NATIONAL LIBRARY OF MEDICINE NLfl DDSfilbfiT b ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section Number ...£(°_1_$__ 7 / Fobm 113c, W. D., S. G. O. 3—10643 (Revised June 13. 1936) NLM005816896 SYLLABUS loa^'V/ OBSTETRICAL LECTURES MEDICAL DEPARTMENT OF THE UNIVERSITY OF PENNSYLVANIA, By RICHARD C. NORRIS, A.M., M. D., 0 • » Demonstrator of Obstetrics, University of Pennsylvania ; Assistant Obstetri- cian, University Maternity; Physician to the Methodist Episcopal Hos- pital ; Obstetrical Registrar, Philadelphia Hospital; Consulting Obstetrician and Attending Gynecologist, South-eastern Dis- pensary and Hospital for Women and Children. THIED EDITION. PHILADELPHIA: W. B. SAUNDERS, 925 Walnut Street. 1895. hlS52s 1995 Copyright, 1890, 1891, By W. B. SAUNDERS, Press of W. B. Launders, Philadelphia. DEDICATED TO The Medical Class or the University op Pennsylvania. PREFACE TO THIRD EDITION. The Author offers to the medical class a third edition of the Syllabus in order to include the additions which have appeared in the lectures during the past two years. He desires also to gratefully acknowledge the reception the book continues to receive from his own and other students. 1028 Spruce St., October, 1893. PREFACE TO SECOND EDITION. The experiment of placing a book of this character in the hands of the medical class having demonstrated its use- fulness, and the exhaustion of the first edition, have induced the Author to prepare a second edition, in which the same plan of brevity and conciseness has been followed. Much of the text has been re-written, and new material added, notably in the chapters on Infant Feeding, Pathology of the Puerperium, Obstetric Operations, and Dystocia. At the request of many of the Author's pupils an Index has been added. 1028 Spktce Street, Philadelphia, July, 1891. ( ix ) PREFACE TO FIRST EDITION. With the approval of Professor Hirst this Syllabus has been prepared to meet the difficulty of accurate note-taking, which most medical students encounter. The subject-matter has been so arranged that uninterrupted attendance upon lectures is essential to a full knowledge of the course. The design of the book, therefore, is to secure for the student a logical and consecutive outline of his work, and to aid him in classifying the knowledge he acquires in the lecture-room. The Author desires to express his indebtedness to Professor Hirst for many suggestions, and for his kindly interest in the preparation of the work, and to indulge the hope that the medical class may find the book of some service to them. Philadelphia, December, 1889. (xi) CONTENTS. PART I PAGE Menstruation.........17 Ovulation.........18 Insemination.........20 Fertilization.........20 The Amnion.........26 The Chorion.........28 The Umbilical Cord.......80 The Decidu^e.........31 The Placenta . . . . . . . • 33 Physiology^ of the Mature Fcetus . ... 36 Circulation :......30 Excretions.........36 Multiple Impregnation......36 Super-impregnation.......37 Diseases of the Fcetus in Utero .... 38 Deformities and Monstrosities . '. . . .38 Infectious Diseases.......40 Diseases of Skin, Brain, Serous Membranes, Heart, Connective Tissue, Tumors, "Rachitis, Anasarca, Fractures, Anchyloses, Luxations, Amputations, External Violence......39, 40 Maternal Conditions affecting Fcetus . ... 41 Festal Death, signs of, changes in Fcetus after . 42 Syphilis.........42 Habitual Death of Fcetus......44 Physiology of the Newborn Infant ... 45 Respiration.........45 Weight..........45 (xiii ) xiv contents. PAGE Digestion ....... ° • 45 Excretions.........45 Temperature 45 Eyesight....... 45 Pulse..........45 Blood..........46 Liver..........47 Heart..........47 Cord..........47 Medico-Legal Points.......47 Anatomical Points .....'.. 47 Premature Infants ....... 48 Incubation and Gavage......48 Sclerema.........48 Management of Newborn Infant .... 48 Clothing.........48 Feeding.........49 Cleansing .........56 Airing..........56 Resting-Place........56 Injuries to Infant During Labor .... 56 Brain..........56 Peripheral Nerves.......57 Skull..........57 Scalp..........57 Face.......... 58 Neck..........58 Limbs..........58 Trunk..........58 Bowel..........59 Asphyxia Neonatorum.......5g Diseases of the Newborn Infant • • • . 61 Diseases of the Lungs.......gl Syphilis.........63 Mastitis.........64 Specific Fevers........64 Congenital Deformities......04 contents. XV Nasal Catarrh Diseases of the Mouth . Colic .... Diarrhoea Constipation Diseases of the Skin Ophthalmia Neonatorum Hemophilia . Icterus .... Cyanosis Congenital Heart Affections Diseases of the Umbilicus Tetanus Melsena Intestinal Perforation and Intussusception Buhl's Disease Winckel's Disease (Edema Neonatorum . Bloody Discharge from Genitalia of F Sudden Death of the Infant Medication . Pathology of the Puerperal State Abnormalities of Involution Acute Tympanitis Puerperal Anaemia Repair of Injuries after Labor Puerperal Hemorrhages Anomalies of the Breasts Diseases of the Urinary Apparatus Diseases of the Nervous System . Puerperal Fever .... emale Chi ldren PART II. Anatomy of the Pelvis Obstetrically Considered 97 Deformities of the Pelvis......100 Pelvimetry.........102 xvi contents. PAGE fcetometry.......<■ 105 Anomalies of the Soft Parts.....105 Antisepsis........• 106 Diagnosis of Pregnancy ...... 110 Physiology of Pregnancy......113 Pathology of Pregnancy......118 Diseases of the Genitalia......118 Diseases of the Alimentary Canal .... 123 Diseases of the Urinary Apparatus .... 126 Diseases of the Nervous System.....130 Diseases of the Circulatory Apparatus . . . 132 Diseases of the Respiratory Apparatus . . . 134 Diseases of the Osseous System.....135 Infectious Diseases.......135 Diseases of the Skin.......136 Injuries and Accidents......137 Surgical Operations.......137 Abortion, Miscarriage, Premature Labor . . . 138 Extrauterine Pregnancy......141 Labor..........150 Physiology.........150 Management ........152 Puerperium.........154 Physiology.........154 Management........158 Mechanism of Labor.......161 Obstetrical Operations......176 Induction of Premature Labor and Abortion . . 176 Forceps.........179 Extraction of Breech.......182 Version.........183 Embryotomy........187 Symphyseotomy..... . 189 Csesarean Section........ 189 Laparo-elytrotomy.......192 Coelio-cystetcomy........192 Abdominal Section for Obstetrical Complications . 193 contents. XV11 Dystocia..........193 Anomalies in Expulsive Force.....193 Excessive Uterine Action.....193 Uterine Inertia.......194 Anomalies in Force of Resistance .... 195 Maternal Obstructions......195 Labor in Deformed Pelvis .... 195 Congenital Anomalies of Development in the Genital Canal......196 Closure and Contraction of the Cervix . . 196 Closure and Contraction of the Vagina or Vulvae.......197 Uterine Displacements.....197 Tumors of the Genital Canal . . . . 197 Tumors of Neighboring Organs . . . 197 Fcetal Obstructions......198 Overgrowth.......198 Malformations and Tumors .... 198 Diseases........198 Mal-presentations and Positions . . . 199 Multiple Birth......]99 Abnormalities in the Foetal Appendages . 200 Dystocia due to Accident to Child or Mother . . 200 Prolapse of Cord.......200 Rupture of Cord.......200 Placenta Prrevia.......201 Accidental Hemorrhage.....202 Postpartum Hemorrhage ..... 204 Hemorrhage from Injuries of Lower Parturient Canal........205 Rupture of Uterus...... 206 Inversion of Uterus . . . . . . 207 Rupture of Pelvic Joints and Bones . . . 208 Diastasis of Recti Muscles.....208 Dystocia due to Disease......208 Puerperal Convulsions......208 Shock.........210 xviii CONTENTS. PAGE Typhoid, Pneumonia and other Adynamic Diseases 211 Valvular Heart Disease.....211 Sudden Death........211 Post-mortem Delivery.......2i2 SYLLABUS OF OBSTETRIC LECTURES. LECTURES TO GRADUATING CLASS. PART I. Menstruation. Definition.—A periodic discharge of a sanguineous fluid from the uterus and Fallopian tubes, occurring during the time of a woman's sexual activity, from puberty to the menopause. Time of Occurrence.—In temperate climates, in Teutonic and Anglo-Saxon girls, the first menstruation occurs oftenest in the fifteenth year. It is influenced by (a) Race, {b) Mode of Life, (c) Climate, (d) Heredity, (e) Genital Sense. Once established it should return every four weeks. Time of Cessation.—Usually in the 45th year. <■'■ Phenomena. 1. Congestion.—Manifested in changes in uterine body, mucous membrane, adnexa, and peritoneum. 2. Molhnina.—The clinical and subjective manifestations, as nervous irritability, pigmentation, enlargement of thyroid, changes in voice and circulation, etc. 3. Rise of Temperature.—0.5° C. 4. Character of Flow.—Alkaline and composed of blood, shreds of mucous membrane, vaginal and uterine secretion. Is darker than ordinary blood and should not clot. 5. Duration of Flow.— The avex-age is three days. 6. Quantity.— Four to six ounces. 2 (17) 18 obstetrical lectures. Theories in explanation of its occurrence. , 1. Why it occurs:— (a) Cleansing. Plethora. The ancients' idea. (b) Pfliiger's. The ripening of the ovule within the ovary and the development of the Graafian follicle, producing a nervous irritation culminating at the end of the menstrual month, which leads to congestion and other menstrual phenomena. (c) Result of the death and degeneration of the ovule. If the ovule happens to be impregnated, menstruation is prevented. If conception has not occurred, the congested condition of the mucous membrane, prepared to receive and surround the ovule, results in the menstrual discharge. (d) Comparative anatomy and physiology. Explained by similarity to heat or rut. (e) The most satisfactory theory is that it occurs in obedience to a central nervous influence reflected through the sympathetic nervous system to the ovaries and uterus. 2. How it occurs:— (a) Kundrat, Engelmann, Williams: By fatty degeneration of the mucous membrane. (6) Leopold : By diapedesis. This is the most recent expla- nation. Connection between Ovulation and Menstruation.—From Leo- pold's investigations upon 29 pairs of ovaries, examined at vary- ing intervals after the menstrual period, it appears that men- struation and ovulation may occur independently—i. e., neither is dependent upon the other, but both have a common cause. Women may conceive without ever having menstruated, and may menstruate, after oophorectomy for instance, without ovu- lating. Ovulation. The Ovary.—Weight, 5.5 grms. or 78 grains. Diameters, 38 x 19 x 13 mm. or 1£ x £ x £ inches. Constituent parts :-r-stroma, glandular substance, epithelial covering, bloodvessels, lym- phatics and nerves. The epithelial covering of the ovary differs from the epithelium lining the rest of the peritoneal surface, in ovulation. 19 that it is columnar and has a special function in the formation of the ovum. Development of Graafian Follicle.—The specialized columnar epithelium covering the ovary dips down into the ovarian sub- stance, forming "egg-cords," and carries highly specialized cells. A constriction occurs above and below one of these spe- cialized cells and the follicle thus formed is an immature Graafian follicle, containing an immature ovum. These follicles at first lie under the capsule of the ovary, but later are deeper in the ovarian structure. Anatomy of Fully Developed Graafian Follicle.—From without inward.—1. Theca folliculi, composed of tunica fibrosa and tunica propria. 2. Membrana granulosa. 3. Discus proligerus, surrounding the ovule. 4. Liquor folliculi. Anatomy of Ovum.—From without inward.—1. Vitelline mem- brane. 2. Zona pellucida. 3. Internal cell membrane : these three comprising the cell wall. 4. Yelk, or cell contents. 5. Ger- minal vesicle, or nucleus. 6. Germinal spot, or nucleolus. Maturation of the Ovum and Preparation for its Impregnation. 1st stage. Karyokinesis. Amphi-aster stage. 2d stage. Extrusion of two polar globules. 3d stage. The female pronucleus. It is thought these changes occur to prevent parthenogenesis. Discharge of Mature Ovum (Ovulation).—Theories to account for its occurrence. 1. Sexual congress. 2. Periodicity. 3. Congestion—increasing the amount of liquor folliculi. 4. Influence of sympathetic nervous system. Mechanism of Escape of the Onde.—Tunica propria fails at the part nearest surface of ovary (called stigma) ; tunica fibrosa also gives way after a time, from pressure of the liquor folliculi, which increases in amount as a result of the liquefaction or watery secretion of the cells of the membrana granulosa. At this weakened spot (stigma) the ovule and discus proligerus are situated, and they escape together when the tunica fibrosa ruptures. Thickening of the fibrous and peritoneal coverings of the ovary from inflammation (peri-ovaritis) sometimes pre- 20 obstetrical lectures. vents rupture and discharge of ovule and causes dysmenorrhcea and sterility. Mechanism of Transmission to Tubes and Uterus.—The ciliated epithelial cells in the tubes, by their lashing movement, start a current in the moisture always present on the peritoneal surface toward the uterus. The ovule is carried by this current into the tube. Sometimes there occurs external or internal trans- migration ; i. e., the ovule enters the tube on the opposite side either through the fimbriated or the uterine extremity. Time of Occurrence.—Usually at the height of the menstrual congestion. Intermenstrual ovulation is, however, not infre- quent. The Formation of the Corpus Luteum.—When the tunica propria ruptures, and the ovum escapes, the follicle fills with blood (the hematin of the extravasated blood giving rise to the "yellow" color). The tunica propria then enlarges by active multiplica- tion of its cells and projects into the cavity of the follicle in ray- like folds. Shrinking and cicatrization occur, causing the per- manent pits or depressions which mark the surface of the adult ovary. The corpus luteum spurium, or, better named, that of menstruation, reaches the highest period of development in from ten to thirty days. The corpus luteum verum, or, better, of pregnancy, is simply an exaggeration or further development of the corpus luteum of menstruation, the greater growth due to the increased blood supply to the whole genital apparatus. It is no longer considered of any medico-legal value. It grows for thirty or forty days after conception, then remains station- ary until after the fourth month, when it begins to atrophy. At term it is only two-thirds its largest size. One month after de- livery it is reduced to a small mass of fibrous tissue. Insemination and Fertilization. Insemination.—The deposition of seminal fluid within the genital tract of a female during sexual congress. Seminal Fluid.—A yellowish-white, opaque, sticky fluid, vary- ing in quantity at each emission from one-fourth to two drachms, possessing a very peculiar odor, and neutral or alkaline in reaction. #~' insemination and fertilization. 21 Constituent Parts:— (a) Chemical examination : Water, 82 per cent.; salts, mainly phosphates, 2 per cent. ; proteine matter, fats, spermatid. (b) Microscopical examination : Crystals of phosphates, sper- matozoa. Filtration shows active constituents to be the spermatic par- ticles. Abnormalities of Spermatic Fluid:— (a) Aspermatism, when no discharge of fluid occurs. May be congenital, acquired or relative. Acquired when resulting from gonorrhoea, prostatic abscess, tuberculosis, neurosis. It is said to be relative when the discharge does not occur at the desired time. This variety may be due to fear (neurosis) or sexual excess, to an anatomical defect preventing emission, to defec- tive action of the nervous centre governing the act of emission, to anaesthesia of the penis. (b) Polyspermism—excessive quantity of fluid. (c) Abnormalities in color : Red when tinged with blood from the mucous membrane ; yellow, with pus (gonorrhoea); violet, from the presence of indigo, in consequence of excessive venery ; green, when to this last there is added gonorrhoeal discharge, and beer color, when jaundice is present. (d) Oligospermism—quantity deficient, or number of spermatic particles diminished. (e) Azobspermism. The particles dead when emitted, or alto- gether absent from the fluid. A physiological absence is the rule before puberty and in old age. Gonorrhoea is most fre- quently the cause of acquired azobspermism. Chronic alcoholism may produce it. It has been found that the man is at fault in about 20 per cent, of sterile marriages. Characteristics of the Spermatic Particle:— (a) Length, 5o^ inch. (b) Motility : Its own length in one second. Hymen to cervix in 3 hours (Marion Sims). An inch in 7£ minutes (Henle). Can push aside epithelial cells ten times their size. (c) Vitality or longevity : Are destroyed by heat, cold, acid solutions, mineral poisons, by lack of water. In some cases, as result of chronic disease or alcoholic or sexual excesses, they 22 obstetrical lectures. may be dead when emitted. Solution of bichloride of mercury, 1 to 10,000, will destroy them. Under some circumstances their vitality is remarkable. They have been found alive in criminals three days dead, in a bull six days dead, in a cow six days after insemination. They remain alive for months in the bat and in the hen, for three years in the queen bee, and in the living female have been found in the cervix eight days after copula- tion. Origin:— (a) Of indifferent constituents: Cowper's glands, prostate, vesiculse seminales. (b) Of seminal particles : By a process similar to that in the female, the spermatoblasts undergo the changes of karyokinesis and extrusion of the seminal globule, the spermatic particles thus remaining. Their first appearance in the fluid is at the fifteenth or sixteenth year. Mechanism of Ejection or Emission.— Muscular contraction empties the vesiculse seminales and accelerates the passage of semen along the urethra. Mechanism of its BecepMon.—From observations on the lower animals, confirmed upon the human being, the uterus, during the orgasm, becomes shorter and broader, descends into the vagina, is softer, and the os, alternately opening and closing, is observed to have a suction action, which draws the semen within the uterus. Exceptions. — When the orgasm in the male does not occur simultaneously with that of the female the alkaline mucus in the cervix protects the spermatic particles from the acid vaginal secretion, and the seminal lake bathing the cervix allows the particles, by their locomotion, to enter the uterus. In cases where conception has followed insemination during unconscious- ness, or when the semen has been deposited only on the external genitals, or when the uterus is retroverted, or in those rare cases of atresia of the vulva associated with vesico-vaginal fistula, copulation occuring through the urethra with the depo- sition of semen in the bladder, the reception of the particles is explained by their wonderful powers of locomotion. Time at which Inse>nination is least likely to be followed by Fer- INSEMINATION AND FERTILIZATION- 23 tilization.—Seventeenth to twenty-third day after the appear- ance (in the three-day type) of menstruation. It is most likely to occur the first few days after menstruation. Meeting-place of Particle and Ovule.—The general opinion is that this occurs in the ampullae of the tubes. A more recent theory is that it takes place in the fundus of the uterus or uterine extremity of the tubes, for the following reasons : By the movement of the epithelial cilia in the tubes, and the vermiform movement of the tubes themselves, the ovule is carried to the fundus in three days. The usual discharge of the ovule is at the height of the menstrual flow ; and as fruit- ful copulation usually occurs four to seven days after menstru- ation, the ovule has at this time reached the fundus. Mechanism of Fertilization. (a) Attraction of Spermatic Particles Toward Ovum.— The male elements of some plants, as ferns, are attracted by malic acid, which is excreted by the female organs of these plants. Simi- larly an excretion of the ovule or discus proligerus is thought to attract the spermatozoa. (b) Penetration of Ovular Coats by Spermatozoa.—It is probable that normally in the human being but one particle penetrates the cell contents, thus preventing the development of twins, monsters, etc. After its entrance the particle loses its tail, thus forming the male pronucleus. (c) The Union of Male and Female Pronucleus.. The Ooide is now fertilized or impregnated, and_ the subseqxient changes are briefly as follows:— ~~ Jlj • • >■ 1. Segmentation of the vitellus or yelk, until completely sub- divided, when a mulberry-like mass is formed, called the muri- form body. The outermost of these spheres resulting from the cleavage are called epiblastic, and the innermost, hypoplastic spheres. 2. The epiblastic spheres arrange themselves in a layer under the wall of the ovule, thus enclosing the hypoblasts spheres, except at one point, which is called the blastospore. 3. The blastospore closes. 4. A fluid forms between the epiblastic and hypoblastie 24 OBSTETRICAL LECTURES. spheres, and the latter collect in a mass which becomes lens- shaped and adheres to the layer of epiblastic spheres at the site of the blastospore. The fluid accumulates until the ovum has the appearance of a thin-walled vesicle, which is called the blastodermic vesicle. 5. Extension of the hypoblastic mass. 6. A layer of cells develops between the epiblastic and hypo- blastic layers, called the mesoblast, the blastoderm now consist- ing of three layers, epiblast, mesoblast, and hypoblast. 7. A central thickening of the hypoblast forms an opaque, cir- cular spot on the blastoderm, called the embryonic area. 8. A groove, called the primitive groove, appears in the em- bryonic area. 9. By an arching-over process, folds springing from the sides of the primitive groove (dorsal plates) join to form the spinal canal, and by a similar process folds springing from the base of the dorsal plates (abdominal plates) enclose the abdominal cavity. The cephalic and caudal extremities are formed by folds rising at either end of the groove. From the epiblast are developed the central nervous system, superficial layer of skin, the organs of special sense; from the mesoblast, bone, muscle, connective tissue, bloodvessels, and genito-urinary organs. From the hypoblast, the epithelium of the respiratory and alimentary tracts and glands. The Average Date of Conception after Marriage.—Normally im- pregnation occurs after the first menstruation succeeding mar- riage, but it is customary to speak of sterile marriages only after eighteen months have elapsed. Development of Embryo and Foetus in the Different Months of Pregnancy. First Month.—Indistinguishable from ovum of other mammals. Is a flattened vesicle. The embryo is nourished by yelk sac which, even at the end of the first month, is larger than the cephalic extremity of the fcetus. Visceral arches are distinct. Heart, first traces of liver and kidneys, eyes, rudimentary ex- tremities, oral and anal orifices are formed. Spinal canal closes. r AMNION AND CHORION. 25 (Spina-bifida results if this fails to occur at this time.) Length, 1 cm., or .4 inch. Second Month.—Grows to 4 cm. in length, and is about the size of a pigeon's egg. Visceral clefts close, except the first, which forms the external auditory meatus, tympanum^and Eu- stachian tube. At this time arrest of developflTent results in hare-lip, umbilical hernia, or exomphalus.A^Eyes, nose, and ears are distinguishable. The first suggestion of hands and feet ap- pear, and are webbed. External genitals also now develop, but sex is not to be differentiated. Third Month,— Maternal blood affords nourishment; 9 cm. long and about size of goose egg. Fingers and toes lose their webbed character and nails appear as fine membranes. Points of ossification are found in most of the bones. The neck sepa- rates the head from the trunk, and sex is determined by the appearance of the uterus. Weight, 30 grins. = 460 grains. Fourth Month.—16 cm.= 6 in. in length. Lanugo is present. Intestines contain meconium. Sex is well defined. Weight, 55 grms. = 850 grains. Fifth Month.— 25 cm. = 10 in. Vernix caseosa appears in places. The face is senile and wrinkled. Eyelids begin to open. Quickening occurs. Heart sounds are heard. Weight, 273 grms. = 8 oz. Sixth Month.—30 cm. = 12 in. Hair grows longer. Eyebrows and lashes appear. Testicles approach inguinal rings. Weight, 676 grms. = 23^ oz. Seventh Mmith.—35 cm. = 14 in. Pupillary membrane disap- pears. Weight, 1170 grms.= 41 \ oz. Evjhih Month.—40 cm.= 16 in. Down on the face begins to disappear. Left testicle has descended. Ossification begins in lower epiphysis of femur. Nails do not project beyond finger- tips. Weight, 1571 grms. = 3^ lbs. Ninth Month.—45 cm. = 18 in. Subcutaneous fat increases. Diameters of the head about 1 to 1£ cm. less than at term. Weight, 1942 grms.= 4^ lbs. Mature Fains.—50 cm. long. Weight, 7* lbs. Skin is rosy; lanugo has disappeared. Nails are perfect and project beyond fino-e'r tips. Eyes are opened. The centre of ossification in the 26 OBSTETRICAL LECTURES. lower epiphysis of femur is 5 mm. in diameter, while that of the cuboid bone is just begininng to show. Diameters of head are normal. Length of foot 8 cm. Lengths and Weights of Foius:— 1st month, 1 cm. .4 in. 2d " 4 1.25 3d " 9 3 30 grms. 460 grains. 4th " 16 6 rjo 850 " 5th " 25 10 273 8 ozs. 6th " 30 12 676 23A " 7th " 35 14 1170 41J " 8th " 40 16 1571 3£ lbs. 9th " 45 18 1942 44, " 10th " 50 21 3250 7£ " Amnion and Chorion. Amnion. Definition.—The amnion is the innermost of the foetal mem- branes, is continuous with the foetal epidermis at the umbilicus, forming a complete sheath for the umbilical cord and forming a sac or bag in which the foetus is enclosed. Development.—Tbe epiblast extends from sides, caudal and cephalic extremities of foetus, and curving backward approaches behind same until the reduplications meet and thus form two cavities, the True and the False Amniotic Cavities. The True contains the liquor amnii; the Fedse, the yelk sac and its ves- sels, which later will be constituents of the umbilical cord. Anatomy.—Is like that of serous membrane, i. e., a layer of connective tissue and a layer of endothelial cells. Function.—Chiefly to secrete the liquor amnii. Liquor Amnii. Quantity.—One to two pints at term. Specific Gravity. —1007. Composition.—Water, albumen, various salts, urea, epithe- lium. Reaction.—Alkaline. AMNION AND CHORION. 27 Origin. — From both foetus and mother, mainly the former. Function.—Distends uterus and protects foetus, affording an equal temperature for it and receiving its secretions. Does not nourish beyond adding to its supply of water. Abnormalities of the Amnion. Its pathology is similar to that of all serous membranes, i. e., inflammation, exudations, serous and plastic. (A) Abnormalities of Secretions :— (a) Oligohydramnios.—Kare ; 1 in 3000 or 4000 cases. Is dis- advantageous, because walls of uterus not kept apart and foetus apt to be injured or deformed. During pregnancy the mother is likely to suffer pain, and labor is usually difficult. (b) Hydramnios.—When two quarts or more of fluid may be present. Occurs about 1 in 250 to 300 cases. Cause.—Production may be increased ; absorption may be de- creased. It may be the fault of foetus, mother, or both. On the part of the foetus there may be (a) excess of urine ; (b) ex- cessive transudation of foetal serum, from vessels under placen- tal surface, which do not disappear about the third or fourth month when hydramnios exists, or from any condition raising the blood pressure in the umbilical veins, as cirrhosis of the liver (syphilitic), an abdominal tumor, or any abnormality in vascu- lar system of foetus, (c) From foetal skin. A pathological con- dition of this is found in some cases, as nsevi, elephantiasis con- genita cystica. Having its origin in the mother, the hydramnios may be a part of a general dropsy or be due to an exaggerated hydrsemia. Very rarely does it arise from both foetal and ma- ternal causes, and a distinct cause cannot always be found. It is most frequently of foetal origin. Diagnosis.—The existence of pregnancy, great movability of the foetus, and the distention of abdomen greater than the period of duration of the pregnancy would account for, are three im- portant signs. When there is a very large amount of fluid the diagnosis is very difficult. It may be mistaken for ovarian cyst, ascites accompanying pregnancy, distended bladder with retro- version of gravid uterus. 28 OBSTETRICAL LECTURES, Classes.—Acute. Rare. There is a sudden transudation of fluid from some traumatism. Symptoms.—Pain, difficulty in respiration, at times orthopnoea, fever. Chronic.—Begins at the third or fourth month and steadily increases, usually causing but little trouble. Treatment.— Immediate evacuation in the acute variety ; in the chronic this is, as a rule, not required. If necessary, the life of the foetus is not to be considered, as it will usually be diseased. Aspiration through uterine wall condemned. The membranes are to be punctured at the os, using the hand as a plug to prevent sudden escape of fluid. (B) Abnormalities of Color and Consistency.—Normally slightly opaque in the latter months of pregnancy, the liquor amnii may be green or brown from the presence of meconium, or tinged with red if the fcetus is macerated. (C) Putrefaction of the Liquor Amnii.—Most likely to be asso- ciated with death and decomposition of the fcetus, but occa- sionally there is an intensely putrid odor to the liquor amnii, with physometra, and yet the child is born alive. (D) Plastic Exudation.—Usually occurs early when amnion and foetus are near each other, and thus forms bands of adhe- sion between them, and even causes amputations of fcetal ex- tremities and premature detachment of the placenta. (E) Abnormal Tenuity.—Rare. The amnion may rupture and become separated from the chorion, which remains intact, form- ing bands or strings by being rolled upon itself. The strings thus formed may encircle the fcetus. (F) Cysts.—Of no clinical importance. (G) Rupture.—Abortion may result. Occasionally the amnion and chorion are perforated at a situation remote from the in- ternal os, and the liquor amnii dribbles away for some weeks, or even months, before delivery. This is called an amniotic bydrorrhcea. The Chorion. Definition.— The chorion is the outermost of the foetal mem- branes, and is formed from the external layer of the non-»errni- THE CHORION. 29 nal epiblast. The fietus at term is surrounded by three mem- branes—the deciduee, reflexa and vera (derived from maternal structures); the other two, chorion and amnion, from foetal structures. The chorion is the median of the three membranes. Development.—From the non-germinal epiblast, a single layer of cells springing from the outer layer of the blastodermic mem- brane. Chorionic Villi.—The villi of the chorion are hollow at first, and are composed of an external epithelial and an internal mucoid layer. Later they contain bloodvessels. Until the third month these projections into the maternal tissue abstract nutri- ment, oxygen, etc., from the deciduee. and serve to keep the ovum in the upper portion of the uterus. After the third month hypertrophy of one portion takes place (chorion frondosum) to form the placenta; elsewhere the villi atrophy (chorion leve). The function of the chorion leve is to protect the integrity of the ovum. Anomalies of the Chorion. Pleicenta Membremacea.—The normal atrophy of a portion does not occur, and placental villi are developed over the entire sur- face of the chorion. Such placenta? are thinner than the normal. Diseases of the Chorion. (a) Cystic Degeneration of the Villi.—This is an hypertrophy and myxomatous degeneration of the villi with the formation of cysts varying in size from that of a millet seed to a hen's egg. The old name of hydatidiform mole is not a good one, a>s mole is a meaningless term. Frequency.—1 in 2000. Mortality.— Over 13 per cent. Causes.—Diseases of endometrium, or uterine wall; circula- tion of villi cut off by absence of allantois or its vessels. It may occur repeatedly in the same individual. Symptoms.— Sudden increase in size of uterus at third or fourth month usually, hemorrhage, absence of fcetus, and pos- sibly discharge of cysts. It may be possible to feel the grape- like masses through the os uteri. 30 OBSTETRICAL LECTURES. Causes of Death.—Hemorrhage, sepsis, perforation of uterus. Treatment.—Is usually incompatible with foetal life. Hem- orrhage controlled by tampon. If diagnosed early, abortion should be induced, as it assumes sometimes a malignant type and spreads to uterine wall, and thus has caused fatal hemor- rhage and sepsis. This possible thinning of the uterine wall should contraindicate the use of the curette in unskilled hands. (6) Fibro-myxomedous Degeneration.—Up to the present time has been found only in the placental portion. (c) Chronic Inflammation. The Umbilical Cord. Development.—About the twentieth day after conception a diverticulum from the caudal portion of the intestinal canal is formed. It becomes constricted a short distance from its origin, the one portion to form the bladder; the other (larger) leaves the abdominal cavity with the omphalic or vitelline duct, and as an elongated cyst (allantois) rapidly grows and comes in con- tact with the entire chorion. Vessels soon develop, two arte- ries and two veins, which communicate with the villi of the chorion. One of these veins disappears and the two arteries remain. These three vessels, with the omphalic duct, the remains of the umbilical vesicle, and the pedicle of the allantois receive a covering of mucous tissue (Wharton's jelly) and a layer of the amnion, and compose the umbilical cord. The fully developed cord at term is 20 to 21 inches in length, \ to \ inch in diameter, containing three tortuous vessels, one vein and two arteries, which possess valves. The umbilical vesicle is the sac containing the nourishment oi the embryo until the development of the chorion and placenta. Abnormalities of the Cord. 1. Length.—It may be very short (one centimetre), thus pre- venting descent of the foetus or giving rise to hemorrhage from premature detachment of the placenta, or it may be very long (70 inches) and be found coiled around the foetus. THE DECIDUJ5. 31 2. Thickness.— The cord may be almost as thick as one's ivrist in places, from an excess of mucous tissue, the other con- stituent parts being normal. 3. Torsion,—Eight to ten twists normal. Due to twisting of arteries around veins. Usually has no effect. If extreme the bloodvessels may be occluded. Great torsion usually occurs after the death of the fcetus. 4. The Vessels.— There may be stenosis; atheroma; hyper- trophy of valves ; an overgrowth of connective tissue in the substance of the cord, as from syphilis; varicosities; rupture of the bloodvessels, forming a haematoma as large, perhaps, as an apple. 5. Coils and Knots.—Loops and true knots may be formed, which are usually not tight. Intra-uterine amputation, not due to these, but to the formation of amniotic bands. The cord is found coiled around the neck about onee in every four cases. Tangling of the cords in twin pregnancies and labors is not very uncommon. It is a dangerous accident to the children. 6. Insertion.—(a) Central is usual. It may be (6) marginal, or (c) velamentous (when the vessels run between the amnion and chorion before entering the placenta), or (el) meso-cord, when a fold of the amnion is arranged analogous to the meso- rectum. 7. Hernia.—Due to arrest of development of lateral plates. 8. Cysts.—Due to liquefaction of the mucous tissue in the cord, or to apoplexies in the cord. 9. Calcareous Deposits.—In the bloodvessels, or mucous tissue. Are often associated with syphilis, but of no significance. 10. Tumors.—Some of the above-noted conditions are the cause of localized swellings: rarely a low-grade fcetus amor- phus may be attached to the cord so intimately as to look like a tumor in its substance. The Deciduse. Development.—After the ovum is impregnated the mucous membrane of the uterus hypertrophies to tenfold its normal thickness, due to proliferation of young connective-tissue cells 32 OBSTETRICAL LECTURES. above the uterine glands. These proliferated cells are called "decidual cells." The ovum, lying in the folds of the hyper- trophied mucosa, finally is completely surrounded. That portion of the mucous membrane reflected over the ovum is the decidua reflexa. The portion under the ovum, the decidua serotina, and the uterine mucous membrane elsewhere, the decidua vera. The decidua serotina helps to form the placenta; the de- cidua vera undergoes a partial atrophy in the latter months of pregnancy and is cast off in part with the ovum in labor, in part by disintegration in the lochial discharge ; the decidua reflexa begins to undergo degeneration at the second month and by the seventh month has disappeared. Diseases. 1. Apoplexies.—These are a common cause of early abortions, and are apt to occur prior to the second or third month. Causes.—Bright's disease, repeated congestions from frequent coitus, injuries, blows, etc. 2. Inflammations, Chronic. — (a) Hyperplastic endometritis gravidarum. The hypertrophy of the mucous membrane is exaggerated, deflects nourishment to itself and gives rise to apoplexy and early abortion of a fleshy mass. It is usually the result of chronic endometritis prior to pregnancy. The decid- ual apoplexies may be multiple and distributed all over the sur- face of the ovum, projecting into its cavity, producing the so- called "subchorial tuberous hsematomata of the decidua." (b) Polypoid endometritis gravidarum. The hypertrophy confined to certain areas. Is very rare. Leads to abortion, second to fourth month, (c) Catarrhal endometritis gravidarum. There is an abnormal hypertrophy of the uterine glands, giving rise to the secretion of a few ounces to a pint or more, with periodic discharges, of thin mucus, called hydrorrhoea gravidarum. (d) Cystic endometritis gravidarum occurs very early. The glands hypertrophy. May be cured by subsequent growth ol the decidua? or may continue to produce hydrorrhoea gravid- arum. 3. Inflammations, Acute.—(a) Hemorrhagic endometritis as THE PLACENTA. 33 occurs in cholera. Causes abortion, (b) Exanthematous en- dometritis, the exanthema developing on the uterine mucous membrane, as on other mucous membranes. In several reported cases of measles complicating pregnancy, abortion has occurred about the time of appearance of the eruption. (c) Purulent endometritis. Very rare. 4. Atrophy.—May affect either of the deciduse. Ill-developed placenta may result, or ovum not properly held in place may drop and develop a " cervical pregnancy.'''' 5. Tumors.—Decidual polyps of fibrin on a basis of decidual tissue, like stalactitic formation on rocks. "Deciduoma,"atumor composed of decidual elements, remaining, perhaps, a long time in utero, occasioning hemorrhage, discharges, and, per- haps, sepsis, but so lightly attached to the uterine wall that its removal is easy. Another variety of deciduoma (deciduo-sar- coma) is malignant, giving rise to metastases and ending fatally six or seven months after confinement. The Placenta. (A) Development.—At the third month the chorion villi atrophy, except at the decidua serotina, where they take on an extraordinary growth to form the placenta. Each villus is composed of connective tissue holding capillary bloodvessels, is covered with epithelium, and projecting into the maternal tissue is surrounded by a capillary network from the maternal blood- vessels. Later, these capillary networks disappear, leaving large sinuses or lacunae, which receive blood from the little curling arteries rising up through the decidua serotina and into which the villi of the placenta dip. (B) The Fully Developed Placenta.—At term the placenta weighs one pound, is one inch thick at its central portion and seven inches in diameter. The foetal side is covered by the amnion and penetrated by the cord. The maternal surface is dark red, divided by sulci into lobules or cotyledons and covered with a grayish transparent membrane composed of the cells of the upper layer of the decidua serotina. It is normally situated at the fundus, anteriorly or posteriorly. 3 34 OBSTETRICAL LECTURES. (C) Functions. — It absorbs oxygen and nutriment, acting as vicarious lung or gill, and serves as alimentary tract, kidney, liver, and bowel. The epithelium of the villi, in carrying on these functions, has a selective power. Variola germs are readily absorbed, tuberculosis very rarely. Anomalies. (a) Position—as placenta praevia. (b) Size—as placenta membranacea. (c) Shape—as horse-shoe placenta. (d) Weight—may be above or below normal. (e) Number—as placenta duplex, tripartita, etc. There may be accessory growths, as placentae succenturiatae, placenta spuria, marginata, etc. Diseases. (a) (Edema.—Often accompanies hydramnion and macerated fatus; stenosis of umbilical vein ; general effusions in the mother. The villi may be normal. (b) Degenerations:— 1. Cellular Infiltration. — Occurs in syphilis. Villi are dis- tended with granulation cells, bloodvessels obliterated, and foetal life perishes. 2. Fibrous and Fatty Degeneration of Villi.—Causes. Any abnormality, accident or disease of placenta abrogating its function, as hemorrhage from the placenta, chronic interstitial placentitis, diseases of endometrium. " White infarcts" and fibrin nodes of the placenta, formerly believed to be pure fibrin formations, are probably localized de- generations of the decidua. Prognosis.— If extensive, fa4us dies. If small, a correspond- ing degree of ill development of foetus. Primary fatty change only occurs after death of the foetus. 3. Phthisical Placenta.— An exudate from villi into lacunae, which undergoes a cheesy change. 4. Calcareous.—Very common. Occurs in indifferent places and has no effect on functions of the placenta. THE PLACENTA. 35 5. Myxomatous. —Similar to the same change in the chorion. Is usually localized. (c) Apoplexies.—Very common. Are a frequent cause of abor- tion. Usually on the maternal face of, or in, the placenta. Rarely subamnionic, and consequently of foetal origin. The foetus may thus bleed to death. Causes.— Traumatism, maternal diseases (especially Bright's disease), foetal diseases. (d) Syphilis.—It is disputed whether there be a distinct form of the disease in the placenta which offers a diagnosis of syphilis. Prof. Hirst inclines to the belief that there is this distinctive form of placental disease. The pathological manifestations differ with the time of infection, as follows :— 1. When the spermatic particle is diseased there is cellular infiltration of villi. 2. When the mother is infected during fruitful coitus, there is, in addition to the cell infiltration, an overgrowth of connec- tive tissue over the cotyledons. 3. When the mother is infected before conception, gummata appear in maternal tissue. 4. When the mother is infected after conception, the placenta is ordinarily not diseased (Frankel). Prognosis.—For foetus : the cell infiltration destroys the blood- vessels and foetal life perishes. For the mother : not indifferent. From the connective-tissue development adherent placenta likely to occur, increasing the risk of sepsis, hemorrhage, inversion of uterus, etc. (e) Acxde Placentitis.—Very rare. (/) Cysts.— Result from old hemorrhages. Are never large and of no clinical importance. (g) Tumors.—1. Fibroid change or Myxoma Fibrosum; 2. Localized Hypertrophies; 3. Organized Thromboses. There- may remain in the uterus after delivery fragments of placenta, on which, as a basis, fibrin and blood collects until a large poly- poid tumor is developed. Rarely a " destructive placental polyp " grows into the uterine wall in a malignant fashion, with a fatal termination. 36 OBSTETRICAL LECTURES. Physiology of Mature Foetus. Foetal Circulation. From the placenta the blood passes through the umbilical vein to the under surface of liver. A part enters the liver and is carried to the ascending cava by the hepatic veins, the smaller portion passing direct to ascending cava through the ductus venosus. Joining the blood from the lower extremities it then passes to the right auricle, and guided by the Eustachian valve enters, through the foramen ovale, the left auricle. Thence to left ventricle, to aorta, the greater part being carried to upper extremities and head. Returned by the descending cava to the right auricle, it passes to the right ventricle, and a small por- tion being carried to the lungs through the pulmonary artery, the remainder reaches the aorta through the ductus arteriosus. From the aorta it passes through the hypogastric arteries, to the umbilical arteries, to the placenta, a small portion of this mixed blood being carried by the aorta into the lower extremi- ties. Foetal Excretions. Bowels.—Inactive during intrauterine life. Meconium is dis- charged if foetal life is threatened, as by an apoplexy, coiled or compressed cord, etc. If it occur during labor, should always be a danger signal except in breech presentations. Bladder.—Is evacuated during intrauterine life aud urine is always albuminous. The urinary secretion is not essential to the development of the foetus. If the fcetus has lived a few hours, the kidneys will show orange- colored infarcts of urates, which are of medico-legal value. Multiple Impregnation. Frequency.— Twins, 1 in 89 births. Triplets, 1 " 7,900 " Quadruplets, 1 " 371,126 " These statistics are from European sources, and will not hold PHYSIOLOGY OF MATURE FCETUS. 37 good for this country, where multiple pregnancies are less fre- quent. Two cases have been reported—one in Italy, the other in Texas—of six children at a birth. Twins.—How it occurs. 1. Two ovules discharged at once from separate Graafian fol- licles in same or different ovaries. 2. Two ovules from same follicle. 3. Unioval, i. e., from a single ovule two foetuses developed by a division of the layers of the early formed membrane. Unioval twins have single placenta and chorion, but two am- nions ; otherwise each foetus has its own placenta and chorion, as well as amnion. The ova lie side by side, one in front of the other, or one above the other. Prognosis. — Mother—Liability is greater to albuminuria and eclampsia, to post-partum hemorrhage from over-distention, and labor is apt to be long and difficult. Foetus.—Much graver. If from two ovules, one in twenty- three born dead ; from a single ovule, one in six. Reasons for gravity of prognosis to foetus : — 1. Lack of room, hence ill-developed ; under weight and size. 2. If one is stronger and better developed it attracts more nu- triment, and finally crowds and compresses its fellow, flattening it out (Foetus Papyraceus). 3. In unioval the anastomoses between foetal and placental vessels apt to produce monsters. 4. Hydramnios apt to occur. 5. Many complications at birth. It is possible for one of twins to be discharged prematurely, perhaps early in pregnancy, while the other goes on to mature development. It is also possible for one to die, and even to putrefy in utero, while the other remains healthy. Super-Impregnation. (a) Super-fcetation. — The product of conception occupying the uterus, a second impregnation follows a subsequent coitus. (b) Super-fecundation.—Two or more ovules fecundated at or near the same period of time. 38- OBSTETRICAL LECTURES. The possibility of its occurrence after a long interval doubted] since there is no proof of ovulation during pregnancy. The limit is within a few days. The absence of menstruation dur- ing pregnancy is explained by the following: hypertrophy of de- cidua and bloodvessels surrounded by organized tissue prevent- ing diapedesis; absence of periodic engorgement, shown by lack of ovulation ; obliteration of uterine cavity after the third month. Determination of Sex.—At birth the proportion is 106 boys to 100 girls. At puberty it is about equal. Theories.—None satisfactory. The parent possessing the greater mental, physical, and sexual development may have some influence. When determined.—Not known. Up to the third month embryo has equally the elements of both sexes. Diseases of the Foetus in Utero. Mortality.—One-fourth of all die before term. Deformities and Monstrosities. Every departure from the normal is classified under one of the following:— 1. Hemiteratic. 2. Heterotaxic. 3. Hermaphroditic. 4. Monstrous. 1. Hemiteratic, semi-monster—i. e., an approach to monstrosity —include :— Anomalies of (a) growth (as dwarfs, giants). (b) volume (as microcephalic head, large breast, etc.). (c)form (as deformity of pelvis). (d) colerr (as albinism, melanism, mole, etc.). (e) structure (as abnormal ossification of cartilage). " °y (/) displacement of splanchnic organs (as hernia, spina bifida, encephalocele). DISEASES OF THE FOETUS IN I'TERO. 39 " by (g) displacement of non-splanchnic organs (as club- foot, scoliosis, bow-legs). " by (h) change of connection (as anomalous attachment of muscles, tendons, nerves). Anomalous (i) evenings (as patulous foramen ovale, rectum open- ing into urethra). " (j) imperforations (as rectum, vagina, oesophagus). " (k) union of organs (as horseshoe kidney, webbed fingers). Anomalies by (I) disjunction (as hare-lip, cleft-palate). " (m) numerical diminution (as absence of one or more fingers). " (n) augmentation (as six fingers, three testicles, six toes). 2. Heterotaxic—Anomalous order, reversal of natural position of organs, as liver on left side, pyloric and cardiac ends of stomach reversed. 3. Hermaphrodism.—A vicious conformation of the genital organs comprising elements of both sexes. When called upon to make the diagnosis always exclude an ill-developed male, as cleft scrotum, or rudimentary penis. By this error males have been educated as females. 4. Monstrosities.—A living creature so much deformed as to excite wonder or disgust. (A) Aidositic Monsters.—Those capable of independent ex- istence. These are further subdivided and etymologically named :— (a) Ectromelic (abort-limb). Absence of upper or lower extremity. (6) Symelic (union-limb). Lower limbs fused. (c) Celosgmatic (hernia-body). Extreme hernia. (d) Exencephalic. Brain normal, but cranial bones not developed. (e) Pseudencephalic. Bones of cranium lacking and rudi- mentary brain. (/) Anencephalic. No brain and no development of cranium (g) Cyclocephalic. The two eyes fused. Reversal of eyes and nose apt to occur (rhinocephalic). 40 OBSTETRICAL LECTURES. (h) Otocephalic. The two ears meet under chin, and lower portion of face not developed. (B) Omphalosite.—Possessing an imperfect kind of life, which ceases when the umbilical cord is divided. It only occurs in twin pregnancy ; the intimate anastomosis of vessels in unioval sometimes allows one heart a preponderating power, and the other, not used, atrophies. These may be (a) Acardiac. (b) Acephalic. (c) Asomatic. (d) Foetus amorphus or anideus (a shapeless mass of flesh). (C) Composite Monsters :— (a) Double autositic. Named by the portion of the body which unites them, asxyphopagic (joined by xyphoid), synsomatic (joined by bodies), syncephalic (joined by heads), etc. (6) Double parasitic, as an extra pair of legs, extra child hanging from abdomen, etc. (c) Triple monsters. Very rare. Diseases of Foetus. Infectious—Causes.—Specific microorganisms which in some way pass through maternal blood to foetus. The conclusion from many conflicting observations is that this is not invariable, but possible. Several theories have been advanced to explain how the microorganisms reach the foetus. The following are some of the diseases which have been found in the foetus : smallpox, measles, erysipelas, typhoid, pneu- monia, cholera, syphilis, malaria, recurrent fever, yellow fever, leprosy, anthrax. The power of various organisms to trans- mit themselves is not equal. Small-pox very apt to pass from mother to fcetus; tuberculosis, but one case reported. Even if foetus is not inoculated, abortion is apt to occur. Congenital Skin Diseases—as ichthyosis. Intra-cranial Disease-^as sclerosis or tumors of brain, etc. Inflammation, recent or old, of Serous Membranes—ascites, hydrothorax, hydrocephalus. Valvular Diseases of Heart. DISEASES OF THE FCETUS IN UTERO. 41 Overgrowth of Connective Tissue—in intestines, bloodvessels, liver, etc. (largely due to syphilis). Tumors—as distended bladder, congenital goitre, sacral tumors, etc. Rachitis.—Signs of congenital rachitis—head square and bent to one side, spine tortuous, joints enlarged, pigeon breast, curved long bones. Anasarca—usually due to obstruction of the circulation, or pathological alteration of the blood (leukaemia, anaemia). Congenital Cystic Elephantiasis.—Multiple cystic tumors of skin, with thickening; great enlargement of lymph channels and bloodvessels. Spontaneous Fractures of the Long Bones—most commonly due to rachitis, and then apt to be multiple. Anchyloses and Luxations.—Anchyloses are very rare, are due to inflammation of the joint membranes and seriously prevent normal mechanism of labor. Luxations are rarely intrauterine, but frequently the result of mismanaged breech and arm pre- sentations when much force is used. A rigidity of the muscles due to prolonged pressure may be confounded with the above. Intrauterine Amputations-caused by amniotic bands. External Violence—of medico-legal interest. Maternal Conditions affecting Fcetus :— 1. Nervous Disturbance in the Mother.— Maternal impressions ; emotions (sometimes fatal). 2. Abnormalities in Temperature. — F panites uteri or physometra. 3. Saponification. 4. Mummification. Occurs sometimes after missed labor. r>. Calcification. Lithopredion produced as in extra-uterine pregnancy. 6. Absorption (before third month). A very favorable termina- tion in extra-uterine pregnancy. It may also occur in intra- uterine pregnancy. Syphilis of Foetus. Infection of foetus occurs in three ways:— 1. From diseased Ovule. 2. From diseased Spermatic Particle. 3. From Maternal blood. The embryo will be syphilitic in DISEASES OF THE FCETUS IN UTERO. 43 about one-fourth of the cases in which the mother has been infected after conception has occurred. The poison can also pass from foetus to mother, thus explain- ing several curious phenomena, as the appearance of secondary symptoms in the mother in the latter months of pregnancy, without the history of a primary sore. Manifestations.—Protean and polymorphous, as in the adult, although it should be remembered that the characteristic signs in the living infant do not usually develop before four to six weeks. There may be an overgrowth of connective tissue in all organs of the body. (a) Skin.—Pemphigoid eruption, especially on soles of feet and palms of hands. (6) Bones.—An embryonal tissue, a transition stage between cartilage and bone, by a premature attempt at ossification, is not sufficiently nourished, dies and undergoes a fatty change, leaving between diaphysis and epiphysis of all the long bones a jagged yellow line. (c) Liver.—Normally is ^ of body weight. Syphilis of fcetus shows liver much increased in size and weight. (d) Spleen.—Normally rJff of body weight. Much increased in syphilis. (e) Lungs. — One of three conditions found :— 1. Overgrowth of connective tissue, constituting fibroid pneu- monia or phthisis (most common). 2. Catarrhal or White Pneumonia. By an overgrowth of epithe- lium in the air-vesicles the lung dies, fatty degeneration follows, giving the lungs a dead-white appearance, with imprint of ribs. 3. Gummata—rarest. Effect of Syphilis upon Life of Foetus.—" In 83 per cent, of all habitual foetal deaths the parents are syphilitic. In 657 preg- nancies in syphilitic women 35 per cent, ended in abortion, and a large number of the children expelled at term were stillborn (Charpentier). Of 414 pregnant women with syphilis only 63 per cent, arrived at term." Of 100 syphilitic mothers only 7 children were living after 3 months. Diagnosis.—By history of father or mother, and by an exami- nation of skin, long bones, liver, spleen and lungs. 44 OBSTETRICAL LECTURES. Treatment.—Syphilitic patients should not be allowed to marry without a prolonged course of treatment (for a year), to be fol- lowed by a mild treatment of the mother throughout pregnancy. ' In married people sexual intercourse should be interdicted, to avoid abortion, during the treatment. The time that must elapse after parents are affected before foetus may be expected to be free from the poison varies. In one case after twelve years the foetus was syphilitic. If the mother is contaminated at the fruitful coitus, or before, treatment should be begun at once. Both mercury and iodide of potash can pass to the foetus and modify its syphilitic disease. Chlo- rate of potash (10-20 gr., t. d.) may be given in any disease interfering with the development of the placenta, to supply oxygen, as recommended by Penrose, Sir J. Y. Simpson, Barker, Bruce, and others. Habitual Death of Foetus. Causes in order of frequency :— 1. Syphilis.—Eighty-three per cent, of all cases of habitual foetal death. 2. Metritis, endometritis, and uterine displacements. 3. Altereitions in maternal blood, as anaemia or plethora. 4. Chronic diseases of the mother.—Tuberculosis, cancer, malaria, diabetes, nephritis. (In nephritic mothers 86 per cent, of children are born dead or too feeble to survive long.) 5. Causes resident in fcetus, as recurring deformities. 6. Chronic poisoning. — Saturnism. Tobacco. (In the Virginia factories such effects not noticed.) 7. Causes referable to father, as phthisis, albuminuria, chronic poisoning. 8. Habit and heredity. Treatment.— Ascertain cause, and treat that. PHYSIOLOGY OF NEWBORN INFANT. V, Physiology of Newborn Infant. Respiration. Two factors to explain its establishment:— 1. External irritation, resulting from change of environment (from liquid, with temperature of 99°, to air, with temperature of 70°), gives rise to reflex action of all muscles. 2. Maternal supply of oxygen being cut off, there is an accu- mulation of C02, and the primary action of this is stimulant to respiratory apparatus. This cause may be operative in utero and determine intra-uterine respiration, with the inspiration of liquor amnii, meconium, mucus, and blood-clots, and a con- sequent pneumonia. If the membranes are ruptured and there is free access of air to the uterine cavity, there may be a comparatively normal respiration for a while in utero, and the child may even be heard to cry aloud within the womb. Rate of respiration is 44, sinking, after a few months, to 35. Weight. 7.3 lbs. There is a gradual increase, about one-and-a-half pounds before and one pound after the fourth month, for each month. Month. Weight, lbs. Month. Weight, lbs. 1 7.75 7 16 2 9.5 8 17 3 11 9 18 4 12.5 10 19 5 14 11 20 6 15 12 21 Digestion. Accomplished by digestive juices, except the diastatic ferment of the pancreas and salivary secretion. Partially dependent upon bacteria in stomach and intestines. Capacity of Stomach.— Kuowledge of this important to avoid over-feeding. 46 OBSTETRICAL LECTURES. 1st week, 46 cub. cent. 3d month, 140 cub. cent. 2d " 78 " 5th " 260 " 3d and 4th week, 85 " 9th " 375 " The greater the weight the greater the gastric capacity. One one-hundredth of body weight -+- 1 gramme each day (Ssnitkin). One ounce at birth and an increase of one ounce per month up to the sixth month, after which it is somewhat less (Emmet Holt). The time required to digest this amount of food is one to two hours. Position of Stomach,—Its axis is almost longitudinal, which explains frequent regurgitation and vomiting. It is high on left side under the false ribs. This explains presence of air in the stomach. Excretions. (a) Urine.—Always albuminous for first few weeks. Quantity has never been estimated. Always acid. Specific gravity 1003-5. A trace of sugar is often found in breast-fed babies. Voided 6-20 times in 24 hours. Does not always stain diapers, and mistake may thus be made of supposing none to have been voided, (b) Bowels.—Meconium for the first 48 hours. Later, it becomes light yellow, is not formed, is sour and acid. The normal frequency of evacuation is four times in 24 hours. Temperature. Peculiarities are irregularity and height, with the variations above 98°. Slight causes will produce great changes. Eyesight. Always hypermetropic. Pulse. 125-160, as shown by heart sounds. Blood. Total bulk to body weight 8 per cent. ; six to seven millions red blood-corpuscles to the c. m., which are more spherical and do not tend to form rouleaux. Shadow corpuscles abundant. White blood-corpuscles more numerous, viscid, and deliquescent PHYSIOLOGY OF NEWBORN INFANT. 47 than in adult. The ordinary jaundice of the newborn infant is due to the superabundance of red blood-corpuscles whieh are destroyed in the liver, giving rise to an excess of bile pigment. It is reasonable to suppose that it is also hematogenic, the destruction of the red blood-corpuscles setting free haemoglobin in the blood. The foetal blood contains a large amount of haemo- globin. At birth there is 120.2 per cent, compared with 93.8 per cent, in mother, and this increases for 36 to 48 hours, then diminishes. Liver. Blood supply diminished, capillaries less distended, secretion of bile lessened. Lower pressure in hepatic veins. Capsule of Glisson swollen, associated with exfoliation of the cord. Heart. Exhibits transition from foetal to infantile circulation by closure of foramen ovale and obliteration of ductus arteriosus. Cord. After 24 hours, line of demarcation at its base. Necrosis of amniotic covering. Mummification of mucous tissue. Destruc- tion of its vessels. Cord drops off about 4th day, followed by retraction of granulating button within the umbilical ring. Medico-Legal Points. It is impossible to definitely determine whether child has lived and whether injuries on its body have been inflicted with murderous intent. Discoloration about the neck points strongly to strangulation. Anatomical Points. To be borne in mind when making autopsies to determine cause of death of newborn infant. The normal relatively large size of thymus gland and heart. An enlarged thymus may completely close the trachea. Lungs should be inflated and overlap heart. Liver, 5fc of body weight. Ductus choledochus should be patulous. The sigmoid and appen- dix very large and the bladder relatively large. Examine hypo- 48 OBSTETRICAL LECTURES. gastric arteries for septic infection. To facilitate an examina- tion of the opening of the air-passages and the oesophagus majf-i incision splitting lip, symphysis of lower jaw and tongue. Abnormalities in the Physiology of Premature Infants. The two main deviations are— (a) Low temperature—variations below 98°. (b) Inability to ingest and digest food. Treatment.—Incubation and gavage. In the absence of the most approved incubator, such as Tarnier's, one can be readily improvised with an ordinary baby bath tub, several layers of cotton-wool, and a number of beer bottles filled with hot water. Gavage is the regular feeding of the infant with freshly-drawn mother's milk through a small soft catheter passed into the stomach at each feeding. Mortality of this Treatment:— At 6 months 22 per cent, saved. " 7 " 38 " " " 8 " 89 " " " 8^ " 95 " " Sclerema. A disease only found in these premature infants. Occurs most often in lying-in hospitals. The most prominent symptom is a hardening of the skin, beginning in the legs and spreading, usually sparing breasts and belly. Jaundice or a hemorrhagic condition usually accompanies it. Temperature is very low, 95°. Its pathology is not well understood. The most probable explanation is that the large excess of palmitic acid in infants solidifies at this low temperature. The condition is a grave one and apt to be fatal. Management of Newborn Infant. Clothing. A baby should be clothed in winter as follows : A binder of flannel or knit wool, twice around abdomen, a knit shirt, diaper, knit shoes, and two skirts,- the first flannel (in midsummer, linen)' and finally its dress. The skirts should be supported from the TON. X>-J^ MANAGEMENT OF NEWBORN INFANT. 4fJ shoulders by sleeves or tapes. A knit jacket may be worn over the dress. A light flannel shawl or cap is desirable to protect the child from attacks of coryza. As an infant usually urinates very frequently, the diapers are changed about 20 to 24 times a day. To prevent chafing one of the following powders should be used: Compound talcum, borated talcum, oxide of zinc, and lycopodium, rice flour. If chafes occur, cold cream is the best simple remedy. Feeding. Human Milk. Secretion established at the end of forty- eight hours. Derives its origin from an overgrowth of epithe- lial cells lining the glands, their infiltration with fat, and sub- sequent rupture. Specific gravity, 1024-35, reaction alkaline. Each minute fat globule is surrounded by a pellicle of serum albumin. Chemical Constitution. Meigs. Vogel. Gautrelet. Water.......87.163 89.5 88.1 Fat........4.283 3.5 4.0 Casein.......1.046 2.0 2.2 Sugar.......7.407 4.8 6.2 Ash........0.101 0.17 0.5 Fat.—This constituent of human milk is subject to rather wide variations in quantity under the influence of diet and general health. Under normal conditions, however, it stands pretty constantly at 4 per cent. Proteids of Milk.—The proteids of milk are casein and lact- albumin. Casein.—Casein is, strictly speaking, the curd of milk, formed by a digestive ferment acting upon "caseinogen,'1 a proteid analogous to fibrinogen, myosinogen. Caseinogen is a peculiar substance, neither an alkali-albumin nor a globulin, but occu- pying a distinct position among proteids. Lact-albumin.—A proteid resembling closely serum albumin, but somewhat different from it. It is present in small quanti- ties—£ of 1 per cent. When the milk is curdled a new proteid 4 ^4 3 77& 50 OBSTETRICAL LECTURES. appears in whey, called "whey proteid," which is soluble and non-coagulable by heat. Sugar.-Thi* is lactose ; it is not strong in sweetening prop- erties. Ash.—The ash of human milk is made up mainly of potas- sium, sodium, calcium, and phosphoric acid. Quantity of Milk at each Nursing.— Rather difficult to deter- mine. It may be estimated by : (1) The infevnfs gain in weight after each feeding. This is not constant, varying from 3 to 6 ounces. (2) Capacity of stomach (see page 44). (3) Quantity in 24 Ivours, divided by the number of nursings. At the end of the 7th day the quantity in 24 hours is 14 ounces ; at the end of the 4th week, 2 pints. Factors Influencing Sec return—(a) Quality.—The quantity of fat experiences the greatest variations. 1. Time. — The quality of the milk varies with the time at which it is withdrawn. There is a difference between what may be called the fore milk, middle milk, and stripping?. The middle milk should be selected for chemical analysis, as it will give the average proportion of the several constituent parts. 2. Intervals between tlie Nursings.—When the infant is fed too frequently the milk becomes more concentrated, contains less water, and its specific gravity is higher. 3. Diet.—The quantity of fat is increased by a nitrogenous diet. If the mother eats too little albuminous food, or too little fat, the milk is poor in fat. If the diet contain too much meat, fat, or malt liquor, it will have an excess of fat, which the in- fant cannot digest. The proper diet does not differ from the ordinary diet. The quantity of casein, which is more com- monly in excess in the better class, can be reduced by regular exercise. Cutting down the diet will not suffice ; it reduces the whole quantity, but not the proportion of casein. (b) Quantity.—This may be improved by the addition of a half pint of milk, to be taken at eleven and four o'clock, and to some a half pint of malt liquor may be given at dinner, watching its effect upon the child. Always see that the nurse does not interfere with the diet. MANAGEMENT OF NEWBORN INFANT. 51 Conditions Interfering with the Mammary Function.—(a) Atrophy of glandular elements and overgrowth of connective tissue, as from ill- developed physique, pressure of corsets, refusal to nurse, etc. [b) Diseases.—Any acute, infectious disease, as the exanthe- mata, erysipelas, diphtheria, typhoid, mammary abscess. When convalescence is once fairly established, even after several weeks, the milk supply will usually return, when the child should be transferred from its bottle to the breast. In phthisis the quan- tity is not often affected, but the quality is impaired. There is apt to be less fat and casein, and the milk may contain the tubercle bacillus. A syphilitic mother should not nurse her child, for fear of infecting it, if it be not already infected, but a syphilitic child may be suckled by its mother without danger of her infection (Colles' Law). Any disturbance of maternal health may cause the reappearance of the colostrum corpuscles, with ill effect upon child. They should not be found normally after the eighth or tenth day. The possibility of their reap- pearance is of medico-legal interest. (c) Hemorrhage, as when much blood is lost during the puer- perium, or by the early return of profuse menstruation. Nursing is not interfered with if the hemorrhages in the latter are not profuse. (d) Emotions.—How these affect the milk is not yet explained —possibly by the production of leucomaines. When the mother is influenced by profound emotions, her milk may become even poisonous to her child. (e) Dnigs.—The following drugs have been demonstrated in the nursing child's system after administration to the mother: Sodium salicylate, potassium iodide, salts of mercury, opium, chloral, and atropia. The last is particularly likely to affect the child, and should be administered with caution. If the mother cannot nurse her child, it should be fed by a wet nurse. Selection of Wet Nurse. This should be governed by the following considerations :— (a) She should have milk of good quality, which is best judged by the appearance of her own child. 52 OBSTETRICAL LECTURES. (6) She should, preferably, be a multipara, and of suitable age; her child approximately the same age as the one to be nursed ; nipple should be well shaped; and it is of advantage to have made a chemical analysis of her milk. (c) Equable disposition and absence of disagreeable qualities. (d) She should not have syphilis. Artificial Feeding. Asses' and goats' milk are more like human milk than is cows' milk, but as they are not conveniently procurable the last is used. To properly appreciate why so large a proportion of artificially-fed children die annually, particularly in the hot summer months, it is only necessary to study the differences between cows' and human milk. The most important differ- ences may be briefly tabulated as follows :— (1) Gross Appearances.—Cows'—a dead white in color, and opaque. Human—apt to be yellow ; sometimes bluish. More trans- lucent. (2) Reaction.—Cows'—acid. Human—alkaline. (3) Specific Gravity.—Cows'—1030-35. Human—1024-35. (4) Curd Comparison,—The coagulum produced by a digest- ing ferment, as rennet, is dense, tough, and digested with diffi- culty in cows'; light, flocculent, and easily digested in human. This difference is due merely to the larger quantity of case- inogen in cows' milk, and to the acidity. Dilute cows' milk and make it alkaline, and the curd on the addition of rennet is as light and flocculent as in human milk. (5) Chemical Comparison.—Cows' milk contains more casein and less sugar. Comparative Analyses. Water Fat Casein Sugar Ash Meigs. Human. Cows'. 87.16 87.1 4.28 4.20 1.04 3.25 7.40 5. 0.10 0.52 Human. Cows'. 89.5 87.5 3.5 3.5 2.0 3.5 4.8 4.8 0.17 0.75 Gautrelet. Human. Cows'. 88.1 85.61 4.0 4.0 2.2 3.5 6.2 6. 0.5 0.85 MANAGEMENT OF NEWBORN INFANT. 53 (6) Histological Comparison. —It is asserted that the albuminous envelop surrounding the fat globules is thicker and tougher in cows' milk. Colostrum corpuscles are found in human milk5 normally, up to the eighth or tenth day. They return under influences interfering with lactation, as described above. (7) Bactcriologiccd Comparison.—Human milk comes from the breast sterile. Cows' milk in cities, particularly in hot weather, after twenty-four hours, swarms with all kinds of pathogenic and non-pathogenic micro-organisms and their products—pto- maines. Tyrotoxicon is the most virulent ptomaine found in milk. (8) QuantiUdive Comparison.—Human milk is furnished in quantity and at intervals suitable for the infant. Artificially fed children are apt to be over-fed. Preparation of an xVktificial Food. In making an artificial food with cow's milk as a basis, three factors must be borne in mind : the quantity required, the dif- ferences in chemical composition and reaction, and the microbe infection. The first may be regulated by the following table, based upon an extensive study of the capacity of the infantile stomach:— Age. Interval. Number of feedings in 24 hours. Amount of food at each feeding. Total amount in 24 hours. 1st week . . . 2 murs. 10 1 oz. 10 OZS. 2d to 4th week . 2 n 9 1| ozs. 13^ " 2d to 3d mouth . 3 u 6 3 " 18 " 3d to 4th month 3 u 6 4 " 24 " 4th to 5th month 3 u 6 4-4^ " 24-27 " Gth month . . 3 t< 0 5 " 30 " 8th month . . 3 U 6 6 « 36 " 10th month . . 3 u 5 8 " 40 " The difference in chemical composition and reaction may be removed by diluting the whole to reduce the casein, adding fat 54 OBSTETRICAL LECTURES. and sugar, and making alkaline. The microbe infection of cows' milk may be obviated by sterilization. The following formula accomnlishes these purposes :— To Make 2 Ounces. 1. Have ten bottles prepared clean every morning. 2. Put in each of them, through a clean glass funnel: Cream......dr. iv. Milk......dr. ij. Water......oz. j. Milk sugar.....gr. 1. [One measure.] 3. Stopper the mouth of each bottle with dry baked cotton, and sterilize for twenty minutes. 4. Set aside to cool. 5. Add lime-water, dr. ij. to each bottle before use. 6. Apply a plain rubber nipple to the bottle. 7. Warm to blood-heat in warming-cup. Sterilization is accomplished by exposure to steam heat in a closed vessel. The Arnold's steam cooker is the best apparatus for the purpose. Clinical experience has shown that milk sterilized by steam loses its nutritive qualities, so that a certain proportion of infants will not thrive upon it. This difficulty can be obviated to some extent by the predigestion of the milk before sterilization, as in the following formula:— 1. Have ten nursing-bottles prepared clean every morning. 2. Take Cream......5 ozs. Milk......2£ ozs. 3. Put in skillet; add pancreatin powder ; heat over alcohol flame for six minutes ; stir and sip constantly ; do not overheat. 4. Of this mixture, put in each bottle 6 drs. (to make 2-oz. bottle). Use funnel. 5. Add to each bottle 10 drs. sugar solution. 6. Stopper the mouth of each bottle with dry, baked cotton, and sterilize for twentv minutes. MANAGEMENT OF NEWBORN INFANT. 55 7. Set aside to cool. 8. Before use, put bottle in warming-cup; apply nipple im- mediately before giving it to infant. Make sugar solution by dissolving 1 oz. sugar of milk (1 pow* dcr) in a pint of warm water. The pancreatin powder, for the quantity indicated on the card, consists of— fy Pancreatin . . . . 2£ grs. Bicarbonate of sodium . . 5 grs. The sodium salt furnishes the alkalinity desired, so that lime- water may be dispensed with. The disadvantages of steam sterilization may be still further obviated by the so-called Pasteurization of the milk mixture. Make up whole quantity by preceding formula and stir in the pancreatin powder, if predigestion is considered desirable. Divide among the bottles to be used in 24 hours. Set these in a receptacle, pour in boiling water till it reaches the level of the milk in the bottles, put on a cover and set aside for 30 minutes to cool. Then put the bottles on ice till they are used. This raises the temperature of the milk to 150°+, which prac- tically sterilizes it without impairing its nutritive value. Condensed Milk. It is possible to obtain a chemical imitation of human milk which is practically sterile, not impaired in nutritive qualities, and which at the same time is easily prepared as follows :— Condensed milk ... 1 part. Water (boiled) ... 10 parts. Cream, 1 drachm to the ounce of the mixture. Milk is condensed in vacuo at a comparatively low tempera- ture. Condensed Milk Analysis. Moisture.....24-25 Fat..... 9.5-10.5 Nitrogenous matter 11.5-12.5 Milk sugar . 11-13 Cane sugar 39-40 22 56 OBSTETRICAL LECTURES. This analysis shows the necessity of diluting in the proportion of 1 to 10 to reduce the casein percentage. When thus diluted it is too poor in fat; hence the addition of the cream, which, by the following analysis, is seen to contain 13 per cent, or more of fat:— Cream Analysis (Meigs). Water . . 79.122 Fat . 13.362 Casein . . 2.919 Sugar . . 4.140 Ash . 0.457 Cleansing. Daily bath in the middle of the day in the warmest part of the room. Temperature of water 90P-{-. Castile soap and soft sponge. Airing. In summer the baby may be taken out after the second month. In winter after the third month, for a few minutes about noon, although each baby is a law unto itself in this respect. Resting Place. Preferably a crib. Pathology of Newborn Infant. INJURIES TO INFANT DURING LABOR. Classified according to seat of injury. 1. Brain. The injury is most frequently the result of faulty use of for- ceps or extraction of after-coming head. It may be (ct) a men- ingeal hemorrhage, varying in extent from rupture of a small vessel to longitudinal sinus. If lesser in degree, the child may live to adult age, but is apt to have paralysis or mental impair- PATHOLOGY OF NEWBORN INFANT. 57 ment. (b) The brain substance may be crushed, (c) Injuries not so grave, hut affecting intellectual or physical centres, and the subse- qurut mental or physical development of the individual, (d) Com- pression—causing asphyxia. 2. Peripheral Nerves, Facial and brachial plexuses most frequently damaged. The majority of cases of facial hemiplegia due to faulty use of forceps. Recovery usually in the course of a week. Should this fail to occur, the faradic current may be used with advantage. The brachial palsies result from unskilled attempts at extracting the shoulders, and are more likely to be permanent. 3. Skull. (a) Spoon-shaped Depressions of Parietal Bone.—A prominent promontory or forceps may cause them. [b) Fractures.—Require an antiseptic dressing. Recovery sometimes occurs. (c) Distortion.—Very common. Result of different presenta- tions and positions. Disappears within the first three days. 4. Scalp. [a) Caput Succedaneum.—A serous infiltration of that portion of the presenting part corresponding to external os. Disappears in three days and requires no treatment. (b) Cephedo-hcematoma.—A more dangerous condition, and to be distinguished from the above. Occurs about once in two hundred cases. Two or three days after birth, usually, a swell- ing develops, rapidly increasing in size, with signs of a cystic tumor, distinctly confined to boundary of one of the cranial hones. It may be bilateral, may occupy the parietal and occipital bones, and may occur before birth. It is due to a subpcricranial hemorrhage, giving rise to a bony sensation at the lifted edges of the pericranium and later a peculiar crack- lin<>- or crepitus. Non-interference is the treatment, except when the hemorrhage is excessive or suppuration occurs. The former may be controlled by pressure and cold ; the latter requires in- cision and drainage under strict antisepsis. (c) Contused and lacerated ivounds. 58 OBSTETRICAL LECTURES. (d) Sloughs.—The vitality of the scalp may be destroyed by forceps or prolonged pressure, and sloughs appear in a few days. Require ordinary surgical treatment. 5. Face. Caput succedaneum may form. Eyes and mouth may be injured by careless examinations or extraction of after-coming head. The former may be injured by the forceps. The globes may be luxated to complete exophthalmos: the recti muscles maybe permanently paralyzed; there may be subconjunctival or pal- pebral ecchymoses, (edema of the lids and temporary ptosis; fracture in the roof of the orbit; exudation of blood into the anterior chamber. 6. Neck. (a) Injury and thrombus of muscles, with reactive inflammation. most frequently of sterno-cleido-mastoid, with the development <>f torticollis. Usually recovers without treatment. lb) Fracture, dislocedvni or dec a j Motion. 7. Limbs. Fractures, which are usually a separation of diaphysis and epiphysis, requiring surgical fixation and extension. Union is prompt. They are usually the result of faulty management o'i the physician's part, but may be spontaneous. Avulsion ( f the limbs sometimes occurs in efforts to extract a premature or macerated foetus. 8. Trunk. Perforations of the groin and perineum may occur, as result of use of blunt hook or forceps applied to breech. There may be rupture of some important viscus, like the spleen or liver, with fatal hemorrhage into the peritoneal cavity, especially in syphilitic children. Or visceral hemorrhage may occur with- out actual rupture, but to a sufficient degree to abrogate the functions of the organ. Fracture of the clavicle in extracting the after-coming head may result in the puncture of the lung by the broken end of the hone and fatal emphysema. The kidney, spleen, and liver have been ruptured in attempts to PATHOLOGY OF NEWBORN INFANT. 59 extract the breech. Subcapsular hemorrhages in these organs are observed quite frequently. In the pleura there are often ecchymotic spots in asphyxiated children, with minute but multiple extravasations in lungs and brain. 9. Bowel. The large bowel may rupture, from pre-existing ulceration, usually at the sigmoid. ASPHYXIA. Asphyxia of the newborn child results in consequence of an insufficient supply of oxygen. Physiology of the Institution of Respiration.—The sudden change in its environment (liquid 99° to air 70°) produces an exagge- rated stimulation of all muscles to reflex action. Placental respiration is abolished, and the accumulated C0.2 primarily stimulates, finally paralyzes the respiratory centre. Causes:— (a) Intrauterine. 1. Foetal inspiration. 2. Any interference with placental respiration paralyzing the brain centres, as premature detachment of placenta; coiling, compression or prolapse of the cord ; diminution of the calibre of the umbilical vessels, as from syphilitic periphlebitis; ex- cessive and prolonged uterine contraction. 3. Prolonged pressure on foetal brain by pelvis or forceps, para- lyzing brain centres. • 4. Grave systemic diseases of the mother, including hemor- rhage, uterine or pulmonary. 5. Immature development of the infant. 6. Anomalies or diseases of the foetus preventing the entrance of air into the respiratory tract, or preventing the proper distri- bution of blood from right ventricle to lungs, as a patulous fora- men ovale or atresia of the pulmonary artery. (b) Extrauterine. 1. Placing the infant after birth in a position unfavorable for respiration. 60 OBSTETRICAL LECTURES. 2. Precipitate labor. Probably by producing premature sep- aration of a portion of the placenta. 3. Interference with the access of air to respiratory passages, as by a caul, unruptured membranes, or maternal discharges. Varieties:— (a) Livida. Accumulation of C02 is excessive, yet circulation and reflexes are preserved. Prognosis favorable. (b) Pallida. Usually an advanced stage of the former, char- acterized by weakness of the heart and slowing of its pulsations to a marked degree and abolition of reflexes. Prognosis unfavor- able. Treatment.—If possible, should be prevented by removing the cause. 1. Extraction of mucus from throat and fauces by holding the child by the feet and cleaning the mouth with finger. 2. Application of an exaggerated stimulus, as slapping, rub- bing, immersing in warm water, and pouring ice-water on epi- gastrium ; electricity, if at hand preferably faradic, one pole being placed on epigastrium and the brush applied down the sternum, flanks, and thighs. In the pallid variety only the most powerful of these are useful. 3. Artificial respiration. (a) Sylvester's method. (Not recommended.) (6) Marshall Hall's modified to suit the requirements of the newborn infant by suspending in a towel, and thus rolling it from side to side. (c) Schultze's. (Probably the best.) The infant should be wrapped in a towel to protect it from being chilled, and after practising the swinging movements fifteen to twenty times, it should be immersed in warm water to bring up the temperature when the movements may be repeated. (d) Mouth-to-mouth insufflation. Secure exit of air by hold- ing the infant with the head extended, and after inflating the lungs flex the head and compress the chest. Do not hold the nose to prevent the escape of air, as sometimes advised. The air-vesicles are not so likely to be damaged. (e) Catheterization of larynx with soft catheter. DISEASES OF THE NEWBORN INFANT. 61 (/) As a last resort tracheotomy and catheterization through the wound. Only required in most exceptional cases. Risks Attending Artificial Respiration.—Injuries, as apoplexies ; Schultze's method may injure the spine ; hemorrhagic effusions in the pleura? and lungs ; rupture of the air-vesicles in insuffla- tion ; trachea and larynx may be injured. Lung may be punc- tured if the clavicle is broken. DISEASES OF THE NEWBORN INFANT I. Diseases of the Lungs. 1. Atelectasis. 2. Syphilis of the Lung. 3. Septic Infection. 4. Tuberculosis. 5. Pneumonia. 0. Pulmonary Apoplexy. 1. Atelectasis. Cause.— Not known. Sometimes obstruction to entrance of air, as by an enlarged thymus, clot of blood, curd of milk, etc. Diagnosis.—Usually not made. Dullness on percussion usually on one side. Respiration slightly accelerated and imperfect. Absence of fever. These signs present at birth. Pathological Anatomy.—One lung is found shriveled up, is not crepitant, and sinks when placed in water. Prognosis. —Not necessarily grave. Treatment.—If the diagnosis is made, gentle sufHation of lung with catheter might be made. 2. Syphilis of the Lung.—The diagnosis can be made by a his- tory of syphilis in the parents, by the signs of foetal syphilis together with the cyanosis and physical signs of pneumonia. The temperature is very low, necessitating the use of an incu- bator. Treatment is of no avail, the child usually dying within 24-36 hours. Pathological Auedomy.—An enormous overgrowth of connec- tive tissue is fouud, compressing the bloodvessels and diminish- 62 OBSTETRICAL LECTURES. ing the capacity of the air-vesicles. As some air has entered the lung, a cut-off portion.never sinks, but does not float buoy- antly. The " white pneumonia " of syphilitic infants is rare. It is the result of proliferation, desquamation, and fatty degen- eration of the epithelial cells in the lungs, giving the latter a white appearance, and distending them so that the thoracic cavity is well filled out and the lungs bear the imprint of the ribs. Respiration is impossible. 3. Septic Infection.—liare since the introduction of antisepsis, Results from the inspiration of septic matter. 4. Tuberculosis. —Caused by mouth to mouth respiration by a tuberculous person. Very rare. 5. Pneumonia— Is caused by the inspiration of maternal dis- charges, resulting from intrauterine respiratory efforts when asphyxia is threatened. Pneumonia arising from this cause develops twenty-four hours after birth, in a child apparently healthy, temperature at this time beginning to rise and respirations growing more rapid. Cough, although a variable symptom, is often incessant. The child is restless, refuses nipple, is cyanotic, at times gasps for breath, and there may be dullness over one or both lungs. The diagnosis cannot always be made by the physical signs ; only a small patch may be involved. There is usually a history of dystocia. When a newborn infant has a high temperature. septic infection or pneumonia should be suspected, and when in doubt treat as for the latter. Prognosis.—Grave. Recovery or death in a few days. Treatment.—^ to 1 gr. carbonate of ammonium in gss — 3j muci- lage of acacia every four hours. Tinct. digitalis, drop doses every two or four hours. Mustard bath once, twice, or thrice daily.* Cotton jacket. Mother's milk, from medicine dropper, every hour, and with this a few drops of brandy every two or three hours. Patholocjical Anatomy.— Shows the features of catarrhal pneu- * The bath is made as follows : Three large pitchersful of water 100° F., and a tablespoonful of mustard ; allow the child to remain in the bath for five minutes, or until the temperature of the latter falls to 95°, when the infant should be removed to a warmed blanket. DISEASES OF THE NEWBORN INFANT. 63 monia. A cut-off portion always sinks (thus distinguished from syphilis of the lung). 6. Pulmonary Apoplexy.—This is a rare accident in young in- fants, the result of severe straining in crying or coughing. There is haemoptysis, the quantity of blood usually not very great. II. Syphilis of Newborn Infant. Symptoms. —The child is often ill-developed and ill-nurtured, but the characteristic signs do not usually develop before four to six weeks. In order of frequency these signs are— Coryza syphilitica. The discharges are very irritating to the upper lip, and frequently produce crusts and even ulcera- tion. Maculo-papular syphilide. Roseola. Especially marked on the heels. Cutaneous papules and mucous tubercles. Rhagades oris et ani. Pemphigus. Cutaneous ulcers. Paronychias. Pseudo-paralyses of extremities. Due to infirm connection between diaphysis and epiphysis or to painful periostitis, which inhibits motion. Hemorrhagic diathesis. Bone diseases. Fever. Disease of testicles. Enlarged from overgrowth of connective tissue. Treatment. — Best results from internal use of calomel with chalk or soda, T\ grain given twice a day, gradually increasing the dose. Should vomiting or diarrhoea occur, resort to inunc- tion, rubbing a piece of mercurial ointment as large as end of finger on binder every other day. Always carefully watch for poisoning. This treatment should be kept up for months, replacing it from time to time by tonics or drop doses of the syrup ferri iodidi. Prognosis. - If the child is well nourished by its mother or wet 64 OBSTETRICAL LECTURES. nurse, the prognosis is very good, so long as some important in- ternal organ is not seriously affected. In artificially fed children it is very bad. The wet nurse is liable to be infected, and she should not be ignorant of her danger. III. Mastitis. Four days after birth the breasts in both sexes contain colos- trum, which has disappeared by the twentieth day. During this period there may occur in the breast of the child patholo- gical processes like those in the breast of the puerpera. They can enlarge, become painful, the skin angry red, secretion much increased, and even mammary abscess develop. Treatment.—Avoid squeezing. Apply cooling lotions, as lead- water and laudanum, and oil the skin to relieve tension. If suppuration supervene, poultice and open early. IV. Specific or Essential Fevers. (a) Exanthemata. The infant may exhibit the exanthema at birth or take the disease subsequently. Treatment is the same as under other circumstances. (b) Erysipelas. (c) Malaria. (d) Septicaemia. Infection occurs through umbilicus. The most important treatment is prevention (see Diseases of Umbili- cus) ; usually occurs in the first two weeks of life ; may develop as late as the fourth. V. Treatment of Certain Congenital Deformities. Hare-lip.— The deformity prevents suckling ; hence immediate plastic operation in the first few hours of life. Cleft-palate.—Too serious an operation to be undertaken at this time. Supernumerary Digits.—Contain rudimentary bone. Ligature and snip off. Tongue-tie.— Snip superficially with scissors and tear with fingers. Umbilical Hernia.—There are two varieties : (a) A knuckle of intestine covered by skin, occurring in two per cent, of babies DISEASES OF THE NEWBORN INFANT. 65 and treated by a convex button, cork, or hard rubber compress on a strip of adhesive plaster, (b) An exomphalic condition due to defective development, the intestines covered by amnion. If the exomphalic condition be even the size of an apple, an imme- diate plastic operation is indicated. Spina Bifida.—To be distinguished from the less serious con- ditions—fibroma, myxoma, or lipoma of buttocks, and from parasitic growth by inclusion. In spina bifida a hardened patch is found at the prominence of the tumor due to the attachment at that point of the cauda equina. Treatment.—Lay the tumor open, dissect out the sac, make traction upon the latter, when the cauda equina will retreat into the canal; ligate with cat-gut the pedicle formed and accurately close up the wound with buried cat-gut sutures under strict antisepsis. Imperforate Rectum.—Examine the anus and rectum imme- diately after birth in all cases. To avoid the danger of faecal accumulation inguinal or lumbar colotomy should be per- formed. In simple cases a cruciform incision over the imper- forate anus is sufficient to open the rectum. The mucous membrane is then stitched to the skin. VI. Nasal Catarrh. Causes.—When not syphilitic, usually faulty clothing, ventila- tion or temperature of the room. VII. Diseases of the Mouth. (a) Aphthec— Rounded, pearl-colored vesicles seen in mouth and on lips. Washing the mouth daily with a clean linen will prevent them. Boric acid, gr. v-x to the ounce, is curative. (b) Thrush.—Coalescence of white spots, with an areola of reddened mucous membrane. Is often seen in hospital practice. Now thought to be due to the presence of a parasite, the sac- charomyces albicans. Treatment.-Boric acid, gr. xvj to xx to 3j of honey. 3ss of this three or four times a day. The associated symptoms of malnutrition, diarrhoea and vomiting indicate attention to hygi- enic surrouudings and the general health of the child, 5 66 OBSTETRICAL LECTURES. (c) Gonorrhceal Stomatitis.—A violent inflammation of oral mucous membrane due to gonococcus. Cleanliness and mild disinfection of the mouth will effect a cure. (d) Sublingual Cysts.—Probably from occlusion of duct of a submaxillary gland. Appears in the first few days after birth, and may reach such a size as to displace the tongue and to in- terfere with sucking. Treatment—puncture. VIII. Colic. Diarrhoea. Constipation. (a) Colic.—Attention to diet. One grain of pepsin may be given in 3j of hot water, and a few drops of brandy or gin. Milk of assafeetida gtt. xx-xl, or soda mint 3j, may be used, and a spice plaster applied to the abdomen. (6) Diarrhoea.— Attention to diet. Frequent movements may be checked with the following :— $. Acid sulphuric aromat. Tinct. opii camph,, aa, gtt. iv. (c) Constipation.—In acute cases a dose of castor oil (;5j), the soap stick, a glycerine suppository or injection (gtt. xv-xx in 3j of water), or the following may be used :— I£ Calcined magnesia, Sugar of milk, aa gr. viiss. For chronic constipation the daily injection of warm soap suds (f.^ij) through a funnel and catheter or soft-bulb rubber ear syringe, are least harmful. IX. Skin Diseases. (a) Gum, due to the irritation of atmosphere and clothing. Is a papular eruption resembling acne, but never becoming pus- tular. Treatment.—Cleanliness, cosmoline, and proper clothing. (b) Simple Acute Pemphigus.—Rare. From the second day to the fourth, fifth or sixth week, vesicles the size of a pea to a quarter- or half-dollar appear indifferently over the whole body except soles and palms, and last from twelve to fourteen days, without manifestation of constitutional disturbance. Is contagious ; may be carried by nurse, and may be commu- DISEASES OF THE NEWBORN INFANT. 67 nicated to mother or nurse. It disappears without treatment. The specific microbe, it is claimed, has been discovered. (c) Syphilitic Pemphigus.— Usually occurs in utero, and the child is born with vesicles, the soles and palms most often affected. The disease is associated with marked evidences of malnutrition and constitutional disturbance, and yields only to specific treatment. X. Ophthalmia Neonatorum. Symptoms.—Usually after twenty-four to forty-eight hours the eyes are oedematous and puffed out, and there appears a sero- purulent discharge, which is soon greenish pus. If the lids can be separated, the conjunctivae are red and velvet-like in appear- ance, and later the cornea may lose its epithelium,.ulcerate, and be perforated. Treatment.—(a) Prophylactic. Crede method. As soon as head is born warm water is dropped in the eyes. When the delivery is completed the eyes are again cleansed with warm water, followed by one or two drops of a ten-grain solution of nitrate of silver. A vaginal douche of bichloride is not always effective, because the cervix is not reached. There is danger of poisoning or sending air into the uterine veins if the cervix be injected. (b) Curative.—The eyes are cleansed every hour, alternating with a concentrated solution of boric acid and bichloride of mer- cury, 1 to 5000 or 8000. Morning and evening, nitrate of silver, 20 grains to the ounce, is dropped in the eye. If only one eye be affected, bandage the other carefully with a pledget of lint to protect it. The mouth, the nose, and the ears of a new-born infant may be the seat of inflammation from gonorrhceal infec- tion. XI. Hemophilia. A disposition to bleed, which is inherited. The manner of transmission is peculiar-, always through mother to male children, who do not transmit it. The female children show no evidences of it, but do transmit it. The cause is not known, and it manifests itself all through life. Treatment is of no avail. It 68 OBSTETRICAL LECTURES. should be remembered that a hemorrhagic diathesis is sometimes due to syphilis, and in such cases specific treatment is of value. XII. Icterus. Two classes of cases :— (a) Jaundice very light in degree. Face and breast only affected. Very common. Cause,—Hepatogenic. The very small common biliary duct fails to empty into the bowel the excess of bile produced by the liver. (See page 47.) Disappears third or fourth day after birth, and usually requires no treatment. Fractional doses of calomel may be given. (b) Whole hody is jaundiced. Urine and feces discolored and may contain blood. Is rare. Cause.—Hepatogenic. Is also seen in Buhl's and Winckel's diseases, in septic infection, producing disintegration of the blood, in atresia of the bile duct, and polycystic disease. Prognosis of malignant variety.- If from Buhl's or Winckel's diseases, or from septic infection, as is commonly the case, is usually fatal. XIII. Cyanosis. Causes, in order of frequency: Pneumonia (often syphilitic), premature birth, asphyxia, atelectasis, degeneration of the blood, malformation of heart and bloodvessels, interference with nerves of respiration, malformations of respiratory tract, congenital pleurisy, partial occlusion of trachea. XIV. Congenital Heart Affections. From intra-uterine endocarditis, as stenosis of right and left auriculo-ventricular orifices, stenosis of aortic and pulmonary orifices. From defective development, as patency of foramen ovale, atresia of the pulmonary artery, stenosis of the conns arteri- osus, defects in the ventricular septum. DISEASES OF THE NEWBORN INFANT. 69 XV. Diseases of Umbilicus. (a) Septic Infection.—The ulcer is covered with a grayish diphtheritic membrane, has a reddened areola, and may lead to general infection. An acute, high fever in a new-born infant suggests septic infection or pneumonia. The latter may be septic. Treatment—Prophylactic — The ulcer should be exposed at the daily bath, cleaned with soap and water, and dressed with salicylic acid, 1 part; starch, 5 parts. Tape, soaked in an ethereal solution of iodoform or antiseptic Chinese silk, should be used to ligate the cord at birth. Curative.—The ulcer to be touched with solution of bichloride (1 to 500), and dressed as above. (b) Umbilical Fungus.— An overgrowth of granulations. Cau- terize with nitrate of silver. In about one-fifth of these cases nitrate of silver fails, the tumor is more solid, and is the remains of the omphalic duct called an enteroteratoma. It should be ligated and cut off. The cord may persist unchanged or a spur of well-organized connective tissue may project from the um- bilicus. (c) Omphalitis.—A peculiar inflammation of the umbilicus, in which the abdomen is conical, skin and subcutaneous con- nective tissue hard, red, and infiltrated. It is always septic in origin, requires disinfection, poultices, and early incisions, with stimulants and nourishment. A later stage is gangrene. Prog- nosis is serious. (d) Disease of Fes-seta—Always due to septic infection, and invariably ends in general septicaemia, which is fatal. (e) Hemorrhage (Omphalorrhagia).—From the cord or umbili- cal ulcer. It may be primary from careless ligation of the cord; or secondary, after the cord drops off (the vessels of the cord close from placental end, and the hypogastric arteries may be patulous after the cord drops off, when increased blood pressure or han- dling the ulcer may bring on hemorrhage). Mortality, 70-83 per cent. Treatment. — Re-ligate the cord. In bleeding from the um- bilical stump, if bleeding vessel seen, ligate. Usually requires 70 OBSTETRICAL LECTURES. Monsel solution and pressure, liquid plaster of Paris, or suc- cessive layers of bismuth with gauze and collodion. As a last resort, transfix with hare-lip pins or ordinary large size needles, and apply figure-of-eight ligature. If there is enough stump of the cord, draw it out and transfix with two pins or needles and ligate below them; if this is impossible, the pin should transfix the abdominal wall just below the umbilicus, so as to occlude the hypogastric arteries. Should the hemor- rhage continue, it can be controlled by a pin above the umbil- icus to occlude the umbilical vein. XVI. Tetanus. Is infectious, the poison entering through umbilicus. Occurs almost exclusively in hospitals, and is usually fatal. The treat- ment should always include a thorough disinfection of the navel. XVII. Melaena. An extravasation of blood into stomach and intestines, occur- ring most often in the first few hours of life. Duodenal ulcer, some congenital defect increasing intra-abdominal blood pres- sure, or hemophilia may be the cause. To be distinguished from vomiting of blood due to a fissured nipple. Treatment.- Gallic acid, gr. ij every hour. Ergot hypoder- matically, ice-bag to stomach, hot bottles to thighs. Mortality 50 per cent. XVIII. Perforation of Intestines and Intussusception. The former are situated at the flexures of the large bowel (sigmoid, splenic, hepatic), due to pressure necrosis resulting from accumulation of meconium. Post-mortem intussusception should be borne in mind as more common than in the adult. XIX. Buhl's Disease. Parenchymatous inflammation with acute fatty degeneration of all organs. Symptoms.— Icterus, cyanosis, diarrhoea, vomiting, etc. are DISEASES OF THE NEWBORN INFANT. 71 present, but nothing sufficiently characteristic to make a diag- nosis before death. XX. Winckel's Disease. Acute hsemoglobinuria with jaundice, cyanosis, and fatty de- generation of all organs caused by a micro-organism. These two diseases are probably rare and peculiar manifesta- tions of septic infection perhaps due to the reception of a large dose of poison directly into the blood through the umbilical vein. XXI. (Edema Neonatorum. This affection is always due to kidney insufficiency and is in- variably fatal. XXII. Bloody Discharge from Genitalia of Female Children. Not very rare. Perhaps analogous to breast changes in the newborn. The condition is not dangerous and requires no treatment. The blood conies from the uterus, like the menstrual discharges. Appears three or four days after birth and lasts only a few days. XXIII. Sudden Death of Apparently Well Children. Causes.-(a) Overlying by mothers, accidentally or intention- ally. (b) Diseases: most commonly pneumonias, apoplexies, more rarely perforation, intussusception, rupture of large viscus, or oilier diseases, as above. (<■) Occlusion of trachea by enlarged thymus or by curds of milk. Medication. The following are some of the drugs and their doses required in the first four weeks of life. Opium, as paregoric 2-5 gtt., laudanum ±-$ gtt., mercury, as calomel ^-i gr., castor oil 15 gtt. to 3j, nitrate of silver & grain, pepsin gr. j-ij, gallic acid gr. ss.-ij., etc OBSTETRICAL LECTURES. Pathology of the Puerperal State. I. Abnormalities of Involution. These may be anomalies by (A) excess, superinvolution, (B) by defect, subinvolution. Involution.—The old theory was that by fatty degeneration and absorption the uterus was regenerated from the embryonal muscle cells in the outer layer. This has been disproved. The degeneration is chiefly fatty, but there are other degenerative processes at the same time. Regeneration is not absolute, i. e., the whole muscle cell is not destroyed, but loses its redundant tissue. The process is rather an atrophy, and stops after the muscle fibre reaches its original size. This same process affects the mucous membrane, peritoneum, uterine annexa, vagina and vulvae. Below the contraction ring it is an intermediate pro- cess, mainly retraction of overstretched tissue. (A) Superinvohdion.—An exaggeration or abnormal prolonga- tion of that process by which the parturient uterus regains its normal conditions. Is rare. Its diagnosis and treatment be- long to Gynaecology. (B) Subinvolution.—A retarded or arrested involution. Causes.—(a) Anything increasing blood supply, as hypertrophy of mucous membrane during pregnancy, fibroids, inflammatory conditions resulting from sepsis, mechanical interference with pelvic circulation, leading to its engorgement, as heart disease, premature getting up, premature resumption of sexual inter- course. (6) Anything interfering with contraction of uterine muscle, as retained placenta, polypoid tumors, large masses of decidual tissue, uterine displacements, distended bladder or rectum, dragging adhesions. The cause is always a local one, i. e., typhoid, pneumonia or other diseases occurring during the puer- perium have no influence in retarding involution. Diagnosis.—Abdominal palpation in the early stages discloses abnormalities in the daily diminution in size of the uterus. Later there is a history of the continuance of the bloody lochia. 1st day, normally, the fundus one finger above umbilicus. PATHOLOGY OF THE PI KRPERAL STATE. 73 2d day, the fundus level with navel. 3d and 4th day, the fundus a trifle below navel. 5th and 6th day, the fundus two fingers below navel. 7th, 8th, and 9th day, the fundus three to four fingers above symphysis. 10th, 11th, and 12th day, the fundus a little above, at, or below symphysis. Involution is not complete for six weeks, and to determine the size of the uterus subsequent to its retraction below the sym- physis (12th day), the following intrauterine measurements have been made:— 10th day . . . 10£ cm. 5th week ... 7^ cm. 15th " ... 9.9 " 6th " ... 7^" 3d week ... 8.8 " 8th u ... 6,'„ " 4th " . . . 8 " 10th and 12th week 6£ " 7 cm. is the normal measurement of the non-pregnant uterus, and this table shows, therefore, a physiological super-involution which is overcome by subsequent engorgement of uterine vessels. An examination should always be made on the fourteenth day, when the patient is about to get up. Return of the bloody lochia for a day or two is common, but prolonged beyond this time it indicates subinvolution associated very likely with a displacement. Treatment.—Varies with the cause. If due to hypertrophied deciduae, polypoids, retention of placenta or placentae succen- turiatae—curette, placental forceps and fingers. Never allow bladder to be distended nor constipation to exist. Correct dis- placements, combat septic inflammation, treat any heart dis- ease, and if fibroids or general lack of tonicity be the cause, give a pill of ergotin (gr. j), strychnia (gr. ^ff),and quinia (gr. ij), and administer faralism daily. The routine administration of ergot not recommended. It does not secure contraction, and often lias an ill effect upon the child through the mother's milk. II. Acute Tympanites. Relieved by injections of assafuetida; turpentine by the mouth ; pressure by firm binder from trochanter to ribs; rectal 74 OBSTETRICAL LECTURES. bougie. The large intestine may be punctured as a last resort. Sometimes there is complete paralysis of the coats of the bowels and enormous distension, with persistent vomiting and obstinate constipation, the symptoms resembling those of in- testinal obstruction. Large doses of strychnia, hypodermatic- ally, are indicated ; puncture of the bowel or abdominal section, and evacuation of the intestines at several points. III. Puerperal Anemia. A subinvolution of the blood. The physiological hydremia of pregnancy fails to disappear. Causes.— Any wasting or depressing disease, loss of blood from post-partum or other hemorrhages, cancer, puerperal chorea, or insanity. Prognosis. — Yields usually to timely treatment. May pro- gress to pernicious anemia if neglected. Treednunt. — Iron (Blaud's pill). Arsenic seems to be needed in some cases. IV. Repair of Injuries after Labor, Slight lacerations and tears heal rapidly. Even extensive injuries, as fistulfe, sometimes heal spontaneously. .Small sloughs should be touched with nitric acid to promote granula- tions which may close the opening. If this fails, a fistula be- tween the vagina or uterus and bladder, rectum, sigmoid flex- ure, or higher bowel remains to be dealt with by a secondary operation. Laceration of the cervix, if productive of serious hemorrhage, should be closed by suture. Always stitch a laceration of the perineum when beyond a half-inch in length, being careful to apply sutures, so that fistulaa may not result. When the perineum has been torn, a douche is given after delivery of the placenta, and ab- sorbent cotton soaked in 4 per cent, solution of cocaine', although not necessary, may be placed in the vagina, while the doctor prepares his instruments to repair the injury. If the sphincter has been torn, the two edges are united by interrupted sutures. Vaginal tears are often situated in the line of one or the other sulci, usually sparing the posterior column, and PATHOLOGY OF THE PUERPERAL STATE. 75 are best united with a curved needle and three sutures of silk- worm gut. The first stitch is passed in a manner somewhat similar to the crown suture in Emmet's operation. It is in- troduced laterally on a level with the lowest myrtiform car- uncle, buried under the tissues and emerges, crossing high up the laceration in the lateral sulcus where it is visible. It then disappears under the posterior column of the vagina, reappears traversing the tear in the other lateral sulcus, is again buried and merges at the vaginal orifice directly opposite the original point of entrance. The other two sutures unite superficially the edges of the torn perineum which the first suture has ap- proximated. If there has been extensive abrasion of the mucous mem- brane in consequence of the passage of the head, or extensive ulceration in the puerperium, the raw surfaces may unite, thus producing partial or complete atresia of the lower genital tract. Any of these injuries will produce an immediate elevation of temperature after labor above the normal rise. V. Puerperal Hemorrhages. Hemorrhages occurring during the puerperium, from 24 hours after labor until the completion of involution (6 weeks). Hem- orrhage is called post-partum when it occurs within the first 24 hours after labor. Causes, in Order of Frequency:— (a) Retained Secundines. (6) Displaced Uterus. (c) Displaced Thrombi. (d) Emotion. (e) Relaxation of Uterus. (/) Retained Clots. ('> Preventive Treatment of Infectious Puerperal Fever. Secure absolute cleanliness of doctor, nurse, patient, instru- ments, atmosphere, etc. Hands. — Washed with soap and water followed by immersion in alcohol and solution of bichloride 1 to 1000. Instruments.—2 per cent, solution creolin, 5 per cent, carbolic solution or boiling water. In hospital work the bedding should be washed in bichloride solution, and the patient given a bath just before labor. Atmosphere. — Selection of well-ventilated room is important. Use occlusive dressing of corrosive cotton and gauze, which should be changed frequently. External Genitals. — Cleaned when each pad is applied, never using a sponge, but preferably baked cotton, or corrosive jute. Guard the patient from other infectious fever, i. e., the physician should not go direct from an infectious disease, as scarlet fever, to an obstetric case. II. Non-infectious Fevers. The temperature of women during the puerperium is very variable, and easily influenced by causes which in health would have no effect. Non-infectious puerperal fever may be due to :— (a) Emotion. (b) Exposure to cold and consequent internal congestion, especially of breasts and abdomen. (c) Constipation. (d) Reflex irritation. The irritation may have its source in an inflamed mammary gland or nipple ; it has been a tape-worm, and perforation of the uterus by a curette. (e) Cerebral diseases. Hemorrhage or embolism. (/) Eclampsia. (g) Insolation. (h) Syphilis. (i) Exacerbations of acute or chronic diseases contracted dur- ing or before pregnancy. Influence ef Child-bearing upon Phthisis.—The laity believe it 96 OBSTETRICAL LECTURES. to be favorable. This is not the fact. Pregnancy, the puerperal state, and lactation are a drain on woman's strength, and can cause the development of phthisis in those predisposed to it. If already present, the symptoms are exacerbated. Primary tuberculosis of the uterus, developing during the puerperium, has been noted. SYLLABUS OF OBSTETRIC LECTURES. LECTURES TO THE COMBINED CLASSES. PART II. Anatomy of the Pelvis Obstetrically Considered, The false pelvis is that expanded portion situated above the ilio-pectineal line. The true pelvis is that part of the cavity beneath the ilio-pecti- neal line. I. Position. The obliquity to the horizon in the erect posture is 55° at the superior strait, 10° at the inferior strait. II. Shape. The false is irregularly funnel-shaped, exerts no special influ- ence on the course of labor, and is accessory to the true, serving to direct the presenting part into the true. The true is similar to a truncated cylinder, five inches in depth behind, one and a half in front, and three and a half laterally. The shape of the inlet or superior strait is most frequently cordiform. May be circular or elliptical. The shape of the cavity is irregularly circular, and the outlet or inferior strait is cordiform. III. Size. (a) Inlet.—The antero-posterior or conjugate diameter, measured from the upper edge of the promontory of the sacrum to a point 7 (97) 98 OBSTETRICAL LECTURES. an eighth of an inch below the upper border of the symphysis, is 11 cm. The transverse, the longest possible transverse distance, is 13| cm. The oblique, from upper edge of one sacro-iliac junc- tion to opposite ilio-pectineal eminence, is 12| cm. (b) Cavity. —The plane of pelvic expansion perforates the middle of the symphysis, tops of acetabula, and the sacrum between the second and third vertebrse. Diameters : anteroposterior 12| cm.; transverse 12£ cm. The plane of pelvic contraction passes through tip of sacrum, spines of ischia, and under surface of symphysis. Diameters : antero-posterior 11£ cm. ; transverse 10^ cm. (c) Outlet.—Antero-posterior 9^ cm. ; transverse 11 cm. IV. Direction of Pelvic Canal. Represented by a curved line parallel to concave surface of sacrum, and equally distant from sides of pelvis. Development of Adult Pelvis.—The foetal pelvis represents a funnel, and the development of the irregularities and peculiari- ties of the adult pelvis may be accounted for by three factors, viz. :— (a) Weight of the body, (b) counter-pressure of the femora, (c) force exerted by the ligaments. The sacral curve and lateral aspects are thus explained. The Bony Pelvis Filled avith Soft Tissues. (a) Muscles.—Ilio-psoas, obturator internus, pyriformis coccy- geus, levator ani, retractor ani, sphincter ani, constrictor vaginae, transversus perinei. The levator ani plays a most important part in the sexual life and physiology of woman. A vigorous contraction of this muscle pulls the rectum and vagina towards the symphysis, and, when distended during labor, serves to direct the head out under the symphysis, thus relieving the strain on the perineum. It is active during the orgasm in the female, and directs the male organ toward the cervical canal. During parturition the function of the muscles of the pelvic caned (ilio-psoas, obturator, pyriformis, etc.) is mechanical. They serve as bumpers or protectors to the bony wall, and de- flect the presenting part in the most favorable direction for its ANATOMY OF PELVIS OBSTETRICALLY CONSIDERED. 99 expulsion. The situation of the ilio-psoas muscles diminishes the transverse diameter of the inlet, so that in the pelvis during life the diagonal is the greatest diameter, thus explaining the great frequency of oblique positions of the preseuting part. These muscles on either side subtract about 2^ cm. from the oblique and about 5 cm. from the transverse diameter. They are subject, however, to some displacement and compression during labor. The muscles of the pelvic floor (levator ani, coccygeus, trans- versus perinei, etc.) are passive, in one sense, during parturition. They yield only outward aud backward, and by resisting the passage of the presenting part, are frequently lacerated, yet the direction of their resistance serves to deflect the head outward and upward Under the symphysis. (b) Ligaments.—The obturedor membrane closes the foramen and serves as a cushion to protect the presenting part. The sacro-sciatic ligaments close the pelvic wall, afford protection and give direction to the presenting part. (c) Connective lissue.—A knowledge of the distribution of the pelvic fascia is of importance in determining the course of ex- tension of interstitial bleeding or absorbed infecting organisms. From both sides of the uterus the connective tissue extends in three directions. Laterally, it is included in the broad ligament, and, travelling along the round ligament, it reaches the mous veneris and inguinal region. Anteriorly, it skirts the bladder and'is continuous with the subcutaneous connective tissue of the abdominal wall. Posteriorly, it skirts the rectum, is included in the meso-rectum, and is continuous with the connective tissue of the posterior abdominal wall. It also follows the three canals which perforate the pelvic floor, the urethra, vagina, and rectum, and thus is continuous with the subcutaneous connec- tive tissue of the external genitalia and perineum. (d) Bloodvessels.—The ovarian arteries, leaving the abdomi- nal aorta, enter the pelvis on either side, and passing between the laminae of the broad ligament, are distributed to the ovaries and tubes, a branch going to the fundus, another traversing the uterus to anastomose with a branch of the uterine artery. The uterine artery passes downward from the anterior trunk of the 100 OBSTETRICAL LECTURES. internal iliac to the neck of the uterus. Ascending the sides of the uterus, a branch meets the ovarian, and a branch, the circu- lar artery of the cervix, supplies the cervix. The latter is some- times ruptured during labor, or cut during operations upon the cervix, and gives rise to profuse hemorrhage. The venous sup- ply to the pelvis is very abundant. (e) Lymphatics.—Important in their relation to septic absorp- tion. The lymph spaces of the uterus, lying between connec- tive-tissue bundles, and covered with endothelial cells, empty, by means of their ducts, into the lymphatic glands. These lead to the thoracic duct. The most important glands are the uterine, inguinal, obturator, hypogastric, lumbar, and sacral. Infection occurring in the lower fourth of vagina the poison spreads through the inguinal chain of lymphatics; above the lower fourth the poison travels through the other plexuses which are so freely anastomosed as not to be differentiated. Spreading along obturator muscle, abscesses appear on buttock or thigh (rare). (/) Nerves.—Principally from sympathetic system. The ute- rine plexus sends off the two hypogastric plexuses, and from these filaments pass to ovaries and uterus. Deformities of the Pelvis. Frequency.—13 to 14 per cent. (Classification of Schauta.) A. Anomalies of the Pelvis the Result of Faulty Development. (1) Simple Flat. (2) Generally Equally Contracted (justo-minor). (3) Generally Contracted Flat (non-rachitic). (4) Narrow Funnel-shaped. Foetal or Undeveloped. (5) Imperfect Development of One Lateral Mass of Sacrum. (Nsegele's Pelvis.) (6) Imperfect Development of Both Lateral Masses. (Roberts's Pelvis.) (7) Generally Equally Enlarged (justo-major). (8) Split Pelvis. ANATOMY OF PELVIS OBSTETRICALLY CONSIDERED. 101 B. Anomalies due to Disease of the Pelvic Bones. (1) Rachitis. (2) Osteomalacia. (3) New Growths. (4) Fractures. (5) Atrophy, Caries, and Necrosis. C. Anomalies in the Conjunction of the Pelvic Bones. (a) Too firm union (synostosis). Apt to be found in elderly primiparse, particularly at the sacro-coccygeal joint. (1) Of symphysis. (2) OT one or both sacro-iliac synchondroses. (3) Of sacrum with coccyx. (b) Too loose a union or separation of the joints. (1) Relaxation and rupture. (2) Luxation of the coccyx. D. Anomalies due to Disease of the Superimposed Skeleton. (1) Spondylolisthesis. (2) Kyphosis. (3) Scoliosis. (4) Kvpho-scoliosis. ,, /. '- * ■"; &*< - ' E. Anomalies due to Disease of Subjacent Skeleton. (1) Coxalgia. (2) Luxation of One Femur. (3) Luxation of Both Femora. (4) Unilateral or Bilateral Club-foot. (5) Absence or Bowing of One or Both Lower Extremities. The simple flat pelvis is the most frequent variety in this country. The contraction is at the conjugate diameter of the inlet. The narrow, funnel-shaped pelvis occurs in those whose bony development has ceased or in those who never have walked. In the latter the three developmental factors which produce the normal adult pelvis have been inoperative. In the split pelvis 102 obstetrical lectures. the deformity is at the symphysis and is associated with extrophy of the bladder. The characteristics of the rachitic pelvis are: excessive rotation of the sacrum on its transverse axis, resulting in an abnormal projection of the promontory and increased sacralcurve; decrease in depth of pelvic cavity ; the curve of the iliac bones is exagerated and their anterior spines more widely separated. This form and the generally contracted are next in frequency to the simple flat in this country. The greatest contraction is in the conjugate at the brim. Osteomalacia is very rare in this country. It gives rise to the " beak-like" projection at the symphysis. The new growths causing deformity may be any of the tumors that can develop from bone. Small nodules on the promontory or spines of ischia may lacerate the soft parts or puncture the child's head. When the pelvic joints are too firmly united the physiological loosening which happens during the latter months of pregnancy cannot occur. Anchylosis of the sacro-coccygeal joint is not infre- quent in old primiparse. Spondylolisthesis is a slipping down of the last lumbar vertebra into the pelvic cavity. The.finger in the vagina can often feel the bifurcation of the aorta. In kyphosis the weight of the body is from above downward and from before backward. The sacrum is thus pushed backward, is narrowed, tuberosities of the ischia approach each other, increasing the diameters of the inlet but diminishing the outlet, particularly in its transverse diameter. The distortion resulting from scoliosis is a lateral displacement of the promontory giving rise to an oblique deformity. Lordosis is the compensatory curve associated with kyphosis. Pelvimetry. Table of Measurements. Pelvis. Iliac spines, 26 cm. Iliac crests, 29 cm. External conjug., 20^ cm. Internal conjug., diagonal, 12J cm. anatomy of pelvis obstetrically considered. 103 True conjug., estimated, 11 cm. Right diagonal, 22 cm. Left diagonal, 22 cm. Between Trochanters, 31 cm. Circumference of Pelvis, 90 cm. An accurate measurement of the pelvis by means of the pel- vimeter will disclose any change in shape or size of the pelvis, indicate the degree of the deformity, and thus influence the treatment. The measurements are made externally and inter- nally between certain bony prominences. The varying factors in the external measurements to be taken into consideration are the thickness of the skin, subcutaneous tissue, and the bones. Estimation of the Size of the Inlet.—An approximate idea of the transverse diameter is gained by measuring externally between the anterior superior spinous processes of the ilia (26 cm.); between the crests of the ilia where they are most widely sepa- rated (29 cm.); between the two trochanters (31 cm.). The transverse diameter may be determined more accurately by an internal measurement called the internal ascending oblique (Lohlein). This is measured, by the finger in the vagina, from the centre of the sub-pubic ligament to the upper anterior corner of the great sacro-sciatic foramen. The transverse is 2 cm. longer than this diameter. An idea of the length of the antero-posterior diameter of the inlet is derived from the external conjugate, measured from the depression under the spine of the last lumbar vertebra to the upper edge of the symphysis (20| cm.). The internal measure- ment for estimating the antero-posterior diameter is made by the fingers reaching from the middle of the sub-pubic ligament to the top of the promontory, and is called the internal conjugate diagonal (12| cm.). This diameter is necessarily longer than the true conjugate, and it has been found that by subtracting If cm., the true conjugate is estimated. The possible sources of error in thus estimating the true conjugate are found in the fact that the internal conjugate diagonal does not take into account the height and angle of the symphysis, two factors which obviously influence the length of the true conjugate, while they have no 104 OBSTETRICAL lectures. effect upon the diagonal conjugate. Normally the height of the symphysis is 4 cm., and its angle 105° (conjugato-symphyseal angle). If this were always the case, subtracting If cm. from the measured internal conjugate diagonal would be absolutely cor- rect. As a matter of fact, both the height and the angle vary, and by the following rules the true conjugate can be accurately determined. For every .5 cm. increase in the height of the symphysis above the normal, add .3 cm. to If cm., and subtract the sum from the measured internal conjugate diagonal. The converse of this is applicable to a decrease in height of the symphysis. For every degree of increase of the conjugato-symphyseal angle above the normal, add half that number of mm. to If cm., and subtract the sum from the measured internal conju- gate diagonal. The converse of this is also true. The oblique or diagonal diameters may be measured externally from the posterior superior spinous process of the ilium to the opposite anterior superior spine (22 cm.). Estimation of the Size of the Cavity.—No external points of measurement. Its general size, or the presence of a tumor, is learned by a vaginal examination. Estimation of the Size of the Oidlet.—As it is increased in many varieties of deformity, and but rarely contracted, external meas- urements are not required in the vast majority of cases. It is decreased in the kyphotic pelvis. The distance between the tuberosities of the ischia (11 cm.) is ascertained by Chantreuil's method : placing the two thumbs on the tuberosities, and an assistant measures the distance between them. Chief diagnostic points of the commoner forms of pelvic deformity. Simple Flat Pelvis.—The external conjugate will be less than 20^ (19 or 18) and the internal conjugate diagonal less than 12|. Flat Rachitic.—The external conjugate lessened (18 or under). Internal conjugate diagonal lessened (11 or under). Conjugato- symphyseal angle is increased ; about 2 cm.*, not If cm., is sub- tracted. The relation of the distances between the spines and crests is disturbed. These measurements in the ordinary type in this country will be about 25 and 26. ■1 i< ANATOMY OF PELVIS OBSTETRICALLY CONSIDERED. ]().") Justo-minor.—All the diameters less, but normal relation main- tained. Justo-major.— All diameters increased, but normal relation re- mains. In private practice it is by no means necessary accurately to measure the pelvis of every pregnant woman. When, however, there exist evidences of some deformity, as rachitis, kyphosis, coxalgia, a history of grave difficulty in previous labors, etc., a vaginal examination should be made to estimate the conjugata vera, and other measurements taken as may be indicated. FcBtometry. Table of Measurements. Child. Length.......50 cm. Bisacromial......12 " Head. Bitemp........8 cm. Bipariet........91 " Occip. front.......11| " Occip. mental......13£ " Trachelo-bregm......9^ " Circumference, occip., front. . . . 34£ " The weight of mature infant is 3250 grin. In connection with the size of the pelvis, a second important factor influencing the difficulty of labor is the size of the fcetus, particularly of its head. Estimation of the Size of the Foetus.—An approximate idea of its size can be determined by abdominal palpation. When the head has not engaged, its relative size to the inlet, which is of obvious importance, may be discovered by an effort to push it through the superior strait. Anomalies of the Soft Parts. Anatomical anomalies of the maternal soft parts engaged in parturition may be the following:— 106 OBSTETRICAL lectures. Uterus didelphys (double uterus; failure of union of ducts of Miiller; separation throughout entire genital canal). Uterus bicornis duplex (the two uteri in juxtaposition, a septum dividing them). Uterus bicornis unicollis (bifid uterus; imperfect union of ducts giving bifid form). Uterus unicornis. One duct arrested in development, or there may be partial development of one horn (rudi- mentary horn). Uterus cordiformis (arcuate uterus; fundus not devel- oped ; its surface depressed). Uterus incudiformis (anvil shaped). Uterus septus (subseptus, partitus, semipartitus, etc.; dividing septum present, wholly or in part). The vagina is divided by a longitudinal septum in cases of uterus didelphys, uterus bicornis duplex, and sometimes in cases of uterus subseptus. The vagina and cervix may be divided longitudinally without division of the uterine cavity. Incomplete transverse septa of the vagina are sometimes seen. Antisepsis. Mortality of Septic Infection.— In large cities the average death- rate of confinement cases is about one per cent., the greater pro- portion being due to septic infection. In Philadelphia about thirty thousand women are annually confined at term, and of these between two and three hundred die from septic infection. Functions of Micro-organistns.—The widespread distribution of micro-organisms is now well known, and investigation has shown their chief function to be disintegrators and destroyers of dead animal and vegetable matter. Ptomaines.— In their work of disintegrating and destroying dead animal matter, poisonous products are produced, called animal alkaloids or ptomaines (rtro/ua, dead body). When the latter are absorbed, they give rise to various pathological and clinical manifestations, some proving fatal to animal life, others causing a rise of temperature, etc. Phenomena Resulting from Microbe Invasion.__The cells of liv- anomalies of the soft parts. . 107 ing matter resent their invasion and a struggle for supremacy begins. By their higher specialization for greater resistance, the skin and mucous membranes ordinarily serve as barriers to their entrance, but if these are passed, the more delicate and less resisting cells take up the combat. The result is largely dependent upon the extent of invasion, the virulence of the mi- crobe, and the individual power of resistance of the living cells. Invasion in Puerpera.—The examining hand may be infected, and through the placental site or lacerations of the parturient canal an entrance into the general system is effected. A fatal result in every case is avoided, in two ways: As a rule, the examining hand is not infected with the particularly virulent varieties, and in many cases the living cells are able to resist the germs that may have gained access. These elements of safety are invalidated, however, by the following facts : The germs that may have been introduced, when at their work of disintegrating the dead animal matter, as clots, shreds of mem- brane, deciduse, etc., grow, multiply, and increase in virulence, and the power of resistance of the vital cells varies in different individuals. Therefore, it is impossible to predict the character of the germ that may be absorbed, whether virulent or other- wise, and in no case can we know an individual's power of resistance. With so much uncertainty surrounding every case, it is obviously necessary to apply our knowledge of germicides, and endeavor to prevent the introduction and further develop- ment of micro-organisms. Table of Comparative Germicidal Power. In solutions of justifiable strength. Bichloride of mercury, Creolin, composed of coal tar, resin soap, fat soap, and caustic soda. Thymol, Benzoate of sodium, Salicylic acid, Carbolic acid. The bichloride of mercury is effective but dangerous. Creolin 108 OBSTETRICAL LECTURES. is probably as powerful as the bichloride ; thus far has been found much less dangerous, and is therefore recommended. Application of Antisepsis to Obstetrics.—The advantages of anti- septic precautions in obstetric practice have been clearly demon- strated by an enormous reduction of mortality since its employ- ment has become so general. At one time in the Vienna Hospital the mortality was one death in nine cases ; now it is .3 per cent. In the Paris Maternite it has been ten per cent., while recently in the same hospital there were 1000 cases without a death. At the Philadelphia Hospital the mortality has been reduced from 7 per cent, to less than 1 per cent. Semmelweis, the originator of antiseptic practice in obstetrics, accomplished the following striking reduction in mortality in his hospital by requiring stu- dents to disinfect themselves before attending the cases :— Year. Confinements. Deaths. Per Cent. 1846 4010 459 11.4 1847 3490 176 5. 1848 3556 45 1.27 Antisepsis in Hospital Practice. (a) Disinfection of the Patient.—When the signs of beginning labor manifest themselves, the patient should receive a bath and be supplied with clean clothes. After labor is completed the vagina should receive one douche of 2 per cent, solution of cre- olin by means of a fountain syringe, preferably of glass, the vaginal tube also of glass, with lateral perforations. If an in- trauterine injection be required, the glass tube, a two-way metai catheter or stiff rubber catheter, may be used, preferably with a fountain syringe. (b) Disinfection of the Bed.—The lying-in bed should contain the following: 1, a pad about a yard square, composed of an upper layer of flannel, a piece of blanket and a layer of mack- intosh, all to be soaked in bichloride solution, 1 to 2000, and dried before using; 2, a sheet covering; 3, a rubber blanket; 4, a second sheet, and under this, 5, another rubber cloth, to protect the mattress. (c) Disinfection of the Attendants.—The bands and wrists of doctor and nurse washed in warm water with soap and brush; diagnosis of pregnancy. 109 nails pared and cleaned; hands and wrists rinsed in alcohol and placed in bichloride solution, 1 to 1000, for at least one min- ute, after which they should not be dried on septic towels, etc. (d) Disinfection of Instruments.—If not easily corroded, soaked in bichloride solution, 1 to 1000; otherwise, immerse in boiling water or use 5 per cent, solution of carbolic acid. This applies to all instruments used in vagina, urethra or rectum. Protection after Labor.—The pads which receive the lochia should be changed six times in twenty-four hours for three days, and less frequently subsequently as may be needful. Protect the parturient tract from invasion by the occlusive dressing, or vulvar pad, composed of sublimated gauze, and corrosive cotton within this, to protect vulvar opening. In private practice carbolized gauze and salicylated cotton may be substituted to avoid a vulvar dermatitis. The dressing to be changed six, seven or eight times daily for the first three days and less frequently afterward. When changed, the external genitalia should be washed several times daily with baked cot- ton and bichloride solution 1 to 2000. Antisepsis in Private Practice. The patient, nurse, clothing, etc., are usually sufficiently clean. Avoid infecting the patient by thorough personal disinfection of doctor, nurse, and instruments. An occlusive dressing should be used to prevent infection from the atmosphere. The woman should lie upon a pad or folded sheet, which can be changed frequently. The vulvar pad should be changed six or seven times a day for the first three or four days, and the external genitalia be washed off with a warm corrosive sublimate solu- tion. A vaginal douche is not necessary in a normal case. The lying-in room should not contain a stationary wasbstand nor be in close proximity to water-closet. An open fireplace is desirable. 110 obstetrical lectures. Diagnosis of Pregnancy. Subjective Signs.—Arranged in the order of their relative importance. (A) Cessation of Menstruation.—Is the most valuable of the subjective signs, but is not always to be depended upon. It may occur independently of pregnancy, in immigrants experiencing a sudden change in climate ; in various mental disorders, as hysteria, mania ; as the result of old peri-uterine inflammation ; it often accompanies phthisis. In pregnancy the menstrual discharge may occur during the first three months. Sometimes this may be due to failure of union of the deciduse. Rarely it may continue throughout the whole period of gestation. (B) Neiusea and Vomiting.—Are reflexly associated with the developing fcetus, and occur usually at the 6th or 7th week. They may occur reflexly from other conditions, as a displaced uterus, an organ which is badly inflamed, congestion or inflam- mation of the tubes and ovaries, growing tumors within the pelvic cavity, etc. They may be altogether absent, yet rarely in some individuals they appear so early, and with such prompt- ness and regularity, as to constitute a most valuable sign. (C) Changes in Size and Shape of Abdomen.—At first hypo- gastric flattening, due to sinking of the uterus in the early weeks from its increased weight. This is associated with irrita- bility of the bladder. Later the abdomen is enlarged, which may be due to other causes, as deposition of fat, accumulation of fluids, various tumors, etc. (D) Changes due to Increased Blood Supply to the Genitalia and Breasts.—These are tingling and a sensation of fulness in the breasts, with the development of colostrum ; leucorrhoea; in- creased temperature of the genitalia. Are of comparatively little value. (E) Quickening.—Is the sensation experienced by the mother as the result of foetaL movements, and usually first appears be- tween the fourth and fifth months. Not experienced in some patients. Movements of intestines may simulate, particularly in hysterical women. DIAGNOSIS of pregnancy. Ill (F) Alterations in the Nervous System.—Changes in disposition, mental peculiarities, perversion of taste. A disposition to faint and actual syncope. All these subjective and some of the objective signs of pregnancy may be simulated in cases of pseudo-cyesis or spurious pregnancy. Objective Signs.—Are of much more importance and value. Are obtained by employing the senses of sight, touch, and hearing. (A) Inspection. (a) Face.—Chloasmata, splotches of irregular pigmentation on brow and cheeks. Development of the dark rings under the eyes. (6) Breasts.— Enlarged ; veins distended and tortuous; nipple prominent; deposition of pigment—widening the areola and developing the secondary areola. Enlargement of the glands of Montgomery ; presence of colostrum. All these signs can be manifested independently of pregnancy, and rarely may be absent, (c) Abdomen.—Is pear-shaped, with the narrow end downward ; tumor is situated in the median line, spreading with approximate equality to either side. Striae are present. The umbilicus at the sixth month is level with the surface of the abdomen and later pouts. It is surrounded by a ring of pig- mentation which spreads above and below along the linea alba. Foetal movements can be seen if the pregnancy be far advanced. In the latter months the mucous membrane of vagina and vulva is violet or purple. (B) Touch.—(a) Abdominal palpation. By this method are learned the size and shape of the uterus ; in advanced cases, the position of the foetal back, head and extremities ; the intermit- tent uterine contractions (Braxton Hicks) ; foetal movements. Braxton Hicks's sign is available by the last of the third month, and although it may be produced by any tumor which sufficiently distends the uterine wall, as a collection of blood. soft fibroma, etc., it is almost a positive sign. It may, how- ever, occur sympathetically in extra-uterine pregnancy and it is said that the contractions of an irritable distended bladder may be mistaken for the rhythmical contractions of the gravid womb. Foetal movements are absolutely diagnostic. [b) Combined examination—(\) Softened cervix.—Caused by the increased blood supply and oedema. A ready rule of prac- 112 obstetrical lectures. tice is, that " when the cervix is as hard as one's nose, pregnancy does not exist; when soft as one's lips, pregnancy is probable" (Goodell). Rapidly-growing myomata, acute metritis, haenia- tometra, can thus simulate pregnancy by softening the cervix. (2) Hegar's sign. This is a softening of the lower uterine seg- ment, which is situated between the cervix and the upper uterine segment. Can be elicited by the forefinger in the rectum, thumb in the vagina, and pressure on the fundus above. (3) Enlargement of the uterus, with change in shape and consist- ency. In the early months deposition of lymph upon the uterus may lead to an error in diagnosis. (4) Ballottement. With one hand over the fundus, and the fingers of the other in the vagi- na, an impulse is communicated to the contents of the uterus by the vaginal hand, when the fcetus will be felt to strike the fundus, and returning, will impinge upon the vaginal hand. This is a positive sign, and is available in the fourth month. A small cystic tumor of the ovary, with a long pedicle, and an extra-uterine gestation, are possible sources of error. (C) Auscidtution.—(a) Fozted heart sounds. Rate, 120 to 160 per minute. Available in the fifth month. The third positive sign. Are to be distinguished from the pulsations of the abdominal aorta. The area of their maximum intensity in anterior posi- tions of the vertex is an inch below the umbilicus, to the left or right; in posterior positions, in the flanks, on a line which passes through the umbilicus. Their absence does not exclude the existence of pregnancy.. (b) Dulness on percussion. A positive diagnosis of preguancy before the sixth week is impossible. Clinically, the signs of pregnancy may be divided into three trimesters or periods of three months each. The 1st.—Will manifest the following signs : enlargement and bogginess of the uterine body ; soft cervix ; enlargement of the breasts ; nausea and vomiting ; Hegar's sign ; cessation of menstruation. The 2d.—In addition to above. Braxton Hicks's sign ; feeble foetal movements ; ballottement; heart sounds ; blue discolora- tion of vaginal mucous membrane. The 3d. All the above present to a greater degree ; outlines diagnosis of pregnancy. 113 of foetal body distinguishable by abdominal palpation; pre- senting part to be felt through roof of vaginal vault. Estimation of the Duration of Pregnancy.—Ordinarily the cessa- tion of menstruation is depended upon. A convenient rule for predicting the date of the confinement is to count back three months from the date of appearance of the last menstrual flow, and add seven days (Naegele). An approximate idea may also be gained by noting the height of the fundus: — 4th month, midway between umbilicus and symphysis. 6th month, on a level with the umbilicus. 7th month, midway between umbilicus and xyphoid. 8th month, at the xyphoid. 9th month, descends almost to the depth at which it was at the 7th month, the presenting part having entered the superior strait. Diaejnosis of Life or Death of the Foetus.—The foetal heart- sounds are the most valuable sign when heard. Positive knowledge of foetal movements is also of great value (see page 40). Knowledge of the life or death of the foetus is often of great importance when complications arise whose treatment may require the termination of pregnancy, as nephritis, etc. Diaejnosis of the Situation of the Developing Ovum.— Whether intra- or extrauterine (see Extrauterine Pregnancy). Uieujnosis of a Prior Pregnancy.—Of medico-legal value, (a) Cervix lacerated, usually laterally. (6) Cervical canal irregu- larly enlarged, usually admitting first joint of index finger. Striae pale and glistening ; evidently old scars. Physiology of Pregnancy. Alterations in organs and tissues in consequence of pregnancy. (A) Local Changes. I. Uterus. (a) Development of Constituent Parts.-I. Muscle. Fibres hypertrophied eleven times as long, five times as broad as those 8 114 obstetrical lectures. of the non-pregnant uterus. The theory of an additional hyper- plasia of these structures has never been actually demonstrated. 2. Connective tissue. Increased chiefly by absorption of fluid and consequent increase in bulk. 3. Peritoneal covering. Increased by both hypertrophy and hyperplasia of the constituent elements. 4. Bloodvessels.—Arteries increase in calibre, length, and tortuosity. Veins grow to a very large size ; their covering is reduced to the intima. They are surrounded by the uterine muscle, which obliterates them after labor. 5. Nerves. Increased more by a development of the con- nective tissue about them (neurolemma) than by an increase of the nerve elements. 6. Lymphatics. Increased by hypertrophy and hyperplasia. The lymph spaces below the uterine mucous membrane are enormously enlarged, and the lymph-tubes leading from them through the uterine muscles reach the size of a goose-quill. These lymph-tubes or vessels are collected in a plexus beneath the peritoneum, which is continuous with the general lymphatic system. This arrangement and development explain the remarkably rapid absorption of the uterus after labor, and account for the ready absorption of infecting material, with peritonitis often- times as an early symptom. (b) Anatomy of the lTterus at Full Term.—The muscle fibres of the non-pregnant uterus have a very irregular distribution. In the pregnant womb three layers may be distinguished - an outer, middle, and internal layer. The outer is continuous with the muscular fibres in the round ligaments and tubes, and is mainly longitudinal in arrangement. The middle layer is composed of bundles, which pass from their peritoneal attach- ment obliquely downward and inward to be attached to the submucous tissue. Above the "contraction ring" this oblique arrangement is less marked, while below it is more pronounced. The internal layer is thin and poorly developed, except at definite points. Its arrangement is chiefly circular, and is specially developed at the openings of the tubes and internal os. (c) Changes in Volume, Capacity, and Weight.—Before inipreg- <> r^ / 2^< 7 , o h »,' •■ <~ ---i^O- fLs '&- *- * "C- /1 : ^ 'tyjue~£i-(>i£i/ (7 - V ( physiology of pregnancy. 115 nation the length of the uterine cavity is about 2i inches ; at term, it is increased to 12 inches ; while its breadth is 9 inches and depth 8 inches. The capacity changes from 1 cubic inch to 400 cubic inches ; weight from about 2 ounces to 2 pounds. (d) Changes in Form, Position, Direction, and Topographical Relations.—From flattened pyriform to spherical or fig-shaped, and, finally, ovoidal. During the early months the position of the uterus is altered by sinking into the pelvic cavity, as a result of the increased weight. After the third month it rises until it is almost in contact with the diaphragm, and before term (four weeks in primiparae, ten days or one week in multi- para}) sinks again into the pelvic cavity, owing to the engage- ment of the lower portion of the uterus with the contained presenting part of the foetus within the pelvic canal. After the third month the laxity of the abdominal wall allows it to fall forward. In consequence of the position of sigmoid flexure and rectum, it is slightly tilted to the right and rotated on its longitudinal axis. The topographical relation of the in- testines is important. They are always situated above and behind the uterus, thus giving no resonance over the anterior abdominal wall. II. Alterations in the Cervix. Is softened, but its canal is undilated until the first stage of labor is well advanced. III. Alterations in Vagina and Vulva. Changes due to increased blood supply, as noticed in enume- rating the signs of pregnancy, as darkened color, increased secre- tion and over-development in the muscular and mucous walls. IV. Pelvic Joints. Loosening of their connections and increase in motility, thus facilitating the passage of the foetal body. V. Abdominal Walls. (a) St retelling of all the constituent parts, with the formation of striae, resulting, as was formerly supposed, from cracks in the 116 obstetrical lectures. subcutaneous connective tissue and deeper layers of the skin, but now believed to be due to thinning and disorder of the ar- rangement of the connective-tissue layer of the skin. If the stretching is painful, relief is afforded by inunctions with cocoa butter, sweet oil or vaseline, to increase the pliability of the skin. (b) Separation of the recti muscles.— Exceptionally, the abdomi- nal contents may be extruded. (c) Increased deposition of fat, as in other parts of the body. This is probably nature's provision for sustaining the woman during the first few days of the puerperium. VI. Bladder and Rectum. The growth of the pregnant uterus mechanically interferes with their functions, hence irritability of the bladder and con- stipation are frequent. By interfering with their blood supply, hemorrhoids may develop, not only of the anus and rectum, but of the bladder as well, which rarely give rise to hemorrhage. (B) Changes in the Several Systems of the Body. General Changes. I. Circulatory System. (a) Blood.—Whole quantity increased. Water and fibrin- making elements increased ; red corpuscles relatively diminished; haemoglobin diminished ; white corpuscles actually and rela- tively increased. * (6) Heart.— Left side said to hypertrophy, and, in conse- quence of unusual determination of blood to the brain, there are developed on the inner table of the skull new formations of bone, called osteophytes. It has been claimed that the pulse of a pregnant woman does not undergo the usual acceleration when the patient changes from an horizontal to erect posture. (Jorisenne's sign of pregnancy.) This is of no value. The pregnant woman is liable to cardiac nerve storms. II. Urine. Becomes more watery ; specific gravity diminished ; quantity -*- physiology of pregnancy. 117 of urea normal. The kyesteinic pellicle is no longer regarded of any diagnostic value. III. Digestive System. Nausea and vomiting; torpor of intestines and rectum, in- ducing constipation. IV. Nervous System. Alterations in disposition ; perversions of taste; disposition to melancholia; severe neuralgias, especially of the face and teeth. V. Changes in Weight. An increase of T's part of the original body weight (Gassner). This estimate is not uniformly correct, as irregularities are fre- quently met with. VI. Changes in the Respiratory Apparatus. Lungs are shorter but broader, leaving the capacity un- changed ; alterations in the expired air of no clinical import- ance. (C) Prolongation of Pregnancy and Missed Labor. Pregnancy is quite commonly prolonged. It may have a duration of 320 days, or 40 days above the average. In about 6 per cent, of women the duration is over 300 days. The result may be most serious in consequence of overgrowth of the foetus. Missed labor means the occurrence of a few labor pains at term, their subsidence and the retention of the product of conception in utero for a varying period thereafter. " Missed labor" usu- ally turns out to be extrauterine pregnancy or pregnancy in one horn of a uterus bicornis; it may be due, however, to obstruct- ed cervix from cancer, conglutination, etc. (D) The Management of Normal Pregnancy comprises correction of constipation, examination of urine, advice in regard to exercise, diet, exposure to cold and wet. 118 OBSTETRICAL LECTURES. Tonic remedies are sometimes called for. Phosphate of lime is administered by some routinely, and strychnia in latter months is claimed to beneficially influence labor and puerperal involu- tion. The nipples should be prepared for their future function by application of glycerole of tannin and water, equal parts, twice a day for four weeks preceding confinement. Pathology of Pregnancy. I. Diseases of the Genitalia. 1. Displacements of the Pregnant Uterus.—It may be displaced forward, backward, to either side, downward. It may form part of the sac contents in inguinal and ventral hernia, and may be twisted upon the cervix. (a) Anteflexion.— Usually the growth of the uterus replaces the organ spontaneously, but when bound down by bands of adhesive inflammation, pain aud difficulty in urination result, until finally the uterus expels its contents, or forces its way up into the abdominal cavity. Treatment—Massage, and efforts to replace it through the vaginal vault. Late in gestation the whole body of the uterus may fall forward, producing a pendulous abdomen, in conse- quence of greatly relaxed abdominal walls, diminution in the length of the abdominal cavity, as in kyphosis, prevention of the entrance into pelvis of presenting part, as in rachitic pelvis, or separation of the recti muscles. Treated by abdominal binder. (b) Retroflexion or Retroversion.—Of rather frequent occur- rence. Explained almost invariably by the previous existence of such a displacement. Symptoms.—The earliest and most distinctive is dysuria, which should lead to a vaginal examination to confirm the diagnosis. In neglected cases, or where nature has not corrected the dis- placement spontaneously, incarceration occurs. The symptoms of this manifest themselves after, the third month, and are : oc- clusion of the bowel and urethra, with their associated symp- toms ; congestion, inflammation and suppuration of the uterus, which may finally slough with the development of peritonitis and septic infection. PATHOLOGY OF PREGNANCY. 119 Terminations when Artificial Means are not Employed.—Sponta- neous replacement (more likely in retroflexion than in retro- version); spontaneous abortion; incarceration; expulsion of the uterus from the body as a whole; rarely by sacculation of the uterus. Prognosis.—Always satisfactory as regards maternal life when treatment is adopted early. When overlooked or neglected death frequently occurs. In fifty-one fatal cases the following, in order of frequency, were the causes of death : Uraemia and exhaustion; rupture of the bladder; septicaemia; peritonitis from inflammation of the bladder; pyaemia; rupture of the peritoneum and of the vagina; errors in treatment; gangrene of the colon. Treatment.—Replacement. If undertaken early, manual means, pressing fundus in the direction of one or the other sacro-iliac joints, the patient in the lithotomy position. Failing, resort to knee-chest posture and a repositor to press upon the fundus. The cervix should next be drawn downward with tenaculum, at the same time continuing the efforts to replace the fundus. If successful, a large-sized pessary or tampon should be applied until the growth of the organ maintains it in the abdominal cavity. When bound down by strong inflammatory bands, steady and long-continued pressure should be supplied by large tampons in the posterior vaginal vault. Failing, filially, abor- tion should be induced. Trcidmcnt ivhen Incarcerated.—Attempts at reposition as above. These unavailing, as is usual, induce abortion. If it is impossi- ble to effect an entrance into the cervix for this purpose, it is justifiable to puncture the uterine wall through the vaginal vault, and thus draw off the liquor amnii. The organ may now respond to efforts at replacement, or permit the cervix to be drawn down and its canal dilated, to accomplish the evacuation of its contents. If the bladder is seriously distended, it should be emptied by the urethra, or supra-pubic puncture with an as- pirating needle may be necessary. Be sure that the bladder is emptied, and not merely the lower segment, which is frequently shut off from the rest of the bladder by pressure of the cervix. 120 OBSTETRICAL LECTURES. Should soft catheter fail, use metallic prostatic catheter. As a last resort, vaginal hysterectomy is justifiable. (c) Displacements to Either Side.—Include latero-position, latero-version, latero-flexion. Latero-position is usually a con- genital defect due to abnormally short broad ligaments, placing the whole uterine body more to one side of the abdominal cavity. Latero-flexion is also congenital, due to imperfect development of one side of the uterine body. Right latero-version is the rule during pregnancy. These malpositions complicate labor more than pregnancy (see Dystocia). (d) Prolapse. — Causes.—Impregnation in an organ already prolapsed, or the consequence of retroversion, relaxed vaginal walls and outlet; the increased weight leads to prolapse in the first few weeks of pregnancy. Terminations.—(1) Complete spontaneous reposition, which is most frequent. (2) Incomplete reposition, continuing in that state to full terra. (3) Failure of retraction, inducing incarcera- tion. (4) Failure of retraction, inducing abortion. Pregnancy will not continue to term in a completely prolapsed organ. Treatment.—Reposition and application of some variety of ball pessary, retained by a firm T-bandage. When incarcerated, attempts at reposition should be cautious, but if they fail, owing to adhesions and oedema, abortion should be induced and the organ replaced. (e) The Pregnant Uterus forming a Part of a Hernial Protru- sion.—Occurs exceptionally, in inguinal and ventral, but never in crural hernia, the uterus getting into the sac before or after impregnation. The ventral variety is most frequent, and may occur between abnormally separated recti muscles, or, more rarely, is seen on the lateral aspect of the abdomen. When it occurs in the very exceptional inguinal variety, the pregnancy is apt to be in one horn of an abnormally developed uterus. Treatment.—Attempts at reposition. These failing, entering the hand in the uterus, version and extraction are to be consid- ered. The last resort is Caesarean section or amputation of the pregnant uterus. (/) Torsion.—Slight degree of torsion from left to right, physiological and constant. A more exaggerated degree may PATHOLOGY OK PREGNANCY. 121 be due to some abnormal condition, usually inflammatory, near the uterus, which results in twisting it upon its longitudinal axis. An ovary may thus be brought in front and be subjected to traumatism during manipulation of the abdomen. 2. Disease of the Uterine Muscle. — (a) Rheumatism. The most common ; occurs in those of rheumatic diathesis. Symptoms.—Great pain, localized in the uterine walls, lasting throughout the latter months of pregnancy, and increased periodically by the intermittent uterine contractions. The therapeutic test is, perhaps, the most valuable factor in the diagnosis. Treatment.—Administration of salicylate of sodium. (b) Metritis.—Is almost invariably acquired before impregna- tion, exercises a most deleterious influence upon gestation, and usually results in abortion. Symptoms.—When pregnancy continues, there is great pain, a feeling of weight and heaviness, and usually distressing and obstinate vomiting, which, in some cases, may indicate the induction of abortion. Treatment—Glycerine tampons may be tried, although very likely to induce abortion. (c) New Growths.— Complicate labor more than gestation. 1. Fibroids—are the most frequent, grow rapidly from increased blood supply to genitalia, and in exaggerated cases some opera- tive interference is demanded. The same is true of other pelvic tumors to a less degree, as (2) ovarian cysts. 3. Malformations of the Uterus.— Complicate labor more than gestation (see Dystocia). 4. Diseases of the Cervix.—The same may be said of these, except bad cases of laceration with eversion and carci- noma, which very frequently induce abortion or premature labor. Minor complications may arise from inflammatory pro- cesses within the cervical canal, giving rise to mucous or even bloody discharges. Supposed menstruation persisting through- out pregnancy is probably thus accounted for. 5. Diseases of the Vagina. —Due to increased blood supply or specific infection, (ct) Leucorrlwu; feeling of heat and discomfort, (b) Specific infection. Affects rather the new- 122 obstetrical lectures. born infant and mother soon after delivery. Requires ener- getic treatment to eliminate such complications. Bichloride douche, 1 to 2000 b. d., and a tampon dusted with tannic acid. A study of vaginal secretions during pregnancy (Doderlein) has thrown additional light on the question of septic infection after labor. In the normal secretions, especially of virgins, there is a large non-pathogenic bacillus which seems to have a destruc- tive action upon other micro-organisms, by producing an in- tensely acid environment (probably due to lactic acid). In patho- logical secretions the reaction is weakly acid, neutral, or alkaline; there is also an increased amount of mucus, bubbles of gas, epithelial cells, and a large number of mixed micro-organisms. Out of 195 pregnant women examined, 44.6 per cent, bad patho- logical secretions. Whenever the secretion was pathological, the, large bacilli were absent. Of cases with pathological secre- tions, only 10 per cent, bad streptococci. These remain in the vagina unless they are carried into cervix and uterus by exam- ining finger or instruments, (c) Hemorrhoids. Guard the part from traumatism, which can produce alarming hemorrhage. (d) Colpohyperplasia cystica. (e) Polypoid hypertrophies of the vu- ginal mucous membrane. 0. Diskasks of the Vulva. -Also largely due to increased blood-supply, (a) Hemorrhoids, (b) Vegetedions. Require no treatment beyond protection, (c) Pruritus vulvtr. May be a neurosis or due to the vaginal and cervical discharges. Is oftentimes intractable. Treatment belongs to Gynaecology, (d) (Edema. May be unilateral or bilateral, and in some cases ex- treme in degree. Usually associated with other dropsies in kidney insufficiency. May be due to pressuie or in unilateral form to labial abscess. Treatment: Hot fomentations and pos- sibly puncture. Relief of cause if possible. 7. Bleeding from the Genitalia During Pregnancy.— Causes.—(1) Separation of the Placenta, praevia or normally situ- ated, and in early pregnancy separation of the membranes (threat- ened abortion). (2) Persistence of Menstruation.— Recognized by its periodicity. (3) Cerviad Endometritis. — Hemorrhage is slight. (4) Intr(xcervical Polyp.—The loss of blood progressively in- pathology of pregnancy. 123 creases in amount as a result of the rapid growth of the polyp during pregnancy. (5) Malignant Tumor of Cervix. (0) Malignant Tumor of Vagina.—Both are recognized by the history of previous disease, the occurrence of bleeding when anything comes in contact with the diseased surface, as after coitus, and by digital and speculum examination. (7) Hemorrhoids.—About meatus, vulva, or in vaginal walls. (8) Apoplexy of Placenta. s. Periuterine Inflammations and Adhesions.—Old cases. may be benefited by massage. Appropriate treatment during the intervals between pregnancies is required. Fresh attacks of periuterine inflammation in pregnancy, depending upon oophoritis and pyosalpingitis, are exceedingly dangerous. A woman may be impregnated though she have at conception a pyosalpinx and densely adherent tubes and ovaries. 9. Loosening of Pelvic Joints.—When pronounced, in- terferes with locomotion. The diagnosis is made by a vaginal examination, the patient in the erect posture taking a few steps. Treatment: Application of a firm binder about hips and pelvis, or rest in bed if exaggerated. 10. Breasts.—(o) Mammary Abscess. Its cause, course, and treatment same as when it occurs during the puerperium. (b) E-zema of the Nipples. Is very obstinate and resists treat- ment. Relief only occurs after delivery. II. Diseases of the Alimentary Canal. 1. Mouth.—(a) Caries of the Teeth. Is of rather common occurrence, particularly in the upper classes. As a rule, it is best not to advise interference, as dental operations might pro- voke abortion. (b) Gingivitis.—Gums spongy, inflamed, bleed easily, possibly ulcerated. Obstinately resists treatment until pregnancy is concluded. Occasionally the gingivitis extends to a stomati- tis, and rarely lasts through, and is aggravated by lactation, only disappearing when the child is weaned. (c) Toothache.—Develops with or without other pathological 124 obstetrical lectures. changes in the mouth, and resists treatment. Usually subsides when pregnancy has advanced beyond the first half of gestation. (d) Ptyalism.—Cause not known. Astringents, belladonna, chloral, etc. may be employed. Disappears usually in the latter months. May recur in each succeeding pregnancy. 2. Stomach.—There is a physiological, an exaggerated, and a pernicious vomiting in pregnancy. The last is a serious disease. Pernicious Vomiting.—Causes.—(1) Reflexly, from irritation of the uterus and its contained nerve-endings by the stretching of the uterine walls. It is thus more common in primiparae, in twin pregnancy, when chronic metritis or displacement of the uterus • exists, and when the nervous system is hyperaesthetic or disar- ranged. (2) Inflammation of the lining membrane of cervix or uterus. (3) Engorgement of neighboring organs, as inflamed tubes or ovaries. (4) Some pathological condition of the stomach, as chronic gastritis, gastric ulcer, etc., pregnancy increasing the irritability already present. (5) Rarely some pathological condition of the intestinal tract, as polyps, bands of adhesions. (0) Increased indulgence in sexual intercourse. The last is a not infrequent cause. (7) Kidney insufficiency is an important cause, very often operative, when the vomiting recurs late in pregnancy. Diagnosis.—Of the cause is difficult; of the condition easy. There are perhaps fever, great emaciation, and loss of strength, which may prove fatal. The worse cases occur between the second and fourth months. Mistakes are sometimes made by overlooking the existence of pregnancy. Treatment—Remove the cause, if ascertainable. (a) Hygienic.—Includes regulation of the diet, attention to gastro-intestinal tract, etc. Advise a light breakfast of tea and bread or milk, taken in bed before getting up, the patient lying flat upon her back. Sexual intercourse should be restrained. Oftentimes there is improvement when the sensation of swallow- ing is removed by a cocaine spray or (esophageal tube. Rectal alimentation in extreme cases, the enemata being non-irritating, so as not to provoke an exhausting diarrhoea. Four to six ounces may be given three or four times a day, predigested. Liquid peptonoids, p.ancreatized meat or milk. The " rest PATHOLOGY OF PREGNANCY. 125 cure," combined with other treatment, has proved efficient in some cases. Some tolerance of the stomach may at times be established by allowing apparently unsuitable articles of food when specially desired by the patient. (6) Medicinal.—The drugs that have been used are innume- rable. Of these may be mentioned iodine, gtt. j-ij in water; oxalate of cerium, subnitrate of bismuth, tinct. mix vomica, antipyrin, wine of ipecac, menthol, hydrobromate of byoscin. Nervous sedatives, as bromides, chloral, and opium, are the most reliable. Sodium bromide, gr. x, in aq. camph., ^iv, four times a day. If necessary, resort to enemata of sodium or potassium bromide, gr. xl, and chloral, gr. xx, two or three times a day, dissolved in water. (c) Gynaecological.—Replace a displaced uterus. If the cervix or canal is inflamed, apply with a cylindrical speculum a 20-gr. solution of nitrate of silver. Peroxide of hydrogen has been similarly used. If applications to the canal are made with an applicator, abortion may result. When due to metritis, treat- ment does not accomplish much at this time. Glycerine tampons may be used after simpler plans fail, as they may induce abortion. Empirically, a 15 per cent, solution of cocaine may be applied to cervix and vaginal vault, and, similarly, dilatation of the cervix with the fingers has been successful in certain cases. (d) Obstetrical.—Induction of abortion or premature labor should be done as the last resort, and yet not too late. The mortality of the pernicious vomiting of pregnancy is high ; of 239 cases, 95 died ; of 57 cases treated by the usual means, 28 died ; of 30 cases treated by the induction of abortion, 9 died. 3. Intestines.—(a) Constipidiou.—Should be guarded against to prevent overwork of the kidneys. Cascara sagrada, the weaker mineral waters, and pulv. glycyrrhizae comp. may be used. Active purges may interrupt the course of gestation. (b) Diarrhaa.—When the ordinary remedies fail, nerve seda- tives may control it, as it is sometimes explained by intestinal irritability, resulting from pressure of the gravid womb. (c) Gastricand Intestinal Indigestion.-—The latter is quite com- mon in primiparae, and gives rise to severe abdominal pains. 4. Liver.—Jaundice may result from a mild catarrhal condi- 126 OBSTETRICAL lectures. tion of the bile-ducts, which may have existed before pregnancy. This class of cases is of little clinical importance. It should be remembered that a serious condition may develop as the result of excessive work thrown upon the liver—namely, an acute degeneration of the whole hepatic structure. Another explana- tion is that poisons (such as may produce eclampsia) circulating in the blood act upon the liver, producing acute yellow atrophy. Treatment.—The simple catarrhal jaundice is treated by regu- lation of diet and bowels, and securing a free discharge of bile. The graver form is rapidly fatal. 5. Hemorrhoids. —Guard against constipation. Astringent applications may be made. Operative interference is likely to interrupt pregnancy. III. Diseases of the Urinary Apparatus. 1. Kidneys. (a) Kidney of Pregnancy.—Pathology.—Anaemia, with fatty infiltration of the epithelial cells, and without auy acute or chronic inflammation. Cause. — Obscure. Has been attributed to pressure on the bloodvessels ; to the compression by the gravid uterus; serous condition of the blood in pregnancy; influence of the weather, and to spasmodic contraction of the renal arteries. It is most probably due to a diminution of the blood supply. Symptoms.—Albuminuria. Hyaline and granular casts, with epithelium filled with fat, may be found. Frequency and Course.—About six per cent, of all pregnant women have albumin in the urine. Occurs most frequently in primiparae ; runs a subacute course, manifesting itself most plainly in the latter months of gestation, and can influence the general health, course of pregnancy, and occurrence of eclampsia, the same as inflammatory renal diseases. Upon the foetus, also, it exerts practically the same influence in the production of placental apoplexies. The dangers are greatest when the con- dition develops suddenly. It disappears with the cessation of gestation. "Treatment.—Practically the same as for true nephritis. PATHOLOGY of pregnancy. 127 (b) Acute and Ghronv- Nephritis. — These may occur at any time during pregnancy, with their usual symptoms. The extra amount of work thrown upon the kidneys at this time makes the prognosis more grave, and demands the most energetic treat- ment. Premature expulsion of the ovum and outbursts of eclampsia are frequent. The chronic variety is more frequently a complication, and may be acquired before or during preg- nancy. Differential Diaejnosis.—If the kidney disease existed before pregnancy, marked symptoms will develop in the earlier months. If these develop in the later months, the disease has had its origin during pregnancy. It is often difficult to distinguish between the following :— Chronic Nephritis. Kidney of Pregnancy. History may point to its ex- Kidneys normal at this time. istence before pregnancy. Urine likely to be increased. Urine likely to be increased. Presence of albuminuric reti- Absence of same. nitis. Symptoms apt to be pro- Same in latter months. nounced in earlier months. Autopsy gives evidences of Anemia and fatty degenera- inflammatory changes. tion. No inflammatory changes. Persists after delivery. Disappears after delivery. Casts early and in abundance. Casts only in bad cases, not appearing until other symptoms have developed,and not in large numbers. Treatment.—It is always of paramount importance to know in any case of pregnancy what the condition of the kidneys may be; hence in all cases the urine should be repeatedly examined, at least every ten days during the latter weeks. If the quantity of albumin is small, if there are no casts, no history of a pre- vious nephritis, and no symptoms of general systemic disturb- ance, dietetic and hygienic management may be sufficient so long as the case is kept under careful observation. When con- siderable quantities of urine are voided or the amount is 128 obstetrical lectures. seriously diminished, when casts and oedema are found, the patient should be put to bed for the greater part of the day, the bowels kept open, and milk diet and Basham's mixture given. Where an exclusive milk diet is impossible, milk soups, a slight amount of toast, the lighter vegetables—squash, asparagus, beets, salad, spinach, etc. —may be allowed in small quantities. Three grain doses of caffeine have given good results as a diuretic. Benzoic acid is also recommended. If, under this or any other more active eliminative plan of treatment, the symp- toms grow progressively worse, induction of abortion or prema- ture labor may be necessary. This should not be delayed too long. Serious eye symptoms always indicate it. Eclampsia can occur after the expulsion of the foetus. (c) Renal Tumors.—Rare. Are to be diagnosticated and treated according to the individual features of the case. (d) Dislocation of the Kidney.—The right is almost always the one affected. Not infrequently associated with displacements of the gravid womb. Abortion may result if it happens to become twisted upon its pedicle, and from pressure the kidney of preg- nancy may develop. (e) Diseases of the Pelvis of the Kidney.—(I) Pyelitis. Prema- ture expulsion of foetus apt to occur. It is met with much more frequently after labor. (2) Hydronephrosis. A displaced and adherent gravid uterus may occlude the ureters with this result. Requires reposition of the uterus. (3) Stone. Apt to induce abortion. Renal colic is to be treated in the usual manner. 2. Diseases of the Bladder. (a) Irritability.—Is functional, and occurs in hyperaesthetic individuals from pressure of the gravid womb. Treatment.—Reposition of uterus if displaced. When neurotic, nerve sedatives are indicated. (b) Incontinence of Retention.—Is the most common symptom of a backward displacement of the uterus. (c) Veskal Hemorrhoids.—Due to increased blood supply and pathology of pregnancy. 129 pressure of womb. Hacmaturia may be a symptom. If extreme, astringents may be injected. (el) Cystitis.—More frequent after labor; complicating preg- nancy, it may be due to gonorrhoea. (e) Vesical Calculi.—Important that they be discovered before labor, and removed through the urethra or by vaginal lithotomy. (/) Cystocele.— Complicates labor. (g) Injuries, Tumors, Extrophy.— Are- very rare, and should be treated as their individual peculiarities may indicate. 3. Anomalies of the Urine. (a) Polyuria.—An exaggeration of the physiological altera- tion. (6) The urine may be diminished in quantity and more concen- trated, as the result of errors in diet and inactivity of skin and bowels. (c) Lipuria.—Explained by the unusual quantity of fat in the blood of some pregnant women. An oiled catheter may be the source. (d) Chyluria.—Is of no pathological import. (e) Peptonuria.—Occurs in pregnancy in consequence of foetal death or without ascertainable cause. (/) Hemtduria.—Produced by vesical hemorrhoids usually. It may be caused by tumors, stone, acute nephritis. (g) Glycosuria.—Ranks next in importance to albuminuria. May be found in from sixteen to fifty per cent, of cases. Is said to be from absorption from the breasts, for the sugar is lactose and not glucose. Diabetes mellitus occurs more frequently in pregnant than in non-pregnant women, and when it exists before pregnancy, the latter condition increases its severity. In seven out of nineteen cases the disease determined ftetal death, and in four out of fifteen cases the mother died shortly after labor. (h) Albundnuria.—Found in six per cent, of pregnant women. Cause.—Kidney of pregnancy or nephritis. 9 130 obstetrical lectures. IV. Diseases of the Nervous System. 1. Brain. (a) Inflammatory Diseases.—Are accidental complications and rare ; exert no special influence upon pregnancy, nor do they specially modify the course of gestation, except cerebro-spinal meningitis, which is infectious, and therefore has the same influ- ence upon and is influenced in the same way by pregnancy as the other infectious fevers. (b) Anemia and Conejestion.—(See Eclampsia.) Apoplexy re- sulting from congestion has no influence upon the course of preg- nancy or labor. 2. Spinal Cord. Inflammatory Diseases.—Also accidental and without influence upon pregnancy and labor. 3. Paralyses. Paraplegia may be present and yet pregnancy and labor be uncomplicated. 4. Peripheral Nerves. Obstinate neuralgias, which are little benefited by treatment, and disappear after labor. It should be remembered that lo- calized pains of a neuralgic character, in the head, face, or breast, are a common symptom of advanced kidney disease in pregnancy. Multiple neuritis may be determined by pregnancy. 5. Neuroses. (a) Chorea.—Milder grades are not uncommon. Sixty per cent, of cases are in primiparae. Heredity, chlorosis, rheuma- tism and the existence of the disease in the patient's childhood are predisposing causes. In the graver variety premature ex- pulsion of the ovum is apt to occur, followed by death of the mother in about thirty-three per cent, of cases. Insanity often develops in these cases. Treatment.—Fowler's solution, iron, and nutritious diet for the milder cases. The graver cases may require an anaesthetic, and pathology of pregnancy. 131 finally induction of premature labor, which is usually followed by spontaneous recovery. (b) Epilepsy.—Comparatively rare. Usually does not influ- ence unfavorably the course of gestation. Convulsions often absent during pregnancy, but make their appearance again dur- ing and after the puerperium. It is most likely to be confused with Eclampsia (see Eclampsia). The infant frequently dies after birth, presenting the symptoms of the maternal disease. (c) Hysteria.—Occurs frequently in its minor grades, and, as a rule, does not exert an unfavorable influence. (d) Tetany.—Pregnancy may determine an attack, usually of mild grade, ending in recovery, but possibly fatal from interfer- ence with respiration. 6. Organs of Special Sense. (a) Eyes.—Failing vision should always indicate an examina- tion for advanced kidney disease. Occasionally there occurs complete temporary blindness, associated only with anamiia of the eye-ground, due to reflex contraction of the retinal artery. (b) Hearing.— Disturbances of this sense are rare, usually tem- porary, but may be permanent, and up to the present time are inexplicable. Some anomaly of the external auditory canal may be found, as a haematoma, which was the cause in one re- ported case. 7. Psychical Alterations. Melancholia, mania, dementia. Frequency.—Of all cases of insanity in women, about eight per cent, have their origin in child-bearing. About one in four hundred confined become insane. Causes.—(a) Predisposing.—Strain of gestation in those pre- disposed by hereditary influence ; temporary causes of mental disturbance ; great reduction in physical strength. (b) Exciting.—Exaggerated anaemia, as from prolonged lacta- tion ; septicaemia ; albuminuria ; profound emotions, as exagge- rated fear of impending danger ; dystocia, as hemorrhage after labor; great exhaustion, etc. Chorea results rather from the 132 OBSTETRICAL LECTURES. same predisposing causes, and should not be considered an ex- citing cause. Symptoms.—May be maniacal, melancholic or demented—i. e. exaggerated stupidity, lethargy, and mental confusion. Time of Occurrence.—Most frequently during puerperium, next in lactation, and least during pregnancy. Mania is the most frequent form, melancholia next, dementia last. Diagnosis.— Easy. Important to distinguish puerperal in- sanity from (1) the temporary delirium of labor, (2) delirium tremens, (3) the delirium of fever, especially septicaemia, and (4) preexisting insanity. Temporary Delirium of Labor. — Exceedingly common. Is usually momentary, and varies in degree from hilarity to exag- gerated mania. Delirium Tremens.—Labor, like an accident or surgical opera- tion, can precipitate an attack in hard drinkers. Delirium of Fever.— Most commonly due to septic infection. Oftentimes it is necessary to wait until the fever subsides to determine whether it be the cause of the mental symptoms. Preexisting Insanity.—Determined by the previous history. Prognosis.—About two-thirds recover their reason in three to six months ; of the other third, from two to ten per cent, die of septic infection or exhaustion ; the rest remain permanently insane. Treatment.—Modified rest cure, best carried out in an asylum, combined with administration of iron, arsenic, and nutritious diet, together with open air exercise and careful supervision to prevent any injury to themselves or attendants. V. Diseases of the Circulatory Apparatus. 1. Endocardium. Valvular disease of the heart usually has its origin prior to pregnancy. It may originate from septic infection. Prognosis.—Abortion is induced in about twenty-five percent. of cases as the result of placental apoplexies, or stimulation of the uterus to contraction by the accumulation of CO.. Preg- nancy also increases the danger of the heart lesion. In fifty- eight serious cases twenty-three died after premature deliver) PATHOLOGY OF PREGNANCY. 133 of the child. In milder cases the prognosis is not so grave, yet the danger is increased. Complications to be dreaded during gestation are : (a) a fresh outbreak of endocarditis, (b) fatty de- generation of the papillary muscles, and especially (c) congestion of the lungs. If the disease be of long standing and advanced degree, about half the cases will die. If recent and limited, the symptoms may only be aggravated. Treatment.—Same as under other circumstances. If maternal life is threatened, induce abortion or premature labor, guarding against a fatal result after the expulsion of the contents of the uterus by venesection should other organs become engorged, and by the application of pad and binder to prevent the ill effects of sudden diminution of intra-abdominal pressure. 2. Heart Muscle. (a) Suppurative myocarditis, only seen in connection with septic infection; (b) brown atrophy ; (c) fatty degeneration which may occur acutely in consequence of septic infection, or the accumulation of poisons in the blood when the kidneys are inactive. 3. Graves's Disease and Goitre Are unfavorably influenced by pregnancy. The former may have its origin in pregnancy. It predisposes to hemorrhages and foetal death. It may disappear after delivery. The latter may take on such an exaggerated development during pregnancy that asphyxia is threatened. 4. Bloodvessels. The disease of most clinical interest is varicose veins, in rectum, anus, pelvis, bladder, exernal genitalia and lower ex- tremities. In the last there may develop a pressure oedema. Causes.—Changes in the investing muscular sheath of the veins, increased quantity of blood, and mechanical disturbances by the growing uterus. Atheroma and degenerative changes may be found in the vessels as the result of kidney insufficiency. Complications. — Rupture with possibly fatal hemorrhage, or extensive extravasation of blood under the skin. Thromboses and phlebitis with suppuration and septic infection may occur. 134 obstetrical lectures. As the result of itching and scratching eczema or even erysipelas may develop. Treatment.—Elastic bandage or stocking when in the legs. Small doses of heart tonics may be given and constipation avoided. Absolute rest in cases of thromboses, to prevent em- bolism. Lead-water and laudanum when there is any inflam- mation. Abscesses should be opened. A mechanical protection should be applied to affected part to prevent the development of eczema or erysipelas, and itching may be relieved by weak solu- tions of carbolic acid or cocaine. 5. Blood. Pregnancy very often has a direct influence in producing those blood diseases which are characterized by a marked alteration in its constituent parts. Pernicious anaemia and leucocythsemia can have their origin in gestation, and should they already exist their prognosis is rendered more serious. Pregnancy may be interrupted by the existence of these blood diseases. The anaemia of pregnancy may be so exaggerated as to simulate these, yet arsenic, iron, and nutritious diet after delivery will usually effect a cure. Purpura hemorrhagica is apt to be rapid- ly fatal in pregnancy, which it always interrupts. Usually de- stroys the foetus. Death may be due to post-partum haemor- rhage or to sepsis. VI. Diseases of the Respiratory Apparatus. 1. Nose. The sense of smell is more acute, and peculiarities in this sense are developed, as abhorrence for certain odors, which may excite nausea and vomiting in neurotic individuals. More important is the disposition to epistaxis, which may be so severe as to threaten life. More frequently, however, this complication occurs during labor. It can only be relieved by the rapid termination of labor. 2. Larynx. If a tumor, tubercular or syphilitic disease be present, there f PATHOLOGY of pregnancy. 135 is a constant danger of (edema of the glottis, which will require tracheotomy. 3. Bronchi and Lungs. (a) Bronclwxl Catarrh ordinarily is not harmful, but constant coughing can cause abortion, and the hydraemic condition of the blood predisposes to pulmonary oedema. (b) Pneumonia. — Symptoms are much aggravated, mortality increased, and in the vast majority of cases the foetus is expelled prematurely. (See Pathology of Puerperium.) (c) Emphysema.—Quite common. Symptoms aggravated and abortion apt to occur. Inhalations of oxygen may be given to counteract the accumulation of COr (d) Asthma Gravidarum.—May only appear in pregnancy, and disappear the moment it is terminated. May only appear in labor. The attacks may be much aggravated by gestation and obstinately resist treatment. (e) Phthisis.—The influence of pregnancy upon this disease is most unfavorable, and in those predisposed gestation maybe the determining factor which brings on an attack. (/) Miliary Tuberculosis is rapidly fatal and may be mistaken for septic infection. (g) Pulmonary Embolism is a possible accident. (h) Pleurisy.—Exerts no deleterious influence upon, nor is it affected by, pregnancy. (/) Hemoptysis.—May occur in latter months of pregnancy Without phthisis or other lung disease. Often the result of " cardiac nerve-storms " in pregnant women. VII. Diseases of the Osseous System. Osteomalacia, a decalcification of the bones due to a peculiar ostitis and periostitis. Pott's disease, in its active stage, is aggra- vated by pregnancy, and the mortality is much increased. VIII. Infectious Fevers are always more serious when complicating pregnancy, their symptoms being more severe and mortality greater. Even measles at this time may become a deadly disorder. Upon pregnancy their influence is, as a rule, unfavorable. 136 OBSTETRICAL LECTURES. Sixty-five per cent, of typhoid cases are complicated by abor- tion. The infants may be idiotic if they go to term. Syphilis rather exerts its influence upon the foetus. Jf the mother is diseased before impregnation, the foetus and appen- dages exhibit characteristic pathological alterations. If the mother acquires the disease from the foetus, she may exhibit all the secondary signs without the appearance of a primary lesion. If she be infected during gestation, as a rule, the mother is affected, the foetus escaping, although the latter is not so absolutely exempt from infection as at one time claimed. Should infection occur at the time of impregnation the primary sore may become almost malignant, ulcerate into the vagina, resist treatment, and complicate the puerperal state. Treatment—All the infectious diseases are to be managed with little reference to pregnancy. If abortion is threatened, it should not be combated, as it is an effort on the part of nature to im- prove the maternal condition. IX. Skin Diseases, The following have their origin in pregnancy :— 1. Impetigo Herpetiformis. The favorite seat of the eruption is in the groin, around the umbilicus, on the breasts, in the axilla. The small pustules become crusts, around which new pustules develop until the entire surface of the skin in the course of three or four months becomes covered. Rigors, high intermittent fever, great pros- tration, delirium, and vomiting accompany the eruption. The disease appears, as a rule, during the second half of gesta- tion. Modern observation has shown that it is not absolutely confined to pregnancy. Of twelve cases ten terminated fatally, but they exercised no influence upon the course of gestation. 2. Herpes Gestationis Is characterized by a pemphigoid efflorescence, exhibiting ery- thema, papules, vesicles, and bullae. It appears early in preg- nancy, continues during gestation, and disappears during the PATHOLOGY OF PREGNANCY. 137 puerperal state. Neurotic symptoms are associated with it, showing its probable nervous origin. 3. Pruritus. Its usual seat is the external genitalia. It may be general. Causes.—Neurosis ; irritating discharges ; parasites. Rarely in the general variety it may be necessary to induce premature labor. 4. Exaggerated Pigmentation. Spots of pigmentation may appear on breasts, thighs, and abdomen as large as ten cent pieces or a quarter. The chloas- mata on the face may be exaggerated. X. Injuries and Accidents. Severe injuries usually result in abortion. The most serious accidents of pregnancy are those which cause rupture of some of the lareje bloodvessels of the external genitalia or lower ex- tremities. One of the rarest accidents is spontaneous rupture of the uterus. It may occur in consequence of a previous (Cesarean section; chronic inflammation and degeneration of the uterine walls, reducing them to little more than connective tissue; traumatism ; a former rupture of the uterus which has healed, but left a weak spot in the uterine wall, closed by cica- tricial tissue. Spontaneous rupture of the uterus in pregnancy almost always occurs at the fundus, and frequently at the pla- cental site. A very serious accident of pregnancy is detach- ment of a normally situated placenta with internal hemorrhage. (See page 202.) XI. Surgical Operations. When life or health is seriously threatened by delay until recovery from the puerperal state, surgical operations upon pregnant women are justifiable, and permission may be given for their performance without very great fear of inducing there- by an abortion if septic infection is avoided. Upon nervous and irritable women, however, slight operations may induce abortion. 138 obstetrical lectures. XII. Abortion, Miscarriage, and Premature Labor. Abortion.—Expulsion of ovum before the fourth month. Miscarriage. —Expulsion from the fourth to the sixth month. Premature Labor.—Delivery of a foetus that has become viable. Frequency.—Correct estimate difficult. One to four or five pregnancies. Causes. — (1) Death of the foetus; (2) abnormalities and diseases of the membranes, including the decidua?; (3) patho- logical conditions of the placenta and apoplexies of the ovum : (4) traumatism ; (o) certain diseases of the mother directly affecting the product of conception (see Diseases of the Mem- branes and Foetus) ; (6) conditions of the mother causing con- traction of the uterine muscle and premature expulsion of the normal ovum. The last cause includes the following :— (a) Irritable Uterus.—The expulsion, in such cases, results from a trivial cause, as a long walk, purgatives, jolting, con- gestion of the pelvic organs, chronic constipation, reflex irrita- tion as from suckling, extraction of a tooth, pruritus, ovarian disease, sea-bathing. Even the sight of another woman in labor has been known to cause abortion. At the menstrual epoch these causes are most liable to produce abortion. Ib) Sjjasmodi<- muscular action in the mother. 1. (Jliona.- Less than half the cases go to term. The prema- ture expulsion of the ovum explained by physical exhaustion, blood stasis, and excess of C02 in the uterine muscle stimula- ting to contraction or by choreic movements of the uterus. 1. Eclampsia. More than one-half the cases abort as the result of asphytfia* of the uterus, accumulation of urea, carbonate of ammonium or ptomaines, or due to the convulsive action being shared by the uterus. 3. Uncontrollable vomiting and cowjhing. Of 51 cases 20 were delivered before term. 4. FJpihptic, hys- terical, cholermic, and tetanoid convulsions. (c) Conditions of the maternal blood which stimulate the uterus to expulsive ejforte. 1. Poisons of all tlie infectious fevers. It is yet undecided PATHOLOGY OF PREGNANCY. 139 whether the abortion is due to irritative action of micro-organ- isms, leucomaines, or to a diminution of the oxygenating power of the blood. 2. Acnumulcdion of CO,. When there is an accu- mulation of CO.,, as in pneumonia, heart disease, emphysema, etc., inhalation of oxygen may be given with some hope of suc- cess. 3. Fever. (d) Local conditions. 1. Tubal or ovarian disease, with perimetritis and adhesions, or other inflammatory diseases in the neighborhood of the uterus, as ap- pendicitis. 2. Fibroids, polyps. 3. Uterine displacements. 4. Lacerations of the cervix in irritable uteri. 5. Over-distention from hydramnion or multiple pregnancy. (e) Placenta prasvia, obesity, contagious abortion. These are rare causes, and the last are really cases of septic infection. Many of these causes may be operative in a number of succes- sive pregnancies, producing the so-called " habitual abortions." Clinical Phenomena.—1. Hemorrhage. 2. Pain. 3. Expul- sion of some portion of the ovum. All three are rarely typi- cally manifested in every case. Their duration varies from almost instantaneously to days or weeks. In early abortions hemorrhage is more pronounced than pain, and the blood is extruded in coagula. The appearance of the substance ex- pelled varies with the period of pregnancy and entirety of the product of conception. The chorional coat may be entire, the deciduae may surround the embryo, or it may be surrounded by the amnion. Most frequently the decidua vera remains be- hind, and hence the danger of sepsis. Mortality.—In 1012 cases there were 14 deaths, a mortality of 1.38 per cent. Of 116 criminal abortions 60 died. Diagnosis.—(a) Threatened abortion. Hemorrhage, and more or less pain in a patient with signs of early pregnancy. (b) Inevitable abortion. Persistent hemorrhage ; dilatation of os; ovum presenting ; considerable pain ; portions of ovum ex- pelled ; effacement of the angle between the upper and lower uterine segment (Tarnier). Exceptionally one or more of these may be present and the case go to term. (c) Incomplete abortion. Examination of fragments discharged by floating them in water. Digital examination will usually find 140 OBSTETRICAL LECTURES. the os patulous, and detect shreds of deciduae, the placenta or foetal membranes in the uterine cavity. (d) Complete abortion. Uterus is firmly contracted ; os retracted and digital examination of the uterine cavity difficult or impossi- ble. The diagnosis must depend upon the history ; the exami- nation of the discharge ; the enlarged uterus ; lochial discharge, and possibly the establishment of milk secretion, which is more marked the later the date of pregnancy. Finally, the disap- pearance of the presumptive signs of pregnancy which had previously existed. Diagnosis of Miscarriage.—Escape of liquor amnii indicates rupture of the membranes. As the result of the death of the foetus, there is a cessation of foetal movements and growth of the uterus, a disappearance of the reflex and psychical disturb- ances characteristic of pregnancy, and possibly the appearance of the milk secretion. The pain is greater than in abortion and is more like labor pain. At this stage of pregnancy the placenta is intimately adherent to the uterine wall, and often fails to be- come detached. For this reason the hemorrhage is apt to be serious and the danger of sepsis great. Prognosis of Abortion and Miscarriage.—The ovum is inevitably destroyed. The dangers to the woman are hemorrhage, particu- larly its secondary effects, and sepsis. Retained fragments may develop into polypi. Treatment.—(a) Preventive. Includes the treatment of the causes that may exist in any given case. Enjoin rest at men- strual epoch, and restrain sexual intercourse where there is an irritable uterus. Replace a displaced uterus ; before impregna- tion repair a lacerated cervix ; treat any inflammatory condition about the uterus. If it be due to any of the general diseases, do not attempt to prevent the occurrence of the abortion. (b) Threatened Abortion. Absolute rest in bed. Drugs to diminish nervous sensibility and muscular action, as opium, potassium bromide, chloral. Opium should be given in full doses by the mouth, hypodermatically, or by the rectum. The fluid extract of viburnum prunifolium in drachm doses is very efficient. It may be combined with opium, administering the latter by suppository. PATHOLOGY OF PREGNANCY. 141 (c) Inevitable Abortion. If the hemorrhage is profuse before dilatation of the os occurs, control the bleeding by vaginal tam- pons of antiseptic wool or baked cotton. Remove in eight hours and reapply if required. Often when the first one is removed, the ovum or fcetus may be found extruded, when the urgent symptoms may subside. Intrauterine tampons of little balls of iodoform cotton or strips of iodoform gauze may be used if re- quired. Deciduous membrane in the earlier months, the placenta in the later, are apt to remain behind. The best method to em- ploy for their removal is a disputed question. The expectant plan combines the use of ergot, tampon, and great care to avoid rupturing the membranes. If the abortion be incomplete, rest in bed, small doses of ergot, vaginal, aud, if possible, intrauterine, antiseptic douches. At the first indication of sepsis, or if hemor- rhage persists after the expulsion of a part of the ovum, the uterine cavity should be cleared out. The active treatment, which is the better plan, is the use of the tampon to control bleeding, and as soon as the os is sufficiently dilated, the removal of the uterine contents by one of the fol- lowing methods : The finger ; the curette in experienced hands ; the method of expression (Hoening) ; the placental forceps ; after which an intrauterine douche of a two per cent, solution of creolin should be given. If needed, Hegar's dilators may be used to stretch a retracted os. After-Tradment—Very little required after active treatment beyond confinement to bed until involution is complete. When the expectant plan has been followed, antiseptic douches are to be used, and the earliest sign of sepsis looked for. XIII. Missed Abortion. By this term is meant the death of the embryo, threatened abortion, the subsidence of symptoms and the retention of the ovum for a varying length of time—occasionally very great—in utero. XIV. Extrauterine Pregnancy. Frequency. — The exact proportion to intrauterine gestations is difficult to determine. It is said to be about 1-500. In the 142 OBSTETRICAL LECTURES. larger cities a large number occur annually. Many cases are never diagnosticated. Classification based upon tlie Situation of the Developing Ovum.— 1. Tubal. (a) Tubo-uterine or interstitial. (b) Tubal proper. (c) Tubo-ovarian. 2. Ovarian. 3. Abdominal. Secondary abdominal. (a) Tubo-abdominal. (b) Utero-abdominal. Cause.—Obscure. Any disease of the mucous membrane of the tube depriving it of cilia, forming mucous polyps or other- wise obstructing its calibre, predisposes to its occurrence. Peri- toneal adhesions constricting or distorting the tube and con- genital narrowness of the tubes are also causes. A diverticu- lum in the tube and an accessory tubal canal have been noted. Clinical History.—In each of the situations noted above, the course of gestation is somewhat different, and presents a dif- ferent clinical picture on account of the difference in the sur- rounding anatomical structures which are involved. The gen- eral presumptive signs of pregnancy.are usually the same as in intrauterine gestation, but there is apt to be considerable pain. Occurs oftenest between 20th and 30th year. Youngest woman, 14; oldest, 47. Changes in Uterus and Vagina.—In all forms these changes are rather constant. Most of the alterations characteristic of intrauterine pregnancy are found, i. e., hypertrophy of the vaginal mucous membrane, with increased blood supply (pur- ple tinge) and increased secretion ; cervix softened and os patu- lous ; uterus enlarged, and, in the vast majority of cases, de- ciduous membrane developed, which undergoes the same change as in intrauterine gestation preparatory to its separa- tion and extrusion, which occurs in extrauterine gestation between the eighth and twelfth week, as a complete cast of the uterus and even of the tubes or in shreds. The common PATHOLOGY OF PREGNANCY. 143 course is absence of menstruation until the death of the em- bryo or rupture of the sac when the menses return with discharge of decidua and metrorrhagia may continue for a long time. The other changes in the maternal organism vary with the situation of the developing ovule. Clinical History of Tubed Pregnancy.—Usually the woman has had children, but a long interval has elapsed since the birth of the last child. The most frequent situation of an extrauterine gestation is about the median portion or outer third of the tube. In this position it may grow upward into the abdominal cavity distending the tube walls to the point of rupture, or it may grow downward between the layers of the broad ligament, and then backward and upward behind the posterior parietal layer of the peritoneum. The tubal walls grow thicker from the de- velopment of their muscle fibres, except at spots, especially on upper and posterior surfaces, where rupture may occur, the individual, perhaps, experiencing severe cramp-like pain, fol- lowed by symptoms of profound shock and death in a few hours. Fever is often seen, sometimes to a high degree, even before rupture occurs. Exceptionally, the gestation may proceed to full term, which is more common when the ovule has at first grown downward. When rupture occurs it usually takes place between the eighth and twelfth week, but may be seen as early as the 30th day or after the sixth month. If upon the upper or posterior aspect of the sac, the contents are extruded into the peritoneal cavit}' with an intraperitoneal hemorrhage. If rupture occurs on the lower aspect, the contents and hemor- rhage find their way between the layers of the broad ligament and pelvic fascia, giving rise to an extra-peritoneal haemato- cele. The first variety is usually fatal; the last is not always directly dangerous to life. But the layers of the broad liga- ment may rupture when distended with blood, and the bleed- ing then becomes intraperitoneal and unlimited. The bleed- ing may also be limited by peritoneal adhesions shutting off the peritoneal cavity and forming a closed sac in the iliac region. From adhesions to intestines complications, such as perfora- tion and obstruction of the bowel may occur. There may be 144 OBSTETRICAL LECTURES. multiple (twin) extrauterine gestation; coincident intra- and extrauterine pregnancy and pregnancy first in one tube and then in the other. Clinical History of Interstitial Pregnancy.—The ovule develops in the uterine wall, the inner side of the sac often projecting into the uterine cavity, and having on the outer side the round ligament and a greater part of the tube. The usual termina- tion is rupture into the peritoneal cavity. Rupture into the uterine cavity and expulsion of the ovum through the cervix are possible. Clinical History of Tubo-ovarian Pregnancy.—The ovum de- velops between the fimbriae of tube and ovary. The sac may rupture with the usual consequences of such accident. It is possible, however, to see a development of the ovule to matur- turity. The ovule may lodge upon the ovarian fimbria and thence grow between the layers of the broad ligament. Clinical History of Ovarian Pregnancy.—The ovule, impreg- nated while it is still within the Graafian follicle, reaches some degree of growth and development in this situation. Is ex- ceedingly rare. A few undoubted cases on record. One case in Philadelphia went to term. Clinical History of Abdominal Pregnancy.—Also rare. Several authenticated cases. Is likely to go to full period of gestation and mature development of foetus. In this and the preceding variety there is a sort of decidua formed from which the chor- ion and placenta draw nutriment. In abdominal and advanced tubal gestation the liquor amnii is absorbed after the death of the foetus. The abdomen is consequently reduced in size and the tumor is changed in consistency. Clinical History of Utero-abdomined Pregnancy.—Very rare. The pregnancy is at first intrauterine, but the ovum escapes into the abdominal cavity through an opening in the uterine wall, retaining some connection by the placenta, with the uterine cavity. The process of extrusion must be gradual. These cases follow either the Caesarean section or rupture of the uterus at a previous labor. The fcetus may advance to term. PATHOLOGY OF PREGNANCY. 145 Terminations of Extrauterine Pregnancy. (a) Death and absorption of early embryo with absorption of liquor amnii, ettrophy and disappearance of gestation cyst. (b) Rupture of the Sac and Profuse Hemorrhage.—Occurs most commonly in the tubal variety, where the growth is upward toward abdominal cavity. May occur when the ovule grows down between layers of broad ligament; also in tubo-uterine, tubo-ovarian, ovarian and abdominal. Up to second month the extruded embryo may be absorbed. The hemorrhage may be fatal in a short time, two hours; usually takes from 8 to 16 hours for the woman to bleed to death, and maybe longer. The hemorrhage may be fatal as late as the second, third, or fourth day, or there may be successive hemorrhages, perhaps days apart, until the patient is gradually exhausted or is suddenly destroyed by an unusually profuse outpour of blood. Surpris- ingly small tubal gestation sacs can on rupture give rise to fatal hemorrhage. The determining cause of rupture is not always apparent. It can occur while the patient is lying quietly in bed: but may follow the straining of defecation or urination, coitus, a gynaecological examination or an operation like curet- tement, or any sudden physical effort or mental excitement. Rupture of the sac or of a bloodvessel in its wall, with pro- fuse hemorrhage, has occurred long after the destruction of the embryo and cessation of growth in the sac (two years in one case). (c) Rupture of sac with extrusion of contents, and interstitied hem- orrhage into sac walls without escape of blood into peritoneal cavity or between layers of broad ligament.—This is followed by atrophy of ovum and sac. (d) Death of the Fcetus after third month.—Occurs most often in abdominal or tubo-ovarian, though possible in pure tubal. 1. The fcetus may be converted into a lithopaedion or be mum- mified, and in these conditions removed by operation through abdomen, vaginal vault, or possibly the rectum. 2. The soft parts may macerate, leaving the bones, which may remain as an abdominal tumor or ulcerate into bladder, intestines or through anterior abdominal wall. 3. The foetal body may pu- 10 146 obstetrical lectures. trefy from contiguity of the intestines and their contained mi- cro-organisms and access of germs. Or from the same cause the sac is converted into an abscess. (e) Termination of Ovarian Pregnancy.—Arrest of development of the ovum at an early period occurred in one case, and the small cystic tumor containing the foetal bones was retained. In another the foetus went on to full development, died, and was removed at least one year later. Rupture of the sac and profuse hemorrhage may occur. (/) In tubo-uterine, the ovum and embryo may be discharged into the uterine cavity and evacuated by the natural passages. Two authenticated cases. Rupture and hemorrhage into peri- toneal cavity are more usual. (g) In cases of so-called tubal abortion there is an internal rup- ture of the ovum, and blood is poured through the fimbriated extremity of the tube into the abdominal cavity. (h) It is asserted that a tubal pregnancy may rupture in its early stages, the embryo be expelled into the abdominal cavity, retaining its connection with the tube b}r the cord and placenta, and the foetus continue to full development. This is called a secondary abrfomincd pregnancy. Rupture in these cases has pro- bably not occurred, and the sac wall carefully examined would probably show enormous dilatation of the tubal wall. (f) Growth and development of the placenta after foetal death.— This has been asserted, but does not occur. (j) Profuse Hemorrhage into gestation sac, forming a large hivmatoma. Ik) Hsematoceles and Htematomata in the abdomen, pelvis and . pelvic connective tissue in a third or more of the cases are due to the hemorrhage from a ruptured gestation sac. The blood may collect in front of'the uterus (anteuterine haematocele), more commonly behind the uterus (retrouterine haematocele); may be encapsulated in the neighborhood of either broad ligament or may be contained in the pelvic connective tissue on either side of the uterus. These collections of blood may suppurate and thus prove fatal. They can be evacuated through the ab- domen or often through the vaginal vault. If not too large, they are absorbed. PATHOLOGY OF PREGNANCY. 147 Symptoms.—Uncertain, (a) Subjective. In the early months may be indistinguishable from those of intrauterine gestation. In the tubal variety, which is more common, there is often no indication of any abnormality until rupture occurs. In some cases this may be preceded by severe cramp-like pain in one or the other iliac region, accompanied or followed by the discharge of deciduous membrane. The temperature may at the same time be elevated and the general health much impaired. When advanced development occurs, as in abdominal and some cases of tubal, no symptoms may arise until the time for labor has passed, when pain and other complications may arise. There is usually cessation of menstruation for one or two periods; then a return in the shape of irregular bleedings which may last for months. In some cases irregular bleedings begin with conception and last till rupture—there is no cessa- tion of menstruation. In others one period is slightly delayed ; those after and before are normal. Again, the delayed period may be unnatural in character. In exceptional cases the men- struation occurs at the normal time, but is more profuse or scantier than normal. Other symptoms noted have been : irritable bladder or dysu- ria; marked constipation or even obstruction if the tumor is on the left side; oedema of the corresponding limb and aching pain in it, especially at the groin; or numbness and even loss of power. Pulsating vessels may be felt in the vaginal vault. (b) Objective. 1. Tubal. Tumor felt to one side of, behind, or possibly in front of the uterus, which is smaller than would be expected from the duration of the pregnancy. In advanced cases ballottement may be practised. The uterus is usually displaced forward, backward, or to the side opposite the tumor. If the discharged membrane can be obtained it will present characteristics of decidua in fragments or as a complete cast of the womb. 2. Interstitial. Diagnosis difficult or impossible. The uterus enlarges to a greater degree than in any other variety, and it may be impossible to determine whether or not it is symmetri- cally enlarged. 3. Abdominal. When the ovum occupies Douglas's pouch, 148 OBSTETRICAL LECTURES. the foetal parts may be made out. A sacculated uterus may be mistaken for this. Diagnosis.—In spite of a most careful history and physical examination, the diagnosis is occasionally impossible. Usually it is not made until rupture has occurred. At this time a his- tory of early pregnancy, sudden collapse, and symptoms of in. ternal hemorrhage, with abdominal distension and a vaginal examination showing effusion into peritoneal cavity, makes the diagnosis and indicates immediate laparotomy to prevent further hemorrhage and peritonitis. These symptoms have been pretty closely simulated by rupture of a varicose vein in the broad ligament and by rupture of an ovarian cyst or other pelvic tumor during pregnancy. But as all these conditions demand the same treatment a mistake in diagnosis between them is of no consequence. Should the cramp-like pain cause a patient to consult a physician, and should she give a clear history of impregnation—all the earlier signs of pregnancy, the discharge of blood and membrane which the microscope shows to be decidual, with the detection of a very sensitive tumor in the neighborhood of the uterus on which ballottement may perhaps be practised and the uterus not very much enlarged —the diagnosis is justified, and treatment also, even if it involve a serious operation. Among the conditions in the pelvis that may make the diagnosis impossible are abortion, in conse- quence of, or coincident with, some growth near the uterus; pyosalpinx, with an indistinct or untrustworthy history of pregnancy; intrauterine pregnancy, with rapid development of a fibroid on one side of the uterus ; development of an im- pregnated ovule in one horn of a two-horned uterus or on one side of a double uterus. Prognosis.—About two-thirds die; one third spontaneous cure. Treated by abdominal section the mortality is about 5 per cent. Of those that do not die directly in consequence of the tubal gestation a large proportion are invalids, and many die at a re- mote period from various complications, as bowel obstruction ulceration, suppuration or hemorrhage. Treatment.—Differs as it is met with in its early stage, or after rupture; whether interstitial, tubal, ovarian, or abdomi- PATHOLOGY OF PREGNANCY. 149 nal; whether the foetus has reached advanced development, as in abdominal; whether the conditions following foetal death require the treatment. If the diagnosis has been made early, laparotomy and removal of the foetal sac. Electricity is an uncertain and unreliable remedy, and the cures ascribed to its use are most likely the result of nature's effort to effect a cure. Laparotomy is more trustworthy, and in these cases is almost always a difficult operation, not to be undertaken by an unskilled operator. In favorable cases, in which a trained nurse may be kept in con- stant attendance, and in which the physician can reach the patient quickly, it is justifiable to wait, after diagnosticating extrauterine pregnancy, to see if the embryo does not die and the sac atrophy—quite a frequent occurrence. After rupture the indication is for immediate laparotomy, evacuation of the blood from peritoneal cavity, ligature of the sac, and its entire removal. Rupture followed by hemorrhage is, however, not invariably fatal. In interstitial little can be done until rupture and hemorrhage have occurred, when laparotomy may be performed, ligating the bleeding point, and, if possible, clearing the sac of its contents, along with the placenta. Where this is impossible, ligation of the uterine and ovarian arteries is indicated, or possibly supra- vaginal amputation of the uterus. It might be well, the diag- nosis being established, to try to effect evacuation of the foetal sac into the uterine cavity after thorough dilatation of the cer- vical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intrauterine pregnancy, Tubal and ovarian are to be treated as outlined above, when discussing the treatment of early extrauterine gestation and after rupture. In eidvunced extrauterine pregnancy always delay until just before the natural duration of normal pregnancy, when the foetus and foetal sac should be extracted by abdominal section. Five such operations have been done, with five maternal re- coveries. When death of the fcetus has occurred, it is best not to subject the woman to the danger of the several possible termi- nations, but to perform laparotomy and remove the foetus and 150 OBSTETRICAL LECTURES. its entire surrounding sac. If the exsection of the sac is found to be too difficult or dangerous, it is permissible, some weeks after foetal death, to cut off the cord short, leave behind the atrophied remains of the placenta, stitch the sac wall to the abdominal wall, and thus drain the sac externally. In case the gestation sac is low down in Douglas's pouch, bulging the pos- terior vaginal wall, vaginal section and the delivery of the foetus by the natural passage may be considered, but it is, as a rule, too dangerous, the mortality being about 50 per cent. It is applicable in case of an old gestation sac undergoing suppura- tion and containing a much macerated or disintegrated foetus. XV Pregnancy in One Horn of a Uterus Bicornis or Unicornis. Pregnancy in an ill-developed horn of the uterus may exact- ly resemble a tubal or interstitial pregnancy, and may end in rupture. This is particularly true if the impregnated ovule develops in a rudimentary horn, in which the conditions are almost the same as in a tube, except that rupture takes place later. On the other hand, a pregnancy of this sort may ter- minate prematurely, or even at term, by expulsion of the prod- uct of conception through the natural passage. The diagnosis of pregnancy in a uterine horn is difficult or impossible. It is mistaken, usually, for tubal gestation. Labor. Physiology. Labor occurs usually 280 days, after the appearance of the last menstrual period. Causes of Occurrence at this Time. [a) Periodicity.—The muscular action at the periods is espe- cially marked at the tenth. (6) Over-distention of Uterus, followed by lietraction. (c) Maturity of Ovum (fatty change of attachment). [d) Heredity, or Body Habit, which is, perhaps, the most powerful. At this time slight causes, as exercise, purges, ex- citement, may begin the process. SUtlti^^^i LABOR. 151 Signs of Beginning Labor. (a) Subsidence of Uterus.— This is a premonitory sign. Occurs about four weeks before term in primiparae, two weeks or less in multiparae. Cause.—Over-distention of abdominal muscles. It may occur suddenly, and be followed by relief of pressure symptoms above, while those below may be increased, as excessive vaginal secre- tion, (edema, etc. If it does not occur, it indicates a malposition of the foetus, or some obstruction, as contracted pelvis. (b) Pains.—Are colicky, intermittent; felt over the sacrum, or beginning in front and passing back to sacrum. (c) Blood-tinged Mucus.—Due to expulsion of the mucous plug in cervix and torn cervical vessels. (d) Dilatation, of Os.—The most important. Rare exceptions should be noted in which the labor is arrested for days or weeks with the os dilated to an inch or more, and the membranes pro- truding into the vagina. When the os is found dilated about one-half, labor is not infrequently terminated four to four and a half hours later. Clinical Signs of Labor. (a) Contractions of Uterine Muscle.—At each contraction the uterus drives the liquor amnii through the cervix, diminishes the area of intrauterine space, and produces an expansion of the birth canal. The contraction lasts about a minute, recur- rincr at intervals of ten to fifteen minutes, which decrease as labor advances. (6) Behavior of the Patient—For about the first ten hours the sacral and abdominal pains are increasing in frequency and severity. During the second stage the voluntary muscles are brought into play, as shown by her straining and bearing-down efforts, the pains increase in frequency and strength, and there is a desire to empty bladder and rectum. (c) Phenomena of Birth of Head and Shoulders. — The head retracts after each pain, and there is an intense pain and outcry as the head passes the perineum. Restitution is followed by birth of anterior shoulder. A condition of contentment and happiness succeeds the 152 obstetrical lectures. birth of the child until the uterine and abdominal contrac- tions endeavor to separate and expel the placenta. These pains may be delayed beyond fifteen minutes in many cases. Phenomena of Placental Separation and Expulsion.—The pla- centa is separated by a diminution of the placental area, and is expelled like an inverted umbrella. The pouch-like dilated lower uterine segment often contains the placenta, hence artificial aid in its complete expulsion is often required. A slight elevation of temperature is normal directly after labor. Management of Labor. Summons to an obstetric case should receive immediate atten- tion. (a) Armamentarium.—Ether, brandy, vinegar, a large new sponge, pads, clothing for mother and child, fountain syringe, should be provided before confinement. The obstetric bag should contain: soap, nail-brush, tablets of bichloride, 5 per cent, carbolized vaseline, iodoform tape or antiseptic Chinese silk, pocket-case with sutures and needles, needle-holder, ergot, hypodermic syringe, iodoform gauze, absorbent cotton, forceps; a small faradic battery is desirable. (b) The Examination.—Abdominal palpation and auscultation should determine the position and presentation; touch should ascertain the state of the perineum, dilatability of vagina, and its secretions, roominess of pelvis, condition of cervix, effec- tiveness of pains, and should confirm diagnosis of presentation. (c) Treatment of the First Stage.—The bowels should be evacu- ated by an enema (soapsuds Oj, turpentine 3j), urine voided, patient allowed to remain out of bed, examinations to be made at intervals of an hour or hour and a half, and when the os is the size of a silver dollar the patient should be put to bed, lying on that side toward which the back of the fcetus looks. (d) Ancesthesia.—Cocaine and belladonna locally are not effec- tive. Chloroform is not dangerous. Ether is preferable, except in eclampsia. By giving it only in the second stage its admin- istration for too long a time is avoided, and by producing only '$ per cent, of all cases the breech presents, and in about one- half of 1 per cent, the foetus will be transverse. Explanation of the Great Frequency of Cephalic Presentations.— Assumption of that position by the foetus, because it affords it the greatest degree of comfort and the best opportunity for growth and development. Explanation of the Great Frequency of Presentation of the Vertex. —Mechanical arrangement of fcetal head and body, diagram- matically represented by two bars attached to one another ; that representing the head joined to that representing the spinal column, not at its middle, but at a point nearer one end of the bar (~T )■ An equal force exerted upon this mechanical arrange- ment will result in the greater flexion of the longer bar, which represents that portion of the foetal skull in front of spinal column. Positions of Vertex Presentations. —There are four: 1. L. O. A., left occipitoanterior, the occiput looking to left acetabulum. 2. R. O. A. 3. R. O. P., right occipito-posterior, the occiput looking to right sacro-iliac joint. 4. L. O. P. Of all vertex cases 70 per cent, are L. O. A., 30 per cent. R. O. P. Explanation of Frequency of L. O. A. and R. 0. P.—The posi- tion of the rectum shortening the left oblique diameter and the projection of the spinal column to which the foetus adapts its anterior concave surface, the back thus looking forward and turned a little toward the right because of the right lateral ver- sion of the pregnant uterus. Forces Involved in the Mechanism of Labor. 1. .Forces of Expidsion :—■ Uterine muscle. Abdominal muscles. 2. Forces of Resistance:— Lower uterine segment, cervix, vagina, vulva. Pelvis. Fcetal body. The forces of expulsion are furnished by a great part of the uterine muscle (upper uteriue segment) and muscular action of 164 obstetrical lectures. the abdominal wall. (That portion of the uterine canal which must be dilated to allow the escape of the foetus is called the lower uterine segment; that portion above the point at which the dilatation ceases, i. e., the contracting muscle, is called the upper uterine segment; the boundary line between these, often marked by a perceptible ridge, is called the contraction ring.) The Manner in which the Uterine Muscle Exerts its Force upon the Foeted Body.—By a diminution of the intrauterine area. The abdominal muscles diminish the area of intra-abdominal space. The degree of force exerted by their combined action has been given as from 17 to 55 pounds. The forces of resist- ance are furnished by that portion of the parturient tract which must be dilated, i. e., from contraction ring to vulva, including (a) the lower uterine segment, cervix, vagina, and vulva. The dilata- tion of lower uterine segment and cervix is not simply mechani- cal, the serous infiltration of lymph spaces lessening the tendency to contraction and retraction. The dilatation of cervical canal is also assisted by the longitudinal fibres drawing the cervix up over the presenting part. Below the cervix, dilatation is effected mainly by the mechanical stretching of its walls. (b) The bony wedls of the pelvis.—Only offer sufficient resistance to so delay the progress of presenting part as to insure gradual dilatation of the soft resisting structures. (c) Foetal body.—Head most important. The foetal head may be divided into yielding and unyielding portions. The yielding consists of the cranium, composed of the frontal (2), temporal (2), parietal (2), and occipital bones. These are separated from one another as follows : The two frontals by the frontal suture ; the frontal from parietal by coronal suture ; the two parietal by sagittal suture ; the two parietal from occipital by the lambdoidal suture. At junction of lambdoidal and sagittal sutures there is a membranous space called the posterior fontanelle, triangular in shape. At junction of frontal, coronal, and sagittal sutures there is also a membranous space called anterior fontanelle, kite-shaped, larger than the former. This portion of the skull yields by overlapping of the bones. The unyielding portion comprises face and base of skull. The bones here are fixed. MECHANISM of labor. 165 A transverse vertical section of the skull is wedge-shaped, taperiug toward the neck. Possible Presentations of the Head. — Vertex. That conical portion with apex at smaller fontanelle and base at the plane of the biparietal and trachelo-bregmatic diameters. Face. Brow. Larger Fontanelle. Parietal Eminence. Mechanism of the Several Presentations and Positions. L. O. A. Diagnosis.—By abdominal palpation, auscultation, and vagi- nal examination, the back is found to the left, extremities to the right above, bead below, heart sounds one inch below and to the left of umbilicus; the examining finger detects vertex presenting, occiput toward left acetabulum and sagittal suture in right oblique diameter of pelvis, and smaller fontanelle, recognized by the junction of lambdoid and sagittal sutures, the top of occipital bone overlapped by parietal bones. 1st Step.—Accommodation of size of foetal skull to pelvis by flexion, and accommodation of shape of foetal skull to shape of pelvic inlet by moulding. (Occurs before the onset of labor.) 2d Step.—Further flexion and moulding. (Occurs at the beginning bf labor.) 3d Step.—Lateral flexion of the head, the left ear approach- ing the left shoulder, and the right parietal bone presenting. This is to accommodate the direction of the child's body and head to the direction of the parturient canal. lfth Step.—Dilatation of lower uterine cavity and cervical canal. 5th Step.—Descent of head to pelvic floor by extension of fcetal spine. 6th Step.—Anterior rotation of occiput. Cause.—The head driven through the funnel-shaped parturient canal and meeting the resisting pelvic floor moves in the direction of least resist- ance, i. e., anteriorly toward median line. 7th Step.—Propulsion and extension of the head until it is delivered. 8th Step.—Restitution. (A theoretical movement not often seen.) 166 OBSTETRICAL lectures. 9th Step.—External rotation. 10th Step.—Descent, rotation, and birth of shoulders. 11th Step.—Delivery of remainder of the body. Abnormalities in Mechanism. (a) Flexion at Inlet—Imperfect vertical flexion in flat pelvis. Conservative on the part of nature to bring bitemporal diameter (8 cm.) in relation with contracted conjugate. Associated with this we find anomalies of position and lateral flexion, i. e., the occiput situated transversely, the sagittal suture in transverse diameter of the pelvis and the lateral flexion exaggerated as the result of the increased obliquity of pelvis to trunk and increase of conjugato-symphyseal angle. This is accompanied by over- lapping of the right (anterior) parietal bone. In exaggerated lateral flexion the anterior parietal bone or even the ear may present. (b) Direction.—In anterior displacements of the pregnant uterus, there is an abnormal backward direction of the present- ing part. (c) Rotation.—Abnormal weakness in resistance or propulsion results in incomplete rotation. (d) Vertical Flexion at Outlet—Incomplete when head does not encounter normal resistance in pelvic cavity. (e) Extension.—Failure of extension of the head occurs as the result of weakness or destruction of the levatores ani muscles. (/) .Restitution.—Fails when neck is a long time twisted or tightly gripped by the vulva. (g) External Rotation.—Dae to failure of rotation of shoulders. Is of frequent occurrence. (h) Anomalous Descent and Rotation of Shoulders. R. O. A. Diagnosis.—Palpation reveals back to the right anteriorly; extremities to the left above ; head below. Heart sounds near median line below umbilicus. Digital examination shows small fontanelle toward right acetabulum; sagittal suture in left oblique diameter. Mechanism.—Does not differ from the mechanism of L. O. A., MECHANISM OF LABOR. 167 except the occiput being directed toward the right acetabulum, rotation of head and face occurs in the opposite direction, i. e., the occiput rotates anteriorly, moving from right to the left. R. O. P., AND L. O. P. Posterior positions of the occiput are primary or acquired. Primary when head enters inlet with occiput posterior (common); acquired when head rotates from anterior position at the begin- ning of labor to a posterior position at its close (rare). Diagnosis.—Palpation reveals back in the flank (right, in R. O. P. ; left, in L. O. P.); extremities to the opposite side in front; head below. Heart sounds in the flank below a trans- verse line through umbilicus. Digital examination shows small fontanelle toward right or left sacro-iliac joint; sagittal suture in an oblique diameter. Mechanism. — Similar to mechanism of anterior positions, including anterior rotation of the occiput to symphysis. As a consequence of this prolonged rotation a peculiarity is the rotation of the shoulders at the superior strait through a quarter of a circle, a movement not seen in anterior positions, and in consequence of the greater distance which the occiput has to traverse the clinical manifestations of this stage are different, i. e., there is greater pain and labor is more prolonged. After rotation has occurred the shoulders descend and rotate on the pelvic floor, as in anterior positions. The further mechanism is identical with that of anterior positions. Cause of Forward Rotation of Occiput.—Same as in anterior positions, i. e., whatever portion of the foetal head first strikes tlw, pelvic floor, whether it encounters this structure behind or in front of the median transverse line, will be directed forward under the sym- physis pubis. Abnormalities in Mechanism. Backward Rotation of the Occiput complicates labor by pro- tracting its course, increasing the danger of foetal death and subjecting the mother to increased risk of injury. Causes.—1. Anomtdies of Force. — Anterior rotation is the resultant of the forces of expulsion and resistance, hence any 168 obstetrical lectures. condition disturbing the normal relation of these forces will interfere with the normal rotation. Thus backward rotation occurs when there is diminished expulsion, increased resistance, or decrease in resistance as occurs in cases of very large pelves, relaxed pelvic floors, small and yielding heads. 2. Anomalies of Flexion.—When flexion is imperfect the anterior vault of the cranium (as in those rare cases of presen- tation of the large fontanelle), the brow, or chin first strikes tlie pelvic floor and is therefore directed forward, and the occiput thus directed backward. 3. Insuperable Hindrances to Forward Rotation.—In some cases when flexion is only partially disturbed and the occiput first strikes the pelvic floor, the occiput will rotate backward, because the large diameter of the head (fronto-occip. llf cm.) engages and rotation from one oblique diameter of the pelvis, through the smaller transverse to the other oblique, is impossible. The occiput will also be directed backward for the same reason when the foetal head is over size, or accompanied by a prolapsed ex- tremity ; when the pelvis is deformed, particularly kyphotic, generally contracted and Naegele's ; when there is an abnormal projection of the lumbar and sacral vertebrae interfering with rotation of shoulder. Rarely there maybe rotation of the head without a corresponding movement of the body, and thus re- sults an exaggerated torsion of the neck. Mechanism when Occiput Rotates into Hollow of Sacrum.—The occiput is propelled forward over perineum by increased flexion until the face is finally born under the symphysis by partial exten- sion. This mechanism subjects the cranium of the foetus to dan- gerous pressure, and increases the danger of perineal rupture. Abnormalities in Mechanism just described.—Abnormal resist- ance to descent of occiput, resulting in conversion into presenta- tion of large fontanelle, brow, or face. Causes.—Projecting ischiac spines, central tear of perineum. Treatment of Posterior Positions of Vertex Presentations. Bear in mind the causes of rotation backward, and try to prevent its occurrence, (a) Secure perfect flexion of the head MECHANISM OF LABOR. 169 by placing patient on that side toward which the fcetal back is looking, (b) Secure normal action of expelling and resisting forces. If the pelvic floor is weakened and does not supply sufficient resistance, reinforce it by two fingers in the vagina or single blade of forceps. If expulsion is faulty, administer a single large dose of quinine, or forceps may be resorted to. If backward rotation occurs in spite of preventive treatment, extra precautions should be made to protect vaginal walls and perineum from laceration, and to avoid a protracted second stage. These can usually be accomplished by judicious use of forceps. It may be necessary rarely to first convert into a face presentation. Prognosis.—Not so favorable as in anterior positions of occi- put. Forceps often required (once in seven cases). Laceration of soft parts more frequent. The mortality of the foetus in- creased from 5 per cent, (normal vertex) to over 9 per cent. Luckily backward rotation occurs in only about 1| per cent, of all labor cases. Face. The head is extremely extended. The chin is the most dependent part presenting, hence the classification by its situa- tion, left mento-anterior, right mento-anterior, etc. Frequency.—Occurs about once in 250 labor cases. Diagnosis.— Bulk of cranial vault felt to one side of hypogastric region ; a deep groove between occiput and the child's back may sometimes be made out. Heart-sounds loudest over anterior surface of ftetus, i. c, on that side of abdomen upon which the extremities are felt. The diagnosis, however, must usually rest on digital examination, which shows before onset of labor high situation of presenting part; flattening of anterior vaginal vault; the contrast between the smooth outline of foetal fore- head and irregular contour of the face. As soon as the os is dilated the characteristic features of the face can be felt. Has been mistaken for the breech. Should be considered an abnor- mality and entails greater danger upon mother and child. Causes.—Conditions preventing flexion, as tumors of the neck ; increased size of thorax ; constriction of cervix about the neck ; 170 OBSTETRICAL lectures. coiling of cord around neck; tonic contraction of neck mus- cles. Conditions favoring extension, as mobility of fcetus; oblique position of child and uterus, especially when abdominal sur- face of child is directed downward and pelvis is flat; altered shape of head; tumors upon the back, as spinal meningocele. Causes which promote extension of the trunk and shoulders, and consequently of the head, as over-filled bladder of the mother pressing upon the child's back. After the bead has reached the pelvic cavity it may be due to the conversion of an occipito-posterior position into that of the face, as already described. Mechanism.—Comprises the following steps :— 1. Extension. 2. Moulding. 3. Lateral inclination. 4. Descent. 5. Anterior rotation of chin. 6. Its engagement under symphysis pubis. 7. Delivery of head by flexion. 8. Restitution. 9. External rotation. 10. Delivery of body as in vertex presentation. Abnormalities in Mechanism. The most common is delay in forward rotation of chin under symphysis. This is due to the difference between the lateral depth of the pelvis (3j inches) and the length of the foetal neck (ly inches), /. c, the chin does not meet with sufficient resist- ance. Should the chin be directed posteriorly, where the depth of the pelvis is even greater, the delay is absolute, and such cases can only be terminated by artificial assistance. If left to nature the upper portion of thorax (9 cm.) is forced in the pelvic cavity, along with the posterior half of the child's skull (9£ cm.), and it is impossible for these two diameters to pass through the pelvis. Prognosis.—Fatal mortality 13 to 15 per cent. Maternal, from less than 1 to 6 per cent. Treatment.—If the chin is directed well forward, the case mechanism of labor. 171 may require no interference at all. Often, however, these cases are difficult and demand active treatment. Before labor begins, or in the early stages, convert into vertex by the method of Schatz (external manipulation). If this fails, the method of Baudelocque (internal and external manipu- lation) should be tried. This failing,, version may be at- tempted if the face is not impacted in the pelvis. While labor is in progress, guard against rupturing the membranes, that the os may be more thoroughly dilated and the liquor amnii not drained away. If anterior rotation of the chin is delayed, it may be hastened by two fingers pressing on the cheek and chin ; or, if necessary, pressure may be applied with a single blade of the forceps. These failing, straight forceps may be used to effect rotation, and if the chin is directed ante- riorly traction may be made. If the chin is directed backward, traction should not be employed. Finally craniotomy may be necessary. When the case progresses with or without assist- ance care must be exercised in the final delivery of the head, not to push the neck too forcibly against symphysis when try- ing to prevent laceration of the perineum. Brow. Head midway between complete extension and complete flexion. The largest diameter of the head presents. Of all presentations of the head it is the most unfavorable for mother and child. The four positions are classified according to the direction of the chin. Freqxiency.—In Guy's Hospital there were 14 brow presenta- tions among 24,582 births (1 in 1756). Diagnosis.—Is made by a digital examination. Mechanism.—The steps are similar to those of face presenta- tion. When the chin is directed posteriorly the case is an im- possible one for the same reason as in the posterior position of the face. Prognosis.—Foetal mortality, 30 per cent. ; maternal, 10 per cent. Treatment—Before labor convert into vertex. This can some- times be accomplished by external pressure on the occiput to secure flexion. If this fails, insert hand in the vagina and pull 172 obstetrical lectures. occiput down. Next try to convert into face if the chin is anterior. If this fails, version should be tried. It should not be resorted to if the waters are drained off" or the presenting part is fixed in the superior strait. Finally, if the chin is anterior, apply forceps ; if posterior, and conversion into vertex presentation, performance of version and rotation are all impos- sible, craniotomy is indicated. In face and brow presentations with the chin posterior, the cardinal rule is not to use forceps except as rotators; if traction is resorted to at all, even in mento-anterior positions, it should be employed with the greatest caution and gentleness. Very rarely the head may be brought down far enough to meet with resistance, and thus be rotated anteriorly, but unless the head yields to moderate traction, embryotomy is preferable. Presentation of the Greater Fontanelle. The head is midway between flexion and extension. In its clinical features this presentation resembles a brow. The de- scent of the head is difficult and tedious, the anterior (frontal) portion rotates forward, but with great difficulty, and serious injury to the maternal soft parts is almost unavoidable. Treatment—Convert into a vertex presentation by pulling down the occiput with the fingers. Breech. Presentation of any part of the pelvic extremity of the foetal ellipse. The classification is according to the direction of the sacrum, left sacro-anterior, right sacro-anterior, etc. Frequency.—Occurs in 1.3 per cent, to 3 per cent, of all cases, the first figures referring to mature births alone. Causes.—1. Abnormalities in shape of foetus or uterine cavity. Include reversal of uterine ovoid (the lower uterine segment larger than upper) ; foetal monstrosities ; twin pregnancy (in 25 per cent, of cases the breech presents). 2. Increased mobility of the foetus. Diagnosis.—Head above, breech below. Heart sounds are heard on a transverse line above umbilicus. Digital examina- tion shows high position of the presenting part; absence of MECHANISM OF LABOR. 173 dome-like projection of vaginal vault which is found in pre- sentation of head ; the bag of waters projects as a pouch-like protrusion ; by pressure on the fundus with the other hand the characteristic features of the breech may be detected, i. e., the nates and sulcus between them, tip of sacral bone and coccyx, the thighs, external genitalia and anus, evacuation of meco- nium, which in breech cases is not of serious import. Mechanism.—Comprises the following steps :— 1. Descent of breech to pelvic floor. Occurs very slowly be- cause the soft breech is an ineffectual dilator of the cervix and ineffectual irritator of reflex uterine contraction, hence many hours may be required. 2. Rotation forward of anterior hip. The anterior hip first strikes the pelvic floor, but owing to the insufficient resistance which the soft breech encounters the rotation is imperfect. 3. Birth of anterior hip, posterior hip, thighs, and trunk; 4. Engagement and descent of shoulders in oblique diameter. 5. Rotation forward of anterior shoulder. 6. Birth of anterior followed by posterior shoulder. 7. Descent of head in oblique diameter. 8. Rotation forward of occiput, which is always the part to first strike the pelvic floor. 9. Delivery of head in the following order: Chin, face, fore- head, anterior fontanelle. Prognosis. — Foetal mortality 30 per cent., including badly managed cases. There is some added danger of injury to ma- ternal soft parts. Treatment—Before labor, external version, if practicable. After labor has begun, inaction until body is born to umbili- cus, unless maternal or foetal life threatened. At this time in- terfere, bring the patient in the lithotomy position to edge of bed, and deliver by pressing upon fundus with one hand, the other baud in the vagina to favor anterior rotation of the shoul- der, flexion of the head, and to direct the head through the vagina. 174 OBSTETRICAL LECTURES. Abnormalities in Mechanism. The most frequent and important are (1) backward rotation of the occiput and (2) excessive rotation of the breech. Back- ward rotation of the occiput is very exceptional, and the mech- anism now differs as the head remains flexed or becomes extended. When flexed, the chin, face, forehead, anterior fontanelle slip out under symphysis in the order named, and the head is delivered. When extended, the chin catches upon the symphysis, the head is extremely extended and is born by the occipital protuberance, small fontanelle, cranial vault and face slipping over the perineum. The following rules for man- aging these cases should be remembered : If flexed, the body of the child should be carried downward. If extended, the body should be carried upward over the mother's abdomen. Excessive rotation of the breech occurs as the result of pro- lapse of posterior extremity, and is of no great practical im- portance. Shoulder. Transverse position of the child in utero resolves itself into a shoulder presentation as the result of uterine contraction when labor begins. Shoulder presentations are classified according to the position of the back and head. When the head is to the right the back can be in front or behind. The same is true when the head is to the left. The back is directed anteriorly twice as often as posteriorly, and the head more than twice as often is found toward the left. Diagn/>sis.—Abdominal palpation reveals the foetus in a trans- verse position. The heart-sounds are more distinct at a point corresponding to the interscapular region of the child, and some- times cannot be heard. Digital examination shows the charac- teristics of the shoulder, viz., axilla, clavicle, spine of scapula, acromion process, head of the humerus, ribs. Causes.—1. Abnormalities in the shape and position of the uterus, as pendulous abdomen ; uterus bicornis ; kyphotic spine ; uterine fibroid and other abdominal tumors ; multiple pregnancy (in twin pregnancies the shoulder presents once in 22 cases). 2. Conditions preventing engagement of cephalic or pelvic /"■-> £%t? r~jt ^ ns$ r~j-C-tn l mechanism of labor. 175 extremity, as deformity of the pelvis ; abnormally large child ; monstrosities ; placenta praevia. 3. Abnormal mobility of the foetus, as occurs in hydramnion, after fcetal death, or in premature birth. Mechanism.—Strictly speaking, there is no mechanism of shoulder presentations. The course of these cases is impac- tion of the shoulder, ascension of contraction ring, destruction of the foetus by prolonged pressure, and death of the mother by rupture of the uterus or exhaustion. As a matter of fact, however, nature can in exceptional cases effect delivery in one of three methods :— 1. Spontaneous version. The transverse position converted into a longitudinal by uterine contraction. 2. Spontaneous evolution. The breech slips past the shoulder and is delivered. 3. Body doubled up (corpore reduplicato). Treatment.—Version. Mechanism of the Third Stage of Labor. Theories of Separation:— (a) Placental area diminished. (b) Placenta pushed off. (c) Separated by retro-placental clot. The first probably correct. Theories of Expulsion:— (o) Edgewise (Matthew Duncan). (b) Like inverted umbrella (Schultze). The last probably correct. Abnormalities. (a) Retention.—Occurs frequently. Hemorrhage is slight. The placenta is situated in the dilated lower uterine segment and upper portion of the vagina. Treatment.—Proper application of Credo's method of expres- sion. Sometimes atmospheric pressure determines its reten- tion ; a finger then may be hooked over one edge to pull it down. 176 obstetrical lectures. (6) Adhesion.—Occurs once in 312 cases, and is usually par- tially detached. Diagnosis. — Crede method of expression fails and there is alarming hemorrhage. Treatment—Pass the hand along the cord to the fundus and complete the separation with the finger-tips, using them as a paper-cutter ; pinch through any dense spots of adhesion, close the fingers about the placenta, stimulate the fundus by friction through the abdominal wall, and allow uterine contractions to expel the hand and contained placenta. Prognosis.—Many die from hemorrhage ; seven per cent, from sepsis. Most exceptionally the placenta can be retained in utero for months without doing harm. Among the rarest anom- alies in regard to the placenta during labor are hernia of the placenta through the muscular coat of the uterus during labor, and prolapse of the normally situated placenta. The latter is most likely to happen with twins, after rupture of the uterus, or in premature labor, but it has been observed at term, without injury to the uterus, and in a single pregnancy. There is not necessarily profuse hemorrhage nor other disadvantage to the woman, but the foetus dies unless it is extracted at once. Obstetric Operations. Induction of Premature Labor and Abortion. Abortion. When performed before viability of child (180th day). Indications.—When the patient is a subject of disease origi- nating in or aggravated by pregnancy and life endangered thereby, viz.:— 1. Pathological Vomiting.—Only after all known remedies and rectal alimentation fail. 2. Grave Albuminuria.— As when oedema, headache, casts, failing vision, etc., threaten eclampsia. 3. Death of the Embryo or Foetus. 4. Certain Intrauterine Diseases.—As acute hydramnios and cystic degeneration of the chorion villi. obstetric operations. 177 5. Uterine Hemorrhage from placenta pnevia (partial and cen- tral) may be so profuse as to demand interference early in pregnancy. 6. Certain Nervous Diseases.— As acute mania, melancholia, or associated inflammatory changes in the brain. Rarely chorea. 7. Certain Blood Diseases.—Pathological hydraemia (pernicious anaemia), leucocythemia. 8. Displacements of Gravid Uterus.—Retroflexion, prolapse, her- nia, resisting other treatment. Always secure consultation and share responsibility. Methods.—Many have been resorted to, but have been found either too dangerous, slow, or ineffectual. Such are the use of ergot, cotton-root, injections upon cervix or between membranes, inflated rubber bags in vagina or uterus, rapid or gradual dilata- tion of the cervix, perforation of the membranes, electricity. The method recommended is a combination of the good feat- ures of some of those mentioned, and is as follows :— 1st. Disinfect canal by antiseptic douche and pledget of mer- curialized cotton in cervix. 2d. Fix anterior lip of cervix with tenaculum and dilate cer- vix to size of thumb with Hegar's dilators. 3d. Iodoform gauze tampon in cervix and lower uterine seg- ment, and a tampon of antiseptic wool in vagina. Remove at the end of 24 hours. If the ovum is not discharged from the uterus, dilate the cervix further and reapply a larger tampon. The discharge of the ovum is often facilitated by introducing placental forceps and nipping off a small piece of decidua. When the second tampon is removed, if the ovum has not come away, remove it, using, with strict antiseptic precautions, the finger, or, with greatest care, curette. If there is urgency in the case and the patient can stand an anaesthetic, ether is given, the os dilated with bougies and fingers, the ovum cleared out with finger, curette, and placental forceps, leaving the uterus clean. An iodoform gauze tampon is then inserted and allowed to re- main 24 hours to insure drainage. While the interruption of pregnancy before the 180th day is called the induction of abortion, the method given is only applf- 12 178 obstetrical lectures. cable up to the fourth month. After that time the plan is the same as for the induction of premature labor. Premature Labor. When performed after viability of child., Indications.—l. For diseases as above^ 2. Special Indications.—As (a) Contracted Pelvis (8-9J cm.), [b) Placenta Praevia, (c) Advanced Phthisis, Grave Heart Dis- ease, etc. threatening mother's life, (d) Habitual Death of Foetus just before term. Methods.—Antiseptic vaginal douche, Sims's position or dor- sal decubitus, aseptic hard-rubber bougie passed in for 7 or 8 inches between deciduae vera and reflexa, and kept in place by vaginal tampon of iodoform gauze. Labor begins after a vari- able period, 3 hours to a week, the average being 36 hours. The introduction of a second and larger bougie may be neces- sary after 12 hours. After 36 hours, if softening of the cervix has been accomplished, it may be further dilated by means of Barnes's bags.* A very satisfactory plan recently introduced (Pelzer) is the injection of about 2-4 oz. of sterilized glycerin be- tween the membranes by means of a rubber tube attached to a syringe. If the mother's condition demand immediate deliv- ery, the method is as follows: («.) Perforate the membranes; (b) forced dilatation of cervix with fingers or Hegar's dilators, fol- lowed, if it is still impossible to insert the whole hand, by Barnes's bags (each remaining 15 minutes); (e) forceps, or, pref- erably, version and extraction (accouchement force). * To apply Barnes' bags successfully the following points should be borne in mind : Before using them the capacity of each bag should be tested with syringe ; to secure entrance into cervix roll the bag in its long diameter and catch with dressing forceps ; apply the rubber tube to the rectal nozzle of syringe, and after inflation compress with catch forceps. Allow the bag to remain in place for one hour, leaving the patient in lithotomy position in bed, to prevent rupture of the bag. ■~it*i W ■£--£. , OBSTETRIC OPERATIONS. 17'J Forceps. Uses and Functions. (a) Tractor—most important. (b) Rotator. (c) Lever. (d) Compressor—dangerous. Indiceitions:— 1. Anomalies in Expulsive Forces—as uterine or abdominal in- ertia. 2. Anomalies in Resistance—in the pelvis, soft parts, or foetal body, as minor degrees of contracted pelvis, abnormal rigidity, or large foetal head. 3. Threatened Foetal Life—as prematurely detached placenta, compression or prolapse of the cord, prolonged pressure on foetal head, feebleness of foetal heart, sudden death of mother, during the second stage of labor. If the heart sounds sink to 100 for a minute forceps should be applied. 4. Debilitating diseases, acute or chronic, rendering the ordinary forces insufficient—as phthisis, typhoid, heart disease, etc. In such the forceps should be applied at the beginning of the second stage to avoid asphyxia or to save the mother's strength. 5. Life Endangered—as in heart-clot, eclampsia, hemorrhage, rupture of uterus. 6. Abnormal Positions and Presentations and Anomalies in the Mechanism of Labor. — As in face presentations to secure anterior rotation of chin ; elevating or depressing the handles when the head is over-flexed or under-flexed. As a general rule, they should be applied when the head, during the second stage, has been stationary for two hours. Contraindications :— 1. Os must be dilated. Exception. When maternal or foetal life is threatened, it is allowable to apply them to a partially dilated os, as when rupture of the uterus is threatened, as shown by the approach to the umbilicus of the groove over the contraction ring. 2. Head must have engaged at the superior strait. Exception. To bring head down as a tampon in marginal placenta praevia. 180 OBSTETRICAL LECTURES. 3. Membranes must be ruptured. 4. Must not be used as tractors in impossible positions and pre- sentations—as face with chin posterior. 5. Should not be employed unless head be of average size. If too small or too large, apt to slip and lacerate the soft parts. 6. Should not be employed when the disproportion between the head and canal is too great. Forceps in Contracted Pelves. — Two factors, size of foetal head and degree of contraction, must be considered to determine between the use of forceps at term and induction of premature labor. The determination of the size of the foetus must be left to each individual's skill and experience in abdominal pal- pation. In contracted pelvis, if justo-minor, with conjugate 9£ cm., or over, it is justifiable to deliver with forceps at term. If the conjugate be less than 9£, induce labor preferably at 36th week. In the simple flat or rachitic fled, 9 cm. is the limit in primi- parae ; 9£ cm. in multiparae, whose uterine and abdominal forces are not so strong as in primiparae, and in whom rupture of uterus is more apt to occur. There are, however, no well- defined rules, but it may be said that when the case is seen early in the labor version or nothing is the treatment, the former only when the natural forces are insufficient to secure engagement. The use of the forceps to fix the head in the su- perior strait is justifiable if one has skill in their use and judg- ment to determine when the attempt should cease. If the head is in the superior strait, it is forceps or nothing, the former when interference is indicated. Remember that the operation is a difficult one. The instrument has to be inserted a greater dis- tance, prevents nature's mechanism, grasps the head over fore- head and occiput, and is thus more likely to injure the skull and its contents and is more liable to slip from the head, injuring the vagina. As beginners you will not dare to rotate the blades to the side of the child's head. The obliquity of the pelvis is greater, making it more difficult, even with an axis-traction in- strument, to deliver in the axis of the parturient canal. Finally, a choice must be made of forceps, version, craniotomy (if the child is dead), or symphysiotomy—the last only when the OBSTETRIC OPERATIONS. 181 head cannot be brought through the pelvis without the certain destruction of the child. Forceps Recommended.—Simpson, for the low Operation, Poullet v. Hecker or Tarnier, for the high operation. Sawyer's, to pro- tect perineum as the head emerges. Rules for Application. — In using the Simpson forceps, the left blade is always applied first. The left blade should be held in the left hand and introduced into the left side of the pelvis. Right blade right hand, right side of pelvis. With the diagnosis of the presentation assumed, and the va- gina douched if there is a suspicion of gonorrhoea or septic dis- charge, the steps in the application of the blades may be sum- marized as follows: 1. Having introduced two fingers of the right hand into the vagina, the left blade, grasped at the lock by the left hand as a pen, is held almost perpendicularly, with the tip of the blade opposite the vulva. 2. The tip of the blade should enter the vagina and traverse the perineum toward the sacrum. 3. Rotate the blade outward in its long axis, to bring it in apposition with the posterior inclined plane of the pelvis, and thus escape the promontory of the sacrum when the handle is depressed. 4. Depress the handle, carrying it to the left side, the fingers of the right hand in the vagina guiding the blade and protect- ing the soft parts. 5. Introduce the right blade in a similar manner, substituting right for left in the above description. 6. To grasp the head properly and facilitate locking, rotate forward the right blade when the head occupies the right oblique diameter (L. O. A. and R. O. P.), the left when the head is situated in the left oblique (R. O. A. and L. O. P.). Depres- sion of the handles towards the perineum often aids locking. Too great compression of the head may be avoided by placing a folded towel between the handles. Tractions should be made in a line parallel to the axis of the parturient canal—with the pains when present, at corresponding intervals when absent. 182 OBSTETRICAL LECTURES. During the intervals between the tractions the grip on the handles should be relaxed to release the head from compression."* Preliminaries to the Operation.—Always secure patient's con- sent to avoid blame if an accident occur. An anaesthetic always renders the operation less difficult, but when it is to last only a short time (half hour) it may often be dispensed with. The disadvantages of an anaesthetic are vomiting, possibly post-partum hemorrhage, and retardation of the milk secre- tion for 24 hours. The lithotomy position at the edge of the bed is the most convenient. The blades should be immersed in a 5 per cent, solution of carbolic acid or boiling water, rubbed with a 50 per cent, solution of carbolic acid in glycerine and folded in a clean towel. Just before using them vaseline should be applied to their outer surfaces. Extraction of Breech. Breech labors are normally slow and tedious. The indica- tions for interference are : Delay for 24 to 36 hours ; rapid and feeble pulse; exhaustion and perhaps elevated temperature; bad foetal heart sounds. Methods of Extraction in the Order of their Efficiency: 1. Manual.—Seizing a foot by passing the hand into the uterus, extracting the leg up to the knee, thus "decomposing" the breech presentation, and affording a convenient handle by which to control the subsequent progress of the foetus. Another plan is to place the hand on the infant's back so that the little and fore fingers hook over the crests of the ilia, while the middle and third fingers are extended along the spine. This is not so good. For both manoeuvres the patient must be anaesthetized. 2. Forceps.—Apply over the trochanters and avoid compress- ing the handles. Make traction by hooking fingers over shoulder of instrument. 3. Fillet.—Each end of a strip of bandage is passed between a thigh and the abdomen, brought down in front of the exter- nal genitalia and drawn tight until the centre of the bandage is * The skill and manual dexterity required in all forceps operations can only be acquired by actual practice ; hence the student must avail himself of the opportunity to learn the technique of all the opera- tions in the Laboratory of Operative Obstetrics. OBSTETRIC OPERATIONS. 183 in contact with the child's spine. "Very difficult to apply, and therefore of little practical value. Requires anaesthesia. There is a perforated blunt hook in the shops which facilitates its ap- plication ; also an apparatus on the plan of Bellocq's canula. 4. Blunt Hook.—Caught between the child's thigh and abdomi- nal wall. It is very apt to fracture the thigh or perforate the abdomen, but may be employed before resorting to embryotomy. Version. Version is an operation or manoeuvre to change the position of the foetus in utero. Varieties:— (a) Version by the head (cephalic). (6) Version by the breech. (c) Podalic. Methods :— (a) Postural. (b) External manipulation. (c) Internal manipulation. >/ -t •* A \ (el) Combined or Bi-polar. -r I Indications for 1 rersion:— 1. Presentations of the trunk—usually shoulder. 2. Deformity of pelvis. 3. Sudden dangers, when the head presents, but is not engaged, aud the child is to be delivered rapidly, as eclampsia, heart-clot, premature detachment of placenta, rupture of uterus, death of mother. 4. Malpositions of the head, as presentations of the ear, parietal bone, brow or face. „ ^. . 0 5. Placenta praevia,, -< J »" <^" l-v* 1' '>, "Yhsivtt-r- i i A- £ J J- 40 ^/fc J'*~ .^f ~A< v./ CXc/^ u^s ty Psn>S*-^-~f? -r ^£- DYSTOCIA. 205 ^ (c) Ice applied internally and externally, but not persisted in. Ether poured upon lower abdomen will usually evoke uterine contraction. (d) Handkerchief soaked in vinegar squeezed at the fundus. (e) Hot water. (/) Electricity., (g) Intrauterine tampon of iodoform gauze. (h) Drugs, as iodine, turpentine, styptic salts of iron, etc., are dangerous, as the coagula produced by them may extend into the vessels, are firm and must be broken up by putrefaction, exposing the patient to septic poisoning. They are only to be used when everything else fails. The two first named are the least dangerous, and are sometimes very effective. The bleed- ing can sometimes be controlled temporarily by compressing the posterior lip of the cervix against the symphysis and man- ipulating the fundus externally. Treatment of tlie After-condition.—While controlling the hemor- rhage, nurse should administer hypodermic of ether, raise the foot of the bed, and remove pillow from under patient's head. When the bleeding has ceased administer an enema of hot water with a little salt in it, and frequently repeated small doses of hot, strong coffee, milk, hot water and brandy, and surround the patient with hot bottles and cover with thick blankets. Auto-transfusion by bandaging extremities, com- pressing abdominal aorta, or actual transfusion into a vein or the subcutaneous connective tissue between the scapulae (8 oz. of T65 of 1 per cent, of ordinary NaCl solution—about 40 grs. to the pint). When reaction is established, a hypodermic of mor- phia may be given. Very rarely, indeed, an uncontrollable post-partum hemorrhage is seen from a firmly contracted uterus (once from rupture of aneurismal vessel; once in neph- ritis, presumably from atheromatous vessels). (4) Hemorrhage from Injuries of Lower Parturient Tract—Ex- ceptionally may be fatal. The most common source is in the anterior wall of vagina near the urethra, where it should be controlled by antiseptic catgut or silk ligature. Exceptionally an anomalous artery may be torn in the cervix or perineum re- quiring immediate operation. If in the cervix, ligate or pass 206 OBSTETRICAL LECTURES. suture under the bleeding point; if in vagina, tampon and apply continous suture from below upward. (5) Rupture of Uterus. Cause.—Serious obstruction to labor or external violence. Frequency.—One in 4000 cases. Morbid Anatomy.— Rent usually begins in lower uterine seg- ment, and is transverse, but may extend perpendicularly up to and over the fundus. It usually involves all the coats of the uterus and opens a way into the peritoneal cavity, but it may involve the mucous and muscular without the peritoneal cover- ing, or very rarely the peritoneal and muscular, but not the mu- cous, or, perhaps, the peritoneal coat alone. Diagnosis.—Placenta Praevia, Accidental Hemorrhage, Rup- ture of Uterus are the three causes of grave ante- or intra-par- tum hemorrhage. In the last there is shock, violent pain, great alarm on the part of the patient, the membranes are broken, the presenting part recexles, the contractions cease, the examining hand finds the rent, and perhaps feels coils of intes- tines. The child may be felt in the abdominal cavity with the uterus small and firmly contracted. The danger signal is thin- ning of the lower uterine segment and a high position of the contraction ring. The seat of rupture is usually in the lower segment. Prognosis.—Mortality in general practice. 90 per cent. Statis- tics from the experience of experts gives the following: 60 cases of complete rupture without active treatment, mortality 7S.S percent.; 70 cases treated by irrigation and drainage, mortal- ity 64 per cent.; 193 cases treated by abdominal section, mor- tality 55.3 per cent. Treatment.—Varies with the cause. Err on the side of the mother's safety. Deliver by podalic version if not engaged ; forceps or craniotomy after engagement. If the rent is small and situated low down, the hemorrhage ceases and there are no clots nor meconium in the peritoneal cavity, and if there is good drainage, no active treatment required beyond irrigation with | per cent, solution of creolin. Draiuage can be secured by using a double tube passed through the rent into the peritoneal cavity, or by an iodoform gauze tampon. AVhen the rent is lA/lt.-L-fr"Ct<.}' .^X^ A / ., £ , -v /- -v CA^r^^€ C tvu^u ^jt-o, crv-v - d v <- j j 7) ~"j. o 4 . - ~?*t~Tt- DYSTOCIA. .207 large, hemorrhage profuse, and the child is in the abdominal cavity, open abdomen and suture after the Sangej^method, or amputate the uterus after apply a gjecure nceucj/^ It is believed that rupture of the anterior wall is more dan- gerous than rupture of the posterior wall, because the drainage is not so good. During the puerperium the uterus may rupture as a result of septic ulceration, pressuie necroses, or more rarely from malignant cystic degeneration of the chorion. In such cases the prognosis is graver than in rupture during labor. Laparotomy is always required, and amputation of the uterus is usually necessary. (6) Lacerations of Cervix, Vagina, and Pelvic Floor.—Already re- ferred to in minor grades. Vagina may be ruptured into rec- tum without involvement of perineum, or at the vault into the peritoneal cavity. The base of the broad ligament may be ex- posed and the uterus injured. (7) Inversion of the Uterus.—The rarest of all accidents to the mother, and happens before or after delivery of the placenta with equal frequency. It may be partial or complete. Causes.—It may arise spontaneously in the so-called paralysis of the placental site, or it may be due to too vigorous traction on the cord, compression of the fundus, or may occur after separation of adherent placenta. Symptoms.—Occurs suddenly and is usually associated with shock and hemorrhage. Physical examination per rectum re- veals a cup-like body containing, perhaps, the prolapsed tubes and ovaries, or by rectal and abdominal touch a transverse slit may be felt at the margin of the inversion. The fundus cannot be felt through abdominal wall. Sound or finger not will pass be- tween tumor and contracting cervix, as would be the case were the tumor a polypus. It has been mistaken for a polypoid tumor and the inverted womb torn or cut away. Treatment.—Occasionally spontaneous reduction occurs, par- ticularly when the inversion is partial. Remove the placenta if still adherent and reduce by pressing the fundus with the fingertips in the direction of the axis of the superior strait, i. e., upward and forward to pass the sacral promontory. Sometimes 208 OBSTETRICAL LECTURES. complete reduction cannot be accomplished until the end o- the puerperium. (8) Other accidents to the mother are Rupture of Symphysis, re- quiring a binder or plaster bandage; Separedion of Sacro-iliac Joints, and Fracture of Pelvic Bones by Faulty Use of Forceps; Fracture of Sacro-coce-ygeal Joint; Lacerations and Perforations with Instruments; Diastasis of Abdominal Muscles; Rupture of some part of the Respiratory Tract and Subcutaneous Emphysema. The last is not dangerous if of larynx and trachea, with em- physema only of neck and face and not of the whole trunk. Much more dangerous if of pulmonary vesicles with em- physema of subpleural and interlobar connective tissue, and consequent embarassment of heart and lungs. (C) Dystocia due to Disease. 1. Convulsions.—Definition.—Muscular spasms with or without unconsciousness, occurring during pregnancy, parturition, or the puerperium. Causes.—Eclampsia, hysteria,epilepsy,tumors of the brain, meningitis, profound anaemia following post-par- tum hemorrhage, apoplexy; or there may be present that curious nervous condition during and after labor, so easily responding to reflex disturbances, in which the convulsions may arise from some trifling irritation, as that of an overdis- tended bladder, the introduction of the hand in performing version, the pressure of the head upon the perineum, exagger- ated after-pains. Eclampsia.—Is the name given to the most frequent variety of convulsions in the child-bearing woman, the result of kidney insufficiency. Causes.—Obscure. Theories of causation : (a) Urea. (6) Car- bonate of Ammonium, (c) Urinaemia. (d) Trauber-Rosenstein. (e) Prof. Hirst approves the following : Anaemia in the deeper portions and congestion of the surface of the brain, due to the sudden rise of arterial pressure resulting from the accumulation of poisons in the mother's blood (probably leucoma'ines generated in the foetal body), her kidneys being unable to excrete them. Excretion may become insufficient by the development of kid- ney of pregnancy, of nephritis, or by pressure upon the ureters. DYSTOCIA. 209 The kidney may be diseased and yet functionally sufficient, or healthy, anatomically, but functionally insufficient. Freepwncy.—Occurs once in three hundred cases; most fre- quently in primiparae, and during labor; least frequently dur- ing the puerperium. It develops with greater frequency in mul- tiple pregnancies and is said to occur as an endemic, i e., con- nected with climatic changes. Symptoms.—(a) Prodromal.—Sharp pain is sometimes felt in the head, epigastrium or under clavicle ; muscae volitantes with failure of vision and rolling of the head. (b) Of the Attack.—A few moments after the above the attack comes on with a stare, pupils at first contract, eyelids twitch, eyeballs roll, mouth pulled to one side, the neck is then affected, and the spasm finally spreads to trunk and upper extremities. The lower part of lower extremities is rarely spasmodically affected. Consciousness is lost for a minute or two, and during the varying intervals between the attacks there is a progressively deepening stupor. The temperature usually rises steadily with each successive fit. Differential Diagnosis.—In eclampsia there may be a history of albuminuria, oedema, etc. The patient catheterized and urine heated in a spoon over gas or lamp flame will always show coagulation after one or two convulsions. (It should be remembered that in about 16 per cent, of cases albuminuria has not been present, before the convulsive attack.) The tem- perature is elevated and unconsciousness more or less profound. Proejnosis.—30 per cent. die. Influenced by the violence and frequency of the attacks, the character of the pulse, degree of coma, and perhaps the height of temperature. The cause of death may be any of the following : (Edema of brain, lungs or larynx, apoplexy, asphyxia, exhaustion, heart failure, over- whelming accumulation of the poison. Mortality of the child, 50 per cent. Treatment —(a) Preventive.—The urine of all pregnant women should be critically examined. If there be evidences of nephritis or the kidney of pregnancy, a restricted diet consisting largely of milk should be advised. Colds should be avoided, diuretics administered, and cathartics to prevent constipation. If the U ^10 OBSTETRICAL LECTURES. symptoms fail to respond to this treatment, the induction of premature labor should be considered. {b) Curative.—Indications are to eliminate the poison and combat the spasm. Includes the treedment of the spasm, the treatment eluring the intervals, and the obstetric treatment At the approach of and during the spasms, inhalations of chloro- form. In the interval between the convulsions, venesection in strong plethoric cases, 24 to 30 ounces ; croton oil, two or three drops in a little sweet oil, glycerine, or butter (elaterium may be used) ; an enema containing chloral £j, repeated three to six times in twenty-four hours if necessary ; hot bath 100° or more, with ice or cold cloths to the head, or, what is more practicable in private practice, a hot wet pack ; veratrum viride gtt. xv of the fluid extract hypodermatically, repeated in doses of five drops as often as may be necessary to keep the pulse at sixty. In twenty-four cases in which veratrum viride was used the mor- tality was sixteen per cent. Guard the patient from injury, especially the tongue, which may be protected by placing between the teeth a brush handle wrapped in a handkerchief. For the coma succeeding the convulsions administer concen- trated saline solution 31J every fifteen minutes until free catharsis is produced. Morphia and pilocarpin should not be employed. Nitrite of amyl is not in very great favor on account of the danger of post-partum hemorrhage. (c) Obstetric Treatment—During labor if the os is dilated, ter- minate the labor with forceps or by version. If the convulsions occur early, and the os is not dilated, wait until partial dilata- tion occurs, and complete the delivery by combined version and extraction if the head is not engaged. If the head is fixed in the pelvis, use forceps. During pregnancy do not attempt a forced delivery unless the case resists ordinary treatment and becomes desperate, or unless it is highly important that the child should be born alive. Caesarean section has been done for eclampsia 11 times with 4 deaths. This treatment can scarcely ever be justifiable. 2. Shock.—Lowered temperature, leaking skin, running rapid pulse, and other symptoms of shock may develop after labor. DYSTOCIA. 211 Cases of shock have been reported, said to be due to compres- sion of the ovaries, when Crede's method of expressing the placenta has been employed. 3. Typhoid. — Rare. Premature labor occurs in 65 per cent, of cases. Labor unfavorably influences the disease, often causing profound shock after delivery. Active stimulation should be employed during labor, and forceps used in the second stage. 4. Pneumemia or other Adynamic Diseases.—Require stimulants. Whiskey, digitalis, carbonate of ammonium administered in the first stage, and labor terminated in the second. 5. Valvular Defect in Heart.—Extensive mitral disease fre- quently causes death ; mortality 53 per cent. The heart is embarrassed during pregnancy or labor, and manifests its weakness directly after the expulsion of the child or placenta. When the discharge of blood is profuse, cardiac failure is rare in these cases, thus indicating the treatment: Venesection, removing 8-16 oz., if there is not much blood lost after labor. Nitrite of amyl directly after labor has given very good results. Digitalis should be given in the first stage, and forceps or ex- traction by the feet (in breech cases) resorted to in the second. Sudden Death during or directly after Ltd tor. Causes.—1. Profound Mental Impressiems, as sudden joy, grief, fear, exaggerated shame, excessive pain. 2. Shock. 3. Heart Failure.—It may be due to advanced kidney disease, fatty degeneration, fibroid patch, rupture of aneurism, myocar- ditis, etc. So small a matter as an intrauterine injection has caused death in these cases. 4. Accidents of Labor, as accidental, unavoidable, or post- . partum hemorrhage, rupture or inversion of uterus. 5. Rupture of Heemate/ma, externally or internally. 6. Syncope.—This is not usually fatal. It is favored by the determination of blood from the brain, as by hemorrhage. Thromboses in the heart may form, and those in the uterine sinuses may be prolonged and embolism result. Prolonged syncope, associated with air hunger and other symptoms of profuse internal hemorrhage, is almost always fatal. 7. Embolism and Thrombosis, especially of Pulmonary Artery.— 212 OBSTETRICAL LECTURES. May be the result of syncope, or it may possibly be caused by entrance of air. Embolus of fat from pelvic connective tissue has occurred. Symptoms.—Sudden shock, heart failure, rapid respiration, air hunger, followed usually by death, although not invariably fatal. 8. Rupture of Gastric Ulcer. 9. Acide Purpura Hemorrhagica. 10. Rupture of Peritoneal Adhesions. 11. Rupture of Aorta. 12. Rupture of Cyst in Auricular Septum. 13. Angina Pectoris. Effect of Maternal Death upon the Foetus.—The foetus survives rarely more than a few minutes. It has lived for two hours. When making an autopsy on a parturient woman, it is con- venient to split the symphysis and remove the genital tract in one piece. Post-mortem Delivery.—Accumulated gases have caused de- livery of foetus, giving rise to the suspicion of burial before death. INDEX. ABDOMEN, appearance of iu preg- nancy, 110 Abdominal muscles, action of in labor, 164 palpation, 162 plates, 24 Abortion, after treatment of, 141 causes of, 138 complete, 140 diagnosis of, 140 ergot iu, use of, 141 hemorrhage in, 140 in cardiac diseases, 132 iu chorea. 130 incomplete, results and treat- ment of, 141 induction of, indications for, 176 method of, 177 inevitable, 139 in retro displacements, 119 in vomiting of pregnancy, 125 membranes in, retention of, 141 missed, 141 mortality of, 139 opium in, use of, 140 prognosis of, 140 prophylaxis of, 140 symptoms of, 139 tampon in, 141 threatened, treatment of, 140 treatment of, 140 Abscess in mastitis. 80 ischio-rectal, 94 Accidental hemorrhage, 202 Accouchement force, 178 After-coming head, extraction of, 185 After-pains, 156 Agalactia, 78 Albuminuria in eclampsia, 209 iu pregnancy, 126, 129 treatment of, 127 Alimentary canal, diseases of, dur ing pregnancy, i23 Alimentation, rectal, iu hypereme- sis, 124 Allantois, 30 Amnion, 26 abnormalities of, 27 development of, 26 false, 26 fluid of, 26 true, 26 Amputation, intrauterine, 28 Anaemia cerebral, causing eclamp- sia, 208 pernicious, in pregnancy, 134 puerperal, 74 Anaesthetics in eclampsia, 210 in labor, 152 Anomalies of breasts, 77 of pelvis. (Vide Pelvis, deform- ities of.) of soft parts, 105 Ante-flexion in pregnancy, 118 Antisepsis, 106 in hospital practice, 10,- in private practice, 109 reduction of mortality by, 108 Antiseptics, table of comparative power, 107 Aphthae, 65 Armamentarium of obstetrician, 152 Arms, liberation of, in head-last labors, 186 Artificial feeding, 52 respiration, 60 risks attending, 61 Asphyxia, causes of, 59 livida, symptoms of, 60 pallida, symptoms of, 60 treatment of, 60 Atelectasis, 61 Auscultation in pregnancy, ) 12 213 214 INDEX. Average date of conception after marriage, 24 BACTEEIA in lochia, 155 Balotteuieut, 112 Barnes' bags in dilatation of cervix, 178 Bed, preparation for labor, 108 Bladder, calculus in, 128 diseases of, in pregnancy, 128 diseases of, in puerperium, 81 irritability of, in preguancy, 128 Blastodermic vesicle, 23 Blastospore, 23 Bleeding from genitalia during preg- nancy, 122 from genitalia of female infants, 71 Blindness in pregnancy, 131 Blood, changes of, in pregnancy, 116 discharge of, from genitalia, 122 of female children, 71 diseases of, in pregnancy, 134 of newborn infants, 46 Braxton Hicks' sign of pregnancy, ill Breasts, anomalies of, 77 care of, during pregnancy, 79 during puerperium, 159 diseases of, during pregnancy, 123 during puerperium, 79 in newborn infant, 64 Breech, extraction of, 182 presentations, 172 Brow presentations, 171 Buhl's disease, 70 CESAREAN section, 189 indications, 191 Porro, 190 Pono-Muller, 190 Sanger, 190 Caput suecedaneum, 57 Cardiac diseases complicating preg- nancy, 132 Caul, 2(10 Cavity of pelvis, axis of, 98 diameters of, 98 Cephalo-haematoma, 57 Cervix, changes of, in pregnancy, 112, 115 diseases of, in pregnancy, 121 rigidity of treatment of, 196 Changes iu maternal organism in pregnancy. 113 Child. ( Vide Newborn Infant.) Chorea complicating pregnancy, 130 Chorion, 28 anomalies of, 29 definition of, 28 development of, 28 diseases of, 29 Circulation, affections of, iu preg- nancy, 132 fcetal, 36 Cleft-palate, 64 Colic of newborn infant, 66 Colostrum, 158 corpuscles, return of, 51 Condensed milk, 55 Confinemeut, prediction of date of, 113 Congenital heart affections, 68 Constipation in pregnancy, 125 Convulsions, puerperal, 208 Cord, abnormalities of, 30 care of, after labor, 154 coiling of, 31 constituents of, 30 development of, 30 hemorrhage from, 69 insertion of, 30 prolapse of, 200 rupture of, 200 shortness of, 200 Corpus luteum, formation of, 20 spurium, 20 verum, 20 Cows' milk, 52 Craniotomy, 188 indications for, 1.-8 method of performing, 188 Crede's method of placental expres- sion, 134 Curette in abortion, 141 Cystitis, 81 DEATH, maternal, effect of, upon foetus, 212 of fietus, signs of, 42 sudden, during or directly after labor, 211 of apparently well children, 71 IND1 Decapitation, 188 Decidua, development of, 31 diseases of, 32 reflexa, 32 serotina, 32 vera, 32 Deformities, congenital, treatment of, 64 pelvic, 100 Delirium of labor, 132 Development of amnion, 26 of chorion, 29 of decidual, 31 of embryo, 24 of placenta, 33 of umbilical cord, 30 Diameters of fcetal head, 105 of pelvis, 98, 102 Diet in puerperium, 159, 160 in renal insufficiency, 128 Digestion in the newborn, 45 Dilator, Barnes', in premature labor, 178 Hegar's in abortion, 177 Directions to nurse, 160 Diseases - complicating pregnancy, 118 Displacements of uterus. (Vide Uterus.) Dorsal plates, 24 Douche, uterine, in abortion, 141 hot, in post-partum hemor- rhage, 205 vaginal, after labor, 97 Dry labor, 200 Ductus arteriosus, 36 venosus, 36 Duration of pregnancy, 150 estimation of, 113 Dystocia, 193 from accidents to child or mother, 200 from disease, 208 from fcetal obstructions, 198 from maternal obstructions, 195 ECLAMPSIA, 208 diagnosis of, 209 etiology of, 208 prognosis of, 209 treatment of, curative, 210 obstetric, 210 prophylactic, 209 EX. 215 Ectopic gestation, 141 Electricity, in asphyxia of newborn, 60 in extra-uterine pregnancy, 149 in post-partum hemorrhage, 205 Embryo, development of, in differ- ent months of pregnancy, 24 Embryotomy, 187 Epilepsy complicating pregnancv, 131 Episiotomy, 153 Ergot, contra-indications in labor, 195 in abortion, 141 in post-partum hemorrhage, 204 Erythema, infectious, 93 Ether in labor, 152 Evisceration, 189 Evolution, spontaneous, 175 Excessive uterine contraction, 193 Expression of placenta, Crede's, 151 External genitalia, changes of, iu pregnancy, 102 version, 184 Extra-uterine pregnancy, 141 causes of, 142 classification of, 142 clinical history of, 143 diagnosis of, 148 frequency of, 141 prognosis, 148 symptoms of, 147 terminations of, 145 treatment of, 148 FACE presentations, 169 forceps in, 171 management of, 170 mechanism of, 170 version in, 171 Feeding, artificial, of infants, 52 natural, of infants, 49, 161 Fertilization, 23 mechanism of, 23 most likely time of, 22, 23 Fever, infectious, in pregnancy, 135 of puerperium, 83 non-infectious, of puerperium, 95 puerperal, 83 causes of, 83 peculiar manifestations of septic, 92 216 INDEX. Fever, prognosis of, 92 symptoms of, 89 treatment of, 90 general, 91 local, 90 preventive, of infec- tious, 95 specific in newborn, 64 typhoid, in pregnancy, 136 Fibroid tumors complicating labor, 197 Fissure of nipple, 79 Fcetal appendages, 29 in twin pregnancies, 37 circulatiou, 36 head, diameters of. 105 palpation of, 105 heart sounds, 112 movements, 111 Foetoruetry, 105 Foetus, causes of presentation of, 163 circulation of, 36 death of, 41 causes of, habitual, 44 changes iu structure after, 42 diagnosis of, 42 deformities of, 38 development of, 24 diseases of, in utero, 3S-44 dystocia, due to, 198 estimation of size of, 105 excretions of, 36 lengths of, during pregnancy, 26 maternal conditions affecting, 41 monstrosities of, 38 overgrowth of, 198 pathology of, 38 physiology of, 36 svphilis of, 42 viability of, 176 weight of, at term, 26 Force, anomalies of uterine and ab- dominal, 193 Forces involved in mechanism of labor, 163 Forceps, anaesthetic in application i of, 182 application of, 181 contra-indications to use of, 179 in breech presentations, 128 Forceps, in brow presentations, 172 indications for use of, 179 in deformed pelvis, 180 in face and brow presentations, 172 in head-last labors, Ls7 preliminaries to use of, 182 traction with, 181 Fractures, of newborn, 58 pALACTOCELE, 81 VJ Calactorrhcea, 78 Gavage, 48 Germinal spot, 19 vesicle, 19 Gingivitis, 123 Goitre in pregnancy, 133 Graafian follicle, 19 Gravid uterus, displacements of, 118 HEMATOMA, 76 Haemoptysis in pregnancy, 135 Hand, selection of, for podalic ver- sion, 185 Hare-lip, 64 Head, fcetal, .8S, 164 after coming, extraction of, 185 caput succedaneum of, 57 cephalo-haematoma of, 57 diameters of, 105 distortion of. 57 sinking of, into pelvis, 151 Heart, diseases of, complicating labor, 211 pregnancy, 132 sounds, fcetal, 112 Hegar's sigu of pregnancy, 112 Hemophilia, 67 Hemorrhage, accidental, 202 concealed, 202 frank, 202 from injuries of lower partu- rient tract, 205 in abortion, 140 in placenta praevia, 201 post-partum, 204 after-treatment of, 205 causes of, 204 treatment of, 204 puerperal, 75 umbilical, 69 unavoidable, 201 INDEX. 217 Hemorrhoids of bladder, 128 of pregnancy, 126 Hernia, of gravid womb, 120 umbilical, 64 Herpes gestationis, 136 Hydramnios, 27 Hydrocephalus, 198 management of labor compli- cated by, 198 Hydronephrosis, 128 Hydrorrhoea gravidarum, 32 Hyperemesis in pregnancy, 124 causes of, 124 Hyperemesis, treatment of, 124 hygienic, 124 medicinal, 125 gynaecological, 125 obstetrical, 125 Hyperlactation, 78 Hypoblast, 24 Hysteria in pregnancy, 131 in labor, 82 TCTERUS of newborn, 68 1 Imperforate rectum, 65 Impetigo herpetiformis, 136 Impregnation, most likely time of, 22 Incarceration of retro-displaced gravid uterus, 119 Incontinence of urine, 81 Induction of abortion, 176 indications for, 176 method of, 177 of premature labor, 178 indications for, 178 method of, 178 Infant, newborn. {Vide Newborn Infant.) Infectious diseases complicating pregnancy, 135 puerperium, 94 erythema, 93 Injuries, after labor, repair of, 74 during pregnancy, 137 Inlet of pelvis, diameters of, 97 Insanity, puerperal, 82, 131 Insemination, 20 Inversion of the uterus, 207 Involution of the uterus, 72, 155 Irritability of bladder, 116 of uterus, 138 JAUNDICE of newborn infant, 68 Joriseune's sign of pregnancy, 116 KIDNEY insufficiencv in preg- nancy, 126, 127 treatment of, 127 of pregnancy,126 Knots in umbilical cord, 31 Kyesteinic pellicle, 117 Kyphosis, 102 LABOR, anaesthesia in, 152 antisepsis in, 106, 107 attention to child after, 154,161 bladder and rectum iu, 152 chloral in, 152 chloroform iu, 152 clinical signs of, 151 death, sudden, after, 211 delayed, treatment of. (Vide Dystocia.) determining causes of, 150 examination in, 152 in contracted pelvis, 195 injuries after, repair of, 74 management of, 152 mechanism of, 161 in brow presentations, 171 in contracted pelvis, 166 in face presentations, 169 in pelvic presentations, 172 in vertex presentations, 165 missed, 117 pathology of. (Vide Dystocia.) perineum, care of, during, 153 phenomena of, 151 premature, induction of, 178 premonitory signs of, 151 preparation of bed for, 108 pulse after, 156 rupture of membranes in, 153 temperature after, 157 Laceration of perineum, 153 cause of, 153 preventive treatment of, 153 repair of, 74 Lactation, 154 Laparo-cystectomy, 192 -elytrotoniy, 192 Laparotomy for obstetrical compli- cations, 193 218 INDEX. Liquor amnii, 26 function of, 26 origin of, 26, 27 Liver, acute yellow atrophy of, 126 Lochia, 155 Locking of children in twin labor, 199 NASAL catarrh, in newborn in- fant, 65 Nausea of pregnancy, 110 Nervous system, diseases of, iu preg- nancy, 130 Neuralgia in pregnancy, 130 Newborn infant, 45 airing of, 56 anatomical points about, 47 aphthae of, 65 artificial feeding of, 52 asphyxia of, 59 bathing of, 56 blood of, 46 bloody discharge from genitalia of female, 71 bowels of, 46 Buhl's disease of, 70 cleansing of. 56 clothing of, 48 colic of, 66 congenital deformities of, 64 constipation of, 66 cord of, 47 cyanosis of, 66 diarrhoea of, 66 digestion of. 45 diseases of, 61 excretions of, 46 eyesight of, 46 feeding of, 49, 159 gavage of, 48 heart of, 47 hemophilia of, 67 icterus of, 68 incubation of, 48 injuries of, 56 intestinal perforation in, 70 intussusception in, 70 jaundice of, 68 length of, 105 liver of, 47 management-of, 48 mastitis of, 64 meconium of, 46, 173 medication of, 71 medico-legal points about, 47 melaena of, 70 nasal catarrh of, 65 oedema of, 71 ophthalmia of, 67 pathology of, 56 pemphigus of, 66 physiology of, 45 premature, abnormalities in physiology of, 48 pulse of, 46 respiration of, 45 sclerema of, 48 MACERATION of fcetus, 42 Mammary glands, changes of, in pregnancy,111 diseases of, 79 Mastitis, 79 in newborn infant, 64 Mechanism of labor, 161. {Vide Labor, mechanism of.) of third stage, 175 Meconinm, 46, 173 Medication of newborn infant, 71 Mehena, 70 Menstruation, 17 causes of, 18 duration of, 17 phenomena of, 17 relation of, to ovulation, 18 Mental disorders, 131 Mesoblast, 24 Micrococci in puerperal fever, 83 Milk, condensed, analysis of, 55 as an infant food, 55 cows', analysis of, 52 mother's, analysis of, 49 compared with cows', 52 proteids of, 49 quantity of, at each nursing, 50 secretion of, 49 factors, influencing, 50, 51 Milk leg, 92 Miscarriage. (Vide Abortion.) Missed abortiou, 141 labor, 117 Monstrosities, classification of, 38 Multiple impregnation, 36 causes of, 36 prognosis of, 37 Mummification of fcetus, 42 INDEX. 219 Newborn infant, skin diseases of, 66 specific fevers of, 64 stomach, capacity of, 15 stomatitis of, 06 sublingual cyst of, 66 sudden death of, 71 syphilis of, 63 temperature of, 46 tetanus of, 70 thrush of, 65 umbilical diseases of, 69 urine of, 46 weight of, 45 Winckel's disease of, 71 Nipples, care of, during pregnancy, 79 during puerperium, 159 diseases of, 79 diseases, treatment of, 79 fissure of, 79 inversion of, 79 Nurse, directions to, 160 wet, selection of, 51 OBJECTIVE signs of pregnancy, 111 Obstetric operations, 176 Obstetrician, armamentarium of, 152 Obstructed labor due to fcetal ob- structions, 198 maternal obstructions, 195 Occipito-posterior positions, 166 management of, 168 mechanism of, 166 (Edema neonatorum, 71 Oligohydramnios, 27 Omphalorrhagia, 69 Operations, obstetric, 176 Ophthalmia neonatorum, 67 Ovulation, 18 Ovule, anatomy of, 19 changes in fertilized, 23 PALPATION, abdominal, 162 Pathology of labor. ( Vide Dys- tocia.) of pregnancy,118 Pelvic cavity, diameters of, 98 direction of, 98 Pelvimetry, 102 Pelvis, anatomy of, 97 angle of, 97 deformities of, 100 diagnosis of commoner forms of, 104, 105 management of labor in, 195 development of, 98 diameters of, 98 Pemphigus, simple acute, 66 syphilitic, 67 Perineum, laceration of, 153 repair of, 74 support of, 153 Peritonitis in puerperal fever, 87 Pernicious vomiting of pregnancy, 124 Phlebitis, septic. (Vide Phlegmasia.) Phlegmasia alba dolens, 92 Phthisis complicating pregnancy, 95, 135 Physiology of mature fcetus, 36 newborn infant, 45 Physometra, 42 Pigmentation, exaggerated, of preg- nancy, 137 Placenta, adherent, 176 anatomy of, 33 anomalies of, 34 degenerations of, 34 development of, 33 diseases of, 34 expression of, 154 expulsion of, 152 functions of, 31 praevia, causes of, 201 diagnosis of, 201 frequency of, 201 prognosis of, 202 treatment of, 201 retention of, 175 separation of, 152 situation of, 33 Pleurisy complicating pregnancv, 135 Pneumonia complicating labor, 211 • pregnancy, 135 of newborn infant, 62 Podalic version, 185 Polygalactia, 78 Position, diagnosis of, 162 definition of, 161 Positive signs of pregnancy, 111, 112 Post-mortem delivery, 212 Post-partum hemorrhage, 204 220 INDEX. Post-partum hemorrhage, causes, 204 treatment, 204 Predicting date of confinement, 113 Pregnancy, changes in maternal organism in, 113 general, 116 local, 113 diabetes in, 129 diagnosis of, 110 diseases of, 118 duration of, 150 extrauterine, 141 clinical history of, 142 diagnosis of, 148 signs of, 147 terminations of, 145 treatment of, 148-150 hydraemia of, 116 Pregnancy in one horn of uterus, 150 insanity of, 131 kidney of, 126 management of, 117 multiple, causes of, 37 fcetal appendages in, 37 pathology of, 118 abortion, 138 accidents, 137 alimentary canal, 123 circulatory apparatus, 132 displacements of gravid uterus, 118 extrauterine gestation, 141 genitalia, 118 infectious diseases, 135 injuries, 137 miscarriage, 138 nervous system, 130 osseous system, 135 premature labor, 138 respiratory apparatus, 134 skin, affections of, 136 surgical operations, 137 urinary apparatus, 126 physiology of, 113 prolongation of, 117 signs of, 110-113 objective, 111 subjective, 110 Premature labor, induction of, 178 indications for, 176 method of, 177 Preparation for labor, 108, 152 of artificial food, 53 Presentation, definition of, 161 diagnosis of, 162 varieties of, 165 brow, 171 face, 169 greater fontanelle, 172 pelvic, 172 shoulder, 174 vertex, 165 Prolapse of cord, 200 of gravid uterus, 120 Pruritus, 137 Pseudocyesis, 111 Ptomaines, 106 Puerperal convulsions, 208 erythema, 93 fever, diagnosis of, 89 infectious, 84 morbid anatomy, 85 non-infectious, 95 peculiar manifestations jf, 92 symptoms of, 89 treatment of, 90 hemorrhage, 75 insanity, 131 pemphigus, 94 rheumatism, 93 state, after-pains, 156 antisepsis in, 109 breasts in, 159 catheter in, 158 circulation in, 156 diagnosis of, 158 diet in, 159, 160 directions to nurse, 160 duration of, 154 involution of uterus in. '55 lochia in, 155 loss of weight in, 157 malaria in, 94 management of, 158 nipple, care of, 159 nursing in, 159 pathology of, 72 abnormalities of invo- lution, 72 anaemia, 74 anomal ies of th e breasts, 77 diseases of nervous sys- tem, 82 diseases of urinary ap- paratus, 81 INI) Puerperal state, pathology of, fever, 83 hemorrhages, 75 injuries, repair of, 74 physiology of, 154 puise in, i,56 retention of urine in, 156 secretions in, 156 temperature in, 157 tetanus in, 94 urinary function in, 156 vaginal injections in, 96, 97 visits during, 158 Puerperium. (Vide Puerperal state.) AUICKENING, 110 RACHITIC pelvis, characteristics of, 102 Rectum, imperforate, in newborn infant, 65 in labor, attention to, 152 Respiration, artificial, 60 institution of, physiology of, 59 Respiratory apparatus, diseases of, in pregnancy, 134 Restitution, 165 Retained placenta, 175 Retention of urine, 156 Retroflexion of gravid uterus, 118 Rigidity of cervix, 196 Rupture of cervix, 74 of membranes, 53 of perineum, 7*; 153 of symphysis, 208 of uterus, 206 GANGER'S operation, 190 U Secretion of milk, 50, 157 Section, Caesarean, 189 Segmentation of ovule, 23 Selection of wet nurse, 51 Seminal fluid, 20 Septicaemia, 83 Septic infection, avoidance of, 158 mortality of, 92, 106 of lung in newborn infant, 62 symptoms of, 89 Sex, determination of, 36 EX. 221 Shock, after labor 211 Shoulder, presentation of, 174 dangers of, 175 diagnosis of, 174 treatment of, 175 Signs of pregnancy, 110-113 Skin, diseases of, in pregnancy, 136 Spina bifida, 65 Spermatic particle, 21 Spontaneous amputations, intra- uterine, 41 delivery in transverse presenta- tions, 175 evolution, 175 fractures, 41 version, 175 luxations, 41 State, puerperal. (Vide Puerperal state.) Sterilization of infants' food, 54 Stomatitis, gonorrhceal, 66 Subinvolution, 72 Sublingual cysts, 66 Super-fecundation, 37 -fcetation, 37 -impregnation, 37 Supernumerary digits, 64 Sutures of fcetal head, 164 Symphyseotomy, 189 Syphilis, causing abortion, 43 in pregnancy,136 of the fcetus, 42 of the lung in newborn infant, 61 of newborn infant, 63 TAMPON in abortion, 140 in placenta praevia, 202 in post-partum hemorrhage, 205 Tetanus of newborn infant, 70 puerperal, 94 Thrush, 65 Tongue-tie, 64 Torsion of cord, 31 Traction with forceps, 181 Tubal pregnancy, 142 Tuberculosis of newborn infant, 62 Tumors complicating labor, 197 Twin pregnancy, 37 appendages in, 37 Twins, dystocia due to, 199 management of, 199 •7O0 INDEX. Tympanites, acute, 73 uteri, 42 Typhoid fever in labor, 211 in pregnancy, 136 UMBILICAL cord, abnormalities of, 30 constituents of, 30 development of, 30 hemorrhage from, 69 prolapse of, 200 Umbilicus, diseases of, 69 hemorrhage from, 69 Unavoidable hemorrhage, 201 Urination, disturbances of, in preg- nancy, 116 in puerperium, 81 Urine, anomalies of, in pregnancv, 129 Uterine inertia, 194 muscle, diseases of, 121 involution of, 72 rheumatism of, 121 Uterus, action of, in labor, 151, 164 anomalies of, 105 bicornis, pregnancy in, 150 changes of, in pregnancy, 113 in puerperium, 72 dimensions of, 115 displacements of gravid, 118, 197 incarceration of gravid, 118 inertia of, 191 inversion of, 207 involution of, 72 Uterus, irritability of, Lis malformations of, 105 one-horned, pregnancy in, 150 rupture of, 206 sinking of gravid, 151 tympanitis of, 42 VAGINA, anomalies of, 105 changes of, in pregnancy, 113 color of, in pregnancy, 111 diseases of, in pregnancy, 121 injuries of, treatment. 74 Valvular heart disease in labor, 211 Varicose veins in pregnancy, 133 Vegetations of vulva, 122 Vernix caseosa, removal of, 154 Version, contraindications for, 183 indications for, 183 methods of, 183 varieties of, 183 Vertex, positions of, 163 presentation, mechanism of, 165 posterior position of, 166 Visits of physician after labor, 158, 159 Vomiting in pregnancy, 110, 121 Vulva, diseases of, in pregnancy, 121 haematoma of, 76 pruritus of, 121 vegetations of, 121 WET nurse, selection of, 51 Winckel's disease, 71 NATIONAL LIBRARY OF MEDICINE NLH DM5173^fl 7 NLM045173987