy- lactic treatment are concerned.1 Their obstetric treatment does not differ materially from that of eclampsia occurring during labor at term, here to be considered. Puerperal convulsions during labor, besides arising from uraemia, may be due to other forms of blood-poisoning, viz., cholaemia (retention of bile) ; imperfect elimination of car- bonic acid by the lungs; medicinal poisons, as lead, nar- cotics, etc. ; septic poisons, as those of typhus and other fevers. The opposite conditions of congestion and anaemia of the brain may produce eclampsia; as may also general amvmia, plethora, hydraemia, and leukaemia. Convulsions often precede death from hemorrhage during labor. They may arise form violent emotional disturbance, or from reflex irritation due to indigestible food, fecal accumulations, etc. The well-known increased excitability (so-called " convul- sibility") of the nervous system in pregnant and parturient women predisposes to eclampsia from slight causes. Symptoms and Clinical History___Previous occurrence of decided renal symptoms, general dropsy, etc., during preg- nancy, especially signs of impending uraemia. 1 See chapter viii., page 91. 23* 270 puerperal eclampsia. Preceding the actual occurrence of a spasm, there are irritability of temper, slight or severe headache, dizziness, spots before the eyes, impairment or loss of sight, tinnitus aurium, hallucinations, deafness, intellectual disturbance, unusual desire to sleep, with perhaps stertorous breathing, vomiting, etc. Some or all of these may be present. The actual convulsion may resemble epilepsy or hysteria. Text-books give three varieties : epileptic, hysterical, and apoplectic. Hysterical attacks are slighter in degree, and consciousness is not entirely lost. Apoplectic ones are rare, and are followed by complete coma and paralysis, due to effusion, or a clot of blood within the cranium. The typical puerperal convulsion is epileptic in character. It begins with rolling of the eyeball, puckering of the lips, drawing of the lower jaw on one side, bending the head back, or towards one shoulder. Then follow twitching of the facial muscles and of those of the extremities; protrusion of the tongue ; grinding of the teeth ; violent jerking of the arms ; in fact, clonic spasm of the voluntary muscles, and of some of the ?'wvoluntary ones, notably those of respiration ; hence lividity of the lips and face, distended veins in the neck, and apparent impending cyanosis. At first, however, the respi- ration is hurried and irregular, hissing, through bloody froth, between the teeth. Urine and feces sometimes involuntarily discharged. Duration of the convulsion from one to four minutes. Complete unconsciousness during paroxysm, the patient having afterwards no recollection of it. The fits may recur at varying intervals, of minutes or hours, and in vary- ing number, from two or three to twenty, thirty, or more. They are apt to recur with the recurrence of a labor-pain. The uterus may participate in the spasm, and expel the child rapidly. Prognosis___Always serious both to mother and child, increasing in gravity with the severity of the symptoms and existing impediments to speedy delivery. The convulsions may persist even after labor. Fortunately they do not occur more than once in four or five hundred labors. Treatment of Convulsions during Labor___If possible ascertain the cause. A history of uraemia attends most cases, the treatment for which (purgatives, diaphoretics, certain diuretics, and methods of reducing renal congestion) has been already considered (chapter viii.). Should this treatment not have been previously employed, purgation PUERPERAL eclampsia. 271 may still be of benefit. A drop of croton oil, or a fourth of a grain of elaterin, may be placed on the back of the tongue if the woman be comatose ; or, if she can swallow, calomel and jalap may be given by the mouth. The relief of convulsions, meanwhile, chiefly claims our attention. During the paroxysm, prevent the patient from self-injury, and place a piece of wood, or a spoon-handle wrapped in flannel, between the teeth, to protect the tongue from being bitten. When the fit is over, the remedies are: in decidedly pletho- ric women, bleeding from the arm. It reduces cerebral con- gestion and vascular fulness—conditions indicated by a strong, full, bounding pulse and lividity of the face—and/nay pre- vent a fatal apoplexy. After bleeding, or when it is not deemed advisable, inject \ grain of morphia hypodermically, and give full doses of chloral hydrate (gr. xv-xx) wdth bro- mide of potassium (gr. xxx) every three or four hours. If the patient cannot swallow, inject the chloral and bromide into the rectum in closes of xxx grains each. Anaesthesia with ether (some prefer chloroform) may be resorted to, on the approach of returning paroxysms. As a general rule it is advisable to deliver by forceps as soon as dilatation of the os uteri will permit; but this is not by any means always required. Should the convulsions have been sufficiently controlled by other remedies, labor may go on and be left to complete itself, any violent efforts with forceps being liable to provoke a repetition of the eclampsic paroxysm. If the convulsions continue in spite of treatment, delivery offers the only port of safety. Then, if the os is not sufficiently dilated for forceps to be applied, it may be either incised or dilated with Barnes's bags—the former perhaps being, on the whole, preferable—though neither proceeding is universally commended, the other al- ternative, of version by the feet, being sometimes selected instead. Version, however, ought not to be attempted unless the conditions favorable for its easy performance are present. Anything like violent or prolonged manipulation during its performance would be almost sure to increase the convul- sions. Much will depend upon the particular circumstances of each case and the judgment and skill of the operator. When circumstances render both forceps and version difficult, and inadvisable, and the symptoms increase in severity in 272 puerperal septicemia. such a degree as to threaten the woman's life unless delivery soon take place, craniotomy may be required, even though the child still live. Such cases are very exceptional. It is sometimes advantageous to rupture the membranes early, even before dilatation of the os, the pains afterwards becoming more efficient, and the tendency to convulsions diminished, owing perhaps to consequent reduction in the size and weight of the uterus and in its pressure upon renal veins. The hot, wet pack, and vapor bath can be used to advan- tage, even during labor, and without interfering with its progress, retained urinary excreta being thus eliminated with the profuse perspiration that ensues. In puerperal convulsions not of uremic origin, diligent inquiry must be made for other causes, and their removal attempted. Distension of the bladder and rectum, or a stomach overloaded with indigestible food, may lie at the root of the disorder. Treatment accordingly. Hysterical convulsions require valerian and other anti- spasmodics. Anemic patients may need alcoholic stimu- lants, and afterwards iron, food, and bitter tonics. During third stage of labor the placenta must be delivered without delay ; clots removed, and firm uterine contraction secured. Then, perfect rest in a dark room, cold to the head, laxative enemata, attention to the bladder, milk diet, and, if convulsions still continue, morphia or chloral and bromide of potassium, as before. Subsequent renal disease may, exceptionally, require treatment. CHAPTER XXXIII. PUERPERAL SEPTICAEMIA. SEPTIC AND NON-SEPTIC PUER- peral inflammation. Puerperal Septicemia (Child-bed Fever, Puer- peral Fever) is a fever beginning within a week after labor—usually from the third to the fifth day, inclusive- attended with septic infection of the woman's blood, ani PUERPERAL SEPTICEMIA. 273 with acute inflammation of one or more of the reproductive organs, or of their annexce, or of both. Other organs not belonging to the reproductive system—notably the serous membranes—may be secondarily inflamed also. Hence may arise in respect to the reproductive organs :— Puerperal metritis (inflammation of the uterus). Puerperal vaginitis (inflammation of the vagina). Puerperal peritonitis (inflammation of the peritoneum). Puerperal cellulitis (inflammation of pelvic cellular tissue). Puerperal phlebitis (inflammation of uterine and pelvic veins). Inflammation of the uterus may involve one or more or all of the tissues of the organ—mucous membrane, paren- chymatous and muscular wall, serous covering, subserous cellular tissue, veins, lymphatics. Inflammation of vagina may be superficial (catarrh of the mucous membrane), or deep (attended with ulceration). The ulcers may become diphtheritic in character. Inflammation of peritoneum may be limited to the folds of peritoneum within the pelvis (pelvic peritonitis), or ex- tend to those higher up in the abdominal cavity (diffuse or general peritonitis). Inflammation of the cellular tissue may affect chiefly the cellular layer connecting the uterus with its peritoneal covering (parametritis), or extend to other layers within the pelvic cavity (pelvic cellulitis). Inflammation of the veins and lymphatics may be con- fined to limited areas or special branches of those vessels, or involve many of them. Since the separate diagnosis and clinical isolation of these numerous inflammations are often extremely difficult, it is fortunate they do not each require a decidedly different treatment. Puerperal Inflammation without Septicemia___The seve- ral inflammations, just mentioned, may occur after labor without septica'inia, or clinical evidence of septic infection. Such cases are accompanied with fever resulting from the acute inflammation going on ; they are likely to follow bruis- ing or other traumatic injury of the parts during labor. The great danger is, that they are liable to be attended with septicaemia later during their course ; hence, as we shall see, their treatment, in so far as relates to antiseptic precautions, 274 PUERPERAL SEPTICEMIA. ought to be nearly the same as when septicaemia actually exists. The septic element is not, however, a necessary in- gredient in these cases. Causes of Puerperal Septicemia__The physiologi- cal condition of women soon after labor itself predisposes them to septic poisoning, from absorption into the blood of ef- fete matters produced by involution of the uterus and other organs. Failure to reassimilate, or to excrete, such products of tissue-disintegration, leads to their accumulation in the blood and consequent septic poisoning, or at any rate consequent increased susceptibility to other sources of septic infection. These additional sources of septic contamination may originate in the woman herself (autogenetic infection), or be introduced from without (heterogenetic infection). Sources of Self-infection..—Decomposing retained coagula of blood, fragments of membranes, ovum, or placenta ; putrid lochia, a dead fcetus, decomposing sloughs following pressure and inflammation of soft parts; tissue decomposition, as in carcinoma, or pus accumulations. Previous bad health, and the debility and blood changes following profuse hemorrhage, increase the susceptibility to septic infection from these and other sources. Sources of External Infection___Septic poison conveyed from other women already affected with puerperal septicaemia on sponges, clothes, sheets, bed-pans, instruments, or the hands of physicians, nurses, and attendants, or by a tainted atmosphere. Hence endemics of the disease in hospitals and special localities. Infection by cadaveric poison from the hands of persons previously engaged in dissection or post-mortem examination of bodies, especially of bodies dead from septicaemia, or other decidedly infectious or contagious complaints. Infection from persons suffering from typhus fever, scarlet fever, erysipelas, diphtheria, and other zymotic diseases. The influence of cadaveric poison from bodies not pre- viously affected with septicaemia, and of poison from other zymotic diseases, has been questioned, but it is better to admit it, and err, if at all, on the side of safety. Mode of Entrance of Septic Poison___The septic matter is absorbed into the blood, chiefly through freshly wounded surfaces made by slight lacerations or fissures about the os POST-MORTEM APPEARANCES. 275 and cervix uteri, vagina, fourchette, perineum, etc., which nearly always occur during labor; or through the surface from which the placenta lias been separated. More exten- sive ruptures of perineum, vagina, or uterus, of course in- crease the danger. It is also possible, that the unbroken mucous membrane may absorb the poison, especially when exfoliation of its epithelium, after labor, has taken place. But this last is an unsettled point as yet. When the wounded surfaces begin to heal—to granulate— the danger of septic absorption is generally over. Granu- lating surfaces do not absorb the poison. Hence the woman is comparatively safe, as we have seen, after five or six days following delivery. Prognosis___Puerperal inflammation with septic infection is always serious, though much can be done, with proper treatment, to save life. Danger increases with degree of septic infection. When the poison is extremely virulent— as in epidemics and endemics of. the disease—death may occur within twenty-four or forty-eight hours, even without recognizable post-mortem evidences of inflammatory lesions. Cases of less severity may continue five or six days, when, if death do not take place, convalescence usually begins. Much will depend upon the extent and severity of coexisting inflammations, and the organs or tissues involved. Among the worst cases are those involving the veins, lymphatics, and peritoneum. Inflammations of the uterus, vagina, and cellu- lar tissue are somewhat less fatal. Puerperal inflammations with fever, but without septic infection, are far more likely to recover than septicaemic cases. Post-mortem Appearances__In profound septiccemia, when the septic infection is rapidly fatal, there may be no appreciable lesions, other than significant blood changes, such as occur in many malignant endemic and epidemic diseases. The blood is darker and more watery, with an offensive odor; its red corpuscles are diminished, and white ones in- creased. Ecchymoses may, however, be found in various organs, and the microscope reveals histological evidences of commencing, but undeveloped, inflammation. In puerperal peritonitis with septiccemia, the peritoneum contains a brownish, dirty-looking fluid, with floating flakes 276 puerperal septicemia. of lymph. Patches of fibrinous exudation exist on many of the viscera, but there are no recent adhesions. Other serous membranes may present the same appearances. Intestines congested and distended with flatus. In puerperal peritonitis without septicaemia, the inflam- matory exudation does become organized, forming adhesions by which the adjacent layers of the peritoneum become matted together. In puerperal metritis the womb is found enlarged; its tissues infiltrated with pus, perhaps in a semi-sloughing,'or even gangrenous, state. The mucous membrane is softened and thick, or ulcerated and gangrenous, especially along the margins of existing fissures upon the cervix, or of the pla- cental site. The uterine cavity contains tenacious mucus, blood, and epithelial debris. In puerperal phlebitis the inflamed veins are thickened and enlarged, and contain effused lymph, fluid pus, and blood-clots in various stages of disintegration. In many cases pyaemic abscesses are found in the joints, lungs, liver, kidneys, spleen, eye, and other organs, with evidence of numerous intercurrent inflammations. In puerperal vaginitis the vaginal walls and vulvar mu- cous membrane are swollen, congested, oedematous, or ulcer- ated, sloughing, and gangrenous. Sometimes ulcers are covered with diphtheritic deposit. Vesico-vaginal and recto- vaginal fistulas may exist. In puerperal cellulitis and pelvic peritonitis there are masses of effused lymph exuded between the folds of pelvic peritoneum, or in the subserous cellular tissue, forming thick, diffuse adhesions. The inflammatory exudation may de- generate into pus ; hence purulent collections and fistulae, from burrowing and opening of resulting abscesses. Post-mortem appearances usually present a combination of pathological lesions due to coexistence of two or more of the above named inflammations. Symptoms, etc—These vary with the degree of septic infection and local inflammation, and the particular organs inflamed. Septiccemia, without clinical evidence of local inflamma- tion, begins with shivering, or a distinct chill, followed by fever. Temperature 103°, 105°, or more. Pulse small, feeble, and rapid, from the first, varying from 120 to 140 or symptoms, etc. 277 150 per minute. Little or no pain and tenderness over uterus and abdomen. Decided tympanites. Tongue coated ; first moist, then dry, and later brownish or even black. Lochia arrested ; or, if present, very offensive. Diarrhoea, which may be difficult to control. Clammy sweats ; anxious countenance; breathing shallow and panting; breath of heavy, sweetish odor; muttering delirium; stupor; coma. Usually ends fatally, and in a few days. Thus the charac- teristic features of septicaemia are from the first asthenic or adynamic. Prostration of vital powers, tending to the so-called " typhoid" condition. Symptoms of Local Inflammation. Metritis (In- flammation of Womb) is one of the milder forms of puerperal inflammation. Begins with chilliness, which may be absent or overlooked. Then comes fever; rise of tem- perature rarely over 102° or 103° ; pulse 100°, 110° ; fever may be remittent or intermittent. Uterus is enlarged, flabby, and tender on pressure ; its involution is retarded ; after- pains severe ; lochia fetid, and retain bloody character longer than usual; os uteri hot, swollen, and tender to touch, and higher up than usual. Moderate tympanites, or perhaps none. Respiration not much accelerated. To these symptoms may be added those of septicaemia, just previously described, which, of course, altogether changes the general aspect of the case ; or the metritis and septicaemia may begin together. Vaginitis (Colpitis—Inflammation of Vagina) begins with chilliness and mild fever, as in metritis. Local symptoms are: Swelling, redness, oedema, and tenderness of vagina and vulva. Discharge thin, foetid, and purulent. Painful defecation and urination. Mucous membrane may proceed to ulceration and sloughing, or even gangrene. Ul- cers may become diphtheritic and spread to neighboring parts. To these symptoms may be added those of septicaemia, or vaginitis and septicaemia may begin together. Puerperal Peritonitis is one of the most common, most severe, and most fatal forms of puerperal inflammation. Usually associated with septicaemia from the first. Symp- toms then are : Severe chill ; high fever ; temperature 104°, 24 278 puerperal septicemia. 105°, or 106° ; pulse rapid, 120 to 160 per minute ; small, thready, and feeble, with possibly some tension at first. Thirst. Tongue successively furred, red, dry, brown, or black. Expression anxious ; sense of impending danger. Great pain and extreme tenderness on pressure over the whole, or a large part, of the abdomen. Great tympanites. Diarrhoea, probably preceded by constipation in the begin- ning. Vomiting—ejecta being greenish, or even feculent. Decubitus on the back, with knees drawn up. Respiration altogether thoracic, short, jerky, and accelerated to 30, 46, or 50 in a minute. Lochia arrested or fetid.'* Breasts flabby ; milk suppressed. Later: diarrhoea profuse, offensive, and uncontrollable ; delirium ; clammy sweat; cold extremities ; hiccough ; picking at the bed-clothes ; and, most commonly, death. Intercurrent attacks of inflammation in other serous mem- branes—pleura and pericardium—liable to occur. In puerperal peritonitis without septicemia, the pain and tenderness of the abdomen extend over a smaller surface in the neighborhood of the uterus, and not higher up. The bowels are constipated. Tongue not much altered. The fever is sthenic, instead of asthenic ; pulse wiry and hard, instead of feeble, though still frequent. The symptoms of profound involvement of the nerve-centres, delirium, etc., are absent, or mild in degree. To these symptoms there is constant danger that those of septicaemia may be superadded, when the case would, of course, present the characters just previously described. Puerperal Phlebitis (Inflammation of Uterine or other Veins) begins with a chill or slight shivers, fol- lowed by fever and rise of temperature, 102°, 103°, ending in profuse perspiration. Fever remits. Pain in uterus, but not severe; a tender cord-like induration may some- times be made out on one side of the womb, by grasping it through the abdomen. Slight tympanites. Tongue coated. Bowels loose. Lochia generally plentiful but offensive. Symptoms of peritonitis are absent. The disease is difficult to isolate, clinically, from metritis, until lodgment of thrombi or emboli in distant parts develops secondary abscesses and pycemia, which is the great danger. Then'occur: succes- sive chills at irregular intervals; continuous fever; higher SYMPTOMS, ETC. 279 temperature; small and rapid pulse; with delirium or stupor ; dry, brown, cracked tongue; tympanites and ty- phoid symptoms. Pains in various parts, notably in the joints, wdiich are (some of them) flushed with erysipelas redness, and tender to the touch, followed by swelling and fluctuation, from for- mation of abscesses. Pus formations also occur in liver, lungs, spleen, kidneys, muscles, and sometimes in the eye. Symptoms of septicaemia nearly always superadded. In- flammation frequently extends to peritoneum and uterus. Puerperal Cellulitis and Puerperal Pelvic Pe- ritonitis are, clinically, almost inseparable, and may be here considered together. (By pelvic peritonitis is under- stood inflammation of those folds or layers of peritoneum covering or immediately attached to the uterus and pelvic cavity ; in fact, inflammation of the pelvic folds of perito- neum and not of the abdominal folds.) Symptoms are: Premonitory sleeplessness, excessively painful after-pains, and slightly frequent pulse. Then, in a few days, chill and fever, more or less marked. Tempera- ture 103°-105°. Pulse seldom over 115 or 120. Pain in the pelvis, extending to lower part of hypogastric region, with tenderness on pressure along sides of uterus. Pain may be slight, or overlooked, or increased by extending lower limbs. Bowels constipated ; painful defecation. Head- ache. Tongue coated, but moist. Fever and other acute symptoms subside in about a week. But relapses are com- mon. If the inflammation continue, exudation takes place in the inflamed tissues, leading to swelling and induration alongside of and around the uterus, on one or both sides, forming diffuse tumors which can be felt both by vaginal and abdominal or rectal examination. Such cases become chronic, and may end in suppuration and abscess, which last may burst externally, or into some adjacent viscus. To these symptoms those of septicaemia may at any time be superadded. The several inflammations whose symptoms have now been enumerated, seldom occur separately in puerperal women. It is far more usual to find several of them coex- isting, or running into each other; hence the clinical fea- tures of any single case may be thus modified. 280 puerperal septicemia. Treatment__While, as we have seen, local puerperal in- flammations may occur from traumatism, etc., during labor, without any necessary septic infection, such cases are excep- tional, and during their course are liable to become septi- caemic, hence it is safest to adopt antiseptic treatment in all cases. Antiseptic Treatment.—Ascertain whether there exist, and if so remove, either with the fingers or by carbolized injections, any retained fragments of placenta, ovum, membranes, blood clots, or lochia in the uterus or vagina. The injection to consist of a two per cent, solution of carbolic acid (about two drachms to the pint of tepid water). It may be injected into the vagina alone, or into the uterus also, according as one or the other is assumed or known to contain septic mat- ter. Since vaginal injections are quite harmless, and since the uterus may not contain septic matter, the vagina should be first washed out; when, if symptoms be relieved, and no offensive discharge subsequently flow from the uterus, the latter may not require to be injected. But in bad eases it is generally otherwise: the womb must then be washed out also. The injecting tube (for the uterus) must either consist of a double canula, or it must be ascertained that there is ample room for the injection to escape through the os, alongside of the tube, as fast as it is thrown in, which must be clone slowly, and continued until the returning fluid is free of all offensive odor, and as clean almost as when introduced. It may be repeated two or three times in twenty-four hours, always by the physician and not by the nurse. The immediate effect of each uterine injection is a sense of comfort announced by the patient (who often asks for its repetition), and wdthin an hour or two decided reduc- tion of fever and lower temperature. It may require to be continued several days or a week. Next in importance to antiseptic injections is support oj the patient by food, and, if necessary, alcoholic stimulants. Give milk, or strong beef essence, or beef tea, in small quan- tities frequently repeated. A single tablespoonful every hour may be all the stomach will retain. When the pulse is feeble and frequent, with other signs of great debility, give good brandy, rum, or whiskey in half-ounce doses every three or four hours; or more frequently still if exhaustion treatment. 281 be very profound. As much as half a pint, or even more, may be required each clay. To reduce temperature, give quinine in doses of 15 or 20 grains twice daily, or ottener if required. Its unpleasant effect upon the ears and head may be diminished by giving with each dose 10 or 15 minims of hydrobromic acid. As a substitute for quinine, salicylic acid, or salicylate of soda, in doses of 15 or 20 grains, may be given ; but it is contraindi- cated when the pulse is very feeble. Another substitute— highly recommended by Playfair—is " Warburg's Tincture" (which, however, contains quinine). Dose 3ss. It produces profuse diaphoresis, but is often rejected by the stomach. To relieve pain—especially in extensive peritoneal inflam- mation—inject morphia hypodermically in large doses, gr. ^, ^, or even ^. There is a special tolerance of it in peritoni- tis. The specific " opium treatment" of general peritonitis consists of giving one or two hundred grains of opium daily —or an equivalent of morphia—for several successive clays. Recoveries are reported, even of the, apparently, most un- favorable cases, but the method is not generally admitted or practised. In addition to morphia, warm stupes, with tur- pentine, applied over abdomen, lessen pain and tympanites, and are salutary in producing some counter-irritation. Arterial Sedatives___Tinctures of aconite, of digitalis, and of veratrum viride have been employed in small doses, fre- quently repeated, to reduce the frequency of the pulse. They are, however, unsafe, and not to be trusted to unskilful hands. Cold.—Various methods of applying cold for the relief of high fever have been devised. Sponging with cold water and vinegar, or water with alcohol and bay rum, and the wet sheet—" wet pack"—are the most available. Ice caps to the head, ice bags over the abdomen, cold affusion, con- tinued irrigation of the uterus or rectum with cold water, and cold baths, have also been resorted to, and with benefit, but are not in general use. Blood-letting___Venesection is not advisable. Leeches to the abdomen, at the very beginning of peritonitis, relieve pain and sometimes appear to cut short the inflammation. Purgatives, if given at all, must be administered at the onset of the attack, and always with caution against subse- quent diarrhoea. Should there have been previous constipa- 24* • 282 PUERPERAL SEPTICEMIA. tion, castor oil, or calomel, gr. v-x, with double that quantity of soda bicarb., may be given once, as recommended by Prof. Parker; but in general peritonitis enemata are preferable. Turpentine, with the latter, is of value when there is tympa- nites. Constipation having been relieved, no repetition of purgatives is admissible. In the pycemic phase of the disease accompanying phle- bitis, opium is not well borne. Tincture of chloride of iron (10-20 minims every three or four hours) is given, as in surgical pyaemia, but is of dubious utility in very bad cases. Antiseptic treatment, food, stimulants, and surgical manage- ment of complicating pus-formations form our chief reliance. In pelvic cellulitis—or pelvic peritonitis—apply warm stupes or poultices over lower part of abdomen, and use pro- longed hot douches in the vagina. Collections of pus in the pelvic cavity to be relieved by aspiration or incision. In the latter event antiseptic washes and drainage may be after- wards employed. Prolonged rest after convalescence. Sloughing ulcers arid diphtheritic patches, in addition to antiseptic washing, may, when within reach, be touched with hydrochloric acid, or with a ten-per-cent. solution of carbolic acid, or with a mixture (in equal parts) of tinct. iodin. and liq. ferri persulph. Diphtheria of puerperal wounds is nearly always associated with septicaemia ; hence food, stimulants, quinine, iron, etc., will be required as in other cases of septic poisoning. Prophylactic Treatment of Puerperal Septiccemia.—Pro- tection from the sources of septic infection (autogenetic and heterogenetic) already stated. Pure air and perfect venti- lation of hospitals and lying-in rooms, the latter especially by means of some opening level with or higher than the ceil- ing (where foul air always collects) and admission of pure air from below. Destruction of all sponges, clothes, etc., used by a puerperal septicaemic patient. Absolute antiseptic cleanliness with regard to instruments, hands, and appliances used in the lying-in room. Carbolized vaginal injections, twice daily, after all prolonged labors, especially when at- tended with laceration. Physicians and nurses wdio have attended puerperal septicaemic cases must not go to other lying-in women, without complete change of clothing, a car- bolized bath, and use of nail-brush. Infected clothing to be burned, boiled, or subjected to prolonged antiseptic fumiga- tion. CENTRAL VENOUS THROMBOSIS. 283 CHAPTER XXXIV. CENTRAL VENOUS THROMBOSIS--PERIPHERAL VENOUS THROMBOSIS--ARTERIAL THROMBOSIS. Central Venous Thrombosis (Heart-clot)__Blood in the right ventricle of the heart coagulates, forming clot, which plugs, and perhaps extends into, the pulmonary artery, thus usually producing sudden death by asphyxia, in con- sequence of obstruction to entrance of blood-current into lungs. Causes—Conditions by which tendency to blood-coagula- tion is increased, viz. : 1. Hemorrhage, either before, during, or after labor. Blood-loss is always followed by increase of fibrin in the blood retained. Increase of fibrin favors coagu- lation. 2. Slowness or feebleness of blood-current; hence syncope (in which the heart is almost at rest)—whether from hemorrhage, or from exhaustion following a long labor, or from sudden reduction of intra-abdominal pressure after rapid delivery, or from previous debility—favors coagulation. Great feebleness of the circulation, without syncope, may produce if. 3. Septic infection of the blood, and accumulation in it of effete matters resulting from involution of uterus, etc. 4. Excess of fibrin, common to blood of pregnant women. 5. Thrombi in other veins may give off fragments (emboli), which lodge in ventricle or pulmonary artery, and constitute nuclei for growth of larger clots by accretion. Several ot the above conditions may be combined in lying-in women. Post-mortem Appearances___Firm, leathery, laminated, and decolorized clots in right ventricle and pulmonary artery, and its larger branches. Coexistence of thrombi, sometimes, in other veins. Symptoms___Sudden occurrence of intense dyspnoea, pre- ceded, or not, by syncope. Extreme pallor, or lividity of face. Violent gasping and respiratory motions, which are short and hurried. Pulse thready, feeble, fluttering, or 284 PERIPHERAL VENOUS THROMBOSIS. nearly imperceptible. Skin cool or cold. Intelligence may be unimpaired. Death may occur in a few minutes; or, if obstruction in pulmonary artery be not complete, the symp- toms may ameliorate, but return, and repeatedly, when pa- tient attempts the slightest movement. Some live hours, some days; a very few recover. Cardiac murmur may some- times be heard over site of pulmonary artery. Diagnosis__Dyspnoea and asphyxia, with sudden death, may be produced by entrance of air into uterine vessels at placental site—the air having reached the vagina and uterus, by use of imperfect syringes, or during manual and instru- mental deliveries, or from placing the woman in the genu- pectoral or latero-prone positions, or sudden removal of ab- dominal pressure after violent pains that have expelled liquor amnii may, if vulva gape, produce aspiration of air into vaginal canal. Gases may be produced in utero, from decom- position. Symptoms are nearly the same as heart-clot; so is treatment. Sudden deaths from hemorrhage, shock, uterine rupture, and concealed bleeding from separation of a normally placed placenta, have already been mentioned. Treatment of Heart-clot—Prevent the accident, when, as after severe hemorrhage, etc., it may be anticipated, by keeping the head low, and enjoining absolute repose in recum- bent posture, not permitting the woman to elevate her head for any purpose whatever. Treat the accident, when it has occurred, by bold administration of stimulants,—whiskey, brandy, ammonia, etc. Whiskey ^j, or sulphuric ether 5j, may be repeatedly injected hypodermically. Fresh air. Milk and beef essence. Absolute and perfect rest. The slightest movement may be fatal. Apply warmth to the surface. Prolonged rest, after subsidence of violent symp- toms, until blood is restored by iron, quinine, and food. Peripheral Venous Thrombosis.— Clots of blood, forming in the peripheral veins, occur for the most pait in the veins of the lower extremity or pelvis (notably in the crural, tibial, or peroneal); and thus, leading to obstruction, produce swelling of the limb; hence peripheral venous thrombosis is the new name for old-fashioned " milk-lec." (Synonyms: "White-leg," "phlegmasia dolens," "oedema lacteum," "crural phlebitis," etc.). peripheral venous thrombosis. 285 Causes and Pathology___Not definitely settled. Condi- tions favoring blood-coagulation (just mentioned as pro- ductive of central thrombosis) act as predisposing causes. The disease is apt to occur after placenta praevia, or after manual extraction of placenta. Coagula from placental site may float into hypogastric veins, and obstruct blood-flow through crural veins. Multiparity ; feebleness and debility ; difficult and complicated labors ; inflammations about the pelvis, following obstetrical operations ; hemorrhages ; septic infection ; cancerous and other pelvic tumors ; occurrence of erysipelas, and of puerperal and other fevers during child- bed, may be set down as causes. The disease may occur after abortion (especially when some part of the placenta has been retained), and sometimes it begins independently of both abortion and labor. Formation of blood-clots (thrombi) in the affected venous trunk is, at present, most generally admitted as the starting- point of the local phenomena, though various other theories severally regard the venous obstruction as being secondary to phlebitis, cellulitis, lymphangitis, etc. Symptoms___Usually begin within one, two, or three weeks after labor. Premonitory malaise, depressed spirits, weak- ness, and irritability of temper. Pain in the limb, perhaps first referred to the hip-joint, or inguinal region, and then extending to thigh and leg; or may begin in the ankle or calf of the leg and extend upwards. It is a dull, dragging pain, increased by motion. Chill followed by fever. Arrest of milk and lochial secretions ; the lochia, if present, are of- fensive. Pulse may reach 120; temperature 101° or 102°, with evening exacerbation. Tongue coated. Bowels con- stipated. Restlessness; sleeplessness; thirst. Chill, fever, etc., may be absent in mild cases. Within twenty-four hours limb begins to swell; swelling increases until skin is tense, white, and shining, from oede- matous accumulation of effused serum in the cellular tissue. Complete loss of power in the leg, the patient being unable to turn it over in bed. Some loss of sensation in it, a " wooden" feeling. Its temperature increased. Affected vein, or veins, may be felt as thick, hard cords, rolling under finger, red and tender. On the inside of thigh the femoral sheath feels as large as a walking-stick ; a red flush, and 286 PERIPHERAL VENOUS THROMBOSIS. tenderness on pressure, mark its course. Glands of groin may be swollen, inflamed, and hard. Vulva oedematous also. In a week or two both local and general symptoms abate. Swelling diminishes by absorption of effused serum, ending in recovery. Other cases terminate in suppuration and ab- scesses in the limb, pelvis, or lymphatic glands of groin. Rarely gangrene occurs. Floating fragments of thrombus may lodge in distant parts, producing metastatic abscesses in lungs, liver, joints, etc., with pyaemia, septic infection, and death. In cases of recovery some swelling, impairment of mo- tion, and liability to relapse, may continue for weeks or months. Prognosis__A fatal termination is exceptional. It is to be feared in pyaemic cases, and in those attended with sup- puration of the limb. Complete recovery, as regards the limb itself, may be long delayed, owing to partial or com- plete occlusion of venous trunk, and its conversion into a fibrous cord. Treatment—Perfect rest and slight elevation of the limb. Swathe it in flannel wet with hot water, and cover flannel with oiled silk, or apply hot flaxseed meal poultice con- stantly, together with turpentine, laudanum, or belladonna, to relieve pain. Leeches and blisters are recommended, but are best omitted. Rest and moist warmth are all-sufficient for acute stage. Local treatment after subsidence of acute symptoms con- sists in application of dry flannel ftandages in place of poul- tices. Rest and elevation of limb to be continued until affected veins are entirely restored. Gentle, very gentle, frictions with stimulating liniments, or iodine, may be used to promote absorption, with caution not to disturb thrombus and cause it to float away to some more dangerous locality. Douches of salt water, etc., and an elastic stocking may be of service. General Treatment.—Avoid depletion. The disease is one of weakness rather than strength. Morphia hypoder- mically, or Dover's powder internally, to relieve pain. Food: liquid nourishing diet of milk, soup, beef-tea, etc. Alco- holic stimulants may be necessary. Quinine, tinct. fe. chlorid., and bitter tonics are of service, but alkalies and INSANITY DURING GESTATION, ETC. 287 other medicines given with a view to dissolve the clot have not been proved to be efficient. Arterial Thrombosis and Embolism__Very rarely clots (thrombi) form in the arteries of puerperal women, instead of, or as well as, in the veins. They may also result from the breaking up of a venous thrombus, the fragments of which pass through the heart, and go on in the arterial system until arrested by some artery too small to let them pass. Such arrested floating fragments of a thrombus are called " emboli." Arrested detached fragments of " vege- tations" from cardiac valves, following rheumatic endocar- ditis, sometimes occur. Symptoms depend chiefly upon defect or arrest of func- tion and nutrition of the particular organ, or part, whose artery has been obstructed by the clot. Paralysis and aphasia result from plugging of cerebral arteries, and blind- ness from obstruction in the ophthalmic. When the brachial or femoral arteries are the seat of thrombi, the respective limbs below the obstruction suffer a reduction of tempera- ture, loss of motion and of sensation, or, instead of this last, severe neuralgic pain. Pulsation in the artery is lost below the obstruction and strengthened above it. Gangrene may occur when the collateral circulation is inadequate to sustain nutrition of the limb. Treatment___Rest and good diet, with perhaps stimulants, and anodynes to relieve pain. In time the obstructing body will disintegrate or undergo absorption, but no treatment of which we are aware can hasten these processes. Gangrene belongs to surgery. CHAPTER XXXV. INSANITY DURING GESTATION, LACTATION, AND THE PUERPERAL STATE. The old term puerperal mania, inasmuch as it implies simple mania, and only during the puerperal period, is becoming obsolete. Viewed more comprehensively, mental 288 INSANITY DURING GESTATION, ETC. derangements in the female having a causal relation with reproduction may be classified, chronologically, as follows:— 1. Insanity of pregnancy. 2. Insanity of the puerperal state. 3. Insanity of lactation. These, it is evident, may overlap each other, or occur successively in the same patient. The insanity, at whichever period it occurs, presents one of two special, and to some extent opposite, phases, viz., mania, and melancholia. Both are sometimes combined. Mania is characterized by paroxysmal violence, mental fury, raving, etc. Melancholia means continued despon- dency, steady gloom, quiet depression, suspicion, mistrust, etc. The mental atmosphere in melancholia is steadily dark from impending clouds; in mania it is violently agitated as from a cataclysmic storm. Causes___The three varieties of insanity have certain causes in common, viz., hereditary predisposition ; primi- parity after 30 years of age; pre-existence of insanity, epi- lepsy, hysteria, dipsomania, and other neuroses are predis- posing causes. During pregnancy, constipation, indigestion, mental worry from accidental circumstances adding to the depression and despondency common to pregnant women, as, e.g., seduction, desertion, etc., contribute to produce the disease. Special causes of insanity during the puerperal period are : difficult, painful, prolonged, and complicated labors; post-partal hemorrhage; eclampsic convulsions ; ex- haustion and debility, as from over-frequent child-bearing, from lactation during pregnancy, or from previous disease. Violent mental emotion, as fright, shame, sorrow, etc. Septic infection, and albuminuria with uremic contamination of the blood are probably (?) additional causes. The in- sanity of lactation is essentially a disease of debility and anemia, these conditions arising from prolonged lactation, frequent child-bearing, post-partal hemorrhage, or other causes of exhaustion. An ill-nourished brain cannot per- form its normal functions. Symptoms—The insanity of pregnancy commonly begins about the third or fourth month, or from then to the seventh, rarely later. Symptoms follow the melancholic type, and are sometimes exaggarations of previously existing mental, moral, and emotional disturbances, usually noticed as signs INSANITY DURING GESTATION, ETC. 289 of gestation. There are headache, insomnia, gloominess, or irritability of temper, personal dislikes, etc., with tendency to suicide. Cure before delivery is exceptional, and there is liability to mania during or after labor. The insanity of the puerperal period is most frequently, but not always, of the maniacal type. In very painful labors, when the head is just passing the os uteri, or perineum, a temporary frenzy, or " delirium of agony," is sometimes suddenly developed, but soon passes away. This is not the kind of mania now under consideration. Puerperal mania proper begins usually within two weeks after delivery. It may be a week or two later. Sometimes it comes on within a few hours, rarely in a few minutes, after labor. It may, or may not, be preceded by premonitory symptoms, such as restlessness, headache, insomnia, or sleep disturbed by pain- ful dreams, manifestation of suspicion and dislike towards relatives and attendants, etc.; soon followed by incoherent talking, probably upon amatory, obscene, or religious topics. Patient steadily refuses to take food, and, as excitement in- creases, refuses to stay in bed, tears off her clothing, screams, sings, prays, attempts self-mutilation or suicide, or to inflict injury upon others. In time, the paroxysm of mental ex- citement sobers down to melancholy, but fresh outbreaks are liable to occur on slight provocation. During excitement, the pulse is accelerated and small. The digestive system is usually at fault, as shown by furred and coated tongue, and constipated bowels. The urine is high colored and often passed involuntarily; there may also be involuntary stools. When mania is absent, the melancholia symptoms are: persistent refusal to take food; insomnia; intense depression; religious or other delusions; weeping; praying; gloomy silence; tendency to suicide, infanticide, etc. Signs of digestive derangement. The insanity of lactation is generally of the melancholic type, but may be associated with transient mania. It is much more common than insanity of pregnancy; less so than that of puerperal period. Is usually attended with symp- toms of anemia. May degenerate into dementia and hope- less insanity. Prognosis: as to life, the puerperal form, usually favor- able, but not always. Extreme frequency of pulse, elevation of temperature, and coexistence of pelvic or other inflam- 25 290 INSANITY DURING GESTATION, ETC. mations, are of grave significance. Mania is more danger- ous to life than melancholia. The prognosis, as to restoration of reason, is less favorable in melancholia. In this respect also, previous existence of insanity, or its coming on during lactation, or during latter half of pregnancy, are unfavorable, though not invariably so. Insanity coming on early in pregnancy and constituting simply exaggeration of usual mental eccentricity of gestation is less serious. Sometimes weeks or months pass before a cure is effected. There are no special post-mortem appearances other than those of anemia or coexisting inflammations. Treatment___The transient frenzy of acute suffering during delivery is relieved by anaesthesia. True insanity, at whichever of the three periods it occurs, and whether of the maniacal or melancholic type, requires remedies addressed to general condition of patient, rather than to mental symptoms. No depletion is called for, but, on the contrary, food, rest, sleep, and strengthening medi- cines. At the outset give a laxative, mild or stronger, according to strength of patient and previous constipation, but always with caution as to reduction of strength by excessive purg- ing. After its operation secure sleep by bromide of potas- sium (3ss every eight hours), or, if this is inefficient, give, with each dose, hydrate of chloral gr. xx. Thirty grains of chloral with sixty of the bromide may be given by enema, if patient refuses to swallow. Opium and morphia are, on the whole, objectionable—certainly so in mania cases; the latter may be given hypodermically in melancholia. Feed the patient with solid meats if she will take them. If not, give beef-tea and as much milk as possible. The latter will sometimes be accepted as a drink, when the pa- tient declines to eat, especially when brought in an earthen instead of a glass vessel, and in a darkened room. Cold to the head, warm pediluvia, a bath of 90° F., or the hot, wet pack for refractory patients, assist in promoting sleep. Good nursing is of great importance. Every patient should be constantly watched—to prevent self-injury—but without her being aware of it, if possible. Strangers are more acceptable to most patients than husband, relatives, and friends. The bladder and rectum require special care to secure their being regularly evacuated at proper intervals. INFLAMMATION OF THE BREASTS. 291 Beware of bed sores. Great tact necessary, by firm yet gentle persuasion, to induce the woman to take food. Its artificial administration by force, seldom advisable, though sometimes necessary. The room should be quiet and dark. The woman must not nurse her child. Insanity coming on during lactation always requires im- mediate weaning of the child, and in addition to food, sleep, etc., iron and quinine are necessary to restore the blood. The propriety of sending patient to asylum, depends much on facilities for good nursing at home. When the latter are wanting, an asylum is demanded. Mania, being of shorter duration than melancholia and less likely to be followed by confirmed dementia, may be managed at home in most in- stances. In chronic melancholia, sending the patient to an asylum should not be unduly postponed. During convalescence avoid all sources of mental excite- ment. Continue careful feeding, sleeping medicines at night, laxatives and tonics until strength is fully restored, when change of scene and cheerful surroundings complete the cure. CHAPTER XXXVI. inflammation and abscess of the breast__ lactation and weaning. Inflammation of the Breasts (Mammitis, Mas- TiTis)---Inflammation may attack the substance of the mam- mary gland itself (" glandular mastitis"), or the layer of cel- lular connective-tissue lying underneath the gland, between it and the pectoralis major muscle (" subglandular mastitis," or, more properly, submammary cellulitis). A more cir- cumscribed form of inflammation occurs in the subcutaneous tissue immediately beneath the areola of the nipple (subcu- taneous mastitis). Either variety of inflammation may terminate in resolu- tion without suppuration taking place; but in every case an opposite termination is to be feared, viz., the formation 292 inflammation and abscess of breast. of pus, and consequent " mammary abscess" ("gathered breast"). In "glandular mastitis" the inflammation and suppura- tion (when the latter occurs) are usually confined to one lobule, or to two contiguous lobules, of the gland ; but, wdien the abscess has discharged its contents, the inflammatory and suppurative processes may go on to the next adjoining lobule, and so on to another and another, until a great part of the gland is destroyed by this succession of abscesses, the woman becoming meanwhile seriously, or even dangerously, debilitated by continued suffering and exhausting purulent discharges. In submammary cellulitis inflammation is more diffuse— not confined to tbe vicinity of any particular lobe of the gland; and, wdien pus forms, it is apt to infiltrate itself between the gland and chest-wall, separating the one from the other, or leading to long, sinuous tracts, which eventually form fistulous openings, through which matter is discharged. In neglected cases the fistulous orifices may enlarge by sloughing of their borders into ulcerated surfaces of consid- erable size. In one such case I was able, by lifting the gland away from the chest-wall, to look in at one fistulous ulcer and see daylight admitted through others on the opposite side. This form of inflammation may begin, de novo, as a cellu- litis : or the latter may be associated with, or produced by, inflammation of the gland itself, the glandular abscess, when deep-seated, discharging its pus posteriorly into the cellular tissue lying beneath the gland. It is not of frequent occur- rence. The "subcutaneous" form of mastitis usually terminates in suppuration, forming small abscesses, or boils, in the vicinity of the areola, their openings sometimes forming fistulous communications wdth the milk ducts. Causes of Mammary Inflammation___The most common cause is continued distension of the gland from accumulation of milk, especially when the latter is associated with eroded or fissured nipples, which render suckling extremely painful. Other causes are : sudden depressing emotions ; exposure to cold ; mechanical injury, as from pressure of clothing, blows, etc. Women who have once suffered from mammary ab- scess, are likely to do so at succeeding deliveries, probably INFLAMMATION OF THE BREASTS. 293 because adhesions and contractions of previous inflammation have produced obstruction in some of the lactiferous ducts. Symptoms__Inflammation of the breast, of either variety, may or may not be preceded by excoriation or fissures of the nipple. So, too, a lump may form in some part of the gland from accumulation of milk, and be attended with some slight tenderness on pressure, but yet be dissipated* under proper treatment, without inflammation taking place. Such an indurated nodule, however, is never safe from superadded inflammation upon very slight provocation. When the in- flammatory process really begins the symptoms are: Chill, fever, rise of temperature, hot skin, frequent pulse, head- ache, thirst, anorexia, etc. Locally, lancinating pain in the breast, increased by pres sure; increased hardness, heat, swelling, and, at first, very slight redness. Should the case terminate in resolution, the symptoms gradually disappear in a few days. When it goes on to suppuration, both local and general symptoms increase in severity. There is constant throbbing pain, increased ten- derness and swelling, decided redness and heat of skin over the inflamed part, which also appears glazed, shining, and oedematous. The hard lump has now become soft and fluc- tuating ; the latter, however, by no means distinct at first, or when the abscess is small or deep-seated. The fever is continuous, but liable to exacerbations following slight rigors, occurring several times a day. If left alone the pus eventu- ally makes its way to the surface, the abscess bursts, and is discharged, greatly relieving the pain and tension ; and either recovery soon follows, or subsequent renewal attacks devel- ope later, as before described. Inflammation without abscess occurs most often within the first week after delivery. Inflammation with abscess is more frequently a later occurrence, coming on in three or four weeks after labor, or, again, the acute symptoms of in- flammation may apparently disappear, leaving only a feeling of weight, with some pain and tenderness, and yet suppura- tion may occur, even after several months. The symptoms now described occur, varying in degree with the extent of inflammation, in each variety of mam- mitis. When, however, the subglandular cellular tissue is inflamed, a few of the symptoms are considerably modified; 25* 294 INFLAMMATION AND ABSCESS OF BREAST. thus the whole breast is swollen and tender, instead of there being one special point of tenderness, and every motion of the arm produces extreme pain, owing to movement of the chest muscles underneath the gland. The pus is slow in coming to the surface; may accumulate in large quantities before doing so, and lead to severe constitutional disturbance and numerous fistulae and sloughing ulcerations. In protracted cases of either form of inflammation, accom- panied with profuse and prolonged purulent discharge, symp- toms of prolonged exhaustion and debility may ensue. Mammary abscess usually affects one breast only, though sometimes both. The secreting function of the diseased gland, though not at first necessarily arrested (for the healthy lobules continue their secretion), is eventually lost from the necessity of withholding the child from suckling the inflamed breast! When, however, the inflammation has been only slight, and the abscess small, lactation may often be resumed after convalescence. Treatment—In the very beginning try to get rid of inflammation without suppuration taking place. In each variety of the disease enjoin rest in bed, with rest of the inflamed organ by not allowing the child to suckle from it. Keep down the secretion of milk by saline cathartics and abstinence from fluids. Three or four leeches may be applied in the neighborhood of the inflamed part, bleeding from their bites being afterwards encouraged by warm fomentations. Leeches are of value only when applied early, and appear to be of greater service in proportion as the inflammation is not deep seated. Tincture of belladonna added to the fomenta- tion, or the extract (3j) mixed with olive oil (|j) smeared over the breast, both relieve pain and lessen the lacteal secretion. The inflamed breast must be supported, by a handkerchief or sling, from hanging down, especially towards the axilla. Internally the woman will require opiates to relieve pain, quinia to control temperature, and a diaphoretic mixture (R. Liq. ammon. acet. gss, with spts. eth. nit. 3ss, every two hours) to promote elimination of fluid from the skin. Instead of leeches and warm fomentations, the lead and opium wash (R. Plumbi acetas, Jij ; extract, opii, gr. xvj ; aquae, Oj) may be kept constantly applied on flannel or patent lint, covered with oiled silk to prevent evaporation. LACTATION AND WEANING. 295 Painting the breast with tincture of iodine during the first twenty-four hours has been highly recommended as an abor- tive measure. In cases where accumulation of milk in the inflamed breast is very great, and not relieved by the remedies given, it may be necessary to mitigate the tension by gentle expression with the hand, previously anointed with camphorated oil ; but, on the whole, breast pumps, suckling, and manipula- tion, are not generally advisable, on account of the irritation they produce. The child, of course, suckles from the healthy breast. When symptoms of suppuration begin, the local treatment consists in applying hot poultices, preferably of flaxseed meal, until fluctuation can be detected, when the abscess must be opened without delay. In subglandular cellulitis, the point of opening must be at the lower margin of the base of the gland. An aspirating needle may be required to detect pus accumulation early in these cases, before the incision is made. In other cases, incise over the most soft and prominent portion of the abscess, the incision radiating from the nipple so as to avoid cross-cutting of the milk ducts. The breast should be first cleansed and anointed with carbolized oil, and, after the incision, treated with antiseptic dressings. A strip of carbolized lint, or drainage tube, must be kept in the opening to prevent union, for a few days, or until the discharge has become insignificant in quantity. Long sinu- ous tracts and fistulae may require antiseptic injections and drainage; or their walls may be stimulated to healthy gran- ulation, by an occasional injection of nitrate of silver, or sulphate of copper, as in ordinary surgical wounds. In every case of considerable duration, good food, iron, quinine and bitter tonics, will be necessary to prevent debil- ity and exhaustion. Lactation and Weaning__No arbitrary rule can be laid down suitable for all cases, as to the length of time a woman should nurse her child. About one year is the average time at which weaning may take place. Many mothers nurse their children longer. With savages lacta- tion is often continued several years, or until the advent of another child. AYith many delicate and sensitive women in 296 LACTATION and weaning. the higher walks of life it is impossible to continue lactation beyond a few months, and many of those who persist in pro- longing lactation beyond a year, suffer in consequence, from anemia, menorrhagia, and permanent impairment of their capacity for lactation, as is demonstrated when future chil- dren are born to them. Besides a general incapacity for producing milk, without exhaustion, there are certain conditions which should pro- hibit a mother from nursing her child. These are : a strong hereditary tendency to cancer, scrofula, and insanity ; con- stitutional syphilis ; great emotional excitability. A violent fit of anger has rendered the lacteal secretion sufficiently poisonous to produce convulsions in the child. Lesser, but more constant, degrees of emotional excitement produce deterioration of the milk to an extent which may still be injurious. The return of menstruation, and the recurrence of preg- nancy, during lactation, usually change the milk and make it unfit for the child. Exceptionally, this is not the case. Some pregnant and menstruating females continue to secrete milk that agrees with the child. The health of the infant will indicate to which class its mother belongs. When from any reason the woman is not able to nurse, the infant must either be fed by hand or supplied with a wet nurse, the latter course being always preferable, when it is practicable. In selecting a wet-nurse it should be ascer- tained that she is free from all of the impediments to lacta- tion just referred to; that her digestion and appetite are good ; that her disposition is cheerful and good-natured ; that she is free from eruptions on the skin ; has sound gums and teeth and an inoffensive breath ; and that her own child is healthy and well nourished. Her breasts and nipples must be normal, and it should be known that fulness of the breasts has not been artificially contrived by permitting milk to accumulate for many hours before the examination. The age of the wet-nurse, when there is room for choice in this particular, should be between 20 and 28 years; and the time of her confinement as nearly as possible coincident with that of the mother whose child she is to nourish. When no wet-nurse can be procured, the child must be artificially fed by hand. Directions for the preparation of its food have been previously given in chapter xii. (p. 127.) DURATION OF PREGNANCY. 297 CHAPTER XXXVII. THE JURISPRUDENCE OF MIDWIFERY. An obstetrician, even when not an acknowledged expert in medico-legal matters, may, from his professional relations with patients or persons implicated in legal trials, be com- pelled, on the witness-stand, to give evidence-of a scientific or quasi expert character. Under such circumstances a painful lack of scientific knowledge, often sufficient to defeat the ends of justice, and coupled with corresponding embar- rassment on the part of the physician, is not unfrequently exhibited in our courts. Hence I have ventured to add, in so far as may comport with the brevity of this work, a few rudimentary remarks upon medico-legal topics of an obstet- rical character, which, while treating the subject only super- ficially, may, perhaps, afford some assistance to the unavowed expert, or confessed ?«i-expert medical wdtness. The works on " Medical Jurisprudence," by Dr. Alfred Swaine Taylor, and by the Drs. Beck, are my principal sources of informa- tion for what is to follow. Duration and Unusual Prolongation of Preg- nancy---The average duration of pregnancy is ten lunar months (forty weeks—280 days). The moral character of a female, and the legitimacy and consequent hereditary rights of offspring, may depend upon the acknowledged degree to which it is possible this normal duration may be prolonged, as when a woman gives birth to a child eleven or twelve months after the death (or continued absence from other cause) of her husband. It is undoubtedly possible for preg- nancy to be prolonged four, five, six, seven, and even eight weeks beyond the normal period, and the child be born alive.1 Cases are recorded in Taylor's Medical Jurispru- 1 A child may die near full term (after symptoms of labor have begun and disappeared), and remain in utero months and years afterwards,—so-called "missed labor cases." 298 THE JURISPRUDENCE OF MIDWIFERY. dence, 5th Amer. ed., pp. 473-481 ; Play fair's Midwifery, 2d Amer. ed., pp. 154, 155 ; Lusk's Midwifery, 1st edit., pp. 109, 110; Leishman's Midwifery, 2d Amer. edit., pp. 178-181 ; Meigs's Treatise on Obstetrics, 3d edit., pp. 228- 234; Beck's Jurisprudence, 11th edit., vol. i., pp. 600-604, etc. Those who assert such cases to be fabulous and unreli- able, may be answered with the statement that the same amount of prolongation has been observed in other animals (cows and mares) in which the date of coitus was positively known. The possible unlimited retention of the child in certain cases of extra-uterine gestation must be remembered in rela- tion with the duration of pregnancy, in so far as it may affect the character of the woman. The child, after full term in such cases, always dies. Children born after over-long pregnancies may be over- large in size, but are not always so. Short Pregnancies with Living Children—A liv- ing child, and one that continues to live, being born nine, seven, eight, six, or five lunar months after marriage, may be the cause of suspected pre-marital inchastity on the part of the mother, and possibly of alleged ground of divorce by the husband, together with other legal and social complica- tions. The child is undoubtedly viable at the end of the seventh lunar month. Exceptionally, children born at the sixth month have lived and been reared. Cases are even recorded where the infant survived a short time when born at the fifth, and even at the fourth, month. (See Playfair's Midwifery, 2d Amer. edit., p. 229 ; Beck's Medical Juris- prudence, 11th edit., vol. i., pp. 599-600; also p. 388; Meadow's Manual of Midwifery, 4th Amer. edit., pp. 93, 94; Taylor's Medical Jurisprudence, 5th Amer. edit., pp. 468-471). The possibility of exceptional cases must always be remembered and stated. Appearances of Fcetus at Different Periods of Gestation—A medical witness may be asked to express an opinion as to the probable duration of a given pregnancy, from the appearance of the child. He cannot be positive or exact. F03TUS AT DIFFERENT PERIODS OF GESTATION. 299 During first month?—Foetus a semi-transparent, grayish, gelatinous mass, about one-twelfth of an inch in length, with no definite structure, head, or extremities. Pedicle of umbilical vesicle can be traced into unclosed abdominal cavity. Towards end of first month appearances more nearly resemble those of— Second month__Fcetus, at commencement of second month, about half an inch in length. Body weighs about 60 grains, is curved on itself; convex behind, concave in front. Head just distinguishable. No extremities. Eyes represented by two dark dots ; the mouth by a cleft. Chorion formed and covered on all parts with villi. Towards end of second month. Body one, or one and a half inches long. Head and extremities distinctly visible. Upper extremities appear first. Umbilical cord distinct, but untwisted (straight), and inserted into lower part of abdomen. Chorion distinct from amnion. Formation of placenta be- ginning. Third month__Body grows to length of 2, 2^, and by end of month to 3 or even 3^ inches. Fingers and toes formed, but are webbed. Head large compared with body. Nose, ears, anus, and mouth formed,—the two latter closed. Eyes prominent; lids joined together. Pupillary membrane visible. Umbilical vesicle and allantois have disappeared. Chorial villi atrophied. Placenta separate and distinctly formed. Genitals visible. Fourth month__Body grows from 3^ to 5^ or 6 inches in length by end of month. Weight from 3 to 5 or 6 ounces. Sex distinguishable. Mouth and anus open. Nails begin to appear. Chorion and amnion in contact with each other. Fifth month__Body grows from 5^ or 6 to 9 or 10 inches in length by end of month.2 AVeight increases from 6 to 10 ounces. Head one-third the length of whole fcetus. Flair and nails visible. Sixth month__Length 11 or 12 inches. AVeight one pound. Hair distinct; also eyelashes. Eyelids still agglu- 1 The text here refers to calendar months. I find no records of appearances at different lunar months. 2 For this, and the succeeding calendar months, allowing two inches for each month will give a rough approximate average of the child's length: 6th, 12; 7th, 14, etc. etc. 300 THE JURISPRUDENCE OF MIDWIFERY. tinated, and pupils still closed by pupillary membrane. Clitoris prominent. Testicles still in abdomen. Seventh month__Length about 14 inches. Weight 3 or 4 pounds. Eyelids open. Pupillary membrane disappearing. Sebaceous matter on skin. Nails distinctly formed. Testi- cles descending, or descended, into scrotum. Eighth month__Length about 16 inches. AVeight 4 or 5 pounds. Pupillary membranes gone. Nails reach to ends of fingers. Testicles in scrotum. Sebaceous matter on skin more plentiful. Ninth month__Length 18 or 20 inches. Average weight 6 to 8 pounds. Males usually larger than females. Nails horny, and reach beyond finger-ends; those of toes not so long. Meconium in rectum. Hair more or less abundant. Umbilicus placed midway between head and feet; but to this there are numerous exceptions.1 Cases in which a AVoman may be unjustly sus- pected of Conjugal Infidelity__Delivery of a mature or premature child having taken place, the woman (without having meanwhile seen her husband, and without having again submitted to coitus) may, in the course of one, two, or three months, be delivered of another child, which may be either mature or premature. Such cases are susceptible of explanation in three ways:— First. In twin pregnancies one child may be expelled and the other follow only after several weeks or months. (For cases, see Taylor's Medical Jurisprudence, pp. 486-489 ; Ramsbotham's Obstetrics, p. 468; Leishman's Midwifery, p. 193; Churchill's Midwifery, American edition, 1866, pp. 177-178, etc.) Second. The woman may have a double (bi-lobed) uterus, in each side of which is a fcetus, the two uterine cavities expelling their contents at different times. (For cases, see Playfair's Midwifery, pp. 58 and 161; Leishman's Mid- wifery, pp. 188, 189; Taylor's Jurisprudence, p. 488; Churchill's Midwifery, p. 178.) Third. A pregnant woman submitting to coitus during the early months of gestation may have a second ovule im° 1 It will he observed that the external appearances of the fcetus only have been mentioned. SIGNS OF RECENT ABORTION. 301 pregnated (super-foetation), perhaps, just prior to the sub- sequent death or departure of her husband. The two foe- tuses may be born at different times. (For cases, see Taylor's Jurisprudence, p. 487 ; Leishman's Midwifery, pp. 186-188; Playfair's Midwifery, pp. 161, 162; Churchill's Midwifery, pp. 177-178.) The occurrence of super-foetation has been questioned, but its possibility, and its actual occur- rence as a matter of fact, is now generally admitted. AVhen the two children are of different race or color—one white, the other black—(" super-fecundation)" the fidelity of the female may be justly questioned. True and False Moles__The diagnosis of bodies ex- pelled from the genital canal, not due to impregnation, from those necessarily the result of coitus, has been already suffi- ciently considered. (See Hydatiform Pregnancies, p. 105, and Moles, p. 106.) Diagnosis of Pregnancy__(See pp. 69, 70-84.) Signs of Recent Abortion in the Living__AAdien the fetus and its membranes, in a case of suspected abor- tion, are concealed, a medical witness may be required to give evidence as to existing signs of recent abortion in the female. Abortion during the first three months of preg- nancy may, even so soon as twenty-four hours after delivery, leave no proofs whatever of its occurrence, in the living woman, that can be recognized by examination. The ordinary signs—at best ambiguous—viz., dilatation of the os uteri with some lochial (bloody) discharge there- from, enlargement of the uterus, swelling and relaxation of the vulva and vaginal orifice, enlargement of the breasts, secretion of milk, presence of darkened areola round the nipple, etc—may either be wanting, or, on the other hand, result from other causes. Signs of Recent Abortion in the Dead__Even the post-mortem signs of abortion during the first three months of pregnancy, may so completely disappear in the course of a few days after delivery, as to leave no positive evidence. Satisfactory proofs may, however, be obtained, if examina- tion be made within forty-eight hours after expulsion of the 26 302 THE JURISPRUDENCE OF MIDWIFERY. ovum. Then we find usually some enlargement of the uterus, both of its cavity and walls, the latter being thicker and with larger bloodvessels than in a normal and unim- pregnated state. Cavity of womb may ^?) contain remnants of blood-clots, membranes, or placenta. Its lining may in- dicate, after and during latter part of third month, the pla- cental site—a darkened and rough surface. Fallopian tubes and ovaries of deep color from physiological congestion of pregnancy. True corpus luteum in ovary. Caution: even these evidences of early abortion—.how ever soon after de- livery—can scarcely be more than presumptive. Menstrua- tion and uterine diseases require to be excluded (often very difficult) before certainty can be attained. The value of the corpus luteum is considered more at length below. Signs of Recent Delivery during Later Months and at Full Term in the Living and in the Dead__ Symptoms in the living are : AAfoman more or less weak and incapable of exertion. (Exceptions possible, especially with women in lower walks of life, and among negresses, Indians, and savages. For cases, see Beck, vol. i. pp. 376-377.) Slight pallor of face; eyes a little sunken and surrounded by darkened ring, and a whiteness of skin resembling conva- lescence from disease. The above symptoms often absent after three or four days. Abdomen soft: its skin relaxed, lying in folds, and traversed by whitish shining lines (linece albicantes), especially extending from groins and pubes to navel. (Exceptions:' these may be the result of dropsy, tumors, or a former pregnancy.) Breasts, after first day or two, full, tumid, and secreting milk. (Exceptions: some women secrete no milk after delivery.) Milk may be, or may be alleged to be, result of a previous pregnancy (before the one in question). Detection of colostrum corpuscles in milk shows delivery to be recent. Nipples present charac- teristic areola, especially "secondary areola," outside the disk. External genitals relaxed and tumefied from passage of child. Uterine globe felt in hypogastric region through walls of abdomen. Os uteri swollen and dilated sufficiently to"admit two or more fingers. Lochial discharge : its color varying with interval since delivery, maybe distinguished from menses and from leucorrhcca by its characteristic odor, sometimes described as resembling that of " fish oil." Ab- SIGNS OF RECENT DELIVERY. 303 pence, by laceration, of fourchette; but this is persistent after one labor. Os uteri fissured by radiating shallow lacerations or resulting cicatrices ; the latter being, of course, permanent. All these signs may be wanting, or become so indistinct, in a week or ten days after delivery, as to be unreliable. In other cases they are available for two or even three weeks. Examine as early as possible in all cases. Signs tn the Dead—These may be available two or three; weeks after delivery. Not reliable later. They are : Enlargement, thickening, and softer consis- tency of the uterus. Y)m\nv first day or two, womb will be found seven or eight inches long and four broad;1 its walls 1, or l-1- inch thick ; section presenting orifices of enlarged bloodvessels. After one week, following a full term labor, womb between 5 and 6 inches long (about the " size of two fists ") ; after two weeks, five inches ; at a month the organ may have contracted to its unimpregnated size. Uterine cavity, during first day or two, and perhaps later, contains bloody fluid, or coagula of blood, and pulpy remains of de- cidua. Placental site presents valvular, semi-lunar shaped vascular openings, and looks dark, resembling gangrene in appearance. Fallopian tubes, round ligaments, and ovaries, purple from congestion. Spot where ovum escaped from the ovary especially vascular. Orbicular muscular fibres around internal openings of Fallopian tubes distinctly visi- ble for one or two weeks. All the above signs become less marked as interval since labor increases. Ovary presents true corpus luteum : value of evidence furnished by it var- iously estimated by authorities. Chief characteristics of " true " corpus luteum—the corpus luteum of pregnancy— are : its large size, long duration, its being (usually) single, and its having a distinct cavity (either empty or filled with coagulated blood), which is either substituted or followed by a stellate radiating, puckered cicatrix. Cavity as large as a pea, may remain three or four months after conception. Ovary is enlarged and prominent at site of true corpus luteum. True corpus luteum varies greatly in size and 1 When, however, death has occurred from hemorrhage, and there is no contraction of the uterus, the organ will be found as a large flattened pouch measuring ten or twelve inches in length. 304 THE JURISPRUDENCE OF MIDWIFERY. duration in different women. During first three months its average size is nearly one inch long by half an inch broad, and during remaining months of entire pregnancy it mea- sures about half an inch long, and a little less in width. Getting smaller toward the end of pregnancy, it still re- mains one-third of an inch in diameter for some days after parturition, and presents a sort of hardened tubercle even a month or more later. False corpus luteum (that following menstruation) grows only three weeks, when it measures about half an inch by three-quarters, and then retracts, be- coming an insignificant cicatrix by the seventh or eighth week. It is not prominent, has no cavity, no radiating cicatrix, and is associated wdth others, like itself, perhaps in both ovaries. Evidence of pregnancy derived from corpus luteum is corroborative of other signs only: taken by itself, it cannot furnish positive proof either way, owing to liability to ex- ceptional variations in its development. It certainly cannot prove child-birth, for, after impregnation, foetus may have been absorbed and ovum may have degenerated into hydati- form mole. Unconscious Delivery__It is easy to imagine crimi- nal cases—ex. gr. infanticide—in which a plea of uncon- scious delivery might be set up. Medical testimony would, in such instances, be required, as to the possibility of its occurrence, in general, and also as to the likelihood of its having taken place in any given ease. AVomen have un- doubtedly been delivered unconsciously during sleep and syncope ; during the coma of apoplexy, puerperal eclampsia, asphyxia, typhus, and other malignant fevers; also while under the influence of narcotic poisons, and anaesthetics, as well as after death. Others have been delivered while at stool, mistaking their sensations for those of defecation (?). Delivery during ordinary sleep very improbable in primi- parae, or in women with small pelves ; less so in those with over-large pelves. Examine circumstantial evidence, and insist on full statement of facts from the woman herself, before admitting unconscious delivery in any particular case. Its possibility, however, is undoubted. (For cases, see Tay- lor's Med. Jurisprudence pp. 417, 418, 419; Beck's Med. Jurisprudence pp. 371, 372, 373.) CRIMINAL ABORTION. 305 Feigned Delivery.—Delivery has been feigned for the purpose of extorting charity, compelling marriage, produc- ing an heir, or disinheriting others, etc. AVhen the woman has (admittedly) never been pregnant before, her fraudulent pretensions may be detected (usually, and especially if a recent delivery is claimed), by finding breasts unenlarged and presenting no appearance of milk-secretion, or charac- teristic areola ; no lineae albicantes upon the abdomen ; no enlargment or irregularity of the os uteri; no discharge from vagina; a firm, solid, well-contracted, small and easily movable womb. Compare alleged date of delivery with appearances of child alleged to have been delivered, noting skin, vernix caseosa, umbilical cord, size, hair, etc., of the latter. (For cases, see Beck's Med. Jurisprudence, pp. 342 to 355.) AVhen a pretended delivery has been preceded by others (one or more), detection is more difficult. Signs of recent delivery may, or may not, be present. Examine for them. Inquire into any mystery or concealment respecting situa- tion of female before alleged delivery, during alleged preg- nancy ; also as to her age and fertility, or previous prolonged sterility; also as to age, decrepitude, or impotency of alleged father. Criminal Abortion—Foeticide___A medical witness may be required to state the natural causes of abortion, in general, and also his opinion, in particular, as to whether alleged (or proven) existing natural causes did, could, or were likely to produce it, in a given ease. Such evidence may be necessary to eliminate natural from criminal causes, as, for example, when a female having aborted, spontaneously, attempts to fix the crime on an innocent person; and in other cases. The natural causes, certain fevers, acute in- flammations, syphilis, violent mental emotion, etc. etc., have already been mentioned. (See "Abortion:" causes of pp. 98, 99.) An opinion as to the efficacy of one or more of them, in a given case, must depend (1) upon their intensity, location (of inflammation), virulence and malignity (of fever), etc., and (2) upon the nervous irritability, or suscep- tibility—in fact predisposition to abort—on the part of the patient, especially as to history of previous abortions, and the " abortion habit." 26* 306 THE jurisprudence of midwifery. Medical evidence may be required also as to accidental causes in general, and their probable efficacy in given cases. Such causes are: Blows, falls, jarring the body by railroad and street-car accidents, joggling over rough pavements in vehicles, horseback exercise, etc. After blows upon the abdomen the uterus, as well as the child, may or may not present evidences of contusion, laceration, incision, etc. Examine for them. Bones of child have even been broken and reunited in utero. As to the efficacy of accidental causes, the influence of predisposition to abort is paramount. Women have been subjected to repeated and prolonged mechanical violence without aborting when no predisposition existed. Books teem with cases. (For remarkable ones, see Beck's Jurisprudence, pp. 490, 491.) On the other hand, women with predisposition abort after very slight causes. Predis- position indicated by great emotional excitability, nervous habit, sensitiveness, and anemia ; or by plethora, with (pre- vious habitual) profuse menstruation ; or by previous exist- ence of other constitutional diseases acting as spontaneous causes of abortion; and by existence of the " abortion habit." Medical Testimony as to Medicinal Abortives and Instrumental Methods—Medical witnesses should neglect no opportunity of stating (what are actual facts, viz.) that all these methods are (1) uncertain in their opera- tion upon the child; (2) always dangerous and often fatal to the mother; and (3) sometimes fatal to mother without affecting infant. Children have survived and lived after the mother's death where premature delivery has been in- duced by criminal means. Emetics have been given in large doses, and induced violent vomiting without producing abortion. The spasmodic contraction of the abdominal walls and diaphragm accom- panying emesis are more dangerous in proportion to greater size and development of the uterus; hence during later months. Fifteen grains of tartar emetic have been taken without interrupting pregnancy (Beck, vol. i. p. 475). Cathartics—Purging carried too far, continued too long, and wdien accompanied with tenesmus, as after admin- medicinal abortives. 307 istration of decided drastics, may produce abortion, espe- cially during later months. Cathartics may be given during early months, especially when no predisposition exists, with- out decided effect. Pregnant women attacked with disease may be purged freely without abortion. (Cases: Beck, vol. i. pp. 475, 476.) Diuretics—A drachm of powdered cantharides (in one case), and one hundred drops of oil of juniper every morn- ing, for twenty days (in another), have been taken to induce abortion (Beck, vol. i. pp. 477, 478), but in both instances living children were born at full term. Cantharides, how- ever, has induced miscarriage in some cases (Beck, vol. i. 478). These, and such other diuretics as broom, nitre, fern, etc., exert no specific action on the uterus ; and they, to- gether with mineral and irritant poisons, such as arsenic, corrosive sublimate, sulphate of copper, etc., can only be considered abortives when they occasion shock, or produce sufficient irritation or inflammation to affect the general sys- tem, often at the expense of the woman's life. Juniperus Sabina is a popular abortive, of undoubted efficacy in some cases, from the consequent irritation or in- flammation it induces. It probably has no direct action upon the uterus. It has produced death, and has been taken for criminal purposes in sufficient doses to produce severe gas- tritis without abortion following. Physicians administering it to women suspected of pregnancy, or without being pre- viously satisfied that pregnancy does not exist, would be fairly open to suspicion of criminality. Secale Cornutum.—On trials for criminal abortion a medical witness must be prepared for a close examination on the specific emmenagogue properties of this drug (Taylor). Despite differences of opinion on the subject, the latest con- clusion, and which seems inevitable, is, that this medicine has a specific action as a direct uterine excitement, even when the uterus is not already in active contraction. For- merly it was supposed to act only when uterine contractions had already begun. Large doses have, however, been taken to produce abortion without effect (see Beck, vol. i. p. 483). Its emmenagogue properties increase as pregnancy advances, 308 the jurisprudence of midwifery. and are probably more marked at periods corresponding with the former catamenia. (For numerous references and cases, etc., see Taylor's Jurisprudence, pp. 433, 434, 435 ; and Beck, vol. i. pp. 482, 483.) Tanacetum Vulgare has acquired popularity as an abortive. It possesses no specific action upon the uterus. The oil, in doses of one drachm, four drachms, and eleven drachms, was taken respectively in three cases, each of the women dying in a few hours, without abortion coming on (Taylor, pp. 436, 437). Hedeoma Pulegioides and Polygala Seneka are reputed abortives, but of doubtful efficacy. The former is a decided emmenagogue. One case of abortion from its odor (ft) is reported (Beck, vol. i. p. 481) ; but I find none due to seneka. Mercury__Crude quicksilver (even in quantities of a pound at once), and medicinal preparations of mercury, even given till salivation, have been given without producing abor- tion. Ptyalism from mercury may, howrever, produce it in those predisposed. Bloodletting—Bleeding, leeching, and cupping were formerly considered abortives; but there is abundant evi- dence to the contrary. Instrumental Methods—The reader is already fami- liar with the methods of inducing labor for beneficent pur- poses, elsewhere considered. Devices somewhat akin to them are resorted to for criminal purposes. In such cases examine carefully (1) the kind and extent of injury (if any) inflicted upon the uterus (especially the os and cervix) and the child ; (2) note by what sort of instrument such injury could have been inflicted ; (3) whether it could have been done by the female herself, or implied the interference or assistance of some other person; and (4) whether it indi- cated anatomical knowledge, or a want of it, on the part of the operator. Instruments may be introduced into uterine cavity repeatedly during first three months of pregnancy without disturbing amniotic sac or discharging liquor amnii, INFANTICIDE. 309 and gestation still continue. After rupture of amnion, uterus begins to act in 10, 20, 40, or 60 hours—sometimes not for a week. AVhen contents of uterus are submitted for inspection, be certain whether or not they contain a fcetus, mole, or hydatiform mass. Diagnose ovum in early cases by seeing villi of chorion under microscope, if no foetus be present. If there be a fcetus, ascertain its probable age (see p. 299). As to period at which a child in utero becomes alive or "quickens," be ready to state that it is a living being from the time of conception—as much so at any time during the first month as during the last. The idea of life being imparted to it at any given period during pregnancy is an error, long ago discarded. Child-murder after Birth—Infanticide.—AVhen a mother is suspected of killing her own child, medical tes- timony is necessary as to (1) whether she has been delivered of a child ; (2) whether signs of delivery agree, as to time, etc., with appearances of child as to maturity, and length of survival after birth. (For signs of delivery, see pp. 302- 303 ; and for signs of maturity, p. 300.) Inspection of Child's Body—Original notes (made on the spot) to be kept, as to the following points :— 1. Exact length and weight of body. 2. Peculiar marks or deformities about it. 3. Marks of violence and probable mode of their produc- tion. 4. Umbilical cord : whether cut, tied, or torn ; its length and appearance of its divided bloodvessels. 5. Arernix caseosa on groins, axilla, etc., as indications of washing and other attentions. 6. Odor, color of, and separation of cuticle from skin, as evidence of putrefaction. Duration of Survival after Birth.—Signs uncer- tain, but great precision not demanded of medical witness. Length of survival for shorter time than twenty-four hours not to be determined by any sign. Drying, etc., of navel- string may occur in the dead. Usual appearances are during— Second 24 hours: Skin less red than during first day. 310 THE JURISPRUDENCE OF MIDWIFERY. Meconium discharged but large intestine still contains green colored mucus. Amount of lung-inflation unreliable, though perfect inflation indicates many hours of life. Cord some- what shrivelled, but still soft and bluish-colored from ligature to skin. Third 24 hours: Skin tinged yellowish, cuticle sometimes cracked preparatory to desquamation. Cord brown and drying. Fourth 24 hours: Skin more yellow ; desquamation of cuticle from chest and abdomen. Cord brownish-red, semi- transparent, flat, and twisted. Skin in contact with it, red. Colon free from green mucus. Fifth and Sixth 24 hours: Cuticle desquamating in various parts in small scales or fine, powder. Cord sepa- rates fifth day, but may not do so till eighth or tenth. Duc- tus arteriosus contracted ; foramen ovale partly closed. Sixth to Twelfth day : Cuticle separating from limbs. If cord was small, umbilicus cicatrized by tenth day; may not be healed completely till three or four weeks—much depends on the mode in which it has been dressed. Body heavier. Ductus arteriosus entirely closed; exceptions quite possible. AA7as the Child Born Alive ?—This question involves several, upon which medical testimony may be required, viz: (1) Did child live (as indicated by pulse, etc.), but without breathing ? Children may so live for a short period (during which violence maybe used), but there are no satis- factory post-mortem medical data to enable a witness to ex- press a positive opinion on this point. Absence of respira- tion does not prove child to have been born dead, for it may have been drowned (in a bath) or suffocated intentionally at the moment of birth. Marks of violence may afford un- certain proof. Marks of putrefaction in utero prove death before birth; they are, chiefly, flaccidity of body, so that it easily flattens by its own weight; skin reddish-brown—not green ; that covering hands and feet is white with cuticle sometimes raised in blisters containing reddish serum. Bones movable and readily separated from soft parts. These ap- pearances occur after child has remained dead in utero eight or ten days; scarcely available sooner. (N. B. The skin may become greenish when body is long exposed to air.) (2) Did child breathe as well as live? (3) If so, did it WAS THE CHILD BORN ALIVE? 311 fore Res Lungs. . 1 : ;piration. Body. 70 After Respiration, Lungs. Body. 1 : 35 . 1 : 52 1 : 42 . 1 : 49 1 : 39 . 1 : 60 1 : 45 . 1 : 47 1 : 40 breathe perfectly, or imperfectly ? Evidences of child hav- ing breathed, are :— 1st. The Static Test—The absolute or actual weight of the lungs is increased after respiration, owing to greater quantity of blood they contain. Hence 1000 grams has been proposed for average weight of lungs after respiration, and 600 grains before respiration. Actual weight of child and of its organs varies so much in different individuals as to render this test totally unreliable. A second method of its application (Ploucquet's test) is to take the relative weight of the lungs as compared with that of the body, before and after respiration. Different observers have obtained the fol- lowing average results:— Ploucquet Schmitt . Chaussier Devergie Beck Hence this test is certainly not infallible, but may furnish corroborative, proof. 2d. The Hydrostatic Test (specific gravity of lungs)___Its general principle is, that before respiration the lungs sink rapidly when placed in water; after respiration, they float high in that fluid. They may, however, float from other causes, viz., from gases developed in them during putrefac- tion, from artificial inflation, and from emphysema. In these cases the contained air (or gas) can be forced out of the lungs by compression (to be applied as described below, see p. 312), so that they afterwards sink; this cannot be done after perfect respiration. Artificial inflation does not in- crease weight of lungs. After imperfect respiration (as in feeble children, or those who only take a few gasps) the air can be expelled by compression, so that this is not to be dis- tinguished from artificial inflation. Exceptionally, the lungs may sink after respiration, from congestion, inflammation, and other diseases having in- creased their weight. Incising the lung and squeezing out its extra blood, or cutting it up and coihpressing each piece, 312 THE JURISPRUDENCE OF MIDWIFERY. will generally cause the organ, or some pieces of it, to float, if the child bas breathed. Application of Hydrostatic Test—Having opened chest, note position of lungs (before respiration they occupy a small space at upper and posterior parts of thorax); their volume (of course increased after breathing); their shape (before respiration borders sharp or pointed, after it, rounded) ; their color (before breathing brownish-red, after it, pale-red or pink) ; their appearance as regards disease and putrefaction ; and whether they crepitate on pressure (as they will after respiration). Take out lungs, with heart attached, and place them in pure water having temperature of surrounding air. Note whether they float (high or low), or sink (slowly or rapidly). Separate them from the heart; weigh them accurately, and then place them in water again, and note sinking or floating as before. Subject each lung to pressure with the hand, and note sinking or floating again. Cut each lung in pieces and test floating again. Take out each piece, wrap it in a cloth, and compress with fingers as hard as possible, and test float- ing, etc., as before. The crucial test of perfect respiration is each piece floating after the most vigorous compression. Value of Respiration as Evidence of Live Birth.— Respiration does not prove child to have been born alive, for it may have breathed (imperfectly at least), and even have been heard to cry in the vagina or uterus1 before birth was complete, as in face cases, and retained head in breech pre- sentations, etc. Exceptionally a child may live and even breathe (by bronchial respiration only) for hours and even days with partial, and twenty-four hours with actually com- plete, absence of air from the lungs. (Cases: see Taylor, pp. 335, 336, 337; Beck, vol. i. p. 517.) The lungs retain their fcetal condition of atelectasis. That they are not hepa- tized is proved by their susceptibility to artificial inflation. Physiological explanation of life under such circumstances still wanting. Probably complete absence of air is only ap- 1 It is said a child has been heard to cry in utero weeks before delivery (Taylor, pp. 350, 351; Beck, vol. i. pp. 537, 538). On this point one feels disposed to adopt the remark of La Fontaine and Velpeau : " Since learned and credible men have heard it, I will believe it; but I should not believe it if I heard it myself." CAUSES OF DEATH IN NEW-BORN CHILDREN. 313 parent instead of real, owing to our means of demonstration being imperfect. Here the hydrostatic test is inapplicable, but the fact does not lessen its value in proving signs of res- piration that do exist in other cases. Evidence of Life from Circulatory Organs.—The contracted or open condition of the foramen ovale, ductus arteriosus, and ductus venosus, furnish no reliable evidence of live birth. Evidence from Stomach__The presence of farinaceous or other food in the stomach proves the child to have been entirely born alive, at least in the absence of any proof that the food was placed there after death. Natural Causes of Death in New-born Children, and which, of course, have a direct bearing upon infanti- cide, are : Prematurity of birth ; congenital disease, or mal- formation ; protracted or difficult delivery ; compression of umbilical cord ; hemorrhage from the cord or umbilicus (see pp. 127, 159, 260, 264). Violent Causes of Death in New-born Children may be either accidental or criminal. Death, however, may occur without any marks of violence, as from cold, starva- tion, suffocation, and drowning. In so far as these latter are concerned an obstetrician may be required to testify as to the newly delivered female having sufficient strength, knowledge, sanity, and presence of mind to take proper care of her child, and prevent those occurrences. In primipara*, when deliv- ered alone, the lack of these conditions may exonerate her from intentional guilt, as when the infant has been proven to have died by resting on its face in a pool of blood, or some other discharge ; or when it has been delivered into a vessel containing water, on which the woman was seated, while mistaking her symptoms for those of defecation, etc. etc. The opinion of an obstetrician in these cases, however, must be very guarded, especially in single women and those de- livered of illegitimate children. The circumstances attend- ing delivery should first be accurately known, or at least diligently inquired into. The same caution necessary in death, with marks of violence, as in fractures of the skull, 27 314 THE JURISPRUDENCE OF MIDWIFERY. alleged to have occurred by the child falling during sudden delivery in the erect posture, or by innocent attempts at self-delivery, or attempts made by a midwife or other person. Marks of strangulation round the neck may be mistaken for those due to coiling of the navel-string round the same part, and vice versa. In death from coiling of the cord there are no deep marks on, extravasation of blood beneath, nor ruf- fling or laceration of the skin, nor injury of the deeper seated parts, as there usually are in homicidal strangulation. In strangled children the lungs have usually been inflated by respiration. In death from coiled cord they retain their fcetal condition. Marks on the neck may, possibly, be made by forcible efforts at self-delivery, or by cap-strings,1 or by bending of the head forcibly towards the neck soon after death, or as an accident of labor. These must be distin- guished from homicidal marks. Pale, shallow marks may be made by coiling of the navel-string, but they are not accompanied with extravasation, etc. Fractures of the skull, from the use of instruments during labor, or even from force of uterus without instruments, and from falling of the child when the mother is suddenly deliv- ered while erect, or while sitting in a water-closet, etc., can scarcely be distinguished from fractures or other injury due to criminal violence, except by circumstantial evidence, or by comparing size of child with pelvis in certain cases. The existence or non-existence of puerperal insanity (mania) is an important question in these cases. Medical Evidence of Rape__Medical evidence in rape is usually only corroborative of circumstantial proof, but may become leading testimony in cases of false accusa- tion, or of brutal attempts upon infants and children. Medical witnesses, before expressing an opinion as to whether rape has been perpetrated, should first understand the legal definition of rape, as to whether it mean contact, vulvar penetration, vaginal penetration, emission, rupture of the hymen, etc., one or more. The rule laid down in the United States is that " there must be some entrance proved of the male within the female organ." That is enough. No matter about emission, etc. 1 These, however, have been used for homicidal strangulation. examination for venereal DISEASE. 315 Marks of A'iolence upon the Genitals are: ecchy- mosis, contusion, and laceration of the parts, with or with- out bleeding. Redness, tenderness, heat, and swelling from subsequent inflammation. All of these may disappear in two or three days after the act. In young children laceration of the perineum and of the vaginal wall, and penetration of the abdominal cavity, with fatal result, have occurred. Note that mechanical injury of the parts may result from other causes. In the absence of additional proof a physician may only be able to state that the injuries are such as might be produced by rape. Inflammation, ulceration, and even gangrene of the vulva may also result from disease, as in the vaginitis and vulvitis of young children from worms, scrofula, uncleanly habits, erysipelas, malignant fevers, etc. In these laceration and dilatation of the parts are absent, while the redness and purulent discharge are usually greater than fol- low violence. Marks of A'iolence upon the Body__In women pre- viously accustomed to coitus these are important, as evidence of resistance on the part of the female. The genital signs may be wanting. Note exact form, position, and extent of any marks upon the body. If bruises exist, note presence or absence of color zones, indicating date of alleged assault. Examination of Clothing—Cut out stained spots from the clothing, whether dry or moist, and pale or colored, place them in a watch glass with just enough water to thoroughly moisten them for fifteen minutes, then squeeze out a few drops of their contents, and examine, under microscope, for human blood corpuscles and spermatozoids of seminal fluid. The evidence thus afforded, it is plain, may or may not be important, according to circumstances. The same may be said of microscopical examination of vaginal mucus for sper- matozoa, whether in the living or the dead. Loose fibres of clothing, examined microscopically as to their color and ma- terial, may sometimes furnish evidence of importance as to personal contact of persons wearing such clothing. Examination for Atenereal Disease__The existence of gonorrhoea or syphilis, either in the male or female, and its conveyance from one to the other, may afford either nega- 316 the jurisprudence of midwifery. tive or positive proof pro re rata. It should always be in- quired into, and the time of its appearance after the alleged coitus, in the person said to have been infected by the other, duly noted. Signs of Virginity__The presence of an unruptured hymen affords presumptive, but not absolute proof that the female is a virgin. The hymen may be congenitally absent, or ruptured from causes other than coitus, and impregnation, without vaginal penetration during intercourse, may take place, the hymen remaining intact. Pregnancy resulting from Rape was formerly thought to be impossible. The contrary is now universally admitted. Conception may or may not occur, as after ordinary inter- course. Impotence.—A medical opinion may be required as to sexual capacity, in a male accused of rape, bastardy, etc. Congenital impotence, from defective development of organs, is very rare. It is indicated by the individual being (usually) fat, without hair on the face, and none or but little on the pubes; by his testes and penis remaining small; his voice weak and of the falsetto quality. There is complete absence of sexual desire, and a general deficiency of virile attributes. The age of puberty varies. It is usually from 14 to 17 years; exceptionally not until 20 or 21. Rape, legally de- fined to mean " some penetration," has been committed by boys of 13, 12, and even 10 years (Cases in Taylor, p. 500). Procreation, however, is impossible until spermatozoids ap- pear in the seminal fluid. They have been recognized micro- scopically at the age of 18, but may undoubtedly appear sooner. Boys have become fathers at 14, perhaps earlier (Case of 14, in Taylor, p. 502). The beard, voice, devel- opment of the organs, and other marks of virility, should be our guides in any given case, rather than age alone. Impotence from Advanced Age__Procreative power has been retained till the age of 60, 70, 80, and 90 years. Such individuals usually retain also an extraordinary degree of bodily and mental power. Sexual capacity may be lost much sooner. Age alone cannot define any limit. impotence from loss of organs, etc. 317 Impotence from Loss of Organs, etc—Loss of both testicles does, but loss of one does not, render a man impo- tent. F^xamine for cicatrices, etc., upon scrotum. Even after removal of both, enough spermatic fluid may remain in the ducts to confer procreative power, for two or three weeks. Persons in wdiom one of the testicles remains in the abdomen are not usually impotent. AVhen both testicles remain un- descended the individual mayor may not be impotent—usually the former—according as the organs are or are not imperfect in their development. Medical opinion to be based chiefly on signs of virility before stated, and on examination of secretion for spermatozoa. As to impotence arising from injury of the generative organs, brain, spinal cord, etc., or from general diseases, a medical opinion must rest upon the circumstances attending each case. 27* INDEX. ABDOMEN, enlargement of, in pregnancy, 78, 79, 83 Abdominal pregnancy, 104 Abortion, 98-102, 214 criminal, 305-309 signs of recent, 301 Accidental hemorrhage, 221-226 Adherent placenta, 226 After-pains, 123 Albuminuria, during pregnancy, 90-92 Allantois, the, 64 Amnion, the, (53-65 Anaesthetics, use of in midwifery, 265-267 Ante-partal (ante-partum) hemor- rhage, 21(5-220 hour-glass contraction of ute- rus, 257 Anteversion of uterus, during preg- nancy, 95 Arm presentations, diagnosis of, 165,166 treatment of, 175 Arm, prolapse of, in cross births, 17(5 Articulations of pelvis, 26, 31 loosening of, during labor, 237 Ascites, in child, obstructing labor, 244 Atresia, of vagina and vulva, 253 of cervix uteri, 256 Attendants, during labor, 117 Attentions to new-born child, 121 Axis of parturient canal, 32, 33 BAG of waters, 63, 109 rupture of, 117 Ballottement, 72, 73 Bartholini, glands of, 48 Bed, preparation of, for labor, 116 Binder, after labor, 121 Bi-polar version, 168 Bladder, calculus in, obstructing labor, 255 of child, distension of before birth, 244 irritable, 93 prolapse of, during labor, 254 Blastodermic membranes, 61, 62 Blunt-hook, 177 Breast signs of pregnancy, 76, 77 Breasts, inflammation and abscess of, 291-295 Breech presentations, 150 diagnosis of, 148,158, 159 mechanism of, 151-158 treatment of, 159-162 use of forceps in, 190 Brow presentations, 149 C^SARIAN section, 191-193 Calculus in bladder obstructing labor, 255 Cancer of cervix uteri obstructing labor, 256 Carus' curve, 33 Cephalotomy, 196 Cephalotribe, 198 Cephalotripsy, 197 Cerebral tumors, in child, 242, 243 Cervix uteri, changes in, during pregnancy, 80 Chapped nipples, 125 Child, washing of, etc., after deliv- ery, 121 Child-bed fever, 272 Child-murder, 309-314 Chloral hydrate, uses of, in labor, 249, 267 Chloroform, use of in labor, 265 Chorion, the, 64 Circulation, fcetal, 68, 69 320 INDEX. Clitoris, the, 45 Coccyx, 26 Cohen's method of inducing labor, 215 Colostrum, the, 124 Complex (complicated) labor, 263 Conjugal infidelity, suspected, 300 Constipation, in pregnancy, 89 after delivery, 124 of infant, 124 Convulsions, ursemic, 91, 92, 269 Cord, umbilical, ligation of, 119 dressing of, 122 prolapse of, 259 Corpus luteum, 55 Cranioclast, 197, 199 Craniotomy, 195-200 Craniotomy-forceps, 198,199 Crotchet, 199, 200 Curve of Carus, 33 Cutting operations, on child, 195 on mother, 191 Cystocele, during labor, 254 Decapitation, 201 Decerebration, 197 Decidua, the, 65 Deformity, of pelvis, 202-212 Delivery, signs of recent, 302, 303 feigned, 305 unconscious, 304 Dental caries, during pregnancy, 85 Descent, in mechanism of labor, 133 Diameters, of fcetal head, 42 of pelvis, 35, 36 Diarrhoea, of pregnancy, 90 Diet, of mother, after labor, 125 of new-born child, 127, 216 Difficult labor, from obstruction of soft parts, 253 Diphtheria, puerperal, 277, 282 Diseases of pregnancy, classification of, 85 Displacements of uterus during pregnancy, 94, 95 Dressing of navel-string, 122 Dropsy, with albuminuria, during pregnancy,91 Dyspnoea, during pregnancy, 97 Dystocia, 253, 202 ECLAMPSIA, 269 Elbow, diagnosis of, 166 Embolism, 287 Embryotomy, 195, 200 Encephalocele, 24:5 Ergot of rye, uses of, 267, 268, 307 Ether, sulphuric, use of in mid- wifery, 266, 267 Evisceration, 200, 201 Evolution, spontaneous, 164 Excerebration, 197 Exenteration, 200 Exostosis, 26, 205 Extension, in mechanism of labor, 134 External version, 168 Extra-uterine gestation, 102-104 gastrotomy in, 194 Exvisceration, 200, 201 FACE-PRESENTATION, 141 £ diagnosis and prognosis of, 148 mechanism of, 143-147 treatment of, 148,149 use of forceps in, 189 Fainting during pregnancy, 96 Fallopian tubes, 51,52 pregnancy, 102 False pains, 115 Feces, impacted, obstructing labor, 255 Fecundation, 61 Feeding, artificial, of child, 127 Feet, presentation of, 158,159 Feigned delivery, 305 Fibroid tumors, obstructing labor, 255, 258 Fillet, 177 Flexion, in mechanism of head pre- sentations, 132 Flooding after labor, 221-226 Foetal circulation, 68, 69 head, 39 diameters of, 42 -heart sounds, 70 Foetus, appearances of, at different periods of gestation, 298, 299 nutrition of, 67 signs of death in utero, 260 Footling presentations, 158, 159 Forceps, 178-180 application of, to head, at in- ferior strait, 181-187 in pelvic cavity, 187 at superior strait, 187- 189 INDEX. 321 Forceps— in breech presentations, 190 in face presentations, 189 Tanner's, 188 Fossa navicularis, 44 Funis, structure of, (57 dressing of, 122 ligature of, 119 presentation and prolapse of, 259 short and coiled, 263, 264 pASTRO-ELYTROTO.MY, 194 \J hysterotomy, 191 Gastrotmny, 193, 194 Generative organs of female, ex- ternal^} internal, 46 Gland, vulvo-vaginal, 48 Graafian follicle and contents, 54 Guard-crotchet, 199 HAND-AND-FOOTpresentation, 263 Head, foetal (seeFutal head), 39 large size of, 244 premature ossification of, 245 presentations, 129 positions of, 130 mechanism of, 131-138 Heart-clot, 225, 283, 284 Hemorrhage, ante-partal ("ante- partum"), 216-220 post-partal (" post-par turn"), 221-229 from inversion of womb, 229 secondary, from navel, 127 Hernia, during labor, 255 Hip-dislocation, pelvic deformity from, 205, 206 Hour-glass contraction of uterus, ante-partal, 257 post-partal, 22(5 Hydatiform pregnancy, or mole, 105, 106 Hydrocephalus, 242,243 Hydrostatic test, 311 Hvdrothorax and hydronephrosis, '244 Hymen, 45, 253 as sign of virginity, 316 ICTERUS neonatorum, 127 Imperforate hymen, 253 Impotence, 31(5, 317 Impregnation, 61 Inclined planes of pelvis, 28 Incontinence of urine, 93 Induction of premature labor, 212- 216 Inertia uteri, a cause of flooding, 222-225 Infanticide, 309-314 Infantile jaundice, 127 Infants, premature, care of, 216 Inferior strait, 30, 36 Innominate bones, 26 Insanity, puerperal, etc., 2S7-291 Instruments, obstetrical, 177 Intermittent uterine contraction, a sign of pregnancy, 74 Inversion of uterus, 228-230 Involution of uterus, 51 JAUNDICE of infant, 127 V Jurisprudence of midwifery, 297-317 Juvenile pelvis, the, 203 KIDNEY, diseases of, during preg- nancy, 90-92 Kiestein, in urine, a sign of preg- nancy, 81 Knee presentations, 158,159 Kyphotic pelvis, the, 205, 209 LABIA majora, the, 44 thrombus of, 97, 235,236 minora, the, 45 Labor, 107 causes of, 107, 108 difficult, from obstruction by soft parts, 253 duration of, 112 forces of, 108 foretelling date of, 107 lingering, 245 management of natural, 112— 120 " missed," note to 297 pains of, 108 phenomena of, 110, 111 powerless, 251 precipitate, 202, 203, 251 322 IND EX. Labor— preparation for, 112 stages of, 109 symptoms of, 109,110 tedious, 245-253 twin cases of, 239, 240, 241 Laceration of cervix uteri, 234 of perineum, 236 of vagina and vulva, 235 Lactation, 123, 124 duration of, 295 insanity of, 289, 291 Laparo-elytrotomy, 194 Laparo-hysterotomy, 191 Laparotomy, 193 Leucorrhoea during pregnancy, 95 Ligaments of uterus, 49, 50 Lochia—lochial discharge, 122,123 Locked twins, 241 Lying-in, duration of, after labor, 128 MALACOSTEON pelvis, 204 Malpresentations,149,162-167 Mammary glands, anatomy of, 56, 57 inflammation and abscess of, 291-295 pain in, during pregnancy, 96 signs in, of pregnancy, 76, 77 Mania, puerperal, 287 Masculine pelvis, 203, 209 Mechanism of natural labor, 128 Membranes, rupture of the, 117 Menstruation, 57-00 vicarious, 60 Mental phenomena of pregnancy, 81, 288 Milk, deficient flow of, 126,127 excessive flow of, 126 fever, 125 intra-venous injection of, 226 leg, 284-286 Missed labor, note to, 297 Molar pregnancy, 105, 106 Moles, 106, 107 Mons veneris, the, 43 Monstrosities, 242 Morbid longings, during preg- nancy, 78 " Morning sickness," 77, 86 Multiple pregnancy, 238-240 Myrtiform caruncles, 46 \TATURAL labor, 107 1\ Navel, sore, 127 Navel-string, 67 dressing of, 122 ligation of, 119 secondary bleeding from, 127 Nervous derangements of preg- nancy, 97 Neuralgia of face during pregnancy, 86 Night-dress, preparation of, for labor, 117 Nipples, chapped, 125 sunken, or flat, 126 Nymphae, 45 OBLIQUE deformity of Naegcle, 204, 209 diameters of pelvis, 36 Obstetrics, definition of, 25 Obturator foramen, 30 Occipito-anterior positions, 131- 137 posterior positions, 137-138 _ Occlusion of os uteri, &9ff "ZS'i Os uteri, changes of, during preg- nancy, 80 rigidity of, 249 swelling of its anterior lip during labor, '249 Ossification, premature, of fetal head, 212, 245 Osteo-malacia, 204-206 Ovarian (extra-uterine) pregnancy, 104 tumors, impeding delivery, 258 Ovary, anatomy of, 53, 54 Ovum, development of, 61 PAINFUL mammae, during preg- nancy, 96 Pains, false, 115 of labor, 108 Palpitation, during pregnancy, 96 Parovarium, 56 Parturition, 107 Pelvimetry and pelvimeters, 206- 209 Pelvis, articulations of, 26, 31 axis of, 32, 33 bones of, 24 brim of, 27 cavity of, 28 deformed, 202-213 IND EX. 323 Pelvis, deformed— varieties of, 202-205 mechanism of labor in, 210 management of labor in, 210-213 premature labor, 213 diameters of, 35, 36 false, the, 27 floor of, 38 inclined planes of, 28 joints of, 26, 31 their loosening during la- bor, 237 male and female, 34 measurements of, 35, 36, 37 muscular appendages of, 37 ossification of, 29 planes of, 31 the true, 28 tumors of, 26, 205 Perforation of fetal cranium, 196 in hydrocephalus, 243 Perineum, anatomy of, 39 management of, during labor, 118 rigidity of, 249 rupture of, 23(5, 237 Peritonitis, puerperal, 277, 278 Phlegmasia dolens, 284 Pierce-crane, the, 19(5 Pigmentary deposits during preg- nancy, 81 Pinching of anterior lip of os uteri in labor, 118, 249 Placenta, formation and anatomy of, 66, 68 adherent, 226, 227 delivery of, 120, 121 partial separation of, before labor, 220, 221 praevia, 216-220 retained, 224, 22(5-228 Placental "expression," 120 souffle, 73 Plug, vaginal, 100, 101, 215 Plural births, 238-240 Polypus, diagnosis of, from inver- ted uterus, 229 impeding delivery, 257 Porro's operation, 195 "Position" of presentation, defi- nition of, 114, 117 diagnosis of, 139 Post-partal ("post-partum") hem- orrhage, 221-229 Posture of child in uterus, 128 Powerless labor, 251 Precipitate labor, 202, 203, 251-253 Pregnancy, differential diagnosis of, 82 diseases of, 84 doubtful signs of, 75 duration of, 69, 211, 297 early diagnosis of, 70 extra-uterine, 102 late diagnosis of, 82 positive signs of, 70 prolonged, 211, 297 short, with living child, 298 signs of, their classification, 69 spurious (pseudocyesis), 83 Premature labor, 98, 298 induction of, 212-216 Preparation for labor, 112, 116, 223 Presentation, definition of, 115 Prolapse of funis, 259 Prolapsus uteri during preguancy, 94 Pruritus vulvae, 95 Pseudocyesis, 83 Puberty, signs of, 59 Pubic arch, 30 Pudenda, the, 43 Puerperal cellulitis, 279 convulsions, 91, 269 fever, 272-282 insanity, 287 mania, 287 metritis, 277, 280 peritonitis, 277, 278 phlebitis, 278 septicaemia, 272-282 vaginitis, 277, 280 ^ICKENING, 71 , Quinine, use of in labor, 269 RAPE, medical evidence of, 314- 316 Rectocele, during labor, 254 Respiration, an evidence of live birth, 312 Restitution, in mechanism of labor, 135 Retroversion of uterus, in preg- nancy, 94 Rickets, deformed pelvis from, 203 Rigid os uteri, 249 perineum, 249, 250 " Roberts pelvis," the, 204, 209 324 INDEX. Rotation, in mechanism of labor, 133, 134 Rupture of perineum, 236, 237 of uterus, 230-234 of vagina and vulva, 235 SACRO-ILIAC synchondroses, 26 Sacro-sciatic ligaments and foramina, 29 Sacrum,.the, 25 Salivation of pregnancy, 85 Shoulder presentation, 162 diagnosis of, 165, 169 treatment of, 167, 174- 176 "Show," the, 110 Sigaultian operation, 191 Smellie's scissors, 196 Sore navel, 127 Sore nipples, 125 Spondylolithesis, 205, 209 Sponge-tent, for inducing labor, 215 Spontaneous evolution, 164 version, 164 Spurious pains, 115 pregnancy, 83 Static test, the, 311 Strait, the inferior, 30, 36 the superior, 27, 35 Suckling, frequency of, 123,124 Sunken nipples, 126 Super-fecundation, 301 Super-fetation, 301 Suppression of menses during preg- nancy, 75 Symphysiotomy, 191 Syncope, after flooding, treatment of, 225, 226 during pregnancy, 96 TAMPON, use of, in abortion, 100,101 to produce premature de- livery, 215 Tedious labor, 245-253 Tests for albumen in urine, 91 static and hydrostatic, 311 Thrombosis, arterial, 287 central venous, 225, 283, 284 peripheral venous, 284-286 Thrombus of vagina and vulva, 97, 235, 236 Toothache during pregnancy, 85,86 Transfusion of blood, 226 Transverse presentations, 162-167 Triplets, 238 Tubal pregnancy, 102 Tubes, Fallopian, 51, 52 Tumors obstructing delivery, 255- 258 Tunica albuginea, 53, 54 granulosa, 54 Turning (see Version), 167 in placenta praevia, 219 Twins, 238 locked, treatment of, 241 UMBILICAL cord, structure of, 67 coiled or short, 263 dressing of, 122 ligation of, 119 Umbilical vesicle, 62 Unconscious delivery, 304 Uraemia, 91 Uraemic convulsions, 269 Urine, albumen in, 90, 91 incontinence of, 93 kiestein in, 81 retention of, after labor, 124, 125 during pregnancy, 93 in young infant, 124 Uterine souffle (or murmur), 73 Uterus, action of in labor, 107, 108 anatomy of, 48, 49 'arteries and veins of, 50 contractions of, during preg- nancy, 74 displacements of, during preg- nancy, 94, 95 functions of, 51 inertia of, a cause of flooding, 222-225 inversion of, 228 involution of, after labor, 51 lymphatics of, 51 nerves of, 51 rupture of, 230-234 stricture of, 225, 257 VAGINA, anatomy of, 46 atresia of, obstructing labor, thrombus of, 97, 235 tumors of, 255 Vaginal douche for inducing labor, 214 INDEX. 325 Vaginal— examination during labor, 113- 115 Vaginismus, 255 Varicose veins during pregnancy, Vectis, the, 178 Ventral gestation, 104 Vernix caseosa, 121 Version (or turning), 167 by external manipulation, 168 by combined (bi-polar) ma- nipulation, 168-170 by internal (podalic) manipu- lation, 171 difficulties of, 176 in head presentations, 172-174 in placenta praevia, 219 in transverse presentations, 174,175 spontaneous, 164 Vertex presentations, 129,131-138 Vesical calculus, 255 Vestibule, 45 Vicarious menstruation, 60 Violet color of vagina in pregnancy, 80 Virginity, signs of, 316 Vitelline membrane, 54 Vitellus, 54 segmentation of, 61 Vomiting during pregnancy, 77, 86-89 Vulva, 43 atresia of, 253 oedema of, 253 pruritus of, 95 thrombus of, 235, 236 Vulvo-vaginal gland, 48 WEANING, time of, 295 " Whites." during pregnancy, 95 ^ONA pellucida, 54 28 CATALOGUE OF BOOKS PUBLISHED BT HENRY C. LEA'S SON & CO. (LATE henry c. lea.) The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. Gen- tlemen will therefore, in most cases, find it more convenient to deal with the nearest bookseller. In response to a large nvmber of inquiries for a finer binding than is usually placed ov medical books, we now finish many of our standard puhlications in half Russia, nsins in the, manvfacture none bnt thehest materials. To foster the growing taste, the prices have been fixed at so small an advance over the cost of leather binding as to bring it irithin the reach of all to possess a library attractive to the eye as well as to the mind. Detailed catalogues furnished or sent free by mail on application. HENRY C. LEA'S SON & CO., Nos. 706 and 708 Sansom Street, Philadelphia. PERIODICALS Free of Postage. 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