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FENWICK, M.A., M.D. Pro/; Obstetrics and Diseases of Women and Children, Royal Colleje of Physicians and Surgeons in affiliation with Queen's University, Kingston ; Member of the Royal College of Surgeons, England ; Fellow of the Obstetrical Society, Edinburgh; and Surgeon to the Kingston General Hospital. ■> 1 J J 1 1 J > \ ■% i > •• * ' « 4 > •1 1 4 > » J', V. ' » J i i i i KINGSTON, ONTAKIO : JOHN HENDERSON & CO., 1889. / Lt'-i. (X'i'--V^ Entered according to Act of the Parliament of Canada, in the year one thousand eijfht hundred and eighty-eight, by Kknnktii N. Fknwick, M.A., M.D., Kingston, Ontario, in the Office of the Minister of Agriculture. the M pr l/ l-\ PREFACE. The object of this little book is to furnish an outline of the main facts in Obstetrics and the Diseases of Women and Children, and includes a synopsis of the physical signs of Diseases of the Chest and Diseases of the Skin. It is really a syllabus of my sessional lectures with such additions and alterations as I thought would make it more valuable for reference in emergencies. While seeking to meet the wants of the medical student in I general, and my own class in particular, the work does not pretend to originality, nor does it aim at supplanting the larger text books on the subject which are not always within I the reach of every medical student. Elegance of expression has often been sacrificed to con- jciseness, for obvious reasons. In conclusion, I wish to acknowledge my indebtedness to [Mr. J. R. Shannon, B.A., for valuable assistance in revising [proofe. 141 King St. W., Kingston. 146756 Ti CONTENTS. OBSTETRICS. Page. The Female Organs of Generatiox. 1 I. External 1. The pudenda. Mons veneris, labia Majora and minora, Clitoris, vestibule, hymen 2 Curunculse myrtiformes, and Fossa navicularis 2. The Vagina. II. Internal. • • 4 1. The Uterus. 2. The fallopian tubes. 5 Graaffian follicle. 6 Parovarium, ovum. III. Periodical Ovulation. 7 1. The discharge of the ovum. 2. Menstruation. 8 3. The Corpus luteum. 10 False and true. IV. Fecundation of the Ovum. 11 V. Development of the Ovum. 12 1. Formation of nucleus of vitellus. - - - - 13 2. Segmentation of vitellus. 3. Formation of the membranes. 14 Amnion, allantois, chorion, Umbilical Vesicle. 15 4. Preparation of the Uterus to receive it. - - - 16 Decidua vera, refiexa, and serotina. 5. Formation of the Placenta, the umbilical cord. - - • • - - - 18 VI. CONTENTS. VI. Development of the Embryo. 1. Of its various parts. 2. As a whole. B. Pregnancy. I. Changes occmTing in the mother. 1. In the sexual apparatus. 2. In the system at large. II. The Higna of pregnancy. 1. Cessation of the Menses. 2. Mammary sympathies 3. Abdominal enlargement. 4. Ballottement. . . - . 5. Quickening. 6. Auscultation. \ - - - (a). Pulsation of foetal heart. (6). Uterine souffle. 7. Jacquemier's Test. - - - 8. Intermittent Uterine Contractions. 9. Kyestine in the Urine. 10. Morning Sickness. » = 11. Salivation. III. The Disorders of Pregnancy. • 1. Local. (a) (Edema of Labia. . (h) Pruritus of ^'ulva. (c) Metritis. 2. Reflex. (a) Neuralgia. (b) Salivation. (c) Vomiting, f'rfj Constipation. (e) Syncope. (f) Insomnia. 3. Mechanical, .... Hygiene of Pregnancy. IV. Abnormal Pregnancy. 1. Due to peculiar conditions of uterur (a) Double, (b) Displacements. 2. Due to peculiar conditions of decidua. 19 20 22 23 24 26 26 27 28 29 30 30 GONTEETS. VU. C. 33 34 35 36 3. Due to peculiar conditions of placenta. - • • 31 As to form, position, development, and nutrition. 4. Due to peculiar conditions of amnion and its fluid. (a) Excess — hydramnion. (h) Deficient. 5. Due to peculiar conditions of the cord. 6. Due to peculiar conditions of the chorion. Hydatidi- form mole. V. Prematv/re expulsion of the ovum. Abortion. Causes — 1. Maternal, (a) Predisposing. (b) Exciting. 2. Foetal. Diagnosis, prognosis. Treatment. 1. The prevention of habitual abortion. 2. The arrest of threatened abortion. 3. The management of inevitable abortion. (a) Where the sac is not -uptured. (b) Where the sac is ruptured. 4. The management of neglected abortion - - 37 5. The management of premature labors. VI. Extrauterine pregnancy, or ectopic gestation, • - • 38 1. Tubal pregnancy. 2. Ovarian pregnancy, 3. Abdominal pregnancy. Symptoms, termination, diagnosis. Treatment. 40 1. Cases of early gestation. 2. Cases of advanced gestation. (a) Foetus living. ' (b) Foetus dead. Labor. I. Duration of pregnancy. 41 II. Cause of onset of labor, III. Symptoms, 42 Premonitory. Ist stage. 2nd stage. 43 3rd stage. - • •44 ■■^^OtitSMUrit vm. CONTENTS. K> I IV. Duration of labor. V. The expellent forces. 45 1. The uterine contractions. The nervous mechanism of labour. - - - 46 2. The accessoiy forces. - 48 VI. The mechanism of labour. 50 1. The female pelvis. Its planes ami axes. 51 2. The fatal head. 53 Its sutures, fontanelles, and diameters. • - 64 VII. Eutocia or normal Inhor. The position of vertex, - - - - - 56 1st Position. 1. Descent and flexion. 56 2. Rotation. 57 3. Extension. 4. Restitution. 5. Expulsion of the trunk. 2nd Position. 58 3rd Position. 1. May be converted into 2nd. 2. Persistent 3rd. 4th Position. 59 Management of labour. - 59 Of 1st stage. - 61 Of 2nd stage. 61 Of perineum. 62 Of 3rd stage. 63 Use of aQ -esthetics. VIII. Dystocia or extraordinary labor. - >' - • • 64 1. From imperfect uterine eflforts. (a) Irregular action. (b) Inertia. 66 Use of ergot — its indications and contra-indications. 66 2. From impeded uterine efforts. (a) Connected with the foetus. (a) From abnormal position, (i) Face presentation. CONTENTS. is,. (ii) Breech presentation. • • - 68 Management. - - • - 70 Treatment of aftercoming head, (iii) Shoulder prejentation. • - 71 Terminations and treatment. - - 72 ()9) Size and form, (i) Large heads, (ii) Deformities. iy) Number. Multiple pregnancy. Twins. 73 (b) Connected with the passages. (a) Pelvis. 74 (i) Contracted pelvis proper. 1st. Pelvis ^quabiliter Justo-minor. 2nd. The flattened pelvis. - - 75 3rd. The flattened generally con- tracted pelvis, (ii) Irregular forms. 1st. The Nacgele Oblique. 2nd, The Kyphotic. . 3rd. The Scolio- Rachitic. Measurement. - - - 76 I. Internal pelvimetry. II. External pelvimetry. Influer^ce of contracted pelvis. 1. During pregnancy. - • 77 2. During labor. Treatment. - • - 78 (/3) Os uteri. (i) Obliquity. 79 (ii) Rigidity. (iii) Induration, (y) Vagina. (i) Atresia. (ii) Tumors. (c) Connected with the secundines. - - - 81 (o) Liquor amnii. (i) Abundant, (ii) Deficient. ^ Z. CONTENTS. (y9) The membra les. 81 " • (y) The cord. (i) Short. - (ii) Entangled, (iii) Presenting. (, not viscid, and containing a small quantity of album- inoid matter coagulable by heat. The Parovarium or organ of Rosenmiiller is the remains of the Wolffian body lying in the folds of the broad ligament between the ovary and the fallopian tube. It consists of from 12 to 15 tubes of fibrous tissue lined by ciliated epithelium and is often the seat of so-called Parovarian cysts. The Germ Cell or Ovum when ripe is 1-125 in. in size, glob- ular in shape and consists of : — {a). Zona Pellucida, or external membrane, clear, structure- less, strong and resisting, 1-2,500 in. in thickness. This with ons'fETRica. . 7 radiating HtriatioiiH bocoiiioH the vitelline lUeinhruiie. In fislieK and niolluscH tiiere exiHtH a niicropyle ur poruH for the pasHago of the spermatozoa, and though thia has not been demonstrated in the mammalia or in man, it ))rol)ably exists. (6). The VUellus, c lied the principal or formative yolk, contains the elements which are to undergo development into the embryo. It is a semi-fluid mass containing besides the ger- minal v£ 'cle, numerous granules which are largo strongly- refracti.^ ^ 'obular bodies, very bright; and between these are smaller and not so distinct albuminous granules. (c). The Germinal Vesicle is the enlarged nucleus of the primordial ovum, and is clear, globular, 1-700 in. in size, em- bedded in the vitellus, its position varying. In its interior are a number of fine granules and a large dark spot, {d). The Germinal Spot, which is 1-3,000 in. in size. m. PERIODICAL OVUIjATION. 1 . The Discharge of the Ovum. A ripe Graaffian fol- licle about 2 5 in. in size presents a rounded elevation with en- larged blood vessels upon the surface of the ovary, and at the most prominent portion is an ovoid spot which is entirely free from blood vessels, called the macula folliculi, where for a time before rupture a process of fatty degeneration is going on. At the same time at other portions of the follicle there is a growth of cells which projects into the interior, as well as an extension of blood vessels in the form of loops. These changes, together with the increase in pressure of the liquid contained in the fol- licle, causes the latter to burst, and with the liquid the discus proligerus and ovum are expelled. The periodical ripening of the ova and their discharge consti- tutes " ovulation " and may be considered as the primary act of reproduction. It is necessary to bear in mind then tl .t the ova exist originally in the ovaries as part of their natural struc- 8 OBSTETRICS, r 4 'i »' >t ture ; that t.hey only become fully dovelopod at a certain age, viz : that of puberty, when the generative function ia about to be established ; that successive cro})s of these ova ripen and are discharged in the adult female independently of sexual inter- course. Furthermore the ripening and discharge of the ovum are acconipanied by a peculiar condition of the general system known in the lower animals as " rutting " and in the human female as menstruation. 2. Menstruation. During infancy and childhood the sex- ual system is inactive, but at the age of 1 4 or 1 5 the human female undergoes a remarkable change and arrives at what is termed the age of puberty. There is then a marked increase in the general development of the body ; the limbs become fuller and more rounded ; a giowth of hair appears upon the mons veneris ; the mammary glands increase in size and take on a new stage of development ; Graaffian follicles enlarge and appear ready to rupture. At this time is also noticed a change in the moral as well* as the physical attributes of the female ; a seeming consci- ousness of a capacity for new functions and a change in feeling towards the opposite sex which gives rise to that modesty so becoming and lovely in the true woman. The female now becomes capable of impregnation and con- tinues so, in the absence of pathological conditions, until the final cessation of the menses, known as the menopause or climac- teric which usually occurs at 45 years of age. Puberty occurs earlier in warm than cold climates, and its onset is earlier in some girls than in others. Together with these changes then in the female at puberty a discharge or flow from the genital organs is established, and this recurs every 28 days, corresponding to the period of dis- charge of the ovum. Each period begins with a feeling of gen- eral malaise, a sense of fulness and weight in the pelvic organs, and an increase of vaginal mucus, which has a peculiar fishy OBSTETRfCS. 9 odour. Those feelings are soon relieved by a discharge of blood I which is usually kept fluid by the acid vaginal mucus. It lasts on I an average four days, and measures about 6 oz., becoming gradu- ally less in amount, and lighter in color until it stops. The mucous membrane of the uterus at this ,ime is thicker and softer and smeared with blood. From the 1-25 in. in thickness it becomes 1-5 in. thick, loosely attached, tnrown into folds, and its glands [enlarge. A fatty degeneration of the surface of the mucous membrane and of its blood vessels gives rise to the hemorrhage. Except a considerabL^ desquamation of epithelium there is no true exfoliation of the mucous membrane in normal menstrua- tion although there is in membranous dysmenorrhcea. The process of menstruation may be thus explained : An ovum ripens ; the swelling of the Graafian follicle irritates the nerve termini in the ovary, which irritation is propagated to the central organs. Through reflexefj by vaso-motor pro- cesses an arterial congestion jf the internal female sexual organs is set up. This in turn increases the liquor folliculi, so that the theca folliculi bursts and allows the ovum to escape, — ovu- lation. At the same time the uterine mucosa becomes so hyper- semic that there occurs a bursting of the peripheral vessels, hemorrhage occurs upon the surface of the uterine mucous mem- brane, constituting menstruation. It is immediately after the menses that sexual desire is decidedly marked and at this time impregnation is most apt to take place. As we should naturally expect removal of the ovaries prevents ovulation and menstruation and usually removes sexual desire. The ovum when discharged from the ovary enters the fimbriated extremity of the fallopian tube, the fimbriae being covered with vibratile ciliated epithelium, inciting a kind of vortex in the peritoneal fluid which carries; toward and into the tube everything lying near it. This is seen experimentally in the lower animals with coloring matter which is even drawn from one side to the other when the opposite tube is occluded. The ovum then passes 10 OftSTETRICS. I along the tulx) to tho uterus by the nioveinent of the ciliated epitheliuin. Accidental causes may arrest it at the surface of j the ovary, and if impregnated, give rise to "ovarian preg- nancy ; " if it drops into the abdominal cavity, we have " abdominal pregnancy," or i.. arrested in the fallopian tube, " tubal pregnancy." If sexual intercourse do not take place the ovum passes down to the uterus unimpregnated, loses its vitality after a short time and is carried away with the uterine discharges. The menstrual flow is therefore onlv the external manifestation of a more important process taking place within. Its disorders constitute amenorrhcea, dysmenorrhsea and monorrhagia. 3. The Corpus Luteum . Let us see now what takes place in the Graafiian follicle after the expulsion of the ovum. Its office of providing for the formation and growth of the ovum is now over and it passes through a process of oblitr«ation. The bloody cavity left becomes converted into a peculiar solid spher- oidal body called the corpus luteum, the growth and retroces- sion of which are modified by pregnancy, so that we have two varieties, that of menstruation and that of pregnancy. (a). The Corpus Luteum of Menstruation, often called the false corpiis luteum. After rupture, blood fills the cavity of the Graaffian follicle and soon coagulates. This begins to con- tract and the serum sepai^atea from the clot and is absorbed, while the clot becomes smaller and denser, and its coloring mat- ter becomes partially absorbed. At the same time the vesicular membrane becomes thickened and convoluted, beginning at the deeper part of the follicle. This hypertrophy reaches its maxi- mum at the end of three weeks, and the ruptured follicle has now become completely solidified, showing a prominence upon the ovary and a minute cicatrix. After this it diminishes in si/e, its central coagulum continues to be absorbed, loses still its coloring matter, and the whole goes on atrophying. The OBSTETRICS. 11 convohited wall aKSUines a more decidedly yellow color, under- goes fatty degeneration and at the end of eight or nine weeks the whole is reduced to an insignificant yellowish cicatricial mark, and finally all traces of it disappear. At a post mortem several of these may be seen in various stages of growth and atrophy. Such then is the process that takes place independently of sexual intercourae or impregnation. (b). The Corpus Luteum of Pregnancy. The true corpus luteura presents a difference in the rapidity and degree of its development, due to the sympathy which exists between the uterus & the ovaries. As soon as pregnancy takes place menstruation is arrested, no ^ore ova come to maturity and no more Graaffian follicles are ruptured during the whole period of gestation. Hence we might expect that the corpus luteum would be affected by an influence which affects the system in general so profoundly. During the first three weeks its growth is the same as the false variety, but during the fourth week instead of retrograd- ing it continues developing, the external wall growing thicker and more convoluted. This growth goes on until by the third and fourth month it reaches its maximum, about the sixth month it begins to retrograde, and aftei- delivery atrophy goes on rapidly, and after lactation has come to an end the ovaries resume thcdr ordinary function as before. \ ^ IV. FSOUNDATION OF THE OVUM. The last change and one which indicates its complete maturity, is, that the germinal vesicle comes to the surface and disappears from view, as also the germinal spot. In place of the germinal vesicle a spindle-shaped body appears. The granular elements of the vitellus arrange themselves around each of the two poles of the spindle in the form of a star. When this takes place the peripheral pole of the nucleus or altered germinal vesicle, along 12 OBSTETRICS. I I •i r with somo of Uiocollular substance of the ovum, protrude upon the surface of tlie vitelhis, where they are nipped off from the ovum in the form of small corpuscles jusi like an excretory pro- duct. These bodies, which are not made use of in the further development and growth of the ovum, are called polar or direct- ing globules. The remaining part of the germinal vesicle stays within the vitellus and travels back towards the centre of the ovum to form the female pronucleus. As a rule only one sper- matozoon penetrates the ovum and as it does so it moves towards the female pronucleus while its head becomes surroun - ded with a star ; it then loses its head and tail, the latter only sei ving as a motor organ while the remaining middle piece swells up to form a second new nucleus, the male protonucleus. The union of these two elements forms the first embryonic seg- mentation sphere or blasto-sphere. (^Landois). Should union of the sexes have taken place by the fusion of the germ cell and sperm cell, a new stimulus is imparted to the growth of the former, and the fecundated ovum starts on a peculiar course of development by which it is finally converted into the body of the young animal. Many questions of great interest arise in connection with fecundation such as hereditary influence ; miaternal influence ; determination of sex, and effect of previous pregnancies. V. DEVELOPMENT OF THE OVUM. It is probable then that the ovum is fecundated either in the fallopian tube or in the pavilion near the ovary. The ovum as it passes down the fallopian tube becomes covered with an albuminous secretion which in birds is very abundant and con- stitutes the " white of f^gg" This serves to protect and nourish the ovum for a short time, and if the spermatozoa have not pene- trated the vitelline membrane near the ovary, it prevents their doing so now. OBSTETRICS. 13 The next thing noticed, wliether the ovum has been fecunv.n disordered, and there is often dizziness and syncope. n.-THE SIGNS OF PREGNANCY. In the early periods of pregnancy no decided diagnosis can be made, but as it advances it is not long before certain phenom- ena clearly show the presence of the embryo. The signs of pre^Tj- nancy then become a part of every physician's outfit to be used as a means of differential diagnosis for the satisfaction of him- self and his patients; for there are several diseases of the uterus and its appendages, and of contiguous abdominal organs which it is essential to distinguish from pregnancy. 1 . Cessation of the Menses. In married women, if pre- viously healthy, this is a positive sign. In newly married Mei-sons menstruation is often very irregular, so that they may miss a period and yet not be pregnant. Cases again occur rarely where menstruation goes on during pregnancy, but it is scanty, ' comos from the cervix and is likely to be hemorrhagic and fre- quently results in abortion. When conception occurs immediately before the menses it frequently does not arrest the discharge though it usually diminishes the amount. All the causes of amenorrhoea must be borne in mind. 2. Mammary Sympathies. At a very early period of pregnancy the breasts become full and sensitive and tender. The superficial veins become larger, and visible under the skin. ■■«« OBSTETRICS. 25 ragm ; areola, face, Towards the seventh month a serous or milky discharge exudes from the nipples. These changes, however, may occur in dis- placements and uterine tumors. Then after fecundation, the nipple, which in the virgin is short and the areola pink, becomes turgid, enlarged, and prom- inent, and its colov deepens owing to increased vascularity and development of the lactiferous tubes. The areola enlarges, darkens from deposit of pigment, and becomes elevated, soft and puffy. The sebaceous follicles of the areola also enlarge and become prominent. 3. Abdominal Enlargement. After conception and the consequent uterine development there is a gradual enlarge- ment of the whole of the lower part of the body, not merely of the hypogastric region, but also of the sides and nates. The woman is conscious of a sense of fullness, weight and pressure, and often perceives an increase in the size of the waist, her clothes become too tight and oppressive even before she notices any swelling in the abdomen. Subsequently the distension is proportionate to the develop ment of the uterus, much depending on the size and height of the woman, her degree of emaciation or obesity, gaseous accum- ulations in the bowels, diseases of liver or spleen, tumors, dropsy, deformity, quantity of liquor amnii, size of child, or multiple pregnancy. The enlargement of the abdomen from pregnancy might be mistaken for other conditions : — (a). Distension frorti retained Menses. Here the previous his- tory and the presence of imperforate hymen or atresia of vagina or uterus would show what it was. The existence of a pelvic tumor in a girl who has never mens^.ruated will of itself give rise to suspicion, as pregnancy under such circumstances is of extreme rarity, liien general symptoms will be found to have existed for a longer period than if pregnancy were 26 OBSTETRICS. present, such as periodic attacks of pain at the menstrual periods. There will also be absence of mammary changes and other signs of pregnancy. (b). Uterine and Ovarian Tumors. Menstruation does not cease in ovarian disease and is usually increased in fibroids. Then the character of the tumor, fluctuation in ovarian tumor, and the hard nodular masses in fibroid, the history of the case, the length of time, the absence of cervical softening and auscultation. There is great difficulty when these growths are complicated with pregnancy. (c). Tympanitis, or " Phantom Tumor" is recognised by the percussion-note and the absence of uterine tumor, as demons- trated by placing the hand on the abdomen and directing the patient to make alternate deep inspirations and prolonged expi- rations. During each expiration press the hand more firmly, until by and bye the hand feels the spinal column and no intervening bodv. In some cases it is of advantage to put the patient under chloroform. 4. Ballottement. Is a manipulation by which the foetus may be felt floating in the fluid contents of the uterus. The patient lying upon her back, introduce one or two fing- ei-s of one hand up to the anterior fornix of the vagina, at the same time steadying the uterus outside by the other hand. Then by a sudden impulse of the fingers against the anterior part of the uterus above the cervix the fcetus is felt like a ball floating loosely in a bag of water. When distinctly felt this is a positive sign of pregnancy. 6. Quickening. This sign, which simply means the move- ment of the foetus as felt by the mother, is the first satisftictory proof that she is pregnant with a living child. It usually occurs at four and a half months, but may be earlier or as lat(^ as the fifth month. The firet sensation is trifling and is often OBSTETRICS. 27 (lo\scribed as like flatulence, but more frequently as being pecu- liar, sudden, vibrating or like the fluttering of a bird held in the hand. As pregnancy advances the intervals of these motions become shorter, and the sensations more decided. Pal- pation, esf>ecially with a cold hand, often detects motion. The woman may be deceived by flatulence, corpulency, pulsa- tions of abdominal aorta, impulse of the heart felt in the epi- gastric region, aneurism, or irregular action of the abdominal muscles ; so it is better to trust to your own senses rather than those of the patient. 6. Auscultation. This may be direct or indirect and by it we may detect : — (a). Pulsations of the Fobtal Heart. We can in this way detect the rhythm, strength and frequency. The average beat is lAO per minute, and it is best heard when the dorsum of the chilu is anterior, and is most frequently heard bea<- ' er the left groin of the mother about midway toward the um .-as, bee luse the first position of the vei-tex is most common. ''^ould you not detect the foetal heart sounds, do not be too hasty in deny- ing pregnancy, nor rashly suppose the child is dead. Auscul- tation also assists in detecting twins. (6). Uterine Souffle. This is a murmuring, cooing, hissing, or bellows-like sound, ai}.d corresponds to the pulsations of the mother's vessels; hence it is really dependent, not on the placenta as formerly supposed, but on the blood-vessels of the uterus. It is believed that during^^regnancy the uterus is analogous to an erectile tissue, and that the sound depends on the rapid passage of blood from the arterial into the distended venous sinuses. Hence when the circulation is excited, or the mother very ner- vous, the sound can be detected over the whole body of the uterus, but it is generally confined to that portion of the uterus where the j)lacenta is located, and the circulation is most active. •5 I 1;. 28 OBSTETRICS. W\^i. (C^^-Co, This sound may not be detected at all in some cases, or it may appear and disappear. As an auxilliary sign it is one of importance. 7. Jacquemier's Test. The violet color of the vulva and vagina is due to the pressure of the uterus on the large veins of the pelvis. It can often be seen enrly in pregnancy upon the cervix, but this may also arise from a tumor. 8. Intermittent Uterine Contractions. These pain less contractions of the uterus, followed by regular periods of relaxation, occur during pregnancy, and are owing to periodic discharges of nerve force. They may be increased by manipu- lation and often serve as a valuable m3ans of diagnosis. 9. Kyestine in the Urine. This is a gelatino-albumin- ous pellicle which forms on the surface of urine of pregnant women after it is allowed to stand a few hours. It is seldom seen before the second month and is most marked between the third and seventh months. These signs which we have thus far described are sometimes known as sensible or positive signs, but there are others not infrequent which are not peculiar to pregnancy as they may be found in other states. If, however, they are noticed in healthy married women, when there is no evident disease, they would render it very probable that pregnancy had occurred. They have hence been called rational or probable signs. They may be tr' Hing, or they may be distressing and severe, and they gradu - ally merge into the diseases peculiar to pregnancy. 10. Morning Sickness. This is usually a feeling of nausea or sinking at the epigastrium, or vertigo, felt on rising in the morning. It may be slight or go on to violent vomiting. It usually occurs early in pregnancy and lasts three months. It may occur in the evening, or it may be absent altogether. 1 1 . Salivation or increased flow of saliva is a common indication in pregnancy. OBSTETRICS. 29 it may )ne of Iva and kins of )on tho e pain- iods of )eriodic nanipu- 1 bum in- regnant seldom een the tnetimes lers not may be healthy Y would ley have may be ' gradu- )ling of a rising raiting, ihs. It ;ommon Hesidos th(5S0 we may have frequent desire to micturate, piuritis vulvae, nervous irritability, etc. It is impossible to draw a line between the rational signs and tlie disorders of pregnancy, between the normal and the abnor- mal. Thus the simple nervousness of pregnancy may be so augmented as to result in convulsions ; the nausea may result in distressing and dangerous vomiting j the fullness of the blood-vessels may lead to general plethora or local congestion ; tlie normal merges into the abnormal ; the healthy into disease, and this bi-ings us naturally to a consideration of : — III. THE DISOEDBRS OF PREGNANCY. 1. LoCStl. — («). (Edema of Labia. This is caused by pres- sure upon the veins, and especially if the pelvis is large, the uterus sinking lower and pressing upon the veins. The labia are swollen and there is stiffness in walking. Treatment con- sists in rest in the recumbent position, attention to the bowels, and bathing with warm water and acetate of lead lotion. {h). Pruritvs of Vulva. This is intollerable itching caused by acrid discharges or uncleanliness, or by diabetes. To be treated similarly to the last. (c). Metritis. Is usually caused by cold or violence and is confined to the muscular coat. The pain is severe, continuous, and increased by pressure. It often gives rise to adhesion of the placenta. It is treated by hot fomentations with turpentine, by morphia and rest. 2. Reflex. — (a). Neuralgia. Treated by tonics and quin- nine. (6). Salivation. When excessive, treated by atropia., " » (c). Vomiting. Often becomes distressing and in some cases even dangerous. It is best treated first by simple remedies as bismuth, oxalate of cerium, ingluvin, hydrocyanic acid. This (^.r<^ /-/ M r; 1 '%■ *■ 30 OBSTETRICS. fjiilin;^, (!lilr)ral, or tinrituro of iodine in drop doses may succeed. If not, j)aint tlio os witli solution of cocaine 4 p. c, or with nitrat(? of silver, or use the s])inal ice bag. Failing with this dilatf* the os with ntoal dihitor, and in rare cases it may bo necessary to inchice abortion. ,1/ . • (d). Oonstipahon. ' ^' • ' ^^ (e). Syncope. {/). In8omnia. 3 Mechanical. Ventral hernia, prolapse of rectum and ])iles, en(!uresis and dysuria, cramps, varicose veins, anasarca, and albumenuria. Hygiene of Pregnancy. As the respiratory activity is ijicreasod and more C O 2 eliminated, pure air is essential. Country air is better than town, and close confinement is to be avoided. The diet should bo nutritious and easily digested, and a large ap\)etite should be restrained. The dress should be loose and easy, garters and tight corsets should be avoided, but flannel drawers should be worn. Gentle exercise should be encouraged, such as quiet walks and drives. Special care should be taken to avoid over-exertion at the men- strual periods. R.iilway journeys should be interdicted, and the marital relations should be infrequent, as this in newly nuirried pei-sons is a frequent cause of abortion. Frequent bathing is beneficial as it I'elieves the kidneys of a portion of their work. The genitals should be frequently washed. The friends should bo instructed to exercise forbearance and gentleness on account of the increased irritability of pregnancy. rV. ABNORMAL PREGNANCY. 1. Due to Peculiar Conditions of Uterus.— (a). Donhle Vtei'^us. There are various forms, such as uterus and ct>rvix double juid vagina single ; uterus double and cervix and vagina single ; uterus double, cervix single and vagina double ; OBSTETRICS. 31 or the uterus, cervix and vagina double througliout. All these forms permit of normal utero-gestation on either side or on both .sides simultaneously, provided each half of the genital canal be sufficiently developed. If pregnancy occur on one side only, a docidua vera is developed on the other side and expelled at the end of pregnancy. (b). Displacements. During the first few months of preg- nancy the uterus may be retroverted and this may go on until it becomes incarcerated behind the sacrum, resulting in reten- tion of urine or abortion. It should be replaced and held up for a few months by a pessary or in some rare cases it may be neces- sary to induce abortion. 2. Due to Peculiar Conditions of Decidua. End- ometretis deciduae may be acute, resembling Asiatic cholera, or chronic, and give rise to hydrorrhcea gravidarum. This may be the result of previous endometritis existing before pregnancy ; the result of syphilis ; irritation of diseased ovum ; or retention of a dead foetus. It may result in abortion or adherent placenta. 3. Due to Peculiar Conditions of the Placenta.— (a). As to Form. Instead of being round it may be horse-shoe shape, or like a battledore. (6). As to Position. It may be attached over the os, consti- tuting placenta prsevia ; over the fallopian tubes ; or in extra- uterine pregnancy at various points in the abdominal cavity. (c). As to Development. It may be abnormally large, due to hydramnion or hyperplasia ; and if too small it may give rise to defective development of the foetus. * (d). As to its own Nutrition. It may have undergone fatty, calcareous or pigmentary degeneration. 4. Due to Peculiar Conditions of the Amnion and its Fluid. — (a). Excess of Amniotic Fluid or Hydramnion. ^1 ;// / ).■ ;' i' 1 7 32 OBSTETRICS. CauafiH. Usually rosults on tho f" ^^"^^ ^^ Treatment. If the diagnosis is doubtful, non-interfere*^'"- '>ut careful watching would be best, but if certain, there is always great danger of hemorrhage and the sooner the uterine con- tents are removed the better. The tampon and ergot should be employed, and in some cases the os may be dilated and the fingers used to scoop out the cysts. Bear in mind the gi'eat danger of hemorrhage and meet it actively and promptly. V. PREMATURE EXPULSION OF THE OVUM. An interruption of pregnancy any time before the sixth month is spoken of as an abortion or miscarriage, after that as a premature delivery. There is little hope of the fcetus living before the end of the twenty-eighth week, or seventh lunar month, or 196 days. Aboi-tion is very frequent and is said to occur as often as one to every 10 labors. The number of fcetal lives lost is therefore enormous. They occur more frequently in multipara, and many cases of early abortion are mistaken for dysmenorrhcea and unrecognised. Their influence on the future health of the i 34 OllSTKTIUOS. |niti(Mit is iiiiportimt ; tlu^y are rarely fiital, hut from loss of blood often lea«l to gn;at debility and an^ one (tf the nioHt fiuitfu! sources of uterine disiiase, [)robal)ly l)ecauH(! the patient is more careless during convalescence and thus involution of the uterus is interfered with. U|) to the end of the third month the ovum is cast off in mass, the decidua afterwards coming away in shreds or in one mem- brane. After that, the j)lacenta being formed, the amnion is first ruj)tured, the fietus is expollcMl and the membranes an; shed as in natural labor. Often, howtiver, the placental adhe- sions are firm and the secundinos being retaincnl give rise to hem- orrhage or septic poisoning, so that abortion is more dangerous than natuial labor. Causes. The premature expidsion of the ovum is affected by contraction of the uterine fibnjs ; the causes of abortion therefore are all those which produce this effect. 1. MP.ternal. — {a). Predisposing. Over-heated and ill- ventilated rooms; overfatigue and excessive indulgence in the pleasures of society ; alcoholic indulgence ; over-fiequent coitus ; fevers; zymotic diseases; bronchitis; pneumonia; syi)hilis ; lead-poisoning ; in short, all those circumstances that increase the susce[)tibility oi* irritability of the cerebro-spinal nervous system. (6). E'.^' Anything that directly or ^indirectly excites the ut J contract and expel its contents, such as fright, anxiety, jud^len shock, over-suckling, excessive vomiting, falls, accidents, presence of a fibroid tumor in the uterus, old peri- toneal adhesions, and displacements of the uterus, especially retroversion or flexion. 2. FCBtal. Death of the foetus, which may occur from effusions of blood into the structure of the placenta, from degenerations of its structure, or from atrophy, mpture, twisting or knotting of the cord. Pro cases onsTKTRica. 35 Si/iaplmun. Tlio two symptoms am homorrliayis aiul pain. Altor tim tliinl inuiith thoro aro often premonitory symptoms such as fulness, and weight in the pelvis, sacral pains, fretjuent micturition, periodic lal»or-liko pains, and a mucous or watery (lisoharjLje. These symptoms, followed by hemorrhage, indicate 11 tlireatened abortion, the hemorrhage and pain increasing in amount until the ovum is finally exj)elled. During the Hrst three UKmths, if the death of the foitus has occurred before the completion ")f the abortion, it often happens that eveiy v«;stige of the e ibryo may disap})ear and you cannot find it iimong the clots or secundines. In cases where there are iil)normal adhesions to the walls of the uterus, retained portions of the secundines may remain aftcn- theovum is ex[)ell(id. In other cases, esprcially after the third month, l^he membranes rupture and the embryo escapes with the licpior amnii. While usually the retained portions quickly follow, it often happens that the cervix contracts u])on the contents and a period of rest follows. This gives rise to what is commonly known as an incomplete abortion. The henion-hage may cease for a time, and then recur with expulsive j)ains and force out the contents ; or more frequently there is putrid deconq)osition of t^ie retained portions, the woman being thus exposed to septicaemia which, although rarely fatal, gives rise to continuous fever, recurrent and exhaustive^ hemorrhages or perimetritis. There is, perhaps, no more fruitful source of uterine disease than a mis-managed abortion. Diagnosis. Hemorrhage, pain, dilatation of cervix, and descent of the ovum, are sure signs of an abortion. When called to a case of hemorrhage occurring during pregnancy, at once examine the clots, even breaking them up under water, for traces of the ovum. Prognosis. All cases of s[)ontaneous abortion, if uncompli- cated, p,re, under proper treatment, devoid of danger, and fatal cases are usually due to the ignorance, imprudence or wilfulness 36 OBSTETRICS of the patient, or else to malpractice on the part of tho physician. Treatment.— I. The Prevention of Habitual Abor- tion. If it is duo to syi)hilis, mercury or potass, iodid. are indicated. If to retroflexion, use a pessary af^er replacing the uterus ; this should always be removed after the third month. In the newly married, if abortion accidentally occ.:i-s, it fre- quently recura, being kept up by a morbid condition of the endo- metriun? lUsed by the shortness of the interval between the I -egnancies, which does not allow the restorai/ion of the mucous membrane to a normal condition. A six weeks rest from coitus will often cure such cases. In many cases of so-called habitual abortion, fluid extract of viburnum prunifolium (black haw) in dr. ss — i doses 4 times a day is very beneficial. 2. The Arrest of Threatened Abortion. This may beaff*eeted where the death ofthe ovum has not taken place, and where the hem »rrhage arises from a slight detachment only of the decidua or placenta. Pain in the back during pregnancy should always be a warn- ing to rest. If ever so slight a hemorrhage should occur the patient should lie down and keep perfectly still on her back. Restlessness, pain and anxiety should be allayed by a full dose of opium or a hypodermic of morphia. Then the black haw may be given and the patient should be kept in bed a full week after the final disappearance of all threatening symptoms. 3. The Management of Iiievitable Abortion,— (a.) Where the Sac is not Fuj^tured. In these cases the hemorrhage is rarely profuse. The ovum is forced into the cervix by the uterine contractions and acts as a plug, the eff'used blood coagulating between the ovum and the uterine wall. • In such a case, interfei'ence with the finger or tampon is OBSTETRICS. 37 of tho I '•'^i"6oessary ami does harm, unless you are at a distance from the patient and fear to leave lior on account of the dread of hemorrhage coming on, or if it is long retained in the cervix ; then you may dilate with the finger and hasten its exit. (b). Where the Sue is Ruptured. Here the liquor amnii escapes and . I'enioval of pressure allows profuse liemorrhMge. The indication is ^"^ check hemorrhage and empty the uterus, and the most effectual niethod to stop the former is to further the latter. If possible, remove the ovum by introducing the finger, sweep the cavity of the uterus and withdraw its contents, j)ressing on the outside with the left hand. Then wash it out with a stream of warm bichloride solution (1-5,000). If the os is not sufficiently dilated use a steel dilator, which can only be properly done with a speculum. 4. The Management of Neglected Abortion. If a patient comes to you two or three weeks after the supposed completion of an abortion, with a history of recurrent hc^iorr- hages, you may be sure the ovum is there yet and the fetid dis- charge and absorption of septic matter may lead to chills, fever, and uterine or pei'imetric inflammation. In such cases tho hemorrhage, septicaemia or perimetritis may terminate fatally. You should at once empty the uterus and wash it out, and in some cases it may be necessary to use a dull wire cui'ette. 5. Management of Premature Labors. Here the tampon may be usually discarded, and after rupture of the membranes and expulsion of the ftetus, hemorrhage may be con- trolled by grasping the fundus and compressing the uterine walls. You may introduce the fingers and remove the placenta assisted by compression with the left hand. In any of these manijjulations the physician's hands should be scrupulously clean and then washed in bichloride solution (1-1,000) and smeared with carbolized vaseline or salicylic cream (vaseline 8 parts, acid salicyl. 1 part). lAbor- lid. are ting the lonth. , it fre- e endo- een the mucous n coitus labitual haw) in 'his may ace, and only of a warn- ucur the Br back, full dose law may sek after tion,— ases the into the B eff'used .11. upon IS 38 OBSTETRICS. VI. EXTRAUTERINE PREGNANO'^ OR ECTO- PIC GESTATION. As the spermatozoa travel along the fallopian tube towards the ovary to meet the ovum, the latter after fecundation may be arrested and undergo development at some point outside of the uterus, and so we may have tubal, ovarian, or abdominal pregnancy. 1. Tubal Pregnancy. This is the most frequent of the three varieties. Causes. Catarrhal affections of the tube attended with loss of ciliated epitlielium ; dilatation of the tube ; anything which causes obstruction, such as flexions, constrictions, presence of polypi, etc. As the ovum developes, the mucous membrane of the tube thickens like the decidua and receives the club-sha[)ed extremi- ties of the villi ; a decidua reflexa is rare ; the placenta is I)urely a fcetal organ. As the ovum developes, the tube stretches. If allowed to progress, at any early period, usually within the first three months, rupture of the sac occurs at the point of least resistance and usually at the site of the placenta, death occurring from hemorrhage or acute peritonitis. Tubal pregnancy has been produced artificially in a bitch by exj)Osing and ligating the fallopian tube. 2. Ovarian Pregnancy. Cases are on record where fecundation and development take place in the Gi-aaffian follicle, the walls of which, together with the ovarian stroma, furnishing a membranous envelope like an ovarian cyst. Rupture of the sac usually occurs within three or four months. 3. Abdominal Pregnancy. In those rare cases where tlie ovum L < been fecundated and drop})ed into the abdominal cavity, whenevcM' the ovum comes into contact with the peritoneum, a connective tissue proliferation is set up which riM OBSTETRICS. 39 surrounds it with a vascular sac. The walls of this keep pace with the growth of the ovum, and form adhesions to the intes- tines, mesentery and omentum. St/viptoms of /(Extrauterine Pregnancy. Tlie earlier stages resemV)le those of the intrauterine form. Menstruation usually ceases. Up to a certain point the hypertrophic clianges occur in the uterus in the same manner, the mucous membrane being converte I into a decidua and a mucous plug fills the cervix. Then there are ^ ..roxysmal pains in the sac and uterine pains like those of labor which are often followed by the expulsion of portions of decidua. When rupture occurs the symptoms are those of internal hemorrhage, and shock, viz.: — yawning, languor, pallor, fainting, clammy perspiration, rapid feeble pulse, intermittent vomiting, collapse and acute ansemia. Termination. Although the usual ending of these cases is the rupture of the sac causing death from hemorrhage or peri- tonitis, sometimes they terminate in recovery. Thus a dead f(i3tus may be retained for years, or when it dies previous to rupture the ovum may degenerate into a mole, or the foetus may undergo mumification and be converted into a lithopcedion. So that we may thus have : 1. The death of the fcetus and its becoming encysted in its own membranes. 2. The rupture of the sac, and the death of the mother from hemorrhage, shock or inflammation. 3. The rupture of the sac and the encysting of the fcetus in the cavity of the abdomen. 4. The occurrence of inflammation and abscess which may destroy the patient, or result in a fistulous communication between the sac and intestines or bladder, through which the foetus may be evacuated in pieces, and subsequent obliteration of the sac "and complete recovery of the patient. Diagnosis. Tiie existence of the signs of [»regnancy ; the presence of a tumor external to tlie utei-us ; the occurrence of •??^ 40 OBSTETRICS. paroxysmal pains ; and the exclusion of an ovum from the uterine cavity as determined by the sound. Treatment. Varies with the stage of pregnancy and the condition of the fcetus. 1. Oases of Early Gestation. The indication is to imitate nature, for spontaneous recovery commonly follows the accidental death of the embryo. This may be accomplished in various ways, such as puncturing the sac with a trocar or Pacquelin's cautery, to inject the sac with atropia or morphia ; or, best of all, and the only method which should always be resorted to in these cases, is by means of electricity. The faradic current is applied for five to ten minutes daily for one or two weeks Some recommend laparotomy. 2. Oases of Advanced Gestation.— (rt). Fv&tus Living. In many cases extrauterine pregnancy escapes detection until too late to employ a foeticidal method, and she may have gone nearly or quite to her full time before the diagnosis is made. Now although it may bo very desirable to endeavor to save both mother and child by laparotomy, the history of the primary oj)eration shows that there is only one chance in nine of saving the mother, and one out of two in saving the child The elements of danger are the functionally active condition of the placenta up to the moment of separating it from the foetus; the abnormal chai-acteristics of the [)lacenta itself; the vas- cularity of the cyst wall ; and the peculiar position and non- contractile basis on which the placenta is attached. (6). Foetus Dead. It is found by experience that if the woman [uisses through the period of danger, viz., pseudo-labor, without rupture of the sac, and the child dies, a longer delay of ten weeks, on the average, will enable a secondary laparotomy to be performed with a prospect of saving the woman in over 70 per cent of the cases. The reason is that after foetal death the placental functions cease, the vessels of the cord gradually close, as well as those OBSTETRICS. 41 the Id the is to 's the led in !ar or 'phia ; lys be The one or until directly concerned in the oxygenating process of the child's blood ; the placenta undergoes a process of carnification, be- coming more solid and tough and less vascular, and the vessels which enter it from the mother are only of a number and calibre sufficient to keep its tissue from decom[)Osition, Hence, if the foetus be now removed by laparotomy, exfoliation may slowly take place without opening any important blood-vessel or necessarily favoring septic absorption. The placenta should be left to come away spontaneously, the wound being closed above, and left open below for the passage of the umbilical cord, and the introduction of antiseptic injections. C. — Labor Is the process by means of which the fully developed fcxitus is extruded from the mother's body, and as it is accompanied by suffering and muscular exertion it has been termed labor, travail or child-birth. I. THE DURATION OF PREGNANCY. Is often a moral and a legal question. The average period is 280 days or 40 weeks or nine calendar months. Cases have been prolonged to 10 months. The laws of France, Scotland and Austria allow a possible limit of 300 days, and no case beyond this from a single coitus has been scientifically established. A simple rule to determine the period of expected onset of labor is to count back three calendar months from'the last men- strual period and add seven days. U. 'i'HE CAUSE OF THE ONSET OF LABOR. During the first three months the growth of the uterus is more rapid than that of the ovum, which is freely movable within the uterine cavity except at its placental attachment. In the fourth month the decidua reflexa becomes so far adherent to the chorion that it can only be separated by some degree of force, and the amnion is in contact with the chorion. > I I p.: -/, >u>^ y-^XsL^/VvO 42 OBSTKTIIICS. After the fourth month the aininou jiiid chorion become agglutinated, though even at the end of pregnancy they may be with care soi)arated from one another. After the fifth month the agglutination of decidua vera and reflexa takes place. In the last half of pregnam.y tlie rapid development of the ovum causes a corresponding expansion of the uterine cavity, the uterine walls become thinned, so that by the end of gestation they do not exceed two or three lines in thickness. The great extension of the uterine cavity is not owing simply to over- stretching, as is proved by tlio fact that the uterus toward the close of gestation is increased nearly twenty fold in weight, and by the histories of extrauterine gestation in which uj) to a cer- tain period the uterus enlarges progressively in spite of the absence of the ovum. The increase in weight is due to increase in size and amount of muscular fibre cells, blood-vessels and connective tissue. At the same time that these changes in the uteinis are beino: completed there is increased irritability of the uterine tissue, and finally a fatty degeneration takes place in the decidua ser- otina which soon gives rise to separation of the membranes, the contents of the uterus then acting as a foreign body, contrac- tion takes place, and all being ready labor sets in. Anot ' er element in the causation may be a periodicity inherent in some way that we cannot yet explain in the nerve centres, like the menstrual periodicity of 28 days. III. SYMPTOMS OF LABOR. Premonitory. Subsidence of the abdominal tumor takes place a few hours or a few days before labor sets in, followed by a sense of relief about the heart and lungs. Then a relaxation of the soft parts takes place, followed by increased secretion, and a discharge of a small amount of bloody mucus, known as a *' show," " False pains " are frequent, and there is tenesmus of the rectum, increased fulness of the mammaj, and frequent micturition. th more OBSTETRICS. 43 The nervous system is often aflfeeted and she lias tremors, and is anxious, depressed and fretful. For clinical convenience actual labor has been divided into three stages : — 1st Stage. — Dilatation of the Cervix. The pains become intermittent and regular, and are felt in the back or abdomen or both, and the patient expresses a feeling that they " do no good." There is often nausea, vomiting, pers[)iration and greatly increased secretion. On examination the secretion of the vagina is felt to be abun- dant, the OS is felt enlarging, the membranes protruding and soon the presenting part can be felt. As the pains increase in intensity and frequency the external OS is put u[)on the stretch, its edge becoming thin and sharp. As the pain subsides the os relaxes and the membranes retreat. At the same time the softening, relaxation and hypersecretion of the soft parts increase. There are three elements in the opening of the oe r I. The mechanical stretching by the bag of waters ; 2. The contraction of the longitudinal fibres of the uterus, which draw the cervix open, and 3. The relaxation of the circular fibres. The membranes then ru})ture and that part of the fluid in front of the ])resenting ])art escapes, while the rest may be retained for a while. The head then presses down into the cervix so that finally this and the vagina become one continuous canal. Should the membranes be late in rupturing, and be stretched over the child's head and face when born, this is known as a " Caul." 2nd Stage. — Expulsion of the Child. The symptoms of the first stage gradually and insensibly glide into those of the second stage, the contractions of the uterus rapidly becoming more frequent, returning every two or three minutes and becoming more pr longed The uterine pains are now reinforced by 44 OBSTETRICS. the abdominal inusclos and the woman feols thai they are easier borne because she can help lierself. The glottis serves as a sort of safety-valve action, for if the pains are weak slie holds ' her breath and bears down, and if they are excessive she cries out, the glo'tis opens and the muscles do not have the same purchase. The head now makes progress, the perineum bulges, the labia ga[)e, the head recedes during the interval and then advances during the pain, the pressure on the rectum leads to evacuation of the bowel, the perineum thus stretches over the head and finally the head is boin with gi-eat agony, a gush of amniotic fluid and usually more or less laceration of the four- chette, especially in primipara. There is usually an (edematous swelling on one or other parietal bone caused by pressure of the circle of contact, which is known as the capu*^ succedaneum. The second stage is one of danger to mother and child ; to the mother from all those accidents which may arise from dis- turbance of the vascular and nervous systems, to irritation of uterus, vagina and perineum, and most of those complications which give rise to tedious and difficult or impracticable labors. The child's life may be endangered or destroyed by pressure on its body or on the cord or placenta. 3rd Stage- — Expulsion of Placenta. After the birth of the child there is a short respite from pain, seldom longer than 10 or 15 minutes when the pain and bearing down recura. A hard and tense tumor is felt through the abdomen, a finger in the vagina feels the placenta at the os or in the vagina. The placenta then usually })resents its fcetal surface or edge, and is soon expelled with the membranes and more or less blood. IV. DURATION OF LABOR. The average time for a primipava is 17 hours, for a multipara, 12 hours. 'n\Q first stage occuiues 10 out of the 12 hours. Althougli OBSTETRICS. 45 ty are I'ves as holds cries same bulges, longer and more tedious it is generally a safe stage tor the mother as well as the child, the mother not being usually at this time liable to any of the accidental complications of labor, and the child, if the niembranes are unruptured, is very slightly disturbed by the contractions of the uterus which have no effect in compressing its tissues or injuring the attachments or func- tions of the placenta. The second stage is short compared with the first, occupying two hours or less in a labor of 12 hours, depending on the strength of the woman, the relaxation of her tissues, her age, constitution, etc. The third stage is short, usually only 10 or 15 minutes, but may take half an hour. It is a stage of danger to the mother from exhaustion, syncope, collapse, but especially from hemorr- hage. Hysteria, puerperal convulsions, etc., may complicate this stage. Delivery being now acco»T»plished the nervous and vascular excitement rapidly disappear, and the mother feels weak, and often faint and exhausted. She also feels cold and chilly and often has a tremor or rigor, accompanied by depression and anxiety of mind. The puhe becomes less frequent, small and weak, hands and feet are often cold. In less than half an hour there is a reaction, the surface becomes warmer and the pulse full and natural, and she has a tendency to sleep which will refresh her exhausted system. v. THE EXPELLENT FORCES. These are the essential and the accessory. 1. The Uterine Contractions (essential). That the uterus is a contractile organ, is proved by its hardness and rigidity and its alteration of form ; the sensations of twisting, grinding and contraction ; the rigidity and alteration of the size of the OS ; the tension and protrusion of the membranes ; the m 46 OBSTETRICS. descent of the child ; the jn'e.ssufo of tlie uteni.s on the hand when introduced in version ; and hy the ra[)id diminution and obliteration of its cavity after evacuation of its contents. Sometimes the)-e is a general and uniform contraction of the uterine muscular fibres bv which the walls are rendered more; firm and tense, and its contents compressed. It is this tonic rigidity or contraction of the uterus which compresses the placenta after the birth of the child, and when this is ex})elle I the walls regularly condense and obliterate its cavity, so ])re- venting hemorrhage. This tonic contraction is usually j)ainless and is dependent entirely on the sympathetic nervous system. Nervous Mechanism of Labor. The uterus is independent of direct volition, for its rythmic contractions go on in insensibility from apoplexy, coma, anaesthesia, etc. Tt is, however, under the influence of emotions, as is seen when the pains leave by the excitement of the physician's presence, and come back when he retires. It is in this manner that encouragement and hope tend to help the progress of labor. The causes of uterine contractions are : — 1. Periodic Centric Discharges of Energy. This is seen during pregnancy in the alternate contraction and relaxa- tion of the uterus, and in the contractions induced by ergot, by excess of CO.^, and zymotic diseases. 2. Reflex Stimulus. — ( « ) Through the Cerebrospinal Nerces. Examples of this are the contractions of the uterus caused by suckling, cold to the body, the pressure of the head on the perineum, or the hand drawing back the perineum. (6) Through the Sympathetic. Examples of this are whe.e a dead ovum acts as a foreign body ; the beginning of ordinary labor ; the use of the bougie to induce premature labor ; and the dilating pressure of the bag of membranes or the foetai head. OBSTETRICS. 47 XiYj've Centres and Nerves. 'Dwie are two centres in the cord, one in tlio niodullu and one in the lunilmr region, ami tliore are also nerve centres situated in the uterus itself. The centre in the medulla is for rellox stimuli, transmitted by tlio cerebo-sj)inal nerves of the upper })art of tlie body; from the action of C O.^, etc. The centre in the lumbar region immediately (governs the uterus. Stimuli are transmitced to it throu h the cord from the centre in the medulla, and also indirectly, as by emotions, from the brain. The nerves carrying the stimuli from the uterus are the sympathetic, but these have fiiauKints from tlie spinal cord through the lumbar and sacral nerves, and lience the pains of labor. When labor has fully commenced the uterus takes on a more decided action ; the alternate contractions and relaxations at first at long intervals becoiue more and more rapid and vigorous, and the intervals shorter. As these contractions are more or less painful they are known as '' pains." In the first stage they are said to be cutting, gri ding, twisting, but in the second stage pressing, bearing down, forcing. The pain is experienced in every part of the uterus during a pain. While the tonic contractions of the uterus are pain- less and resemble those of the heart and other hollow viscera ; the clonic contractions of labor are painful, because the uterus is directly or indirectly connected with the spinal pord. This is especially the case with the nerves of the cervix, thus accounting for the greater sensibility of this portion of the utefus. The first effect noticed of these clonic contractions is that the os becomes rigid, then thinner and slightly open ; after the pain it becomes soft, relaxed and yields more readily to the finger. This process goes on until in a few hours the os is dilated, quicker in multipara than in primipara. As a rule when the edges are thin and knife-like, the dilation will be slow, epecially if considerable density remains after the con- 48 OnSTETRICS. traction has siihHidod WIioii this ed^'CH aro thicker and softer the o8 (Milarges more rapidly. Should the liquor aninii have escaped prematurely there is often great retardation of the vrocess, especially in primipara, and it is know as a " dry labor." Dilatation of the os is effected mostly by the longitudinal fibres, by which the length of the uterus is shortened, there is descent of the fundus and elevation of the os, and while the cir- cular fibres of the os also contract, the action of the longitudinal fibres is more powerful, so that the circular ones yield and the OS becomes dilated. Then the bag of waters, or the presenting p irt of the child, may be regarded as a mould upon which thn cervix expands. The membranes now usually rupture as the OS becomes completely dilated and the expulsive stage ^begins. The descent and delivery of the child are accomplished by a continuation and increase of the contractions of the longitudinal and circular fibres of the uterus by which its cavity is dimiu- islied in every direction, and the child, greatly compressed, is expelled through the only opening which exists at its inferior extremity. The pains increase in severity as labor advances owing to the fundamental law that the contractions of the uterus are inversely as the size of the organ. The more the longitudinal and circular fibres are shortened, the more efficient is their action. Hence, when the membranes are ruptured and the liquor amnii evacuated the pains become more severe and prolonged. So, as the child descends they increase, and finally the most severe contractions are felt at the termination of laboi , when the last portions of the infant escape from the uterus. The placenta then being detached acts as a foreign body and is expelled by the same forces. 2. Contractions of Abdominal Muscles and Dia- phragm (.accessory). Some have gone so far as to think that the expulsive stage of labor is mainly performed by this means, OBSTKTUIC8. 49 i. soft cr ero IS I i para, l)iit tho f>u;t that labor iiuiy be cornpUjted midor aiucsthosia, or ill paraplo^'ia, and that in inertia of tht3 uterus no amount of voluntary action of tho al doniinal inuHol(!H will oxptd tho child or arrost h(5niorrhago is Hufficiont proof that it is not. Tho action of theso niuselos is of groat importance, howovor, as an accessory force, for by their coml)ined action tho viscera of the abdomen can be compressed and a particular direction can be given to this force as required, just as in the acts of sneezing, coughing, vomiting, and defecation. Before the os is dilated there is not much disposition to strain, and it ought not to be encouraged, for nothing can be gained at tliis time, but it rather delays dilatation by increjusing nervous excitement and rigidity of the os. When, however, the OS is dilated, the sense of fulness, weight and pressure in the pelvis causes a disposition to strain which cannot be resisted and ought to be now indulged. The first enect is rupture of the membranes, then the tonic contractions of the uterus are increased, so that the walls of the uterus are brought into close contact with the t)ody of the child increasing at tlie same time its flexion. Their next effect is to strengthen and increase the contrac- tions of the uterus by fixing and supporting it and making equable pressure upon its surface, and giving a proper direction to its axis. The uterus being fixed by its attachments and pressing against the brim of the pelvis cannot descend lower, so that the abdominal muscles act through its walls directly upon the child forcing it downward through the pelvis. These forces also facilitate the distension and elongation of the perin- eum and enlargement of the vagina ; they aid in the detach- ment and expulsion of the placenta and clots, and finally in expelling them from the vagina. In breech cases it is this force which expels the head and the woman can thus effectually help hei-self. 5 fi'T m/'-i ^ 50 OBSTETRICS. VI. MECHANISM OF LABOR. Tliis comprehends the movements of adjustment by which the foetus accommodates itself to the dimensions of the bony pelvis, and to the variations in the direction of the [)arturient canal. To thoroughly understand the process it will be necessary to study the pelvis and the foetal head : — 1. The Female Pelvis. The bony pelvis is formed by the union of the sacrum, coccyx and the two ossa innominata. The sacrum is shaped like a wedge and consists of a vertebral portion with twoalte or wings. In early life it consists of five vertebrsB but afterwards they amalgamate into one single piece. Its base articulates with the last lumbar vertebra with which it forms a projecting angle known as the jyromontory of the sacrum. The sacrum measures 4| in. long by 4^ in. wide, and has two curves, a lateral and a longitudinal. The coccyx is composed of four rudimentary vertebraj. It is attached by a hinge joint to the sacrum, and is pushed back during defecation and child birth. When anchylosed it is a hindrance to labor. The ossa. innominata up to the age of puberty consist of three bones, the ilium, ischium, and pubis, and although they are afterwards amalgamated, they still retain the same names. The articulations are the symphysis pubis, and the sacro-iliac synchondroses. During pregnancy the fibres of the pubic fibro- cartilage become infiltrated with serum and the ligaments elong- ate, so that at full time the distance between the pubic bones is doubled, and, at the same time, a slight degree of mobility exists at the sacro-iliac joint. This arrangement facilitates labor; thus at the beginning of labor as the head enters the brim the woman naturally chooses to sit up, to walk about, or if in bed to recline with the legs extended, positions which favor the rotation backward of the upper portion of the sacrum, and con- sequently increase of the antero-posterior diameter of the superior OBSTETRICS. 61 strait. As the head, however, descends to the floor of the j)elvis, tlie patient instinctively draws u[) her knees, throws the body forward, and during a pain contracts the abdominal muscles. In this way she succeeds in tilting up the pubis, in pressing the promontory forwards, and in rotating the point of the sacrum backward, thus increasing the conjugate diameter at the pelvic outlet. I^he ligaments are the obturator membrane closing ohe obturator foramen, and the greater or lesser sacro-sciatic liga- ments which convert the notches into foramina and assist ir forming the inclined planes of the pelvis. The complete pelvis is divided by the ileo-pectineal line into two parts, the false above, and the true below. The latter is a basin-like cavity, closed in by soft parts below, and called the exca\ ation. In order to understand the changes in the shape and dimen- sions of this bony canal it is usual to describe certain planes and axes. Planes and Axes of the Pelvis. By a plane is meant simply a superficial surface without reference to depth or thick- ness. The upper and lower 0[)enings are termed respectively the upper and lower straits, while the space between is the cavity of the pelvis. The plane of the superior strait or brim of the pelvis is bounded by the linea pectin a and has an elliptical contour with a depression behind produced by the projection of the promontory of the sacrum. Its dimensions are determined by measuring its diametei^s. The antero posterior or conjugate diameter extends from the iipper Vjorder of the symphysis pubis to the promontory, and meaF"'*'}s 4^ inches. The oblique diameter extends, the right from the right sacro- iliac syn>- Uondrosis forward, the left from the left sacro-iliac n 52 OBSTETRICS. synchoiuirosis forward to the acotsiliuluiu, aiul measures f) inches. • The tranr verse ilianieter is the widest distance between the ilia, and measures 5^ inches. The axis of the sufjerior strait is a line per})endicular to the centre of its plane, and extends from the umbilicus to the coccyx. The plane of the inferior strait, or the outlet, is bounded by the subpubic ligament, the pubic rami, the rami and tuberosities of the ischia, the sciatic ligaments and the coccyx. The conjugate diameter of the outlet extends from the lower borde:- of the symphysis to the extremity of the coccyx and measures 3| inches, but when the coccyx is pushed backward it measures 4|^ inches. The oblique diameters of the outlet are unimporty |)eriosteiim and dura mater. The sutures are the frontal, coronal, sagittal, and lambdoidal. The anteiior fontanelle or bregma is rhomboidal, the pos- terior fontanell(! is smaller and triangular. The Diameters of the Head. 1. A ntero- posterior : a. Occipito-mcntal 5^ inches b. Occipito-frontal 4| " c. Sub-occipito-bregmatic 3| " 2. Transverse : . a. Bi-parietal 3| inches b. Bitemporal 3^ " c. Bi-mastoid 3 " 3. Vertical : a. Fronto-mental 3^ inches b. Cervico-bregmatic 3| " The articulation of the head with the spinal column at a point nearer the occi[)ut than the sinciput is of importance in the mechanism of labor. It converts the head into a lever, consisting of two unequal portions. As the child's head passes through the pelvis the I'esistance to i* s passage causes flexion of the chin upon the thorax. VII. EUTOCIA OR NORMAL LABOR.. Vertex presentations alone are to be regarded as norjnal, as they only realize the ..echanical conditions compatible with the highest degree of safety to both mother and child. Perfect acquaintance with all the details of tlii, natural process is neces- sary to a scientific knowledge of midwifery. The physician OBSTETRICS. 55 who is well acquainted with the inechauism of labor, can by various measures facilitate such changes as to shorten the progress of labor and thus diminish the anxieties, sufferings and dangers of the lying in woman, and also greatly increase the chances for the safety of her child. By presentation is meant that portion of the fuetal ellipse which is felt toward the centre of the canal of the pelvis or vagina. By position is meant the relation of the prescniting part to the pelvic cavity. There are four positions of the vei'tex. 1. Left occipito- anterior. 2. Right occipitoanterior. 3. Right occipito-pos- terior, and 4. Left occipito-posterior. The mechanism of labor in vertex presentations is usually described as consisting of several acts, viz : Descent, flexion, rotation, extension, restitution and expulsion of the trunk. Let us now study the mechanism of the first position, des- cribing each act, and then we can see how the other positions differ afterwards. \st Position, Left Occipito-anterior, L. 0. A. Occiput is to left acetabulum. This is the most frequent and the most favor- able of all the positions of the vertex. The reason the long diameter of the head generally enters the pelvis in the oblique and not in the transverse diameter, is that the psoas and iliacus reduce the latter to the same length as the former, and as the child lies usually with its back forward to accommodate its con- cave anterior surface to the convexity of the mother's spine, so the head more naturally then enters the oblique than by twisting as it would if it engaged in the transverse diam- eter. Then as the left oblique diameter is partially occu- pied by the rectum and sigmoid flexure of the colon ; as the pregnant uterus generally has a natural obliquity to the right i» F;'.''^i 66 onSTETRKJS. and is rotiited on its axis so tliat its front looks towai'ds the right and its left is foremost and most dependent, the fcjetus is most readily accommodated to the shape of the nterus when its antero-j)osterior nearly corresponds with the transverse or great- est diameter of the uterine cavity, and hence the first position is most common. On exaniination the finger comes in contact with the pos- t or "^^p^i^^r angle of the parietal bone, and detects the right branch of the lambdoidal structure. Followingthis downwards and backwards you come to the ovorlap])ing edges of the pos- terior fontanelle. 1. Descent and Flexion. These movements are usually assviciated, descent taking place owing to the essential and accessory forces, flexion being due to the vertex meeting some resistance in the parturient canal, the force transmitted through the spine causing the descent of the occiput and flexion of the liead on the chest. The head enters the pelvis in the axis of the brim, with the bi})arietal diameter parallel with the plane of the superior strait. It is a passive movement, and takes place as soon as the occiput has met with sufficient resistance to arrest its further progress, the end being the substitution of a shorter diameter for a previously longer one. Thus the average length of the sub-occipito-breginatic diameter of the flexed head, 3| in., is f in. less than the occipito- frontal or maximum diameter of the head when midway between extension and flexion. Another cause of flexion, inde[)endent of the bony pressure, depends upon the relation between the shape of the head- and the pressure exercised upon it at the girdle of contact either with the OS or the imperfectly expanded soft parts, the propel- ling force being the general fluid pressure transmitted to the foetus through the liquor amnii. The head forms an unequal wedge, the slope at the occipital end being steeper than at the The except OBSTETRICS. 57 fVoutal, so that tho forco and resistance just explained result in flexion of the head upon the chest. 2. Rotaanterior inclined plane while the right sweeps the hollow of the sacrum. 4ih Pobition, Left Occipito-posterior, L. 0. P. Here the occi- put is to the left sacro-iliac synchondrosis, and the liead occu- jties the left oblique diameter. This position is less frequent owing to the presence of the sigmoid flexure of the colon and the rectum. It may be converted into the 1st position or become persis- tent 4th, the cause and mechanism being precisely similar to tliat of 3i*d position, but reversing the plant^s. MANAGEMENT OF LABOR. Were labor always the natural physiological process it ought to be, no treatment whatever would be demanded. Thus tlu'oughout the world thousands of children are daily born with- out the least supervision by an instructed physician, in many cases in secresy and retirement, and often delivery is safely effected even in opposition to superstitious practices and igno- rant interference. The savage woman retires, it may be to the forest, and secluded even from her female companions brings forth her child, and i)erhaps in a few hours is sufficiently restored to attend to her own and her infant's necessities, and speedily returns to her usual laborious occupation. While somewhat similar cases rarely occur in civilized society, still the difficulties and dangers of labor are exceedingly augmented as the indulgences and luxuries of life are multiplied. The diminution of physical power, the nervous excitability, the physical alterations from tight lacing, and the mental and IT 60 OBSTETRICS. iiioiul i'0(lis|>oHo to vari- ous complications, wliile at tiio aaiiie tiiun the natural processes are more imperfectly and less elticiently executed. Now while meddlesome midwifery is bad, it is necessary to know when to interfere as well as when to abstain. It is therefore your business to carefully watch the whole process of labor, to ascertain whether it is peifectly regular, and to detect the least deviation from the natural i)rocess, and thus you may often lender timely assistance. You should sustain tlie mind and spirits of the mothei and explain to her what sensations sh(» should encourage and what she should resist, and in wiiat nmnner she can most effectually promote her safe delivery. Pre})arat6ry Treatment. When called to a case you should go at once, for it is better to be a few hours too soon than ono minute too late. If it is in the country or any distance from your office go prepared for every emergency, and take youi- ])ocket case, enema syringe, hy[)odermic syringe, the very best fluid extract of ergot, chloroform, perch loride of iron, chloral, your obstetric forceps, and a solution of bichloride of mercury in alcohol (dr. 1 — oz. 1). At the house see that they have brandy, and plenty of hot and cold water. See yourself that the bed is properly mad(i and the patient arranged. After the patient has become at ease with you, suggest an examination to " see if all is right." By the finger in the vagina you will recognise not only the ])resentation but the condition of the vulva and perineum, the state of the rectum and bladder, the length of the vagina, the degree of dilatation and softening of tlie cervix, the amount of cervical and vaginal secretion, the hardness of the child's head, and if the membranes are not ruptured the quantity of the amniotic fluid. It is best to examine the patient while lying on her left side, but in some cases she may best be uj>on her back, and you OBSTKTKIC8. 61 DUTlt of s head, of the hIiouM wait for a pain, })ut afterwanlH ku(!|> the Hn^oi* there to soe tlie elVect «hning tlie interval. You Hhouhl'also try to map out the position of the fcetus on tlio ah(U)nien by palpation and if the fuital niovomenta are absent auscultate. While this is going on enquire into the history of the '^ase, such as the length of previous labors, her health during preg- nancy, the number of [)revious pregnancies and whether she is now up to full time, when the pains began, as to their frequency and situ ition and if the membranes ha'^e ruptured. If asked as to duration of labor be guarded and possibly ambiguous. MANAGEMENT OF FIRST STAGE. Before making any vaginal examination the hands and nails should be scru[)idously clean, and then washed in a solution of bichloride (I to 1000), and the finger smeared with vaseline. During the first stage, you should make occasional, but not too frequent, vaginal examinations to see if dilatation is going on. Caution her to pass urine frequently and occasionally retire from the room to allow her to do so. If the rectum is felt to be full use an enema. She should be encouraged to sit up and walk about, but never to l)ear down during this stage. Warm drinks may be employed. When the os is dilated you may rupture the membranes if that has not occurred spontaneously, since they have finished their work and now only retard labor. MAISTAGBMENT OF SECOND STAGE. You should now insist on the recumbent posture, as the erect is unsafe for both mother and child. The position on the side or back is a matter of indifference, but may be varied with advantage, and now you should make more frequent examina- tions. So long as the advance is regular do not interfere, but I % 62 OHSTETRICS. hIiouM. tli<5 pains Hliickon y«ii hIiouUI not let tlin tlunition of tin; second sta^o exceed tlio pliysiological liniitH. A very rapid Becond stage is not natural as it (iudangeis the integrity of th'L» V < / » ' »> •**> i >-^ tf7 UiJi?>'«/.**^» 2. From Impeded Uterine E^orts.— («). Connected vvth the Fobtus. (a). From Abnormal Position. (/). Face Presentation. It occurs once in three hun- dred cases. Symptoms. You notice the high position of the presenting part, and make out the forehead, nose, eyes, mouth, etc. Be careful not to mistake it for breech, and. use the greatest gentle- ness if you suspect a face for fear of injuring the eyes. Causes. The cause of face presentation is a furtherance of the slight extension in the early part of labor which is so apt to produce occipito-postei lor. positions. This extension movement may arise from congenital enlarge- ment of the thyroid gland which separates the chin from the chest ; from increased size of the chest, interfering with flexion ; from stricture of the cervix about the neck of the child, the uterine walls adding to the circumference of the thorax ; from mobility of the foetus due to small size or excess of amniotic fluid; from oblique position of the child and uterus especially ^n cases of rapid escape of amniotic fluid ; or lastly from coiling ( f cord round neck of foetus. Mechanism. In face presentations the chin corresponds to the occ the tw( sible fo First Mento-A of the \ (I). . the san The chi put is p descent child's r exceptio the thor (2). 1 inclined arch, th sacrum. (3). 1 the shoii stretchei chest, th brow, ve (4). h left shou ond posi plane, ai accordinj Secohc Here ex except w At full t delivery of the ch the :ion ; the trom ilins OBSTETRICS. 67 the occiput in vertex presentatiojis, and there are four positions, tlie two first being possible, the third and fourth being impos- sible for d livery to take place. First. Mento-anterior Position. (Possible). Left and Right- Menle-Iliac. The movements are sjmewhat varied from those of the vertex. (1). Descent and Extension. Here extension occurs by the same rules that produce flexion in vertex ])resentations. The chin sinks deeper and deeper in the pelvis, while the occi- put is pushed backward against the dorsum of the child. The descent of the head is normally limited by the length of the child's neck, as it is only in the case of a very small child, or exceptionally roomy pelvis, that the head and upper portion of the thorax can enter the pelvis simultaneously. (2). Rotation. The chin now impinges on the anterior inclined plane, rotates forward and engages under the })ubic arch, the vault of the craoium sweeping the hollow of the sacrum. (3). Flexion. The chin now emerges benea,th the pubic arch, the shoulders press upon the base of the skull, the perineum is stretched by the cranial vault, thj head now flexes upon the chest, the chin rounds the symphysis while the mouth, nose, brow, vertex and occiput appear in succession. (4). Restitution. The shoulders now engage ; in first ]>osition left shoulder impinges on right anterior inclined plane ; in sec- ond position right shoulder impinges on left anterior inclined plane, and the chin is thus directed to the left or right thigh according as it has been first or second position. Second. Mentoposterio7' Positions, also called Mento-sacral. Here extreme extension takes place and delivery is impossible except with a small foetus, a dead fcetus, or a very roomy pelvis. At full term, with a fully developed foetus and a normal pelvis, delivery is an impossibility owing. to the simultaneous entrance of the chest and head. -^ t^*^-'" '' fi^^> J 'IF h ; t r ' 1 i !'■ w'i ' % I 68 OBSTETRICS. Treatment. Be careful not to. rupture the membranes, for the face is ill adapted to dilate the cervical canal, and rupture of the membranes in these cases is apt to be followed by complete escape of the amniotic fluid which would endanger the life of the child. Manipulations to push up the face and bring down the occi- put by pressure of the fingers usually fail. It is better to restore the normal attitude of the child by flexing the trunk and leaving the head to resume spontaneously its proper position as it sinks in the pelvis. It is performed by seizing the shoulder and breast with the hand through the abdominal walls, then lifting the chest upward and pressing it backward, at the same time steadying or raising the breech with the other hand applied near the fundus, so as to make the long axis of the child conform to that of the uterus, and finally pressing the breech directly downwards. As the child is raised the occiput is allowed to descend and then as the body is bent forward, flexion of the head is produced by the side walls of the pelvis. After the membranes are ruptured exercise great caie as to the eyes and admitting air into the mouth. In mento-pnsterior positions the chin may sometimes be brought forwards by one blade of the forceps acting as a lever. In these cases, however, if not early rectified ci-aniotomy has usually to be resorted to. (n). Breech Presentations. I have classed these under the head of dystocia, not because there is always necessity for interference, or any danger to the mother, but because there is danger to the child, and in primipara there is usually necessity for some intervention on the part of the physician, •otherwise breech presentation might come under the head of natural labor as some have described it. We may have regular breech presentations where the legs are bent up in front of the body, or irregular giving rise to footling and knee presentations. The] is as on Cans presenc( fcetus, i contract mature -Diayi high up and the Mechc child's h ing to th right an( \st Pc ])Osition slowly. Descei impinges under th the sacrii The le, l)lane, wl The he in the ri anterior i laces wee of vertex Irid Pc lar to fin to second '6rd Po position < ^f OBSTETRICS. 69 ions. The proportion of breech cases, (excluding premature births)^ is as one to sixty. Causes. The absence of the conditions which determine the presence of the head, or which interfere with the fixation of the fcetus, such as excess of amniotic fluid, lax uterine walls, and contractions of the jjelvis. They occur very frequently in pre- mature labors, and when the child is dead. Diagnosis. The bag of waters is a[)t to be very large and high up ; the sacrum, coccyx, anus, and tuber ischii are felt ; and the presence of meconium is positive proof. Mechanism. The position is defined by the direction of the child's back or sacrum, and we have four positions correspond- ing to those of the vertex, viz : Left and right dorso-anterior^ right and left dorso-posterior. Xst Position, Left Dor so-anterior. This corresponds to first position of vertex, and is the most common. The cervix dilat"& slowly. , Descent and rotation of the hips take place. The left hip imi)inges on the right anterior inclined plane and is dire<^ted under the pubic arch, while the right hip sweeps the hollow of the sacrum. The left shoulder then impinges on the right anterior inclined plane, while the right shoulder sweeps the hollow of the sacrum. The head now engages, the long diameter of the head being in the right oblique diameter, the occiput impinges on left anterior inclined plane, comes under the pubic arch, while the face sweeps the hollow of the sacrum precisely as in first position of vertex. 'Ind Position, Right Sacro-anterior. The mechanism is simi- lar to first position, but reversing the planes, and corres})onda 10 second position of vertex. '6rd Position, Right Sacro-posterior. This corresponds to 3rd position of vertex, is often converted into 2nd or 1st position I ,,1 ■ ■ !» I 'v if I i ii jji 70 OBSTETRICS. but it may persist and then the chief difficulties are from resist- ance of coccyx and perineum to flexion, the neck of the child being thus pushed so far forward that it is difficult for the fore- head or even for the face to get readily under the pubic arch. 4tured, you may bring down the arm, and see which one it is, and in which direction the palm points. Positions. Dorso-pubic of right and left shoulder, and dorso sacral of right and left shoulder. Thus in dorso-pubic positions , if the head lie in the left iliac fossa, the right shoulder presents, and vice-versa. So in dorso-sacral positions, if head lie in left iliac fossa, left shoulder presents and vice-versa. Terinifiations. There are three possil)ie terminations which I 1 72 OBSTETRICS. may occur naturally although we can never trust nature to accomplish them. 1 . Spontaneous Rectification. Here the membrane^ are unbroken, and it takes place by means of the circular fibres of the uterus,' assisted by^the j)atient lying on the opposite side to which the breech is deflected. The head is made to j)resent. 2. Spontaneous Version. Here the membranes have been ruptured, one side of the uterus contracts more vigorously than the other, so that the .shoulder is pushed up and the breech brought down as the presenting part. 3. Spontaneous Evolution. The presenting arm and shoulder are tightly jammed down and the head is strongly flexed on the shoulder. As much of the body of the foetus as the pelvis will contain becomes engaged, and then rotation occurs ; this brings the body of the child into the antero- posterior diameter. The shoulder projects under the arch of the pubis, becomes fixed, and the body of the child becomes depressed and curved until it is expelled. Treatment. This consists in turning, or if impacted may require decapitation, evisceration or embryulcia, for which, see obstetric operations. ((3). Size and Form. (i). Large Heads. May give rise to dystocia and may require forceps, or turning. In these cases great care should be used in giving ergot. ' ■ '\ (ii). Deformities. These include hydrocephalus, encephalo- cele, spina bifida, ascites, and multiple foituses like the Siamese twins. (y). Number. Multiple Pregnancy. Although the human female is said to be uniparous, tiiere are exceptions, and twins occur ouce in 85 cases, triplets once in 7,000, while quadru- plets and quintuplets occur still more infrequently. A CO tion, b belongii developi and mof^ l»y reten and fru pregnan TWINJ father's others ; It ma time, wl is provec develope sides of s nancy w Again an embrj When in its ow sufficient ovum wi own mei are genei ont circu Twins The w( of a sinsrl usually a It is al abdomen distinct f( TW OBSTETRICS. 73 A condition closely connected with this subject is super/vela- tion, by which is meant the fertilization of a second ovum belonging to another period of ovulation after the first lias been developing for a month or more. Some doubt its possibility and most of these cases may be explained by a double uterus, l»y retention of one twin, by an interval between insemination and fructification of an ovum, by pre-existing extrauterine pregnancy and inaccurate information. Twins. Are often hereditary, and this sometimes runs on tlie father's side ; some races are more apt to have them than others ; and women married late in life are apt to have twins. It may occur by two or moi'e ova being fertilized at the same time, whether they have come from one or different ovaries, as is proved by the fact of two corpora lutea being found equally developed ; from the occasional occurrence of pregnancy on botii sides of a double uterus, and from the occurrence of twin preg- nancy with one ftetus in utero and the other extrauterine. Again, twins may arise from an ovum having a double yolk, an embryo developing from each. When twins develop from two ova each foetus is contained ill its own chorion. If the ova are embedded in the decidua at sufhciently distant points the placentae will be separate and each ovum will have its distinct reflexa. Usually each foetus has its own membrane and liquor amnii, an I although the placentte are generally united in one mass yet each has its own independ- ent circulation. Twins from the same ovum are always of the same sex. The weight of each child in a case of twins is less than that of a single delivery, but the conjoined weight is greater. They usually average five or six pounds each. It is almost impossible to diagnose twins before birth. The abdomen is more distended and broader and you may hear two distinct foetal heart sounds. ¥\ n ^< I ii 74 OBSTETRICS. Twin labors are UHually easy, tlie first stage is apt to \>e tedious from inertia, tlie second stage is apt to bo rapid, and inertia is apt to occur in the tliird stage so that post partuni lieniorrhage is to be dreaded. The intei'val between the first and second child is usually from five to 30 minutes ; sometimes both may present heads, but usually one is head and the other breech. Both placonta3 usually follow the birth of the second child. Manageynent. Tie the cord after the birth of the fii'st child and wait not more than half an hour; if pains do not return, rupture the membranes, and by external manipulation, the second child soon follows. The most serious complication is " locking " i. e., the interference of the second child with the deliveiy of the first one. Thus tlie first child presents a head but a foot or hand may be found presenting with it. Ti-y and determine if it belongs to the first or second child, but in all cases it should be pushed u[) as far as [mssible until the head has com[)letely engaged in the pelvis. In all cases of twins there is danger of inertia, and post- partum hemoi-rhage is to be anticipated and prevented oi checked. (6). Connected ivith the Passages. (a). PKLYIS. A classificati>m of contrtacted pelvis is difficult ; in the great pro[»ortion of cases, however, the diminution of space is usually at tlie brim and it is to these cases that the term " contracted pelvis" is usually applied, the others being irregular forms. (i). Coit ."acted Pelvis Proper. 1st. Pelvis ^quabiliteh JusTO-MixoR. This is a symmetrically contracted pelvis charac- terized by a general diminution of all the diameters, but no devi- ation, or but little, from their relative proportion in the normal pelvis. It is simply below the standard size, and is due to a premature arrest in the develoj)ment of the bones so that the pelvis retains its infantile type. 2nd. shortei itic or burden to oste a shall of the mainly [)resse!>i the san of the 1 the sac superio 3rd. combin the tra rachitic (n). Pelvis. synch or sacrum side. ' outside 2nd. ture or ral dire( which tory bei is rende and the 3rd. oral cur arch, pi I! Ir't OBSTETRICS. 75 ) to a t the 2n(l. Thk Flattenkd Pelvis. Here the conjugate diameter Ih Hhorteiuicl but tlie tmiLsvorse remains normal. It may he racli- itic or non-rachitic, and is often due to lifting or carrying heavy burdens before the age of puberty, to arrest of development, or to osteomalacia. The result of these conditions is to produce a shallow ])elvis with a contraction at the brim and a widening of the outlet. This deformity, when resulting from rickets, is mainly due to the weight of the super-imposed body, which pivsses the promontoiy forwards toward the median line. At the same time the sacrum is rendered more horizontal, the bodies of the vertebrae sink between the alje so that the concavity of the sacrum from side to side is effaced, and the ])OSterior superior spinous i)rocesses are approximated. 3rd. Flattened Generally Contracted Pelvis. This is a combination of the other two varieties and there is nan-owing in the transverse as well as the conjugate diameter. It may )»e rachitic or non-rachitic (n). Irregului' contracted Pelvis. at. The NiEGELE Oblique Pelvis. This consists in com])lete anchylosis of one sacrc-iliac synchondrosis, in destruction or defective development of the sacrum on that side, and displacement towards the anchylosed side. The cavity is obliquely ovate. You notice an inequality outside and the patient linn)s. 2nd. The Kyphotic Pelvis. Is due to po.sterior spinal curva- ture or caries of the vertebrte, and as a result of this an unnatu- ral direction is given to the weight of the superini})osed trunk, which is communicated to the base of the sacrum, the promon- tory being thus thrust upwards and backwards, the symphysis is rendered prominent, the transverse diameters are diminished, and the conjugate increased. 3rd. The Scolio-Rachitic. This accompanies scoliosis or lat- eral curvature of the .'-i)ine. There is expansion of the i)ubic arch, prominence and lowering of the promontory, widening and ■ ■ I : ^n f1-1 1'. I «.ais ^f^t- IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 11.25 11 1^ 1^ 2.2 U iiii ! -- IIIIM |||||_l£ LA. Ill 1.6 V] t^ /2 ^^^ > ■> ^;; V] .'^'*-^' ^ "o^.^- "> V y ^ Photographic Sdences nnmnrQtinn 23 WbST MAIN ST'.EET WEBSTER, N.Y. l4580 (716) 872-4503 .\ ,v ^^ fv 76 OBSTETRICS. elongation of the sacrum and irregular kidney-shaped pelvic inlet, the pelvis being laterally tilted and asymmetrical. Diagnosis of Contracted Pelvis. On enquiring into the his- tory you usually find a previous occurrence of rickets indicated by late dentition, square head, pigeon breast, attacks of indiges- tion and profuse perspiration, tumefied abdomen, small stature, spinal curvature, enlarged joints, and bow-legs. Then an enquiry into the j-revious labors, if thero have been such, will throw light on the case. MEASUREMENT. 1. Internal Pelvimetry. The patient is placed upon the back and the diameter which is now of importance is the diagonal conjugate or sacro-subpubic, and is the distance from the promontory of the sacrum to the lower border of the symphysis pubis. It may be measured by the pelvi- meter, but the fingers are best. While the pomt of the finger touches the promontory ot the sacrum, mark oflf on the back of hand the under border of symphysis and deduct half an inch, this will give the conjugate diameter. 2. External Pelvimetry. Measuie with a pair of cal- lipers from the upper edge of the pubic symphysis to the depres- sion just below the spinous process of the last lumber vertebra. This is normally 7| inches and 'deducting 3| inches for the thick- ness of bone and soft parts, you have 4 1 inches: as the conjugate diameter. Then the distance between the two anterior superior spinous processes should be normally 9^ inches, and between the two most projecting points laterally on the crests of tlie ilia should normally measure 10| inches. I append the c rresponding normal diameters and dimens- ions, as given by Carl Braun and Schroeder : Distance between anterior superior spinous inches. processes 26 cm. or 10.2 Distance between iliac crests 29 cm. " 11.4 n !8. 2 4 OBSTETRICS. 77 Inches. External conjugate diameter (Baudelocque) 20;^ cm. or 7.9 Distance from sacro-coccygeal joint to sub- public joint (A. (Jr. E. Breisky) 12.3 cm. " 4.8 Distance between great trochanters d\^ cm. " 12.3 Pelvic circumference (Kiwisch) 90 cm. " 35.4 Diagonal conjugate diameter 13 cm. *' 5.1 True conjugate diameter 11 cm. " 4.3 INPLUENCE DURING PREGNANCY AND LABOR. 1. During Pregnancy. In the early months it favors retroversion and this gradually merges into flexion and incar- ceration. In the later months tho uterus is elevated more th-ui in normal cases and is more movable, and the abdomen is more pendulous. 2. During Labor. The presenting part is always very high, and faulty presentations are more jipt to occur. The pains are apt to be strong and hence if the mechanical obstruc- tion is not removed the uterus is apt to rupture. The mechan- ism in these cases will depend on the size, form, position, and compressibility of the fcetal head, as well as on the size and shape of the pelvic space. There is usually more lateral obli- quity, because the contracted pelvis prevents both parietal bones from entering at once. Treatment. Our resources in contracted pelvis are the induc- tion of premature labor, forceps, version, craniotomy, and abdominal section, for an account of which, see obstetric operations. before deciding the appropriate method it is important to enquire if pregnancy has advanced to the full term ; if not^ does the case call for the induction of abortion or premature labor ; if the term has been reached, is it })Ossible to deliver through the natural passage ; if the child i^ alive or dead ; if living, do the interests of the mother require the sacrifice of I'ii m 11 78 OBSTETRICS. the child's life ; and lastly, if the conditions ave such as to ren- der it impossible for a living child to be born, what method would be best for the interests of both mother and child 1 To answer these questions it will assist if we divide contrac- ted pelvis into four degrees : — First Degree. Where the conjugate diameter is between 4 and 3| inches, the forceps are indicated. It is assumed that the child may be born alive by the spon- taneous efforts of the mother, but it seems to be forgotten that a large proportion of children will perish and tlie mothers suffer greatly, and their tissues be lacerated, unless assisted. The dangers to the child result from pressure obstructing the circulation, and the dangers to the mother from long continued pressure on the soft parts, causing inflammation and subsequent sloughing of the bladder, vagina or urethra. These results have been attributed to the forceps but are really due to neglect of their timely use. Second Degree. Where the conjugate diameter is between 3^ and 2| inches, version is indicated. Here labor unassisted is hopeless for both mother and child. By turning you bring the narrow part of the head (the bi-tem- poral diameter, 3;| inches) to engage first in the narrowed con- jugate, which the wider dome of the head could not do, and then after turning, manual abdominal pressure may be applied to the head and traction on the body from below. If the child is dead it is always preferable in such a case to perforate and deliver. . Third Degree. Where the conjugate diameter is from 2| to 1 J inches, here craniotomy is indicated, or if the child be alive and not injured by delay or futile attempts to deliver in other ways, and provided the general condition of the mother, her hygienic surroundings and capacity to secure skilled attendants be such section, vided ali Fourt 1| inche and dan< To re( Wiien brii Bet Bel (^^ being m ontory o is notice hard to Treati with" the or apply Latert on the o] {ii). I delay in of the lie and emo edges of It oft< and wlio OBSTETRICS. 79 be such as to give substantial hope of her surviving abdominal section, this operation would be justifiable and preferable, p o- vided also that she and her relatives consent. Fourth Degree. When the conjugate diameter is less than 1| inches, abdominal section is, beyond all question, less difficult and dangerous than craniotomy. To recapitulate : — When conjugate diameter of The proper mode of brim measures . delivery is by : Between 4 and 3| inches Forceps. " 3J and 2f " . Version. " 2| and .1| " Craniotomy, or if child alive, by Abdominal Section. Below 1| inches Abdominal Section and not Craniotomy. (yQ). OS UTERI. (i). Obliquity. This may be lateral or anterior, the latter being more common ; the head is thrown toward the prom- ontory of the sacrum, and labor is thus impeded. The uterus is noticed to be thrown forward, the belly pendulous, and it is hard to find the os as it is so far back. Treatment. Rupture the membranes, draw forward* the os with" the finger, and press on the abdomen with the other hand or apply a binder. Lateral obliquity is often reheved by making the patient lie on the opposite side. (m). Rigidity. This is one of the most common causes of delay in the first stage, and is often caused by premature escape of the liquor amnii. It is very often found in those of a nervous and emotional temperament, the pains becoming cramp-like, the edges of the os being thinly stretched over the head. It often occurs in girls who have been brought up in luxury, and who have had little physical exercise, the exciting causes m ll n ■nM m ■.w% iiii 80 OBSTETRICS. being powerful impressions on the mind, over-stimulating food or drinks, or too frequent examinations on the part of the physician. /-"'^''^^-^ y •i-^-^'^ Treatment. If the membranes are intact, waiting and patience often succeed, but if the membranes are ruptui'ed you may need to assist^ for it is often in these cases that laceration of the cervix oocu»'S. Use first the hot vaginal douche, and if this is not sufficient give chloral hydrate in gr. XVtloses every hall hour for three doses. It often acts well and does not interfere with the strength of the pains. In some cases, where due to severe continuous pains, chloroform is often more useful. {Hi). Induration. This may be due to cicatricial hardeninfj from former lacerations ; to hypertrophy of the cervix from dis- ease antecedent to pregnancy, or to aglutination and closure of the OS. Treatment. Try the same means as in rigidity, and if these fail, it may be necessary to make three or iour notches round the margin of the os with a blunt-pointed bistoury. Should these fail, especially in cancerous disease, craniotomy or Caesarean section may b« necessary. (y). VAGINA. » {%). A.TRESIA. This may be congenital or it may be acquired from lacerations, diphtheiia, variola, enteric fever, cholera or syphilis. Persistent hymen comes under this head. Treatment. The same as that of rigidity or induration of the OS. (m). Tuaiors. These include oedema of the labia, sanguineous effusions, displacements of the bladder, scybala in the rectum, calculi in the bladder, encysted tumors of the vulva, fibroids, steatoma, polypi, soirrhus and ovarian tumors. Treatrnent. This depends on their character and mobility. If they do not interfere with labor let them alone, if they obstruct they ir by itse (c). considf tensior Tree, water i ("). premat and gi\ and rec (y)- ' child if separat («). Afcei where t hastene (in). endange child w] .Gaus( insertio lapse of above al Progn more se occurs ai Treati maintain 1 1 1 N OBSTETRICS. 81 of they may need removal, but every case will have to be judged by itself. (c). Connected with the Secundines. (a). Liquor Amnii. (i). Abundant. This is hydramnion which has already been considered. It impedes labor in the first stage and by over-dis- tension paralyzes the uterus. Treatment. Puncture the membranes high up and allow the water to escape slowly if possible. {ii). Deficient. This may delay labor for the same rea;ion as premature rupture of the membranes. (/5). The Mkmbranes. Thin membranes rupture prematurely and give rise to " dry births," or if tough they may cause delay and require to be punctured. (y). The Cord. (i). Short. Gives rise to danger to the child if it tears and bleeds, or to the mother from premature separation of the placenta and hemorrhage. {ii). Entangled. It is often twisted round the child's neck. Afcer the head is born it may be slipped over its head, and where this cannot be done it may be tied and cut, and delivery hastened (m). Presenting. " Prolapse of the funis," although not endangering the mother, is serious as regards the life of the child which is very apt to be sacrificed. .Causes. Unusual length of the cord, deep placental site, insertio velamentosa, l .ulder ana b»'eech presentations, pro- lapse of the extremities, hydramnion, multiple pregnancies, and above all contracted pelvis. Prognosis. More than one-half of the children die. It is more serious when it complicates head presentations. It occurs as 1 : 300 cases. - •- Treatment. If the membranes are not ruptured try and maintain them so, for the expectant plan is best until dilatation 82 OBSTETRICS. is complete. After rupture of the membranes, if the presen- tation is still high, the cord should be replaced and held up until the child has engaged. ,/ This is best done by placing the patient in the genu-pectoral position ; introduce the hand and place the cord beyond the greatest circumference of the head, and if possible, to the back of the child's neck; sustain the uterus externally by the other hand, and cease during the pains. If this is successful place the patient in the latero-prone position with the hips elevated by a pillow. If this should fail, put a piece of tape through the eye of a flex- ible catheter, and catching a loop of the cord with this push it into the uterus and leave the catheter there until the head engages so as to prevent prolapse again. If these means fail, especially in face presentations, version may be resorted to. (8). Placenta, {i). Adhesion. 1st. Simple Retention. May be caused by spasm of the os ; from maluse of ergot ; large size of placenta ; or from dragging on cord so as to pull placenta against the pubic arch, or invert it so that it is like dragging on an umbrella ; this has been styled " student's placenta." '^^•"^ h uiu. ^^<^ Treatment. There is always danger of hemorrhage while the placenta remains in the uterus, so if Crede's method of removal, together with gentle traction, are not sufficent, introduce the hand, dilate the os, and remove the placenta. 2nd. Hour-glass Contraction. Here portions of the uterus contract feebly, while the circular fibres are thrown into spasm and retain the placenta in the fundus. It may be caused by the maluse of ergot, or by premature dragging on the cord. Treatment. Place the patient on her back, your left hand on the abdomen to steady the uterus, and with the right hand fol- low up the cord, gradually dilate the constricted part with two fingers, and seizing the placenta remove it. 3rd. Morbid Adhesion. May be uterine or placental. The OBSTETRICS. 83 Mlacenta may be thickened, indurated, or have undergone cal- careous degeneratio . There may have been inflammation, and the placenta may be adherent in whole or in part as a result of it. Though it is rare it may be j)resumed to exist when the uterus is large, firmly contracted, the os sufficiently opened, and where suitable traction on the cord and external pressure have failed to i-emove it, and on digital examination you find no spasmodic stricture of the os or uterus. Treatment. If the means for removing a simply retained placenta are not sufficient, insert your fingers carefully between the placenta and the uterine surface, and by slow and cautious movements of the fingers the adhesions are broken down and the placenta freed. Exert no force and be careful not to injure the uterine tissue for hemorrhage, rupture, or inflanmiation may follow. Great care should be taken after these cases to use disinfectants, and the uterine douche with bichloride (1-5,000) should always be employed. {ii). Pr^evia. Is where the placenta occupies that ])ortion of the uterus subject to dilatation i. e., the internal os and lower segment of the uterus. The stretching of the lower segment leaves the mouths of the sinuses gaping, from which the blood pours until the sti eam is arrested either by art or by the super- vention of syncope. As the hemorrhage in such cases is the natural sequence of cervical dilatation, it is called " unavoidable hemorrhage " in contradistinction to hemorrhage from detach- ment of the placenta when situated normally at the fundus or on the side walls of the uterus, which is known as " accidental hemorrhage." Bandl has shown that during labor the uterine body becomes differentiated into a retracting and ever thickening fundus, a stretching and ever-thinning "lower uterine segment," and the cervix. It is not yet finally settled what is cervix and what is ■lii'' 1 84 OBSTETRICS. " lower uterine segment." After labor the lower uterine seg- ment and cervix can be felt at the lower part of the hard retracted uterus, hanging loosely like a flabby hose. Placenta praivia may be central or marginal, called also partial. It occurs as 1 : 1,000 cases. Causes. It occurs more frequently in multipara than in primipara in the proportion of 6 to 1 ; more fiequent in those who have had children rapidly, and in pregnancies shortly fol- lowing abortions. All these conditions fasror relaxation of the uterine walls, dilatation of the uterine cavity, subinvolution of the uterus, and defective development of the decidua. SymptO)iis. Sudden hemorr'>age occurring during the last few weeks of pregnancy without any apparent cause, without warning or pain, often while urinating or asleep. The first out^ pouring may lead to intense anaemia, and if shortly repeated may cause death. It usually ceases when separation of the cotyledons is completed, and after rupture of the membranes, for then i)ressure of the presenting part bears upon the bleeding surface. The hemorrhage is usually arrested during the height of the pains. Diagnosis. It is not usually detected until the first hemor- rhage occurs. A sudden hemorrhage occurring during the last few weeks of pregnancy, without warning, cause, or pain, should always be regarded as suspicious of placenta prsevia. On making a digital exjlmination the os is felt to be soft and boggy, balotte- ment is obscure, the cervix is long, wide, soft, and you can often feel vessels pulsating in it, and you can usually feel the rough, spongy, granular texture of the placenta within the os. Prognosis. Is unfavoi*able if left to nature or if not promptly assisted. No complication in midwifery is more apt to produce sudden and alarming effects, and none requires more prompt ting. OBSTETRICS. 85 and scientific treatment. Tliere aie few cases more apj)a]ling to the young [)ractitioner, and the successful management of a case of this kind at once distinguishes the educated accoucheur from the ignorant midwife. Treatment. Always remember that rliere is no safety fi the mother as long as pregnancy continues if a j)lacenta prsevu exists. When, theref re, you have been summoned to a case of sudden hemorrhage during the latter months of pregnancy and have diagnosed placenta praevia, delay is dangerous. Fre- quent recurrence of such hemorrhage may be seriously exhaus- ting, or one repetition may be fatal, and if we have not acted promptly, perhaps all we shall then have the opportunity of doing will be to regret that we did not act when we had the chance. ■■ We must remember that a certain number of these cases pro- gress to a favorable termination and require no interference. This is more apt to occur in placenta prsevia marginalis, although it is not unknown in placenta prsevia centralis, where the child has been known to be born by strong contractions pushing the placenta out like a cap upon its head. It was on this fact that Simpson's treatment, consisting in the previous removal of the placenta with the hand, and Barnes' method of detaching the placenta from the lower uterine segment, depend. We must not, however, leave it to nature, but each case must be treated according to its condition. If the OS is not dilated you must plug, using of course anti- septic precautions. The tampon strengthens the pains and by the compression it exerts, causes coagulation of the blood escaping fi'om the uterine vessels. Having once introduced the tampon you should never leave the patient until labor is ended. After at most four hours, the plug should be rsmoved and the cervix examined. If the attachment of the placenta has M 86 OBSTETRICS. only been slight to the lower zone, hemorrhage m ly now cease, the presenting part preventing any more, and the case may be allowed to proceed, or you may hasten delivery by ergot or forceps. Barnes recommends separating at once that portion of the placenta Vhich is attached above the inner orifice of the cervix. By so doing he says " we remove an obstacle to dilatation of the cervix, for the adherent placenta acts as an impediment." "Pass one or two fingers as far as they will go through the os uteri, the hand being ))asscd into the vagina if necessary ; feel- ing the placenta, insinuate the finger between it and tLio uterine wall, sweep the finger around in a circle so as to separate the placenta as far as the finger can reach. Commonly some amount of retraction of the cervix takes place and the hemor- rhage ceases." • , Should these means not succeed you can rupture the mem- branes, give ergot and hasten the engagement of the foetus and its delivery. Should hemorrhage still persist, turn by Braxton Hicks' method, bring down one leg and let the case goon natu- rally, as it is quite unnecessary to extract. In placenta prtevia centralis the hand should be passed through the least attached portion and the child turned, a leg brought down, and then lett to nature. In all these cases the most careful antiseptic precautions should be employed after delivery, as sepsis is apt to occur from the low placental site bringing it nearer to the outer world, and neaier the accoucheur's fingers, owing to laceration, and perhaps to im})erfect retraction of the lower uterine segment. 3. Complications of Labor, (a). Hemorrhage. (a). ACCIDENTAL HEMORRHAGE. This is hemorrhage occurring during pregnancy or labor owing to partial separation of the placenta when normally attached. It is rare in primipara, and usually occurs in debilitated multipara. I n OBSTETRICS. 87 Causes. Slipping, straining, lifting heavy weights, stretch- ing, blows, congestion of the terino \essels, causing the uterus to contract, and the i)artia reparation of the placenta, allowing the blood to escape between the membranes and the uterus. Symptoms. More or less bleeding, which is often profuse, depending on the exciiting cause. If the blood collects between the placenta and membranes it may be *• concealed " or " occult " and is recognised by col- lapse, pain and distension of the uterus. Dicu/nosis. HenioiThage occurring during the latter months of pregnancy, the bleeding being increased during the pains, and on digital examination an absence of placenta prjevia. Occult hemorrhage is to be distinguished from rupture of the uterus. In the latter, labor has been going on for some time, the liquor amnii has escaped, the severe labor pains cease, there is recession of the presenting part, severe pain in abdomen, and escape of fcetus into the abdominal cavity. Prognosis. The death rate of the mother is about 15 p.c, but that of the child is very high, so you should always give a guarded opinion as to the child. Treatment. If very slight keep the patient in bed and per- fectly quiet, giving refrigerent drinks. If it still continues rupture the membranes, and if this does not stop it, use tampon or Barnes' dilators to dilate the os, and deliver by forceps or version, using ergot to hasten the labor. (/?). UNAVOIDABLE HEMORRHAGE. (See Placenta praevia). (7). POST Ir-ARTUM HEMORRHAGE. This is by no means an uncommon complication of labor, and may follow the simplest and easiest labors bringing the i)atient in a few moments to the brink of the grave, hence the importance of understanding its cause, mode of prevention and treatment. lUJ aa CBSTETRICS. Symptoms. The bleeding may occur after the birth of the child and before expulsion of placenta, but is usually applied to hemorrhage occurring after the completion of the third stage. It may commence gradually or it may be sudden, and in severe cases so abundant as to deluge the clothes, bedding and even the floor. The hand on the abdomen misses the hard con- tracted uterus and instead it is felt large and soft and flabby. The pulse is rapidly affected becoming thready or impercept- ible. There is intense weakness or faintness, yawning, restless- ness, gasping, she cries out for air, skin cold and covered with perspiration, loss of vision, ringing in ears, twitching, con- vulsions and finally death. Such is the course of a fatal case, but recovery often takes plaice when the patient is at a very low ebb. There is probably no complication of labor in which the life of your patient so much depends upon your presence of mind, skill and resources ; by your assistance she will generally sur- vive, without it she will usually perish. You must therefore be prepared to act instantly, and decisively. Causes. The cause is inertia or atony of the uterus which may result from exhausting labor, rapid evacuation of the uterus, excessive distension, nervous depression, severe general ailments, retained placenta, sudden rising up, etc. Treatment. As the causes arise from disturbances of the mechanism by which hemorrhage is normally prevented, the treatment consists in following nature's method, viz., securing firm contraction and retraction of the uterus. Retraction is an important factor in the arrest of post partum hemorrhage, and by it is meant that reduction of the size of the uterus and thickening of its walls which is not followed by relax- ation and expansion. Hence the blood is squeezed out of the OBSTETRICS. 89 the ax- the uterine sinuses and the vessels more thoroughly closed in pro- portion to the thorough retraction of the uterus. Prophylaxis. If there lias been a history of previous hem- orrhage, she should be treated by tonics and general hygienic measures during pregnancy. Then be careful not to deliver too quickly, avoid all unnecessary traction on the cord, avoid the use of chloroform, and try to secure regular contraction of the uterus, giving a dose of ergot as the head comes upon the per- ineum. Be rn no haste to deliver the body of the child. As soon as it is born keep your hand on .the fundus, making firm pressure on it or gentle friction. Hemove the placenta by expression .md then hold tlie uteias firmly for half an hour or even longer if necessary. Should hemorrhage occur in spite of these precautions, remove pillows from under the patient's head, inject hypoder- mically 2 gr. of ergotine, or ^ dr. fluid ext. of ergot, diluted with an equal quantity of water, into the gluteal region. Introduce fingers or hand into vagina or uterus and remove clots, and then press fingers firmly against cervix making counter-pres- ure from the outside. Should this fail place a bed-pan under the patient and inject hot water into the uterus at a temperature of 112'^ F. This failing, inject in, same way a tumbler full of brandy or whisky. Should j the patient be very faint, inject brandy or ether hypodermically. Lastly ice has been employed, and Barnes recommends the injection of p^rchloride of iron, and Trask uses iodine, but they are dangerous remedies. The ancemia resulting from loss of blood may be treated by auto-transfusion, i. e., by bandaging the limbs, by the trans- fusion of blood by Aveling's apparatus or by the tra. sfusion of a saline solution, (common salt dr. i, bicarbonate of soda dr. J, warm water, 1 pint at temp. 100° F). i is-- 90 OBSTETRICS. V«7 Secondary Uterine Hemorrhage. May appear several hours, or days, or even a week or two after labor, and usiially results from the retention of portions of placenta, or clots, or from partial i-elaxation or want of tone of the uterus, or to congestion of the uterus from some mental shock, or deficient or absent lactation. Treatment. Remove clots or ))ortions of placenta, if retained, and give ergot to cause the uterine tissue to condense. (6). ECIiAMPSIA OR PUERPERAL CONVULSIONS. Few of the complications of labor are more terrible or fatal. It is peculiar to the puerperal state, occurring only during pregnancy, labor, or after delivery ; it resembles epilepsy, and is not to be confounded with hysteria or apoplexy. It occurs once in 500 labors. Symptoms. The premonitory sym})toms are headache, vertigo, A/uvx '^y^' loss of memory, flashes of light before the eyes, contracted pupil, ambliopia, ringing in the ears, nausea, vomiting, dyspnoea cedema of the face and extremities, and finally the, presence of albumen and tube casts in the urine. %^.?<^ f ^*^ ctM^A^^r^^ {•etuM I.' Then the convulsions are ushered in, often suddenly, by twitching of the face muscles, rolling up of eyes, closed jaws, and insensibility, the pulse intermitting, and respiration being sus- pended. This lasts from one to five minutes and then the hvidity of the face diminishes, the skin becomes warmer, the pulse fuller and consciousness })artially returns. In from a few minutes to an hour the fit recurs, and so on, the intervals diminishing and the fits lasting longer, and the unconsciousness becoming more marked. Prognosis. The mortality is about 25 per cent. In favorable cases, after expulsion of the uterine contents, the attacks cease or diminish in frequency, and the coma disappears,^ ending in natural sleep. On awaking the patient complains of hea'^'.ctc either 1 occur c deeper kidney childre danger hemorr Path found i: pregnai headacl; the pre; a tende] for duri salts are of fibrin In 18 seizures associate stantly resembh convulsi '' occurs and it be and comi ursemic : tion it a| Thisv peral cc synonym Seyferi 1. The ^m ill OBSTETRICS. m on, the the LS of hea'^'uche and impaired memory, and has no recollection of either the fits or the lucid intervals. The earlier the convulsions occur during labor the longer or more difficult the delivery, the deeper the coma ; and the greater the insufficiency of the kidneys the worse the prognosis. Usually one half of the children are stillborn. Even after consciousness returns the danger is still not ended. There is a tendency to post partum hemorrhage, inflammation, hemiplegia, mania, and epilepsy. Pathology and Causation. The predisposing causes are found in the increased excitability of the nervous system in the pregnant woman so that she is more liable to spasms, cramps, headache, neuralgia and all nervous afiections. In this respect the pregnant woman resembles the young child. Then there is a tendency to plethora and a hydrsemic condition of the blood, for during pregnancy the red blood discs, the albumen, iron and salts are diminished, while the white blood discs, the elements of fibrin and the water of the blood are increased. In 1842 *Lever noticed the coincidence between the convulsive seizures and renal insufficiency, which may or may not be associated with albumenuria, though the two go pretty con- stantly together. In 1851 Frericks pointed out the close resemblance between puerperal convulsions and the ursemic convulsions of Bright's disease. "True eclampsia," he says, '' occurs only in pregnant women suffering with Bright's disease, and it bears to the latter the same causal relation as convulsions and coma in Bright's disease in general ; it is the result of the nrsemic intoxication with which also in its mode of mivnifesta- tion it agrees." This view was strenthened by Braun, in 1857, so that puer- peral convulsions and ursemia came to be regarded as synonymous. Seyfert thus states the objections to this theory : — 1. That convulsions mav occur without albumenuria. 'if ' ill' t 92 OBSTETRICS. 2. That the albuiuerairia is in many cases the effect and not the cause. 3. That in many fatal cases tlie kidney lesions were absent or wholly insignificant. 4. That convulsions are rare in chronic Bright's disease which had existed prior to pregnancy. 5. That in true uraemia, such as is necessarily produced by the suppression of urine, as, in uterine cancer, where the ureters are invaded, convulsions no not occur. Although these propositions are perfectly correct, in drawing conclusions from them unnecessary stress is laid upon the presence or absence of albumen in the urin'\ It is the renal insufficiency and not albumenuria which causes uraemia and the convulsions. What then is the exciting cause, for convulsions do not occur in every case of Bright's disease, nor even in every case of renal insufficiency. Frericks thought he had found it in sup- posing a ferment which converted the urea into ammonia carbonate. A more scientific explanation, and the one now generally received, is the TraubeRosenstein theory which maintains that " eclampsia takes place when, in persons rendered hydrsemic by the loss of albumen, the aortic pressure was suddenly increased (as it is by the i)ains), the increased pressure giving rise successively to oedema of the brain, then to secondary com- pression of the vessels, and finally to acute anaemia." An anaemic condition of the hemispheres gives rise to coma, while if extended to the motor centres, it cav.ses convulsions. Treatment. Prophylaxis. (Edema of the face and legs should lead you to at once examine the urine, and finding albu- men, put the patient on milk diet, avoiding meat and albuminous food. Saline cathartics, tonics containing iron, use of min< fail in steadily Whe and flu section dermics object i deliver digital and ap bromid( and ren In a loss of of the ing. ] more se In thes< nerve c diminis] gradual] trunks i the fori form en in some • or heart Whei lapid, it toms, a Treat or a hyp '^ OBSTETRICS. 93 of mineral watera, and the Turkish bath. Should all efforts fail in removing the oedema and albumenuria, and should these steadily increase, you should resort to premature labor. When the convulsions have set in, use chloroform iniialations and fluid extract veratrum viride, gtta. 4 every 2 hours. Vene- section is useful in well selected cases, or you may inject hypo- dermically morphia, gr. ^, or pilocarpine gr. ^. Tlien the great object is to evacuate the contents of the uterus by hastening delivery. If the os is not dilated use hot water injections and digital manipulation or Barnes' dilators, rupture memoranes and apply forceps or turn. Afterwards rectal injections of bromide and chloral, and means to restore the renal insufficiency and remove the oedema and albumenuria. (c). SYNCOPE. In a large majority of cases this is merely a symptom of loss of blood, or exhaustion, or of nervous origin, and one of the phases of hysteria, in which case it is not alarm- ing. It occasionally happens, however, that syncope is far more serious, and is occasionally followed by collapse and death. In these cases it is caused by the recession of blood from the nerve centres when the intra-abdominal pressure is suddenly diminished by the rapid emptying of the uterus. The arteries, gradually in such cases, become empty, while the large venous trunks fill with blood, and the sluggish current predisposes to the formation of thrombi, which are prone to disintegrate and form emboli, which get into the circulation and become arrested in some venous plexus or obstruct the circulation in the brain ' or heart. "Whenever the pulse, after delivery, continues feeble, and lapid, it should be, even in the absence of other grave symp- toms, a subject of profound alarm. Treatment, Lower the head, give stimulants by the mouth or a hypodermic of brandy or ether. /V^^*^^^ at^-i^^'/^^ 94 OBSTETRICS. M-.iCh can be clone in the way of prevention, as by avoiding the occurrence of post-partum hemorrhage, not allowing the labor to be too long continued, preventing the patient from suddenly rising in bed, and applying compression to the abdo- men, by the hand and binder. (d). INVERSION OF THE UTERUS. By the condition of acute inversion of the uterus, is meant the depression of the fundus into the cavity of the uterus, which may continue to increase until not only the fundus but the whole body and cervix have passed through the OS uteri, the organ being literally turned inside out. It is rare, occurring only once in |40,000 cases. Causes. Predisposing. Inertia is the almost exclusive cause. ' ' The exciting causes are traction on cord, especially when pla- centa is adherent ; artificial attempts at extracting placenta, especially when accompanied by bearing down efforts on the part of the woman ; and lastly a short or entangled cord may produce it by dragging upon the placental attachment during the birth of the child. Symptoms. These depend on whether it is partial or com- plete, but usually there is great distress and severe pain, great depression and often collapse, indicated by fainting, small pulse, cold clammy skin, and she may die from shock. On placing the hand upon the abdomen a cup shaped depres- sion of the fundus is felt, and in the vagina the uterus can be felt more or less inverted. The patient has a feeling of pressure and bearing down, and usually there is more or less hemorrhage. Prognosis. If the inversion is slight, spontaneous restoration may occur. The more complete the inversion the more danger, and the patient often dies from shock or hemorrhage. Trea and ski and ho introve with tl bougie, to give This excessiN It 0C( Caus( of the w deformil passage tissue. The e external turning. The i( hence, if or ruptu there n. z Lociti the cervi cervix, o: abdomin tibro-mu{ Sympt when the plains of abdomen, 1]] OBSTETRICS. 9& age. tion Treatment. Everything clepemla upon proiiiptness, decision and skill. If only slight, insert the linger, or a conical bougie and hold it in position until the uterus contracts. If it is introverted do not remove the placenta, but seize the tumor with the hand or push up the fundus with the fingers or bougie. You may require to use chloroform, and afterwards to give opium. (e). RUPTURE OF THE UTERUS. This terrible and often fatal accident of labor is the result of excessive muscular contractions of the uterus. It occurs once in 1,500 cases. Causes. The pi'edisposing causes are preternatural thinness of the walls of the uterus, hydramnion, shoulder i)resentations, deformities of the pelvis, or anything which obstructs the passage of the child ; also softening or ulceration of the uterine tissue. The exciting causes are traumatic, such as blows or kicks, externally, the maluse of instruments, or improper efforts at turning. The idiopathic causes are violent action of the uterine tissue ; hence, if delivery docs not speedily take place either exhaustion or rupture must occur. Hence the danger of giving ergot when there n.cy be any obstruction to delivery. Locition of Tear. It may occur at any part, but usually near the cervix. It may be so slight as only to involve the os and cervix, or large enough to allow the child to escape into the abdominal cavity. In very rare cases it may only involve the libro-muscular tissue leaving the peritoneal covering intact. Symptoms. The labor pains have been severe and strong, and when the accident ha|>|)ens they cease abruptly, and she com- plains of a severe, intense, sharp pain in the lower part of the abdomen, the presenting part ceases to advance and frequently 1:! ill HI 96 OBSTETRICS. recedes, while hemorrhage, external or internal, i .mes. If th:3 tear luus been large enough to allow the child to esca[)e into the abdominal cavity it will be felt through the abdominal wall. The ge)'.eral symptoms are mpid [)ro8tration from the shock and hemorrhage indicated by pallor, feeble pulse, cold extremi- ties, op[)ressed breathing, nausea and voiiiiting first of the contents of the stomach, and then of coffee ground matter, clammy perspiration and death. Prof/nosis. Formerly thought to be always fatal, and although these cases were formerly left to nature and death, it has been observed that some patients recover without assistance, and a still larger number when they have been judiciously treated. When the lesion is in the lower part of the uterus, and the child and placenta are speedily delivered, recoveries are not very infrequent. Treatment. Preventive consists in modeiuting or removing the I>redisposing and exciting causes, and diminishing the excessive muscular action. Be careful in the use of ergot or stimulants during labor. . 4 In cases of dystocia, from impeded uterine efforts, you should always act early, knowing that the mother is always in danger of perishing either from exhaustion or rupture of the uterus. When rupture has occurred the child should be removed at once by forceps or version, and after removing the placenta see that the rent does not communicate with the abdominal cavity ; if not treat the case as after natural labor, giving opium and stimulants, but if it does open into the abdominal cavity and there is the least extravasation of the contents of the uterus, at once perform laparotomy, using all the antiseptic precautions, care of the uterine wound and toilet of abdominal cavity as in a case of Csesarean section by the Sanger-Leopold method. OBSTETRICS. 97 D. — Obstetric Operations. I. THE INDUCTION OP PREMA.TURE LA.BOR. Is indicated in cases in which the continuance of i)regnancy or the occurrence of delivery at full term is associated with risks to the mother or child or both, which may be o'.viated by bringing pregnancy to a close at a period when the fcctus is able to maintain a separate existence from the mother. The child is said to be " viable " if born during any of the last three months of pregnancy. Of course the probability of its living will be greater the longer it is retained. When you have the choice of time in inducing jjremxture delivery, it should be between the 33rd and 34th week. The principal indications for the operation are : — 1. A Moderate Degree of Pelvic Contmction. The object here is to save the child's life by obviating the necessity for craniotomy ; or to spare the mother the danger of craniotomy or abdominal section that might be required if pregnancy went to full term. Degree of contracted pelvis in which it is proper to induce jn'emature delivery to save the child's life is where the conjugate is between 2| and 3^ inches. A child at the 28th week may be delivered through a pelvis whose conjugate is 2|^ inches ; at 32nd week, through 3 inches ; at 36th week, through 3| inches, and if conjugate is. over 3^ inches it may be left to full term and be delivered by forceps. 2. Diseases which Imperil the Life of the Mother^ such as chronic affections of the heart or lungs, hydramnion, tumors, ascites associated with dyspnoea, pernicious anaemia, iincontrol- able vomiting, placenta prsevia, chorea, convulsions, albu- menuria with excessive oedema. 3. Habitual Death of Foetus, at a period before which by 8 M :f ■ t 98 OBSTETKICS. experience the fatal ending has occurred. This is often due to syphilis, in which case hoth i)arents .•jhould be treated con- stitutionally. MODES OF OPERATING. 1. Catheterization of the Uterus. A gum-elastic V>ougie is passed into the os and between the membranes and uterus ; left in situ it usually causes the onset of labor in 24 hours. 2. Puncturing the Membranes. This is the oldest of all methods, but is open to the objection to all cases of premature discharge of the amniotic fluid, viz., tedious labor, absence of dilating cone, and danger to foetus from pressure of contracting uterus on i)lacenta and cord. 3. Mechanical IHlatation of Cervix. Best begun by steel dilator and then Barnes' bags. Never use si)onge tents. 4. Vaginal Douche. Is a useful adjuvant to the previous methods. Besides these there are two methods which are uncertain and dangerous, viz., the vaginal tampon, india rubber bag or colpeurynter ; and injections into the uterus. In the choice of methods take them in the order I have given them, and the process may be accelerated by ergot, forceps, or version. Artificial Abortion. Is justifiable when it offers the only hope of saving the life ot ^.e mother, and is called for when : — 1. There is incarceration of a prolapsed or retrofiexed uteinis which cannot be replaced. 2. In those diseases of pregnancy which immediately imperil life, and which have been vainly combated by all the resources at our disposal. ■'■^TVf OBBTETRtCS. ^9 The operation is porfonneil in the same way as for premature labor, and as it is always accompanied by some risk t^" t'le mother, wr slioiikl weigh carefully every circumstance of the case, and if possible have a brother practitioner to share the responsibility/ ''''-• ^"^ '''• '"-'"^ ,v;ft>7il'>i. <.; ^'ihnU^Jo '>ilt onrf/» .•)to ,j;ij'roiri j(w.'ti( '■•;,() I ,>-lv('ihU. ,{c(i). Bipolar or Conibined Method. (Braxton Hicks.) A precise knowledge of the foetal position is essential. Two or three fingers sub passed through the cervix, the pre- senting part is pushed upward, the externa,l hand making pressure in the di''ection to push down the breech. The two hands thus make the extremities of the ellipse move in opposite directions, the movements by which this is affected being a combination of continuous pressure and gentle impulses or taps with the finger t^yH on the head or shoulder, and a series of half sliding, half pushing impulses with the palm of the hand outside. These manipulations are conducted during the inter- vals between the pains. xliis b^eratidri is one of the most important contributions to obstetrical practice during the present century, but requires the membranes intact or at least just evacuated, and the pains not sufficient to cause contraction of uterus upon child. • ^(o)!^ 'TAiernal Afethod. This is the operation which was usually referred to under the head of turning, and before the invention of the forceps was oftener done than at present. 'The patient is placed upon her back aixd put under an anaesthetic. The hand and arm are bared, disinfected, oiled, and passed into the uterus during the interval of a pain, and a foot or leg is seized a.nd brought down, while the othor hand externally on the abdomen, steadies the uterus and assists in the rotation of the child. When a pain comes on desist, and then during interval proceed, using caution and the utmost gentleness. OBSTETRICS. 103 It is a good plan, if it be a shoulder presentation, and an arm protrudes, to tie a tape around the latter to use afterwards in drawing down arm during delivery, and preventing it becom- ing engaged with the head. It will help also to tie a tape round the leg to assist in traction. There is more danger in this method than in Hicks', because the hand has to be introduced wholly into the uterus, which endangers the mother from septicaemia, shock and the risk of lacerating the uterus. IV. CRANIOTOMY. Consists in perforation of the child's head, diminution of its size, and its delivery. It is solely done in the interests of the mother. Indications. In deformed pelvis, wliere the conjugate diameter is between 2| and 1| inches ; in obstruction by irre- movable tumors, or cancer ; in rare cases of rigidity of the os or cicatrices ; in dangerous conditions of the mother, as eclamp- sia, calling for rapid delivery where the use of the forceps or version is not sufficient to meet the case j and in difficult labors where the child is dead or impacted. Signs of a dead child. Absence of heart sounds, cessation of pu^^W*-^*-*-* signs of pregnancy, the patient feels lighter, and the move- ^^^ xj^JxkA ments of the child cease ; by digital examination the cranium feels flaccid and the bones movable under the scalp. The Operation of Craniotomy. The patient is placed upon the back, and chloroform administered to prevent pain and save her feelings. Complete dilatation of the os is not necessary. The bladder and rectum must be evacuated. The perforator, or Smellie's scissors, are plunged into skull, withdrawn and introduced again so as to make a crucial incision. They are then passv'd down to the medulla so as to destroy the life of :ti 104 OBSTETRICS, the child, since if it is delivered quickly it may cry, even if some of the brain substance has been evacuated. In some cases the brain substance may be washed out with a syringe. Then the craniotomy forceps may be employed to break up the skull, being careful not to injure the soft parts of the mother by spicula of bone. To extract the child the blunt hook may be inserted into the foramen magnum or traction may be made with the crnniotcmy forceps. Cranioclasm is a modification of craniotomy, where after using the perforator the cranioclast, which is simply a large and powerful craniotomy forceps, is introduced one blade between the scalp and the skull, and the other insi he skull, so that a larger portion of the bone may be crushed, or a firmer hold takwii to make traction. Cephalotripsy is another modification of craniotomy, the best instrument bein^ ^hatof Braxton Hicks, which consistsof a power- ful pair of forceps having only a slight pelvic curve, and a screw to make powerful compression. The advantage in this instrument is that the skull may be crushed completely within the scalp, and thus avoid injury to mother's soft parts by spicula of bone, and the head may be so diminished as to pass through a comparatively small pelvis, while a firm hold to make traction is effected. Simpson's basilist is also used. V. EMBRYOTOMY, Is applied to those operations on the trunk of the child, which are designed to diminish its volume and resistance. Indications. In extreme pelvic contraction ; in foetal mal- formation ; in neglected shoulder presentation, where version is impossible or cannot be performed without endangering greatly the life of the mother. 1 . Exenteration is the opening of the abdomen or thorax, and the I'emoval of the contained viscera. It is most commonly OBSTETRICS. 105 indicated in shoulder [)resentation where decapitation is not easy, as in extreme pelvic contraction with the head high above the pelvis. ft is performed by using the perforator so as to admit the hand and then removing the viscera, after which it may be possible to seize the feet and turn. 2. Decapitation is to be performed in neglected shoulder presentations where the neck can be easily reach .^d. It may be done by drawing down the prolapsed arm and cutting through the neck with a blunt scissors ; by Braun's decollator ; or by a string passed round the neck which is cut through by a sawing movement. VI. CiESAREAN SECTION. Is an operation by which the foetus is removed from the mother by an incision made through the abdominal and uterine walls. Indications. In extreme degrees of pelvic contraction, where the conjugate diameter is under 2 inches ; in cases of solid tumors which encroach on the pelvic space ; in advanced can- cerous degeneration of the cervix ; and it is permissable if the mother is moribund and the child is known to be alive. Operation. It should be done after dilatation of the os so as to provide a free outlet for the uterine discharges, the pains are then more strong, frequent, hemorrhage is more efficiently controlled, and there is more chance of the child being alive and the natural tissues uninjured. Formerly, the operation was an exceedingly fatal one, the difficulty arising from secondary hemorrhage at the uterine wound or from septicaemia, but by the modern method, known as the Sanger- Leopold operation, the record now, especially in Germany, is a most brilliant one, it being even asserted that where promptly conducted it is safer than craniotomy in some cases. 106 OBSTETRICS. The bladder m emptied and an incision is made through the abdominal wall carefully in the linea alba from below the umbilicus to just above the pubis, an assistant steadying the uterus and preventing the escape of the intestines. The uterus is then incised, avoiding the fundus and cervix, the membranes are ruptured through the os and the child is extracted as rapidly as possible, the placenta and clots are removed, and the wound in uterus is now sutured by deep interrupted silver wire or silk sutures, which include all the tissues but the decidua, and should be ^ an inch apart. The peritoneal surface is then closely stitched with silk, the peritoneal cavity sponged out, es- pecially Douglas' pouch, the abdominal wound closed with cat- gut and treated as after an ovariotomy. The operation should be conducted on strict antiseptic princi- ples. The operation should be performed as early as possible, and the patient should be examined and disturbed as little as possible previously. The internal and external genitals should be washed with a sublimate solution (I : 2,000). Hemorrhage is checked by manual compression or by elastic ligature. In order to avoid the risks incident to the operation, and in certain selected cases, two operations have been designed to this end : Thi incisii cervix 02)6 Poupa outsid< superi( directo with a wards j bladdei obturat upon tJ this inc injure t is then right il removes injected the fistu abdomir otoniy. Vn. OVARO-HYSTEEECTOMY.~(Porro) This consists in Csesarean section, plus removal of the uterus and ovaries. The operation is precisely similar until the removal of uterus, when a constrictor is applied, the uterus and ovaries removed, the stump is mummified with cautery and percloride of iron and treated by the extra-peritoneal method. OBSTETRICS. 107 Vni. LAPARO-EL YTROTOMY. —(Thomas. ) This consists in avoiding a peritoneal and uterine wound by incising the vagina and removing the child through the os and cervix. Opei'ation. A slightly curved incision is made parallel to Poupart's ligament on the right side, from If inches above and outside the spine of the pubis, to one inch above the anterior superior spine us process, cutting layer by layer upon a hernia director. An assistant holds back the peritoneum and intestines with a warm napkin, another draws the uterus vigorously up- wards and to the left ; while another holds a catheter in the bladder in the natural position. A long wooden plug or obturator is inserted into the vagina and the latter is cut into upon the obturator by the therm o-cautery or a red hot knife, and this incision is then torn with the fingers carefully so as not to injure the urethra in front or too far backwards. The catheter is then removed, the uterus tilted and os drawn towards the right iliac fossa, the membranes ruptured and the child is removed by traction, version, or forceps. Then the bladder is ihjected with a little warm uiilk to see if it is injured, and if so the fistula is stitched up with catgut. Then the vaginal and abdominal wounds are stitched up and treated as after ovari- otomy. E. — Diseases of Childbed. I. CONVALESCENCE AND ITS DISORDERS. By " puerperal state " is meant the condition during recovery from labor. 1. The Nervous Shock. The sudden alteration of the eye, the diminished or increased sensibility of the brain, the disturbances of respiration and circulation, the exhaustion, etc., are all evidences of the shock, which is usually in proportion to- the severity of lae labor and the susceptibility of the patient. 108 OBSTETRICS. lb is one of the circumstances which indicates the necessity of keeping the lying-in patient quiet, and as free from all sources of excitement as possible. After labor the most perfect quiet should be enjoined, the room should be slightly darkened, and no person but the nurse, and a few members of the family, admitted, while little talking and no whispering should be al- lowed. The horizontal posture should be strictly enforced and the patient allowed to sleep. 2. The State of Circulation and Respiration. There is usually rapidity of the pulse during the second stage of labor, and after delivery it falls to normal or a little below and so continues for a day or two until the secretion of milk is estab- lished. The temperature and respiration follow the same course, A distinct chill often follows labor, but ir lot serious, and only indicates a nervous influence. When the pulse remains quick and full, instead of sinking, after labor, beware of some complication. 3. The State of the Uterus and Vagina. After delivery the uterus contracts firmly to the size of a child's head, but shortly relaxes slightly and then contracts, this process having the efiect of gradually diminishing the size of the uterus, until about the 8th or 10th day it is small enough to descend into the pelvis. The normal size and condition of the uterus and cervix are not attained until from six to eight weeks after delivery. This is effected by the transformation of the muscular fibres of the uterus i.ito molecular fat which is absorbed into the vascular system of the mother. Should this involution be interfei'ed with as by premature exertion, disease, or perhaps neglect of lactation, it often remains bulky and the foundation for subsequent uterine disease *is laid. Immediately after delivery the uterus weighs 33 oz., at the end of a week 16 oz., and its cavity measures 5| inches ; at the end of a fortnight it weighs 12 oz., and its cavity measures 4 J inches. OBSTETRICS. 109 After labor the vagina is usually hot and tender, and i)i'esent8 abrasions, but it vcrv soon returns to its normnl condition. The contractions of the uterus are accompanied by pains called " after pains," which seldom occur in primipara. They generally begin half an hour after labor and last 30 or 40 hours. They usually have the effect of expslling clots, are increased by the i'.pplication of the chil 1 to the breast, and are sanitary within bounds. Sometimes they are of great severity and long con- tinued, giving rise to great distress and preventing sleep, so that anodynes are required. Should a post-mortem be made a day or two after delivery, the lining membrane of the uterus will be found loose and corrugated, somewhat softened and covered more or less with patches of decidua. The part to \ hich the placenta is attached is raised and the surface uneven like a granulating ulcer. The whole internal surface of the uterus is of a dark ash color, while the discharge upon it is greenish or brownish,^ giving the appearance of a morbid condition of the parts which has even been mistaken for gangrene. 4. The Lochia. Is the discharge which comes from the internal surface of the body of the uterus together with the secretions of the cervix and vagina. At fii*st it is almost pure blood and clots, then it is mixed with serous exudation, leucocytes, epithelial cells, shreds of decidua, and fatty granu- lar cells. About the 9th day it becomes greenish. It has an alkaline reaction and a peculiar smell, readily decomposes and varies in quantity, quality, odour and duration. 5. The Secretions. The skin is usually moist; urine plentiful, and often retained after severe labors. Bowels are usually constipated. The milk comes usually on the 2nd or 3rd day, and the chill should be early put to the breast. Ill 11 no OBSTETRICS. 6. The Diet, Cleanliness, etc. Diet should i)e liglit and nutritious, but not much meat for first few days. The patient should remain in bed for ten days, for more mischief arises from premature exertion than from almost any other cause, and when you remember that it takes from six to eight weeks for the uterus to regain its natural size, the reason for prolonged rest will be understood. Immediately after the expulsion of the. placenta, apply a warm antiseptic pad to the vulva, the external parts having been washed with warm water by the nurse, and see that this is attended to twice a day. If the lochia smell in the least degree offensively, use a vaginal douche of bichloride and car- bolic acid. The patient should always be visited within twelve hours of the confinement, and the urine enquired about, for if it is not passed the catheter should be used, taking every precaution that it is perfectly clean and aseptic. Some prefer to use the vaginal douche after every case, and although it may be unnecessary as a rule, yet in hospital practice it should be insisted upon, and it is always soothing and comforting to the patient. An aperient should be given on the third day. II. DISEASES OF THE BREAST. 1. Sore Nipples. Causes. The too frequent application of the child removes the sebaceous secretion, so that when the skin dries it contracts, hardens and cracks. Another frequent cause is nursing a child suffering from thrush. Symptoms. The nipples become dry, rough, presifehi> crocks, and become excoriated, and a serous discharge exiideb. There ure often deep fissures and even ulceration. The pain is often intense, and it frequently leads to mastitis. 'iih i 1!! OBSTETRICS. HI Treatment. It hIiouIcI be prevented by bathing the nipples during pregnancy with some stimulating lotion. For sore nipples it is best to bathe them with cold water after nursing, and then use Goulard's lotion, or paint them with a. •/;/» tincture of catechu, tincture benzoin co., glycerole of tannin, ^AM^t^ i^t /^^^ or ung. zinci. ox., always using a nipple shield to protect them '- % while the child is nursing. 2. Mastitis. Causes. Although the excessive irritation and congestion whicli occur at the onset of the secretion of milk, exposure to cold, mental emotion, etc., are all supposed to give rise to it, sore nipples furnish, with perhaps rare excep- tions, the starting point from which the inflammation extends to the glands either by the lymphatics or lactiferous ducts. It occurs more frequently among primipara, and during the first two months after delivery. Symptoms. Their severity depends upon the depth and extent of the inflammation. When the gland and fascia are involved the pain is very severe, as well as the swelling and • tension, and the constitutional symptoms are marked by a quick full pulse, hot skin, headache, thirst, etc. Aftei' the inflammation has continued some time, and resolu- tion does not take place, suppuration occurs, being indicated by a chill followed by perspiration, and locally fluctuation and pointing. There are three varieties : {a). The Subcutaneotis. Is the mildest form and may be confined to the areola. When suppuration occurs, it may lead to fistulous communication with the lactiferous ducts. (b). The Glandidar or Parenchymatous. Is the most com- mon variety. The skin becomes reddish over the hardened breast, and the pain is often severe. There is usually a chill and always more or less fever. 112 OBSTETRICS. (c). The Submammary. Is the rarest form ai d is iisuaJly produced by an extension of the sup|)nrativo process from the deep parts of the ghind through tlie connective tissue between the gland and the pectoral muscle. The breast is sometimes lifted up by the pus as on a water-bed. Tiie skin is often not reddened, but is usually (edematous ; the pain is deep seated and dull ; and the constitutional sy)»iptoms are marked. Treatment of Mastitis. The first thing is to take the child away from the breast, and apply a firm pad and well aj)plied bandage so as to compress the affected breast ; give a dose of oj)inm to relieve pain, and a saline cathartic to relieve hyper- temia. The bandago should be left on for from 24 to 48 hours ; if done in time the inflammation will be found to have undergone resolution, and the bandage may or may not need re-application. If it has been too late and suppuration is imminent, apply hot poultices until fluctuation is felt, then with antiseptic precau- tions incise taking care to always cut parallel to the milk ducts ; wash out the cavity with warm bichloride solution (l-SjOOO) and apply a compress of gauze soaked in warm bichloride solu- tion (1-2,000) under oiled silk. This can be changed twice a day, but do not use any linseed poultices after the pus has once been evacuated. In the submammary variety the incisions should be deeper and freolv made. 3. Defective Secretion of Milk. May be due to lack of mammary development, extreme youth, or polysarca. These of course are not amenable to treatment. Temporary insufficiency may be remedied by nitrogenous diet, outdoor life, the consumption of a large amount of fluid, especially milk and gruel, and tincture of iron. Cataplasms of castor oil leaves are said to be beneficial. Tight lacing, by depressing the nipples and breast, frequently results in defective secretion of milk. ^ OBSTETRICS. 113 4. Q-alactorrhaea. A cOo fiee supply of milk somotimes is a source of anuoyance, and soinetimes after lactation is sus- pended, a constant dribbling of milk occurs, which is a groat drain on the system. Treaiitient. Belladonna, compresses, salines and pot. iodid. IIL PUERPERAL FEVER. Puerperal fever, or puer[)eral septiciemia, is an infectious fever due to the septic innoculation of the wounds which result from the separation of the decidua and the passage of the child through the genital canal in the act of parturition. (Lusk.) When one considers the frightful mortality from this single cause, that '* not fewer than 1 in 120 women delivered at or near the full time dies within the four weeks of childbed," and that the condition is now to a large measure amenable to prevention, the resj)onsibility is great devolving on anyone who neglects the precautions necessary to avoid such a terrible scourge. While we do not hold that in every case of puerperal fe^'er the physi- cian, or midwife, is responsible by reason of sins of omission or commission, it is certainly true that as the cause of puerperal fever has been practically demonstrated, a great revolution has taken place in regard to its prevention and treatment. No subject has created more discussion than this, and, per- haps, no subject has given rise to a greater diversity of views in regard to its cause. Thus some have thought it essentially a local inflammation producing secondary constitutional effects ; that it might be due to suppression of the lochia, to circulation of milk in the blood, or that it was a zymotic fever peculiar to and only attacking puerperal women. The latter view, still held by some eminent authorities, is unlikely for several reasons, viz., the symptoms and lesions have no definite character; a retained and decomposing placenta gives rise to a disease in- distinguishable from puerperal fever ; the same although less 9 lU OliSTETUlCS. dangerous may follow an abortion, and it nuiy originate from various kinds of septic material esptjcially from postmortems or erysipelas and scarlet fever. It was in 1850 that Sir James Y. Simpson pul)lislie«l a paper *' On the Analogy between Puer- peral Fever and Surgical Fever," and the researches of Pasteur, Lister, et. al., laid the foundation for the modern view of its true nature. It is now held that p»ierperal fever is identical with surgical septicu'mia, and that it is produced by absorption of septic matter into the system through solutions of continuity in the generative tract such as always exist after labor. The septic poison itself need not be specific for just as in surgical septicaemia any decomposing organic material, whether homo- genetic or heterogenetic, may give rise to it. Thus by one grand swoop have been demolished the various theories of a disease which has been the theme of enormous volumes, and endless discussions in the past. To-day we stand in the presence of an enemy whose stength we assume to have measured. The best obstetricians of the present day hold tliat we have to deal with certain micro-organisms whose vulnerability by cei'tain germi- cides will enable us to vanquish the foe. Let us see now upon what arguments this view is founded :— 1. It can be proved that septic poisons are capable of pro- ducing the lesions usually associated with puerperal fever. Thus a small bit of membrane or })lacenta if retained within the uterus after labor will -^ause offensive lochia, and then give rise to fever which subsides as a rule with the expulsion of the offending substance, and the use of disinfectant washes. Furthermore we find that septic poisons introduced after delivery produce lesions similar tc chose of puerperal fever, in one case causing pytemia, in another partial peritonitis, general peritonitis, diphtheritic inflammatipns, etc., depending on the quality of the poison, the point of entrance, and the resistance of the invaded tissues. m 0BSTETRIC8. 115 2. Both puerperal fever ami surgical septicieniia aire diseases chaiacterized by the presence of bacteria. It is now a well-established biological law that air and water are peopled with organized microscopical beings, of a nature imperfectly determined, but which are generally conceded to be vegetablv3 matters called microbes or bacteria, which live and multiply at the expense of organized matter, causing it to under- go incessant transformations, and giving rise to fermentation, putrefaction and septicaemia. Thus if we expose fresh apple juice to the air the species of bacteria which are fond of sugar find a suitable soil, multiply rapidly, demanding some of the elements of the sugar molecule, allow the remaining atoms to arrange themselves into alcohol and carbon dioxide, and cider results ; other species attack the akohol and leave acetic acid in its place, and vinegar results ; all this constituting fermentation. Again, when a large wound is exposed to the air those bacteria which feed on albumenous material, set to work destroying the plastic lymph which has been thrown out, leaving sulphur-alcohols and ethers in their track, all this constituting putrefaction, and its concomitants, inflammation and suppuration. So again if septicfemia or erysipelas sj^ores are present, the blood becomes infected, and the result is general septicaemia or " blood poisoning." These bacteria are constantly found present in infected wounds, and they are also present in puerperal fever in the pro- portions and groupings that we find them in other diseases due to putrid infection. They are found to ha swarming in the peritoneal exudation, in the blood, and all the tissues, and in this way we can explain the protean phenomena of puerpers 1 fever, as well as the close relationship which it bears to diph- theria, and erysipelas, and scarlet fever. 3. The differences between surgical and puerperal septictemla are due to structural and physiological d' .orences in the wounded 1 116 OBSTETRICS. surfaces exposed to infection. Thus while there is an analogy between the exposed stump after an imputation and the interior of the uterus after delivery, there is this difference, that in the puerperal state you have to take into consideration the blood changes induced by pregnancy, the effects of shock and exhaustion, of hemorrliage, the presence of clots and decidua in a state of disintegration or decomposition, the ease with which poisonous matters are absorbed by the wide lymph- atic spaces, the serous infiltration of the pelvic tissues, the large size of the lymphatics and veins, and the proximity of the peritoneal cavity. Puerperal septicaemia may be autogeuetic or heterogenetic. 1. AutOgenetic The blood itself is a fruitful source of puerperal fever, for after labor the absorption of the products of 'uterine involution gives rise to a large amount of efiete material in the bk>od, and this may be increased in amount after exces- sive muscular exertion and expenditure of nerve energy, the result of a difficult labor or one long unassisted. Again the decomposition of retained portions of membrane, or placenta, or lochia may give rise to it. Again, in some cases exposure to cold, shock or emotion has been known to give rise to the fever. In some of these cases where a relatively large amount of putrid material has been absorbed, death may take place from a form called putrid intoxication or saprsemia, and in these casco no bacteria may be found in the blood, and the blood is not infectious. The reason is that the material has undergone chemical decomposition or putrefi;ction, but has not taken on septic changes ; but if a sufficient time is allowed, the bacteria will have had time to multiply in the blood and tissues, and we then have all the ordinary phenomena of puerperal fever. It must be remembered, however, that in the autogenetic variety, the poison is generally produced by germs received from the air or in some way from outside, and therefore that the sanitary con- I OBSTETRICS. 117 I J dition of the house or locality may have a large influence in its production. Many cases of this kind have been traced to stationary washstands in a bedroom, which have allowed sewer gas to gain admittance to the room. 2. Hdterogenetic Includes those cases in which the poison is due to special contagion. The most dangerous contagion is that due to some forms of puerperal fever itself. All cases of puerperal fever are not contagious ; thus a case of saprsemia is not, and cases of heterogenetic origin are more or less contagious according to circumstances. Puerperal fever may also arise from zymotic diseases, such as scarlet fever, erysipelas, smallpox, or from post mortem poison, especially if the patient has died from peritonitis ; and lastly, from insanitary surroundings such as defective drains and want of cleanlineps. Pathological Anatomy. The local lesions are very various and depend on the seat of absorption and the form of the disease ; thus we have endocolpitis, endom3tritis, metritis, para- metritis, perimetritis, phlebitis, phlebo thrombosis, and lastly septicaemia proper where death is produced before there is time for the development of local lesions. The only changes then found are an altered state of the blood, a staining of the blood vessels, and a softening and swelling of glandular organs, such as the spleen, liver and kidneys. Symptoms. These vary according to the part implicated, the character of the infection, and the amount and virulence of the poison. There is usually a distinct period of incubation. The fever first appears within three days of the birth of the child, and usually on the third day. After the fifth day an attack is rare, and at the end of a week the patient may be regarded as having reached the point of safety. It is usually "ushered in by a chill, but this may be absent, or there may be ■i Mi 118 OBSTETRICS. repeated chills which usually indicate pyremia and phlebitis. The pulse ri.ses, and may reach 120 to 140. The temperature rises up to 102' or in bad crises to 104° or 106°. Where the rise of temperature is gradual, as from the slow decomposition of sometliing retained within the uterus, the chill may be absent. When a chill accompanies the rise it may suddenly go up to 102°. As a rule the temperature tends to rise progres- sively towards a fatal issue, but in some of the most virulently septic forms, especially in purulent peritoniiis, the temperature falls again after an initial rise, while the pulse continues to become more rapid, and the general condition becomes aggravated. The pulse is therefore frequently a more reliable sigh of danger than the temperature. As the patient becomes moribund, the temperature often becomes subnormal. The symptoms vary according to the local lesion accomj^any- ing it. The milder cases are characterized by inflammations of serous membranes, mucous membranes, or the results of the impaction of infected emboli, or secondary inflammations and abscesses. In other cases the fever is so intense that no appre- ciable morbid phenomena are found after death. It is this variety which was so prevalent and fatal in the olde'- lying-in hospitals, and which was likened to cholera in the severity, suddenness and fatality of its onset. The pain and tenderness over the uterus may be slight or severe according to the local lesion. As it advances the. intestines become distended with gas, the countenance becomes sallow and sunken ; the expression is an:xious ; as a rule intelli- gence is unimpaired to the last ; diarrhoea and vomiting frequent- ly set in, the latter even becoming coffee ground ; the lochia are offensive usually, and are soon arrested ; the milk dries up ; these symptoms last usually a week, the pulse beco jing more rapid, weak and thread-like, and the patient sinks with all the indications of profound exhaustion. OBSTETRICS. 119 Treatment. 1. Preventive. It is not always possible to cany out all the directions indicated, but when possible you should endeavour to promote the health of the patient before delivery, bearing in mind that a woman in low and debilitated condition presents a more suitable soil for the seed or bacteria of sepsis to take root and develop. The sanitary condition of the house and the lying-in room should be seen to, especially as to the con- dition of the drains, permanent wash-stands, if they exist, and ventilation. She should have a bath before labor sets in and if possible a vaginal injection of bichloride solution (1-2,000). She should never be allowed to suffer too long without the timely use of forceps, but the greatest care should be used not to cause laceration or unnecessary contusions. Care should be taken that the nurse has not been in attendance at any case of zymotic disease, nor should the pliysician himself have come directly from any such case. The physician should always wash the hands with coarse soap, and bichloride solution (1-1,000), using the nail brush, and applying some antiseptic lubricant before making any vaginal examination. By the most rigid antiseptic precautions it may not even be necessary to give up midwifery practice while attending a case of puerperal fever. After delivery the parts should be washed with bichloride solution (1-2,000), and a piece of gauze soaked in the same applied, and over this an antiseptic pad consisting of absorbent cotton or tow sewed up in gauze, and used instead of napkins. These are cheaper and more cleiinly, for they can be burned after being a few hours in use. 2 Curative. We should watch for any elevation of tempemture or pulse after labor, and remember that all cases of so called milk fever are really mild septicaemia, and treat them as such. The indications are to neutralize the poison at 120 OBSTETRICS. the point of production and so prevent its causing further mis- chief, and to adopt measures calculated to enable the patient to tolerate its presence until it is eliminated or inert. Pain, if present, should be first allayed by a hypodermic in- jection of mor[)hia, and a vaginal injection of bichloride (1-2,000) thoroughly given by the physician himself. Then give quinine, gr. X., and repeat gr. v. every 3 or 4 hours if necessary. If the temperature still keeps up use the intra-uterine douche of bichloride (1-5,000), and if there is any suspicion of retained secundines introduce the fingers, or blunt curette, ar.d remove them. All abrasions should be touched with sol. ferri persulph. and tinct. iodine equal parts. Locally hot fomentations with turpentine, especially if there is a tendency to typanitis, but in other cases Townsend's rubber tube coil may be placed over the abdomen and ice water allowed to flow through it. If a purgative is indicated give •castor oil or calomel. After using the intra-uterine douche introduce a pessary of iodoform gr. 20 or 30. In sthenic cases fluid ext. veratrum viride may be given in drop doses. The strength must be sustained by beef tea, broths, egg- nogg, milk and whiskey. A convenie .t solution of corrosi^ e sublimate can be made by dissolving one di'achm of the salt in one ounce of alcohol. One teaspoonful of this solution added to one quart of wai*m water will give almost to a fraction one part in two thousand, and will be sufficient for each injection. IV. PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. A thrombus is a blood clot formed within a blood-vessel during life, and the entire proces.s, of which the thrombus is the essential element, is designated thrombosis. The thrombus is made up of fibrin and corpuscles. OBSTETRICS. 121 The causes of thrombosis are an abnormal condition of the epithelium, a rapid destruction of the white blood corpuscles, or a stagnation of the blood, and there is always a tendency to this after delivery owing to the excess of the elements of fibrin in the blood, and because it is charged with a quantity of effete material due to involution of the hypertrophied uterus. It is still more apt to occur in the exhaustion following excessive hemorrhage. An Embolus is a foreign body in a blood vessel, usually too large to pass through the smallest cai)illaries, and the disturl)- ances resulting from its presence are included under the term Embolism. Although most emboli are detached portions of thrombi, any foreign body of suitable size may become an embolus. right » 1 . Pulmonary Obstruction. A clot of blood in the & of the heart or pulmonary artery, either formed in situ carried there from another part of the circulation, is a causfc ^' udden death after delivery. Owing to the state of the blood and system above described a thrombus forms in some part of the circulation, a portion of the clot is detached and is carried as an embolus to the pulmonary artery where it is arrested. Symptoms. The patient is suddenly seized with severe dyspnoea, pain in the prsecordia, she starts up and gasps for breath, the face is usually livid or may be pale, there is great distress, anxiety, and restlessness ; she feels that she is dying and calls out for air ; there is cold clammy skin ; the pulse is al- most imperceptible, and death usually occurs in a few minutes. A few cases have been recorded where the clot has not been suffici- ently large to entirely obstruct the circulation in the lungs, absorption taking place and ultimate recovery, but this is in- finitely rare. 122 OBSTETRICS. Cause of Death. It is due to asphyxia : the blood cannot get to the air to be purified. Treatment. Almost every case is so rapidly fatal that there is no time for treatment, but if called to a case, place the patient at absolute rest, the head lower than the body, to favor the flow of blood to the brain, and give brandy, ammonia or sul- phuric ether, hypodermically. Emboli sometimes occur in the arterial system and may become arrested in the cerebral, humeral or femoral arteries, giving rise to hemiplegia, blindness, gangrene, etc. 2. Phlegmasia Alba Dolens, Is a swelling of one or both legs, characterized by pain, tension of the skin, brawny hardness, absence of pitting on pressure, and a shiny whiteness of surface. It afiects the left more frequently than the right leg, probably because that side of the pelvis is more frequently subjected to pressure and bruising than the other from the com- parative frequency of right lateral obliquity of the uterus. It affects multipara more often than primipara, and is very apt to recur. It usually comes on between the 2nd and 4th week after delivery and seldom subsequently. Symptoms. It is often preceded by slight pyrexia, then severe pain and tenderness in the groin along the course of the femoral vein, or in the calf of the leg extending upwards over the whole limb, and you can often feel the femoral vein hard like a whipcord. The swelling then sp»ads and increases in hardness, which is unlike ordinary oedema or anasarca, for after it is fully developed it does not pit on pressure, but is elastic and feels like solid rubber. Its color is pale or sallow and hence the name " white-leg ; " it looks also glossy or greasy and hence the term " marble leg." All movement is painful and ToluTitary motion is nearly lost. In about nine days it makes no further progress, the pain and swelling diminishing. Pathology. It was at one time thought to be due to arrest of OBSTETRICS. 123 the yecretion of milk and its extravasation in the limb, and hence the term " milk leg." The view which is now held is that it is due to thrombosis of the femoral vein and lymphatics. (a). Morbid Anatomy. 1. On opening the limb it is found to be distended with coagulable lymph effused into the cellular tissue. 2. The vein is obliterated by clots, and the walls are thick- ened, and of a dark red color, coated with coagulable lymph, showing inflammation. 3. There are evidences of inflammation of the lymphatics. (6). Nature of the process. It requires more than throm- bosis of the femoral vein to account for the hardness and want of pitting on pressure, and the fact that the tissues are filled with coagulable lymph and not serum. This can only be accounted for in one of two ways : either that there exists obstruction of the lymphatics as well as the veins, or that some toxjfimic condition of the blood exists in consequence of which the fluid poured out is irritating to the tissues, and sets up a kind of quasi-inflammation, leading to the production of coagu- lable lymph. Probably both views are true, for that it is of septic origin is probable, as it occurs in other states such as . ulcerated cancer of the cervix, and in late stages of phthisis. Tyler Smith records the case of a physician who attended a patient suffering from erysipelatous sloughing sore throat, and shortly afterwards three confinements, each of which had phlegmasia dolens. Terminations. It may en<\ in resolution ; persistent aching and oedema of the limb ; in suppuration, which is rare ; in relapse with slow recovery ; and there is always danger, by rubbing, of an embolus being set free and causing pulmonary obstruction. Treatment. Locally, rest in the most comfortable position, hot fomentations with opium under oil silk, or poultices. 124 OBSTETRICS. Subsequently gentle inunctions with ung. iodini co., or ung. hydrarg. c. belladonna are useful. Medicinally opium for the pain, ciuinine, tonics, good diet, and change of air complete the cure. V. PUERPERAL INSANITY. !■ When one recollects the excitable and altered state of the nervous system during pregnancy, partly due to reflex causes, to disordered digestion and to alterations of the blood, it is not to be wondered at that the same conditions which give rise to alterations in character, to loss of memory, to hysteria, or hy- pochondriasis should sometimes lead to mental derangement. In some women, again, there exists a hereditary predisposition to insanity, and the events of pregnancy and child-bed act simply as the sparks that fire the mine. The term puerperal mania is hardly correct, as many of these cases are characterized by melancholy. From 3 to 5 per cent, of all females admitted into asylums suffer from puerperal insanity, and at least one out of every 1,000 lying-in women becomes insane. It is equally prevalent among rich and poor. * It may for convenience be divided into three forms : that occurring during pregnancy, after labor, and during lactation. 1 . The insanity of Pregnancy. Ihis is the least com- mon form, usually assuming a form of melancholia, developing out of the ordinary hypochondriasis of pregnancy, especially in those of a hereditary neurosis. It usually shows itself between the 3rd and 4th month, and the suicidal tendency is often well marked. The prognosis, however, is more favorable than in any other form. 2. Puerperal Insanity (proper). During delivery and at the last part of the second stage, a kind of acute delirium is OBSTETRICS. 125 soDietiraes met with just when tlie suffering is most intense, while the patient in her agony, if not watched, might injure herself or her child. This is not really puerperal mania, and should be rarely seen in these days of aneesthetics, but it may be of importance in a medico-legal point of view. Causes. There is in nearly all these cases a hereditary taint, not always insanity, but she may have inherited an irritable, unstable, or impressionable nervous system. Thus the family history will often show hysteria, epilepsy, chorea, asthma, or stuttering, if not actual insanity. Most of these cases are anaemic, and show signs of a sluggish alimentary canal, especi- ally constipation, and impaired digestion. Grief, shame, anxiety, and sudden fright, are among the moral causes, and some have even held that it had a septic origin. Symptoms. It may assume either the form of mania or melancholia, the former coming on usually within the first three weeks after labor, the latter not until later. The patient first appears out of health, has dyspepsia and sleeplessness, is fretful and anxious, and as the melancholy deepens she has delusions about her husband and child, and has suicidal tendencies. In mania there is an intolerance of restraint, irritability and either unconcern or open hostility to her infant. They often have religious delusions, and some casos are raving mad, tearing their clothes and requiring to be restrained. 3. Insanity of Lactation. Is twice as common as the insanity of pregnancy, but much less frequent than puerperal insanity proper. The causes are the same, and the form of melancholia is more common than mania. Prognosis. More than two thirds of the cases of puerperal insanity recover. Maniacal cases get well on the average in from three to six months, while the meloncholic take longer. " Mania is more dangerous to life, melancholia to leason." 126 0B8 'HICS. Treatment. 8ometliiiig may bo done towards preventing the disease by improving the health during pregnancy, by warning the patient and her friends against all irritating mental or moral influences, and guarding against septic infection during and after labor, and seeing that the patient has a sulKcient amount of sleep. With the first sign of trouble the child should bo taken from the breast, liquid food should be administered at regular intervals, the room slightly darkened, furniture or jnctures which disturb the patient by their associations should be removed ; if possible a trained nurse should be secured to administer food, to attend to the bowels and bladder, to keep the patient covered, and to prevent her doing harm to herself or others. If poor, the asylum is the best method of treatment, but if she can afford it, home treatment is preferable 'since there is always apt to be a reproach oonnected with any one who has once been in an insane asylum ; *' though the recovery is rapid and satisfactory, still she has been insane, and this is never for- gotten by her children. Henceforward there is a certain dread of what may be in the future a skeleton in the closet, not mentioned, but always there," whereas if home treatment is successful, she will only be thought to have been a little queer, the confinement will account for that, and nothing more will either be said or thought of it. feet. GYNAECOLOGY. 127 GYNECOLOGY. Is the stiuly and treatment of the diseases peculiar to women, and does not usually include those occuring at the puer[)cral period. Most of these diseases occur dui-ing her sexual life, i.e., dur- ing the period of functional activity of the uterus and ovaries. Before this she is a child, when her diseases are few and »^' ly be regarded as accidental or developmental, and wlie». ne child-bearing period is over the sexual organs shrivel up and their function no longer influences the system at large. Towards the climacteric there is often developed a tendency to morbid nutrition or degeneration, and hence the frequency of cancer and t^'brc .La ly irregular as to time, quantity or quality, or it may be completely arrested. Sometimes it is replaced by a uterine leucorrhcea. Causes. Sudden cold, bodily or mental shock, fevers and severe disease, change from country to town, etc. Symptoms. The amount of disturbance varies very much, but most f»"^quently there is headache, fever, severe pain in abdomen and head, and frequently hysteria. Sometimes these symptoms are reliev(^,d by vicarious menstruation or uterine leucorrhc3a, or it may ^ast for months with abating disturbance of the system, but niore or less ill-health. Be careful to distinguish it from pregnancy, -f laa-u/,-©-^ ' Treatme^it. In delayed menstruation if the health is unaffected it is best to wait, being careful to find out in due time if there is any congenital defect present. In suppressed menstruation the hot hip-bath and foot-bath, with hot drinks, and an aloetic Jiurge just before the expected ])eriod are often all that is required. TI en a mixture of iron and aloes, or Blaud's pills, with exercise and fresh air. 2. Dysmenorrhcea is menstruation accompanied by pain just before, during, or after the period. The character of the pain and the nature and severity of the accomj)anying symp- toms vary according to the constitution of the individual ; hence there are several varieties, viz. : — Neuralgic, congestive, mecha- nical, membranous, and ovarian. (a). Neuralgic. Usually occurs in young girls or in sterile married women, and m those of a nervous, delicate constitu- tion. The pain is usually severe and frequently in paroxysms, but unaccompanied by fever. (6). Congestive. Usually occurs in those of a sanguine or plethoric temperament, and usually in married women. The 11 'a ^! !■: V\\n m" 146 GYNECOLOGY. i face is flushed, there is usually fever, and severe pain in the back, and aching in the limbs. The pain usually ceases after the flow is estab'ished, and the latter is often profuse. An examination shows enlargement and congestion of the cervix and trequently abrasion. The bladder frequently sympathizes and the breasts are tender. (c). Obstructive. Is caused mostly by atresia of the os or retroflexion, and is readily detected by an examination. The pain precedes the flow, and there is usually sterility. (d). Membranous. Where the superficial layer of the mucous membi-ane of the uterus is cast ofl" as a coherent triangular sac, or else in shreds of a more or less firm consistence. It is accompanied by intense uterine pains like those of labor. Be careful not to mistake it for abortion, where you would find the villi of the chorion, large decidual cells, and epithelium under- going fatty degeneration. Its true ])athology is unknown, and its prognosis is unfavoi able. ii^K^tXU; j '. Ovarian. These are cases where you can eliminate any uterine or periuterine cause, and where there is not merely a neuralgic condition, but the ovaries can usually be felt enlarged, congested, tender or prolapsed ; they are often accompanied by epilepsy ; and the pain precedes the flow by several days. The prognosis is usually bad. Causes of DysmenorrJuiea. Cold during the menstrual period, sudden shock, mental emotion, constipation resulting in sluggish portal circulation, displacement of the uterus, endometritis, atresia, and peri or para-metritis. Treatment of Dysmenorrhcea. 1. During an attack. Mor- phia, hot brandy, or even chloroform, and hot fomentations locally, and hot baths, ^^f^^ ■ ^^ ' '^'^. '' ' " ' ^ 2. To prevent a return. This depends on the cause. If it is GYNECOLOGY. u: neuralgic, strengthen the patient by tonics, exercise and fresh air, and lessen general and local irritability. If due to congestion, ti-eat ■^lly by depletion and applica- tions of iodine or the hot vaginal douche, and generally by saline aperients. If obstructive, dilate thoroughly, under chloroform if necessary, with a steel dilator ; or if due to retro- f cion treat that. If membranous, gi-'^^e Donovan's solution internally, and iodoform pencils to ut .„o. If any of these resist all treatment, especially the ovarian form, it may be necessary to remove the tubes and ovaries. 3. Menorrhagia is applied to excessive menstruation, while " metrorrhagia " is applied to uterine hemorrhage or a flow occurring during the interval of the menstrual periods. The period may occur too frequently, or it may be too copious. There are two forms met with in practice which are, strictly speaking, degrees of the same disorder, but the division is a convenient one. (a). The flow is of natural quality, but the quantity or freq- uency of recurrence is increased. It occurs in the unmarried sometimes, especially in young females who have to work hard, running up and down stairs, or using the sewing-machine. Symptoms. Those of a continuous debilitating discharge, exhaustijn, anaemia, languor, giddiness, pain in the side, and disorders of digestion. (b). The flow is excessive, mixed with clots, and there is often subinvolution and displacements of the uterus. This form is confined usually to married life, and generally in those of a phlegmatic temperament and a constitution impaired by disease. 148 GYNECOLOGY. ^ '■ i|; 'H: Symptoms. The symptoms are more intense, and on exam- in \tion the cervix is large, open, and often eroded. Pathology of MenorrJiagia. (a). Any condition which induces a state of active or passive congestion of the uterus or its lining, such as subinvolution, displacements, fibroids, ovaritis, lacerated cervix and plethora. (b). Anything which creates a solution of continuity of its lining, such as fungoid degeneration. (c). Any. growth having a vascular connection with the uterus, such as fibroids, polypi, products of conception, and cancer. (d). Any dyscrasia ui the blood, such as scurvy, chlorosis or uraemia. There are cases where there is an absence of all these causes, and they might at present be called functional. Diagnosis. It should not be comfounded with abortion or the climacteric — a careful examination should always be made after medicinal treatment has been fairly tried, and it may even be necessary to dilate the os and thoroughly explore. Treatment. In the simple variety, rest ; a generous but unstimulating diet, and a mixture of sulphuric acid and zinc, sulphate, with alum injections may be all that is necessary. If this fails, seek the cause and treat it secundum artetn. Never give iron in menorrhagia. LeucorrhCBa, commonly called " the whites," is a symptom and not a disease. 1. Vaginal Leucorhhcea. (a). Acute. Is characterized by a white creamy discharge of acid reaction, accompanied by heat, soi-eness, fulness, smarting or pain, weight and bearing down in the vagina with a frequent desire to micturate. On examination the mucous membrane is red, swollen and tender. The princi- pal causes are cold, violence, high living and excessive sexual indulgence. mm^ GYNECOLOGY. 149 Diagnosis. It is difficult to distinguish it from gonorrhoea, but in tlie latter there is more bladder trouble, the glands in the groin are usually enlarged, and the history of the case will assist. Treatment. Injections of plumbi acet. or borax and tonics will often be sufficient. In gonorrhoea wash out the vagina with hot water, introduce a speculum and swab out thoroughly with a solution of silver nitrate (gr. 30 — oz. i.) and introduce a tampon of absorbent cotton smeared with vaseline. (b). Chronic. It is very common, as the vagina is exposed to so many sources of irritation. The causes are nearly all those of monorrhagia. There is usually pain in the back and symptoms of a debili- tating discharge. Treatment. Injections, tonics, and the removal of the cause. 2. Uterine Leucourhcea. Is characterized by a thick glairy alkaline discharge, which on examination with speculum is seen to ooze from the os uteri. It occurs often as .vicarious of menstruation, or at the climacteric, and is frequent in chlorotic subjects and after abortions. It is usually of a chronic character, gives rise to back-ache and general debility. Its causes are similar to those of menorr- hagia. Treatment. Seek the cause, which is most frequently endometritis, and treat the local affection, while at the same time give tonics and constitutional treatment. Sterility. The dosire for family, either to perpetuate the name, or for the descent of property, or the mere love of pro- geny, is so strong an instinct that with every other blessing many are miserable because they have no children. There can be no wonder then that you may often be consulted to remove the cause. 150 GYNiECOLOOY. I !• ■ ■ Causes. Bearing in mind the physiology of conception it will be easy to comprehend why barrenness or sterility should so often occur. 1. Anything which prevents tlie entrance of the semen into the uterus. («). Absence of uterus or vagina. (6), Im})erforate hymen. (c). Vaginismus. (d). Atresia of vagina or uterus. , ((?). Cervical endometritis. (J). Fibroids or jjolypi. [g). Displacements. 2. Anything which prevents - the production of a healthy ovum. , (a). Chronic ovaritis, or cystic degeneration of the ovary. {h). Parametritis and [)erimetritis. ' . - (c). Absence of the ovaries. 3. Anything which prevents the passage of the ovule into ■the uterus. (a). Stricture of the fallopian tubes. 4. Anything which destroys the vitality of the semen or pre- vents fixation of the impregnated ovum. (a). Endometritis. (6). Leucorihcea, and gonorrhoea and gleet in the male after marriage, infecting the woman. '' (c). Membranous dysmenorrhoea. (d). Menorrhagia, (e). Abnormal growths, such as fibroids. • IL GYNAECOLOGY. 151 (f). Subinvolution. . . If all these c.iusea are found to be absent, then examine the husband and see if the organs of generation are healthy and sound, and examine the semen microscopically for spermatozoa, and enquire for a history of syphilis. Married women, who are sterile, usually regard it as a reproach to their womanhood ; sterility is therefore a cause of much unhappiness, so that it is well to inform the patient that a. large proportion by appropriate treatment may become fruitful. Treatment, consists in removing the cause if possible. II. MALFORMATIONS. . These can only be understood in connection with the history of development. During the 4th and 5tli week of intrauterine life, the Wolffian bodies are situated on each side of the verte- bral column, and are the primordial or temporary kidneys. Their efferent channels communicate with the kidnevs, but in the female are of no importance ))athologically. From the lower angle of the Wolffian body a ligament extends to the inguinal region which developes into the round ligament of the uterus. At the median margin of the Wolffian body is the germinal gland, which becomes the ovary in the female, the testis in the male. From the anterior surface arises a cord, at first solid, called Miiller's duct, which becomes cf the greatest importance in the female. Both efferent channels of the Wolffian body, as well as the two mutually united Miiller's ducts, insert themselves into the lower end of the urinary bladder at the point between the urethra above and the urogenital sinus below. While the Wolffian body is retarded in its growth into the parovarium, and the function of secreting urine is assumed by the kidneys, Miiller's ducts continue to i« 152 GYN.ECOLOdY. ' develop, and then join together probably at the point vvliere later the vagina is united to the cervix uteri. The sei)tuni between the two duets then divsa})))ears so that a common canal arises, but the ujjper ends remain sejiarate and begin to diverge. The upi)er extremity of the ducts becomes timbriated, the next part becomes the fallopian tube itself, and the lower portions unite to form the uterus, which soon increases in size to form the fundus, and below, the vagina. The inguinal ligament approaches tho upj)er edges of the uterus constituting the round ligament ; tlie germinal glands, becoming the ovaries, sink down to the sides of the uterus, and at the point where the vagina and uro^jenital sinus ioiii a fold juises wliich bpoomes the hymen. Now if Miiller's ducts fail to unite, we have hicornuity ; if they unite externally but the septum fails to disappear, we have bilocularitij ; if one of Miiller's ducts is absent or only partially developed, we have unicortiiti/ ; or though joining and losing the septum in some portion there may be arVested development, we may have the uterus in an infantile state or rudimentary, or entirely absent. Hlii 1*1 'i f > III. STENOSIS OF OS UTERI. hi \'i Normally the os tinc£e is transverse and about two lines in length. Stenosis or narrowing of the os may be congenital, constituting " j)inhole os," which is usually a cause of sterility and frequently conjoined with a long conical cervix, or it may be acquired by the use of strong caustics. It usually gives rise to dysmenorrhceu or sterility, and is readily diagnosed by an examination. i ■'• Treatment. Dilatation with steel dilator, and in some cases the use of stem pessary afterwards. .4-cv^ • «•»«.« ' iii OYNiECOLOOY. 153 IV. INFIjAMMATION. 1. Endonietritis is an inflammiition of tlie lining mem- brane of the cervix uteri. It may be acute or chi-onic. (a). Acute. Is a conconiitjint of acute metritis, inilistinguish- able from it, and treated in the same way. (b). Chronic. Is a very common affection. Pathology. The mucotis lining of the cervix is disposed in folds and ridges known as the arbor vita?, covered by columnar epithelium and studded with numerous villi. Between the folds are the glands or follicles of Naboth, about 10,000 in number. When inflamed this membrane is swollen, and hypenemic ; the glands, being especially involved, pour out a glairy viscid mucous which fills up the cervical canal in the form of a tenaci- ous plug. This often creates abrasion or erosion of the os, and it was this appearance which used to be called " ulceration." Causes. While there is usually some constitutional pvedis- position, as ill-health, scrofula, etc., it is commonly brought on by exposure to cold during menstruation ; by excessive sexual indulgence ; injury from sound, tent, or pessary ; parturition, especially when the uterus has not been completely emptied ; tumors in the uterine cavity ; uterine dis[)lacements, espscially retroflexion and prolapse ; lace ated cervix ; attempts at abor- tion ; and extension of gonorthoea. Symptoms, {a). Leucorrhma. The secretion is thick and -/Ty^^t *» glairy, of alkaline reaction, and is most characteristic of the complaint. Owing to the small amount of sensibility of the cervix, inflammation may be present without attracting the patient's attention until leucorrhoea becomes marked. (6). Menorrhagia. This may frequently lead to anaemia. (c). Dysmenorrhoea is frequent. Then there is weakness in «A-^ 164 GYNECOLOGY. * till II III :| i ' i;^ 'i: iw-\ Ui M: the back, and [)ain in the pelvis and loins, digestive and nervous derangements, sterility and often abortion. After the disease is established constitutional symptoms become more marked, nutrition is impaired, she becomes nervous, hysterical, fretful and desj)ondent. On examination with speculum the os is usually seen to be inflamed or abraded, with a thick glairy seci-etion oozing out Treatment. ^Regulate constipation if present, build up the general health and combat any diathesis that may be j)resent. Then dilate, curette, dry and apply iodized i)henol, and glycerine tampon. Then use a vaginal douche of plumbic acetate and borax every day. In veiy stubborn cases, zinc alum ])essarie8 or fuming nitric acid are useful. Never use intrauteiine injections. 2. Acute Metritis. Is :in inHammation of the muscular and fibious tissue of the uterus. Generally the lining is affected first, and Thomas thinks acute metritis is merely a complication of endometritis. Pathology. The uterus is enlarged, thickened, doughy, infiltrated with serum, the veins engorged, but the cavity is not altered in size. Causes. Mostly from an extension of inflammation from the mucous or serous lining of the uterus, and most commonly as part of the general inflammation produced by absorption of septic matter during the puerperal state. It may also arise from ex})Osure to cold at the menstrual period ; from gonorrhoeal infection ; or the careless use of the sound or curette. Symptoms. It usually begins with a chill, and then fever with more or less general constitutional disturbance. There is a sense of heat, burning and fulness in the pelvis, and pain in OYNifiCOLOOY. 155 the Iiypogiistric and sacral regions, aggravated by every move- ment of the body or in evacuating the bowels or bladder. There is usually nausea, vomiting, diarrluea, tenesmus of the Lladder and rectum. On examination there is tenderness on pressure in the hypo- gastric region ; the vaginal walls are hot and dry ; the cervix is swollen and any movement of it causes pain ; there is tender- ness in all the fornices. The bimanual is almost im})ossible for the pain. Avoid the use of the sound. The acute symptoms usually terminate in a week, resolution gradually taking j^lace, or else it runs into tlie chronic form. Treatment. Remove the cause, especially if supposed to be due to septic })oison. Thus if it occurs during the })uerj)eral state the uterine cavity should be washed out with bichloride solution (1-5,000), and if any [)ortions of placenta or secundines remain they should be removed by the finger or blunt curette. Perfect rest and morphia to ease pain with quinine in gr. v. doses every 4 lioura, and locally hot fomentations and turpen- tine stupes, with hot vaginal injections. 3. Chronic Metritis. Is not correctly a chronic inflam- mation at all, but consists in an increase of connective tissue out of proportion to that of the muscular fibre which remains normal or but slightly increased in quantity, afid is dependant upon long-continued hypersemia. It resembles cirrhosis of the liver, and might in fact be called " cirrhosis of the uterus." " Subinvolution of the uterus " one of its principal causes, cannot be diagnosed from it, and is treated in the same way. PatJiology. Like cirrhosis of the liver, at an early stage the uterus is enlarged, hypera3mic and soft, but iater on it becomes indurated, anaemic and hard. There is an increased amount of connective tissue and a diminution of muscular fibre. 156 GYNAECOLOGY. Jli! il |i I ;| hi! "11 i! m Causes, (a). Of Chronic Mntritisy the result of Subinvolu- tion. Retention of portions of placenta, membranes, or blood clots ; lacerated cervix ; pelvic inflammation after labor ; rising too soon after delivery; non lactation ; and repeated mis- carriages. In the process of normal involution there are two factors, the fatty degeneration of the muscular fibre and the removal of the })roducts of this degeneration. The enhirgement of subinvolution is due to the suVjstitution of connective tissue for the products of this degeneration. (6). Of Chronic Metritis^ the result of repeated congestion. Displacements of the uterus ; pressure of distended bladder or tumors upon the uterus ; endometritis ; the too free use of caustics, and excessive sexual indulgence. Symptoms. She usually dates her sufferings from a previous confinement or miscarriage. After such an occurrence she feels weak, has pains and weakness in the back, a feeling of weight and bearing down in the pelvis, and a want of power in the limbs. Then there is leucorrhoea and irregular menstruation, which may lead to frequent abortions, and shortly to ster- ility. After a time the constitutional disturbances become marked and urgent. On examination the uterus is felt to be enlarged, especially the cervix and os. The uterus is freely movable and its cavity is enlarged so that the sound passes more than 2^ inches, and there is usually endometritis. Treatment. First seek the cause and remove that, such as endometritis, lacerated cervix, fungoid degeneration, displace- ments, etc. Then rest, local depletion by glycerine tampons, the application of tinct. iodine co., and hot vaginal douches. *^^ i*A. fV\,,^ Internally ergot, quinine and nux vomica. If these means W,*-^ fail, trachelorrhaphy often acts well. OYNiBCOLOOV. 157 Wliat is tlie influence of prognancy and parturition on the local contlitioiis of chronic nietritiR? In many cases it is injurious, but it may be so conducted as to accomplish a degree of good which can be obtained in no other way. Thus a natural delivery free from laceration, a prolonged decubitus free from sepsis, perfect cleanliness by m-^ans of vaginal injections, ergot and quinine to secure tonic contractions, suckling of the infant, and a careful return to ordinary exer- tion, are tlie means which may bring about a complete transfor- mation. V. DISLOCATIONS OR DISPLiACEMENTS Include alterations of curvature as well as of position, hence we \\&.\e Jiexions and versions. In the recumbent woman the vagina lies almost horizontally, the concavity being upwards. Between it and the uterus lies the plate-shaped empty bladder and immediately upon it the uterus, so that in the nonnal state there is no free space between the uterus and the bladder. The fundus of the uterus is directed towards the symphysis pubis, and its upper border is on a level with the plane of the superior strait. The cer- vix or vaginal portion of the uterus is on a level with the junction of the sacrum and coccyx. As there is usually a slight bend at the intei-nal os, the cervix points somewhat downwards. Behind the uterus the rectum descends on the left, but often extends beyond the middle line, so that in frozen sections the part above the anus is situated entirely on the light side. Now it is of particular importance to remember that the uterus is freely movable and not absolutely fixed, and that 1. The uterus in toto is displaceable in all directions. 2. It may be moved in such a manner that the upper longer aim of the lever, — the body, imparts motion to the lower 16^ GYNAECOLOGY. m iii! m " \ smaller arm, — the cervix, in the opposite direction, and inversely me cervix to the body. 3. The uterus may be bent upon itself to a slight degree. Thus the uterus, being held relatively in position somewhat loosely between the floor of the pelvis below and the intestines above, as well as by its ligaments, is pushed backwards by a distended bladder, forwards by a distended rectum, sinks on standing, is elevated in coition, and can be moved about by digital examination. As long as the pressure from above and the resistence from below are physiologically balanced, so long the uterus lies in normal position, the ligaments do not imme- diately enter into consideration, — but if the pelvic floor relaxes, or the pressure becomes excessive from above, the uterus will change its position and drag on its ligaments and on their attachments. You should not put too much importance upon slight variations, for unless marked or persistent they are not pathological, and you may sometimes be surprised to find on examining a patient, a well-marked flexion which had not made its presence felt by any symptoms. This however is exceptional, and is due to the fact that flexions and versions in themselves give rise to no symptoms primarily, the symptoms arising secondarily, and being due to 1. Interference with the functions of menstruation, concep- tion or pregnancj'. 2. Chronic metritis or endometritis producea by the displace- ment. 3. r*elvic cellulitis and peritonitis accompanying the displacement and frequently causing it. Causes of Displacements in general. 1. InHnences which increase the bulk and weight of the uterus, such as congesticn, pregnancy, fibroid tumors, subinvolution and u^ pertropny. 2. Influences which weaken or displace its supports, such ill GYNECOLOGY, 159 as defective nutrition, local or general ; enfeebled health, excessive intra-abdominal pressure, violent muscular effort, tight lacing, wearing Iieavy clothing, pressure of abdominal tumors, etc. 1. Anteversion. The uterus is straightened, the noimal angle at the internal os becoming obliterated and the os [)oint- ing backwards. It occurs physiologically in early pregnancy, and pathologically when the uterus is enlarged through chronic metritis. Symptoms. There are none per se, but there are usually the signs of chronic uterine or pelvic inflammation, such as pain in pelvis, difficulty in walking, micturition and defecation and derangements of the digestive and nervous systems. Digital examination detects the os directed backwards, and the body of the uterus is felt through the anterior fornix. The position is felt by the bimanual method and verified by the sound, but be careful in the use of the latter if there is the least suspicion of pregnancy. T7'eatment. Keep the patient in bed, regulate the bowels and bladder, elevate the hips and use an injection of some astringent, or a tampon of glycerine and tannin, and a ca^'^'^lly adjusted abdommal belt. Any complication such as hyperajmia, inflammation or abrasion should be attended to, and the general health built up by tonics. Do not be in any hurry to use a pessary, but if these means fail, you can insert a Grraily Hewitt cradle pessary. 2. Anteflexion. Is an exaggeration of the normal flexion of the uterus, and is more frequent in nulliparae for the reason that it is a frequent cause of sterility. It mt^y be congenital ; or acquired, which is usually due in delicate ill- nourished girls about the age of puberty to tight lacing, or heavy skirts, or to habitual constipation ; or it may be the result of inflamma- tory changes behind the uterus. T 160 GYNECOLOGY. fll i: pi iiil iL: -. 14 ■ If Symptoms, (a). Dysmenorrhvea. This may be exi)lainecl in two ways : — (a). The obstructive or mechanical theory, held by Simpson and Sims, that the flexion causes a narrowing of the uterine canal obstructing the free exit of the menstrual blood which is retained, coagulates, and causes the uterus to painfully contract to expel the clots. While it is objected to this theory that the blood is not always clotted, that it is often in small quantity, and that the pains have not always the distinctive character of labor pains, yet if not the correct view it is difficult to explain the great benefit derived from various modes of treatment based upon it. (/8). The congestive theory, held by the Germans, that the pain is not due to the bend in the uterine canal but arises from the resistance which the muscular tissue of the uterus ofters to the hyperajmia. In normal cases the tissue yields to the distending vessels, but when the uterus is bent upon itself there is an obstruction to the flow of blood, the mucous membrane cannot swell up as it normally does at the menstrual periods, there is thus undue vascular tension and compression of the nerve end- ings in the uterus, causing pain. There is always in this condition of anteflexion more or less density of tissue, the result of chronic inflammation which makes the tissue more dense and resisting, and the increased vascularity at these times causes pain just as in periostitis where pain in the affected limb is increased by its becoming warm in bed, (6). Sterility. Is due to the same cause. Then th^re are dysuria, dys})areunia, leucorrhoea, and often menorrhagia. ^ Diagnosis. 3y digital examination the cervix is felt to be high up, and the os looks downwards anu forwards, while the body of uterus is felt in the anterior fornix forming a distinct villi GYNAECOLOGY. 161 angle. This is verified by the bimanual, and the sound must be bent before it will pass up to the fundus. . It must be differentiated from myoma of the anterior wall of the uterus, in which case the sound passes normally, while the finger in the vagina detects the increased thickness of the anterior uterine wall, its hardness, ii-regularity and want of symmetry, and the increased bulk of the whole uterus. Treatment. Pelvic inflammation if present should be first attended to, and cicatricial bands stretched by the daily use of well applied glycerine tampons. These cases require patience, perseverance and skill, (a). The occasional introduction of the uterine sound. This should be done a few days after menstruation, and if its pres- ence does not irritate you can make a wide sweep of the handle and place the uter is in a state of retroversion for a short time daily. (6). The intrauterine stem pessary, with or without previous dilatation with steel dilator. Keep the patient in bed for a few days so as to watch its effect and withdraw it if there is any irritation. (c) Should these means fail, divide the cervix and keep it open with an intrauterine glass plug. 3. Retroversion. The whole uterus is directed back- wards. Jt is cauaed by sudden strains or blows ; by carelessness after labor, as at that time from its weight and laxity of attachment it is always more or less retro verted or retroposed for a few days ; or by inflammation behind the uterus causing adhesions. The symptoms a ^ ^ ohe same as those of retroflexion. Diagnosis. The cervix is low down, and the os looks down- wards and forwards. By the bimanual the fundus is found to 12 If: 162 GYNAECOLOGY. I W I. i ii^ i h I; I'gt' m f: be absent from the anterior fornix, but can be felt through the rectum, and the sound passes in directly backwards. Treatment. Remove any existing inflammation first and then if there are no adhesions replace the uterus by the biman- ual or by the sound, or combine with these the genu-pectoral position, and retain it in place by a Hodge, Albert Smith, Thomas, or Greenlialgh's pessary. 4- Retroflexion. Besides being turned back the normal angle is reversed. This displacement is one of the most common and most important that you meet with. Besides being i)laced backwards upon itself so that the fundus lies in Douglas' pouch, its size is increased, the cervix is directed downwards and forwards. Causes. The dorsal position and too tight bandaging after confinement, or the patient rising too soon while the uterus is large and heavy and its supports lax and weak, give rise to it. It may however be congenital. Symptoms. There is usually much greater discomfort than in retroversion. (a). Weakness in the back, which may in some cases amount to actual pain. (b). Symptoms of chronic perimetritis. (c). Painful defecation. {d). Leucorrhoea. This is due to chronic endometritis, the displacement causing passive congestion. ((?). Dysmenorrhcea is not so frequent as in anteflexion. {f). Menorrhagia, which is due to chronic endometritis and obstruction. (g). Sterility, which is due to the altered position of the cer- ;l.!^ w {■y. GYNECOLOGY. 163 vix, to endometritis, obstruction of the Fallopian tubes or malposition of the ovaries. (h). Abortion is apt to take place if pregnancy occurs. Diagnosis. The cervix is low, the os directed downwards and the fundus is absent from the anterior fornix, but is felt in the posterior fornix or by the rectum, and the angle between the fundus and cervix can be felt behind. The sound has to be bent and passes backwards. It must be distinguished from pelvic deposits in Douglas' pouch and myoma of the posterior wall of the uterus. Treatment, (a). Replacement. ;^* 'a'jlol*^^''^'^*"'' (a). By bimanual. v, ^^ eritoneal and the subperitoneal. 1. Intraperitoneal hamiatocele is the more serious, and if tlie effusion is rapid, death mav take place lefore it has time to coagulate, or if it is slower, violent inflammatory action ?s sure to be set up. , • 2. The subperitoneal or encysted variety is when the blood is effused into the cellular tissue sun-ounding the uterus, ovaries and pelvic viscera. Hajmatocele is n^ more a disease than haemoptysis, but is a symptom of some })reviously existing pathological condition of the pelvic organs. It is only since 1850 that gy ntecologists have really had their attention drawn to this condition, so liaV)le to occur owing to the abundant venous .supply of the pelvic organs, the congestion induced by menstruation, and the hemorr- hage accompanying the monthly rupture of the Graafian follicle. Causes. 13 The predisposing cause is the period of ovarian 178 GYNAECOLOGY. ii! 8* !i; activity, especially that of greatest sexual vigor, viz. ; between 2() and 30, iiid at the inenstrual period. The exciting causes are suddeu su[)pres8ion of menstruation from cold, mental shock, undue exertion, over fatigue, violent straining at stool, external violence, premature exertion after iihoj-tion, etc. The source of the blood may he from the veins of the pelvic ]»eritoneum, connective tissue, uterus, or excessive hemorrhage from rupture of Graafian follicle. Symptoms. The sudden onset of ansemia, and signs of internal liemorrhage, accompanied by pain, ditticulty in urination and defecation, a feeling of fulness and bearing down and the pres- ence of a tumor behind the uterus. The uterus is pushed for- ward, and when coagulation takes place the tumor can be disi)laced by the finger through the posterior vaginal wall, often 'with a creaking sound, and feels not unlike scvbala in the irectum. The condition often siuiulates acute i)oisoning. " ,. Diagnosis. It is to bo differentiated from pelvic peritonitis, pelvic cellulitis, fibroid in posterior wall of uterus, extrauterine pregnancy and retroversion of uterus. FrognosU'. It may undergo absorption, an indurated mass remaining for months and being finally absorbed, or it may undergo suppuration, or death may occur very early fj'om hemor- . liage or exhaustion. Ictei'us often occurs from absorption of luematin. Treatment. — 1. Preventive. Obstructive dysmenorrhoea should never be neglected. Fatigue, dancing, exposure, etc., should be avoided during the menstrual period. Cases of menor- iiagia and u lortion should also be watched. ti. Curative. — («) Of the subperitoneal variety, the expect- GYN.*:COLQOY. \7\) ant plan is the best : rest, ice bags, ei^'ot. If collapse, use stimu- lants; and If pain, give morphia. Finn l>au(l;tgin«r is gcjod. If suppuration occuis, open ami drain antiseptically. N.;ver incise a recent hsematocele. (6) Of the hitraperilotieal variety, early [)orformance of laparo- tomy and securing the vessels is best. . E. — Diseases of the Tubes and Ovakies. I. OF THE TUBES. Strictures of the fallo[)ian tube may occur from p 'rim^ti'itis, the tube being bound by binds of lymph, <«i the timbriated extrem'ty matted together by lymph so us to effectually close the tube. This results in sterility or hematocele, and if only partial may give rise to extra-uterine gestation. Salpingitis, or inflammation of the tubes, is usually the result of the extension of endometritis and is very fre(iuently caused by gonorrhcea. As a consequence of this, serum may accumulate and distend the tube, when it is called Hydrops tabit', ; or if suppuration results, Fyosalpinx ; or if it tills with blood, Hivniatosalpinx. Diagnosis. This is difficult and often impossible, but hydro- salpinx may sometimes be distinguished from an ovarian cyst by the swelling being more tortuous and elongated, more anterior and often felt behind Poupart's ligament, and often symmetrical ; or if one tube is affected it usually pushes the uterus to the other side. Draw off' some of the fluid with an aspirating needle and examine it. Treatment. Lj* parotomy . II. OF THE OVAEIES. 1. ProlapSB of the ovary into Douglas' pouch sometimes occurs. Here it may become inflamed and fixed, giving rise i i Ki i It " \.f: ■* 180 GYNyECOLOGV. to a sickening fooling in defecation or walking, and to dispar- ennia, and is a very frequent cause of ovarian dysmenorrhcea. It can readily be felt on examination, and is usually the left, to one side of the uterus and low down. Tt is very sensitive to touch, giving rise to the same sickening sensation as pressure on an inflamed testicle. It can readily be distinguished from retroflexion by a careful bimanual and rectal examination, and by the uterine sound. Treatment. The genu-pectoral position and use of a padded Hodge pessary to distend the posterior cul-de-sac. Hot vaginal douche, j)essar.ies of morphia, avoidance of prolonged exertion, regulation of the bowels and the use of potass, broni. 2. Oophoritis. May be acute or chronic, the latter being more common. Causes. Gonorrhoea ; childbirth and abortion ; obstructed menstruation ; acute febrile diseases, such as cholera, the exanthemata, septiciemia. phosphorus and arsenic poisoning and perimetritis. Symptoms. Pain in the iliac fossa radiating to the back and increased by pressure ; the ovary can be felt enlarged and tender. , It may result in resolution, adhesion or suppuration and abscess. Tveatment. Hot vaginal douche, hot fomentations and mor- phia suppositories. In the chronic variety, glycerine tampons, and. potass, iodid. Should it resist all treatment, an operation has been devised for its cure. . Oophorectomy^ or removal of the tubes and ovaries, is indicated m several conditions and known by the name of the operator. Thus Tkittey first did it for the cure of those cases where hy- stero-epiiepsy, convulsions and insanity depend on ovarian disease ; Uegar did it for uncontrollable bleeding from fibroids ; OYN^C'OLOUY. 181 and Tait for intolenible (lysnieiiorrlid'n duo to |)yos;iIi»iiix, hjLMiiatosalpiux, prolapsed or otherwise diseaf^od ovarit^.. OjjcA'ation. May be vaginnl or abdominal, the latter bcini:^ preferable in most cases. Every aiit:is«!ptic precaution must be thoroughly carried out. An incision is made 4 inches long from the mons Viuicris upwards. All bleeding to be carefully stopped as the ti.ssuesare each cut to ihe peritoiKUim, which is then incised. Then pass the index linger down to the fundus and carry it along the fallopian tube to the ovary, wiiich is lifted out, caught with snap forceps, ligated, and the silk cut short. The peritoneal toilet is made cai-efuUy, and the abdom inal incision is closed by one continuous cat gut suture, taking up the edges of peritoneum first, then the sheath of recti, and then the skin. An antise[)tic dressing and binder completes the operation. 3. Ovarian Tumors. They may arise from a Graafian follicle that has not rui)tured but become distended, and when small thev have a similar structure, viz : a fibrous coat derived from the stroma of the ovary and an inner coat lined with epithelium corresponding to the tunica propria of the follicle, and enclosinjr a clear fluid. Thev mav arise from a corpus luteum ; from colloid degeneration of the ovarian stroma ; from pathological development of enclosed germinal epithelium (the so-called Pfluger's ducts). Dermoid cysts are skin-like in structure and contain bones, teeth, hair, etc., and are formed by a displacement of the external layer of the blastoderm, a portion of which becomes included in the part of the middle la^'er from which the ovary is formed. Lastly they arise from malignant development of the connective tissue of the ovary. The cyst of an ovarian tumor may be single or multi[)le, and the pedicle is usually made up of ovaiian ligament, fallopian tube and broad ligament with vessels, all being covered with peri- toneum. The fluid contained in the cysts varies in consistence r m I 182 GYNiECOLOGY. and color from a cleai', thin, watery fluid to a viscid or semi- solid melatinous iiuiss. It does not give a flocculent precipitate as asintic fluid does It may also contain oil globules, choles- tei'ine ciystals, blood and large granular cells, and a corpuscle has been desci'ibed as characteristic of ovarian fluids, a round delicate, transparent cell containing a number of granules, but no nucleus, and varyiii-- iu size from the Wtfts to Wen of an inch. . Ovarian tumors occur most frequently between 20 and 40 years of age, most comnumly in those who are sterile or unmarried. Anything which intensifies ovarian congestion is apt to give rise to tln^m ; thus women who have suffered long from congestive or obstructive dysmenorrhoea are apt to have ovariaji ijrowths. Si/7npi(i7ns. (a). When small ([)elvic). Pain is often felt in the region of the ovary ; there is ovarian dysmenorrl cea, irrita- bility of the bladdei' and a desire to micturate, discomfort in the bowels often amounting to tenesmus, and usually displace- ment of i he uterus. (/)). Whf-it large (abdominal). As the tumor enlarges it fills the abdominal cavity, and the symptoms now are mainly those of pressui'e, such as dyspnoia, aching in the loins, oedema of the legs ant to give rise to it which are connected with refinement and education, such as music, the reading of novels and poetry, the study of art, etc., which develop the emotional at the expense of the physical and intellectual. Treatment. — No cases will s'* test yonr patience and tact as I these, and there is no doubt the greater success which one physi- cian has over another in the treatment of these cases depends j upon a bett u' knowledge of human nattu-e and a greater force of I character. The first thing is to gain the patient's confidence and respect, make he.^ believe that you thoroughly undei'stand I her case, that she is not suspected of shamming, that with her assistance the trouble will be removed, and the effect whicli you (lesire will probably be produced. Sympathy is often injudi- jcious, but firmness is always necessary. If there is hypeises- thesia the bromides are indicated; if anaesthesia the faradic- lelectric current by means of the brush is a specific; for paralysis, jstrychnia, phosphorus and electric^ / ; for vomiting, the valerian- late of caffeine ; for spasms, chloroform inhalations followed by ^ jiiionobromide of camphor ; and during these attacks copious I'ff'i % 190 OYXifiCOLOGY. |:: d 111 S^ y enemata of hot water, in which is mixed 1 ounce of tincture " a^safcetida often acts specifically. II.-HYSTERO-EPILEPSY Is one of the most frijjfiitful of the nervous affections. We cannot yet say positively if it is a special disease or r combina- tion of ej)ile))sy and hysteria. Symptoms. — The attack begins like epilepsy, she recovers consciousness, and then begin contortions of the face, neck, trunk and extremities, tearing with the hands and teeth any- thing within reach, the hysterical element now jiredomiuating, the patient alternately weeping and laughing, gradually becomes sensible again. Sometimes it seems to })revail epidemically. Treatment. — The bromides, and galvanization of the sympa- thetic. ' . III.— NEURASTHENIA. Nerve exhaustion, or nervous prostration, is applied by Erl) and modei-n authorities to a class of grave and intractable ner- vous disorders, familiar to those who see much of the diseases of women. It represents a class of women who have been from one doctor to another, subjected to all sorts of medication, tried all kinds of pessaries, until they have become confirmed invalids, more or less bedridden. Sleepless, the victims of chloral or morphia, worn out in body and mind ; in short, miserable wrecks, burdens to themselves and their families. There is no doubt these cases have been the result of uterine mischief, but they have now got beyond the point at which local treatment can be of any service or ever effect a cure. The pain, backache, leucorrhcea, difficulty in walking, and disordered menstruation have ended in producing a state of general disturbance in which aU the bodily functions have become implicated. The nervous Hi' gyn^xvjlooy. 19i ictnre ' as. We combina- recovers ce, neck, )eth any- iiiiiating, becomes ically. e sympa- :1 by Erl) able ner- iseases of een from ion, tried invalids, 111 oral or miserable I ere is no hief, but reatnient ackache, struation in which nervous system is pjofoundly affected, tiie blood is impoverished, and the |c;enernl nutrition at its lowest ebb. TUere is emaciation, anorexia, dyspepsia, pi'obably made woi'se by morphia. As a result of all Uaa, and partly from pain, she has ab.md )n(Ml ext'r- cise and keepy in the hoiiF^ or even in bed. Moral abcrration-j also arise, both emotional and liystericil. She ciaves sympathy which she often obtains to her own hurt, until at last the whole jiousohold become victimized by the morbid snitishness thus developed. It is in such cases as these that Di-. Weir Mitchell has pro- ]>osed a plan of cure consisting in the removal of the patient from the unwholesome moral sui'roundings m which she i>as been living, away from sympathetic friends to the care of a trained nurse; in the renewal of her vitality by excessive feeding, which under ordinary circumstances could not be assimilated, hut which is rendered possible by passive muscular exercise obtained through the systematic use of shampooing and elec- tricity. The elements of this treatment, which has resulted in many cases of marvellous cure, consist of spclusion and rest ; njiasaye; electricity , the farad ic current with slow interruptions j and forced feeding . 192 PEDIATRIC'S. PEDIATRICS. r- r' i r ■ f. ■ft- While the infant may be reganhMl [)liysically as tlie abstract of the man, poss-^SHing tlie same oi-gans, the same processes of waste and repair, of growth and decay, still theie are somo important structural and functional differences between child- hood and adult life which modify and alter the diseases to whicli the young child is liable. Thus in childhood the tissues ar«i softer, more vascular, and more succulent ; the glandula--, lymphatic and capillary systems are extremely active ; the skin and mucous membranes are softer, more delicate and more sensitive ; the brain is large, vascular, and almost fluid in consistency ; there is excessive nervous excitability due to want of controlling power ; and reflex sensibility is excessively acute. Thus some slight functional derangement such as the presence of indigestible food will cause fevei", extreme agitation or even convulsions, and the onset of any acute affection is apt to be ushered in by a convulsion instead of the chill whicli is often the first indication in the adult. ^ Again, the rapidity with which infants pai-t with their heat, and so become easily chilled, makes them more prone to catarrhal affections which may rapidly prove fatal, and so the cause of death may be overlooked on making a post mortem examination. !..(?■ Then the diathetic tendencies, such as syphilis, scrofula or tuberculosis, are especially active in the young, and exert a remarkable influence upon the growing body, shaping the figure, moulding the features, and so altering the structure that if insanitary surroundings interfere with the nutritive processes the mischief may be widespread. Ui. PKDIATRICS. 193 While (liagnonis is often a difficult task in the ucluK;, it is still much more so in the infaut where our only guide is an objective examination. The best means to overcome the diffi- culties of such an examination is to form a plan or method to study them. So great are tnese difficidties in the clinical examination of children that unless you hav(! been |)i'e[)ared by some preliminary study you will find it a most uncertain and disheartening task to unravel the history and nature of any case that may come to you. The task is one which recpiires pati- ence, good nature, and tact, for the helpless silence of the iufant, the incorrect answers of the older child, the fright, agitation, or anger produced by your examination, or even mere presence, render it difficult to detect the real aberration of function, ^^id lastly, vhe difficulty of obtaining reliable information from the mother or nurse all concur to make vour examination o." children, with a vievv lO find the seat of disease, a most difficult and perplexing one. If possible, you should try to see the child first when asleep, or during or immediately after the act of nursing, as it is then usually more or less drowsy, and more easily managed. While this is going on, or even before you have seen the child at all, you should enquire of the mother or nurse all about the history of the case. Most women are good observers, and especially is this the case in a mother whose watchfulness is increased by affection and anxiety. You should listen attentively to her statements, and although they may be foolish, false, or exagger- ated, she will often be able to detect variations from health which mfght escape the most acute and observant medical examiner. The history should bear upon the causes of the illness, its precise moment and mode of attack, and its course and symptoms up to the present time ; the health of its parents and their previous diseases ; or if they aie dead, the cause of death. The hygienic surroundings should be taken in ; the 14 ^■1 1* I* 194 PICDIATiWC'S. !'< I* r' I I?'': . liouse, the room, the clothing, the food, wliother tlie eliild was nursed or bottle-tod. If one of the eruptive fevers is suspected, euijuire whether it has Imd meiisles, or scarlet fever, and if it has been vaccinates. The exact onset of tiie disease should be got at by going back day by d-iy, or by en(|uiring if it were well on some particular day ; then encpiire into the course of the disease and its treatment up to the date of your visit, being careful not to ask loading questions. Havin,; in tliis way succeeded in obtaining all the information you can I'om the mother, you next proceed ■ :> examine the child yoursoli, and as this is purely objective you must observe the cry, the expres- sion, the various sj)ontaneous movements indicative of uneasiness, of pleasure or i)ain ; the manner of sucking oi' drinking, whether eagerly and witli relish, or languiulse, respiration ; and lastly examine its mouth and throat, its abdomen and the excretions. Let us look at these points particularly : — 1. The Countenance. The complexion of a healthy baby or young child is fresh and clear ; a loss, therefore, of its purity ■;li I'EDIATUICS. 19") f ;\imI cleiiriK'ss is ouo of tlu» first iiulioatioiiH uf diiiestivo (lenuigomont ; the face then Vjecomes mu(hly-lookiii<,'. aiul the upper lip whitish or bluish. In lanhiceou.s disease it is pallid and bloodless ; in cyanosis bluish. In health the face of an infant during sleep has an appearance of comfort and ct)ntent, perhai)S now and then disturl)ed by a gentle sniih'. In sickness the features become contracted, the forehead wrinkled and turrowed, the nostrils dilated, or pinched and thin, while the mouth is drawn and rigid. In a general way it may be stated when the u[)per part of the face is affected some brain trouble is the cause ; the middle of the face indicates trouble in the thorax ; and wrinkles about the chin point to abdominal iiU'ections. Insonuiia is often one of the first indications of illness. The child may only be uneasy in its sleep, or you may notice contractions of the brow, working of the features, tossing and turning in bed, crying out, grinding of the teeth, or it may wake up in a violent fright. 2. The Cry. In a healthy infjint a cry is excited by anything which causes it discomfort or inconvenience, therefore the absence of a cry should lead you to suspect serious disea.se. The cry is often accompanied by contractions of the features, body, or limbs, which may throw light upjn its cause. Violent, obstinate ])rolonged crying indicates one of two things, —ear- ache^ or hunger. In ear-ache the child puts its hand to its liead or presses it against its mother's chest. Pain in the head is indicated by a short sharp cry ; in pneumonia the pain is slight and usually only during the cough, and is usually iiL'companied by distortion of the features ; in pleurisy the pain is increased by moving the child or by pressing the affected side ; the cry of intestinal pain is usually just at stool, and is accompanied by wriggling of the trunk, flatulence, tympanitic belly and drawing up of the legs. 3. Attitude and Decubitus. Healthy children, when \^\ •m 196 PEDIATRICS. f. m W m ■ m y.i. J .'J 1 j m W li< • '. Is;' ' m \m m lir hi Pi ' m r awake, are always in motion, but their movements can easily be distinguished from the constant tossing, impatient fretting and comjikiining of a child that is ill You would readily recognize the languid hesitancy of prostration and weakness, or the still- ness and immobility of stupor and coma. During sleep a healthy infjint or young child usually lies on one side, and turns its head so as to bring the cheek in contact with the pillow. If a child be found lying motionless on its back with closed eyes and face directed to the ceiling, it is ])rob- ably the subject of seri .us disease, such as tubercular meningitis, or inflammatory diarrhoea. If he lies on one side with his head greatly retracted uiion his shoulder, it points to intra-cranial disease. . 4. The Pulse. In the infant it can scarcely be counted except during sleep, and even if its rapidity can be ascertained, the information is of little value because it is so varying, being influenced by every movement or mental emotion. The pulsation of the anterior fontanel le is of far more value as a test of vigor than the pulse. In infants under a year old a sinking of the fontanel le is a sure sign of reduction of strength ; tense- ness and bulging is a sign of excess of fluid or hypersemia of the brain. 6. Respiration. In new-born infants the respirations number 40 per minute, gradually becoming less, but even after the 2nd year they are over 20. Of more importance is the ratio of the respirations to the pulse. Normally in the young child they are as 1 : 3, and if they become as 1 : 2 you should suspect pneumonia or pulmonary collapse. Frequent heavy sighs and long pauses, during which the chest is motionless, should lead you to suspect tubercular meningitis. 6. Temperature. In very young children is best tsihen in the rectum, and is normally 99° F. You should never trust to PEDIATRICS. 197 your hand, for in inflammatory diarrhoea the extremities are often cold while the temperature rises to 104^ or 105° ; while in a baby exhausted with vomiting and diarrhoea the temperature oftei sinks to 97^ 7. General Inspection. Having obtained all tlie infor- mation possible without unnecessarily disturbing the infant, you should strip it completely, and thoroughly examine its body for anything abnormal. Notice if there is any eruption, if the abdominal veins are enlarged ; and if there is any rupture, or if the testicles are undescended. Feel for the edges of the liver and spleen, and the degree of tension of the abdominal walls. Examine the chest with the stethoscope ; then the mouth and throat, and lastly the stools and vomica should be personally examined. TKEATMENT OP THE NEW-BORN INFANT. As soon as the child is born, the cold air upon its chest by reflex irritation causes the first inspiration, the thorax expands, the alveoli of the lungs fill with air, the blood passes from the right side of the heart to the capillaries of the lungs, and is returned arterialized to the left side of the heart. As a consequence of this the ductus arteriosus contracts, the foramen ovale closes, and the left ventricle hypertrophies. Then from diminished arterial pressure in the aorta the circulation in the umbilical arteries ceases, while thoracic aspiration empties the umbilical vein, the cord dries up from the cut surface toward the navel, and drops off about the 5th day leaving a raw sur- face which soon heals, but sometimes a button-liko granulation is left which should be cut ofi" with scissors and touched with silver nitrate. You should personally see that the infant's eyes have been thoroughly washed by the nurse, and attend to the navv.! your- self, for neglect of tha former may lead to troublesome , ( it ■HI' i 198 PEDIATRICS. k i' !l,. ' Si * m i i' is-. ophthalmia neonatorum, and carelessness in regard to the latter has resulted in fatal hemorrhage. Tlie tirst washino should always be thorough, and if there is much vernix caseosa it should be tirst well smeared with lard or oil, and some even prefer to use this alone and wipe off with a soft rag rather than use water at all. i Asphyxia. If the second stage has been unduly long ; the head subjected to prolonged pressure ; if ergot has been injudi- ciously used, producing tonic contraction of the uterus, closure of the uterine sinuses, and pressure upon the umbilical cord • or if there has been [)rematnre sej)ai'ation of the | iuUx, the child may be in a more or less as})hyxiated condition, the face being swollen and livid, and the heart beating very feebly. TreaUnent. If the face is very livid, allow the cord to bleed a little ; stimulate the surface of the body by rubbing with whiskey, sprinkle cold water on its chest, use Sylvester's method of artificial respiration and ])ut the child in a hot bath, where it may be allowed to remnin for a time. Application to the breast should be early, just as soon as the mother is thoroughly rested. For the tirst few days, until the secretion of milk is thoroughly established, the child shoidd be put at long intervals only, otherwise it is apt to irritate and cause sore nipples. Colostrum is aperient and so obviates the use of castor oil. After the How of milk is fully established the child should be put to the breast every two hours, and in a month or six weeks, every three hours. The mother should try to nurse at night before retiring, so that if possible she may not be disturbed during her sleep. Her diet should be simple but nutritious, and she should drink plenty of milk and gruel, and should avoid all excitement, or passion, or severe physical exertion. Weaning of the child depends upon the onset of teething and the condition of the mother, but should be PEDIATRICS. 199 begun about the 8th or 10th month, and usually it ougiit to be removed from the breast entirely at the end of a year. Selection of a Wet-nurse. Some mothers cannot, others will not, owing to the calls of society or business, nurse their infants, and if they can afford to get a wet-nurse it is best to do so, rather than bi'ing them up on the bottle. If there is strumous cachexia, hereditary phthisis, or great debility, it would 1 e better for the mother not to attempt nursing herself, but if possible it should be insisted upon, as it promotes uterine involution. In selecting a %vet-nurse she should be stiong and healthy, ' ot over 35 nor under 18 years of age, and there siiould be an absence of any cachexia or diathesis. The mammary glands should be pear-shaped, firm, large veins superficially, nipples prominent, but not too large ; the«milk should s[)irt out in jets when squeezed and be of a bluish white color and alkaline reaction You should also inspect the nurse's child to see if it is healthy, or if it is thin and wizzened and has " snuffles,' indicating syphilis. Hand-feeding. In some cases the inability of the mother to nurse, her repugnance to a wet-nurse, or her inability to bear the expense, renders hand-feeding a necessity. A young infant should be fed with good new cow's milk, equal parts diluted with water, or lime water, or sometimes barley water, and sweetened with sugar, six tablespoonfuls to be given at a meal. In hot weather it may with advantage be boiled, and often a teaspoonful of cream should be added. Sometimes when this food disagrees, a little gelatine may be added, or some infants' food, in which the farinaceous matter has been converted into dextrine and glucose, may be substituted, or condensed milk will often be found to agree better. For the first week or two it has been estimated that a nursing mother supplies a pint of milk to her baby in 24 hours, and that in ,11 i 200 PEDIATRICS. the later months of lactation about three pints is reached. Therefore although infants vary in the amount of food required, this will furnish a guide in bottle-fed babies. Goats' and asses' milk are better than cows' milk if they can be obtained, and often peptonized milk will be found to agree where all other foods are not assimilated. After six weeks the milk should be less diluted, and after seven months the milk should be thickened with biscuit, arrowroot or ground rice, and after 'J months it ought to get beef tea, broths, and when a year old a little meat every day very finely cut or pounded. Directions for Peptonizing Milk with Extractum Pancreatis. " Into a clean quart bottle put a powder of 5 grains of Extractum Pancreatis and i5 grains of bicarbonate of soda, and a gill of water. Shake ; then add a pint oi fresh rnilk. " Place the bottle in a pitcher of hot ivater, or set the bottle aside in a warm place for an hour or hour and a half to keep the milk warm, about 110° F. " By this time the milk will become well peptonized. " When the contents of the bottle acquire a grayish-yellow color and a slightly bitter taste, then the milk is thoroughly peptonized, that is to say, the caseine (or curd) of the milk has been digested into peptone, as it is naturally in the body. " Partially peptonized milk has no bitter taste — has, indeed, little apparent evidence of any change. " Yet, in most instances, and especially for infants, it is sufficient to partially peptonize the milk. " After the contents of the bottle get warm, then every moment lessens the amount of, the indigestible ingredient of the milk. PEDIATRICS. 201 1^ " The degree of peptonizing necessary in each case is best fleterrained by the readiness with which it is assimilated by the jtatient. " Great heat destroys, or cold checks, the digestive action. " So, after either complete or partial digestion, it is simply necessary, in order to prevent all further action, to at once phice the bottle of peptonized milk on ice, or put the bottle into ii vessel of boiling water, long enough to scald its contents. It may then be kept like ordinary milk. " It must be borne in mind that this is not a cooking or chemical process ; the object is to subject the milk to the action of the digestive principle (the extract pancreatis) at a temperature similar to that of the body. " Peptonized milk may be sweetened to taste, or used for })unch, with rum, etc., or made into jelly ; also in the prepara- tion of such foods as ordinarily require the use of milk ; according to the instructions of the physician." I. DISEASES OF THE INTESTINAL TRACT. '. ft 1. Dentition. Perfectly healthy infants may cut their teeth without any trouble, but in the majority there is usually more or less local irritation and general disturbance. Teething is not a disease, but is a delicate indicator of the child's consti- tutional condition, and when any hereditary predisposition to disease exists, dentition may prove the immediate exciting cause of some grave disorder. Usual Course. The gums are hot and swollen ; there is increased flow of saliva ; the cheeks are flushed ; the child is restless and fretful ; its sleep is disturbed ; its appetite fails ; and intestinal disturbances are common, such as vomiting and diarrhoea. These symptoms may become exaggerated so that restlessness may become e .-■!■ •eme ; the skin become hot and p i^".i iii. « m P! •202 PEDIATRICS. dry ; the tongue foul ; it refuses to take the breast ; and inflam- matory diseases of the brain and nervous system are apt to he induced ; or there may be convulsions or diarrlioea. Skin eruptions are very apt to occur, and should be treated cautiously at first, the more common varieties being eczema, lichen, herpes, and erythema. Besides these complications you may have thrush, pyrexia, stomatitis, diarrhoea, pulmonary catarrh and otitis. The evolution of the teeth corresponds to a similar activity elsewhere ; thus towards the end of the first year the follicular apparatus of the intestines is undergoing considerable develop- ment ; the cerebro-spinal system is passing tlirough a stage of rapid growth and high functional activity, and as most of the organs and tissues of the body are in a state of active change, it is not to be wondered at that the system at large a] uld often be profoundly affected by the process of dentition, Treatinent. The child should be kept in the open air ; the body sponged ; the gums may be rubbed ; the diet should be simple ; the bowels regulated ; any local irritation should l)e relieved, and if the gums are swollen and congested, they may be lanced ; and lastly, constitutional disturbance should be subdued. 2. Thrush. Popularly called " the sprue." Is a disease of the mucous membrane of the mouth and gullet, consisting of white spots looking like portions of milk curd and due to a vegetable parasite called o'idium albicans. Symptoms. Before the appearance of the white spots the mouth is red and sore, the ciiild sucks with difficulty ; is fretful and peevish ; is more or less feverish ; the bowels are loose ami the motions greenish and acrid, so that the anus becomes excoriated, giving rise to the expression that the disease has " gone through " the child. V: PEDIATKICS. 203 Causes. There is usually some cachectic coned. The only food which contains all these II PEDIATRICS. 205 oleiuents in an assimilable foiMii is milk. Now cow's milk, Uesides its difference in constitution from human milk, presents a more important difference in the size and denseness of its clot when curdled. Human miik forms a light, loose flocculent clot which is readily disintegrated and digested in the stomach. Again, the new-born infant has scanty salivary secretion, and its pancreatic secretion has little effect on starch until after the 3rd monih, so that it has feeble capacity for digesting starch. Hence, the danger of giving biscuits or other farinaceous food to a being quite unprepared by nature to digest it, — the result is indigestion, indicated by flatulence, vomiting, diarrhcca; and, if persisted in, — wasting from starvation. Marasmus is seldom seen to any serious extent in infants at tlie biT ASt, unless a new-born child is put to a wet-nurse whose child is much older, for then the milk is proportionately richer in curd and cream, and so the young child cannot digest it. Human milk is also very subject to diatetic and emotional influences on the part of the mother, and so may disagree with the child. . . Symptoms. There is persistent wasting ; the child is peevish from hunger ; at times it cries violently ; it is troublesome and sleepless at night ; the fontanelle is depressed ; it is pale ; its skin flabby ; bowels irregular ; and eruptions are common. Treatment. If possible you should secure a wet-nurse, and this will often at once arrest all the unfavorable symptoms. The change should be preceded by a dose of castor oil, followed by an antacid stomachic. If a wet-nurse cannot be secured, the feeding sliould be carried out as directed before at page 199. 5. Gastric Catarrh. This is one of the most common causes of infantile atrophy, but we now speak of it as affecting children who have passed the peiiod of infancy. 206 PKDIATUICS, Causei*. Exposuio to cold ; and the ing08tioii of unsuitable food. It is especially liable to occur in scrofulous and rickotv children. Symptoms. It may or may not bo accompanied by fever. The cliild is chilly, languid, sallow, dark under the eyes, losos its appetite, vomits, bowels are costive, and it is often drowsy or delirious. IWeatment. Begin with an emetic of vin. ipecac, and then give a mixture of soda, bismuth, and columbo. The diet should be restricted to milk and lime water, and in a few days the child should have a tonic of the ammonio-citrate of iron. 6- Diarrhoea. Is especially common in childhood, and may be of three varieties : — simple, inflammatory, and choleraic. a. Simple D'larrhma. Is a temporary derangement of the bowels resulting from a mild form of catai'rh. Causes. The most common cause is improf)er feeding, either because it is excessive in amount, or unsuitable ; chilling of the surface ; insufficient clothing, or dentition. Symptom,s. It is often sudden; at first the stools are fecal, and lumps of indigestible food are passed, and then they become watery or greenish. Lienteric diarrhoea is when a motion is at once caused by taking food. Treatment. If any irritant is the cause, begin with a dose of castor oil or rhubarb and soda. Then give a chalk mixture with opium, catechu and sp's. of chloroform. In lienteric diarrhoea, give liq. arsenicalis in drop doses. Green diarrhoea is thought by Hayem to be due to a microbe, and he recom- mends a teaspoonful of a two per cent, solution of lactic acid after every stool. PEDIATRIC'S. 20: ^. Itijlammatory Diaii'hmt. May begin Kk»' iho simple Viiriety but soon becomes more violent and rapidly saps the strength of thd little patient. It is a severe intestinal catarrh or entero-coUtis. Si/mptoms. At first like an ordinary looseness, the stools become greenish, olfonsive and acid ; thci child ra[>idlv wastes and becomes weak ; the eyes become hollow ; tlie pulse rapid and feeble ; there is often fever ; and in a few days, if not rt'lieved, it may result in profound depression. Treatment. First attend to the diet, and if the child is not suckled at the breast you should stop tlie use of milk, which in these cases acts as poison. Give cream and whey, or barley water, or weak veal and chicken bi-oth instead. The food should be given cold and in small quantities. Raw meat is often beneficial. Begin with a dose of castor oil, and then gray powder and Dover's powder. When the diarrhoea is checked, and if there is much prostration of vital power try drop doses of liq. arsenicalis or triturations of ai-senic t^^t to ?w gr. Locally, a spiced pad is often very efficacious and agreeable. c. Choleraic Diarrhoea, or Cholera Infatdum. Is the most dangerous variety and only occurs during the summer months. It luns a rapid coarse, inducing in a few houi's a startling cliange in the child, and often ends fatally. Causes* Hot weather, injudicious feeding, bad drainage, etc. . Si/mptoms. It often begins suddenly with vomiting and purging. It first vomits the food, then yellow mucus, and then pure bile. The stools are watery and abundant, squirting out like water from a syringe, and are not especially offensive like the inflammatory variety. The child wastes rapidly ; its eyes are hollow ; its nose sharp ; thirst is extreme ; and it goes on to collapse. 1. 1 208 PEDIATRICS. I TreatmeiU. Give the child a hot muHtard bath, and try tu check the diarrhcua with starch and hiiuhmum injectit)n8. It shoukl be allowed ice water freely ; three teaspoonfuls of iced wine-whey, or whey and cream. The most valuable remedy is sulphate of morphia injected hypodermically in A gr. to ji child one year old, with five drops of ether. The child should be kept warm by hot blankets, and hot water bottles to its feet. 7. Dysontery. Is a disease of the 1 "ge intestine character- ised by mucous and bloody stools, accompanied by pain and tenesmus. It is frecpiently epidemic and is due to ulcerati\ e inflammation of the colon and i-ectum. Treatment. Mild cases are best treated by rest, with light and unirritating diet, and small doses of opium. If unwhole- some food is suspected as the cause, give a dose of castor oil witli a few drops of laudanum. In the chronic form, hydrarg. bichlor. in minute doses is good. 8. Constipation. Causes. Unsuitable diet; excess of farinaceous food ; atony of the bowels in ill-nourished children ; the use of soothing syrups ; or simply neglecting the calls of nature. Symptoms. The bowels are not moved for several days ; the complexion becomes dull and pasty ; there is restlessness, flatulence, tympanitis, and furred tongue. Treatment. Cultivate a habit in the child of regular evacu- ation, and attend to its diet. An excess of starch should be avoided ; oatmeal may be mixed with the milk, and the food sweetened with brown sugar. If the child is very young, soap suppositories, and if older, enemata may be used. Cascara cordial, or minute doses of podophyllin are useful, and massage may be employed to the abdomen daily with good eflTect. F PEDIATRICS. 2oy » llOI food ;, soap Jascara lassage 9. Intestinal Obstruction. Is vnvAy due to any other cause than intussusception. Babies are especially prone to it during their first year. Causes. Drastic purgativ^es ; indigestible food ; violent coughing ; or falls and accidents. One part of the bowel is forced or invaginated fiom above downwards into the part immediately continuous with it, the consequence of which is obstruction of the canal and of the circulation of the intestine ; effusion of blood and Iym|)h takes place, giving rise to adhesions, and if complete, gangrene may result. A swelling can' usually be seen or felt in the abdomen over it. It may occur in the small intestine or in the colon. Symptoms. The child suddenly screams, turns j^ale, cries violently, writhing and drawing up its legs as if in great abdominal pain which comes on in paroxysms. The bowels are obstinately confined, and a little blood is usually passed with straining, and it vomits all food. After a time a distinct swelling can usually be felt deep in the iliac fossa, Treatment. Its ea\*ly recognition is of great importance. Opium should be given at once to ease the pain and arrest peristaltic action. An enema may be tried, but it is best to distend the bowel with air as completely as possible, and this often relieves the pain and unfolds the intussusception if done early. All means failing, it may be advisable in some cases to perform laparotomy. 10. Intestinal Worms, (a). The Small Thread Worm. (Oxyuris Yermicularis) is found in the ccecum and rectum. (6). The Long Bound Worm. (Ascaris Lumbricoides). Inhabits the small intestine, but migrates to all parts of the intestinal tract. (c). The Tape- Worm. Taenia solium^ derived from pork, and Tcenia m£dio-cannellata from heef. 15 f 't 210 PEDIATRICS. When the ripe joints are swallowed by some animal such as a pig or cow, the eggs and embryos, called pro-scolices, escape, and penetrating the tissues enter the muscles, liver, or brain, becoming a cystocercus or bladder-worm. This swallowed in partially cooked pork or beef develops in the human system into the perfect tape-worm. Symptoms of Worms. Itching of the nose, pruritus ani, abdominal pains, variable appetite, fever, vomiting and diarrhoea, or convulsions, are a group of symptoms often point- ing to worms, but the only sure indication is to find either the worms or their ova in the evacuations. Treatment, The small thread worm is best tre.vted by rectal injections of salt and infusion of quassia , the long round worm by santonin ; and the tape-wcrm by ext. male fern, turpentine, or Tanret's pelleterine. II. DISEASES OF THE NERVOUS SYSTEM. 1. General Symptoms. In the young child there is excessive excitability, so that a slight irritant may give rise to symptoms out of all propojtion to the cause. In every acute illness the nervous system shows signs of distress ; thus, in acute indigestion the skin is hot, the child is restless, cries, is often delirious, twitches in its sleep, or may have convulsions. There are certain symptoms, however, which point directly to disorder of the nervous system. Squinting J although not always a sign of brain disease, should alwavs excite alarm. Nystagmus, or rolling of the eyeballs, often indicates brain disease, especially tubercular meningitis, hydrocephalus, or brain tumor. The condition of the pupils is of importance. They are usually contracted during sleep, and dilated when the child is •f.l PEDIATRICS. 211 awake. They are contracted from opium and in the early stages of meningitis ; in the later stages of meningitis, and in other cerebral diseases, they are dilated. Impairment or loss of sight points to brain tumor, meningitis, or thrombosis. - Delirium often occurs in digestive derangements ; in alter- ations of the blood, as in acute specific fevers ; in the early stage of croupous pneumonia ; and in serious brain affections. Drowsiness, while it occurs in brain affections, may occur in pneumonia, fevers, etc. Changes of temper ; tremors ; spasms ; paralysis ; vomiting, independent of food ; and constipation, often point to cerebral disease. 2. Convulsions. Are common in children, especially during the first two years, and depend upon exalted excitability of the reflex centres in the pons and medulla. Causes. They may occur in utero, and many of those cases of death and paralysis of new-born infants are due to convul- sions. The liability to this condition often runs in families, or in individual members of families, and in rickety children. They may be due to reti ;..: causes, such as injuries to the skin, as burns ; to irritation of the alimentary canal, as from indigestible food, or worms ; to iriitr,tion of the gums from teething ; to inflammation of the ear ; retention of urine ; sud- den chilling of the surface of the body ; violent emotions, as terror ; to the onset of some acute illness ; to ansemia of the brain from loss of blood ; or to uraemia. Symptoms. They may come on suddenly, or be preceded by symptoms of nervous excitability spoken of as "inward 212 PEDIATRICS. fits." When the fit sets in the child gets stifi" ; its head is retracted ; its arms and legs become rigid ; the eyes turn up ; and the breathing is labored. Then clonic sipasms come on ; the muscles of the face work ; the tongue is bitten ; there is twitching of the legs and whole body ; and often frothing at the mouth. It is more serious if limited to one side, as it indicates a cerebral origin. A persistent squint ; convulsions without loss of consciousness ; and persistent stupor after the convul- sions all point to organic disease. The congestion of the brain from convulsions due to some reflex cause, if persistent or long continued, may lead to organic cerebral disease. Prognosis. If due to organic disease the upshot is unfavor- able ; but if owing to some reflex cause, the older the child and the shorter the attack, the less danger, although in any case it is always dangerous and alarming. Treatment. Waste no time in seeking for the cause, but at once put the child in a hot bath and apply sponges soaked in cold water to the head. If this does not arrest it, give a whiff or two of chloroform, which will usually quiet the fits, and then seek for the cause and if possible remove it. If due to an overloaded stomach, give an emetic of vin. ipecac. ; if the bowels are loaded, use an enema ; if teething, lance the gums ; if inflammation of the ear, syringe with warm water, or apply a poultice ; if due to uraemia, give pilocarpine. To prevent a recur- rence, give chloral in gr. 2 doses repeated frequently to a child under one year, or else pot. brom., and then improve the general condition, attending to the diet and giving tonics or cod-liver oil if indicated. 3. Hydrocephalus. This is serous effusion into the cavity of the skull and may be congenital or acquired. Causes. It is often due to drunkenness or syphilis on the PEDIATRICS. 213 part of the parents ; or it may be the result of rickets or ansemia. Morbid Anatomy. When congenital, the walls are pressed out, and the head becomes distended ; the frontal bones are prominent, the sutures are widened, and the fontanelles dis- tended. Symptoms. The children so aflfected often die during delivery, and usually within the first two years. The eyes protrude; the head is heavy ; the muscular system is not developed ; as a rule intelligence is backward, while sight and hearing are often impaired ; and nervous symptoms are common, such as headache and convulsions. Treatment. Little can be done except to regulate the bowels and diet. Hydrarg. bichlor. may do good, and strapping the head with ung. hydrarg., or ung.*'potass. iodid. may be tried. 4. Tubercular Meningitis. Is an inflammation of the meninges at the base of the brain, and may occur at all ages. Causes. The tubercular diathesis, the exciting causes being injury to the head, exposure, or overstudy. Pathology. Engorgement of the meninges and vessels of the pia mater is found, together with ventricular efiusion, and a deposit of gray miliary tubercle at the base of the brain. Symptoms. The child is thought for some time not to look well. It is thinner, paler, and listless. A change of character is often noticed, and there is headache and vertigo. The temperature is often slightly elevated. Then severe headache sets in, with vomiting independent of taking food, and obstinate constipation. The headache is severe, frontal, in paroxysms, and is increased by any movement, or by light. The tongue is k 214 PEDIATRICS. not usually coated, and the child takes early to its bed. The abdomen is soft, compressible and doughy ; the pulse is usually slow ; the breathing is irregular, and sighing ; the pupils are first contracted, and then dilated ; and light is painful to the eye. These symptoms steadily go on and become intensified, until coma, convulsions, and paralysis result. The average duration is 12 days. Treatment. Should be one of prevention, although potass, iodid., or iodoform in ^ to | gr. doses, may be tried. An ice bag may be applied to its head, and a purgative should be given, but these cases are usually hopeless. 5. Acute Infantile Spinal Paralysis. (Anterior Polio- myelitis). — Pathology. Is an inflammation of the anterior cornua of the spinal cord, producing changes in the gray matter itself, in the roots of the nerves springing from that situation, and in the muscles, tendons, bones, and joints to which they are distributed. Symptoms. The attack is sudden, the paralysis reaching its height at once. The child goes to bed and wakens up with its limbs motionless. It may affect one muscle, or a group of muscles, one limb, or all, After some weeks or months a partial recovery is the rule, but lue muscles atrophy, and paralytic contractions occur, giving rise to club-foot, etc. Prognosis. It is not fatal, and some cases recover completely, others partially. Electricity is of great importance in determ- ining the result. Thus, every muscle which does not react to the faradic current after the lapse of a fortnight is likely to be permanently disabled. Again, the muscles which have lost all physical connection with the spinal cord, no longer respond to the faradic current, while they react to slow interruptions of the constant current. This is called the reaction of degener- ation. PEDIATRICS. 215 Treatment. Quiet, and rest in bed ; a V)rick purgative ; counter-irritation to the spine ; a diet of milk and broths ; and as soon as any recovery of power is noticed, but not before, the faradic current should be used daily. If no response takes place you should try the constant current with slow interrup- tions. The paralyzed limb should be wrapped in cotton batting and kept warm ; friction and massage should be employed ; and tonics of iron and stryclmia. 6. Pseudo-hypertrophic Paralysis. This singular alFection, in which extreme feebleness of the muscles is combined with an appearance of extraordinary development and vigor, is sometimes spoken of as Duchenne's disease, as he first des- cribed it. tl:. m Symptoms. The spring, so marked in healthy children, is wanting, and it feel« ' '3avy to lift. It can easily be pushed over, and has diffici in rising. It soon has to stand with a characteristic attituc'- ^he legs widely spread out, and its shoulders thrown backward, exaggerating the antero-posterior spinal curvature, and the belly protrudes. This is the conse- quence of weakness of the extensors and flexors of the hip, and the extensors of the knee, muscles which maintain the upright position in walking. In about a year the calves of the legs become enlarged, and a similar change takes place in all the other muscles. As the paralysis extends the patient gets more helpless, and seldom lives long after puberty. Treatment. Yery little can be done. Faradization may be used, with arsenic and phosphorus internally, while it may be necessary to employ mechanical supports. ijy 1 216 PEDIATRICS. in. DISEASES OF THE RESPIRATORY SYSTEM. 1. Examination of the Chest. A. — Physical Signs of Diseases of The Lungs. Physical Signs are elicited by the following means : I. Inspection, by which we learn the form, size and move- ments of the chest. II. Mensuration is the measurement of the chest by the tape line or by the spirometer, to ascertain the amount of air the lungs are capable of receiving. III. Palpation or the application of the hand is used for the same purposes as in other parts of the body and to ascertain the presence of " vDcal fremitus ; " or " fluctuation," and to con- firm the results obtained by Inspection and Mensuration. IV. Succussion is employed to detect thoracic fluctuation by gently but abruptly pushing the patient's trunk backwards and forwards and listening. V. Percussion may be mediate or immediate : (1) Diminution of Clearness to any degree of dulness is caused by effusion, congestion, condensation and oedema. (2) Increase of Clearness is caused by pneumothorax, atrophy, hypertrophy and emphysema of the lung. (3) Tympanitic Sound indicates the presence of quantities of air contained in cavities whose walls are yielding but neitlier very tense nor very thick. It may be of various kinds. {a). Simple. (b). Amphoric Resonance and " metallic tinkling" is similar to that obtained on striking a wine cask when partially or entirely empty. PEDIATRICS. 217 (c). Tubular Sound is heard when any condition exists which brings the larger bronchial tubes unnaturally near the surface, or when any sound-conducting substance is present between the bronchi and surface. (d). The bruit de pot feU or " cracked pot sound " is heard when a cavity exists in the lungs having thin elastic walls and a free communication with the bronchial tubes. VI. Auscultation may also be mediate or immediate. In health two sounds are heard, viz. : the Tubular or Bronchial sound and the Pulmonary or Vesicular murmur. These are altered by disease or new sounds are heard. 1. Changes in the Vesicular Murmur : - (a) As to Intensity. . (a) Increased, or puerile breathing, depends on an increased action of the air cells, usually to make up for deficient action of other parts. ()8) Diminished — more noticeable in inspiration — may be caused by anything which obstructs the passage of air ; by deficient respiratory action, owing to debility or local pain ; by efi'usion ; or deposit of tubercle. (y) Absent, caused by continued furtherance of above causes. (6) As to Rhythm. ' (a) Jerking respiration is only corroborative if heard at the apex in tubercular deposit, as it is so often heard in hysterical persons. {^) Prolonged expiration denotes that the air has difficulty in getting out of the lungs, and is owing to loss of elasticity of the cells from over-distention (clearness) ; or deposits (dullness) ; or from an obstruction in the bronchi. *'^. ^ mi 218 PEDIATRICS. (c) As to Character. — In health the vesicular murmur is characterized by its softness. Any affection which causes the sound in the bronchi to be produced with greater intensity, or to be better transmitted, will occasion harsh breathing, as when the bronchial membrane is swollen, as in Bronchitis, or when there is compression of the lung tissue with partial condensa- tion, as in Phthisis and Pneumonia. 2. Changes in the Bronchial Sound. Here the character is of more importance than rhythm or intensity. To hear well defined bronchial respiration is mostly to meet with complete consolidation of the lung tissue, as in tuber- cular infiltrations and hepatization of the lung. Varieties of Bronchial respiration are : (a) Cavernous Respiration, where a cavity exists. (b) Amphoric Respiration is indicative of a large cavity with firm walls. 3. New or Adventitious Sounds. (a) Rales are sounds generated in the air tubes by the pass- age of air through them when contracted or containing fluid. They may be : (a) Dry. (i) Sibilant Rhonchus (in small tubes) is a hissing, whist- ling or wheezing sound heard in certain stages of Catarrh and Bronchitis. (ii) Sonorous Rhonchus (in large tubes) is a snoring or dron- ing hum. Less dangerous than sibilus. PEDIATRICS. 219 (iii) Dry Crackle. Like sound of blowing into a dry bladder. Heard in emphysema. (/?) Moist, caused by air bursting through a liquid in tubes. (i) Small Crepitation or subcrei)itant rales, (ii) Large Crepitation or Mucous rales, (iii) Gurgling is merely rale of cavities. (6) Friction Sound attends both movements of respiration, but is loudest and most prolonged during inspiration. Best heard in Pleuritis. 4. The Voice and Cough, " Vocal Resonance." {a) Bronchophony denotes increased density of Pulmonary tissue caused by pressure or by deposit, especially in Pneu- monia and Phthisis. {b) Pectoriloquy caused by condensation of the lung around a cavity communicating with a bronchus. Hollow cavernous sound. (c) CEgophony is a bleating variety of Bronchophony. It is due to the presence of pleuritic effusion, or a thin layer of fluid between compressed lung and ear. !^r. B. — Rational Signs. 1. Pain is a symptom of very little value by itself. In Pleuritis you have a severe sharp pain ; in Pneumonia the sensation is a burning one. 2. Dyspnosa may be caused by exertion in weak persons ; .by bodily or mental excitement ; by pressure upon the lungs as by tumors, ascites, and pregnancy. The most aggravated form is *' Orthopnoea." IE I .1 220 PEDIATRICS. 3. Cough may be present when no disease exists in the lungs but there is very seldom any affection of the lungs without a cough. May be, {a) Dry Cough, which is indicative of initation caused by very many causes and usually precedes (6) Moist Cough which is usually accompanied by free expectoration. In Bronchitis you have a loud ringing cough ; in Pleuritis a small suppressed cough ; in tubercle a small dry hacking cough usually most troublesome in the morning; in Pneumonia a slight small cough. 4. Expectoration is mucous and free in Catarrh and Bron- chitis ; purulent in severe Bronchitis and Phthisis ; rusty in Pneumonia ; lumpy and muco-purulent in advanced Phthisis ; suddenly and largely purulent in bursting of an abscess ; in Pulmonary Gangrene u stinking sputa, etc. (c) Constitutional Sijns. Constitutional signs are those which aflfect the system at large. They are fever, night sweats, accelleration of pulse, ema- ciation, loss of strength, loss of appetite, etc. The examination of a child's chest requires gentleness and tact. It should be stripped to the waist. Inspection. In the child respiration is chiefly diaphragmatic, so that forcible movement of the thoracic walls is a sign of labored breathing, and one of the indications of broncho- pneamonia. Great recession of the lower part of the chest or epigastrium is an indication of some obstruction in the larynx. If the chest is laterally grooved it indicates softening of the PEDIATRICS. 00] libs from ncketa. There may be more mobility on one side than the other. Palpation. The movement of the chest can be made out, but vocal fremitus is not so marked as in the adult, for the hiirh I)itched notes of the child's larynx succeed one another too rapidly to be readily |)erceptible by the hand. Fluctuation can often be detected when there is effusion. You should always ascertain the exact site of the heart beat, as it is greatly influ- enced by effusion in the chest. In young children it is always nearer to the nipple than in adults, and as the latter is always lower, and the heart itself relatively smaller, the apex beat is higher than in adults, being usually found in the fourth inter- space. The exact position of tae liver and spleen should be noticed, as they may be pushed down by eff'usion. Percussion. If your hands are warm, and gentleness is exercised there is seldom much opposition. There is greater resonance than in the adult, and this often obscures dulness. The degree of resistance is also important, thus in pneumonia it is dull, and in pleuritic effusion there is still greater resist- ance. It is always best to use two or three fingers in percuss- ing the child's chest as the sound is collected from a larger area of lung than if one finger only were employed. The " cracked pot " sound is always heard in a child if the chest is percussed during expiration, or with the mouth open. Auscultation. Always use a stethoscope because the chest being smaller it is more important to limit as narrowly as possible the area under investigation. The vesicular murmur is coarser and harsher (puerile), and so is apt to be mistaken by the inexperienced for disease, especially at the apices, and expira- tion is often prolonged without any disease being present. i 222 PEDIATRICS. Conduction of sounds from the pliarynx and trachea to the apices is common, so that the breatliing there is often loud, hollow, or blowing, and still does not indicate disease. Weak- ness of vesicular m irmur is very irai)ortant. Bronchial, cavernous, and amphoric sounds are the same as in the adult, but the morbid process is usually a ste[) in advance ; thus cavernous respiration is often a sign of mere consolidation. Be sure to thoroughly and particularly examine the Lack of the lungs in children. 2. Laryngismus Stridulus, or false croup, is a catarrh of the larynx with superadded spasm. Causes. It is rare before two years of age, and is most common between 2 and 7. It is more frequent in boys than girls, and is apt to recur. Symptoms. The child may go to bed well, and wakens up about 12 o'clock with a hoarse, barking, sonorous cough, and ii loud whistling stridor in his breathing, this being confined to inspiration, while the expiration is short and comparatively noiseless. The movements of the chest are labored and violent ; the nares dilate ; the eyes are staring ; and the child has a terrified expression. The seizure lasts from a few minutes to half an hour, gradually subsiding, and the child falls asleep. Diagnosis. The sudden invasion ; the voice is not sup- pressed ; the cough is loud and not muffled ; the stridor is marked in inspiration ; there are no enlarged cervical glands ; and there is an absence of albumen in the urine. Prognosis. Is favorable, death very seldom occurring. Treatment. Put the child in a warm bath and give an emetic of vin. ipecac. A cold wet cloth to the larynx often acts magically. Then give chloral to prevent a rel .pte. PEPIA KICS. 223 lea to the ften loud, I, Weak- e same as L Hte[) in I of mere 3 Lack of a catarrh i is most boys than akens up gh, and a nfined to )aratively )red and the child □a a few shild falls not sup- atridor is 1 glands; i . give an rnx often e. 3. Diphtheria is a specific, infectious and contagious dis- ease, characterized by inflammation of various mucous surfaces and the formation on them of a more or less tough and leathery false membrane. It often follows some zymotic fever such as measles or scarlatina ; it probably has a pythogenic origin ; it has no proper eruption, although sometimes it has one like scarletina, to which disease it seems to be closely allied ; and lastly, one attack does not protect against another. (a) Pharyngeal Diphtheria, Syinjitoms. There is usually a stage of incubation of a day or two ; then there is languor ; slight elevation of temperature ; some difficulty in swallowing; the breath is fetid and the tongue thickly coated, and there is albuminuria. On examin- ing the throat one or more patches of a tough, dirty grayish- white material are seen, which are usually not confined to the tonsil but extend to the soft palate or uvula, and cannot be removed by mere swabbing as can be done with the exudation in follicular quinsy. The cervical glands become enlarged and tender early in the disease, and very soon there is more or less prostration acco'.ding to the severity of the attack. Pathology. It is due to a germ, probably a variety of micrococcus, which is introduced from \vithout by direct con- tact, generally fixes itself on the fauces or larynx and becomes generalized from that point. (6) Laryngeal Diphtheria. When the inflammatory process attacks the larynx it is spoken of as membranous croup. There is still a difierence of opinion as to the identity of croup and diphtheria. Those who hold that they are different affections say that croup is a sthenic disease, while diphtheria is asthenic ; in croup the urine is not albuminous, but it is in diphtheria ; croup is not followed by paralysis, while diphtheria usually is ; croup is neither epi- 224 PEDIATRICS. demic nor contagious, while diphtheria is both. Now t!iese distinctions do not always hold good, indeed they are converti- ble, and while there may be reasons for believing in the possible existence of a non-specific membranous croup, still as it is impossible to distinguish between them with any certainty, and the question of contagion is involved, it is always best to treat every case on the assumption thp.t it is diphtheritic. The very faco that many surgeons ha'/e contracted diphtheria by sucking a tube where tracheotomy had been done in a case of supposed simple membranous croup, ought to convince anyone of their identity. Symptoms. There may or may not have been previous exu- dation in the fauces, and the preceding symptoms may have been slight, when suddenly the breathing is noticed to be stridulous, respiration becomes harsh, the cough, voice and cry are hoai-se. This lasts from a few hours to a few days becomin*,' more marked until dyspnoea and cyanosis set in unless relieved. Sequelce of Diphtheria. These are albuminuria and paralysis. Albuminuria is a constant symptom and is present early in the attack. It is not like that of scarletina in which albuminuria is a late symptom, the urine contains blood and casts, is accom- panied by dropsy, and the kidney is in a condition of inflamma- tion. Paralysis occurs usually two or three weeks after an attack of diphtheria, and shows itself first by a peculiar alteration of the voice and difficulty in swallowing due to paralysis of the palate musclas. It is a symptom which often leads to the detec- ticix of a hitherto unsuspected disease. The paralysis may extend to the ciliary muscle and affect accommodation ; or to the muscles of the eyeball causing squint ; or H may afi'ect the muscles of the body and extremities giving rise to a peculiar attitude and gait. w t jese onverti- possible IS it is ity, and to treat he very sucking ipposed of their ms exu- ly have i to be and cry 3Cominf( elieved. iralysis. early in ininnria accom- lamma- L attack a,tion of 3 of the 9 detec- is may ; or to feet the )eculiar PEDIATRICS. 225 Modes of Death. Diphtheria may destroy life by blood poisoning ; inhibition of the heart's action ; asthenia ; or laryn- geal extension with its consequences, — asphyxia, etc. Treatment. Every means should be taken at once to prevent contagion. The strength should be sustained by a stimulating diet. Iron, quinine, and potass, chlor. should be given intern- ally. Locally a spray of hydrarg. bichlor. and sulphurous acid should be used every hour or two, and the patches may be gently removed, and a saturated solution of boracie acid in glycerine applied several times a day by means of a camel's hair brush. Some prefer chloral solution, iodized phenol, or iron and glycerine. In the laryngeal variety the steam spray is beneficial, and tracheotomy or intubation of the lai'ynx may be indicated in some cases. 4. Bronchitis is a disease which is common in children, and not only dangerous in itself but in its tendency to run into broncho-pneumonia or pulmonary collapse. Causes. It is brought on by damp and cold. It may occur during teething ; from irregularities in diet ; from worms ; or it may cc*Tiplicate measles, whooping-cough, typhoid fever, scarlet fever, diphtheria, and diseases of the heart and kidneys. Symptoms. It usually begins with coryza, sneezing and cough. The cough is at first hard and soon becomes soft. There is no dulness on percussion, and auscultation determines bubbling and squeaking with sonoro-sibilant rhonchus all over the chest. If the inflammation extends to the smaller tubes (capillary bronchitis), or alveoli of the lung (broncho-pneu- monia), the symptoms become very alarming ; the child becomes restless ; great dyspnoea ; face livid and expression of distress ; 16 226 PEDIATRICS. pulse quick and feeble. Dulness, and subcrepitant rales are heard especially at the back of the lungs. Chronic Bronchitis is common in children five or six years of age, especially those of a scrofulous tendency, and is very apt to lead to emphysema. Treatment of Bronchitis. Never neglect a cough in a child, but if feverish at once put it to bed, a poultice with a little mustard should be applied to the chest, and a febrifuge expec- torant given. If capillary bronchitis or broncho-pneumonia sets in give stimulating expectorants and an emetic of ipecac. Opium should be very cautiously used as it is apt to dry up the secretions. In the chronic form liquid tar, counter-irritants, and change of air are indicated. 4. Pneumonia may be croupous or catarrhal. (a) Croupous. Is rare in infancy up to the end of the second year, after that catarrhal and croupous are equally common, and with each succeeding year it is more and more likely to be of the croupous variety. Of late years there has been a growing tendency to look upon croupous pneumonia as an acute general disease of which the pulmonary consolidation is the anatomical expression, and no loriger to regard it as a mere local inflammation. Some have compared it to acute rheumatism and tonsillitis, while others look upon it as a specific fever and class it with typhoid. That it is a general disease with marked local manifestations is shown by the fact that the general symptoms are not propor- tionate to the extent of lung involved ; they precede several days any evidence of local mischief, and the highest temperature is often reached before the point of most complete consolidation ; while the head symptoms, the sweating, the herpetic eruption, and the exudation are peculiar. PEDIATRICS. 227 Symptoms. Are like those of the adult but are often ushered in with convulsions. (h) Catarrhal. Broncho-pneumonia is nearly always a secondary affection resulting from the spread of inflammation from the bronchial mucous membrane to the alveoli, and so it invariably attacks both lungs. Symptoms. It is always preceded by pulmonary catarrh ; more or less fever ; cough, which is short and hacking ; the face is more or less livid ; the labial line is marked ; the pulse respiration-ratio is perverted ; respiration is labored, and dyspnoea or even orthopnoea are common. The paroxysmal cough of bronchitis changes to the short hard hacking cough of pneumonia, which usually causes great distress and exliaustion. Physical Signs. At first are heard only the signs of bron- chitis, for the consolidation being limited to small scattered nodules surrounded by emphysematous air cells can rarely be detected by percussion. Auscultation determines crepitant rales and rhonchus, and unlike croupous pneumonia the rales are not lost when consolidation occurs. As the nodules of consolidation grow larger and coalesce, respiration becomes more labored, cyanotic symptoms appear, and if the child is not relieved it becomes exhausted, sinks and dies. Before this, there is more or less dulness at the back of both lungs, and tubular breathing is heard. There is seldom any dulness in front. Lastly, should a favorable termination occur, there is not the critical fall of temperature seen in croupous pneumonia, but the symptoms gradually abate as well as the physical signs. Diagnosis. One of the greatest difficulties is to exclude phthisis. Prognosis is always doubtful, and the mortality is very large in infancy. 228 PEDIATRICS. Treatment. It may often be prevented by the judicious management of the preliminary bronchitis. Begin with an emetic of ipecac, linseed and mustard to the back of chest, stimulants early, and sustain the strength by nourishing diet. 6. Pleurisy is comparatively rare during the first year, more common during the second year, and after that is one of the most common diseases met with in childhood. It is seldom fatal. The eflfused fluid is apt to become purulent at an early period. /Symptoms. It usually sets in with a chill, then fever and a slight cough ; a pain in the side, causing the child to cry .violently when pressed in the side ; but it usually subsides as the effusion sets in, and this soon turns to pus, constituting empyema. Physical Signs. It is diflficult to distinguish it from croup- ous pneumonia. Palpation detects fluctuation. On percussion there is increased dulness with resistance like that on percuss- ing a thick block of wood, and the alteration of note is got by change of position. By auscultation a friction sound is heard which is peculiar, being crackling or crepitating but very super- ficial. The heart may be pushed over to the right nipple by the effusion. Treatment. Put the patient in bed and at absolute rest ; a light diet ; febrifuge ; and opium for pain. Apply cotton batting to chest with a bandage. Potass, iodid. three or four times a day may be given later, and if pus is detected, and verified by hypodermic syringe, it is best to make a free incision with antiseptic precautions, and after carefully evacuating a portion of the pus, an antiseptic dressing should be applied and changed daily, allowing more pus to escape gradually. cons PEDIATRICS. 229 IV. DIATHETIC DISEASES. 1 . Scrofula. Is the most common of the morbid types of constitution ; affects all ranks ; is found in all part of the world ; is often hereditary ; and is very persistent. Its evi- dences are widespread throughout the body, attacking the skin, the mucous membranes, bones, joints, organs of special sense, lungs, and the lymphatic glands. All these parts are exceed- ingly sensitive, and may be attacked with some obstinate or even incurable form of the disease. They occur early, so that scrofula is especially a disease of childhood, being found more especially from the 3rd to the 14th year, after which its ravages usually abate. Besides actual scrofulous disease, other circumstances deter- mine it in the child, such as cancerous, tubercular, and syphilitic cachexise ; age in the father ; imperfect nutrition in the mother during gestation ; marriage of cousins ; insanitary surroundings in the child ; neglect and bad food ; or lastly, it may be the result of measles, whooping cough, variola or scarletina. Symptoms. In a well marked case it is expressed in the build and general appearance of the child. It is stout, heavy, and looks older than its years ; the face is broad and flat ; the upper lip thick ; the nose wide and its bridge sunken ; the ends of the bones are thick ; and the limbs are soft and flabby. Some scrofulous children are delicate ; and the skin thin and transparent. In a scrofulous constitution there is a tendency to rapid prolifercition of all the epithelial and cellular elements of the body. The lesions are inflammatory in their nature, and characterized by rapid cell growth, and rapid decay of the new formed elements. Diseases, therefore, of this nature, show their constitutional origin by their tedious course ; their sluggish 230 PEDIATRICS. response to treatment ; their origin from some trifling cause ; and their proneness to relapse. Wherever the lesion is, the glands are liable to suffer, and this is so generally recognized that in a popular sense scrofula means simply a chronic enlargement of glands with a tendency to suppuration. (a). Mucous Membranes are especially sensitive in strumous children, and they are very liable to catarrhs. Gastric catarrh is common and differs from that in healthy children by being always accompanied by fever. Intestinal catarrh is apt to lead to ulceration, and so become chronic. Catarrh of the nasal passages is usually accompanied by excoriation of the upper lip, and is apt to lead to ozcena and destruction of the bone, especi- ally if it occurs in a child over two years of age. It is apt to be syphilis in a younger child. If it attacks the eyelids it results in tinea tarsi ; or the eyes, it gives rise to pustular ophthalmia and keratitis, indicated by lachrymation and photo- phobia. If it is a girl you may find vulvitis. Pharyngeal catarrh is very common, leading to enlargement of the tonsils and deafness. Otorrhoea and otitis are common. Pulmonary catarrh is apt to become chronic and give rise to what is commonly called " winter cough." (6). Skin. Scratches are apt to fester, and acute eczema is common in scrofulous children. Small lumps often appear on the legs, arms, or abdomen, at first hard and movable, soon become fixed, inflamed, and suppurate, containing a cheesy-like pus. (c). Bones and Joints. Caries of the vertebrae is very frequent, and disease of the tibia. (d). Lymphatic Glands. Enlargement of cervical glands is most common, but the bronchial and mesenteric are often also affected. They do not always suppurate. « PEDIATRICS. 231 Treatment. Much may be done in the way of prevention by attending to the diet, clothing, pure air, and daily exercise. Iodide of iron and cod liver oil internally. Suppuration may be prevented by minute doses of calcium sulphite, and locally ung. cadmii or oleate of mercury. 2. Infantile Ssrphilis. Is due to hereditary taint, either on the father's or mother's side ; or to vaccination with impure lymph. It may affect : ■ (a) Mucous membranes, giving rise to catarrh, or mucous patches and ulcers on the cheek, glottis or epiglottis. (b) Solid organs, giving rise to fibroid growths or gummata which may be found in the lungs, liver, spleen, or pancreas. (c) Bones, especially the long bones, either affecting the peri- osteum, or the ossifying line of the shaft leading to separation of the epiphysis. Symptoms. These depend upon the degree to which .the system is affected. If it occurs while the child is in utero it may cause the death of the fcetus, and syphilis is a common cause of abortion. If less active the child may be bom living, but it is thin and shrivelled, looking like a little old man ; its body is often covered with pemphygus ; it has " snuffles " and a hoarse cry, and as the internal organs are usually diseased the child sooner or later dies. When a child is born with hereditary syphilis, but apparently healthy you first notice " snuffles," then a discharge from the nose which often leads to ulceration of the septum. Then a rash consisting of copper- colored flat spots appears on the perineum, genitals, and anus, extending over the body, and there are frequently ecthymatous and tubercular spots ; the hair and eyelids often fall out, and the nails become diseased, while the teeth are peculiar, being 232 PEDIATRICS. screw-driver shaped. The fontanelles are slow in cloaing ; the long bones become thickened and the epiphyses loosened, while dactylitis is common. Treatment. When a child is born with syphilis you should treat both parents specifically for some months. In the child begin the treatment as early as possible with mercury, and it is indispensable to use it both internally and externally. Hydrarg. cum creta two or three times a day, or if it disagrees hydrarg. bichlor. ^ to ^V gr. three times a day. Ung. hydrarg. should be smeared on a flannel band and applied to the belly, wrapping freshly every day. Mercurial baths, ^ drm. to 1^ drm. hydrarg. bichlor. to two gallons of water. At the same time improve the general health, and counteract the tendency to anaemia by giving iron and cod liver oil. V. — Diseases of the Liver. \. Jaundice is a symptom and not a disease, being due to various causes. (a) Icterus neonatoi'um. Usually begins on the second day, and lasts a week or ten days. The skin and eyes are yellow ; the stools are clay-colored ; and the urine is dark. It may be simple or malignant. (a) Benign. Is often the result of some trifling derange- ment, and may be caused by severe labor, premature birth, or exposure to cold, damp, or bad air. In many cases it is due to the sudden transference of the chief blood supply from the umbilical to the portal vein, giving rise to engorgement of the hepatic circulation. The liver can usually be felt enlarged, but the jaundice is seldom of any consequence. PEDIATRICS. 233 (13) Grave. May be an indication of very serious disease, and may be due to : (i) Atresia of the bile ducts from malformation. If this is conjoined with umbilical hemorrhage it is rapidly fatal. (ii) Syphilitic injlammation. (iii) Umbilical Phlebitis and Pyaemia. This depends on infection like puerperal fever. (6) Icterus of Childhood. This is due to the same causes as in the adult, duodenal catarrh being the most common. Diagnosis is usually easy. When it persists and becomes deeper you would suspect the malignant form, especially if a child of the same parents has died from a similar condition. The pysemic form is characterized by fever, dry tongue, dis- charge of blood and pus, and swelling and tenderness of the abdomen. Treatment. In the simple form castor oil, followed by small doses of sodse bicarb, is all that is necessary. In the variety due to malformation, if hemorrhage occur it may be necessary to ligate in mass. 2, Amyloid Liver. Known as waxy or lardaceous dis- ease. Cause. There is usually some cachexia such as syphilis, tubercle, or scrofula, and it is most commonly brought on by the existence of chronic suppurations and purulent discharges such as necrosis or empyema. The kidneys, spleen, and lymphatic glands are usually affected at the same time. Pathology, The liver is uniformly enlarged, heavy, dense, its edges thin, of a gray and glistening color on section and stained reddish-brown by iodine, while the addition of sul- phuric acid gives a violet and blue color. n 234 PEDTATRICS. Symptoms. There is no pain, but a feeling of weight and distension of the belly. Palpation feels the liver enlarged, smooth, and hard, with sharp and prominent edges ; the diges- tion is disturbed ; the spleen enlarged j the child is easily tired; there is anaemia ; and hyaline casts and albumen are found in the urine. Prognosis. It is less serious in the child than in the adult, provided the source of irritation and suppuration can be removed. Treatment. Remove the cause, and thus obviate the symp- toms such as diarrhcea, vomiting and aneemia. Then give a liberal diet, and potassic iodide, and ferric citrate internally. 3. Fatty Liver. Is due to excess of farinaceous food, or to tubercular disease. Pathology. The liver is enlarged, soft, and doughy, its edges blunt and receding. "When cut it is yellowish-red, and shows fat under the microscope. Symptoms. There is slight tenderness over the liver, but never jaundice or acites. Treatment. If due to excess of farinaceous food stop that, but if it accompanies scrofula or tubercular disease you must treat the primary trouble. VI. ACUTE INFECTIOUS DISEASES. 1. Mumps. Usually occurs before the 5th year, and sexdom after 14. It rarely occurs twice ; is usually epidemic; is especially common in the spring ; is extremely infectious, the virus being carried by the breath ; and it has a period of incubation of from one to three weeks. PEDIATRICS. 23^ Pathology. It is an inflammation of the salivary glands and ducts, never going on to suppuration, but resolves in a few days. Symptoms. There is fever which often runs up to 103°, accompanied by headache and vomiting. Then the parotid gland swells, becoming tense, elastic, tender, and aching. This lasts fror^ 3 to 6 days, and then subsides, so that by the 10th day it is all away. Metastasis is common ; affecting the testicle in boys, the mammee in girls. A common sequence is deafness. Treatment. Allay fever, and apply hot flannel or poultices to the cheek, but avoid rubbing for fear of metastasis. Ung. belladonnse with glycerine is often beneficial, and the bowels should be regulated. 2. Measles. Is the most common of the eruptive fevers, and is rarely fatal of itself, although some of its complications may prove serious. The contagion is conveyed by the breath, and it has a period of int .bation of 10 days. Symptoms. It begins with signs of catarrh ; the child sneezes, coughs, and its eyes are red and watery ; there is headache ; fever ; furred tongue ; and often vomiting and diarrhoea. Then on the 4th day the eruption appeal's on the chin, temples, and forehead, at first yellowish-red slightly raised spots, which become of a deeper red. The fever and catarrh seem to be increased as the rash appears. The eruption soon fades, and it is often followed by a slight branny desquamation, especially when the rash has been profuse. Complications. The most frequent and dangerous are broncho- pneumonia and membranous croup. Etiology. As a rule it occurs only once in the same indivi- dual but there are frequent exceptions, and cases have been recorded where it has occurred twice in one month. It is 236 PEDIATRICS. especially contagious from the beginning till the end of the eruptive stage when the infection becomes less and less active. It is impossible to isolate a child in the same house with others suffering from the disease, and it takes three weeks from the onset of the eruption before the sick child should be allowed to mix with healthy children. Treatment. The sick room should be kept at a temperature of 65° F. ; the diet should be milk and lime water, or barley water, with any farinaceous food ; a mixture of tinct. *>conite, and tinct. camph. co. may be given for the cough and fever, and if the latter is high quinine or antipyrine may be given ; and complications should be watched for and anticipated. 3. Rotheln. German measles or roseola is an exanthem which resembles measles and scarlet fever combined, but is commonly looked upon as a distinct species since an attack does not protect against measles. Symptoms. After a period of incubation of two weeks, there is headache, fever, and often backache, and after twenty-four hours an eruption of dusky-red, slightly elevated papules, appears on the cheeks, and quickly spreads to the body and limbs. The catarrhal symptoms are seldom well marked but the throat is sore, inflamed, and swollen. Treatment Similar to that of measles. 4. Scarlet Fever. Is a common infectious disease in children, rarely occurring twice in the same person, but some- times appearing in an abortive form in one who is already pro- tected by a previous attack. It is most highly contagious at the time of desquamation. Symptoms. The period of incubation is from a few hours- to a few days, never more than a week. Then there is usually PEDIATRICS. 2 '37 a chill, vomiting, or a convulsion ; the tongue is furred, and red at the edges, but soon becomes very red and rough, — the " strawberry tongue ; " the throat is sore ; the temperature rises, and often soon reaches 105^ ; the pulse is very rapid ; and on the 2nd day a scarlet pointed rash over a uniform pink sur- face appears on the chest and neck, and body. On the 5th day the rash fades, and desquamation sets in, often fine branny scales or the skin may peel off. Three varieties of scarletina are described : simplex, anginosa, and maligna. In the malignant form the severity of the disease is shown by the violence of the nervous phenomena, the cliild being overpowered by the disease in some cases in 36 hours ; or it may be owing to the severity of the throat affection. Sequeke. Diphtheria and rheumatism are apt to complicate early in the disease, while later on albuminuria due to nephritis is apt to occur ; and otorrhcea is common. Treatment. The first thing to do in a case of scarletina is to take every precaution to prevent its spread to the other mem- bers of the family, and this can be done by early isolation and disinfection. The child should be put in a well-ventilated, moderately warm room ; all carpets, curtains, and woollen materials should be removed. The symptoms should be com- bated as they occur. Nephritis, indicated by albuminuria, dropsy, and anaemia should be treated by pulv. jalap, co. and pilocarpine. The diet throughout scarletina should be light, and free fror. albu- men and meat. 6. Varicella.— Chickenpox has a period of incubation of one week, and then slight fever, and an eruption appears, after 24 hours, of papules, which soon become vesicles, and pustules, 238 PEDIATRICS. forming upon the back first and extending over the bodj^ and limbs. Treatment. Most cases only reqiure isolation and protection from cold, regulation of the bowels, and the prevention of irri- tation from picking the eruption. 6. W Hooping Oough. — Pertussis is an infectious disease consisting of catarrh of the air passages combined with peculiar nervous symptoms. It occurs in epidemics, is contagious by breath and expectoration, and can be conveyed by the atmos- phere or clothes ; a second attack is rare. Symptoms. After a short period of incubation the disease begins by catarrh of the air passages, and a troublesome cough which is v/orse at night, and soon becomes spasmodic, consist- ing of a series of short hacks rapidly ioV owing one another so as to prevent inspiration, the child's face becoming livid, and at last it takes a long deep inspiration accompanied by the charac- teristic " whoop " which gives the disease its name. This soon begins again until the ch'ld brings up a large quantity of tough, ropy mucus. Complications. Convulsions and broncho-pneumonia are the most important. Treatment. At first any simple expectorant may be used, and then when the spasm becomes established give belladonna and pot. bromide, or zinc, sulphate and atropia. Quinine also has a good effect, and locally the throat may be swabbed with solution of silver nitrate, or resorcin. VII. — Diseases of the Skin. In childhood the skin is very susceptible to disease ; it is delicate and easily irritated by irregularities in diet, or dis- ordered secretion ; by neglect and want of cleanliness ; the iiii PEDIATRICS. 239 it is the frequency of gastro-intestinal disorders are apt to be accom- panied by eruptions of the skin ; and the parasitic diseases are common. The division of skin diseases which considers them according to the local lesion seems the simplest. 1 . Srythemata. («) Erythema is a superficial inflamma- tion of the skin, occurring in slightly raised patches, diffused or circumscribed ; the redness disappears on pressure but instantly recums ; and it usually en '3 in slight furfuraceous disquama- tion ; the general symptoms being slight. You may have Fugax when of a fleeting character; intertrigo when produced by friction between folds of akin and want of cleanliness ; Pernio^ an unbroken chilblain ; Lceve, occurs on anasarcous limbs due to renal or cardiac disease ; No(hsum, when confined to the fore part of the leg in the form of large, oval, somewhat reised patches resembling nodes. * Treatment, Remove all irritants ; attend to cleanliness ; apply soothing agents such as ung. zinci ; lin. aq. calcis ; or fine starch ; attend to the diathesis ; give an aperient, and tonics may be indicated. (6) Roseola consists of transient red patches or slightly raised rose-colored spots, and is apt to be mistaken for measles. (c) Urticaria is a febrile and non-contagious disease in which hypersemic elevations similar to those that follow the sting of a nettle are produced upon the skin, and consist of wheals accompanied by tingling and burning, suddenly coming and then going without leaving any stain, and unaccompanied by desquamation. It is often produced by the ingestion of shell fish. Treatment, Remove any irritation such as flannels, avoid draughts, use emollient and alkaline baths, and anoint the body with vaseline ; relieve the work of the skin by aperients and 240 PEDIATRICS. diuretics ; prevent the circulation of effete products such as urea, or uric acid ; tone up and lull by anodynes the nerve paresis. 2. VesiculaB. {a) Herpes consists of clusters of vesicles situated on irregular-shaped inflamed patches. There is circinatus occurring in a crescentic form and apt to be mistaken ior " ringworm." Zoster or shingles because the groups of vesicles tend to encircle one half of the body like a girdle ; it follows the course of the cutaneous nerves ; is more frequent on the right than on the left side ; lasts from 1 4 to 20 days ; occurs only once ; and is accompanied by severe neuralgic pain. Preputialis and labialis are other varieties. Treatment. Allay irritation, apply ung. zinci, and give iron and quinine tonics. (b) Eczema is an acute inflammatory disease characterized by a vesicular eruption closely packed upon a more or less inflamed base, which quickly runs together, bursts, and is replaced by a slightly excoriated surface that pours out a serous fluid, which dries into crusts of a light yellow color. The discharge stiffens linen. The principal varieties are simplex, rubrum and impitiginode$. Treatment. A typical case of eczema in its progress towards cure passes through certain stages, viz. : erythema, vesication, ichoration, pustulation and scabbing. It is a curable disease, and its passage through these definite stages should be promoted. It is aggravated by anything which irritates the skin from within or without ; occasionally relieved or even aborted in its slighter forms or earlier stages by soothing remedies ; liable to be complicated by accidental occurrences consequent upon the persistence of congestion, such as oedema, induration, atrophy, 4. pust PEDIATRICS. •241 etc. ; moditietl by constitutional conditions, such as gout, struma and sy[)liilis ; influenced by organic diseases of tlie liver, kidneys, heart or stomach ; and always associated with a lower- ing of the general vitality of the system, r* sk yourself the questions : What variety is it ? What stage ' in 1 And are there any complications ? Lotions are best suited to tlie acute and discharging, while ointments are best for the scaly, stages. When the discharging stage lessens, and thit of desqu imation approaches the tv ease may be regarded as clironic. When the scaliness is distinct but no crusting, use astringents and aosorb- ents ; when scaliness is well marked and a tendency to crusting tarry compounds are best ; and when there is considerable thickening and infiltration of plastic matter use oil of cade and soft soap. In the acute form alkalies and arsenic ;ire good • and in the chronic variety iron and arsenic are better. 3. BullSB. (ct) Pemphigus is chai-acterized by the appear- ance of larije round or oval blebs about one inch in diameter, * . . . . distended with a fluid which is at first clear, but soon becomes milky, and often bloody; the bullae generally occur in suc- cessive crops. Treatment. It should be treated as an asthenic disease ; begin with an aperient and then tonics with iron and mineral acids, and good food. (6). Rupia begins like pemphigus, but the blebs speedily fill with a mixture of blood and pus, giving place to thick scales, beneath which is more or less unhealthy ulceration, yielding a nasty, dirty, fetid discharge augmenting the crusts with successive layers of dried secretion, until they assume a conical form. Rupia is pemphigus occurring in a syphilitic subject, and is to be treated accordingly. 4. PustulSB. (a). Ecthyma is characterized by solitary pustules on an inflamed base and most frequently affects the 17 242 PEDIATRICS. shoulders, buttocks and limbs. It is caused by all that tends to debility and impoverishment of the blood. Treatment. Remove the exciting cause, and combat the cachexia, giving tonics and proper food. (6). Impetigo is characterized by an eruption of small flattened pustules, usually arranged in clusters, and having a tendency to run together and form thick and moist yellowish incrustations. It usually begins on the face and head. Treatment. The natural course of the disease is short and definite. As the discharge is contagious, cleanliness is import- ant ; so destroy the activity of the pus, and change the character of the surface that seci'etes it. Remove the scabs by poulticing, and apply ung. hydrag. ammon. chlor. (gr. v. to oz. i.), and give tonics. 5. Papul80. {a). Lichen is characterized by minute hard, dry elevations of the skin, accompanied by tingling and itching, and slight desquamation. The varities are simplex, planus, and urticatus or " red gum." (6). Prurigo is a chronic inflammation of the skin accom- panied by the development of papules, general thickening of the skin and intense itching. Treatment. Allay itching and give good diet and tonics. 6. SC[UaiI188. ^a). PsoHasis is characterized by the develop, ment of dry closely packed shining scales seated on a hyperaemic cutis. The elbows and knees are the most common sites ; it is chronic ; relapses are frequent ; and it is often hereditary. Treatment. Locally ung. ac. crysophanic, and internally arsenic is a specific. (6). Pityriasis is a superficial and chronic inflammation of the skin, att^^nded with redness and itching, and the production of minute white scales like bran. " Dandruff"" is a mild form. PEDIATRICS. 243 mds Treatment. Locally a wash of hydrarg. bichlor. and arsenic internally. (c). Ichthyosis is characterized by thick, hard, dry, and imbri- cated scales of a dirty gray color, resting upon an inflamed surface. It is often congenital and hereditary. Treatment. Can only be relieved by emollient applications, and tonics with arsenic. 7. Tuberculee. (a). Elephantiasis. (b). Mollitscum. (c). Acne is characterized by small isolated pustules with deep red bases, which after suppurating and bursting, leave behind them minute hard, red tumors, the seat of which is the sebaceous follicles. • (d). Keloid. Is like a cicatrix of a burn. 8. Parasitic!. («). Tinea Tonsurans is recognized by the thickened and brittle or broken condition of the affected hairs by the brawny eruption, and the roundness of the diseased patches. When not on the scalp it is called tinea circinata, and popularly known as " ring-worm." (6). Tinea Favosa is known by the small cup-shaped yellow crusts, each containing a hair in its centre, and somewhat resembling a honey-comb ; there is itching ; the hairs are brittle and fall out ; and it has an offensive odour. (c). Tinea Decalvans, or alopecia areata, is where the hair falls out in one or more circular or oval spots, leaving perfectly smooth bald patches, which may be small in size or extend over the entire scalp. ^ : - {d). Tin£a Sycosis is known by spots of erythematous inflammation which involve the hair follicles causing successive eruptions of small accuminated pustules. It is properly known as the barber's itch. — >! 244 PEDIATRICS. Treatment. Tinea is best cured by the thorough application of some parasiticide, such as tinct. of iodine, crysophanic acid in ether, etc. (e) Tinea Versicolor usually appears in the front of the chest or abdomen in the form of small patches of a dull reddish color, which gradii.illy increase in size, and assume a yellowish tint. Ti'eatment. Solution of hydrarg. bichlor., or sulphurous acid ; or hyposulphite of soda. [/) Scabies commences as a papular, vesicular, or even pustular eruption, which ruptures and produces excoriations ; is intensely itchy ; . is most frequent in the flexures of the joints, especially the fingers, toes, elbows and thighs ; and the itching is mostly at night when the child is warm in bed. The history and the microscope confirm the diagnosis. It is due to an animal parasite. Treatment. The parts should be well washed with soap and water and an ointment of sulphur vivum rubbed in thoroughly^ which is a specific. THE tOPP, CLARK COMPAW, LIMITED, PRINTERS, TORONTO. GENERAL INDEX. Page Abdominal pregnancy '^^ Abortion, Nature and treatment of, - - - - - - 33 Artificial, ^^ Abnormal position of foetus ^^ Adherent placenta - - - - Amyloid liver ^33 Accidental haemorrhage ^^ Anaesthetics in labor " " ^^ Amenorrhcea ^ ** Anteversion and anteflexion ^^^ Anterior polio-myelitis - - .... - - - -14 Atresia of vagma ^ Breech presentation - Breast, Diseases of • 1 ^^ Bimanual examination ^^'' Bladder, Diseases of ^^'^ Bronchitis ......----- Carunculae myrtiformes - - - - - - - - Cancer of uterus - '^ Caruncle - - " " ' " I Cassarean Section - - Calcuh of bladder ' ^^^ 172 Cervix, Laceration of - - - - . • " Chiltlbed, Diseases of ' - 237 Chickenpox Clitoris ■ ■ ->•':- Corpus luteum - - --.,-.'«.-- Conjugate diameter of pelvis - - - - Cord, Presenting " " Complications of labor - - . - ■ - Convulsions, Puerperal - - ----- - • ' Infantile i 246 INDEX. Constipation 208 Convalescence, Disorders of 1^7 Colpitis 142 Craniotomy ^^^ Crede's method in 3rd stage 63 Curette 136 Cystitis 184 Development of ovum 12 Decidua vera, reflexa and serotina 16 Descent of head • • * -oo Deventer's method in after-coming head 70 Deformities 7- D6ntition 201 Diameters of pelvis ^2 of foetal head ^ Diagnosis of female diseases 128 Digital examination 132 Dilator • • • • • - 136 Disorders of menstruation 143 Displacements of uterus 1^7 Diarrhoea -• 206 Diphtheria ' 223 Diathetic diseases 229 Dystocia - 64 Dysmenorrhoea 145» 160 D^'sentery ...-• •• 208 Dysuria 1°6 Eclampsia 90 Ectopic gestation 38 Embryo, Development of 19 Embryotomy 164 Emmet's button-hole operation 187 Empyema 228 Eutocia -64 Endometritis 1^3 Ergot, Uses and contraindications of - •. - • • 65, 66 Expellent forces of labor . 45 Extension of head ^7 Fallopian tubes. Structure of - • - - • • " ^ * Diseases of- •• - • * " * 179 Face Fattj Fecui Fistu Fissu Fibre Fibre Fceta Flati] Flexi Fossa Fonts Force Funis Galac Gasti Gera Graai Gyna Hanc Hem< Haen] Head Hym Hydr Hyd£ Hydi Hyst Hyst Hour Icter Inclii Impe Infan Indu] Invei INDEX. 247 208 107 142 103 63 136 184 12 16 56 70 72 201 52 54 128 132 136 143 157 206 223 229 64 , 160 208 186 90 3S 19 104 187 228 54 153 5, 66 45 57 5 179 Face presentation 66 Fatty liver 234 Fecundation 11 Fistulse 142 Fissure of the urethra 187 Fibro-myoma 167 Fibro-cystic 169 Foetal head 53 Flatus vaginalis 140 Flexion of head 66 Fossa navicularis 2 Fontanelles ^ Forceps, Uses of 99, 100 in Breech cases- - - - 71 Funis, Prolapse of SI Galactorrhaea * ' ' H^ Gastric catarrh * " 205 German measles . - - 236 Graafl&an follicles 6 Gynascology 127 Hand-feeding of infants 1®^ Hemorrhage, Accidental ...----• 86 Post partum ^"^ Secondary uterine 90 Haematocele 177 Head, Large, the cause of dystocia 72 Hymen, Structure of * Imperforate ^^^ Hydramnion Hydatidiform mole ^'^ 212 Hydrocephalus - - - Hysteria ' - - -188 100 Hystero-epilepsy *w Hour-glass contraction - - - - 82 Icterus neonatorum Inclined planes of pelvis - - 52 Impeded uterine efforts • . . 64 214. Infantile spinal paralysis * ^^ Induration of os yo Inversion of the uterus ^^^' ^* 248 INDEX. Induction of premature labor 97 Insanity, Puerperal - - - - 124 Inertia 65 Intestinal tract, Diseases of 201 Intestinal obstruction, and intussusception .... 209 Inspection of external genitals - - - - - - - 131 Irrit ibility of the bladder 185 Jaundice of children 232 Labia majora and minora - 1 Laparo-elytrotomy 107 Laceration of cervix - - - - 1 72 Laryngibiiiua stridulus - • - • '?.'22 Labor, Cause of onset 41 Symptoms 42 Stages of 43 Duration of - - - 44 Mechanism of 50 Management 56, 61 Leucorrhoea - - - 148 Liquor amnii - - -81 Liver, Diseases of, in children 232 Martin's treatment of after-coming head 70 Mastitis - - HI Malformations, of vulva 137 of vagina - - - 141 of uterus 151 Marasmus - 204 Menstruation - • 8 Membranes, Formation of 14 Cause of dystocia - 81 Menorrhagia 147 Metritis, acute and chronic 164, 156 Measles 235 Miscarriage - - - 33 Mons veneris - - - - ... - - -- 1 Munde's pill 66 Multiple pregnancy - - - 72 Mumps - - - - 236 Nervous mechanism of labor 46 New growths, of vulva - - - - - - - - 138 INDEX. 249 of vagina 142 Neuroses 187 Neurasthenia 190 Nervous system of children 210 New born infants, Treatment of 197 Nipples, Sore 110 Nucleus of vitellus 15 Obliquity of uterus 79 Operations, Obstetric 97 Oophoritis 180 Ovaries, Structure of 5 Diseases of ------- - 179 Ovarian tumors 181 Ovariotomy 183 Ovaro-hysterectomy 106 Ovum . . . Q Ovulation 7 Parovarium 6 Parametritis 170 Pelvis, Description of 5^ Contraction 74, 79 Perineum, Rupture of 138, 140 Perimetritis 175 Pediatrics 192 Peptonizing milk - - - . . . - .• . . 200 Pertussis - - - - - - 238 Persistent, 3rd position 68 Positions of vertex - - 66 Pelvimetry - - 76 Perineum, Management of , ,. . - 62 Post partum hemorrhage - - 87 Polypi - - 170 Placenta, Formation of 16 Retention of . - 81 PrsBvia • - 83, 86 Planes of pelvis ' . . - 51 Pleurisy - - - 228 Phlegmasia dolens 122 Physical signs of chest 126 Pneumonia 229 250 INDEX. Pregnancy 22 Signs of 2* Disorders of 29 Hygiene of 30 Abnormal 30 Duration of ^1 Extrauterine 38 Premature labor _ ■ • " 37 Induction of ®7 Prolapsus, Uteri 1^3 of urethral mucous membrane 187 Porro's operation • • • • ■ • • - • 106 Presentation and position 55 Prague method in breech cases 70 Pseudo-hypertrophio paralysis 215 Pudenda 1 Puerperal fever - • -113, 119 Puerperal venous thrombosis and embolism - - - - 120 Pulmonary obstruction 121 Puerperal insanity 124 Quickening ^ Bestitntion 57 Retioversion " 1^1 Retroflexion 162 Respiratory system in children, diseases of ... 216 Rigidity of os - - • • • • - • - - 79 Rotation of head 75 Round ligaments 3 Rotheln • • ' • V ^^^ Rupture of uterus 95, 96 Salpingitis 179 Scarlet fever 236 Scrofula 229 Skin, Diseases of " ' 238 Second position veii»x 57 Segmentation of vitellus 13 Size and form causing dystocia 72 Shoulder presentation 71 Speculum, vaginal • - - • ' 133 SteriUty ^^^ INDEX. 261 Stenosis of os uteri 152 Sprue 202 Stomatitis 203 Sound, uterine 134 Sutures of foetal head 54 Subinvolution 157 Sjmcope 93 Syphilis, Infantile 291 Tenaculum 135 Thomas' operation 107 Thrush 202 Trunk, Expulsion of 57 Tubes, Diseases of 179 Tubal pregnancy 38 Tumors of vagina 80 Tubercular meningitis - 213 Turning 101 Twins, Management of 73, 74 Umbilical vesicle 15 cord 18 Urethra, Diseases of • t 186 Uterus, Structure of 3 Diseases of 143 Varicella 237 Vagina, Structure of 2 Diseases of • 141 Vaginismus 141 Version 101 Vertex, Positions of 66, 58 Vesico-vaginal fistula - • 142 Vestibule 2 Viability 97 Vulva, Diseases of • • 97 Vulsellum 136 Wet-nurse, Selection of 199 Whooping cough 238 Worms 290^ H.: