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NATIONAL LIBRARY OF ME
NLM  D05fll053  S

NATIONAL LIBRARY OF MEDICINE
            Washington
Founded 1836
U. S. Department of Health, Education, and Welfare
            Public Health Service
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NLM005810535 
 
 
 
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LECTURE  NOTES
OBSTETRICS,

                       FOR THE USE OF
          STUDENTS IN THE LONG ISLAND COLLEGE HOSPITAL,
■BY-
  Clrarles Jewett, A. M.,  M. D.,


PROFESSOR OF OBSTETRICS AND PiEDIATRICS IN  THE  COLLEGE, AND

              OBSTETRICIAN TO THE HOSPITAL.
     BROOKLYN, N. Y. :
E .  A. DAY,  M.D.,
     306  Sumner  Avenue,
            1890,
 

     COPYRIGHT BY
  E. A. DAY,  M. D.,
306  Sumner  Avenue,
    Brooklyn, N. Y.
 
         LECTURE  NOTES
                  --IN---

O  B ST KT R I C  S.
       THE  FEMALE  GENITAL  ORGANS.

1.  External Organs of Generation: Pudendum: Tulva.
    The Mons Veneris  is a  fatty cushion overlying the  upper
        half of the symphysis pubis.  In addition  to  fat it
        contains fibrous and elastic tissue.   It is covered with
        skin which abounds in sebaceous and sweat glands and
        becomes  invested with a growth of hair at puberty.
    The Labia Majora are two prominent, rounded,  fleshy folds
        springing from the  mons veneris as if prolongations of
        its lateral halves, and extending downward and back-
        ward  to  a point about one and a quarter inches
        in front of the anal orifice.   They are symmetrically
        placed on  either  side of the median line and lie
        in contact with  each other  in the young nullipara.
        In older  women they shrink and the  labia minora
        protrude between them.   They are thickest  in  front
        and taper  from  before backward.  Their  covering is
        skin.  The outer surfaces are supplied with  hair, the
        inner  resemble  mucous membrane,  but are  sparsely
        covered with fine hair's: ' Ppth  surfaces abound in
        sebaceous and sweat  glands*."'
            They are the analogue of the  scrotum in the
        male.   The  point  of union  in front is the  anterior
        and that behind, the posterior commissure.  Their
        internal structure is made up  chiefly of connective and
        adipose tissue and includes a rich venous plexus. The
        remains of the canal of Nuck may sometimes be traced
        into them on either side. 
4
Genital  Organs.
The Labia Minora are  two thin  folds  of  skin or  muco-
    cutaneous tissue  lying  obliquely upon the inner sur-
    faces of the labia  majora.  Anteriorly each subdivides
    into two folds, the superior folds  uniting in front of
    the clitoris  to form the prepuce  of the clitoris, the
    inferior folds  forming,  by their junction below the
    glans, the frenum of the clitoris.  They are widest to-
    ward  their  anterior extremity, gradually narrowing
    from before backward.
The Fourchette is a transverse  fold  of skin uniting  the la-
    bia majora posteriorly.
The Fossa Naricularis is  the  boat-shaped  surface  between
    the fourchette and the hymen, which  appears when
    the labia are separated.
The Rima Fudendi is the  median cleft  between  the  labia
    of the right and left side.
The Clitoris is the  analogue of the  penis.   It lies  in the
    median line just  below the anterior vulvar commiss-
    ure concealed behind the mucous membrane.  It has
    two  corpora cavernosa and a  glans, but no  corpus
    spongiosum, and  is imperforate.  The corpora caver-
    nosa of  the clitoris are continuous with the crura, by
    which  it is attached to the  ischio-pubic rami.  Its
    length during erection is about one inch.
The Vestibule is  the triangular  space  bounded  laterally
    by the labia minora and below by the  margin  of the
    vaginal orifice.   Its covering is mucous membrane.
    At its  apex is the glans clitoridis.  At  the center of
    its base, or immediately above it,  is the  meatus ure-
    thrae in the center of a  small tubercle or  prominence.
    The meatus lies  three fourths  of  an inch below the
    glans clitoridis, and one  inch above  the fourchette
    in the nullipara.
The Boundary Line between  skin and mucous membrane
    runs along the lateral  borders of the  vestibule and
    passes backward around the vaginal orifice just with-
    out the  base of the hymen.
The Arterial Supply  of  the pudendum is  chiefly  from the
    internal pudic. 
Genital Organs.
5
    The Veins.  The labia, clitoris and urethra abound in erec-
        tile tissue rich  in venous plexuses.  The  bulbi vesti-
        buli are two leech-shaped  masses of veins about an
        inch in length and situated one on either  side of the
        mesial line behind  the labia, opposite the  vaginal
        orifice and the base  of the vestibule.  They lie  be-
        tween the bulbo-cavernosus muscle and the vaginal
        wall, immediately in front of the triangular ligament.
        They communicate  through the  pars  intermedia of
        Kobelt with the veins of the glans clitoridis.
    The Lymphatics of the labia  majora,  minora and  clitoris,
        terminate in the inguinal glands.
    The Nerye Supply of the  pudendum  is derived  from  the
        internal pudic.  It is especially abundant in the clitoris
        and the labia minora.
    The Pudendal Glands.   Sebaceous glands  abound upon the
        skin  surfaces,  especially  on the  nymphae.   About
        half a dozen muciparous glands are to be found in the
        vestibule, grouped about the meatus urethrae.
    The Vulvo-vagiual Glands, or glands  of Bartholin,  are two
        reddish-yellow bodies about the size of a pea or some-
        times larger, lying one on  each  side of the posterior
        portion of the vagina, behind the  anterior layers of
        the triangular ligament.  They lie  partly behind the
        lower extremities of the bulbi vestibuli.  Their ducts,
        about half an  inch  in length,  run  along  the inner
        aspects of the bulbi vestibuli  opening just  without
        the base  of the hymen at the  sides of  the  vaginal
        orifice.

Internal Organs of Generation.

    The Hymen appears  as  a  septum  partially occluding  the
        vaginal orifice, when the  latter  is distended.   When
        the orifice is  closed  the hymen protrudes as  a loose
        fold in the vulvar fissure.  According to Budin, it  is a
        thinned out prolongation  of  the vagina  itself.  Its
        most common  form is  that of a crescent, situated at
        the  posterior margin of the vaginal orifice,  with its 
6
Genital  Organs.
    concavity looking forward.  It may, however, be  an-
    nular, cribriform, or imperforate.  It is usually torn at
    the first sexual approaches.
    The Carunculae Myrtiformes are the remains of the hymen
        torn in labor by the  passage of the child.   They
        appear as  minute fleshy  tubercles  skirting  the
        vaginal orifice or its posterior margin.
    The Hymeneal Orifice  is, in the  rule,  nearly circular.
        The  vaginal, in  the virgin, a  transverse,  cres-
        centic slit, the concavity of the  crescent  look-
        ing forward.
The Vagina  is that part of the genital tract  between  the
    uterus  and the  vulva.   Its direction is nearly parallel
    with the pelvic  brim.  It is a  collapsed tube, its anterior
    and posterior walls lying in  contact.  It  is attached
    above to the uterine cervix at  about the middle  of its
    length, the lower portion of the cervix projecting  into
    the vagina nearly at a right  angle.   Its posterior wall
    is in relation at its upper extremity with the perito-
    neum,  at its lower with the perineal body.  At its
    middle portion it is loosely connected with  the rectum.
    The lower portion  of the anterior wall  is closely
    related with the  urethra and  base of  the bladder.
    The fornix or roof of the vagina is that part of the
    canal immediately about the  vaginal  portion  of the
    cervix uteri.
    Length of anterior wall is about two and a half inches.
    Length of posterior  wall is about  three and a  half
        inches.
    The walls are, however, extremely distensible,  and
        they become  permanently  relaxed  in parous
        women.   The vagina, when  distended,  has  a
        conoidal shape,  the orifice corresponding to the
        smaller  end of the cone.
     Structure.
        Three coats.
             Internal, mucous membrane.
             Middle, muscular coat,  of unstriped muscu-
                 lar fiber. 
                Genital Organs.                    7

             External, a loose layer of connective tissue.
             The mucous membrane is arranged in trans-
                 verse folds or rugae  extending laterally
                 from  a  median ridge on both  anter-
                 ior   and  posterior   walls.  The rugae
                 are most marked  in the lower portion
                 of the vagina.
             Columnae rugarum are the two median ridges,
                 one  on each wall of the vagina at its
                lower end.
             The vaginal  epithelium  is of the  squamous
                 variety.
             The  muscular  coat  consists of  an outer
                 circular and an inner longitudinal layer
                 of unstriped muscular fiber.
             The  external coat  contains the  external
                 plexus of veins.
     The Arterial Supply of the vagina  is chiefly from the
         vaginal, but also from branches of the uterine ar-
         tery at its upper, and of the pudendal at its lower
         extremity.
     The  Veins correspond, but they first form two plex-
         uses surrounding the vagina,  one  in the external
         coat, and one  immediately beneath the mucous
         coat.
     The Lymphatics  of the lower fourth of the  vagina  join
         with those of the pudendum, terminating in the
         inguinal glands.   Those from the remaining por-
         tion of the vagina unite with the vesical and cer-
         vical lymphatics and empty into the iliac glands.
     The Nerves  are from the fourth sacral  and the pudic
         of the spinal system, and the sympathetic nerves
         from the hypogastric plexus.
     The Mucous Glands  are chiefly  confined  to the  lower
         portion of the vagina.
The Urethra.   Intimately connected with the lower portion
     of the anterior vaginal wall is   the  urethra.
     Situation.  The  urethra passes backward below  the
        pubic  arch, and  upward  behind the symphysis 
Genital  Organs.
     pubis to the bladder.  Its lower  three fourths is
     inseparable from the anterior  vaginal wall.
 Size.  Length, one  and a half inches.  It is largest
     at  the  vesical  end,  smallest  at  the meatus
     and is very distensible.
 Shape.   Slightly sigmoid.
 Structure.   Is composed chiefly of muscular and erec-
     tile tissue.
 Skene's Glands.  Two  tubular glands are to be  found
     in the muscular wall  of the urethra at its  lower
     end, near its floor, one on either side of the med-
     ian  line,  which  are known  as  Skene's  glands,
     so  named  from their discoverer.    Their ori-
     fices   lie  just   within  the   meatus  urethrae.
     They  extend upward along  the urethra  about
     three-fourths of an inch.
Uterus.  The uterus is a hollow muscular organ.
 Situation.  It is situated in the  cavity of the pelvis,
     between  the  bladder  and  the rectum,  a  little
     nearer  the sacrum  than the  pubes.   Its  upper
     border is nearly in the plane  of  the pelvic  brim,
     its  lower border about opposite  the tip  of the
     sacrum.  Its long axis is nearly perpendicular to
     the  plane of the pelvic brim.   It is, however,
     extremely movable.
 Shape,  pyriform,  flattened  from  before  backward,
     more  convex  on its posterior than its anterior
     surface, and very slightly anteflexed.
 Size, small and  undeveloped until puberty,  it then
     attains its full size in about two years.
     Length, in the nulliparous  adult, three inches.
     Width, at the  level of the Fallopian  tubes, two
         inches or less.
     Thickness, one inch.
     Weight, in the  nullipara, from  one to one and
         a half ounces.
 Regional Divisions.  Fundus, body, cervix.
     Fundus, that  portion  above the level of the  in-
         sertion of the Fallopian tubes. 
Genital  Organs.
9
    Body and Cervix.  The portion below the fundus
        is about  equally  divided  between the body
        and the cervix.
    Istlimus, the slightly constricted portion between
        the body and the cervix.
    The Portio Vaginalis, that part of the cervix, about
        one third of an inch in length, which pro-
        jects into the upper end of the vagina.
    The cavity of the body, somewhat triangular in
        shape in the nullipara, its anterior and pos-
        terior walls lying  in  contact.   It has three
        openings, one communicating with the cer-
        vical  canal  and  one  with  each  of  the
        Fallopian tubes.
    The  cavity of the  cervix  is somewhat flattened
        from  before  backward,  and  is  laterally
        elliptical, thus  having an irregular  fusiform
        shape.
    The os  internum is  the upper,
    The os externum the  lower orifice of the cervical
        canal.
    In the nulliparous uterus the  corporeal cavity is
        triangular,, fundus  flattened, cervix  conical,
        and the os externum a mere dimple.
    In the parous uterus the cavity is oval, the fundus
        dome   shaped,  the   cervix  cylindrical,
        and the os externum a transverse slit, with
        the  lips  more or  less  fissured.
Structure.
    The Mucous  Membrane.
        Body:—About one twelfth of an inch  thick;
            its epithelium is of the ciliated columnar
            variety, the cilia  propelling toward the
             fundus.  There is  no submucous  layer.
             It  abounds in tubular glands,  which fre-
            quently  are   bifurcated.   They  are
            obliquely placed and lined with ciliated
            epithelium. 
10
Genital  Organs.
    Cervix /—Firmer than that of the body.
        The arbor vitae consists of two median
        longitudinal ridges, one anterior and one
        posterior, each with transverse folds or
        rugae running obliquely outward.  In and
        between the rugae of the arbor vitae are
        mucous  follicular glands known as the
        Nabothian glands.
        The epithelium of the cervical canal is
        of the ciliated columnar variety almost
        to the os externum in the adult.  The
        epithelium of the external surface of the
        portio vaginalis  is  squamous  like that
        of the vagina.
The Musculature constitutes the greater part of the
    thickness  of  the  uterine wall.   Its  fiber
    is of the  unstriped variety.  Best studied at
    the full period of gestation.
    TJiree Layers :
        i.   Outer, very thin, continuous with the
             muscular  layers  of the  Fallopian
             tubes, the ovarian, round, broad and
             utero-sacral ligaments.
        2.   Middle, comprising the bulk of the
             uterine  muscle,—a  mesh-work  of
             longitudinal and transverse bundles.
        3.   Inner, circular layer, surrounding the
             Fallopian tubes and os internum and
             externum.
    This differentiation into  layers is more theo-
        retical than practical.
The Peritoneal Coat.   The  peritoneum  covers
    about two thirds the length of  the  uterus in
    front and extends down beyond the uterus
    over about one inch of the vagina posteriorly.
    The lateral   aspects  of  the  uterus  are
    uncovered  of peritoneum over  the  spaces
    between  the folds of the broad ligament. 
Genital Organs.
ii
Ligaments of the Uterus.
      Broad Ligaments.   The pelvic peritoneum dips down
          posteriorly into the lower pelvis, is reflected
          up  over  one  inch  or more  of the  upper
          end  of the  posterior  vaginal   wall   and
          over  the   posterior surface of the  uterus,
          passes over the uterus, investing its anterior
          surface to the isthmus, and is again reflected
          upward and over  the bladder.  The uterus
          thus  lies  between  the  layers of a trans-
          verse fold of peritoneum, its lateral  surfaces
          between  the  layers  being  uncovered  of
          peritoneum.  The  lateral portions of these
          transverse  folds stretching  from the uterus
          to the sides  of the  pelvis  form  the broad
          ligaments.
      Utero-Sacral Ligaments.   Two  semilunar folds  of
          peritoneum, enclosing unstriped   muscular
          fiber  and  connective tissue, which pass  one
          on each side of the rectum from  the  lower
          portion  of the sides  of the  uterus  to  the
          second bone of the sacrum.   These folds are
          also  known as the folds of Douglas,  and the
          space between them as Douglas' pouch, or
          czd de sac.
      Round Ligaments.  The  cord-like  ligaments which
          pass  from   the   angles   of  the  uterus
          forward through  the  inguinal  canals,  to
          blend with the structures at  and immediately
          below the  external  ring.  Length,  four  to
          five   inches.   They   contain  striped  and
          unstriped muscular  fibers.
          The  ovarian  ligament, the Fallopian tube,
          and  the  round ligament are  enveloped  in
          subsidiary folds of the broad ligament.
          The Infundibulo-pelvic Ligament is that part
          of the superior border of the broad  ligament
          on each side, extending  from  the  Fallopian
          tube to the pelvic wall. 
12                 Genital Organs.

        The Arteries of the uterus  are two uterine and  two
            ovarian.   They  pass  to the uterus  between the
            folds of the broad ligament  on either side.   The
            uterine artery approaches  the  uterus  at about
            the level  of the os externum, the ovarian at the
            level  of the  cornua.   A branch  of the  ovarian
            artery descends  along  the  lateral border of the
            uterus to communicate with the uterine.  Another
            branch   supplies  the  fundus and  anastomoses
            with its fellow of the opposite side.  The arteries
            of the uterus are remarkable for their free anas-
            tomosis  and tortuous course.   Arterial tufts are
            given off to the lateral borders  of the  uterus
            whose branches form  spirals within the uterine
            wall.   They end in a  mesh  work  of capillaries
            about the utricular  glands.   The circular artery
            at the isthmus unites the arteries of the opposite
            sides of the uterus  with each other, surrounding
            the cervix.
        The Veins.  The uterine plexus of veins lies immediately
            beneath  the  peritoneal coat  of  the uterus.   It
            communicates with  large sinuses in the middle
            muscular  coat which are encircled  by muscular
            bundles.    The  venous system  of the  uterus
            empties into the ovarian plexus of veins.
        Lymphatics of  the Uterus.   Very  numerous  and  com-
            municating with the lymph  spaces of the mucous
            membrane and the muscular coat.  They form an
            intricate  network over the  surface of the- uterus
            under  the peritoneum, also over the  Fallopian
            tubes.  They are  fully developed  only during
            pregnancy.   They empty into the lumbar glands.
        Nerves of the Uterus.  Chiefly from  the  sympathetic,
            from the inferior hypogastric and spermatic plex-
            uses.   The  cervix also receives filaments from
            the upper sacral  nerves.   The  uterine nerves
            terminate apparently  in the nuclei of the muscle
            cells. 
Genital Organs.
13
The Fallopian Tubes, Oviducts. Two narrow tubes, one running
    outward from each horn of the uterus and communicat-
    ing with  the uterine cavity.   The outer portion of
    the tube  takes a tortuous course, partially surround-
    ing the ovary.
    Length, three to five inches.
    Divisions.
        The Isthmus is the  portion  of  the tube  next  the
            uterus.   It is the smallest part of the tube and
            is about one inch in length.
        The Ampulla  is  the dilated  portion  of  the tube
            next beyond the isthmus.
        The Fimbriated Extremity, Pavilion or Infundibulum, is  the
            free  trumpet  shaped  end  of the  tube,  the
            margin  of which is fringed  with a number
            of irregular  processes  called fimbriae.
        The Fimbria Ovarica is the  special  fimbria which is
            attached to the ovary.
        The ostium uterinum barely admits a bristle.
        The ostium  abdominale is  of the size of a small
            goose quill.
    Structure.
        Three Layers.
            Outer or  peritoneal coat  invests two-thirds
                 the  circumference  of the tube.
            Middle or muscular coat,  with an inner cir-
                 cular  and  an outer longitudinal layer of
                 unstriped muscular fiber.
            Lnner  or  mucous  coat, lined  with ciliated
                 columnar epithelium.  The mucous mem-
                 brane is disposed  in  longitudinal folds.
                 It has no  glands. The  motion  of  the
                 cilia propels toward the uterus.
    The Arteries of the Fallopian  tube are branches  of  the
        ovarian.
    The Veins open into  the pampiniform or ovarian plexus
        lying  between the folds of the broad  ligament
        below the tube.
    The Lymphatics unite with those  from  the  uterus and
        ovary and terminate in the  lumbar glands. 
14
Genital  Organs.
    The Nerves are derived  from the inferior hypogastric
        plexus on each side.
The Ovaries.  Two  in  number,  one on  each side of the
    uterus, corresponding to the testes of the male.
    Situation.  One  on the posterior fold of each broad
        ligament  about one  inch  or  more  below the
        level of the ilio-pectineal  line and  the same dis-
        tance from the uterus, yet they have great mobil-
        ity within normal limits.   Each ovary is attached
        by its anterior edge to the anterior fold  of the
        broad  ligament, projects through the posterior
        fold, and is connected with  the  corresponding
        horn of the uterus by the ovarian ligament.
    Size.   About one  and a  half inches  in  length  by
        three-fourths in width and one-half in thickness,
        yet variable.  Average weight about eighty grains.
        Size increases during menstruation, also in  early
        pregnancy.   Larger  in  young virgins  than  at
        any other period of life except the first six  weeks
        of pregnancy.
    Shape.  A  flattened  ovoid  or that of  a flattened
        pigeon's egg.   Its free border  is convex.  The
        anterior edge by which it is attached to the broad
        ligament is nearly straight.  This straight border
        is the hilum.  It is thinner at the  hilum, thicker
        at the  convex  border.  Its  superior  surface is
        nearly flat, the inferior convex.  The inner end
        is narrower and  pointed and merges into the
        ovarian ligament, the outer is  more obtuse and
        bulbous.
    The Ovarian Ligament  is a mere cord  containing some
        muscular fiber,  and  extending from  the  inner
        end of the ovary to the horn of the uterus, join-
        ing it immediately behind and below the attach-
        ment of the Fallopian tube.  Is about  one inch
        in length.
    The Arterial  Supply is  derived  from  branches  of the
        ovarian arteries, which enter at the  hilum. 
Genital Organs.
15
The Veins emerge from the hilum and  empty into the
    bulb of the ovary, which communicates with the
    pampiniform plexus.
The Lymphatics together with  those of the  tube and
    uterus, empty into the lumbar  glands.

The Nerves are derived from the  inferior hypogastric
    plexus.

Structure.
    External Structure.
             In  early  life the  external  surface is
         smooth, like an almond.
             Later in life, after  puberty, it becomes
         uneven, acquiring a wrinkled appearance,
         owing  to the  cicatrices  from rupture  of
         Graafian follicles.
             In  very old age it again becomes smooth.
             Its epithelium is that  of a mucous mem-
         brane, columnar and non-ciliated, the germ
         epithelium of Waldeyer.   The peritoneum
         terminates abruptly at the  ovary.

    Internal Structure.
             Consists  of connective tissue, some un-
         striped  muscular  fiber,  Graafian  follicles,
         blood vessels, nerves, lymphatics.
         The  Medullary Zone, or  Zona Vasculosa, is
             the portion about the hilum, reddish in
             color.  Here enter  the blood  vessels,
             nerves and lymphatics.
         The Zona Parenchymatosa, or cortical portion
             of the ovary, grayish in color.
         The Tunica A Ibuginea is a dense layer of ovari-
             an stroma  immediately underlying the
             germinal epithelium.
         The Graafian Follicles, or  Ovisacs. 
16                    Pregnancy.

    The  Graafian Follicles are  most numerous  in  the cortical
        layer.  They are developed from the germ  epithe-
        lium of the ovarian surface.
        Number at  birth, 40000, or more  in  each  ovary.
            Each follicle contains, generally, but  one ovum.
            At  any time  during the  child-bearing period,
        ten  or  twenty  Graafian  follicles  may  be  found
        considerably  developed  near  the  surface  of  the
        ovary.
        Size, i-iooth to i-i6th inch in diameter.
        Structure.
            1.   Tunica Fibrosa.
            2.   Tunica Propria.
            3.   Tunica  (Membrana) Granulosa,  a multiple
                layer of cylindrical epithelium.
            4.   Liquor Folliculi, a clear albuminous  fluid,
                para-albumen.
            The Discus Proligerus, or Germinal  Eminence,
                is  a  heaped  up   mass  of cells  of  the
                membrana granulosa  at  one side, contain-
                ing the ovum.
                     PREGNANCY.

Ovulation.  The process by which the ovum is matured and dis-
    charged from the ovary. It occurs, in the rule,once in twenty-
    eight days, during the period of functional activity of  the
    ovary.  Is attended generally in  the human subject with a
    bloody discharge from the  uterus,—menstruation.   Yet
    ovulation may occur without  menstruation,  and  men-
    struation without ovulation.  Hence an ovule may  ex-
    ceptionally  be discharged  at  any  period  between  the
    menstrual  epochs.   Generally  the  discharge  of  the
    ovule takes  place  during  menstruation.   Usually  but
    a  single  follicle  ruptures  at  each  epoch,  sometimes
    two or  more. 
Pregnancy.
17
Menstruation.  A partial  exfoliation and renewal  of the
    endometrium  usually  attending  ovulation.  It is ac-
    companied with certain local and general nervous and
    vascular disturbances  and, in the human female, with
    a bloody discharge from the uterus.
         A  new growth of endometrium  is  complete  in
    nine or  ten days from the  beginning of each  men-
    strual  epoch.   Menstruation, therefore, is apparently
    designed to fit the uterus for the reception of  a fertil-
    ized ovum.
    Character ofthe Menstrual or Catamenial Flow.  Constituents,
         blood, shreds of endometrium, uterine and vaginal
         secretions.
         Reaction  alkaline.  Does  not  clot in  health.
         Amount  five to  ten ounces.
         Duration, three to seven days.
         The interval between  the  menstrual epochs  is
    usually twenty-eight  days.
    Puberty is  synonymous with sexuai maturity and is
         marked in the female by the first onset of ovula-
         tion and menstruation.  The  anatomical  and
         mental characteristics  of the sex  are  gradually
         developed at this period of life.
     Age of Puberty.   The  usual  age  of  puberty  is the
         fifteenth  year.  It varies with race, climate and
         other influences,  occurring  in exceptional cases
         as early  as the tenth or  as late as  the twentieth
         year of age.
     The Menopause, or  the  final cessation  of menstruation
         and of the capacity for child-bearing, occurs  in
         most women at about the age of forty-six years.
         Occasional variations of ten years or more  on
         either side of this limit are possible.

 Phenomena Attending the Rupture of a Graafian Follicle.
     Increase of fluid  contents from  increased vascularity.
     Loops of blood vessels are projected into the cavity of
         the follicle.   Contiguous portions  of the  ovary
         and, to a certain extent, its whole  structure, ex- 
i8
Pregnancy.
             hibit a similar increase in vascularity.  The follicle
             now appears as a bright red  spot  on the surface
             ofthe ovary.
             Absorption of overlying ovarian structure takes
             place owing to increasing  pressure  ofthe liquor
             folliculi.
             The  follicle  finally ruptures and  discharges its
             contents, an effusion of blood  taking place into the
             follicle after rupture.  The ovum is floated into the
             pavilion of the tube by a  stream  of serum  pro-
             pelled by the cilia  of the  fimbria  ovarica.  It  is
             propelled  through the Fallopian tube partly by
             ciliary motion, and in the narrower portion ofthe
             tube partly by muscular action.
The Ovum.
    Size.  i-i20th inch in diameter at full  maturity.
    Structure.   A  nucleated cell developed from  the germ
         epithelium covering the surface of the ovary.
    Parts.
         i.  Vitelline Membrane .
         2.  Zona Pellucida.
         3.  Vitellus, or Yolk.  A mass  of  oleo-albuminous
             matter containing shining granules.  The vitellus
             tends  to  divide into  segments.   The tendency
             to  segmentation is  increased by fecundation.
         4.  Germinal Vesicle.  1 -700th inch in  diameter, situ-
             ated toward one side ofthe yolk near its surface,
             the nucleus ofthe cell.
         5.  Germinal  Spot.   A  dark,  granular  spot,  about
             1-3000th inch  in diameter,  within the vesicle, the
             nucleolus ofthe cell.
         Female Pronucleus.  The germinal  vesicle becomes
             the female pronucleus.
The Corpus Luteum.  The  body formed in the ovary during the
    retrograde   metamorphosis  of the   Graafian  follicle after
    rupture.
    The Corpus Luteum of Menstruation.  Attains its  full  develop-
         ment  in  two   to  four  weeks,  and  becomes  re-
        duced  to a mere  cicatrix by the end  of about  two
        months. 
Pregnancy.
19
    The Corpus Luteum of Pregnancy.   Growth  continues for six
        or seven weeks;  then
        Stationary to the end ofthe fourth month;
        Subsequently retrogrades slowly until delivery.
        An insignificant cicatrix at the end of a month  after
            delivery.

Impregnation is  the  fructification  of  the  ovum  by union
    with the fecundating elements  of the male.
    The Seminal Fluid, which contains  the fructifying  elements
        of the male, the spermatozoids, is a glutinous alkaline
        non-albuminous fluid, heavier than water, essentially
        the product ofthe testicles.
        Filtration deprives it of its fecundating power.
        About three drachms is ejaculated during the orgasm.

    The Spermatozoids are microscopic  bodies  resembling tad-
        poles in shape.   Each  consists of a flattened  ovoid
        head  (cell nucleus) and a long thread-like tail.
        Length, 1-600th to 1-400th inch.  The filiform tails
        maintain a constant  lashing motion  due  to  amoeboid
        movements of protoplasm as long as the spermatozoids
        retain their fecundating power.

    Vitality of  Spermatozoids.   Under favorable  conditions, with-
        in the genital passages  of the female, the spermato-
        zoids as well as the ovum retain their vitality for an
        unknown period of time.  They have been  known to
        live  in  the  human species  under favorable circum-
        stances for eight days.  They undoubtedly retain their
        fecundating power  for a  much longer time.  Have
        been  found after  copulation in every portion of the
        genital tract, even on the  surface of  the  ovary.   Are
        destructible by extreme heat or cold.
            The seminal elements of man retain their power
        of motion,  however,  between  the  temperatures of
        — 150 and +470 C.  They are  destroyed  by  acids,
        by numerous  other chemical poisons and  by desic-
        cation. 
20
Pregnancy.
    The Migration of Spermatozoids.  Normally the male  fluid is
        ejaculated upon and  about the cervix.   Yet the sper-
        matozoids  may  traverse  the  entire  length  of  the
        genital  tract and  impregnation  is  possible without
        introception of the male organ.   Locomotion is  ac-
        complished by the vibratile motion of  the tail.  Rate
        of  locomotion  one  inch  in   seven and  a  half
        minutes (Henle)
    Impregnation Occurs:
        Where ?  Impregnation takes place in the Fallopian
            tube or possibly in the uterus.
        When ?   It occurs in the great majority of cases within
            a week after the cessation of a menstrual period.
        How ?   A spermatozoid penetrates the zona pellucida
            ofthe ovum, mingles with the egg protoplasm and
            forms the male pronucleus.  A single  ovum is
            fecundated by a single spermatozoid.  The male
            and female  pronuclei unite  to form the vitelline
            nucleus of the fecundated egg.
Development of the Ovum.  The  egg on  leaving the  ovary con-
    sists of the parts above described  and has a diameter
    of  I-I20th  inch.   Cells  of  the  membrana  granulosa
    partially envelope it on its  escape from  the  ovary.   It
    receives an  albuminous  envelope  in the  course of its
    passage through  the  oviduct.  This envelope  supplies
    the first nutriment for the development of the egg.
        Segmentation ofthe vitellus,  or yolk, takes place until
    the whole yolk becomes  a  granulated mass.
    The Blastoderm.  Each granule  becomes  a  separate cell.
        The cells unite to form a continuous  membrane which
        lines the  zona pellucida.  This is  the blastodermic
        membrane from which all the embryonic structures
        are subsequently  formed.  Cleavage  takes  place
        through the vitelline nucleus, its ultimate  segments
        forming the  nuclei  of the cells of  the blastoderm.
            Segmentation in  the  human subject  probably
        does not occupy more  than  eight or ten  days.  The
        ovum  now  has a diameter of i-iooth  to  i-8oth
        inch. 
Pregnancy.
21
        The blastoderm forms in two layers, the external
    and internal layers (epiblast, hypoblast).  A third
    layer, the mesoblast, is subsequently developed.
        From the external blastodermic layer are formed
    the epidermis, the cerebro-spinal axis, etc*
        From the middle layer are developed bone, mus-
    cle, connective  tissue, the heart and  blood vessels
    and the genito-urinary organs.
        From the internal blastodermic layer, the epith-
    elium ofthe alimentary and respiratory tracts, etc.
The Blastodermic Vesicle.  By the accumulation  of fluid  in
    the ovum it  becomes  converted into a vesicle called
    the blastodermic vesicle.
The Area Germinativa or Embryonic Spot.  The  blastoderm soon
    presents an opaque, oval  spot upon its surface, con-
    sisting  of an aggregation of cleavage cells on  the
    inner surface of the membrane.   This  is  the area
    germinativa.
The Area Pellucida is a  clear oval space, which appears a little
    later in the area germinativa, with an opaque border.
The Primitive  Trace  is a shallow groove   or sulcus which
    now develops lengthwise  through the center of the
    area pellucida.
    This is  the first  indication of embryonic structure and
    marks the place ofthe cerebro-spinal canal.
    The Dorsal Laminae are two longitudinal folds which
        spring up on  either side  of the primitive trace.
        They ultimately unite to  form the  cerebro-spinal
        canal.
    The Ventral Laminae  subsequently develop and unite
        in similar manner.
The Umbilical Vesicle.  At this  stage of  development  the
    inner layer  of the  blastodermic  vesicle  becomes
    divided into two  parts, the  embryonic  portion and
    the umbilical vesicle.  The embryonic portion con-
    stantly  increases in size,  the umbilical  vesicle dimin-
    ishes till at the end  of the sixth  week  it  is no larger
    than a pea, and the last vestige of it has disappeared
    by the end of the  fourth month. 
22
Pregnancy.
Development of the Embryo and Foetus.
    First Month :
        Ovum the size of a pigeon's egg.  Length of embryo
            one-third of an inch.             ,
        First  rudiments of fcetal  structure discernible.
        Heart, kidneys,  liver, extremities and the eyes, oral
            and anal orifices begin to be formed.
        Spinal canal closed.
    Second  Month :
        Ovum the size of a hen's egg.
        Length of foetus one and a quarter inches.
        Rudimentary vertebrae.
        Frontal unites with the superior maxillary processes.
        Centers of ossification in inferior maxillary bones and
            clavicle.
        Eyes, nose and ears begin to be developed.
        Rudiments of hands and feet appear, webbed.
        Visceral arches nearly  closed.
        Sexual organs apparent.
    Third Month:
        Ovum size of a goose's egg.
        Foetus about three inches in length.
        Product of conception  now, for the first time, occupies
            the whole cavity of the uterus.
        Placenta distinctly formed, chorionic  villi  atrophied
            over two-thirds the surface ofthe ovum.
        Umbilical cord begins  to be twisted.
        External  parts ofthe embryo well formed.
        Ossific centers appear in nearly all the bones.
        The cavities completely closed.
        Sex differentiated  by the presence  or absence of a
            uterus.
        Active movements begin during the latter part of this
            month.
    Fourth  Month:
        Length of foetus six inches.
        Average weight about  three ounces.
        Ossification well established in frontal and  occipital
            bones. 
Pregnancy.
23
    Sex clearly defined.
    Lanugo present.
    Placenta complete.
Fifth Month :
    Length of foetus ten inches.
    Average weight about nine and a half ounces.
    Eyelids begin to open.
    Ossification begins in the ischium.
    Hair and nails begin to develop.
    First appearance of vernix caseosa.
Sixth Month:
    Length of foetus twelve inches.
    Weight about twenty-three ounces.
    Ossification begins in the pubic bones.
Seventh Month:
    Length of foetus fourteen inches.
    Average weight two and a half pounds.
    Pupillary membrane begins to disappear.
    In boys, testes in the scrotum, at least the left one.
    Ossification begins in the astragalus.
Eighth Month:
    Length of foetus sixteen inches.
    Average weight three and a half pounds.
    Nails completely developed, but  not projecting be-
        yond finger tips.
    Ossification begins in lower epiphysis of the femur.
Ninth Month:
    Length of foetus seventeen to eighteen  inches.
    Diameters of the  head  a  half to two-thirds of an
        inch less than at term.
    Average weight about five and a half pounds.
Tenth Month :
    At term average length of  foetus is from eighteen to
        twenty inches.
    Average weight,  boys seven  and a third  pounds ;
        girls seven pounds.
Signs of Maturity:
    Measurements. 
24
Pregnancy.
     Weight.
     Eyes usually open.
     Plumpness.
     Suckling.
     Lanugo has disappeared from the face.
     Vernix caseosa present only on the back  and on the
        flexor  surfaces of the limbs.
     Finger nails project beyond the  finger tips ; toe nails
        to end ofthe bed ofthe nail.
     Cartilages  ofthe ear and the nose firm.
     Cranial bones hard, sutures and  fontanelles small.
     Centers  of ossification well developed in the lower
        epiphysis  of the  femur and  the  astragalus,
        beginning in the  upper  epiphysis of the tibia
        and the cuboid bone.
Development of Membranes and Placenta.
Membranes.  Two Maternal and two Foetal.   They become
    ultimately  fused  into one which,  with the placenta,
    lines the cavity of the uterus  and contains the fluid,
     (liquor amnii,) in which the foetus floats.
Maternal Membranes.       ,
    A.  DeciduaVera is   developed  from  the  mucosa  of
        the  uterus, and is the  outermost  of  the en-
        velopes  of  the   foetus.  It  increases in thick-
        ness ten  fold in the first month,  i.  e.,  to  two-
        fifths of an inch.
            This  and the decidua circumflexa,  about
        to  be  described,  are  called  deciduae  because
        they  are  thrown  off  with  the   ovum.   The
        decidua  vera ends  at  the  os   internum.  It
        has the  shape of the cavity of the uterus and
        has three apertures,  one corresponding to the
        internal  os and one  to  the opening  of  each
        Fallopian tube.    When thrown  off  it  retains
        the shape of the cavity.   Except at the placenta
        the deciduae  undergo atrophy and are  reduced
        to a single thin membrane  by  the end of the
        third month.
    B.  Decidua  Circumflexa  or Reflexa  or  epichorial   de-
        cidua. 
Pregnancy.
25
            When the  ovum  becomes  embedded  in
        the folds  of the  uterine  mucosa, that  mem-
        brane  grows up  around  it.   This reflected en-
        velope  is  the  decidua  circumflexa  or reflexa.
        It grows with the ovum and comes  in  con-
        tact with the decidua vera at about the end of
        the third month, blending  with  it.   The  en-
        tire cavity  of the  uterus  is from  this time oc-
        cupied with the ovum and its membranes.
    Decidua Serotina or Placental Decidua.  A name  given to
        that part of the decidua vera that  underlies the
        ovum, where the placenta is  subsequently de-
        veloped.
Fcetal Membranes.
    A.  AMNION, the innermost ofthe fcetal envelopes.
            Development.  As soon as the  embryo begins
        to take  shape,  a second  fold of the  external
        blastodermic ridge  springs up entirely around the
        edges ofthe embryo.
            This membranous ridge develops till its edges
        meet  over the back of the embryo.  The surfaces
        brought  in  contact fuse together.  The neck of
        the pouch  thus formed is  subsequently absorbed.
        The pouch itself is the  amnion.  It  has neither
        vessels nor lymphatics.
            The outer blastodermic layer recedes toward
        the zona pellucida to become part ofthe chorion.
    The Liquor Amnii is the  clear  fluid which  accumulates in
        the cavity ofthe  amnion.
        Source.  Chiefly  the  maternal blood vessels.
        Composition.   Water,  a trace  of albumen,
            saline matter, urea.
        Amount.  Between one and  two pints at term.
        Specific  Gravity,  1007.
        Uses  :
            During gestation :
                 Protection of foetus and uterus.
                 Permits  active fcetal movements. 
Pregnancy.
        During parturition :
            Protects foetus and uterus.
            Helps dilate the cervix.
            Facilitates obstetric operations.
            Helps lubricate the passages.
The Allantois.  Before the formation of the amnion is
    complete  a diverticulum  has  pushed  out from
    the posterior  portion of the entoderm or intesti-
    nal canal; this is the allantois.
        The allantois is projected to the external  en-
    velope of  the  ovum, between the amnion and the
    outer blastodermic  fold, and it  expands till it
    completely envelopes the embryo and its invest-
    ing amnion, and lines  the external envelope of
    the ovum  as a flattened sac.
        It forms  about the tenth day and runs its
    course in a few days more.
        Its office is  to project  vessels  from  the
    embryo to that portion  of the  outer envelope
    where the  placenta is  to be  developed,  the
    chorion frondosum.
        The pedicle of the allantois dwindles to a
    mere  cord known as the umbilical communication.
        The amnion in the course of its development
    invests  the  umbilical  communication  forming
    the sheath ofthe umbilical  cord.
        The  umbilical  communication  carries two
    arteries and two veins, the rudimentary umbilical
    vessels  which communicate with the chorionic
    villi.
        One vein  becomes obliterated about the fifth
    or sixth week.
B.  CHORION. The outermost of the envelopes of fcetal
    origin.
    Formation.  A portion of the allantois fuses with
        the  layers  external  to  it,  the  external
        blastodermic layer and the  remains of  the 
Pregnancy.                      27
    zona pellucida.  The membrane thus formed
    is  the  chorion.   Between  the  chorion  and
    the amnion is a  layer of gelatinous  material
    in which the umbilical vesicle lies enveloped.
        The amniotic sac expands till it comes in
    contact with the chorion and unites with it at
    the end ofthe fourth  month.  The interven-
    ing gelatinous material thus encroached upon
    is absorbed except within the amniotic sheath
    ofthe umbilical cord.
        The envelope of the ovum  is now, after
    four months, practically a single membrane,
    the product ofthe union ofthe maternal  and
    fcetal membranes.  They are generally ad-
    herent, though usually  the amnion  may  be
    stripped  off from  the chorion after  the  ex-
    pulsion ofthe placenta.
Villi. Soon after the fixation of the  egg, its sur-
    face becomes   everywhere   covered  with
    transparent villi.   They are at first single, but
    with the growth of the  ovum they elongate
    and become compound.  The outer  surface
    of the  globular  ovum thus becomes every-
    where " shaggy."
        They resemble no other structure found
    in  the uterine cavity.  Their presence  in the
    uterus  is,  therefore,  positive  evidence that
    pregnancy has recently existed.
Blood Vessels.   The villi at first are not vascular,
    but  they  soon  receive vessels from  the
    allantois.
        The capillaries of the  chorial villi enter
    the stem of the villus, follow the subdivisions,
    go to the end of each rootlet, turn, forming
    a loop, and go back to emptyinto the venous
    trunks of the  chorion.   The  chorial villi
    are thus very similar to those of the intestines
    in  structure and in function. 
28
Pregnancy.
             Chorion Laeve.  Toward  the end  of the second
                 month  the  chorion begins  to  become bald
                 everywhere except over  the portion  about
                 the insertion of the fcetal  blood-vessels.
                     Over two-thirds the surface ofthe chorion
                 the villosities  continue to atrophy until by
                 the end ofthe second  month this part of the
                 chorion becomes smooth, the chorion  laeve.
             Chorion Frondosum.   Over  the  remaining third  of
                 the  surface  of the  chorion the villosities
                 develop  more rapidly than  before  till this
                 portion  presents a  thick,  spongy mass  of
                 villosities, the chorion frondosum.
                     They enter into  the formation of the pla-
                 centa.   The   development  of  the  vessels
                 keeps pace with   the growth  of the vil-
                 losities in the placental portion of the chorion;
                 elsewhere the capillaries shrink with  their
                 villi.
                     After the  formation of the  placenta the
                 non-placental  portion  of  the chorion serves
                 only for protection.

The Placenta. When fully formed it is a spongy mass of lenticular
    shape.  Diameter seven to nine inches,  and about one inch
    thick at the insertion  of the cord.   Weight sixteen ounces
    or more after it is detached  from  the uterine wall.
    Two Surfaces.
        Fatal.  A smooth surface of  amniotic membrane.
            Umbilical  cord attached generally at the  center.
        Maternal.  Rough,  divided into irregular lobes or
            cotyledons  from  one-half to one  and  a  half
            inches in diameter, sixteen to  twenty in number.
            These lobes  are separated by membranous parti-
            tions which penetrate the substance  of the pla-
            centa at their borders, as far as the fcetal surface.
            The maternal surface is  covered with the outer 
Pregnancy.
29
         portion of the decidua serotina.  After separation
         of  the  placenta,  it is studded with small open-
         ings, mouths of vessels torn across, oblique open-
         ings  of the veins and the  mouths of the curling
         arteries of Hunter.
Structure. Consists essentially of blood vessels.  The vas-
    cular fcetal tufts, sixteen to twenty in  number,  are
    suspended in lakes of maternal blood.   The lakes are
    supplied by the curling arteries  of the  uterus.   The
    maternal blood returns from the  spaces between the
    fcetal tufts by the coronary vein upon the margin ofthe
    placenta and by sinuses situated in the septa between
    the  cotyledons.  The fcetal and maternal circulations
    do  not  communicate directly.  The fcetal tufts  are
    made up of loops of blood vessels which are bathed
    in maternal blood, from which  nutriment and oxygen
    for the  foetus are  derived by osmose.   Effete matter
    thrown off  from the fcetal circulation is returned in
    like manner to the maternal blood.
Seat.  Usually the anterior or posterior wall of the uterus
    with about equal frequency ; rarely  the insertion is
    lateral.
Function.  At once the  nutritive,  respiratory and excre-
    tory organ of the foetus.
Development.   Begins in  the second, ends with the  fourth
    month of gestation.   The  placenta attains  its char-
    acteristic form and  structure at about the end of the
    fourth month, though its limits are distinctly defined
    at the end ofthe third.
         The chorionic  villi  penetrate the inter-glandular
    portions ofthe mucosa, not the uterine follicles.
         The walls of the crypts into  which  the  villi  dip
    are lined with epithelium and are  very vascular.
         The tufts continue to increase in the number and
    extent of their ramifications and in vascularity.
         The development ofthe decidua keeps pace with
    that ofthe chorionic villi.  The uterine crypts enlarge
    and ramify to correspond.   The capillaries of the  de-
    cidua multiply, enlarge and inosculate  till every loop 
30
Pregnancy.
        of the fcetal villi is  enveloped by a mesh-work of
        dilated  maternal capillaries.  Both systems  of ves-
        sels  grow and  multiply  with the  development of
        the placenta.  As  the  development progresses, the
        anatomical character of the fcetal blood vessels re-
        mains  unchanged.   The maternal capillaries  about
        the uterine crypts  enlarge  and obliterate the  inter-
        spaces,  and  they thus coalesce into great lakes of
        blood.  These   lakes  communicate  freely with the
        uterine  sinuses.
            The placenta then is  made up of four elements:
        Maternal,—uterine crypts, blood  vessels around the
        crypts ;  Fcetal,—chorionic tufts, vessels of the  tufts.
            The fcetal is separated from  the maternal  blood
        only by the walls of the fcetal  tufts.  These walls
        are formed  by  fusion of four walls, viz.: that of the
        uterine  crypt, the uterine  vessels, the chorionic villi
        and the fcetal vessels.
            The fcetal  villi are clothed with a layer of epithe-
        lium.  These cells possibly have  some other function
        than mere osmosis,—a  secretory action.
Umbilical Cord—The pedicle which  connects the foetus with
    the chorion  frondosum, or placenta (alluded to above as
    the umbilical communication).   At the end  of  about the
    first month it becomes invested with a  process  of amnion
    which includes a portion of the vitriform body.   In the
    cord this material  is the gelatine of Wharton.   It serves
    to protect the vessels ofthe cord.
    Insertion of the cord generally central, sometimes lateral,
        marginal or velamentous.  By the latter is meant one
        in which  the vessels separate in  the membranes be-
        fore reaching the placenta.
    Length,  generally   about  twenty inches may be  from
        seven or less to sixty inches.
    Size, about that of the little finger of the adult.
        Capable of  sustaining  a  weight of ten  to twelve
    pounds. 
Pregnancy.
3i
        Embedded  in  it  are two arteries and  two veins at
    first ;  subsequently the veins fuse into one. Exceptionally
    there  is but one artery.  The walls of its arteries are only
    a little thicker than the walls of the veins.   The  cord is
    usually twisted, the vein being wound around the arteries.
        The existence  of  nerves and  lymphatics in the cord
    has not been proven.
    Time of Closure of the Foetal Apertures.
        Umbilical arteries two days after birth.
        Umbilical vein and ductus venosus  generally six to
             seven days.
        Ductus arteriosus  within nine to fifteen days.
Effects of Pregnancy on the Maternal Organism.
    Changes in the Uterus as a whole.
        The first effects of pregnancy are noted  in the uterus.
    It changes in size, shape, situation and structure.
        Size.  Non gravid nulliparous  uterus is about three
             inches in length.
                 At term  the uterus measures at least twelve
             inches in length.
                 Growth begins immediately with the fixation
             of the  ovum, and  is  continuous with the  de-
             velopment  of the  foetus.    Its  growth  during
             the  first two months  is chiefly in the  lateral
             and   antero-posterior  directions.   The  uterine
             enlargement is  partially a dilatation in the latter
             months.
                 The thickness  of the uterine walls at term is
             between one-sixth  and one-quarter inch.
             Farre and  Tanner's Table.
                 LENGTH:                    WIDTH:
        3 Months, 4 1-2 — 5 Inches.        4  Inches.
                                          5
                                          5  1-2  "
                                          6  1-2  "
                               "          7  1-2  "
                                          8
                               "         9  1-2  "
4	< <	5	1-	■2 — 6
5	a	6		— 7
6	a	8		— 9
7	"	10		
8		11		
Q		12	1	-2
 
32
Pregnancy.
    The surface is increased from 5 or 6 to 350 square
        inches.
    The capacity from 1 to 400 cu.  in.,—519 times.
    The weight from one or one and a half ounces
        for the prae-gravid state to two or two and a
        half pounds at term.
Shape.  First  three months, pyriform.  Second and
    third  months the corpus  uteri  is  a  flattened
    spheroid.  The last three months it is generally
    ovoid with the smaller end down.
        In the early  months the normal  anteflexion
    is increased.
Situation.   During the second month the uterus gen-
    erally  sinks lower in the pelvis.  At the  end of
    the third  month  or soon  after, the fundus is
    above  the  brim.  At  the end of  the  fourth
    month the fundus is two or three  inches above
    the symphysis pubis.  Sixth month near the um-
    bilicus.  Ninth month approximates the ensiform
    cartilage.   Within about ten days of labor it
    sinks   and  falls   forward.   During  the  latter
    months the uterus rests  on  the  symphysis pubis
    and abdominal wall, and has a  right lateral ob-
    liquity and right torsion.
Structure.  The changes in its muscular tissue consist
    in hypertrophy of its muscular fiber and extensive
    development of new unstriped muscular tissue.
        The muscular fiber  grows seven to ten times
    in  length.  At the os internum there  is a pre-
    ponderance of circular  fibers in all  the  layers.
    The uterine plexus of veins becomes developed
    into a system of  enormous sinuses in the middle
    coat of the muscularis  and  in the inner coat be-
    neath the  placental attachment.
        The lymph  tubes become  hypertrophied to
    the size of a goose quill.
        Hypertrophy of the nervous tissues  proba-
    bly keeps pace with the development  of other
    uterine structures. 
Pregnancy.
33
Changes in the Cervix.
    Size.   The cervix is as long as it ever is at the eighth
        month, and generally at  the beginning of labor.
        It is then  gradually obliterated  by  dilatation
        from above.   The  apparent shortening of the
        cervix during gestation is due partly to softening,
        and  in part to swelling of the vaginal  mucous
        membrane  and  loose  cellular tissue  around
        the  cervix at the vaginal junction.   The cervical
        enlargement is due in part to hypertrophy, but
        mainly to loosening of its  structure  from serous
        infiltration,  and is  complete at about the eighth
        month.
    Structure.   Softening is progressive from below up-
        ward and involves  the entire cervix  by the end
        ofthe eighth month.
    Shape.  It dilates  during gestation  from below up-
        ward.   At the end of the eighth month the head of
        the  child  may generally be  touched with the
        finger through the  cervix.
Changes in other Pelvic Structures.  The peritoneal covering of
    the uterus is developed by tissue growth—pari  passu
    with the development of the uterus.
        The broad ligaments accommodate themselves to
    the growth of the  uterus  partly by the unfolding  of
    their layers and partly by hypertrophy of structure.
        The ovaries and Fallopian tubes lie in contact with
             the uterus.
        The vagina becomes hypertrophied during  preg-
    nancy.  It  increases in  the  size  and  length  of  its
    walls and in vascularity.
Hypertrophy of the Heart.  Hypertrophy of the left ventricle
    of the heart during gestation  is physiological and is
    designed to meet the increased resistance in the sys-
    temic  circulation  introduced  by  the  new vascular
    arrangements of the uterus and placenta.   It remains
    during gestation.
The Thyroid tttland becomes hypertrophied  during  preg- 
34
Pregnancy.
    nancy, and a certain degree  of enlargement  remains
    permanent.
The Spleen is also enlarged.
Changes in the Blood State.
    The total volume is increased during the latter half of
        pregnancy.
    The proportion of water is little, if at all, increased.
    There are more white corpuscles.
    More fibrin.
    More effete matter (from circulation ofthe foetus).
    Fewer red corpuscles.
    Less albumen.
    Less haemaglobin.
    There is usually a marked gain in the weight of the
        body during the latter months. 
Signs  of Pregnancy.
35
              SIGNS  OF PREGNANCY.

History :  Anamnesis.
    Suppression of Menses.             From date of conception.
             The earliest sign.
             In the absence of other apparent cause  it affords
        strong presumptive  evidence of pregnancy.
             Other possible causes of suppression are
                 Chlorosis;
                 Phthisis;
                 Chronic nephritis;
                 Cold;
                 Change of climate;
                 Emotional causes;
                 Tardy menstruation;
                 Menopause.
             Not available for diagnosis in
                 Lactation;
                 Patients who  have not yet  menstruated;
                 Periodical hemorrhage during the first three
             months from the portio vaginalis, polypus of the
             cervix, the cervical endometrium, chronic decidual
             endometritis, placenta praevia.
    Digestive Disturbances.
        Dyspepsia.                            Early months.
        Nausea.     Generally from 1st  to end of 3rd month.*
             A morning sickness.
             A reflex from  the uterus during its development
        in the lesser pelvis.
             Present for a longer or shorter  time in  the great
        majority of cases.
             Exclude pathological causes.
   *In this table of signs end of month is meant unless otherwise'indicated. The
time given is that from which the sign is available except when otherwise specified. 
36
Signs  of Pregnancy.
        PtyaUsm.  A reflex excitation of the  salivary glands
            sometimes accompanied with excessive secretion
            of mucus in the mouth and throat.
                 Marked salivation is exceptional.
    Certain mammary signs.  Enlargement, sense  of prickling,
        tenderness, weight and fulness.
    Certain abdominal signs.  Enlargement, pigmentation, quick-
        ening.
Physical Signs.
    I.  Mammary.
            Rarely all present.
            Of great value collectively in the primipara; of lit-
        tle use  in women who have borne children since many
        of the  mammary changes  remain in  a measure per-
        manent.
        Size and Firmness.                2nd month or earlier.
            Increase in size ofthe gland.
            The increase is due to development ofthe  acini,
        swelling of the connective tissue, interlobular deposit
        of fat.
            Most significant when progressive.
            Distinguish from overlying fat by palpation.
            Identify the gland by its nodular  border.
            Distinguish from  enlargement due to pathologi-
        cal causes.
        Erectility of Nipple.                         2nd month.
            Becomes turgid and protuberant when lightly
        stroked with the finger.
        Primary Areola.                           2nd month.
            Becomes pigmented,  elevated, cedematous.
            Pigmentation  varies with the  complexion of the
        patient.  Is faintly developed in blondes, marked in
        brunettes and nearly black in  the negress.
            Shades into the  color  of the skin at the upper
        and outer aspect of the areola at the end of second
        month.
            May arise from  pathological  conditions of  the
        pelvic organs.
            Of little value  after the first pregnancy. 
Signs  of Pregnancy.
37
     Glandular Follicles.                        2nd month.
        These are hypertrophied sebaceous follicles.
        Ten to twenty in number.
        Situated in the primary areola.
    Veins.                                   2nd month.
        Everywhere more prominent over the breast.
        Coursing in across the primary areola.
        Sometimes due to pathological reflexes from the
            pelvic organs.
    Milk in the Breasts.                          3rd month.
        A milky serum may be pressed from the nipples.
        Strong presumptive evidence in primiparae.
        Yet milk  secretion is  possible in the virgin or
            even in males.
    Secondary Areola.                           5th month.
        A faintly pigmented areola  around the primary
    areola.
        Characterized  by round, faintly marked, washed-
    out spots  immediately about  the primary  areola, es-
    pecially at its upper and outer aspect.
        Due  chiefly  to   enlarged  and  non-pigmented
    sebaceous follicles.
        Diagnostic when well made out.
II.  Abdominal.
    1.  Inspection.
        Abdomen Flattened.                 In 2nd month.
            Uterus sinks lower in the pelvis.
        Abdomen Enlarged.                      3rd month.
            Uterus rises out of the lesser pelvis.
        Abdomen Pigmented.                    2nd month.
            A pigmented line one-eighth inch wide from
        the pubes to the umbilicus or even to the ensiform
        cartilage.  Not diagnostic.
        Umbilicus.
            Retracted.              In first trimestrium.
            Protruded.          In 8th  and 9th months.
        Lineae Albicantes.                     6th month.
            Due chiefly to partial atrophy from tension. 
Signs  of Pregnancy.
Palpation.
 Size ofthe Tumor.
     Fundus at the pelvic brim.        3rd month.
     Near the umbilicus.              6th month.
     At the ensiform cartilage.       $H months.
     Measurements (see Farre and Tanner's table,
 page 31).
 Character of the Tumor.
     Smooth, symmetrical, pyriform, fluid.
     Detection of fcetal parts in  the last trimes-
 trium and earlier.
 Intermittent Contractions.                4th month.
     Recur at intervals of five or ten minutes. Ob-
 tainable  immediately by gentle  friction.
     Not  interrupted by death of the foetus.
     Exclude haematometra,  soft  fibroids and dis-
 tended bladder.
 Active Foetal Movements.  Quickening.
     As an objective sign,
     By abdominal palpation.         4th month.
     By the bimanual.                12th  week.
     Most promptly obtained by applying  hand
 cold to  the abdomen,  or by first  tossing the
 foetus from side to side.
     Muscular movements begin  10th week.
     May fail in hydramnios,  etc.
     Diagnostic when well made  out.
     As a subjective sign,           4th month.
                      (12th week to 4^ months.)
     Not  wholly reliable as a subjective sign.
     May be simulated by intestinal flatus, spas-
 modic  contractions of the abdominal muscles or
 other causes.
 Passive Movements of the Foetus.   External Ballottement.
     Consists in tossing the  foetus or the  fcetal
 head by  abdominal palpation.
Ausculation.
 Foetal  Souffle.                          4th month.
     Synchronous with the fcetal  pulse. 
Signs  of Pregnancy.
39
    Origin.
    Umbilical from impeded flow of blood in the
        cord, probably due to pressure;
    Cardiac from valvular lesions or certain other
        mechanical or from functional causes.
Uterine Souffle.               4th month or earlier.
    Synchronous with the maternal pulse.
    Due to the current of blood  in  the uterine
arteries and their branches.
    Best heard usually over the lateral  borders
ofthe uterus, especially the left.
    Uterine  fibroids,  chronic  metritis, or  even
ovarian cysts may give rise to a  similar souffle.
    A valuable sign in the  absence of these con-
ditions.
Choc Foetal.                            3rd month.
    The shock  of the fcetal movements as per-
ceived by the ear.
    The  bruit  de choc foetal  is  a  bruit  that
immediately precedes the choc fcetal.
Foetal  Heart-Sounds.               4^ to 5  months.
              12th week by vaginal stethoscopy.
    Rate,  about double the maternal pulse, 120
to 150.
    Generally loudest  directly over the  fcetal
heart.
    Audible over an  area of  about three inches
in diameter.
    May be absent from death of the  foetus.
    May be temporarily  inaudible from dorso-
posterior positions, hydramnion or other causes.
    Method:
         A still room.
         Dorsal decubitus  with  the  thighs  par-
    tially  flexed.
         Listen over the fcetal dorsum.
         Press the abdominal and  uterine walls in
     contact. 
Signs of Pregnancy.
                    Failing, repeat the examination at inter-
                vals of several hours or days.
                    A rhythmical succession of  sounds of
                characteristic quality and rhythm, of double
                the maternal pulse-rate, and which  can be
                counted, alone makes the diagnosis of preg-
                nancy.

III.  Pelvic.
    Dusky Hue of the Vagina.                        2nd month.
            Most  constantly  found  on  the anterior  wall
        immediately below the meatus urethrse.
            Due to hypertrophy of the corpus cavernosum of
        the vestibule and ofthe vaginal  venous plexuses.
            Present in about five-sixths of all cases at the end
        of the 3rd month.
            Valuable when well defined.
            Exclude pathological causes.
    Softening of the Cervix.                           6th week.
            Is progressive from the lower border ofthe cervix
        upward.
            Involves the whole cervix  by the end of the 8th
        month.
            Not always  well defined  in the early months.
            May arise from pathological causes.
            Canal of the cervix becomes progressively more
        patulous.
    Passive Foetal Movements.  Internal Ballottement.
            Available during  the 5th  and 6th months or
        longer  according to the  size  and mobility  of the
        foetus.
            Method:
                 Semi-recumbent or standing posture.
                 Intravaginal finger against the anterior uter-
            ine wall above  the cervix.
                 Foetus tossed  upward falls again and reper-
            cusses the finger.
            Distinguish from
                 Stone in the bladder; 
Signs  of Pregnancy.
4i
                Anteflexed uterus;
                Pedunculated tumor ofthe ovary;
                Internal projections of large cysts ;
                Floating kidney.
            May fail with
                Scanty liquor amnii;
                Abdominal presentation;
                Placenta praevia;
                Multiple foetus or
                Other causes.

The Bimanual.                                  6th week.
        Among the most  reliable  signs obtainable in
    the second  and third months  are  the  changes in
    shape, size  and consistency of  the  uterus due to
    the development  of the  globular ovum in its  cav-
    ity,  viz.:
        Bellying  of the lower  uterine  segment, espe-
    cially in front;
        Elasticity of the corpus uteri;
        Fluctuation ofthe corpus uteri.
        Distinguish from areolar hyperplasia by greater
    density in the latter.
        Distinguish from sub-involution in which the en-
    largement is mainly in length.
        Distinguish from  an anteflexed and hyperaemic
    uterus.

Hegar's Sign.                                  6th week.
    Softening, compressibility and resiliency of the lower
        uterine  segment, especially marked in the median
         line.
    Method:  Uterus depressed  by the external  hand, or
        drawn down by a volsella.
            Thumb of the  other  hand  in  the vagina
        against the lower uterine  segment  at  junction
         with cervix.
            Finger in  the rectum above the utero-sacral
         cul de sac. 
Signs of Pregnancy.
                Tissues between the  thumb  and  finger may
            be compressed almost to  the thinness of a visit-
            ing card.
                Examination may be facilitated by the use of
            an anaesthetic, and by distending the lower end
            ofthe rectum  with water.
    Pulsation of the Uterine Artery.
        Eliminate pathological causes.
    Temperature of the Cervix.
        y2° to yA° F. above that ofthe vagina.
Summary of Diagnostic Signs.
    Mammary Signs Collectively, in the Primipara;
    Intermittent Uterine Contractions;
    Detection of Fcetal  Parts;
    Active Fcetal Movements;
    The Bimanual;
    Hegar's Sign;
    Ballottement;
    Fcetal Heart.
Differential Diagnosis.
        In general, pathological  tumors are distinguished by
    absence of the signs of pregnancy, especially the changes
    in the uterus peculiar to pregnancy.
        Fat in the Abdominal  Walls can be lifted infolds and moved
            over the abdominal muscles.
        Phantom Tumor disappears under anaesthesia.
        Tympanites.
            Generally subsides in the morning.
            Percussion, note tympanitic.
            Palpation negative.
            Abdominal walls can be gently pressed backward
          against the vertebral column.
        Ascites.
            Abdomen flattened at the umbilicus,—in the dor-
        sal position.
            Generally, tympanitic percussion at the summit of
        the tumor from flotation of intestines. 
Pregnancy.
43
            Fluid wave through all parts of the tumor within
        the limits of the fluid.   In pregnancy the wave is in-
        terrupted by the fcetal ovoid.
            Changes of fluid  level in different postures.
        Enlarged Liver or Spleen.
            Tumor traceable from the normal situation  of
        those viscera.  Uterus independently movable.
        Ovarian Cystoma.
            History of asymmetrical enlargement of the abdo-
        men, usually.
            Palpation reveals,  usually  a  globular cyst,  but
        no fcetal parts.
            Marked fluctuation, generally.
        Myomata of the Uterus.
            Submucous.
                History of hemorrhage.
                Density of the tumor.
            Sub peritoneal.
                Surface ofthe tumor nodulated.
            Pregnancy  and  myomata  or  other  pelvic neo-
        plasms may coexist.

                   Plural  Pregnancy.

Plural Pregnancy.
            Frequency of twins, 1-80 to 1-90.
            Frequency of triplets, 1-6000 to 1-8000.
            Quadruple and  even quintuple pregnancies  are
        possible.
            Viability  less in multiple  than in single foeta-
        tion.
            Twins are generally undersized and  of  unequal
        development.
        Origin of Multiple Pregnancy.
                 Simultaneous rupture of two or more Graaf-
             ian follicles in the same or  in different ovaries.
                 Two ovules in one follicle.
                 Single ovule with  a double germ. 
Pregnancy.
 Arrangement of Membranes and Placenta.
   In twin fcetation from two ovules:
        Two amnions, two  chorions, two placentas.
        Placentas  may fuse  at  their margins, each
   having an  independent  circulation.
   In twin fcetation from a single ovule with a double
 germ:
        One chorion  containing  two  amnions; one
     placenta.
        Rarely two foetuses in a common sac by de-
     struction ofthe amniotic septum.
        Children from the same ovule are always of
     the same sex.
 Diagnosis of Twins.
     Size ofthe  tumor;
     Shape  ofthe tumor;
     Greater width;
     Longitudinal sulcus,—not diagnostic;
     Supra-pubic oedema;—occurs also in  simple hy-
 dramnios.
     Multitude of small  parts;
     Two dorsal planes;
     Three or four fcetal poles;
     One head in the excavation and one in the upper
 uterine segment;
     One head in the excavation and  one in the iliac
 fossa;
     Distance from pelvic  pole to fundal pole  over  12
 inches;
     Two fcetal  heart-sounds of different rates;
     Two fcetal  heart-sounds  of  the  same rate, but in
 widely different situations and on opposite sides;
     Heart above the umbilicus and  head  in  the ex-
 cavation;
     Rapidly  successive presentation of a head and a
 breech;
     Four extremities presenting;
     Two amniotic bags at the cervix.
 Diagnosis of Triplets, rarely possible.
Superfecundation.  Twin pregnancy resulting from sepa-
     rate acts of insemination by the same or different
     males. 
Pregnancy.
45
Duration of Pregnancy.
            Not definitely known since the interval between
        insemination and fecundation may vary from i  to 12
        days or more.
            Average interval between the beginning of  last
        menstruation and labor is 280 days.
            Average interval  between the fruitful coitus and
        labor is 273 days.
            A variation  of 40 days above  or below  these
        averages is possible within physiological limits.
     Rules and Methods for Predicting the Date of Labor.
            Naegele's Rule.
                 Count forward 9 months from the beginning
            of the last menstruation and add 7 days.
                 Usually accurate within a week.
                 Count 41-2  to 5 months from the date of
            quickening.
                 Very liable to error.

        Mensuration of the Uterus.
                 6th month, 8-9 inches by 6|  inches; fundus
            near umbilicus.
                 7th  month,  10 inches  by J\ inches; fundus
            midway between umbilicus and ensiform.
                 8th month, 11 inches by 8 inches; fundus at
            or near ensiform.
                 9th month, 12 inches by 9 inches; fundus be-
            low ensiform.
                 Also liable to error.

        Mensuration of the Foetus.
                 Length of the foetus is approximately double
            the length ofthe fcetal ovoid.
                 Fairly reliable.
                 Length of the foetus :
                    6th month, 12 to 14 inches.
                    7th    "    14 " 16   "
                    8th    "    16 " 18
                    9th    "    18 " 20 
46
Pathology of Pregnancy.
        Hygiene of  Pregnancy.

Hygiene of Pregnancy. Ordinary hygienic rules are
    doubly important during gestation, especially in
    the matter of food, clothing, bathing, sleep and
    daily open air exercise.
          PATHOLOGY OF PREGNANCY.

Pathology of the Decidual.
            Apoplexies.   Most common  in  nephritis, me-
        chanical violence.
            Acute endometritis,—hemorrhagic, exanthema-
        tous.
Pathology of the Amnion.
            Deficiency of liquor amnii, oligo-hydramnios.
            Excess of liquor amnii, hydramnios; may amount
        to several quarts.  The foetus is liable to be diseased.
            Plastic  exudation may give  rise  to adhesion
        bands and consequent amputation of  fcetal extremi-
        ties.
Pathology of the Chorion.
    Myxomatous Degeneration of the Chorioa : Vesicular Mole.
            A myxomatous degeneration of the  chorial villi
        resulting in the formation of cysts ofthe villi.
            The  cysts are frequently of the size of a grape;
        may reach the size of a lemon.
            The degeneration begins not later than the tenth
        or twelfth week.
            The degenerated ovum may be retained several
        months.
        Prognosis.
            May become dangerous to the health and even the 
Pathology  of Pregnancy.
47
life of the patient by hemorrhage or possible per-
foration ofthe uterus.
     Almost uniformly fatal to the foetus.
Diagnosis.
     Signs  of pregnancy.
     Abdominal  enlargement  not corresponding
to the period of gestation.
     Uterus too large the first three months, later
too small.
     Absence of  ballottement, of the  fcetal  heart
and  fcetal movements.
     Sanguineous discharge.
     Discharge of cysts, rarely.
     Physical examination of  the uterine  con-
tents.
Treatment.
     As a rule, empty the uterus.
     Tampon and give ergot.
     Dilate the cervix and evacuate with the hand
and curette, cautiously, as the uterine wall is  often
extremely thin.
    Swab the cavity with tincture of  iodine.
     Hot douche.
Pathology of the Placenta.
    Placenta Membranacea. Persistence of villi over the entire
        surface of the chorion.
    Placenta Praevia.  Implantation in the lower segment.
    Placenta Succenturiata.   One or more wholly or partially
        detached cotyledons.
    CEdema.   May occur in hydramnios, occlusion  of um-
        bilical veins, or maternal anasarca.
    Apoplexy.  Cause, nephritis, pelvic congestion, etc.
    Myxomatous degeneration.
    Fatty degeneration.
    Placentitis, acute. 
48
Pathology of Pregnancy.
     Tumors, fibroids, organized blood clots.
     Syphilis.
         Infection by the spermatozoid.
             Hyperplasia  and hypertrophy of  the  placental
         villi.
         Infection during  the fruitful  coitus, or  during the
     early or middle months of gestation.
            Endometritis placentaris and syphilitic disease of
         the villi.
         Infection during latter months of gestation.
            Placenta usually escapes.
         Infection before conception.
            Endometritis  placentaris gummosa.
        The  syphilitic placenta  is larger and paler  than the
            normal.   Always  dangerous, frequently  fatal,
            to the foetus.
Pathology ofthe Umbilical Cord.
            Length, excess or deficiency.
            Occlusion ofthe vessels by excessive torsion.
            Knots.
            Hernial protrusions of abdominal  viscera into the
        cord.
  Ectopic Gestation.  Misplaced or  Extra-Uterine

                       Pregnancy.

Tubal Pregnancy.
    Cause.  Arrest  of the  impregnated  ovum  in  the tube
        from denudation of ciliated epithelium.
    Clinical Course.  The impregnated ovum lodges and devel-
        ops in the  tube, ..   .' ...        -,   ,-
    A.  In the free portion of the tube.
        a. Ruptures almost  invariably before the 14th week
            into 
Pathology of Pregnancy.
49
            i. Peritoneum.  Result, almost certainly fatal by
                hemorrhage or by suppuration. Spontaneous
                arrest of hemorrhage is rarely possible.
            2. Broad  ligament. — Intraligamentous   Preg-
                nancy.
                May die and be absorbed.
                May die and suppurate.
                A  suppurating ovum  may  be  discharged,
              piecemeal, through the abdominal wall, vagina,
              bladder or rectum.
                May go  to term.   At term  spurious labor
              sets in and  child dies.
                May die and be  carried indefinitely  as a
              lithopsedion.
                May  become  intraperitoneal  by secondary
              rupture.   Secondary rupture   is almost  uni-
              formly fatal to the child.
        b.  In rare cases  the ovum may die  before rupture.
    B.  In the  intramural  portion  of the tube ;—Interstitial
      Pregnancy.
          Ruptures before the 5th month into the  peritoneum,
        —generally.
          Result almost surely fatal.
          Rarely is expelled into the uterus.

Abdominal Pregnancy.
          Possible as a rare result of secondary rupture.
          Abdominal pregnancy in the sense  of primary im-
        plantation and development upon the peritoneum is
        sub judice.

Ovarian Pregnancy.
          Possible.
Diagnosis of Extra-Uterine Pregnancy.
    Symptoms.
          Frequently a long period of sterility immediately
        preceding.
          Suppression ofthe catamenia.
          Other signs of pregnancy. 
           Pathology of Pregnancy.

       Pain in paroxysms which are abrupt, most violent,
    supervening  upon  apparent  health,  cramp-like  in
    character and  generally referred  to the  seat of the
    fruit-sac,  the  more acute paroxysms being attended
    with collapse  and the signs of internal hemorrhage.
    At the time of rupture, frequently a sense of  tearing.
       Hemorrhage from  the genital organs.   Usually in
    gushes of larger or smaller amount especially at the
    times of  the  painful paroxysms.  A more  or  less
    copious discharge of blood usually attends the rupt-
    ure ofthe fruit-sac.
      Expulsion  of a  decidual cast,—having  no fcetal
    villosities.
Physical Signs.
  Early months.
      Development ofthe uterus.
      Displacement  of the  uterus according  to the  size
    and situation ofthe fruit-sac.
      Cervix open.
      A fluid tumor beside the  uterus or behind it, tense,
    pulsating, extremely sensitive, rapidly growing.
      Ballottement of the whole tumor in the absence of
    adhesions,—of its contents in  more advanced preg-
    nancy.
      Differentiate from salpinx, enlarged  ovary, small
    ovarian  cyst,  pregnancy in  one  horn  of a  double
    uterus.
      Distinguish from the body of a latero-verted uterus.
  Latter months.
      Fcetal  movements  more distinct  than  in utero-
    gestation.
      Fcetal heart-tones more intense.
      Foetus more accessible to palpation.
      Intermittent contractions absent.
      Explore  the   uterine  cavity  before  opening  the
    abdomen.
      Intra and extra-uterine pregnancy may coexist. 
Pathology of Pregnancy.
5i
Summary of Signs of Extra-Uterine Pregnancy.
  Early Months.
      General Symptomatology:
          Signs of pregnancy;
          Hemorrhage;
          Decidual cast;
          Pains, with collapse.
      Uterus:
          Displaced;
          Enlarged;
          Empty;
          Cervix open.
      Tumor:
          Tense;
          Tender;
          Pulsating;
          Growing.
  Latter  Months, as above stated.
Symptoms of Intraperitoneal Rupture.
          Intense colicky pains.
          Profound collapse with the signs  of internal hem-
        orrhage.
          Later, abdominal  tenderness and evidence of mod-
       erate peritonitis.
Treatment of Tubal Pregnancy.
   Before Primary Rupture.
          Foeticide by electricity, without puncture.
          Faradic Current.
          One pole on the  abdomen, over the tumor, one in
       the  vagina or rectum beneath it.
          Full force of one or two cells.
          Sitting half to one hour.
          Repeat daily till the  tumor shrinks.
       Galvanic Current.
          Electrodes as above.
          Uninterrupted.
            50 to 100 milliamperes.
            Sitting  15  minutes. 
52
Pathology  of Pregnancy.
        Interrupted, 120 interruptions per minute.
          15 to 30 milliamperes.
          One sitting may suffice.
      Laparotomy, as an  alternative, or in case of hemor-
        rhage or sepsis  after foeticide by electricity.
 After Rupture into the Peritoneum.
    Immediate Laparotomy.
        Distinguish between extra and intra-peritoneal rupt-
      ure  by presence or  absence  of tumor in broad liga-
      ment.
    Technique.
        Incision in the median line, 2 or 3 inches in length.
        Determine the  presence  of blood by  inspection
     through the uncut peritoneum or by means of a pipette
     passed  through a  minute opening in the peritoneum.
        Divide the peritoneum,  lift the  fruit-sac and  the
     free  end of the tube, tie the broad  ligament behind
     the tumor and amputate.  Cauterize the cut end of
     the tube, stay all hemorrhage, cleanse the peritoneal
     cavity, flushing it freely with  plain water at uo° F.,
     and  close  the abdomen.
       Laparotomy  being impracticable,  treat  by  quiet,
     sand bags on  the  abdomen over the fruit-sac, com-
     pression ofthe  aorta.
After Rupture into the Broad Ligament.
   Foetus  living.
       Before end of 3rd month, electrical foeticide.
       Later, expectant.
   Foetus dead, open the  cyst, extraperitoneal^ if possible,
     through the abdominal wall, if sepsis develops.
Secondary  Rupture, with dangerous hemorrhage,—treatment
     as in primary intraperitoneal rupture.
At or Near Term.
  Foetus living.
       Laparotomy.  " Primary Laparotomy."
       Control the placental site by hemostatic suture.
       Remove the placenta and larger part of the sac. 
Pathology of Pregnancy.             53
      Close remainder of the  sac and drain through  the
    vagina or through the abdominal wound.
      Or, leave the placenta undisturbed to come away
    later, stitching the sac to the abdominal wound and
    draining.
  Foetus dead.
      Wait for obliteration of the placental vessels, if the
    patient is doing well, two or three months or indefi-
    nitely.
After Term.
      Laparotomy several weeks after the death of  the
    foetus,  " Secondary Laparotomy,"  or only on the  de-
    velopment of dangerous symptoms.
Interstitial Variety.  If diagnosis is possible, may sometimes
    be  safely terminated by  evacuating  the  fruit-sac
    through the uterine cavity.
      On rupture, laparotomy is indicated as in  ordinary
    tubal pregnancy, and in  certain cases  supravaginal
    amputation ofthe uterus may be required.
           Abortion and Premature Labor.

Definition of Terms.
      Abortion, expulsion ofthe ovum in the first three months.
      Miscarriage, expulsion  of a non-viable foetus after  the
        third month.
          The terms abortion and miscarriage are commonly
        used interchangeably.
      Premature Labor\ the premature birth of a viable foetus.

Abortion.
  Frequency.   Occurs in about 10% of all pregnancies.
          A large proportion  of abortions occur at the end of
        the second month. 
54
Pathology  of Pregnancy.
Causes.
  1. Death of the Foetus from
      Foetal Lesions ;
        Developmental;
        Infectious diseases;
        Mechanical violence.
      Placental Lesions;
        Acute anaemia;
        Insufficient development of the decidua;
        Endometritis  or metritis,  from  misplacement  or
      otherwise;
        Fevers;
        Metallic  impregnation,—lead, mercury;
        Disease ofthe cord;
        Syphilis, through disease of the decidua or chorion
      or both;
        Other diseases of the chorion.
2. Placental Lesions, acting directly.
    Arising from
        Reflex irritation ofthe uterus:
          Mammary;
          Ovarian;
          Mental shock;
          Chorea;
          Pruritus  vulvae;
          Rectal irritation;
          Undue irritability, and other causes.
        Oxytocics.
        Placenta praevia;
        Epileptiform  convulsions from  uraemic  or other
      causes;
        Carbonic dioxide poisoning;
        Albuminuria, causing placental apoplexies and ma-
      ternal toxaemia;
        Pelvic adhesions;
        Fibroids ofthe uterus;
        Carcinoma of the uterus; 
Pathology  of Pregnancy.
55
        Misplacement ofthe uterus;
        Over distention from hydramnion or multiple preg-
      nancy.
        Direct interference;
        Other mechanical violence as falls and blows;
        Hyperaemia of the pelvic organs from circulatory
      obstruction in  the  lungs or  liver,  cardiac  disease,
      violent  muscular  exertion,  sexual  excesses,  etc.,
      causing hemorrhage into the placenta;
        Other causes.

Diagnosis.
    Symptoms:
        Hemorrhage;
        Rhythmical uterine pains;
        Chill.
    Physical Signs:
        Cervix softening;
        Cervix dilating;
        Ovum protruding.
        The physical signs make the diagnosis of inevitable
      abortion.
        Severe rhythmical pains with  hemorrhage almost
      certainly result in abortion.
        Examine clots,—breaking them  up under water,—
      for foetus or fcetal appendages.
Prognosis.
        Always favorable  in  good hands, yet many deaths
      occur from mismanagement;
        Dangers, hemorrhage, septicaemia;
        Hemorrhage contributes to the fatal  issue though
      rarely the immediate cause of death.
 Treatment.
        i. Prophylaxis in case of habitual abortion;
        2. Arrest of threatened abortion;
        3. Management of actual abortion;
        4. After-treatment.
  Prophylaxis,  or management of cases with a  history of
      previous abortions. 
56
Pathology  of Pregnancy.
      Seek the cause of former abortions.
      Syphilis, misplacements of the uterus and nephritis
    the most frequent causes of habitual abortion.
      Treat syphilis as in other cases.   Correct uterine
    misplacements.
      In chronic nephritis the uterus should generally be
    emptied.
      Guard the menstrual dates.
      Avoid the causes of pelvic congestion till the criti-
    cal period has passed.
Arrest of Threatened Abortion.
      Absolute rest, maintaining a recumbent position.
      Uterine rest.
      To this end, rectal use of opium, I gr., or its equiva-
    lent, p. r.  n.,  or,
      Pil.  extract, viburni  prunifolli, 4 grs. q. 2 h.
      Remove the causes.
      In case of dead foetus or vesicular degeneration  of
    chorion, empty the uterus.
Management of Actual Abortion.
  Chief objects of treatment the prevention of
      1. Hemorrhage;
      2. Septicaemia.
  Agents  for controlling hemorrhage:
      1. Rest;
      2. Vaginal tampon, simple or styptic.
      Must be aseptic. Renew every six hours, or  use
    cotton impregnated with  oxide  of  zinc, which may
    stand 24 hours;
      3. Cervical tampon together with  vaginal;
      4. Evacuation of the uterus as soon as the ovum is
    separated, or nearly so, by the aseptic finger or curette.
  Means for preventing or arresting sepsis:
      1. Continuous disinfection of the uterus;
      2. Avoidance of preventable lacerations and abra-
    sions;
      3. Evacuation of the uterus.
Expectant Plan.
  Indications.
      Ovum not detached; 
Pathology  of Pregnancy.
57
       Hemorrhage slight;
       No putrilage.
   Method:
       Maintain asepsis.
       Aseptic vaginal  tampon may be used if required
     as a prophylactic against hemorrhage.
       This plan failing, after two or three days empty the
     uterus with curette  and forceps.
       Sooner for cause.
 Radical Plan.
   Indications.
       Cervix dilated.
       Ovum detached or presenting.
       Much hemorrhage.
       Sepsis imminent.
   Manual Method:
       Anaesthetic if necessary;
        Depress and fix  the uterus  by one hand  over the
      abdomen;
        Empty the cavity with one or  two fingers of the
      other hand aseptically.
   Instrumental Method:
        Sims' position,  Sims'  speculum, dressing forceps
      with joint 2\ inches from the distal end;
        Sterilize the vagina and the  uterine cavity;
        Separate the ovum with the  curette;
        Extract with the dressing forceps;
        Curette the uterine cavity;
        Douche the cavity with  a  hot mercurial solution
      and follow with plain hot water;
        Swab with tr. iodin. in case of hemorrhage  not
      controlled by the curette;
        Leave 30 grs. of iodol or iodoform in the uterus.

After-Treatment.
        Rest in bed for one or two weeks.
        Maintain asepsis. 
58             Pathology of Pregnancy.

Premature Labor.  Management same as in term labors.

Signs of Death of the Foetus.
      First half of pregnancy:
          Recession ofthe signs of pregnancy;
          The bimanual,—uterus inelastic;
          Peptonuria.
      Last half of pregnancy:
          Absence ofthe fcetal heart;
          Absence of active fcetal movements;
          Looseness and crepitation  of cranial bones.

Fleshy Mole.—Consists of a retained  ovum  of less than three
        months' development,  of which the embryo has died
        and become absorbed.
    Treatment: Empty the uterus.

Hyperemesis: Pernicious Vomiting.
   Pathology.
          In  part a neurosis.
          Severest forms probably never uncomplicated.
    Complications.
      Uterine Lesions:
          Misplacements;
          Detention in the pelvis, by adhesions or otherwise;
          Decidual endometritis;
          Induration ofthe cervix;
          Erosion or inflammation ofthe cervix.
      Non-uterine Lesions:
          The ordinary  causes  of  vomiting:—intracranial,
        gastric, hepatic,   intestinal, peritoneal,  renal  and
        others.
    Prognosis.
          The majority of cases recover by the third or fourth
        month, when the uterus rises out ofthe pelvis.
          Prognosis is grave in the worst forms. 
Pathology  of Pregnancy.
59
Treatment.
      Treat with reference to the cause if possible.
  Dietetic Measures:
      Humor the appetite;
      Breakfast in bed followed by sleep;
      Sherry wine before rising;
      Strong coffee before rising;
      Cold carbonic acid water  or Vichy, plain  or con-
    taining an alkaline bromide,  i drachm to the syphon;
      Champagne, cold;
      Other  dietetic measures as practised in  ordinary
    vomiting.
  General Therapy:
      Cocaine, gr. i-8th to i-4th, three or four times daily,
    or hourly till three or four doses are taken;
      Cocaine spray to the pharynx, \% solution;
      Chloral,  gr. xx to xxx in solution, by the rectum,
    repeated p.  r. n.;
      The bromides in like manner;
      Morphia,  hypodermically or endermically, over the
    epigastrium, especially if there be local tenderness.
      Strychnia or nux vomica before meals,  in chronic
    gastric catarrh;
      Calomel in full dose or in small repeated doses.
      Oxalate of cerium, gr.  x. q. 2 vel4h., in  mild cases;
      Ether  spray to the epigastrium at the beginning of
    each paroxysm;
      Ice bag to the cervical vertebrae;
      Blister over the 4th or 5th dorsal vertebrae;
      Inhalation of oxygen;
      Faradic current through the stomach;
      Other measures such  as are used in the treatment
    of ordinary  vomiting.
  Local Measures:
      Treat  local lesions;
      Correct malpositions ofthe uterus;
      Cocaine,  20"/0 solution, on and within the cervix; 
6o
Pathology  of Pregnancy.
           Combine with cocaine, Copeman's method of dila-
         tation ofthe cervix below the os internum.
           This treatment may result in abortion;
           Artificial Abortion as a last resort.
           This procedure must never be adopted except with
         the concurrence of competent council.
           Method:—Puncture of the membranes  or  partial
         separation ofthe ovum with a sound.
           Rectal  Alimentation may tide the patient  over a
         crisis when stomach-feeding is impossible.
           Beef blood,  beef juice, Leube's meat solution  or
         predigested milk,  4  ounces, q. 4 h.   Small doses of
         opium may sometimes be added to the nutrient enemas
         with advantage.
           Wash out the rectum daily.
Ptyalism.
           Saturated solution of potassium chlorate as a mouth-
         wash.
           Atropia, gr. i-64th, once to three times daily.
           Bromides, gr. xxx to cxx daily.
           Treatment generally unsatisfactory.
Anaemia.
           Iron, pil. Blaud,  I or 2, t. i. d.; albuminate of  iron in
         liberal doses.
           Citrate of iron, subcutaneously.
           Arsenic, gr. i-40th  to i-20th, t. i. d.
           Generous diet.

Varices of the Lower Extremities.

           Support by bandage or elastic stockings.
Pruritus Vulvae.
           Exclude diabetes.
           Hot fomentations to the vulva.
          Dust the vagina and vulva with subnitrate of bismuth.
          In pruritus from  parasitic causes, vaginal  injections
        and vulvar lotions  of the bichloride of mercury, r to
        2000. 
Labor.
6t
                         LABOR.

Labor.
  Factors:
            I.  Powers;
           II.  Passages;
          III.  Passenger.
  I. Expelling Powers:
          i.  Muscular action of the uterus,—involuntary, the
        sympathetic being the chief motor nerve ofthe uterus.
        Peristaltic but nearly simultaneous,—beginning at the
        fundus probably.
          2.  Muscular action of the abdominal walls,—vol-
        untary in part, partly a reflex involuntary contraction.
          Chief expelling force  the contraction of the un-
        striped muscular fibers of the uterus.
          Proof, labor in paraplegic  women, under anaesthe-
        sia, and the powerlessness of the abdominal muscles
        alone in inertia uteri.
          Power of the uterine  contractions,  50 to 80 lbs.,
        together with the abdominal muscles,—Duncan; ac-
        cording to Schatz, 17 to 55 lbs.
  II. Passages:
          1.  Hard Parts:  Bony Pelvis;
          2.  Soft Parts.
  Obstetric Anatomy ofthe Bony Pelvis.
    Constituent Parts:
          Ossa innominata;
          Sacrum;
          Coccyx.
    Joints:
          Symphysis pubis;
          Sacro-iliac joints;
          Sacro-coccygeal joint. 
62
Labor.
      A slight mobility of the pubic joint is usually pres-
    ent in the latter months of gestation.
      Recession  of the  coccyx  during expulsion  of the
    fcetal head from the outlet, \ to I inch.
False and True Pelvis, or Greater and Lesser Pelvis.
      All above  the ilio-pectineal line is  false pelvis, all
    below, true pelvis.
      The  false  pelvis with  the  abdominal wall forms  a
    funnel-shaped approach to the true pelvis.

Trne Pelvis.
  Brim:  Inlet;  Superior  Strait;  Isthmus;  Margin.
      Located by  the linea terminalis  and  the  upper
    border ofthe sacrum.
      Shape, approximately heart-shaped.
  Landmarks at the Brim:
      Promontory ofthe sacrum, or sacro-vertebral angle;
    due to  the wedge shape of the last  lumbar cartilage
    and ofthe fifth  lumbar vertebra;
      Sacro-iliac  joints;
      Ilio-pectineal eminences situated  at  the ilio-pubic
    joint, on the pubic bone;
      Symphysis  pubis.
  Outlet  of the  Pelvis,  or Inferior Strait.    Lozenge-
    shaped  and  bounded by the tip of the coccyx,  the
    subpubic arch and  the ischial tuberosities.
      A  double triangle whose common  base is  a line
    connecting the ischial tuberosities, the  apex of one
    the  pubic  arch, the other, the tip of the coccyx  or,
    better, the sacrum.
  Landmarks at the Outlet:
      Tip ofthe coccyx;
      Subpubic arch;
      Ischial tuberosities;
      Ischial spines.
      The greater and lesser sacro-sciatic ligaments assist
    in completing the  parturient canal  partly  formed by
    the bones. 
Labor.
63
         The greater arise from the posterior,  inferior spines
       of the ilium and  from the sides  of  the  sacrum and
       coccyx, and are inserted into the inner surfaces  of
       the ischial tuberosities.
         The lesser arise from the sides of sacrum and coccyx,
       and are inserted into the spines ofthe ischium.
         Obturator membrane.
     Cavity.   Bounded posteriorly, in the main,  by the sa-
       crum and  the coccyx.
         Anteriorly, by the pubes, the pubic and ischial rami.
         Laterally, by  the surfaces of the iliac and ischial
       bones.
         The  posterior wall is  smooth,  and  concave from
       above  downward.  Its depth  is 4 to  5  inches,—5!
       measured  on the curve.
         The  anterior wall is smooth,  and concave from side
       to side. Its depth at the symphysis pubis is  \\ inches.
     Planes.   The plane of the  brim cuts the  ilio-pectineal
       line, the  upper border of the sacrum and the upper
       end ofthe symphysis pubis.
         Inclination of the  brim  to  the horizon  is  about
       6op, but is variable.
         The  middle plane cuts the middle of the posterior
       surface of  the pubic symphysis  and the  upper margin
       ofthe third piece ofthe sacrum.
         The  plane of the outlet cuts the tip of the sacrum,
       a  point just below the lower end of the symphysis
       pubis, and the ischial tuberosities.
         A line from  the  tip of  the coccyx to  the  subpubic
       arch makes an angle of about nQ with the horizon.
Pelvic Diameters and Measurements.
  Internal Diameters :
  At the Brim:
    True Conjugate, from the promontory of the sacrum to
      the upper end of the symphysis,—more exactly to a
      point on the symphysis crossed by the  linea  termi-
      nalis. 
64                        Labor.

      Diagonal Conjugate, from the promontory of the sacrum
        to the summit ofthe subpubic arch.
      Transverse Diameter, the greatest transverse diameter.
        It cuts  the points midway  between  the sacro-iliac
        joints and the ilio-pectineal eminences.
      Oblique Diameters, from  the sacro-iliac joints, respec-
        tively, to the opposite ilio-pectineal  eminence.  R.
        O. from the right, L. O. from the left sacro-iliac joint.
    At the Middle Plane.
      Antero-posterior Diameter, from  the  upper margin of
        the third piece of the sacrum to the middle  of  the
        posterior surface ofthe pubic symphysis.
      Transverse, between points corresponding respective-
        ly to the lower margins ofthe acetabula.
      Oblique,  from the center of the  greater  sacro-sciatic
        foramen to  the center of the obturator membrane
        opposite.
    At the Outlet.
      Antero-posterior Diameter.  Lower margin ofthe pubic
        symphysis,  or a point just below  it, to the tip of the
        sacrum,—or as usually defined, from  the lower  end
        ofthe pubic symphysis to the tip ofthe coccyx.
      Transverse.   Between the tubera ischiorum.
      Oblique.  Middle of the  lower edge of  the greater
        sacro-sciatic ligament  to the point  of union between
        the ischium and pubes on the opposite side.
    External Diameters :
      External  Conjugate  Diameter.
           From the fossa just below the spinous process of
        the  last lumbar  vertebra to the  most  prominent
        point on the surface overlying the upper portion of
        the pubic  symphysis.  A prolongation of the inter-
        nal conjugate.
      Ilio-spinal or Inter-spinal Diameter.
           The distance between the  anterior  superior spines
        of the  ilia  measured from the  inner  borders  of the
        sartorii at their origin.
      Ilio-cristal or Inter-cristal Diameter. 
Labor.
65
         In  the  normal  pelvis the greatest external diam-
      eter of the pelvis measured transversely at the crests.
Measurements of the Static or Dried Pelvis.
             Internal,—Approximate Values:
      Antero-posterior       Oblique     Transverse
     Brim,   4 inches        4^ inches      5 inches.
     Outlet, 5   "           43^   "         4   "
         The right oblique diameter at  the  brim is  slightly
      longer than the left oblique.
Measurements of the Dynamic Pelvis.
     Internal:
         The internal diameters  are diminished %  inch by
      the presence of the soft parts in the dynamic pelvis.
         The transverse diameter  at the  brim is still  more
      reduced by the psoas and iliacus muscles.
         The oblique diameter is  the  longest,  in the dy-
      namic pelvis.
         The capacity of  the dynamic  pelvis is still further
      reduced  by the   contained  viscera and the  cellular
      structures.
     External:
         External conjugate, 8 inches;
         Ilio-spinal, 10 inches;
         Ilio-cristal, 11 inches.
         To estimate the internal conjugate from the exter-
       nal,  deduct from 2% to  5 inches for  the thickness
       ofthe bony structures and overlying soft parts.
Diiference Between the Male and Female Pelvis.
     Distinguishing marks of the female pelvis:
       As a whole:
         False pelvis wider;
         True pelvis larger in all diameters and  of shal-
       lower depth;
         Bones lighter and more slender;
         Pelvic inclination greater;
       Brim: Sacro-vertebral angle less prominent; 
66
Labor.
           Pubic spines farther apart.
         Cavity:
          Sacrum shorter and broader;
           Cavity less funnel-shaped.
         Outlet:
           Greater  width of subpubic arch,—750;
           Male, 580;
           Symphysis pubis little more than half  the depth of
          the male.
Obstetric Anatomy of the Pelvic Soft Parts.
         At the Brim: The iliacus and psoas muscles encroach
    upon the  lateral  margins of the inlet to the  extent of yA
    inch, or more,  on each side.
        The  external iliac  vessels lie  on the inner  border
    of these muscles.
        In the  Cavity: There are  no   muscular structures
    over the   median portion of either  the anterior or  pos-
    terior pelvic walls.
        On either  side  of the  median portion lie the pyram-
    idalis/posteriorly, and the obturator internus, anteriorly,
    too thin to affect the pelvic diameters.
        At the Outlet:  The outlet is  closed  by the  pel-
    vic  floor   or  diaphragm  which  is  made  up chiefly  of
    muscles and fasciae.
 Pelvic Floor:
        The upper  aspect of the pelvic  floor is  concave, its
    lower, convex from  before backward.
        Its upper limit is the  peritoneum except where  that
    structure is lifted off to be reflected over the pelvic viscera
    and  their appendages.  Its lower surface is skin.
        At its median  portion it  is obliquely traversed by
    three muscular  slits, the urethra, the vagina,  the rectum,
    all approximately parallel with the  pelvic  brim,  except
    that the lower end  of the rectum turns backward  nearly
    at a  right angle with the vagina.
        The posterior vaginal  wall and the soft structures be-
    hind it constitute the sacral segment  of the pelvic floor of
    Hart; 
Labor.
67
      The anterior wall of the vagina and the soft parts in
  front of it, the pubic segment of the pelvic floor.
Measurements:
      Coccyx to anus,  in the  nullipara, 1^/4.  inches; anus
  to posterior commissure, in  the nullipara, 1% inches; in
  parous  women, 1  inch; in gravid women at  term,  1^
  inches.
      Greatest transverse width, on  the bis-ischial line, 4^
  inches.
      Perpendicular  thickness of the pelvic floor  at  the
  anus,  2 inches.
      Average  projection of  the   pelvic   floor,  below  a
  line drawn from the tip of the coccyx to the lower end of
  the symphysis, is about  1 inch.
      Length of the sacral  segment during labor  at  the
  moment of expulsion,—coccyx to posterior commissure,—
  is 6% inches.
Principal Component Structures:
      Internal or Superior Pelvic Fascia,  continuous with
  the iliac fascia.
      Levator Ani Muscle: each lateral half of the leva-
  tor ani  arises from the horizontal ramus  of the  pubes,
  from  the ischial spine and from the fascia between these
  points.  The  lateral  halves pass  downward  and  back-
  ward, a portion of their fibers  going to  the coccyx,  one
  bundle  uniting with its companion behind the  rectum, a
  portion passing to the lateral aspect and  another  to the
  anterior wall  of the rectum, near the anal orifice.  The
  anterior  or lowermost  bundles pass  to the lateral walls
  ofthe vagina.
      The Coccygeus: Origin, the ischial spine;  insertion,
  the side of the coccyx and the  lower  portion  of  the
  sacrum.
      These two muscles constitute the  deep  muscular
  layer  ofthe pelvic floor.
      They lie immediately below the internal pelvic fascia.
  The former is the most important muscle of the  pelvic
  diaphragm. 
68
Labor.
         The  Sphincter  Ani  lies  below  the plane  of these
    muscles.
         Below the sphincter ani is the skin.
         The  foregoing  structures  belong  to  the  posterior
    portion of the pelvic floor, the anterior limit of which is
    the bis-ischial line.
         The anterior  region  of the pelvic  floor  lies in front
    of this  line and comprises the deep, middle and super-
    ficial perineal  fascia, and,  between  the last  two fascial
    layers,  the transversus  perinei, the bulbo-cavernosus  and
    the ischio-cavernosus muscles.
         The Transversus Perinei: Origin, the ischial tuberos-
    ity; insertion,  the perineal body.
         The Bulbo-Cavernosus:  Origin, the anal  sphincter
    and  perineal fascia  at  the  right and  left of it;  insertion,
    the  lower aspect  of the  clitoris,  the  posterior surface of
    the bulb and the mucous membrane ofthe vestibule.
         The Ischio-Cavernosus: Origin, the ischial tuberosity
    and ischio-pubic ramus; insertion, the crus clitoridis.
         The Perineal  Body is the mass of elastic and muscu-
    lar tissue between the  lower end of  the vagina and  the
    rectum.   Height, \% inches. Length of base, antero-pos-
    teriorly, \% inches,—in the nullipara.
The Parturient Axis.
         Axis of the Inlet :  A line perpendicular to  the plane
    ofthe brim at its central point;  its prolongations cut the
    umbilicus and the tip of the coccyx.
         Continuous with the axis of the uterus.
         Axis of the Outlet:  The perpendicular to  the plane
    of the  outlet  at its middle point, cutting,  if prolonged,
    the  promontory of  the sacrum and the anus.
         Axis of the Outlet of the Soft Parts: axis  of expul-
    sion,—looks almost directly forward.
        Axis ofthe Parturient Canal  is an irregular  parabola.

III. Passenger.
      A factor by  reason of its
            Shape, especially ofthe head; 
Labor.
69
            Size, especially ofthe head;
            Presentation;
            Position;
            Posture.

Obstetric Anatomy of the Fcetal Head.
            The Cranial Vault is plastic owing to the semi-
        cartilaginous character and mobility of its bones.
            The Cranial Base and Face are firm and unyield-
        ing, since  the bones of this region are more highly
        ossified and  more firmly united.
      Bones of the Cranial Vault:  1 occipital, 2 parietal,  2 front-
        al, 2 temporal.
      Sutures :
           Sagittal or inter-parietal;
           Frontal or inter-frontal;
           Coronal or fronto-parietal;
           Lambdoidal or occipito-parietal.
      Fontanelles :
        Anterior, or Large Fontanelle, or Bregma:
           At the anterior extremity of the sagittal suture;
           Kite-shaped or quadrangular ;
           Anterior angle most acute and elongated ;
           Average diameter, one inch ;
           Four lines of sutures run into it.
        Posterior Fontanelle:
           At the posterior extremity of the sagittal suture ;
           Triangular;
           Small, usually a mere depression barely perceptible
        to the finger tip;
           Three lines of sutures running into it ;
           Behind it the squamous or triangular portion of the
         occipital bone  is  movable  upon  the  basilar portion
         by a hinge-like joint of fibrous tissue.
       Protuberances:
       Occipital—one inch or more behind the posterior fon-
         tanelle. 
                      Labor.

   Parietal eminence or bos,—at the center of each parietal
     bone.
   Frontal,—at the center of each frontal bone.
   Vertex:—that  portion  of the  head  lying between the
     fontanelles  and extending  laterally to  the parietal
     eminences.
   Occiput:—that  portion of the  head  lying behind the
     posterior fontanelle.
   Sinciput:—that  portion of the head  lying in front of
     the bregma.
   Measurements of the Foetal Head :—Approximate Values:
   BiparietalDiameter:—Through  the parietal eminences, 3^
     inches.
   Fronto-mental Diameter:—From the summit ofthe forehead
     to  the  center of the lower  margin of the chin, y/2
     inches.
   Occipitofrontal Diameter:—From the tip  of  the  occipital
     protuberance to the root of  the nose, 4^ inches.
   Occipito-mental Diameter:—From  the tip  of  the  occipital
     protuberance to the center ofthe lower margin of the
     chin, 5^ inches.
   Suboccipito-bregmatic Diameter:—From  the junction  of the
     nucha and  occiput  to  the center  of  the bregma, 3^
     inches.
   Bitemporal Diameter:—Between the lower extremities of
     the coronal suture, 3^3 inches.
   BimastoidDiameter:—Between the mastoid apophyses, 2^
     inches.
   Circumference : — Suboccipito - bregmatic  circumference,
     about 13 inches.
     In  male, y2 inch greater than in female heads.
Trunk Diameters :
      Bis-acromial, 4^ inches.
       Bis-trochanteric, 3^ inches.
       The  trunk  diameters  are  much more compressible
     than the cephalic.
Presentation.
     Definition:  Relation  of  the long axis of the  fcetal
       ovoid to the  uterine axis. 
Labor.
7i
Varieties:
  1. Longitudinal;
    Cephalic,—including
      a. Vertex;
      b. Face;
      c. Brow;
    Pelvic,—including
      Breech,
      Feet.
  2. Transverse, including
      Shoulder,
      Arm,
      Other rarer presentations.
     Relative Frequency",—at term.
      Cephalic, 970/ or more.
      Pelvic, 2% or less.
      Lateral, 1% or less.
       Causes for preponderance of the cephalic presenta-
     tion are adaptation, and, probably, gravity.
 Presenting Part.—That  part  of the fcetal ovoid which
     offers at the pelvic  brim.
Position.
   Definition:—Relation of the presenting part to certain
     anatomical landmarks at the pelvic brim.
   Vertex Positions:
       Left occipito-anterior;—L. O. A.;
       Right occipito-anterior;—R. O. A.;
       Right occipito-posterior;—R. O. P.;
       Left occipito-posterior;—L. O. P.
       Relative Frequency:  700/ , 10%, 17%, 3%, respec-
     tively.
   Face Positions :
       Left mento-anterior ;—L. M. A.;
       Right mento-anterior  ;—R. M. A.;
       Right mento-posterior ;—R. M. P.;
       Left mento-posterior ;—L. M. P.
   Breech Positions:
        Left sacro-anterior ;—L. S. A.;
        Right sacro-anterior ;—R. S. A.; 
72                        Labor.

          Right sacro-posterior ;—R. S. P.;  ,
          Left sacro-posterior ;—L. S. P.
      Transverse or Shoulder Positions:
          Left scapula-anterior ;—L.  Sc.  A.,—(Sc.  L. A.,
        Simpson);
          Left scapula-posterior ;—L.  Sc. P.,—(Sc.  L.  P.,
        Simpson) ;
          Right scapula-posterior;—R. Sc. P.,—(Sc.  D.  P.,
        Simpson) ;
          Right scapula-anterior ;—R. Sc. A.,—(Sc.  D. A.,
        Simpson).
          Terms right and left refer to the mother.

   Posture.
      Definition:—Relation of the fcetal members to one an-
        other.
          Normal posture, one of flexion.
          In Cephalic Presentation:—Extreme flexion ofthe
        head  is the  most favorable  posture, since the head
        thus engages by its smallest diameters.
          Extreme  extension  (face  presentation),  not  so
        favorable.
          Semi-extension  (brow  presentation)  or  incom-
        plete  flexion, unfavorable.
        In Breech  Presentation:—Either breech, knee or foot
        may present, according to posture.
        In  Shoulder Presentation :—Either shoulder, elbow
        or hand may present.

Classification of Labor.
        Normal:—The mechanical factors all  normal  and  no
            complication.
        Abnormal:—One or more ofthe factors abnormal.
        Complicated :—Dangerous to the mother  or child,  or
            both, by reason of some accident independent of
            the mechanical factors. 
Labor.
73
        Normal Labor:  Physiology of Labor.

Mechanism.
    Movements of the Head :
    Descent:—Driving  force, the action  of  the  uterine and
        abdominal muscles.
    Flexion: Cause :
      Before engagement in the utero-cervical canal  there is
        a certain degree of primary flexion ;
      After engagement:
          i. Adaptation;
          2. Unequal lengths of occipital and frontal arms of
        the lever.
          Accommodation is still further promoted by mould-
        ing ofthe head.
    Rotation: Cause :
          i. Adaptation;
          2. Slope of the lateral  halves of  the  pelvic floor,
        downward, forward, inward.
          That pole  of the fcetal  head which first lands upon
        one lateral half of the pelvic  floor glides downward,
        forward and  inward under the pubic arch.
          Complete flexion and moulding favor rotation.
    Extension: Cause: Adaptation.
    Restitution : Cause :  Torsion of neck,—untwisting.
          Shoulders  and breech rotate  in similar manner to
        the head, but less perfectly.

Physiological Phenomena.
        Cause of onset, obscure.
        Premonitory Symptom, lightening, occurring general-
        ly within ten days of labor;  not constant.
    Phenomena of Beginning Labor:
          Irritability of the bladder and  rectum ;
          Show; not constant;
          Expulsion of mucous plug; 
74
Labor.
      Rhythmical uterine pains.
      At first pelvic tenesmus  and lumbo-sacral pains.
      Later, pains felt toward the pubic region, radiating
    down the  thighs.
      The uterus hardens with each pain.
Stages of Labor:
  1. Stage of Dilatation :—Ends with  the  complete canaliza-
    tion of the utero-cervical zone.
  2. Stage of  Expulsion:—Ends with  the  birth of  the child.
  3. Placental Stage:—Ends with the  complete  evacuation
    ofthe uterus, and permanent retraction.

1. Stage of Dilatation.
      Dilatation is  accomplished by the traction of  the
    longitudinal muscular  fibers of  the  upper uterine
    segment,  and the hydrostatic pressure of the bag of
    waters.
      By the  traction of the  longitudinal fibers of  the
    uterus  the  lower  uterine  segment  is pulled upward
    over the lower segment ofthe ovum.
      With  unbroken  membranes,  the  ovum  is peeled
    off from the lower uterine segment,  and  protruded
    as dilatation progresses.
      This  protruding portion of the membranes forms
    the bag of waters.
      In vertex presentation it has  a  watch-glass shape.
      The contained liquor amnii is the fore-waters in dis-
    tinction from that above the head, termed  the hind-
    waters ;
      The  protruding bag  of  membranes acts  in some
    degree as  a dilating fluid wedge.
      The  bladder and the whole pubic segment of  the
    pelvic floor begin to be drawn upward during the latter
    part of the stage of dilatation.
      The vessels ofthe cervix, unsupported by pressure,
    become  engorged, and  the cervical  tissues loosened
    by serous infiltration, thus favoring relaxation or dila-
    tation ofthe cervical canal. 
Labor.
75
      The  cervix is at first obliterated with  each pain,
    and restored in  the intervals.
      Subsequently permanent obliteration of the cervix
    is established, the ovum resting against the os ex-
    ternum.
      From this  time the  progress of canalization  is
    marked by the expansion ofthe os externum.
      During  the first stage the upper uterine segment
    becomes  thickened  by retraction  of  the muscular
    structures, and  the  lower  segment correspondingly
    thinned.   The line of demarkation between the thick-
    ened upper and the thinned lower segment is the re-
    traction ring.
      The  bag of membranes ruptures normally on com-
    pletion of the first stage.
      Frequently it ruptures sooner, or only on interfer-
    ence.
      Pains or Labor Pains;—Definition, painful  uterine
    contractions of  labor.
      Cause of the  pain, pressure on the nerve filaments
    ofthe uterus.
      Duration of contraction, 30 to 60 seconds.
      Intervals, at the beginning of labor, about  30 min-
    utes, gradually shortening  as labor progresses; may
    be reduced to a  fraction of a minute at the close ofthe
    second stage.
      The  intensity progressively increases.
      Rarely the first stage is painless.
      Frequently first-stage pains are not as well borne
    as the severer pains of the second stage.
    Average  Duration of the First Stage :
      In primiparae, 15 hours;
      In multiparae, 11 hours.

2.  Stage of Expulsion.

      The  driving force  is the action of the uterine  and
    abdominal muscles. 
Labor.
       Membranes  unbroken, the expelling forces act to
     extrude the entire ovum.
       Membranes broken and foetus consolidated, the ex-
     pelling forces act directly upon the fcetal ovoid.
       Lubrication of the passages is accomplished by the
     increased secretions and by the liquor amnii.
       The  intensity of the pains  is  augmented  by the
     pressure ofthe presenting pole upon the vaginal walls,
     and especially at the vulvar outlet,—at the perineal
     stage of labor.
       Pains of the expulsion stage are distinguished by
     their bearing-down  character.
       An  cedematous tumor is  developed upon the pre-
     senting part of the  fcetal  head as it  engages,—the
     caput succedaneum.
       The head is moulded by elongation in the direction
     ofthe birth-canal, with a corresponding reduction of
     its engaging diameters.
       Generally the head advances with the pains and
     recedes in the intervals.
       The sacral segment  of the pelvic  floor  is relaxed,
     elongated,  and thrust downward and  backward  in
     front ofthe advancing head.
       The  anal orifice is dilated owing to the relaxation
     of its sphincter.
       The length of the sacral segment (from the coccyx
     to  the  posterior commissure) is increased  to 5 or 6}(
     inches at  the moment of expulsion.
       A short pause generally follows the birth ofthe head.
       A gush of bloody water usually attends the ex-
     pulsion ofthe trunk.
     Average Duration ofthe Second Stage:
       Primiparae, 2 hours ;
       Multiparas, 1  hour.
3.  Placental Stage.
  Events:
  /.  Separation of the Placenta:
       From contraction  of the placental site and extrud-
    ing force of the uterine contractions. 
Labor.
77
      2. Expulsion of the Placenta:
          Due  to the extruding force of the uterine contrac-
        tions.
          Sometimes expelled edgewise,  presenting by  its
        margin :
          Sometimes it presents by its amniotic  surface, flat-
        wise.
      j. Retraction of the Uterus:
          Accomplished by repeated contractions, and con-
        sists in a rearrangement of its  muscular fibers,  by
        which the walls are thickened and shortened.
          Duration of the placental stage  is 20 to 30 minutes
        or more.
          Retraction securely ligates the uterine vessels torn
        across on separation of the placenta.
          After-Pains :—The intermittent contractions of the
        uterus after labor are  termed after-pains.
    Average Length of Normal Labor;
          In primiparae, 17 hours ;
          In multiparas, 12 hours.
Management of Normal Labor.
    Preparatory :
          Keep the patient under observation during at least
        the latter months of pregnancy.
          Enforce hygiene.—Fortify the health and strength.
          Urine should be examined weekly during last one or
        two months, earlier and oftener for cause.
          Nipples should be cleansed daily, and,  if sunken,
        may be drawn with the fingers,—during last month.
    Obstetric Armamentarium.
          Obstetric  Forceps, Catheter,—soft  rubber,  Hypo-
        dermic  Syringe, Fountain Syringe,  Uterine  Douche-
        Tube,  Needles,  Needle-Forceps,  Aseptic  Sutures,
        Hand Brushes—Sims' Speculum,  Volsella,  Curette.
          Squibb's Chloroform, Chloral, Squibb's Ergot, Mor-
        phia tablets, gr. }&, Ext. veratri viridis fl.,  Antiseptic
        tablets ofthe biniodide or bichloride of mercury. 
78
Labor.
Hygiene of the Lying-in Room.
       A southern exposure is desirable.
       Continuous ventilation is imperative.
       An open fire is a good ventilator.
       The  room, the  bedding, and the  clothing of the
    patient should be surgically clean.
Preparation of the Bed.
       Spread  over  the  mattress  a rubber  sheet large
    enough to cover the entire width of the bed  and the
    larger part of its length. Cover this with a clean mus-
    lin sheet and pin fast to the bed.   Spread over this a
    second  rubber  covered  with  a muslin  sheet.  Place
    on this  again three clean muslin sheets, twice folded,
    in position to absorb the discharges.*
Examination ofthe Patient.
Preliminary Examination :—A Month before Labor.
  A bdominal:
       Presentation;
       Position;
       Posture;
       Twins;
       Hydramnion.
    Method:
       Locate.
        Small parts;
        Dorsal plane.
       Differentiate fcetal poles  by
        Situation;
        Size;
        Shape;
        Hardness;
        Ballottement of head,—in upper segment.
      Locate
        Cephalic prominence;
        Anterior shoulder;
   * A large antiseptic pad  of prepared jute, or other absorbent material, covered
with cheese cloth, or a Kelly rubber pad, may be used to receive the discharges in
place of the folded sheets. 
Labor.
79
         Fcetal heart;
         Fcetal movements,—feet.
   Vaginal:
       Antiseptic  precautions  as in examination during
    labor.
    Pelvis ample, contracted or obstructed.
Examination during Labor.
1. Verbal:
    Precursory signs:
       Lightening;
       Irritability ofthe bladder and rectum.
    Signs of actual labor:
       Irritability ofthe bladder and rectum;
       Show;
       Expulsion of mucous plug;
       Rhythmical pains in  the lumbo-sacral and lower
       abdominal regions.
2. Abdominal:
       Presentation;
       Position;
       Posture;
       Fcetal pulse-rate, etc.
3. Pelvic:
  Antiseptic Precautions:
       Let the nurse,  after sterilizing  her  own" hands,
    cleanse the external genitals of the patient with soap
    and hot water,—remove the soapy water and bathe
    the parts with one of the mercurial solutions.
       Give an  antiseptic vaginal douche in  case  of foul
    secretions.
       A suitable antiseptic for this purpose is chlorinated
    soda, i in io, or one ofthe mercurial solutions.  The
    latter, however, should be immediately followed with
    a plain water douche to  wash out the mercurial.
  Technique of Hand-Cleaning.
       Clean  the nails dry.
       Scrub the hands and arms thoroughly with soap and
    hot water and a hand-brush for several minutes. 
8o
Labor.
    Rinse off the soap with clean water.
    Scrub  with  one of the  mercurial solutions,  and
  another hand-brush for several minutes.
    Give special attention to the finger tips, particularly
  the free edges ofthe nails,   f'
    Wet well with 9/5% alcohol?**"
    Finally  hold the hands for a  few minutes  in the
  antiseptic solution.
    Use as a lubricant for the hands either the steriliz-
  ing solution, or a 1 in 2000 solution of mercuric iodide
  in glycerine.
    To prevent recontamination, touch nothing  that is
  not aseptic.
    Dip the hand for a moment in  the antiseptic solu-
  tion before each subsequent examination.
    The nurse should cleanse her hands as  the  doctor
  does, before touching the genitals.

Sterilizing Solutions.
    Hydrarg. Biniodid., 1 part in 2000 of  water.  Add
  one part of iodide of potassium to promote the solu-
  tion ofthe biniodide.
    Hydrarg. Bichlorid., 1 part in 2000.  Add one part
  of chloride of ammonium or sodium for each  of the
  bichloride.
    The bichloride  solution should be acidulated with
  acid, tart.,  5-1000, to  prevent  precipitation   of the
  mercurial in the presence of albuminous fluids.
    Cloths, utensils, instruments, etc.,  maybe sterilized
  by  exposure for 20 minutes  to a  dry heat of 2340 F.
  (1120  C.)  (baking in an oven);—or, except metallic
  instruments, by the  use' of one of the above-named
  solutions.  Boiling or steaming for 30 minutes  is suffi-
  cient for all practical  purposes.

Note in Order the Condition of the
    Vulva,—old injuries, rigidity, oedema?
    Vagina,—well lubricated?
    Rectum and Bladder,—full or empty? 
Labor.
81
          Bony pelvis,—especially diagonal conjugate.
          Cervix,—old injuries, dilatable ?  How much dilated?
          Membranes, — ruptured  or  not? — watch-glass  or
        glove-finger protrusion?
          Presentation—Examine all accessible parts, taking
        plenty of time;
          Position,
          Posture,
          Stage of progress.
      Diagnosticate,
          Vertex presentation by the hard and globular  char-
        acter of the  fcetal head,  and  by the sutures and fon-
        tanelles.
          Position, by locating the sagittal suture and finding
       which end is forward.
          Posture by the relative descent of the fontanelles.
          Stage of progress, in the first stage, by the degree
        of expansion ofthe cervix; in  the second, by compar-
        ing the situation of the  leading pole,—occiput,—with
        the landmarks ofthe birth-canal.
          Statement of prognosis must generally be more or
        less guarded. Should be made as  definite as possible.
Management of the Stage of Dilatation.
      For Relief of Severe Pains:
          Chloral, I  drachm, in  doses of  gr. xx, every 15
        minutes;
          Opium, rarely, gr. 1, or equivalent dose of morphia
        or codeia;
          Chloroform,  very rarely, in the latter part of the
        first stage.
      Frequency of Vaginal Examination :
          Should be as infrequent as practicable (I to 4 hours);
          May in many cases be omitted altogether.
          Instruct the patient not to keep the bed, not to bear
        down  with  the pains, and to keep  the bladder  and
        rectum empty.   Prescribe the diet.
          Except in very slow labor, remain with patient after
        the os externum reaches the size of a silver dollar. 
82
Labor.
          Never hurry the first stage,  except when necessary
        to avert positive danger to mother or child.
Management of Expulsion Stage.
          The patient should take the bed at the beginning of
        the second stage.
          Should be dressed for the bed with her linen tucked
        under the  arms  and pinned, and with a folded sheet
        fastened above the hips in the manner of a skirt.
          The membranes should be  ruptured early in the
        second stage, provided there is no contra-indication.
          A handy instrument for perforating the bag of
        waters is a coarse hair-pin straightened and previous-
        ly flamed.
      Obstetric Positions:
          In general, consult the convenience of the patient.
          For examinations, prefer the dorsal.
          During the "perineal stage," the preferred position,
        at least for the primipara, is the lateral.
      Frequency of Examination :
          As infrequent as will permit a proper knowledge of
        the progress of labor (j4 to I hour).
      Anesthetics.
            Chloroform,  plain  or amylized  (amyl. nitrit. i
        drachm to  chloroform I  pint), the preferred anaes-
        thetic  in natural labor.
            May be used in all cases  for a part or all ofthe
        second stage, during the pains only.
            Quantity, five to twenty drops at the beginning
        of each pain,—not enough to abolish consciousness,
        except at the perineal stage; then nearly or quite to
       the surgical degree.
        Method:
            Head low and clothing loose.
            Examine the heart.
            Remove false teeth.
            Smear the nose and lips with vaseline or glycerine.
            Inhaler, a towel spread over the head and  lifted
       at its middle several inches from the face. 
Labor.
83
      Drop the chloroform  on the upper  side of the
  towel.
      Remove the towel in  the intervals between the
  pains.
      Give freely at the moment of expulsion.
Protection of the Cervix.
      Avoid much manipulation of the cervix.  It in-
  vites sepsis.
      Regulate the expelling forces in over-rapid labor
  to prevent tears.
      Regulation  ofthe expelling forces.
          Mainly by regulating the abdominal pressure.
          Chloroform may accelerate, retard or arrest
      expulsion according to the freedom of dosage.
Protection of the Perineum.
      Retard  the  expulsion of the  head for a half hour
  or more, keeping the pelvic floor continuously on the
  stretch  by preventing the recession  of the  head in
  the intervals between the  pains.   Retard by holding
  the head  back  and by regulating the driving forces
  with chloroform.
      Deliver the head  by its smallest circumference.
  Regulate  extension.
      Press the head well up in the subpubic arch as
  the forehead is about to escape.
      Preliminary relaxation of the pelvic  floor by the
  finger is sometimes permissible.
  Episiotomy.
      When extensive laceration is otherwise inevitable,
  incise the resisting ring at the vulvar outlet, bilaterally.
      Cut during  a pain.
      Pass  a narrow blunt-pointed bistoury flatwise
  between the head and the resisting girdle.
      Turn the  edge outward and cut horizontally,
  avoiding the skin.
      Location of incisions, 1 inch from the median line
  posteriorly, when the parts are fully stretched. 
84
Labor.
            Length of incision ^ inch.
            Depth of incision % inch.
            Suture the incisions after labor.
        Management of  the Cord.  If wound  about the neck,
        slip it down over the head.  If this is impracticable,
        cut it and deliver the trunk promptly.
        Delivery ofthe Trunk. Deliver the posterior shoulder
        first by lifting it  over the perineum.
            Extract the  trunk slowly or leave to nature.
        Ligation of the  Cord.  In  general, wait till  notable
        pulsation  ceases at a distance of 6 inches from the
        umbilicus.
            Tie firmly with aseptic narrow linen bobbin, \y2
        inches from'the  umbilicus.
            Place a second ligature a few inches farther away.
            Cut between the ligatures, near the  first,  with
        clean scissors.
            Thick cords should be stripped before tying.
Management of the Placental Stage.
          From the moment the head is born, keep the hand
        on the abdomen over the anterior surface ofthe uterus
        till evacuation and retraction are complete.
          Use only enough gentle friction to provoke normal
        contractions.
      Crede's  Method.
          After three  or four pains supplement the contrac-
        tion,  at  the acme  only,  by  manual  compression,
        through  the abdominal wall, the hand grasping the
        fundus, thumb in front, fingers behind.
          Repeat this manipulation with each pain.
          Don't pull the cord to assist delivery.
          Crede failing after an hour, deliver by hand in vagina.
          On expulsion  of the placenta twist the membranes
        into a rope till detached.
          Examine the Placenta and Membranes to make  sure
        they are complete.
          Examine the  Perineum and the  whole  vulvo-
        vaginal orifice for lacerations, 
Labor.
85
Repair of Perineal Injuries.
    Notable  lacerations  of the vagina  or its  orifice
  should be immediately sutured.
    The perineal  suture  should reunite all  the sun-
  dered structures ofthe perineal body.
    Partial ruptures  may be sutured  on the mucous
  or skin surface or both.
    Complete ruptures on the rectal, the vaginal and
  the skin surfaces.
    Whether from the vaginal or skin surface, all deep
  sutures should  compass  a large  mass of tissues on
  either side of the tear  so that their  loops when tied
  shall be nearly circular.
    Sweep  the  needle deeply  through one  lip of the
  wound, carry  it across just above the  bottom of the
  tear, and  pass it deeply through the other lip.
    The ends of the torn  sphincter  ani should be
  brought together with two or three special sutures.
    Sterilized and waxed silk sutures  best answer the
  purpose; aseptic catgut maybe used for buried sutures.
 Watch  the  Uterus for half  to one  hour, using  gentle
  friction if required.
 Instruct the Nurse  to bathe, with the mercuric iodide
  or chloride solution, the  external genitals and soiled
  portions ofthe patient's body, and to change her linen
  and bed linen if soiled.
 The Lochial Guard must be aseptic, still  better antiseptic.
 The Abdominal Binder  (of unbleached muslin) should
   reach from  the ensiform  to a point below the tro-
  chanters;  may be  moderately tight for  the first 12
  hours, subsequently looser.
 Child's Bath.
     The  face should be washed on birth of  the head;
  the eyes should be cleansed with the mercurial solu-
  tion and well dried, as a prophylactic against ophthal-
   mia neonatorum.
     Smearing the body with sweet-oil or vaseline facili-
  tates the removal of the vernix caseosa. 
86
Labor.
    During  the  bath all  but  the  face  should be kept
  submerged in water at 950 F.
    Feeble  infants  should  not be bathed for  several
  hours or days.   Rub  daily with sweet-oil or vaseline
  instead.
    Carefully avoid chilling.
Envelope the Umbilical Stump in salicylated cotton, and
  hold the dressing in place by a loose  belly-band.
The Condition of the Mother, including the pulse-rate
  and amount of flow, should be noted before leaving.
Instruct the  Nurse with  reference to sleep, diet, evacu-
  ation ofthe bladder, nursing the child, etc. 
PUERPERIUM.
87
                    PUERPERIUM.
Puerperal State.
      Elements of Septic Danger :
        Obstetric wounds of the
          Uterine cavity,
          Cervix,
          Vagina,
          Vulva,—avenues for septic absorption;
        Contusions,—diminished resisting power of the tissues;
        Dead animal fluids,—supplying the soil for the growth
        and multiplication of micro-organisms;
        Enlarged lymphatics and veins,—channels  for  diffu-
        sion;
        Resorption activity ofthe utero-vaginal tract;
        Exhaustion  of the patient,—lowering the  resisting
        power.
      Clinical Course and Phenomena.
          Post-partum rigor.
          Pulse-rate diminished (40 to 64),
          Temperature.
          The  physiological  upper limit,  first four or five
        days, 99^°; later, 990, F.
          Constipation.
          Retention of urine (ischuria),  from lowered intra-
        abdominal pressure and other causes.
          Glycosuria from  resorption of lactose,—for the first
        few days.
      Condition of the Uterus.
        Upper segment, thick and firmly retracted;
        Lower  segment, thin and flaccid for about 12 hours;
        thereafter gradually  regains its shape and muscular
        tone.
        Cavity:
          Inner layer of the  decidua remains to be gradually
        shed during the lochial flow; 
PUERPERIUM.
    Fragments ofthe outer,—superficial,—layer are also
  retained  to  be  detached and discharged  with  the
  lochia;
    Placental  site prominent  and studded  with small
  blood clots.
Involution.                    *
  Definition:  The  retrograde  changes by which  the
  hypertrophied structures, especially of the uterus, are
  restored  to  the non-gravid  condition normal to the
  healthy parous woman.
    It comprises fatty degeneration, absorption and
  also, to a certain extent, reconstruction.
    The endometrium is completely renewed.
  Uterus; Rate of Progress:
  Size:
    At the close of labor, 4 or 5 by 7 or 8 inches;
    Walls, 1 to \\ inches thick;
    Depth  of the cavity, 6 inches, about.
    After complete involution, the thickness, width and
  length are respectively 1, 2  and 3 inches.
    Remains permanently  larger than the virgin uterus.
  Situation ofthe Fundus:
    Immediately after labor, midway between the um-
  bilicus and  the pubes.  A few hours later, near the
  umbilicus.
    Tenth  day, at the level ofthe brim.
    The situation  of the  uterus is modified  by the
  fulness of the bladder and rectum.  It is usually dex-
  tro-verted and anteflexed.
  Weight:
    Approximate weight at close of labor, 30 ounces.
    Approximate weight end  1st week, 20 ounces.
    Approximate weight end  2nd week, 10 ounces.
    Approximate weight end  3rd week, 5 ounces.
    After involution,  10  to 13 drachms,—\y2  ounces
  nearly.
  Duration of Involution:
    Six to  eight weeks or more; 
PUERPERIUM.
89
    Longer  in non-nursing women, after twin  births,
  premature  labor,  much  hemorrhage,  retention  of
  secundines, than in other cases.
  Cervix:
    Expanded and flaccid below the contraction ring
  for 12 hours, and 2^ inches long;
    Cervix then gradually re-formed.
    Os internum then admits two fingers.
    Os externum admits  one finger after 7 to 14 days.
    Involution  goes on  pari passu with that  of the
  upper segment of the uterus.
    Lower border permanently  more or  less notched
  in parous women.
  Vagina: Walls hypertrophied and relaxed after labor;
    Involution progresses with that ofthe  uterus;
    Restoration is not complete.
Uterine Ligaments also  undergo involution.
After-Pains:  The periodical uterine contractions of
  pregnancy and labor  continue  for a  few hours or
  days post-partum;
    Frequently more or less painful in multiparas;
    Usually not so in primiparae;
    They accomplish  and  maintain retraction  of the
  uterus.
Lochia:  The genital discharge following  labor.
  Character:
    More or less  bloody for about 4 or 5  days,—lochia
  rubra; containing  shreds of decidua, membranes and
  placental tissue;
    Then sero-sanguinolent,—lochia serosa,—for 2 or 3
  days;
    Finally creamy,—lochia alba,—and  containing fat
  granules, epithelial cells, leucocytes and cholesterine.
    Reaction alkaline for a week or more, then  neutral
  or acid.
  Amount:   Total amount, about 3^ lbs.
  Duration:  Two to four weeks. 
90
PUERPERIUM.
Management of the Puerperal State.
    Frequency and Number of Visits :
          Once or twice daily for the first three days;
          Once daily thereafter till the seventh;
          Occasional visits during the balance ofthe month.
    Observations  at the First Visit:
          Have all instructions been  observed ?
          General condition  ofthe mother;
          Pulse and temperature;
          Sleep;
          Diet;
          Micturition;
          Lochia;
          Examination of the uterus for size, firmness, ten-
        derness;
          Condition ofthe child;
            Has it passed water?
            Have the bowels moved?
            Temperature, per rectum.
    At Subsequent Visits:
          Pulse and temperature;
          Abdominal examination of the uterus and append-
        ages at each visit;
          Condition ofthe breasts and nipples;
          Examination of the pelvic  organs, per  vaginam,
        once  or  more   during  the  third  or fourth week.
        The case should  not be wholly dismissed till involu-
        tion is complete, and the pelvic organs  are restored
        to their normal non-gravid state.
          Condition ofthe child at each visit.
    Duration of the Lying-in Period.
          First week, in bed.
          Second week, recumbent posture  on  the bed or
        lounge;  may sit erect in bed for  evacuation of the
        bladder or bowels, and during meals.
          Third  week, the chair all or part of the day.
          Fourth week, may have the  liberty ofthe room.
          May leave the room at the end ofthe month. 
PUERPERIUM.
91
General Regimen.
      The bladder should be evacuated  once in six or
    eight hours.
      The bowels  should be opened by a warm enema
    on the third day, once daily thereafter.
      Water 1 pint, or clear glycerine  1 or  2  drachms,
    may be used for the enema.
      Promote rest and  sleep;  they are important  re-
    storatives.
       After-pains  may   be  relieved,  if necessary,  by
    phenacetin, gr. v hourly till two or three  doses  are
    given, or by opium, gr.y to gr. 1.
       Involution of the uterus, if tardy, may be promoted
    by gentle friction, hand on the abdomen ;—galvan-
    ism, ten to twenty milliamperes, one electrode  over
    upper part of sacrum, one  upon the abdomen  over
    the uterus,—sitting ten minutes twice daily;—Faradism
    in like  manner;—ext. ergot, g. 1, t. i. d.;  hot douche,
    —two or three gallons,—temp. 115° F., once or twice
    daily.
 Antiseptic Measures.
       Rigid cleanliness is of first importance.
       Avoidance of infection is better than disinfection.
       The  lochial guard  should  be aseptic  and  must
     be frequently changed,—every three to six hours.
       The external genitals should be cleansed with an
     antiseptic solution on changing the dressing.
       Vaginal or uterine douche only for cause.
       Permit no fetor.
 Use of Catheter, when  unavoidable, should conform to the
     following rules:
       Instrument, soft rubber.
       Precautions: Instrument and approaches must be
     aseptic.   Boil the catheter for 15 minutes immediately
     before using.
       Method:  Let  the patient  or an assistant retract
     the labia, fully exposing the meatus to view.
       Carefully cleanse  the approaches. 
92
PUERPERIUM.
      Introduce the catheter \l/i to 2 inches.
      Repeat every eight hours.
Dietetics.   A  light  diet,  chiefly liquid,  for the first day
    or more till the patient has rallied from the exhaust-
    ion of labor and the  effects  of the anaesthetic; e.g.,
    milk, beef juice, gruels, dropped eggs, dry toast and
    weak tea.
      A fairly liberal diet after the first one or two days.
Lactation and Nursing.
      The true  milk secretion generally begins on the
    third day in primiparae, the second in  multiparas.
      Colostrum is the  thin,  somewhat  viscid fluid fur-
    nished by the mammary glands of the  puerpera  before
    the true milk  secretion is established.  It contains
    fat globules and has moderate laxative properties.
      Contra-Indications to Suckling the Infant.—Among
    the  conditions  which  prohibit  nursing are   recent
    syphilis, phthisis, poor quality or very deficient quan-
    tity of milk, pregnancy.
  Signs of Deficient Lactation.
      Flabby breasts;
      Child not satisfied and showing signs of inanition.
      Weigh it weekly.
    Treatment.   Generous  diet,  milk,  tonics  and  good
    hygiene.
  Nursing.
      Put the child to the breast once in four hours till
    the milk  secretion is established, then  once in two
    hours.
      Gradually increase the  interval to three hours by
    the end of the third month.
      Double one interval in the night.
      Regularity of intervals is imperative.
  Care of Breasts and Nipples.
      Avoid  maceration  of  the nipples  by  excessive
    nursing. 
The Child.
93
          Cleanse  the  nipples after each nursing,  best with
        a weak antiseptic solution,—e. g., a saturated solution
        of salicylic acid in water.
          Gentle  massage  is permissible in  case  of  simple
        milk engorgement.
      Weaning.
          The child should  be weaned, as a rule, when  it
        has eight teeth—usuall)' about the twelfth month;—
        not, however, during the summer months.


                       The Child.
Condition at Birth.
      Weight.—7 to 73^ pounds ;  males averaging more than
        females,—first, less than subsequent births.
      Measurements:
          Length, 18 to 20 inches.
          Other measurements, see pages 71, 72.
      Skin:
          More or less thickly covered with  vernix caseosa,
        which consists of fatty matter,  epidermic  cells and
        sebaceous material.
          Epidermic layer exfoliates in  first few days, leaving
        the skin red and irritable.
      Meconium:
          Consists of intestinal secretions and bile together
        with  lanugo  and epidermic scales derived from swal-
        lowed liquor amnii.
      Circulation:
          The ductus arteriosus, ductus venosus,  and the um-
        bilical veins become obliterated  in a few  days, the
        foramen ovale  generally closing within a  few weeks.
           Pulse-rate, 120 to 140.
      Respiration:
          The lungs are collapsed and  the entire respiratory
        tract is devoid of air till the first respiratory effort.
          The air tract may contain vaginal blood and mucus
        from premature efforts at inspiration. 
94
THE Child.
          The first respiratory movement is due chiefly to the
        reflex effect of exposing the moist surface of the body
        to the air.
      Genito-Urinary Organs:
          The bladder generally contains urine.
          The testicles have both descended into the scrotum.
          The preputial  orifice is too small to permit retrac-
        tion ofthe prepuce over the glans during infancy.
      Special Senses:
          Sensibility ofthe skin is feeble  at birth, fully estab-
        lished during the first one or two  days.
          Taste;—sensitive to strong tastes only.
          Sound;—the child is deaf at birth, since the outer
        ear is  closed and  the middle ear  is  devoid  of air.
        Loud  sounds are audible within  a  few hours, or one
        or two days.
          Sight;—the eye is sensitive to light.
Management.
      Respiration.
          To expand the lungs,  provoke deep inspirations by
        blowing upon the face,  by dashing  a few drops of
        cold water upon  the chest, or by flagellation.
      Treatment of Apnoea.
      Direct Insufflation:
          Child upon its  back.
          Partial extension of the head by a fold of  blanket
        under the neck.
          Cleanse the face and cover with a clean towel.
          Prevent inflation of the stomach by pressure ofthe
        hand upon the epigastrium.
          With  the  intervention of the  towel,  expand the
        lungs gently by mouth-to-mouth insufflation.
          Repeat twenty times per minute.
      Sylvester s Method:
          Child supine.
          Draw the arms well above the head for inspiration;
          Place them by the sides and compress the  thorax
        for expiration; 
The Child.
95
 Sckultze's Method:
     Suspend the child by the shoulders, face from the
   operator,  feet down, placing the thumb in front  and
   fingers over the posterior aspect ofthe shoulders with
   the index fingers hooked  in the axillas,—inspiration.
     Relax the pressure ofthe thumb to assist inspiration.
     Invert the position by swinging the trunk and lower
   limbs upward and toward the  face of the operator,
   flexing the trunk in the lumbar region,—expiration.
 Byrd's Method:
     Hold  the child  supine upon  the two hands of the
   operator, at right angles to the fore-arms.
     Tilt the  hands by lowering their radial borders,—
   inspiration.
     Tilt the  hands by raising the radial borders,—ex-
   piration.
 Faradism of the Phrenic Nerve:
     Place  one pole of a  Faradic battery over the phre-
   nic nerve near the sterno-cleido mastoid muscle.
     Place the other pole momentarily over the  region
   of  the diaphragm, or indifferently, repeating  the
   application at intervals of a few  seconds.
     Avoid over-stimulation.
 Auxiliary Measures:
     Remove the mucus from the throat  with the finger
   and a wet  soft linen, or by aspiration with a soft rub-
   ber catheter.
     If the child is pale and collapsed, give a rectal in-
  jection of water at I05P to  uo° F.
    Maintain bodily warmth by immersion  in water at
  95° F.
    Artificial heat is generally required to maintain the
   normal  bodily temperature, especially in case  of
  feeble infants.  An incubator best answers the pur-
  pose  when  heat must  be supplied for many days or
  weeks.
Bathing.  Should be practised by immersion  in water at
  95°F- 
96                     The Child.

          Repeat  daily,  oftener for  parts  soiled  by  dis-
        charges.
          Should  be  postponed several hours or days in case
        of puny children.   Rubbing daily with sweet-oil or
        vaseline may be substituted.

      Navel Dressing.  Dress the stump of the navel cord with
        absorbent cotton impregnated with salicylic acid or
        oxide of zinc;—turn to the  left side, and retain by a
        loose abdominal binder.

      Nursing.   Apply the child to the breast after the mother
        has recovered from the shock of labor.
          Repeat every four hours till the secretion of milk
        is established, then once in two  hours.   Double one
        interval at night.
          Lengthen the intervals to three hours by the age of
        three months.
          Usually one or more artificial feedings  daily will be
        required after the seventh or eighth month.
          The child should be weaned, as a rule,  after cutting
        eight teeth, except when that period falls in the hot
        months.

       Wet-Nursing.  Best substitute for maternal nursing.
           Choice of nurse:
           Should be of mature age, below thirty-five.
           Multipara  preferred.
           Her child ought to be of the same age  as that to be
         nursed within one or two months.
           A menstruating woman is generally unsuitable,—a
         pregnant one always.
           Sound  health is indispensable.
           Examine  especially for  phthisis,  syphilis and all
         contagious diseases.
           Examine the nurse's child to learn  whether it has
         been well nourished.
           The breasts should be well developed, with promi-
          nent veins and well-formed and healthy  nipples. 
The  Child.
97
                       Artificial Feeding.
First Six Months.
       Milk Mixture!*
            Cow's milk,—mixed dairy milk,        10  ounces.
            Water, previously boiled,                5
            Milk sugar,                              5 drachms.
            Common salt,                            8 grains.t
            Lime-water,—just before  feeding,—    I  ounce.
            Mix.
       Meigs' Mixture. %
            Cow's milk,—mixed dairy milk,          2 ounces. §
            Cream, containing 20% of fat,            3   "      II
            Water, previously boiled,               io   "
            Milk sugar  (recrystallized and perfectly pure), 6^
                                                       drachms.
            Lime-water,—just before  feeding,—     i ounce.
            Mix.
            Either of these mixtures should be prepared, bottled
         and sterilized soon after the milk is delivered.
       Sterilize  as Follows:  Fill  ten  clean  bottlesl to  the
         shoulders, each holding enough for one feeding.
            Plug the mouths  with rubber  stoppers.   They may
         be had, specially made for  the  purpose, at  the drug-
         gists'.  Place them loosely  in  the necks of the bot-
         tles for the  first ten   minutes  of the  boiling,  then
         push  them in firmly and continue the boiling for ten
         minutes longer.
    * This for a child one month old.
    During the first two or three weeks the strength may be equal parts of milk and
water or even weaker.   After the eighth or tenth month the  strength may be gradu-
ally increased to whole milk  at the twelfth.  If hard curds are vomited or passed
undigested in the stools, increase the proportion of water.
    + Have powders,  each containing 5 drachms of milk sugar and eight grains of
salt prepared by your druggist, or use for the  sugar a  measure made to hold one
drachm, and add salt to taste.
    t As modified by Rotch.  Closely resembles  human milk.
    * Use a measuring glass to be had at the drug stores.
    \\ Best, that obtained by the centrifugal machine, since it may be had fresh.
    f Or as many as the number of daily feedings. 
98
The  Child.
       Stand  the bottles  in  a  kettle  and cover to  the
     shoulders with cold water.  Boil twenty minutes*
       Keep on ice in hot weather.
  Feeding:  Warm the bottle to ioo° F.  before feeding,
     then remove the  stopper, add  half a teaspoonful of
     lime-water for each ounce of  the prepared milk.t  and
     slip a clean  rubber nipple over the neck of the bottle.
       Let the child nurse  directly from the sterilizing bot-
     tle.
       Cleanse the  nipple  inside and out after each feed-
     ing, and  the bottle in  like manner.
       Boil the nipple  for ten  minutes  before using,  and
     the bottles before refilling.
Amount and Frequency: Rules for General Guidance.
	INTERVALS	AMOUNT AT	NUMBER	AVERAGE
AGE.	OF	EACH	OF DAILY	DAILY
	FEEDING. %	FEEDING. §	FEEDINGS.	AMOUNT.
First day.	2 hours.	i drachm.	IO	io drachms.
Second day.	2 hours.	\ ounce.	IO	5 ounces.
Third day.	2 hours.	i ounce.	IO	io ounces.
Second week.	2 hours.	2 ounces.	IO	20 ounces.
Six weeks.	2\ hours.	3 ounces.	8	24 ounces.
Three months.	3 hours.	5 ounces.	6	30 ounces.
Six months.	3 hours.	8 ounces.	6	40 ounces.
           Small and feeble children require to be fed  more
         frequently and  in smaller quantities, large and robust
         children less frequently and  in larger quantities than
         the foregoing table  prescribes.   The daily allowance
         required must be determined  for the individual case by
         trial.

   * Or, better, steam the bottles for thirty minutes, in a steam sterilizing apparatus
to be obtained at the drug stores.
   Cow's milk, to be had in its best state, must be  sterilized at the dairy immediately
after milking, and served in the sterilizing cans or bottles.
   f The addition of lime-water (or of baking soda, half a grain to each ounce of
prepared milk) is essential,  since cow's milk is acid, human milk alkaline.
   X Double one interval in the night
   § By measuring glass. 
The Child.
99
          Take the child's weight once a week as a guide to
        the feeding.   A  well  nourished child gains about 5
        ounces weekly during the first five months.
      Peptonized Milk:   Sometimes useful as a  temporary
        expedient when simple sterilizing fails.
          Peptonize the contents of each bottle  immediately
        before feeding, as  follows: For each ounce  of the
        sterilized mixture add extractof pancreas (Fairchild's),
        one-ninth grain, bicarbonate  of sodium,  one-third
        grain, and shake till dissolved.  Stand the bottle in
        water at the temperature of 1050 F. for fifteen minutes.
        If the milk becomes too bitter, reduce  the time to
        ten or even five minutes.
Six to Twelve Months,  Once in  3 to 3^2 hours; 5 or 6 feedings daily.
          Some farinaceous material may,  in most cases, be
        added to the  food, as follows:
      Bread Jelly:  Soak  four ounces  of  stale  wheat  meal
        (Graham)  bread  in cold  water  for six  or  eight
        hours.  Then squeeze  the  water out of it.  Boil the
        pulp for one and a half hours in enough fresh water
        to make a thick gruel.   Rub through a fine sieve and
        allow to stand.   Mix,  while  fresh, one part of the
        jelly thus formed with eight of the milk or cream mixt-
        ure before sterilizing.
      Barley  or Oatmeal Gruel; Boil  for at  least  half an
        hour  a tablespoonful  of barley or oatmeal  in one
        pint  of water.   Occasionally  add water  to  main-
        tain the original  pint.   Strain and add salt to taste.
        Make fresh daily.  Combine with the  milk  or  cream
        mixture, in the proportion of one part of the gruel to
        four of  the mixture, before sterilizing.
          Barley gruel is better if there be looseness of the
        bowels, oatmeal in  case of constipation.
          Undiluted cow's milk mixed, in the proportions given,
        with any of the above-named farinaceous preparations
        is frequently well borne by healthy children after nine
        or ten  months.   The  quantity  of food required will
        be less  in proportion as the strength is increased. 
TOO
The Child.
 Twelve to Eighteen Months.   Four or five feedings daily.
           Whole milk, sterilized, with barley or oatmeal gruel
         or bread jelly in the proportions above given.
           Two or three  ounces of raw beef juice, moderately
         seasoned, may be  given daily,  either mixed with the
         milk or separately.  It should  be prepared at least
         twice a day.
           The  simpler  kinds  of food  requiring  mastication
         may be added  after the child   has  sixteen teeth-
         such as oatmeal and  milk,  or  wheaten  grits,—well
         cooked,—or stale bread and milk.
           Scraped beef  or soft-boiled eggs may be allowed
         two or three times weekly.
 Eighteen  Months to Two Years.  Four or five feedings daily.
           If the child is hearty, a little fine cut meat may be
         given with the midday meal, such as tender beef, lamb
         or chicken.  This, however, is not essential.
           Milk should  be the  basis of the feeding till  the
         child has all its teeth, and  may constitute a part of
         it for several years longer.   Milk, beef juice and  the
         farinaceous preparations above  mentioned  afford a
         sufficient dietary for the entire period of infancy.
           Proprietary foods for  infants  are not to be recom-
         mended.*

 Disorders of the New-Born Infant.—Treatment.
       Constipation.  Manna gr.  xx;  phosphate of sodium, gr.
         xx;  podophyllin, gr. sSs, in aq. anis.; glycerine or soap
         suppository; warm water enema, \% ounces.
       Icterus Neonatorum.  The icterode hue of the  new-
         born is usually not true jaundice.  It is generally due
         to changes in the blood  incident to lack of nutriment
         during the  first  few days, and  disappears within a
         week.
           True  icterus  may  occur from hepatic injuries or
         other causes.
   * For further suggestions in the matter of infant dietary, see  Hygiene of the
Nursery, Louis M. Starr, M. D. 
The Child.
ioi
Intestinal Colic.   Chloral  i  gr. in Aq. i  drachm, once
  to three times daily, p. r. n.
Umbilical  Hemorrhage.  In  bad  cases, transfix  um-
  bilicus with a hare-lip pin and  apply figure-of-eight
  ligature.
    Frequently depends on obstructive causes and blood
  changes that make treatment futile.
Intertrigo.   Oxide of zinc and  lycopodium,  equal parts,
  dusted upon the parts, p. r. n.
Thrush.  For destruction of the  parasite, use locally a
  solution of sulphite of sodium, drachm to the  ounce,
  or peroxide of hydrogen, every 2 hours till the patches
  disappear.
    For the stomatitis which remains after the destruc-
  tion of the  patches, a half-saturated solution of  potas-
  sic chlorate used every 2 hours as a mouth-wash.
Ophthalmia Neonatorum.
  Prophylaxis.  Thoroughly cleanse the  eyes on birth
  of the head, apply one of the mercurial  solutions for a
  few minutes, and dry carefully.
    The instillation  of an aqueous solution of argent.
  nitrat., 10 grains to the ounce, may be used instead of
  the mercurial.
  Curative Treatment.  Cleanse thoroughly every  two
  hours.
    Apply twice  daily, argent, nitrat.,  gr. x-xx  in aq.
  dest. 1 ounce, immediately after cleansing.
    Lubricate the edges  of the  lids with  vaseline to
  prevent gumming  together, and consequent retention
  of pus.
Cephalhaematoma.   If the tumor grows, shave the head
  and strap the tumor firmly.
Tumefaction  ofthe Breasts.   No treatment required. 
102
Pathology of Labor.
             PATHOLOGY OF  LABOR.

   Abnormal Labor : Anomalies of the Mechanism.

Classification of Abnormal Labor.
    Anomalies of
        Powers;
          Excess;
          Deficiency;
        Passages;
        Passenger.

Anomalies ofthe  Expelling Powers.
Excess:—Precipitate Labor.
      Causes:
          Violent uterine contractions;
          Diminished resistance.
      Dangers;
          For the most part, unimportant.
          Chiefly lacerations and post-partum hemorrhage.
      Treatment.
          Moderate  the expelling forces by withholding the
        abdominal pressure, and by  chloroform.
Deficiency:—Prolonged Labor.
    Prolonged First Stage:  Tardy Dilatation.
      Causes ;
         i. Pains feeble,—inertia  uteri,—from
            Anything that lowers  the  muscular or nervous
            tone.
            Full bladder or rectum;
            Emotional causes.
         2. Pains cramp-like, but powerless. 
Pathology  of Labor,
103
      i. Primarily,—from neurotic causes.
      ii. Secondarily from
        a. Excessive uterine distention;
        b. Uterine obliquity;
        c. Adhesion of membranes  to the  lower uterine
            segment;
        d. Dry labor.
  Dangers;
  Inertia Uteri:
      None  if the patient  can have sufficient  sleep and
    nourishment.
  Cramp-like Pains:
      Danger of exhaustion in proportion to the severity
    of the pain.
      Danger from pressure effects  in dry  labor in case
    of both mother and child, and from septic fluids.
      Exhaustion predisposes to prolonged  second  stage.
  Treatment of Inertia  Uteri.
      Quiniae sulphat.  gr. x;
      Empty the bladder and rectum.
      Remove  the causes.
      Faradic current  from upper sacral region to poste-
    rior vaginal fornix. In the absence of danger to mother
    or child,  leave to nature.
  Treatment of Cramp-like, but Ineffectual Pains.
      1. Opium,  1 grain,—not repeated.
      Chloral, 1 drachm in  three doses at intervals of 15
    minutes.
      2. a. Rupture the membranes.
      b.  Correct the malposition by posture,  binder,  or
    manual support.
      c. Peel up the membranes.
      d.  Manual dilatation.

Prolonged Second Stage.
  Causes;
      Exhausted nerve force.
      Excessive uterine retraction. 
104
Pathology  of Labor.
      Dangers;
          Mother,—Exhaustion, pressure effects, sepsis.
          Child,—Chiefly pressure effects.
      Treatment.
          Eliminate obstructive causes.
          Evacuate the bladder and rectum.
          Summon the aid ofthe abdominal muscles.
          Expressio foetus.
          Quinias sulphat., gr. x.
          Hot fomentations  to  the  hypogastrium, or  the
        sacral region.
          Semi-recumbent posture.
          Ahlfeld's birth-stool.
          Forbid ergot.
          Forceps are  indicated when  longer delay  would
        be dangerous to mother or child.

Anomalies of the Passages.

1. Anomalies ofthe Hard Parts: Deformed Pelvis.
      Mortality:
          Maternal, doubled.
          Fcetal, much greater than the maternal.
      Dangers:
          Those of prolonged labor intensified;
          Malpresentation and malposition more  frequent;
          Certain complications,
              Prolapsus funis;
              Rupture ofthe uterus;
              Post-partum hemorrhage, etc.
          The minor degrees of deformity are dangerous  for
        the most part to the child only, and are generally
        capable of successful management by early recogni-
        tion and timely interference.
      Frequency:
          The higher grades of deformity are rare.
          Slight degrees of contraction are by no means so. 
Pathology of Labor.
105
     General Character of the Anomaly :
          Rarely the  abnormity consists in faulty inclination
        only.
          In the majority  of narrow pelves the contraction
        is at the brim, and is most frequently an antero-pos-
        terior flattening.
          Obstruction  may arise from  fractures,  exostoses
        or bony tumors.
Commoner Forms of Narrow Pelvis.
     Flattened Pelvis.
        a.  Non-rachitic;
          The commonest variety of contraction.
          The conjugate rarely falls below 3 inches.
        b.  Rachitic.
          Contracted at the brim;
          Widened at the outlet;
          Ilio-spinal and ilio-cristal diameters  nearly equal.
        Mechanism of labor in flat pelvis.
          The head passes the brim with  its long (occipito-
        frontal) diameter in the transverse of the pelvis, and
        with the sagittal suture level.
     Flattened and Generally Contracted Pelvis.
        a.  Non-rachitic;—The  more common ofthe two;
        b. Rachitic.
     Jnsto-Minor Pelvis : Pelvis ^Equabiliter Justo-Minor.
           Rarest ofthe commoner forms.
           A generally contracted pelvis.
           Relations not in all cases precisely normal.
          Its size bears no relation to the size of the body.
           The  deformity  is due  to arrest  of  development
        from rachitis, scrofula or hard labor in childhood.
Rarer Forms of Narrow Pelvis.
     Funnel-Shaped Pelvis: Male Pelvis.
           Tubera ischiorum approximated.
           Subpubic angle narrow.
           Causes of the deformity,  arrest  of development of
        the  lateral masses  of  the sacrum  and co-operating
        causes. 
Pathology  of Labor.
Kyphotic Pelvis.
     Upper end ofthe sacrum tilted backward.
     Transverse diameter narrowed at the brim.
     Somewhat funnel-shaped.
     Pubic arch narrow.
     Cause, kyphosis in the lumbo-sacral region.
Naegele Oblique Pelvis: Anchylosed Obliquely Contracted Pelvis.
     Contraction in the oblique  diameter from the ace-
   tabulum ofthe  anchylosed side.
     Distance from promontory to acetabulum, and from
   tip  of sacrum to spine of the  ischium, diminished on
   the affected side.
     Walls of the pelvic cavity converge below.
     Pubic arch narrow.
     Cause  of the deformity, anchylosis  of one sacro-
   iliac joint.
Ordinary Oblique-Ovate Pelvis.
     Shape similar to that of the  Nasgele.
     Causes:
        Lateral spinal curvature,—scoliosis.
        Impeded function of one lower extremity from
         Hip disease, or
         Amputation or old dislocation of the femur on
        the dorsum ilii.
         Weight of the body thus  falls  on one  lateral
        half of the pelvis.
Roberts' Pelvis.
     Anchylosed and transversely contracted pelvis.
     Very rare.
     Linear ilio-pectineae approximated.
     Subpubic angle narrow.
     Ischial  spines and  tuberosities in close  proximity
   to each other, and to the margin ofthe sacrum.
     Cause,  arrested  development of  the sacrum and
   sacro-iliac anchylosis of both sides.
Spondylolisthetic Pelvis.
     Very rare.
     Conjugate shortened. 
Pathology  of Labor.
107
          Lower end of sacrum tilted forward.
          Cause, gliding  forward of  the  last lumbar on  the
        first sacral vertebra.
     Osteomalacic Pelvis.
          Promontory approximates the pubes  and the tip
        of the sacrum.
          A prominence opposite each acetabulum.
          Brim pointed anteriorly.
          Subpubic arch nearly or quite obliterated.
          Tuberosities approximated.
          Anterior-superior spines ofthe ilia approximated.
Diagnosis of Pelvic Deformity.
      History:
          Rachitis, as indicated  by  tardy dentition, sweats,
         pigeon breast, curvature  of tibiae or spine, large joints;
          Very low stature;
          Deformities in near relatives ;
          Previous labors.
      Mensuration: Often the only means of diagnosis.
        Method :
          Patient on a hard  table,  in dorsal decubitus, legs
        and thighs partly flexed.
          Schultze's pelvimeter.
        External Measurements.
          Vide p. 65.
          External conjugate,—7 inches average lower limit
        in normal pelvis.
          Ilio-spinal and ilio-cristal both small indicates gen-
         eral  contraction.
          Ilio-spinal equal to or greater than the ilio-cristal,
         flattening.
         Internal Measurements.
         Method :
          Empty the bladder and rectum.
          The hand  is the best pelvimeter for  internal  meas-
         urements.
           Note
           Depth of the symphysis pubis; 
io8
Pathology of Labor.
           Width ofthe subpubic angle ;
           Size and shape ofthe sacrum ;
           Bis-ischial diameter;
           Diagonal conjugate,—as follows :
             Passing the index and second fingers into the vag-
           ina, place the  outer edge of the tip of the second
           finger against the summit ofthe promontory, radial
           edge of the hand against  the subpubic ligament;
             Measure the distance between the points of contact.
           Find true  conjugate  by deducting  one-half  to
        three-quarters of an inch, according  to the depth and
        inclination ofthe symphysis pubis, from length ofthe
        diagonal.
           Note the other  diameters  at the brim,—hand in the
        vagina.
Management of Labor in Narrow Pelvis, Especially Flat Pelvis.
  Conjugate $% inches or more:
        Nature.  Spontaneous delivery of a living  child is
           possible in the majority of cases.
        Alternatives:
           Forceps,—Tarnier ;
          Version (podalic).
  Conjugate 2^ to 3^ inches :
        Premature labor;
        Version (podalic);
        Craniotomy or Version,  if child is dead.
  Conjugate 2y2 to 25^ inches:
        Caesarean  section if all conditions are favorable and
          the mother so elects.  Otherwise,
        Craniotomy.
  Conjugate 2y2 inches or  less :
        Caesarean section, or in certain cases, the
          Porro operation.  See " Porro Operation."
II. Anomalies ofthe Soft Parts.
  Atresias:
      Pudendal:
          Inflammatory adhesions of the  labia majora.
          CEdema vulvae. 
            Pathology  of Labor.               109

    Thrombus.
    Cancer.
    Simple rigidity.
    Rigid hymen.
   Treatment.
    Thrombus ;—Rarely requires incision, evacuation of
    the clots and styptic packing.
    Rigid Hymen ;—Single or multiple incisions.
    Other  Forms of Rigidity.
       Forceps.
       Episiotomy, when delivery without notable lacera-
    tion is otherwise impossible.
 Vaginal:
  Congenital:
    Annular stricture.
    Narrowness throughout.
  Acquired (inflammatory).
   Treatment.
    Scissors ;
    Forceps ;
    Caesarean section.
  Cystocele.
    Treatment.
       Catheterize and replace.
       The use of the catheter  being  impossible, aspi-
    rate.
  Rectocele.
    Treatment:—Replace.
Rigidity of the Cervix:
    Atrophic changes in aged primiparae.
    Hypertrophy of the portio vaginalis.
    Cicatricial tissue.
  Treatment.
    Manual dilation.
    Multiple incisions, rarely. 
no
Pathology  of Labor.
      Cancer ofthe Cervix.
        Treatment.
          Manual  dilatation.
          Removal ofthe cancer during pregnancy.
          Premature labor.
          Cervical incisions  through the healthy tissues by
        thermo-cautery.
          Forceps.
          Caesarean section, in rare cases.
      Occlusion of the Os Externum.
          Treatment.  Reopen the os by incision from behind
        forward.
      Tumors :
          Vesical  calculi.
          Vaginal tumors.
          Uterine polypi.
        Treatment.
          Replace vesical calculus.
          Replacement impossible, remove the  calculus by
          vaginal  lithotomy.
          Push the tumor above the head, with the aid of the
          genu-pectoral position.
          Remove, if pedunculated, with the ecraseur.
          Aspiration of ovarian cysts if reposition fails.
          Ovariotomy during pregnancy.
          Caesarean section.
Anomalies of the Passenger.
  Occipito-Posterior Positions.
    Frequency, 20% of vertex births.
    Mechanism.
        i. Forward rotation of the occiput,
          Above the brim,
          In the cavity,
          At the vaginal outlet.
        ii. Forward rotation ofthe sinciput.
    Dangers in persistent occipito-posterior positions:
        To  the Mother:— 
Pathology of Labor.
ni
        Exhaustion,
        Laceration of the perineum.
      To the Child ;—
        Those of prolonged second stage.
  Diagnosis.
      Abdominal examination.  Vide p. 78.
      Vaginal examination.  Vide p. 81.
        Large fontanelle easily accessible indicates  either
      an occipito-posterior position or an imperfectly flexed
      anterior position.
  Treatment.
      Above the Brim :—Rotate by combined internal and
      external manipulation.
      In the Cavity:
        Promote extreme flexion  by pressure  against  the
      forehead;
        Assist rotation, cautiously ;
        Forceps,—Tarnier,—only after delay becomes dan-
      gerous to mother or child.
      At  the  Vaginal Outlet:—Rotate by backward press-
      ure with the fingers on the anterior temple, combined
      if necessary with forward pressure upon the occiput.
Face Presentation.
  Frequency, 1-250.
  Cause.
      Extension of  the head at the beginning  of labor due to
        Narrow pelvis;
        Brim narrowed by prolapsed extremity;
        Undue projection ofthe ischial spines;
        Impaction of the occiput in occipito-posterior posi-
      tions ;
        Excessive obliquity ofthe uterus ;
        Mobility of the foetus from small size,  or from excess
      of liquor amnii;
        Shape  of the head,—long occipital pole (dolicho-
      cephalus);
        Congenital enlargement of the thyroid ; 
112
Pathology  of Labor.
      Increased size of the chest or neck;
      Cord about the head.
      The extension is  most frequently due  to  a  com-
      bination of causes.
    Very rarely is primary.
    The preponderance of left mento-anterior positions is
    due to the right obliquity ofthe uterus.
Mechanism.
      The head descends with its occipito-mental diame-
    ter  in relation  with  the axis of the birth-canal, but
    with that diameter inverted,—mental pole first.
      The engaging plane is the trachelo-bregmatic, 3 by
    3^ inches or little more.
      The difficulty of face birth is due to the fact that
    the thickness of the neck and a portion of the chest is
    added to  the long diameter of the face as the face
    descends, making a total diameter of 6% inches.
  Positions :
      Left mento-anterior,—L. M. A.
      Right mento-anterior,—R. M. A.
      Right mento-posterior,—R. M. P.
      Left mento-posterior,—L. M. P.
Mechanism of Mento-Anterior Positions.
  Movements :
    Extension ;—Corresponds to flexion in vertex births.
    Rotation ;—Unlocks the difficulty of face birth.
        Failure is more serious than in vertex presenta-
      tion.
        The mechanism is  the same as in vertex (mutatis
      mutandis).
    Flexion ;—Corresponds to extension in  vertex deliv-
      eries.
        The head rests by the lower surface of the inferior
      maxilla  upon  the  ischio-pubic  rami  as a  pivotal
      point, and is expelled by a movement of flexion,—
      the face, the forehead, the vertex and the occiput
      successively sweeping over the perineum.
    External Rotation  or Restitution. 
              Pathology of Labor.*              113

Mechanism of Mento-Posterior Positions.
      In a typical case the birth  of persistent mento-
    posterior positions  is impossible,  since it  would re-
    quire  a diameter of 6% inches to pass  through the
    pelvis.
      Spontaneous rotation of the chin to the front  gen-
    erally occurs.
Prognosis.
      Mortality, 6% ofthe mothers, 13% ofthe children.
      Face ofthe  child greatly disfigured.
Dangers:
    To the mother, exhaustion.
    To the  child, cerebral congestion from pressure on
    the veins ofthe neck.
        Rotation  failing, nearly all die.
Diagnosis.
  Abdominal examination ;
      Cephalic tumor very round and fills only one side
      of the  pelvis;
      Cephalic prominence in relation with  the back and
       generally on  the  same  side  of the  median line
       with the breech ;
      Sulcus at the junction of the head and back ;
       Heart and small parts on the same side ;
       Inferior maxilla accessible to palpation.
  Vaginal examination :
    Diagnostic marks;
       Orbital ridges;
       Nasal  bones;
       Malar bones;
       Alveolar processes ;
       Chin.
 Treatment.
    Nature is competent in a large proportion of mento-
      anterior cases, but in those only.
    Preserve the membranes.
    At the Brim:
       Convert by the method of 
114
Pathology of Labor.
          Schatz,—thrusting the breech forward * with one
        hand, the chest backward and upward with the oth-
        er, by external manipulation;
          Baudelocque,—hooking  the  occiput down  with
        the hand in the uterus ;
          Or both combined,—under chloroform if required.
        Version, especially with prolapsus funis.
      In the Cavity :
        Promote extension and rotation.
        Forceps.
Brow Presentation.—Semi-extension  of the head.
        Persistent semi-extension is rare :  partial extension
        is generally converted spontaneously into vertex or
        face.
  Positions.  As in face presentation.
  Prognosis.  Delivery in  persistent  brow cases is possible,
      only with a relatively large pelvis.
  Diagnosis.
        Abdominal Examination :—Signs of face presenta-
          tion imperfectly developed.
        Vaginal Examination :—Orbital ridges on one side,
          bregma on the other side of the presenting  part.
   Treatment.
        Convert into vertex or face.
        Craniotomy, in dead foetus.
Pelvic Presentation.
   Varieties:—Breech;—Knee;—Footling.
  Frequency:—One in sixty, exclusive  of premature births.
   Causes;
        Narrow pelvis ;
        Uterine tumors;
        Placenta praevia;
        Hydrocephalus;
        Multiple foetus.
        Conditions favoring mobility of the foetus, e. g.,
        Multiparity;
  * Toward the child's feet. 
Pathology of Labor.
"5
      Prematurity ;
      Lax uterine walls ;
      Excess of liquor amnii;
      Shape ofthe uterus possibly;
      Small foetus.

Mechanism;
    Positions:
      Left sacro-anterior,—L. S. A.
      Right sacro-anterior,—R. S. A.
      Right sacro-posterior,—R. S. P.
      Left sacro-posterior,—L.  S. P.
      Rotation in breech is not so marked as in head pres-
      entation.
      The shoulders rotate more or less perfectly.
      The head rotates as in vertex births.
      The posterior hip is expelled first.
      Spontaneous  expulsion of the  after-coming head
      is exceptional.
    In persistent dorso-posterior positions,
      The after-coming head is generally delivered men-
      tal  pole first;
      The chin catching upon  the pelvic brim, delivery
      may be accomplished occiput first.

Prognosis.
  Mother:
      Risk to life not increased.
      First stage may be more tedious.
      Second stage  frequently more rapid.
      In  artificial  delivery, laceration of the  cervix  is
      more frequent than  in vertex births ;  laceration  of
      the perineum  is the rule.
  Child;
      Mortality very  great without interference, one  in
      three or four.
      With skilled management but little greater than  in
      vertex births. 
u6
Pathology  of Labor.
      Causes of foetal mortality ;
        Apncea from
          Separation ofthe placenta,
          Compression ofthe placenta,
          Pressure upon the funis;
        Impeded  blood supply  from retraction  of the
      uterus.
      The danger is increased in  dry labor.

Diagnosis.
    Abdominal examination ;—vide p. 78.
    Vaginal examination.
      Glove-finger protrusion ofthe membranes;
      Absence ofthe hard globular head;
      Tuberosities ofthe ischium;
      Tip of the coccyx, anus, genitals, on a  line bisect-
      ing the bis-ischial line at right angles;
      Femora;
      Expulsion  of meconium  (may  occur  in cephalic
      births);
      Identify foot, knee, shoulder, elbow, hand, by their
      anatomical characters.

Treatment.
  Before Labor.
      External version in favorable cases.
  During Labor.
      The danger to the child is chiefly due to the diffi-
      culty of delivering the after-coming head before the
      child dies of apncea;
      The delivery of the after-coming head is facilitated
      by
      1.  Full dilatation ofthe passages;
      2.  Complete flexion ofthe head and arms.
      Promote 1  by preserving the  membranes till they
      reach the pelvic floor ;
      Accomplish 2 by avoiding  traction till the trunk is
      delivered;—or, when traction is unavoidable, by ex-
      ternal manipulation. 
Pathology of  Labor.
ii7
 Dorso-Anterior Positions:
   Delivery ofthe After-coming Head.
   On expulsion ofthe trunk.
     Examine the funis for pulsation.
     Pull the funis  down and dispose by the sacro-iliac
     joint in that half of the pelvis which offers the most
     room.
   Management ofthe Arms:
   Arms Flexed;—Delivery is easy.
   Arms Extended;
     Seize the feet and draw  the trunk to the side op-
     posite the occiput;
     Pass the free  hand up along  the dorsum and slip
   one  or two fingers over the  shoulder and along the
   humerus to the elbow;
     Sweep the elbow across the face and down.
     Change hands and reverse position of the trunk for
   delivery ofthe other arm.
   Delivery ofthe Head:
     Expressio foetus by an assistant.
     Invoke  all  the  voluntary expelling force  of the
     mother at the  critical  moment; omit anaesthetic.
     Smellie-Veit  Method:—Traction by  two  fingers
  hooked over the shoulders, astride the neck, main-
  taining extreme  flexion -by two  fingers of the other
  hand pressed against the fossae caninae or the lower
  maxilla, trunk lying along the fore-arm of the oper-
  ator  or upon abdomen ofthe mother.
    Wigand-Martin Method: — Maintain  flexion as
  above and  deliver by supra-pubic pressure with the
  other hand.
    Keep the  long  diameter of the  head in the ob-
  lique diameter ofthe pelvis, until past the  brim.
    Forceps:—Applied to head, trunk upon the ab-
  domen ofthe mother.
Dorso-Posterior Positions:
    Rotate the occiput to  the front after the expulsion
  of the body by gentle torsion of the trunk or by press-
  ure on the anterior temple. 
11S              Pathology of Labor.

          Rotation  failing, deliver by traction  downward and
        backward over the perineum.
          The chin catching over the brim of the pelvis, de-
        liver occiput first by traction downward and  forward.
      Nuchal Arm:—Rotate the  body in the direction from
        the misplaced arm.
      Failure of the Powers at or above the brim:—Bring down
        one or both feet.
      Impaction:—Traction by
          Finger,—Fillet,—Forceps.
          In dorso-anterior positions;—The finger or fillet in
        one groin.
          In dorso-posterior positions:—Adjust a soft oiled
        fillet so that  the loop may encircle the pelvis, the free
        ends depending between the thighs.
          Forceps:—Apply one blade over the sacrum and
        ilium, the other  over  the posterior  surface  of the
        opposite thigh.
      Indications of Danger to the Child.
          Funic pulse irregular and feeble;
          Convulsive movements;
          Occasional gasping respiratory movements.

  Shoulder Presentation.

      Varieties;—Shoulder, arm, hand.
      Frequency:— I -2 50.
      Causes;
          Unusual mobility of the foetus from  causes already
          enumerated;
          Undue pelvic inclination;
          Narrow pelvis;
          Low attachment ofthe placenta.
      Positions:
          Left scapula-anterior;—L. S. A.
          Right scapula-anterior;—R. S. A.
          Right scapula-posterior;—R. S. P.
          Left scapula-posterior;—L. S. P. 
Pathology of Labor.
119
  Prognosis;
      1-9 ofthe mothers and 1-2 ofthe children die.
      Danger to the mother,—pressure effects, exhaustion,
      rupture of the uterus.
      Danger to the child;—Pressure, etc.

  Diagnosis:
    Abdominal Examination:
      Absence  of head in the excavation;
      Presence of head in the iliac fossa.
    Vaginal Examination:
      Glove-finger protrusion ofthe membranes;
      Absence  ofthe  hard globular head;
      Absence  of any presenting part at the beginning of
      labor;
      Presenting part a small rounded prominence;
      Distinguish it from the ischial tuberosity by the ab-
      sence of a companion;
      From it radiate the humerus, the clavicle, the spine
      ofthe scapula;
      Neck on  one side, ribs on the other;
      Axilla;
      Elbow, identified by the olecranon;
      Distinguish hand from foot, right from left hand.
    Diagnosis of Position:
      Relation  ofthe  scapula to  the brim;
      Axilla or elbow, looks toward the feet;
      Thumb, toward the head.
  Spontaneous  Delivery.
      Spontaneous Version;
      Spontaneous  Evolution ; —Expulsion  with  trunk
    doubled  on itself.  Possible  only when disproportion
    between  size of the pelvis and the foetus favors.  Al-
    most invariably fatal to the child.
Treatment.
Before Labor.
      External cephalic version.
      Retain by abdominal binder and lateral compresses. 
120
Pathology of  Labor.
    During Labor.
      Ordinary Cases.
          Preserve the membranes.
          Evacuate the bladder and rectum.
        Version:
          Cephalic;
          Podalic;
        Methods:
          External;
          Bipolar;
          Internal.
      Impacted and Irreducible Cases.
        Decapitation.
          By the  blunt hook and scissors;
          By a strong chain ecraseur.  Pass a tape and draw
          the chain into place.
          After decapitation push up the head and deliver the
          trunk, then extract the head, chin-first.
Complex Presentations.
    Head  and Hand.
          Replace the hand.
          Forceps, placing the arm  in the unoccupied side
          ofthe pelvis.
    Hand  and Foot.
          Podalic version.
    Head, Hand and Foot.
          Podalic version.
    Nuchal Arm.
          Diagnosis  by hand in the passages, under chloro-
          form.
          Dislodge the arm. Rotate the body from the nuchal
          arm.
          Version.
Anomalies of Development.
    Multiple Foetus.
        Relative situations of twins:
          One beside the other;
          One above the  other;
          One in front of the other. 
PATHdLOGY  OF LABOR.
121
    Diagnosis.
      Vide p. 44.
    Management.
      Expedite the second birth.
      Forceps or version.
Interlocking Twins.
Presentations:
    a.  Both cephalic. Both heads offering,—one impacted
      between the head and trunk of the other foetus.
    b. One cephalic, one pelvic.   The after-coming head
      ofthe  breech  birth impacted between the head and
      trunk  of the other foetus.

Management.
    Disengagement  by combined internal and external
       manipulation with the aid  of the knee-chest posi-
       tion.
    Decapitation of the first child as a last resort.
Double Monsters.
       Premature birth  and spontaneous delivery the  rule.
       Embryotomy, in difficult cases.

Hydrocephalus.
       Consists of enlargement of the cranial vault, due to
       serous effusion into the cranial cavity.
       The fluid may amount to several pints.
       Spina bifida may co-exist.
 Causes.
       Syphilis, cretinism and other causes.
 Diagnosis.
 Head-first Cases.
   Abdominal Examination.
       Obvious.
   Vaginal Examination.
       Size ofthe cranial vault;
       Elasticity;
        Fluctuation;
        Increased width of sutures; 
122
Pathology  of Labor.
        Large size ofthe fontanelles;
        Sometimes a supplementary fontanelle between the
        anterior and posterior.
        Confirm if necessary by the  hand in the vagina
        under anaesthesia.
 Head-last Cases;—1-5 present by the breech.
        Body wasted.
        Head arrested after birth ofthe trunk.
        Abdominal examination.
 Prognosis.
     Child:
       Generally fatal;
       If born alive, viability feeble.
     Mother:
       Danger of
         Exhaustion;
         Rupture ofthe uterus.
 Treatment.
       Nature.
       Forceps, or
       Perforation,—according to the degree of obstruc-
       tion.
       Cephalotribe as a tractor.
       Breech-first cases,—perforate the head, or open the
       spinal canal and catheterize the cranial cavity.

Dropsy of other Cavities or Emphysema.

 Treatment.

       Aspiration ofthe dropsical cavities, or incision.
       Embryotomy.

Tumors.

 Treatment.

      Fluid tumors:—tapping; incision; laparotomy.
      Solid:—segmentation;  laparotomy. 
Pathology  of Labor.               123
                  Complicated Labor.
Prolapsus Funis.
    Frequency, 1-250.
    Causes:
          Anything which prevents the presenting part from
          completely and continuously filling the  lower uter-
          ine segment;—e. g.,
          Hydramnion;
          Pelvic deformity;
          Malpresentation.—Frequency in head presentation
           1-304, face  1-32, pelvis 1-21, shoulder 1-12;
           Complex presentations;
           Low placental insertion;
           Marginal insertion ofthe cord;
           Twins;
           Excessive length of cord.
    Prognosis.
           No increased risk to the mother.
           No presentation more fatal to child.
           Fcetal mortality 1-2.
           Greatest in vertex and in first labors.
     Diagnosis.
           Before rupture ofthe membranes, differentiate from
           fingers, toes,—loop of intestine  in rupture of the
           uterus.
           Examine for the funic pulse.
           Absence of pulsation for 15 minutes to  be taken as
           evidence of death ofthe foetus.
      Treatment.
           Preserve the membranes.
           Maintain the latero-prone posture.
       Reposition,—in genu-pectoral position.
          Manual.                    ,.,,..            a
           Twist the prolapsed  loop lightly into  a rope and
            replace anteriorly by taxis.
           Detain by passing it over a knee—or by a large asep-
           tic sponge or a rubber bag distended with water. 
124
Pathology of Labor.
          Wind the  cord about the trunk  by rotating  the
          trunk around its long axis.
        Instrumental.
          Reposit by means  of  an English catheter  with  a
          tape attached and loosely looped over the cord.
          Crowd the  head into the excavation  after reposit-
          ing the cord.
          Forceps,—first placing the cord toward the  sacro-
          iliac joint opposite the side ofthe head.
          Version,—especially in malpresentations.
Inversion of the Uterus.
    Degrees and Forms :
          Depression ofthe fundus;
          Partial inversion;
          Complete inversion;
          Inversion ofthe lower segment.
    Frequency,—1-200,000 about.
    Etiology.
          Maladroit pressure on the uncontracted fundus.
          Traction on the cord while the uterus is relaxed.
          A fundal placental seat favors.
          Irregular contractions of the  uterus from  atony of
          the  placental site,—the atonic portion, falling  in-
          ward,  is  extruded downward as a foreign body.
          Rarely occurs after delivery ofthe placenta.
    Prognosis.
        Mortality,—1-5 to 1-3,  from hemorrhage  and shock,
        or peritonitis and gangrene of uterus.
    Diagnosis.
      Symptoms:
          Shock;
          Pain;
          Hemorrhage.
      Signs:
      1. Absence ofthe usual abdominal tumor;—
        Method of  examination.
          Abdominal palpation. 
Pathology of Labor.
125
          Combine abdominal  with  vaginal or rectal exam-
          ination.
          Sound in the bladder and finger in the rectum.
          Catheterize the bladder.
          Exclude morbid growths.
      2. Presence of a vaginal tumor;
      3. Character of the tumor.
          Differentiate from polypus by,
            Special contractility;
            Large pedicle;
            Pain and immobility on attempting torsion;
            Uterine sound.
          Differentiation sometimes difficult.
          Note that the  placenta may be still adherent.
     Treatment.
      Preventive:—Proper  management ofthe third stage.
      Reposition.
        Method.
        Simple Cases,—a few hours after inversion.
          Anaesthesia.
          Place one hand  on the abdomen over the inverted
          uterus.
          Cone the fingers of the other hand  and apply the
          pressure over  the insertion of one Fallopian tube.
          Direct the force to one side of the sacral promon-
          tory.
          Placenta adherent, replace all;
          Placenta partially detached, separate and remove
          the placenta before replacing.
        Difficult Cases.
          Taxis  with the  aid of  the  genu-pectoral position
          and Sims' speculum.
          Elastic  pressure by means of a water-bag, alter-
          nated with taxis.
          Avoid  extreme measures during the puerperium.
Rupture ofthe Uterus.
    Nature of the accident.
          Generally begins in the lower  segment.
          May be partial or complete. 
126
Pathology  of Labor.
        May take any direction and reach any extent within
        the limits of the organ.
        May invade the vagina and bladder.
        The portio vaginalis may be torn off.
        Notable  fissures of  the cervix occur in nearly all
        labors.
        Very rarely occurs during pregnancy.
Frequency:—I-4000.
Causes:
    Predisposing:
        Anything which impairs  the integrity ofthe uterine
        muscularis;
        Carcinoma;
        Myoma;
        Obstructed  labor, leading to excessive thinning  of
        the lower uterine segment.
    Exciting:
        Ergot;
        Operative violence,  such as
          Forceps through undilated os;
          Version during contraction.
          Other operations.
Prognosis.
      Mother:—Mortality, 90 to 95%.
      Child:—Mortality still  greater.
Diagnosis.
  Precursory signs:
        Concurrence of obstruction  with  violent  uterine
        effort.
        Excessive  uterine retraction.—Locate  retraction
        ring by abdominal palpation.
  Signs of Rupture.
  *      Shock;
        Hemorrhage;
        Sudden cessation of contractions,—in complete rupt-
        ure;
        Sensation of tearing; 
Pathology  of Labor.               127
          Recession ofthe head;
          Absence of the signs of fcetal life.
          Abdominal examination;—uterus and child present
          separate tumors.
  Treatment.
    Preventive:
          Remove the cause of obstruction if possible;
          Artificial  delivery in excessive  retraction  of the
          uterus.
    Remedial:
          Incomplete, — drainage  with iodoform  gauze,  or
          iodoform wicking;
          Complete,—extraction through the  rent and subse-
          quent drainage of the abdominal cavity in certain
          favorable cases of posterior rupture  ; craniotomy in
          the grasp of the forceps;
          Laparotomy in case of
            Child wholly in peritoneal cavity;
            Child long dead;
            Much hemorrhage into peritoneal cavity;
            Cervix not dilatable;
            Site of rupture  unfavorable for drainage.
          Cleanse the peritoneum and suture the rent.
          Amputate the uterus if necessary to avert sepsis.

The Hemorrhages.
  Ante-Partum Hemorrhage.
  I. Placenta Praevia.
        Definition; —Implantation  ofthe placenta upon the
          lower zone of the uterine walls.
        Cause of Hemorrhage;—Separation of the lower mar-
          gin of the placenta during canalization ofthe cervix.
        Degrees of Placenta Praevia.
          Marginal,—edge  presenting;
          Partial,—partially covering  the fully dilated  os
          uteri;
          Complete,—wholly covering the fully dilated os.
          Exact central implantation is rare. 
128
Pathology  of Labor.
Frequency:—i-iooo.—More frequent in multiparas  than in
      primiparae.
Causes:
      Obscure.
      Possibly certain morbid  conditions of uterine  mu-
      cosa and consequent tardy fixation of ovum.
Source of the Hemorrhage. The uterus,—not the placenta.
Prognosis.
      Mortality;—Mother ?$, child ft.
      Mortality to both mother and child varies with the
      degree of placenta praevia.
      The maternal  mortality is due  to  hemorrhage,
      shock, sepsis and thrombotic affections.
      The fcetal,  to  apncea,  hemorrhage, prematurity,
      operative causes.
      There are  practically  no  deaths  from  placenta
      praevia before the seventh month.
      The danger increases as gestation progresses, since
      the vessels are larger and separation more liable to
      occur.
Diagnosis.
    Symptoms:
      Usually none in the early months.
      The first  indication generally is a sudden hemor-
      rhage of greater or less severity.
      The first hemorrhage occurs most frequently in the
      seventh or eighth month.  Sometimes not till term.
      Hemorrhage of any note  during pregnancy  de-
      mands investigation, especially in the latter months.
    Physical Signs:
      Placenta may  sometimes  be mapped  out by  ab-
      dominal palpation.
      Unusual  development of the cervix,  especially in
      complete placenta praevia.
      A  boggy feel ofthe cervix  and the lower segment
      ofthe uterus.
      A  cushiony mass between the presenting part  and
      the examining finger. 
Pathology of Labor.
129
      Characteristic stringy feel of the detached surface
      of the placenta,  examined through  the  cervical
      canal.
      Distinguish from clots by less friability.
      In marginal placenta praevia the edge may be felt
      if separated.
Treatment.
    Before Viability.
      In general expectant.
      If the hemorrhage be copious, placenta praevia com-
      plete or the foetus dead, empty the uterus.
    After Viability.
      Induction of labor,—simple  cases excepted.
    Management of Labor.
      The principal indication is  the control  of hemor-
      rhage.
      Hemorrhage controlled,—wait, but remain with the
      patient till delivered.
      Nature is competent in very  rare cases by extra-
        rapid delivery.
      Rupture the membranes in  certain cases of partial
         placenta praevia, and apply a binder.
      Forceps in certain similar cases.
      Tamponade, vaginal with or without  the  cervical.
      Method:
         Sims' position and Sims' speculum.
         Water-bag in the cervix.
         Pack the vagina  full, with  sterilized cotton  in
           small wet pledgets.
         Hold by a T bandage.
         Renew every six to eight hours  with antiseptic
           precautions.
         Mercurials must not be used in the tampon.
      Podalic Version.
         External, bipolar, or  internal,  pushing the pla-
           centa to one  side in latter methods.
         The podalic extremity of the foetus  acts as a cer-
           vical plug. 
130
Pathology  of Labor.
          Leave expulsion to nature.
          Nature failing, extract very slowly and with ex-
            treme care to avoid shock.
      Other Methods.
        Separation of  the placenta from the lower  uterine
          segment (Barnes).
          This permits retraction of the zone uncovered.
          The area  of detachment should be not less than
          4>£ inches in diameter:
        Complete separation and extraction ofthe placenta
          (Simpson).
          Applicable in case
          Child is dead;
          Child not yet viable.
        Extraction  of the child by perforation of the pla-
          centa.—Rarely permissible.
      Precautions.
        Guard against shock, septic infection,  post-partum
        hemorrhage.
        Avoid too precipitate and violent interference.  It
        is the cause of a large proportion of deaths in pla-
        centa praevia.
II. Accidental Hemorrhage:—Hemorrhage from partial sepa-
        ration of a normally situated placenta.
   Varieties.
      Apparent;
      Concealed.
        i. Separation  central, margin adherent.
        2. Separation  at the margin  partially  lifting the
          membranes  beyond the margin.
        3. Separation  the same as in 2, but blood escaping
          into the cavity  of the  ovum by rupture of the
          overlying membranes.
        4. Separation  of the margin of the placenta and of
          the  membranes,  but the lower segment  of the
          uterus  blocked by the fcetal head.
   Causes.
        The  loose attachment  of the placenta  normal to
        the last weeks of gestation; 
Pathology  of Labor.
i-3t
        Violent muscular exertion;
        Violent uterine contractions;
        External violence;
        Blood state,—e.g., of albuminuria, anaemia;
        Placental disease.
  Prognosis.
      Apparent Variety:
        Not usually grave to the mother, frequently fatal to
        the child.
      Concealed Variety:
        Maternal  mortality  50%,—from  blood loss, post-
        partum  hemorrhage, sequelae.
        Fcetal, 90% or more.
  Diagnosis.
      Apparent Variety, obvious;
      Concealed;
        Uterine distention;
        Violent pain  in certain cases from distention of the
        peritoneal coat ofthe uterus;
        Collapse and other signs of internal hemorrhage;
        Bloody liquor amnii.
      Concealed and slight apparent hemorrhage  may co-
      exist.
      Distinguish from rupture  of the uterus which occurs
      later in labor;  from placenta praevia by absence of
      the physical signs of misplaced placenta.
  Treatment,—in either variety.
        Make the uterus contract.
        To that end, rupture the membranes, and apply
        uterine compression by means of a binder.
        Cervical and vaginal tampon  with caution if at all.
        Artificial extraction after full dilatation.
        Version.

Post-Partum Hemorrhage.
        Rare in well  managed labors.
        The  normal blood loss at the close of labor varies
        from two or three ounces to a  pint. 
132
Pathology  of Labor.
 Etiology.
   i. Failure of retraction due to
       Inertia uteri, from relaxed habit of body, exhaust-
       ion, mismanaged third stage, excess of chloroform;
       Atony ofthe placental site;
       Neoplasms;
   2. Blood state,—as in haemophilia, chronic nephritis.
 Diagnosis.
   Symptoms:—Premonitory:
       History  of hemorrhage in previous labors.
       Pulse  at or above  ioo;
       Imperfect retraction;
       Presence of other causes of hemorrhage.
   Signs:
       A sudden outburst  of blood;
       No uterine globe;
       Systemic effects of severe hemorrhage, viz.:
         Pallor;
         Surface cold, clammy, especially the extremities;
         Perspiration;
         Respiration irregular, sighing, sobbing, yawning;
         Pulse rapid, thready, compressible;
         Thirst;
         Jactitation;
         Tinnitus aurium;
         Sense  of apncea;
         Nausea;
         Dimness of vision;
         Syncope.
       Absence of  visible flooding  does not  forbid  the
       diagnosis of hemorrhage.
       A flow of blood with firm uterine  contraction does
       not come from  the uterine  cavity.  Examine  for
       cervical or vaginal  lacerations.
       A thin thread-like stream of bloody serum  indi-
       cates a clot in the  uterus.
Treatment.
  Nature's haemostatics:
      Retraction ofthe arteries; 
Pathology  of Labor.
133
    Valve-like action  of the veins owing to their ob-
    liquity;
    Uterine retraction;
    Thrombosis.
Prophylactic:
    Ligation of vessels by firm and persistent retraction.
    In order to this
      Compel the uterus to expel the child;
      Compel the uterus to expel the placenta;
      Keep the hand over the uterus till the third stage
      is completed;
      Ergot hypodermically in the presence  of the
      recognized  causes of hemorrhage,—at beginning
      of third stage.
Remedial:
  Simple cases:
    Manipulation, by  one or both hands over the abdo-
    men;
    Ergot (hypodermically), fluid extract, one-half to
    one ounce;
    Hot douche, intra-uterine, at a temperature of  1 io°
    to  1200. F.
  Severe cases:
    Hand in uterus raking the cavity vigorously  with
    the finger tips;
    Hot douche, temp. 1159 to  1250 F.j
    Styptics (rarely),  applied with a swab, such as tinct-
    ure of iodine, spirits of turpentine, lactic acid, acet-
    ic  acid (or common vinegar), creolin, chloroform,
     most of which also act to excite uterine contractions.
   Other measures:
     Child to the breast as a reflex excito-motor;
     Compression of the aorta,  very effectual as a  tem-
     porary expedient;
     Faradism of the uterus;
       One pole within  the uterus  and  one over the 
■34
Pathology  of Labor.
          abdomen or upper sacral region;
          Poles both over the abdomen, one on either side
          ofthe uterus;
        Curette;
        Tampon the uterus with sterilized gauze.

Secondary Hemorrhage.
        Definition.—A hemorrhage  occurring within the
        post-partum month later than six hours after labor.
  Treatment.—Curette the uterine cavity.
  Treatment of Acute Ancemia.
        Elevate the hips and  lower the head.
        Bandage the extremities.
        Opium in full doses, 2 gr., p. r. n.
        Rectal injections of a warm. 73% solution of common
        salt, or of nutrient fluids.
        Hypodermic injections of a sterilized .73% salt so-
        lution, 8  to 32 ounces,—aseptically.
        Hypodermic injections of brandy or ether, digitalis,
        strychnia.
        Infusion ofthe sterilized salt solution into a vein.
        Transfusion.
        For the  thirst, a  saline drink,—e. g., a solution of
        ammon. acetat. 
Obstetric Surgery.
i35
              OBSTETRIC SURGERY.

Induction of Premature Labor.
    Indications:
          Certain cases of narrow pelvis;
          Certain cases of albuminuria of pregnancy;
          Placenta praevia after viability ofthe foetus;
          Certain cases of hydramnion;
          Habitual  death of the  foetus in the last month of
          gestation, and  some others.
    Time: 32nd  to 36th or 38th week, according to the rel-
          ative size of the head and pelvis.
    Method:
        First Step;—Hot antiseptic douche against the mem-
          branes for twenty minutes.
        Second Step;—Separation ofthe  membranes from the
          lower segment by means of a uterine sound.
        Third Step;—Insertion of an English bougie between
          the membranes and the uterus.
        Other Methods:
          Either of the above measures alone.
          Galvanism or Faradism ofthe uterus,—mild currents.
    Care of the Child.
          Maintain the bodily warmth by the aid of artificial
          heat.
          Gavage, or feeding through a soft stomach tube in
          very feeble children.

Forceps.
    The Instrument.
        Parts, etc.
          Right and left arms,
          Handles, shanks, blades, lock,
          Pelvic and  cranial curves. 
Obstetric  Surgery.
Principal Pattern.
      Marked pelvic curve;—type, Davis'.
      Moderate pelvic curve;—type, Simpson's.
      Axis-traction forceps;—Tarnier and  its modifica-
      tions.
Care of the Instrument.
      Always boil it for half an  hour after using, or heat
      to 234 deg. F.
      Sterilize before using.
      Keep free from rust and  well polished.
      Occasionally renew the nickel-plating.
Mechanics of Forceps Delivery.
    As a Lever.  Use as a lever to be condemned.
      Oscillating motion of forceps  during extraction  a
      mechanical gain  but  dangerous  to the maternal
      soft parts.
    As a Compressor.  Use  as a compressor permissible
      in case  of seizure over the  frontal  and occipital
      bones  only, since  compensation takes  place main-
      ly by the elevation of the  parietals, elongating the
      occipito-mental diameter.
      No gain as a rule  in other seizures since, the parie-
      tals being included in the grasp of the instrument,
      compensation elongates  a transverse diameter.
      Safe limit of compression, about one-half inch.
    As a Tractor.   The  principal use of forceps.
Indications for Forceps :
    Forces at Fault:—Cases of cephalic  presentation in
      which  nature is clearly incompetent to deliver with
      safety  to mother and child.
    Passages at Fault:—Certain cases of obstruction in
      the bony pelvis or in the soft parts.
    Child at Fault:—Certain cases  of foetal dystocia,—
      e.  g.,  occipito-posterior positions, face  presenta-
      tions, hydrocephalus, after-coming  head, impacted
      breech, and others.
    Complicated Labor:—Certain cases  of placenta  prae-
      via, prolapsus funis, rupture of the uterus and of
      eclampsia. 
               Obstetric Surgery.               137

Dangers of the Forceps Operation:
  To the mother:
    Low operation;
      Practically none;
      Danger of vaginal lacerations in unskilled hands.
    High operation;
      Lacerations of the cervix, the uterus, the vagina.
      Contusions;
      Shock.
  To the child:—Injury ofthe brain from excessive com-
      pression.
Application of Forceps:
  Preparatory Measures:
      Position:—Dorsal,—the American obstetric position,
      —the preferred position; the lateral decubitus is per-
      missible;
      Passages, instrument and operator's hands and arms
      must be aseptic;
      Canalization of the cervix should  be complete, or
      nearly so ;
      The membranes should  be ruptured;
      Correct malpositions if possible;
      Empty the bladder and  rectum;
      Anaesthetic,—chloroform, ether, or a fresh A. C. E.
      mixture.
  Application:
      Apply the left blade first,—on  left side of pelvis.
      Seize  the handle with the thumb and finger of the
      left hand, holding it nearly in a vertical line.
       Pass two or more fingers of the right hand between
      the head  and the  left  wall  of the  passages,  the
      palmar surface inward.
      Pass the blade along the palmar surface of the right
      hand  and between the head and the walls of birth-
       canal,  observing both  the pelvic and the cranial
       curves, hugging the head.
       Pass the right blade in similar manner, the left hand
       serving as a guide. 
138
Obstetric  Surgery.
     Adjust the blades in the best possible seizure.
     Locking.  If the arms do not lock readily, readjust
     the blades till they do.   Never force the locking.

  Extraction -.
     Traction should be intermittent,—a pull and a pause.
     Unlock the arms in the intervals to relieve pressure
     on the head.
    Line of Traction:
     Apply the force in the direction of the birth-canal.
     In order to this, grasp the handles with one hand
     and apply downward pressure with the other rest-
     ing  upon the shanks near the lock.   With forceps
     of moderate pelvic  curve,  simple traction suffices
     after the head reaches the pelvic floor.
     The direction is practically a straight line parallel
     with the posterior surface of the  symphysis pubis
     till the head reaches the pelvic  floor.
     The line of traction should then turn almost direct-
      ly forward.
     Sweep the handles upward till the anterior edges
      of the blades hug the ischio-pubic rami as closely
     as possible without crushing the  intervening  soft
      parts.
    Amount of force, from ioto 80 lbs.
    Time  is an  important element in a safe forceps ex-
      traction.  The resistance  of the moving body, and
      therefore the violence to the maternal soft parts, in-
      creases as the square of the rate of motion.
      At least a half hour should be consumed in a  low
      forceps delivery;  more  in a high operation.
    Perineal stage:
      The forceps may or may not  be removed.
      Take a half hour or more for the perineal stage of
      the delivery.
Advantages ofthe Tarnier forceps, in high operations.
      Axis  traction, minimizing  the traction force by ap-
      plying it to the best advantage.
      Mobility ofthe head, permitting rotation. 
Obstetric Surgery.
139
Version.
    Definition.—The complete or partial inversion of the foe-
           tal ovoid, by manual interference,—substituting the
           cephalic or pelvic pole for  a less favorable presen-
           tation.
           Cephalic version causes the head to present;
           Podalic, the feet.
    Indications:
         Cephalic:
           Certain breech cases before labor;
           Certain shoulder presentations.
         Podalic:
           Certain cases of moderately flattened pelvis;
           Most cases of placenta praevia;
           Certain cases of prolapsus funis;
           Rupture ofthe uterus;
           Difficult Face Cases, brow, complex presentations;
           Most shoulder presentations;
           For rapid delivery in  emergencies, and in certain
           other cases.
    Methods;
           External;
           Bipolar;
           Internal.
    Dangers of Version.
      To the mother,—External and bipolar, practically none,
           as a rule.
           Possible rupture ofthe uterus in difficult cases.
           Internal.   Increased risk of sepsis,—preventable.
           In all, increased danger of lacerations in rapid ex-
           traction, and of shock.
      To the child:—As in spontaneous breech birth, also,
           Fracture of bones;
           Compression ofthe spine in internal version.
  External Version.
    Indications:
           Breech presentations,—before labor;
           Shoulder presentations. 
140
Obstetric Surgery.
  Method;—External manipulation,—one  hand  over  each
        foetal pole;  push the head toward the occiput, the
        breech toward the feet.
        A combined external and  internal method may be
        substituted  for the  external,—one hand over the
        abdomen, two fingers ofthe other in the  vagina.

Bipolar Version.
  Indications:
        Placenta praevia in certain cases;
        In all cases where version  is indicated the bipolar
        should be preferred to internal version, if practicable.
  Advantages, over internal version:
        A minimum of traumatism and  shock.
        Lessened danger of infection.
        May be done early in the first stage of labor.

  Method:
        Dorsal or knee-chest position, one or two fingers of
        one hand through the cervix,—other hand over the
        opposite foetal pole externally;
        Push the breech toward the side on which the feet
        lie;
        Toss the head out of the excavation into that iliac
        fossa toward which the occiput points;
        Toss the trunk  in the  same direction inch by inch
        till the knees present;
        Draw down  a knee or the knees and feet.

Internal Version.
  Application.  All  cases of version  in  which  the  other
        methods are impracticable.

  Method:
        Dorsal or knee-chest position.
        Protect  the  clothing of the operator with  a sheet
        or long apron.
        Pass the hand into the uterus over the abdomen of
        the child, palmar surface toward the child. 
Obstetric Surgery.
141
           Seize the remote foot and invert the fcetal ovoid by
           traction.
           The internal  manipulation may be assisted if nec-
           essary by the  other hand externally.

           Obstetric Surgery of the Abdomen.

         Definitions:
           Laparotomy:  Gastrotomy.—Opens the abdominal
           cavity.
           Laparo-Hysterotomy :  Gastro-Hysterotomy:  Cae-
           sarean Section.—Opens the abdominal cavity and
           also the uterus.
           Laparo-Hysterectomy: Gastro-Hysterectomy: Por-
           ro Operation.—Opens the abdominal and uterine
           cavities and includes the amputation ofthe uterus.
           Laparo - Elytrotomy:  Gastro - Elytrotomy. — Opens
           into the vagina, through the abdominal wall above
           Poupart's ligament, avoiding the peritoneum.
           Pubiotomy.—Divides the symphysis pubis.

 Laparotomy: Gastrotomy.
     Indications:
           Rupture ofthe uterus,—in most cases.
           Extra-uterine pregnancy after rupture;
           Certain  cases  of extra-uterine  pregnancy before
           rupture.
     Operation:
           Consists in opening the abdominal cavity,—generally
           in the median line,—removing its foreign  contents,
           arresting  hemorrhage, cleansing and   closing  the
           cavity.

Cesarean Sectiou : Hysterotomy : Laparo-Hysterotoniy.
          The modern  Caesarean Section has  practically sup-
          planted all  other methods of delivery by  abdom-
          inal section, with the single exception ofthe Porro-
          Muller operation for certain rare  cases. 
142
Obstetric  Surgery.
History :
      The operation antedates the Christian era;
      The earlier operations, however, were post-mortem
      Caesarean sections done a few  minutes after  the
      death ofthe mother to save the child.
      The earliest recorded  case  of Caesarean section
      upon the living subject was done in the year 1500.
Results of the Modern Operation.
      Mothers saved, 75 to jy  per cent.
      German results, 82 per cent.
      Children saved, 93 per cent.
Indications :
      Pelvic obstruction sufficient to make  embryotomy
      impracticable, conjugate of 2 inches or less, or equiv-
      alent contraction of other diameters.
      Pelvic obstruction  such  that  while embryotomy is
      possible  it is more dangerous to the  mother than
      Caesarean section,—conjugate of 2 to 2% inches.
      Cesarean section is permissible under favorable
      conditions with  a conjugate  between 2% and  2^
      inches if the mother so elects.
      Certain cases of cancer ofthe  cervix.
Preferred Time for Operation.
      With most authorities, after labor is established.
      Anticipate exhaustion.
      Before rupture of the membranes there is less trau-
      matism,  the  child is  more  certainly alive and  ex-
      traction is easier.
      Operation before labor permits better preparation,
      the uterus retracts as well and drainage is all-suffi-
      cient or can be made so.
Preparatory Measures.
      Temperature ofthe room 750  to 8oQ F.
      Have ready a supply of  boiled water for irrigation
      at a temperature of 1000  to 1 io° F.
      Slightly elevate the head and shoulders.   Respira- 
Obstetric  Surgery.                143
       tion is thus easier and the tendency  to  prolapse of
       intestines is diminished.
       Evacuate the bladder.
Antiseptic Precautio7is.
       Reinforce the patient's strength before the operation
       by tonics and hygienic measures.
       Move  the bowels 2 or 3 times, a day or two before
       operating if practicable.
       Render the room, table and all surroundings ofthe
       patient aseptic.
       The patient should have a total bath and clean linen.
       Sterilize the vagina and  the cervical  canal, the ex-
       ternal  genitals and immediate surroundings.
       Shave  the pubes.
       Scrub  the surface of the abdomen with soap  and
       water, wash  with  alcohol and finally scrub with a
       1-2000 mercuric iodide or bichloride solution.
       Wrap  the body and extremities warmly with clean
       flannels except the field of operation.
       Cover  the clothing about the field of operation  with
      cloths  or towels wrung out ofthe biniodide solution;
      —or better sterilized by boiling or steaming for half
      an hour.
       Instruments  should be sterilized by exposure for
       half an hour to a temperature  of 234  deg. F., or by
       boiling or steaming for the same length of time.
       The hands and arms ofthe operator  and assistants
      should be sterilized and their clothing covered  with
       fresh laundered operating robes.
Assistants.
       First assistant to  stand  on the side of the  patient
       opposite the operator.
       One to give the anaesthetic.
       A nurse to take charge ofthe  steam sterilizer.
       One to receive the child.
Instruments,  etc.
       Scalpel.  Blunt-pointed bistoury.
       Two scissors, one  straight, one curved on the edge. 
144
Obstetric  Surgery.
       Broad grooved director.
       Tissue forceps.
       Six to twelve catch forceps,—haemostatic forceps.
       Needle-holder and needles.
       Peaslee's needle.
       Long catch forceps for  holding the cheese-cloths
     for sponging.
       A finger-thick  rubber tubing (four feet long)  as a
     constrictor for the neck ofthe uterus.
       A  steam  sterilizer  for  sterilizing  cheese-cloths,
     towels, etc.
       Large  strong catch forceps for holding the knot of
     the constrictor.
       Twenty catgut sutures, No. 5, for uniting the uterine
     muscularis.
       A catgut suture No.  7, bearing a needle,  for con-
     tinuous suture of the uterine serosa.   A similar one
     for the parietal peritoneum.
       A catgut suture, No. 5, for continuous suture of the
     aponeurosis.
       Twelve  silk sutures, No.  12, for re-uniting the ab-
     dominal wound.
       Two dozen cheese-cloth or butter-cloth pads, kept
     hot in  the steam sterilizer.
       A 1-2000 solution of mercuric iodide in glycerine.

Summary of the Conditions of Success.
       Timely operation;
       Aseptic technique;
       Uterine  sutures,—deep 9-10,—superficial  18-20, or
     continuous;
       Maintenance ofthe natural temperature of the ab-
    dominal viscera;
       The  least possible handling of peritoneal surfaces.
Stages of the Operation.
       Median incision ofthe abdominal wall;
      Application ofthe cervical constrictor;
       Median incision ofthe uterus; 
Obstetric  Surgery.
i45
      Extraction of the child and placenta and eventra-
    tion ofthe uterus;
      Toilette ofthe uterus and peritoneum;
      Closure ofthe wounds and dressing of the abdom-
    inal wound.

Technique of the  Operation.
    .  Abdominal incision from the  navel to a point an
    inch above the symphysis.
      Expose the linea alba.
      Incise the tendon,  cautiously, exposing the sub-
    peritoneal fat.
      Close all vessels by compression  or ligation before
    opening the  peritoneum.
      Lift the peritoneum with tissue forceps, nick it with
    the scalpel  or scissors close to  the forceps, and  ex-
    tend the incision to the full length  of the abdominal
    wound, using the finger as a guide.
      Pass a loop of the  constrictor over the fundus  and
    adjust it around the cervix,  tightening it only as re-
    quired to control hemorrhage.
      Let an assistant  hold the uterus, by means of the
    constrictor, firmly against the abdominal incision  and
    in central position.
      Make a short  incision through  the  uterine  wall
    above the retraction ring.
      Lengthen  upward with the fingers  or scissors, falling
    short of the fundus.
      Separate  and  push aside  the edge  of  the placenta
    in case of anterior implantation.
      Puncture the membranes and extract the child,
    preferably by the head.
      Prevent liquor amnii and blood from entering  the
    abdomen by  pressing the abdominal walls against the
    uterus.
      As  the uterus slips out  of  the abdominal  cavity
    hold  back the intestines if necessary  with hot moist
    cloths over the upper portion  of the  incision, or by
    provisional sutures. 
Obstetric  Surgery.
    Keep the uterus wrapped in hot moist cloths.
    Remove the placenta and  membranes and secure
  retraction.
    Compel retraction by manipulation or by Faradism.
    Irrigate the peritoneum if required with plain boiled
  water, or  .73 per cent, salt solution at temp. 1050 F.
    Hot irrigation of the peritoneal  cavity (temp. 1050
  to 1100) relieves shock.
    Avoid irritating the peritoneum by handling, spong-
  ing or chemical  antiseptics.
    Close the uterine wound with nine or ten deep cat-
  gut sutures, avoiding the decidua.
    Close the  peritoneal coat of  the uterus with 12  to
  20 loops of continuous suture  of No. 7 catgut, uniting
  the edges, or the free surfaces after  the manner  of
  Lembert.
    Push the omentum above the  uterus.
    Close the abdominal walls with three layers of sut-
  ures;  the  peritoneum with  a  continuous catgut sut-
  ure,  No. 7 ;  the tendon with  a   continuous  catgut
  suture,  No. 5; the  overlying structures with inter-
  rupted silk sutures, No. 12,  at intervals of half an inch.
    Give ext. ergot fl., half a drachm, hypodermically.
    Dress the  abdominal  wound with  several  thick-
  nesses of sterilized cheese-cloth wet with the binio-
  dized glycerine.
After- Treatment.
    Promote reaction  by artificial warmth,—by stimu-
  lants if required.
    Maintain a rigid cleanliness.
    Catheterize  the bladder every six hours for two  or
  three  days.
    Put the child to the breast as in normal cases.
    Begin feeding  with  light  liquid food after 24 or  36
  hours.
    Remove the abdominal sutures by the 10th or 12th
  day.
    The patient may usually leave the bed  at the end  of
  three weeks. 
Obstetric  Surgery.
i47
Porro Operation:   Laparo-Hysterectomy.
          First performed by Edward  Porro of  Pavia, Italy,
        in 1876.   Subsequently modified by Muller.
      Results;  About 54% of mothers saved,—82%  of the
        children.
      Indications;
          Stenosis ofthe cervix or vagina impeding drainage;
          Certain tumors of the corpus  uteri, as myomata etc.;
          Retrocervical or retrovaginal myomata;
          Septic uterus;
          Hemorrhage after Caesarean  section,  or after rupt-
        ure ofthe uterus,—not otherwise controllable;
          Pregnancy in a rudimentary horn ofthe uterus.
      A dvantages;
          Diminished danger of sepsis;
          Prevention of subsequent pregnancies,—an  advan-
        tage in certain cases;
          Technique simple;
       Technique:
          Abdominal incision;
          Eventration of the  uterus and application of the
        cervical constrictor before the uterine incision;
          Uterine incision and extraction ofthe child;
          Application of a wire ecraseur immediately below
        the  constrictor.  Ecraseur to be left on  several days
        and tightened as stump shrinks;
          Transfixion  of the cervix  with  two or three long
        pins (knitting needles) just above the ecraseur;
          Amputation of the uterus *A inch above the clamp;
          Removal of rubber constrictor;
          Suture of the abdominal wound, stitching the stump
        to the peritoneum in the lower angle;
          Ligation ofthe uterine arteries in the stump;
          Mummification of the stump with liquor  ferri per-
        chloridi;
          Dressing.
          Inversion ofthe stump into the vagina  may be sub-
        stituted for fixation in the abdominal wound. 
148
Obstetric Surgery.
      Tait's Method.
           Abdominal incision large enough to admit the hand.
          Constriction of the cervix with a finger-thick rub-
        ber tube,—passing loop over the fundus.
          Incision ofthe uterus and removal ofthe child and
        placenta.
          Eventration ofthe uterus.
          Pack hot cloths about the cervix to keep blood out
        ofthe abdomen.
          Transfixion of the cervix by two or three knitting
        needles passed through the constricting tube and the
        cervix.
          Amputation of the uterus % inch  above the con-
        strictor.
          Ligation ofthe uterine arteries.
          Suture ofthe abdominal wound, stitching the stump
        in the lower angle.
          Mummification ofthe stump with perchloride of iron
        solution.
          Dressing.
Laparo-Elytrotomy:  Thomas' Operation.
          First proposed in the early part of the present cen-
          tury by Joerg, Physic, Sir Charles  Bell and Ritgen.
          First completed operation by Baudelocque in 1843.
          Revived  by Thomas and done by him in February,
          1870.
      Results
          Fourteen operations with 50% of mothers saved.
      Advantages.
          Avoids opening the peritoneum.  Unimportant.
      Disadvantages.
          Circuitous route and difficult extraction of the child.
          Danger of injuring the bladder.
          The modern Caesarean or the Porro operation is sim-
        pler and safer.
      Technique.
          The usual  preparatory  treatment and antiseptic
        precautions. 
                   Obstetric  Surgery.               149

          Abdominal  incision  on either side, parallel with
        Poupart's  ligament, a little more  than one inch above
        it, extending from  a point one  inch or more  above
        the anterior superior spine of the ilium to a point one
        and three-fourths inches from the pubic spine.
          Go down to, but not through,  the  peritoneum.
          Peel the  peritoneum  from  the transversalis  and
        iliac fasciae and the  posterior vaginal wall, and hold it
        and the intestines upward.
          Isolate and protect the ureter.
          Let assistant push the vaginal  wall up into the in-
        cision by means ofthe finger or an obturator.
          Incise  the vaginal wall  horizontally  with  blunt
        scissors or a cautery knife as far  below the cervix as
        possible.
          Mark the lateral  limit of the bladder by a sound in
        the bladder and the finger of assistant in the vagina.
          Lengthen the vaginal incision by the finger, mainly
        backward.
          Extract the child through the wound by the feet or
        by  forceps,  the fundus being drawn to the opposite
        side by an assistant.
          Deliver the placenta either by  wound or vagina.
          Inject the bladder with milk and water to detect
        possible laceration.
          Pass one or two perforated drainage tubes  through
        the external wound into the vagina.
          Suture the abdominal wound.
          Dressing as in Caesarean section.
          During  convalesence keep the  wound and passages
        free from  septic  fluids by irrigation.
Pubiotomy:  Symphysiotomy.
      History.
          First proposed in  1768.  After half a century it
        became obsolete.
          Revived in 1866 by Morisani of Naples, Italy.
      Method of Operating.
          Incise the overlying  structures down  to the sym-
        physis pubis. 
150                Obstetric Surgery.
          Pass a  strong  curved bistoury from  above  down
        along the  posterior  surface of  the symphysis and
        divide the joint.
          After delivery immobilize the  pelvic bones with  a
        firm bandage.
      Objections to the Operation:
          Danger of injuring the bladder;
          Danger of injuring the sacro-iliac joints;
          Possible caries of anterior pelvic wall.

                Sacrificial Operations.
Embryotomy.
          The general term  for all obstetric operations em-
        ployed to facilitate delivery by  lessening the size of
        the foetus.
          By some writers restricted to operations for reduc-
        ing the trunk.
      Indications :
          Hydrocephalus too large for safe extraction without
        perforation;
          Certain cases of narrow  pelvis,—as  an  alterna-
        tive of Caesarean section, on  choice of  the  mother,
        conjugate 2 or 2^ to  3^ inches;
          Obstructed labor  with dead or  non-viable foetus,
        conjugate above 1% inches.
Craniotomy.
          An operation for the  partial  or complete comminu-
        tion and  removal of the cranial bones.
  Steps.
  1. Perforation.
          Instrument, Smellie's scissors  or other perforator,
        especially the trephine.
          Pass the point of the perforator  against the  head,
        perpendicularly to its surface,  just behind the pubes,
        using the fingers of one hand as a guide and guard.
          Fix the point in the bone by  a  screw-like motion
        and perforate in similar manner.
          Separate the blades in different directions to enlarge
        the perforation. 
                    Obstetric  Surgery.                15 s

           The trephine removes a button of bone.
           Break up the brain throughout with the  perforator,
         especially the medulla oblongata.
           Wash out  the brain  substance  with a stream  of
         water from a  syringe.
  2.  6 omminution.
           With  the craniotomy forceps passed within  the
         scalp, seize the cranial bones one by one.
           Break them up and dislodge them one  by one, by
         rotating the forceps about its long axis.
  3.  Extraction.
           Remove  the bones, avoiding laceration of the pas-
         sages, till the bulk ofthe head is sufficiently reduced.
           Extract the foetus  by  means of the craniotomy for-
         ceps, the crotchet or the cephalotribe.
Cephalotripsy.
           An operation for crushing the  cranial vault.
           Lusk's the best cephalotribe.
           Extraction  may be accomplished by means of the
         cephalotribe or  a  powerful  craniotomy forceps like
         Braun's so called cranioclast,
Decapitation or Decollation.
           Called  for  in  certain  cases of impacted shoulder
         presentation.
      Method, vide p.  120.
Evisceration.
           Includes  all operations for reducing  the size ofthe
         trunk by removal of its viscera. 
152         Pathology of the Puerperium.
      PATHOLOGY  OF THE PUERPERIUM.

Mammary Abscess.
    Causes:
      Predisposing:
          Bad general health;
          Milk stasis;
          Lesions ofthe nipples.
      Exciting:
          Sepsis.
    Forms;
          Subcutaneous;
          Glandular:  Mastitis or Parenchymatous Mastitis;
          In the great majority of cases a lymphangitis;
          Subglandular: Paramastitis.
          Two or all forms may coexist.
    Diagnosis:
        Subcutaneous Form.
          Signs of ordinary phlegmon;
          Generally single.
        Glandular Form.
          More pain;
          More constitutional disturbance;
          Generally ushered in  by a chill;
          Induration ofthe gland;
          Often multiple.
        Subglandular Form.
          Pain deep-seated;
          Gland not indurated;
          Gland floats on the underlying fluid;
          Pass an exploring needle beneath the gland.
    Treatment.
      i. Prophylactic.
         Massage in simple milk engorgement,—without in-
         flammation. 
            Pathology of the Puerperium.         153

          Tonics, especially quinine.
          Aseptic management and curative treatment of nip-
          ple lesions.
      2. Abortive.
          Absolute rest, in true mastitis
          A saline cathartic.
          Oleate of atropia locally,—with care lest the secre-
          tion be too much  repressed.
          Support by a sling with equable compression.
          Quinine.
      3. Treatment of Suppuration.
          Open early and freely, with antiseptic precautions.
          Incision should radiate in  a  direction from the nip-
          ple, avoiding the  areola.
          Counter-opening  if necessary for drainage.
          Antiseptic irrigation frequently repeated.  Peroxide
          of hydrogen  the best antiseptic for the purpose.
          Antiseptic dressings.
          Compression to keep the walls of the abscess cavity
          in contact.

Puerperal Eclampsia.
      Definition:—Eclampsia during pregnancy, parturition or
          the puerperal period,  from causes pertaining to the
          gravid, the parturient or the puerperal condition.
      Frequency, 1-500.
          Most frequent in primiparity, twins, excess of fat.
          Occurs more frequently in pregnancy or labor than
          in the puerperal period.
      Causes;
          The puerperal condition.
          Peripheral irritation.
          Uraemia (so called) the chief cause—the toxic ma-
          terial  acting upon the  convulsive  and the vaso-
          motor centers.
          The uraemia is due to acute parenchymatous or, in
          a certain proportion of cases, chronic nephritis, or
          to acute supervening upon chronic. 
154         Pathology of the Puerperium.

          Doleris  and Butte have found toxic ptomaines  in
          the blood of eclamptic patients.
          The  chief immediate cause  of the  convulsions  is
          acute anaemia of the brain from vaso-motor spasm
          ofthe cerebral vessels.
      Premonitory Symptoms and Signs;
          CEdema, especially ofthe face;
          Debility;
          Headache,  generally frontal,—suboccipital rarely;
          Nausea or other digestive disorders;
          Visual disturbances;
          Epigastric pain;
          Albuminuria;
          Casts.
      Differential Diagnosis.
          Distinguish  from  hysterical convulsions, epilepsy,
          apoplexy.
      Clinical History.
          Symptoms already referred to.
          Eyes fixed.
          Spasmodic  movements, first of  the facial muscles,
          then becoming general.
          Convulsion at first clonic then tonic.
          Asphyxia and cyanosis from  tonic  spasm of the
          respiratory muscles.
          Frothing at the mouth, generally bloody.
          Duration, one or two to five minutes, rarely longer.
          Coma follows, usually subsiding within half an hour.
          Intervals, from a few minutes to several hours.
          Pulse, 100 to 140 deg. F.
          Temperature varies in different cases from normal
          or subnormal to  1050 F., or more.
      Prognosis.
          Graver the earlier  the attack in pregnancy or labor.
          Danger increases with the number of seizures.
          Recovery is rare after a temperature of 1050 F.
          Impairment of the mental faculties  sometimes fol-
          lows. 
     Pathology of  the  Puerperium.          155

 Mortality:
    Maternal about 30%,—from
     Slow asphyxia during convulsion;
     Cerebral hemorrhage or congestion.
    Fcetal about 50%,—from
     Asphyxia, apoplexy or lesions ofthe cord;
     High temperature.
Treatment.
 Prophylactic.
    Treatment ofthe nephritis.
      Milk diet.
      Saline cathartics.
      Diaphoresis.
      Dry cups over the kidneys.
      Digitalis and saline diuretics.
    Bromides or chloral  if required as  prophylactics
    against convulsions.
    Ext. veratri viridis fl. (Squibb),  3 to 6 minims, t. i.
    d., or to keep pulse below 70,—for the same purpose.
    Iron as a restorative.
    Induction of  labor in  cases that  do  not yield
    promptly.
    Acceleration  of the labor, cautiously.
    Chloroform during labor, as an  anti-eclamptic.
   Remedial.
    Chloroform, by inhalation.
     Ext. veratri viridis fl.  (Squibb), 10 to 20 minims
     hypodermically; repeat every half-hour till the pulse
     is below 60 to the minute.
     Catharsis:
       Calomel and salines;
       Elaterium (Merck), % gr.; or
       Ol. tiglii, 1 or 2 minims.
     Wet cups over the kidneys.
     Chloral, 20 to 40 gr-, and bromides % to 1 drachm,

     Morph- sulph., # to 1% gr., hypodermically.
     Nitroglycerine, efoth gr. 
156         Pathology of  the  Puerperium
          Nitrite of amyl,  5 minims, by inhalation.
          Inhalation of oxygen.
          Accelerate the  labor.  Induce labor if  not  spon-
          taneously established.
        Restorative.
          Iron and general tonics.
Puerperal Insanity.   Insanity of Pregnancy, the  Puerperium
    and Lactation.
      Causes;
          Heredity:
          Bad mental hygiene;
          Anaemia;
          Septic infection. — Distinguish from the  transient
          delirium of septicaemia.
      Prognosis.  Generally favorable.
       Treatment.
          Mental and physical hygiene.
          Iron, pil. Blaud, 1 or 2, t. i. d.
          Arsenious  acid,  gr. s'oth t. i. d.
          Arseniate of iron, gr. reth t. i. d.
          Hyoscyamine in maniacal forms, gr.  s&o p. r. n.
          Morphia, cautiously, in melancholia.
          Treat infection as in other cases.
Puerperal Fever:  Puerperal Septicaemia.
      Frequency.
          In  absolutely aseptic practice, nil.  In well man-
          aged, isolated maternities, less than half  of one per
          cent, of puerperal  women die from sespis.
          In general private practice without antiseptics there
          is little less than one per cent, of fatal cases.
          In  pre-antiseptic times "epidemics " were  frequent
          with  a death rate  of three to ten per cent, or even
          more.
          More frequent in primipar^e; than in  multiparae.
      Etiology.
      Cause, septic infection.  Lowered resisting power favors. 
Pathology of the Puerperium.          157
 Sources of Infection:
     Cadaveric and other dead and decomposing animal
     matter;
     Lochia of puerperal fever patients;
     Secretions from suppurating or erysipelatous wounds;
     Diphtheria or  scarlet-fever in  certain cases owing
     to complications involving the presence of wound
     infection germs;
     Idiopathic  erysipelas.
     Self-infection (auto-infection) in the strict sense of
     the term does not exist.
 Vehicles of Infection.
     The hands of  the physician or nurse, instruments,
     utensils, cloths, germ-laden dust, etc.
 Avenues of Absorption.
     The obstetric wounds.
        Of lower uterine segment,  placental site, in  fact
        the entire  cavity of the uterus.
        Lacerations  of the cervix, vagina, introitus.
     Even intact surfaces ofthe genital mucosa.
 Channels of Diffusion.
     Lymphatics and to some extent the veins.
 Bacteriology.
      The  organisms most frequently found are
      The  streptococci,—chain cocci.
      Staphylococci are  occasionally found.
      The  rod-shaped bacteria of  putrefaction are gener-
      ally  present.   Putrefaction' of  lochia  furnishes  a
      favorable  soil for  the  development  of  pathogenic
      organisms.
      Certain other  microorganisms  are believed  to be
      possible factors in the  pathogeny.
      Ptomaines play an important role in the pathogen-
      esis.

Pathology,
      Endometritis;-may lead to salpingitis and ovaritis.
      Metritis.
      Para-metritis. 
158         Pathology of  the  Puerperium.

          Perimetritis or pelvic peritonitis.
          Diffuse peritonitis.
          Uterine  lymphangitis and phlegmonous lympha-
          denitis;—generally attended with peritonitis.
          Phlebitis, uterine, para-uterine, and crural.
          Colpitis.
          Pure septicaemia:—Acute ptomaine poisoning.  Pu-
          trid intoxication.
          Other  remote lesions; e. g.,  pneumonia,  pleurisy,
          pericarditis, endocarditis, nephritis, arthritis, subcu-
          taneous phlegmons and  others.
    Prognosis.
          As  a rule the earlier the attack the graver the prog-
          nosis.
          Most unfavorable in acute putrid intoxication, puru-
          lent peritonitis, pyaemia.
    Diagnosis.
    General Symptoms of Infection.
          First symptoms  generally  developed on the second
          or third  day,  rarely later  than  the fourth  or fifth,
          since the obstetric wounds have by that time begun
          to granulate.
          The majority of cases begin insidiously.
          The attack is frequently ushered  in by a  chill or
          slight chilliness.
          The most  prominent early symptoms are a rise of
          the pulse,—100 to 140,—elevation of temperature,—
          1020 to 1040, F., fetid lochia.
          Eliminate malarial  pyrexia (by*quinine), constipa-
          tion, emotional,  mammary  and  other non-septic
          causes.
    Symptoms of Special Lesions.
      Endometritis:
          Painful and prolonged after-pains;
          Cervix more patulous than normal for the time;
          Cavum uteri containing putrilage;
          Prolonged  bloody flow;
          Involution retarded. 
      Pathology of  the  Puerperium.          159

Metritis:   The  same condition as in simple endometric
    inflammation  together with oedematous swelling of
    the uterus.
Parametritis:
    Localized  pain and tenderness;
    Exudate in one, possibly both broad ligaments;
    Uterus displaced and partially fixed;
    Fluctuation if pus forms.
PERIMETRITIS:
    Pain  and local tenderness usually intense;
    Uterus becomes fixed;
    Tumefaction in vaginal  vault;
    Moderate tympanites;
    Frequently, nausea;
    Lochia scanty.
Diffuse Peritonitis:
    Exquisite  pain in  the early stages;
    Tympanites extreme;
    Vomiting  of greenish fluid;
    Later, shock  and  collapse.
Vulvar Lymphangitis:
    Local tenderness  and swelling;
    Swelling of superficial inguinal glands;
    Red  streaks in the skin, leading from the vulva  to
    the groin.
Uterine Lymphangitis:
    Pain, tenderness and swelling ofthe uterus;
    Frequently associated with signs of peritonitis
Uterine Phlebitis:
    Irregularly recurring chills;
    Marked oscillations of temperature;
    Absence of local  tenderness  and swelling in pure
    phlebitis;
    Metastatic affections of remote organs.
Phlegmasia  Alba Dolens:
  Thrombo-Phlebitic Form:
    Develops several days or even weeks after delivery;
    Is generally preceded by signs of pelvic inflamma-
    tion or some form of sepsis; 
i6o         Pathology  of the Puerperium.

          Pain in the affected limb;
          Limb becomes  swollen, tense, hard, white, glisten-
          ing;
          Affected veins  felt  on palpation as hard irregular
          cords, owing to thrombi.
          Resolution begins after about two weeks.
          Duration may be many weeks.
          There remains  more or less oedema  in standing or
          walking with impairment of muscular power, in a
          certain proportion of cases lasting for months.
      Cellulitic Form.
          Characterized by inflammation, suppuration and ne-
          crosis of connective tissue.
      Colpitis:—Signs of inflammation, simple catarrhal, ulcera-
          tive, diphtheritic;
          Labia often oedematous in ulcerative vaginitis.
      Pure Septic/emia:
          Characterized by pyrexia with absence of percepti-
          ble lesions;
          Countenance sallow, sunken, anxious;
          Occasionally delirium or coma;
          Diarrhoea and vomiting, dark grumous ejecta.
          Runs  a  rapid course, frequently terminating within
          a few days.
      In most cases of puerperal fever several of the lesions
       above described coexist.
    Treatment.
      Prophylactic.
       Prevent infection:
          By careful  disinfection of the  hands, instruments,
          utensils  etc., before each contact with the genitals;
          Cleanse  the external genitals in like  manner before
          examination;
          Disinfect the vagina and  cervix before   labor for
          cause;
          Examine, per vaginam, as seldom as possible;
          In  most cases vaginal examination  may,  when 
Pathology of  the  Puerperium.          161
    special care is required, be omitted altogether;
    Avoid all preventable injury to the passages.
Remedial.
  General Treatment of Infection.
    Catharsis,—hydrarg. chlorid, mit., 10  to  20 gr., and
    a saline.  Repeat p. r. n.
    Dislodge the enemy and reinforce the resisting pow-
    ers of the patient.
    Vaginal douche,  i-iooo  hydronaphthol, or 1-2000
    bichloride or biniodide of mercury. A safe and most
    efficient germicide for the purpose is the peroxide
    of hydrogen in full or half strength.
    Wash out the mercurial solution with a final injec-
    tion of plain  boiled water.
    If the  pyrexia is not relieved  within twelve hours
    douche the uterine cavity  with  one of the above-
    named solutions of half strength, following with  a
    plain water injection.
    This failing, the  uterine cavity  being  septic, im-
    mediately remove all necrotic  material with a large
    dull curette and antiseptic douche.
    Support the  patient with tonics, stimulants (maxi-
    mum dose one quart of brandy or  its equivalent
    daily), and forced alimentation.
  Treatment of Peritonitis.
    Hydragogue cathartics with large stimulating ene-
    mata, to procure several  copious evacuations daily;
    to be continued, p. r. n.
    Moderate doses of opium if required to control pain
    Local antiseptic measures if indicated.
    Dietetic supports, tonics and stimulants.
    In purulent peritonitis, open, irrigate and drain the
    peritoneal cavity.
  Treatment of Parametritis.
    Hot vaginal  douches, several gallons, temp. 110 to
    120 deg F., two or three times daily.
    Antiseptic and  general  treatment as above indi-
    cated, except the  curette. 
 162          Pathology of the Puerperium.

           Pelvic abscess, evacuate  early  and drain,  by the
           vagina or the abdomen as the indications in the case
           may require.
         Treatment of Colpitis.
           Irrigate several times daily with  2^°/° solution of
           creolin,  chlorinated  soda  I  in io,  peroxide of
           hydrogen.
           Touch necrotic patches with liq. ferri perchlorid.,
           tr. iodine, or 50% sol. zinc, chlorid.
         Treatment of Phlegmasia Alba Dolens.
           Keep the limb at rest in a horizontal position.
           Subdue pain by  the local application  of morphiae
           oleas.
           Avoid massage.
           The patient may leave the bed when the swelling
           subsides.
           From that time should use support  by means of an
           elastic (flannel) bandage or elastic stocking.

Canses of Sudden Death in Childbed.
      Shock.  Treatment:—Combat with alcoholic stimulants,
           atropia,  external warmth, rectal  injections  of hot
           water.
      Snycope.  Treatment;—Lower the head; give  diffusible
           stimulants.
      Embolism and Thrombosis.   Cerebral  embolism.   Throm-
           bosis of pulmonary artery.
           Treatment,  expectant,—absolute rest.
      Iir Embolism.   For prophylaxis  avoid  introduction of
           air into the passages and keep the  patient  in  the
           dorsal decubitus for a few hours after delivery.
      Acute Pulmonary CEdema.   Treatment, hypercatharsis;  hy-
          podermic  use of digitalis.
      Non-Puerperal Causes.   Apoplexy; cardiac  disease with
          advanced valvular  lesions, especially mitral  steno-
          sis; myocarditis, and other causes. 
 
 
 
 
 
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