guished in its early growth as located more upon one side of the
pelvis. A uterus enlarged by fibroids which are undergoing a
cystic and often malignant degeneration may give the same phy-
cal signs as the pregnant uterus.
Percussion of the pregnant abdomen should also give informa-
tion regarding the size of the uterus, and hence the period qf
pregnancy. In general, we may say that the uterus can first be
felt above the pubes at the fourth month. In the sixth month it
is at the umbilicus ; at the end of pregnancy, a hand's breadth
above the umbilicus. We add a table, constructed by Duhrssen,
showing the size of the uterus at the different months of pregnancy :
In the 1st month the uterus is slightly enlarged.
In the ad month the uterus is as large as a goose egg.
In the 3d month the uterus is as large as a child's head.
In the 4th month the uterus is as large as a man's head, and can be felt by
external examination above the symphysis pubis.
3
50 MANUAL OF PRACTICAL OBSTETRICS.
In the 5th month the uterus is half-way between the umbilicus and the
symphysis.
In the 6th month it is at the umbilicus.
In the 7 th month it is two fingers' breadth above the umbilicus.
In the 8th month it is the width of the hand above the umbilicus.
In the Qth month it is at the xyphoid process.
In the loth month it is again the width of the hand above the umbilicus.
If anything abnormal be detected in the position of the foetus
indicating disproportion between the child and the mother's pelvis,
an internal examination should be made (Fig. 27). To measure
FIG. 27.
INTERNAL MEASUREMENT OF THE ANTERO-POSTERIOR DIAMETER OF
PELVIC BRIM.
the antero -posterior diameter of the pelvic brim (conjugata vera,
true conjugate) the patient is placed on her back at the edge of a
bed or table, her thighs flexed. The bladder and rectum being
empty, the physician introduces the index and second fingers of
THE DIAGNOSIS OF PREGNANCY. 51
one hand, pushing the cervix aside, and touching the promontory
of the sacrum with the second finger. The edge of the hand is
raised against the sub-pubic ligament, and with the nail of a finger
of the other hand the point where the edge of the pubes presses
is marked upon the examining hand, which is then withdrawn,
and the distance from the tip of the second finger to the point
marked is measured by tape line or pelvimeter. Two centimetres,
or three-fourths of an inch, is deducted for the thickness of the
pubes. The measurement first obtained is thirteen centimetres,
less two, is eleven centimetres, or four and a half inches. It is
well to follow the sacral curve upwards with the examining finger,
to avoid mistaking the projection of other sacral vertebrae for the
promontory.
If the maternal parts be relaxed and labor be approaching, it
is well to attempt to estimate the proportionate size of the foetus
and the pelvis by pressing the presenting part gently downward
FIG. 28.
into the pelvis while its progress is recognized by an internal ex-
amination. It cannot be too strongly urged that it is the duty of
the physician to make preliminary examinations in every case,
as experience has shown us that they can be so conducted as to
give the patient no inconvenience, while affording valuable data
for the conduct of labor.
The pelvimeter which we commonly employ is indexed in
centimetres and inches, and can be conveniently taken apart
and carried in the pocket (Fig. 28).
52 MANUAL OF PRACTICAL OBSTETRICS.
In making a vaginal examination to determine the existence of
early pregnancy, in addition to the softened condition of the os
and cervix, the lower uterine segment may be distinguished in
many cases. The finger may detect softened, elastic tissue just
above the cervix, the body of the uterus swelling out above it as
the body of a jug bulges sharply above its neck. It is often ne-
cessary to examine with one finger in the vagina and another in
the rectum, to obtain this sign distinctly. This is Hegar's sign
and can be found at the third or fourth month.
Cases will come to the notice of practitioners of experience
where the reputation and happiness of the patient may depend
upon the physician's diagnosis. In such cases the greatest cau-
tion must be exercised ; the physician must give no statement
which can be misconstrued. He will do well to satisfy himself
with a statement of what he actually finds after a careful examina-
tion. He may then state that such symptoms and conditions
sometimes accompany pregnancy, but that an absolute diagnosis
at the moment of speaking is impossible.
CHAPTER VII.
THE HYGIENE OF PREGNANCY.
THE care of the pregnant woman should begin from the time
when her condition is first suspected. Fortunately for her, that
which is best for her, if pregnant, is also proper care if she be
not pregnant, but suffering from any condition which may give
rise to a supposition of pregnancy. A subject of perhaps the first
importance at this time is the patient's dress. It is best to lay
aside corsets, or if the patient will not do this, to wear such as
have been carefully made to fit the body loosely. Better than
corsets are waists of various sorts, to which skirts can be buttoned,
and which are so devised as to avoid injurious pressure. The
important point is to remove from the abdomen the pressure of the
patient's clothing, and the benefit to be derived from this will not
be realized until a radical change in the patient's dress is made.
If skirts are not attached to a properly constructed waist, they
should be supported from the shoulders by suspenders.
Next to the patient's skin should be worn woolen of fine qual-
ity and light weight. The so called combination suits, in which
shirt and drawers are virtually one piece, are excellent in this con-
dition. Woolen or silk stockings should be worn, and, if possible,
supported without encircling garters. Shoes and slippers should
be sufficiently easy to avoid pressure, and if warm clothing is
necessary, dresses and wraps may be altered or made so as to keep
the patient thoroughly warm while distributing the weight of the
garments as evenly as possible, and suspending them from the
shoulders. Many of the pressure symptoms from which patients
suffer during the early months of pregnancy are more relieved by
the adoption of suitable dress than by any other measure.
The first symptom for which the physician will commonly be
asked to prescribe is nausea and vomiting. The patient should
53
54 MANUAL OF PRACTICAL OBSTETRICS.
be informed that these symptoms are almost the invariable accom-
paniments of her condition, and that they will grow better as
time goes on. Drugs should be used as sparingly as possible, and
the case can often be palliated by simple precautions regarding
the taking of food. Many patients get on comfortably by taking
a breakfast in bed. Others are helped by a cup of soup, or tea,
or coffee, hot water, an effervescing drink, champagne, brandy-
and-soda, while severe cases require confinement in bed and the
most careful feeding, nutritive enemata being especially useful.
Slight dilatation of the cervix relieves a considerable number of
cases of the vomiting of pregnancy. The finger is the best di-
lator, or a hard rubber dilator of about the same size. Where
endocervicitis is present alterative applications are indicated. A
strong solution of silver nitrate, gr. 20 to the ^, has been often
advantageous. Creolin or iodine is also useful. Such applications
should be followed by a glycerine tampon.
In general, it may be stated that every cause of irritation about
the womb should be removed, and this, in many cases, will greatly
diminish the nausea and vomiting. It is especially necessary to
see that 'the patient does not suffer from constipation, and her un-
pleasant sensations will often disappear when this is remedied.
Should these measures, however, not be sufficient, and the patient
become anaemic, the aid of drugs should be sought. Oxalate of
cerium, or valerianate of cerium, sub-nitrate -of bismuth, pan-
creatin, pepsin, and ingluvin may also be tried. Two and a half,
or five grains, of one of the compounds of cerium, frequently
repeated, often gives good results. Bismuth may be used in these,
and larger doses. The digestive ferments may be given with
food, or pre-digested food may be employed. Should this not be
sufficient, one drop of tincture of iodine may be given, or creo-
sote, or carbolic acid. Cocaine, or wine of cocoa, will often be
successful when all else has failed. Fowler's Solution and tincture
of nux vomica may be given in doses of one drop of each. Num-
berless other remedies have been employed, and each case must
be studied and treated upon its own merits. It must be remem-
bered, however, that the local treatment of the uterus, and the
THE HYGIENE OF PREGNANCY. 55
patient and skilful use of small quantities of suitable nourishment,
with the digestive ferments, furnishes the most rational- method of
treating these complications. If the trouble persists, the physi-
cian should assure himself that the uterus is not dislocated, espe-
cially by some backward displacement. It will often be possible,
by using finely carded wool or jute in the form of antisepticized
tampons, to restore the uterus to its proper position, and relieve
the patient's symptoms. In cases of obstinate vomiting in preg-
nancy, every remedy should be tried which offers the slightest
prospect of success. Among those recently employed is menthol,
which may be given in doses of from one to five grains.
The question of the interruption of pregnancy will depend
upon the presence or absence of dangerous anaemia in the mother.
As our study of the blood progresses, we shall undoubtedly be
able to recognize conditions dangerous to mother and child alike,
by microscopic examination of the maternal blood ; at present,
however, the general rule may be stated that whenever the mother
is threatened with dangerous anaemia, pregnancy should be in-
terrupted at once. It may be possible, after the uterus has been
emptied, to cure an endometritis, or remedy some other condition
which has caused the patient's suffering. A repeated pregnancy
would then result successfully. In replacing a retroverted preg-
nant uterus, it will be well to hold it in position by some device
other than a stiff pessary. Tampons such as have been already
mentioned may be covered with ointment of equal parts of lanolin
and cosmoline, to which is added powdered boracic acid, ten
grains to the ounce. In hospital practice, an ointment of balsam
of Peru, cosmoline, and iodoform may be used to advantage.
Warm douches may be very cautiously taken if there be extensive
irritation about the uterus, and if the douches can be administered
by a thoroughly competent and careful person.
Regarding the further hygiene of pregnancy, it may be stated
that moderation is the golden rule. The patient's usual tastes in
the matter of food and drink should be consulted and continued.
She will do well to avoid fatigue, especially standing and walking
for long periods. There should be an abundance of sleep, and
56 MANUAL OF PRACTICAL OBSTETRICS.
an abundance of fresh air. Lukewarm baths should be taken
daily, or if preferred, a sponge-bath of moderately cold water.
She should avoid long drives over rough roads, but should fre-
quently take drives of moderate length and over smooth roads.
Seasickness should be avoided, and any excitement or over-strain.
Very hot churches and theatres, and crowds of any sort should be
shunned. At the same time, every care must be taken to make
the patient's life during this period one of interest and pleasure.
Her natural forebodings should be met by kind encouragement,
and books and surroundings which furnish healthful diversion may
be amply supplied. There is sufficient evidence that the mother's
emotions influence the child powerfully to make it necessary for
her to avoid fright, or an outburst of any violent emotion. It
should be remembered that the teeth are especially liable to de-
teriorate during this period, and the services of a dentist may be
sought early in pregnancy. The patient should be urged to take
moderate exercise in the open air. Her diet should be of the
most easily digested and nutritious articles of food. If the patient
be found to be lapsing into a condition of mal-nutrition, arsenic,
iron, cod-liver oil with hypophosphites, malt and meat extracts
may be persistently given. Koumyss, Matzoon, and Mellin's
Food will be found useful in such cases.
CHAPTER VIII.
THE ATTITUDE AND LOCATION OF THE FCETUS ; THE DURATION
OF PREGNANCY.
AT five or six months of pregnancy the foetus begins to as-
sume a definite position in the uterus, and can be recognized
as having a definite relation in situation to the mother. By a
natural law of accommodation, an ovoidal body contained
in a cylinder naturally turns its long axis parallel to that of
the cylinder. This is exemplified in the fact that as the foetus
grows, it assumes a position which, in a majority of cases,
brings the head to present at the brim of the pelvis, the breech
and feet occupying the fundus of the uterus. The ovoidal shape
of the foetus is the result of a condition of flexion which approxi-
mates the limbs and head to the trunk. During the early months
of pregnancy the specific gravity of the amnial liquid is so great
that the foetus floats readily about, assuming no definite position ;
but as it increases in size, its specific gravity exceeds that of the
amnial liquid, and hence the heaviest portion of the foetus tends
to sink lowest in the uterus, and this fact, together with the law of
accommodation already mentioned, results in the attitude and lo-
cation of the foetus. In obstetric phraseology these facts are de-
scribed under the head of (Fig. 29)
POSITION AND PRESENTATION. By position is meant the rela-
tion which a definite portion of the foetal body bears to a defi-
nite portion of the birth-canal of the mother. By presentation
is meant that portion of the foetus which descends lowest in the
birth-canal, and which comes first to the notice of the obstetri-
cian on examination. As we have said, ordinarily the head of
the foetus sinks lowest, and hence presents most frequently. The
majority of presentations, then, are head presentations. From
the fact that the attitude of the foetus is that of flexion, it results
57
58 MANUAL OF PRACTICAL OBSTETRICS.
that the top of the head or vertex is the portion of the cranium
which is most frequently lowest, and hence presents. Thus it
happens that the majority of head presentations are vertex pre-
sentations. Should the attitude of flexion of the head not exist,
but should the head have become extended, the face of the foetus
will be lovvest, and hence, while the head will continue to pre-
FIG. 29.
THE USUAL ATTITUDE AND LOCATION OF THE FCETUS.
sent, the face instead of the vertex will be the portion of the
head sinking lowest into the pelvis.
On the other hand, the child may present by the lower ex-
tremity of the trunk or breech, and thus the long axis of the
fcetal ovoid be brought to correspond with that of the cylindrical
birth-canal of the mother. Occasionally, through some failure
in the law of accommodation, the foetus at the moment of labor
becomes turned transversely across the birth-canal, and then a
THE ATTITUDE AND LOCATION OF THE FCETUS. 59
transverse position results. The efforts of the uterus to expel the
child thus turned across the birth-canal result in bending the head
upon the trunk with a lateral flexion, the shoulder of the child
sinking downward, and finally presenting in the birth-canal.
If we enumerate the presentations which may occur, we shall
find five : the vertex, the face, the breech, the right and the left
shoulder. If we consider the situation which any of these pre-
senting portions may occupy in the mother's pelvis, we shall have
the positions and presentations grouped together.
It is of the utmost importance that, in studying obstetric
cases, the obstetrician remembers the simple fact that the mother's
pelvis has two sides, the right and the left. If the bony pelvis
be examined, it will be seen that the points projecting furthest
toward the centre of the pelvis from each side are the spines of
the ischia; extending obliquely upward and outward from these
points there will be seen a slight elevation or ridge on the bony
surface of the wall of the pelvis. This slight ridge, like a water-
shed, divides each side of the pelvis into an anterior and poste-
rior half. The pelvis may then be said to have a left anterior
compartment and a right anterior compartment, a left posterior
compartment and a right posterior compartment. It only remains
to locate the foetus in one of these four compartments to com-
plete what is technically described as a presentation and posi-
tion (Fig. 30).
It must be remembered, however, that more important than
the especial compartment in the pelvis occupied by the present-
ing part is the question as to which side of the abdomen the
back of the foetus occupies. In fact, the more rational and
modern view makes but two positions : If the back of the child
be toward the left side of the mother's pelvis, it is the first posi-
tion ; if the back of the child be toward the right side of the
mother's pelvis, it is the second position. When the mechanism
of labor is considered, it will readily be seen how this simple
division of positions accounts for the phenomena of labor. In
the majority of cases the back of the child lies upon the left side
of the mother's abdomen, the vertex presenting at the entrance
6o
MANUAL OF PRACTICAL OBSTETRICS.
FIG. 30.
to the pelvis, and turned in its left anterior compartment. The
resulting position and presentation is a left occipito-anterior,
and this will be found in more than three-fourths of all cases.
THE DURATION OF PREGNANCY is usually two hundred and
eighty days. Instances where pregnancy is prolonged for ten
months and more are not rare.
The cause for the termination
of pregnancy has not been
clearly demonstrated ; but it
is most probably the fact that
the foetus can no longer be
adequately nourished by the
mother. The accumulation in
the mother's blood of irritat-
ing compounds derived from
the processes of foetal nourish-
ment causes an increased ex-
citability to reflex stimuli. As
the foetus grows, its move-
ments become more vigorous,
until the uterus is roused to
contraction, and labor results.
Rhythmic contractions of the
uterus continue during preg-
nancy, and furnish a sign of pregnancy. They assist in bringing
the long axis of the foetus to coincide with that of the uterus.
In estimating the duration of pregnancy it is best to avoid fix-
ing an especial date, especially with primiparse. From ten days
to two weeks' variation from a calculated date is not unusual.
It is customary to reckon from the last day of menstruation, and
a simple rule of calculation may be stated as follows :
Count backward three months from the last day of menstrua-
tion, and add one year and seven days to the date thus reached.
In questioning patients to ascertain the date of last menstrua-
tion, the answer elicited will usually refer to the date of the
beginning of menstruation, instead of the end, the day desired.
LATERAL SURFACE OF THE PELVIS.
CHAPTER IX.
NORMAL LABOR; THE HEAD PRESENTING.
BY labor is understood that process of contraction of the uterus
and abdominal muscles which results in the extrusion of the foetus.
It may be commonly divided into three stages ; the first, the stage
extending from the beginning of expulsive uterine contraction
until the birth-canal is fully dilated ; the second, the interval oc-
cupied by the extrusion of the foetus ; the third, the time required
for the delivery of the membranes and placenta.
The characteristics of the first period of labor vary in different
individuals in first and subsequent labors. Intermittent uterine
contractions occur frequently during pregnancy, and have much
to do with accommodating the foetus to the birth-canal. The
beginning of a first labor is usually characterized by an intensifi-
cation of these wave-like uterine contractions, occupying a vary-
ing number of hours. Thus a patient may be in this stage of
labor for one or two days before active pains begin. As the
name indicates, uterine contractions or labor pains are attended
by suffering. Nerve fibres in the walls of the uterus are com-
pressed by the contractions of the uterine muscle, and nerve
trunks lying along the brim of the pelvis are also subject to con-
tusion. The stage of intermittent uterine contraction is marked
by the dilatation of the os uteri and the gradual obliteration of
the cervix. When this process is completed, the membranes
commonly rupture, and the actual expulsion of the child begins.
The diagnosis of labor often requires perception and judgment
on the part of the physician. He will frequently be called to
primagravidae who imagine themselves in labor because abdomi-
nal pain is experienced. Acute indigestion, muscular rheuma-
tism of the walls of the abdomen, intercostal neuralgia, and an ex-
61
62 MANUAL OF PRACTICAL OBSTETRICS.
aggerated nervous condition may all give rise to the sensation of
abdominal pain. The practitioner can best satisfy himself as to
the presence or absence of genuine labor pains by placing his
patient in a comfortable position upon a bed or couch, and hav-
ing her clothing so arranged that his hand can rest upon the ab-
domen. He will then appreciate the frequency and vigor of
uterine contractions, and after a short time of observation can
generally determine whether labor has actually commenced or
not.
The arrival of the physician, especially if he be a stranger, will
not infrequently cause the pains of the first stages of labor to
cease for a short time. Tact should be used in approaching a
parturient patient for the first time, and the physician will do well
not to enter her room until his coming has been announced and
a few moments have elapsed. During the second stage of labor
uterine contraction will usually go on without interruption.
As labor proceeds, the sensations of pain which at first are
diffused through the abdomen will commence in the back, exten-
ding along the sides of the abdomen to the supra-pubic region.
Although intermittent, they will increase in frequency and sever-
ity until, the membranes having ruptured, they become later in
labor almost continuous. Positive information regarding the ex-
act stage of a labor can be obtained by internal examination
only. In multigravidae, experience enables a patient to estimate
with greater accuracy the exact stage at which the practitioner is
summoned. A vaginal discharge of blood-stained mucus is usu-
ally a symptom of the dilatation of the cervix, and the beginning
of actual labor.
The mechanism of labor in head-presentations consists of the
adaptation of the head to the brim of the mother's pelvis, the de-
scent of the head and body of the child into the cavity of the
pelvis, the rotation of the child as a whole toward the anterior
surface of the mother's body, and, finally, its expulsion. During
the later weeks of pregnancy, the intermittent uterine contractions
to which reference has (Fig. 31) been made, aided by the elasticity
of tissues previously distended will generally result in the descent of
NORMAL LABOR; THE HEAD PRESENTING. 63
the presenting part into the cavity of the pelvis in multigravidse.
In primagravidte, however, at the commencement of labor the
head will probably be found at the brim of the pelvis, resting
FIG. 31.
THE FCETUS IN A PRIMAGRAVIDA.
against its upper edge (Fig. 32). The movement of accommodation
by which the head enters the pelvis will consist in adapting the di-
ameters of the foetal head to those of the pelvis. The head en-
04 MANUAL OF PRACTICAL OBSTETRICS.
tering obliquely in the majority of cases, the vertex being at the
left anterior half of the pelvis, the chin and face of the child will
point toward the right posterior portion. It will be remembered
FIG. 32.
THE FCETUS IN A MULTIGRAVIDA.
that the oblique diameters of the pelvic brim in the living patient
measure four and three-quarters inches, twelve centimetres. The
occipito-frontal diameter of the head measures also four and three-
NORMAL LABOR; THE HEAD PRESENTING. 65
quarters inches, or twelve centimetres. By relaxing the iliopsoas