^0. IMAGE EVALUATBON TEST TARGET (MT-3) 2^ Ac // ^ y_ 1.0 1.1 "' KiS 12.2 IL25 i i.4 IM 1.6 ^ Photographic L-ciences Corporation 33 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4 5G3 ^ V iV •sj \\ ^iA Ibca's Scries of Pocket Tcxt«5ooiism.scs of Injann/, Mrdill r„ln ml;,, Mnutna/, r,„„„/„. Fe/low oj' the Obftctrintl Sucitl!/, l.undoii, Kuijland. sf:rii;s kditki) uy BERN I}. (fALLAUDET, M.I)., DnunnMrator of Anntounj ,u,d m.tnn-lor in S,n;rn, r,M,yr ,, nj,„,, „„„ ,„,,,„„,^ Culumfna rnurr.it,, Xav Vork ; Visiti,,, Su.ynn,. iHlrmr llus,,iud, .^V „■ y,,,-,:. ILLUSTRATED WITH ONE MLNDRED AND FORTY-NINE ENGRAVINGS. LEA BROTHERS c^- CO., PHILADEEPHIA AND NEW YORK, KiikTL'il iict'drdiiif: tn Acl dl' ('()iiKr(.'.ss, in tlu' year I'.Hio, Ijy I.KA nUOTlIKUS & CO., Ill llii' Ollicf iif tlu! Liljriu'iiiii of Coiij^ross, ill \Vashiiig!ua. All riglils rcscrvuil. 'f i^ ^^ 9 WESTCOTT & THOMSON, ELECTROTYPEHS, PHILADA. PREFACE. TliK aim of tlie autlior in writing this " juxkot t('xt-))0()k " lia.s been to sii|)j)lya short, concontratcd treatise :y of pregnancy, of labor, and of the puer- perium has been dealt with rather fully, Ix'lnre the considera- tion of their patholoiry. Normal labor and tlu^ more fi'e(juent diflicnlties have been dwelt on at some leni^tli, while the rarer conditions and more comj>licate(l operations have been deseribed moi'e in outline. In order t(» condense the work as fai" as possible the con- sidei'ation of the phvsiolojxv and palliolou;v of the iicirhoni has been dispensed with, these subjects beiiiu' tlie j)ra(;tical usefulness i)t' the book, a special eHbrt has been made to combine conciseness with clearnvss, and to keep it within a convenient number of |):i«i'es. The standard works on obstetrics have been larufcly drawn from, particularly those of Jewett, Hirst, Playfair, etc. The author takes this o])]iortunity to acknowledu-c his indebte. (iallaudcl for his l)ainstakini2: work in editinu' the book. MoxTUEAL, Canada. XOXSfO CONTENTS. MENSTRUATION. TACK Dt'liiiitioii ; cjuiso; striU'tiiral cliaii^t's ; onset; cli;' at'tt'r; (liinitinii ; iiK'ii(i|iaMsc 17, is Ovii.ATidX : ( Iraaliaii t'olliclo ; oviiin ; iiiatiiialion ol' nviim ; cnipus liitfiim ; ovulatidii and menstruation lS-21 PREGNANCY (Normal). Emijuyolooy: linprognatioti and conception; scincn ; feiiilization of tlie ovnrn ; developnieni of tlu' (lei'i memhranes ; aiiniion; yolk-sac; aiiantois; lu'achus; innhilical cord; chorion: development nf the placenta ; structure; villi; capillaries; iilacenta and meni- hranes at term; functions of [)lacenta ; ovum at diflercni periods of liregnancy ; fo'tal circulation 21 8S CiiAN(;i:s IN Matkun'AI, Ohoanism : Items; increase in size; changes in shape and structure ; relation to pelvis and ahdonuMi ; alterations in cervix, vagina, and vulva; changes in hreasts ; alterations in other than the generative organs; lincic alliica?Ues .'W— 1 1 Duration OK Piuocjnancy : Date of fruitful coitus ; rule for deter- mining; height of fundus uteri ; date of (luickening M, 4') DiAfiNosis OF Phi:(;nan('Y : First trimester: su|)pression of nuMi- struation ; nausea and vonuting; mannnary changes; vesical irritation; nervous disorders; softening of cervix; violet dis- coloration of vagina ; softening and enlarn-cnu-i.i of liody of uterus; second trimester: fretal movement; uterine soullle ; fo'tal heart-sounds; i»ignientalion ; hallottemeut : third tri mester : pressure-symptoms ; varices; disturliancesof res|»iration and digestion ; fa'tal movements; striie; settling; siunmary of 5 6 CONTENTS. I'AdK (liiifi^nosis; (lilU'reiilial diafijiio.sis of pregiumrv ; dingnosis of parity or milliitiiiity ; (liaf>;ii()sis ol' life or (leath of child . . . 45-51 IlytiiKNK AND MANA(ii;MKNT «)K I'uKONANCY : Diet; I'xercise ; c'lotiiiii}^; hathiiifj: ; care of breassts ; care of other organs and fiUK'tions ; examination o4-r)() OBSTETRIC ANATOMY. Anatomical Klkments in Laisur 56,57 Tin; Utkius: Walls; niiiscle-lihres ; uterine segments; ligaments; peritoneum ; relation of full-term uterus to eontiguou; structures 57-61 TllK I'i';i,vi-(iKMTAh Canal: JJoiiy pelvis: general description ; joints; moliility of pelvic joints; false and tiue pelvis; inlet; sui)erior strait; inferior strait; outlet; cavity of privis; lat- eral grooves; i)i.nies of i)elvis ; pelvic diameters, conjugate; transverse; ol)li(iue ; measurements; inclination of the pelvis; soft pai's of the pelvic canal : nuiscles ; rectum ; {)elvic floor; segments of (loor ; fascia ; j)erineinn ; i)arturient axis ; other axes 61-76 Thk Imktis: Mature folus ; the head: vault; base; sutures; fontanelles; ob.stetric landmarks ; diameters of fa'tal head ; cir- cumferences of planes of fo'tal head ; moulding of head ; im- |M»rfance of (lexiou of head ; Ortal trunk : diameters; mobility of lie;id and trunk ; postiu'c of fo'tus ; presentations; cephalic, pelvic, somatic; positions; vertex, face, breech, .shoulder; centre of gravity of fietus; Aetal movements 76-96 MECHANISM AND COURSE OF NORMAL LABOR. (lENKiJAT, Dkfinitiox.'S ani> IvriOT.odY: Kut(H'ia ; uncomplicated vertex present:itions ; primigravida ; priinii)ara; nudtipara; stages of labor ; dm ation of normal labor ; causes of the on.set of lal)or ; forces of labor; uterine contractions ; pains; refr.ic- tion ; polarity; contraction of abdominal nmscles and dia- I In-agm ; gravity 96-102 Laiu)r — First Staoe: Premonitory signs and symptoms; charac- , teristic signs and sym])toms of the onset of lal)or; mechanism of the first stage ; dilatation of cervix ; liydvostatic i)ressure of the bag of waters ; action of longitudinal fibres of uterus ; rupt- ure of membranes; ])rcsenting ])art of fretus as dilator; dry labors; os uteri ; initial labor-pains; reflex vomiting; anatomy of soft parts 102-107 CONTENTS. 7 I'AtiK Laiiok— Skcon'I) Stauk: Mecliaiiism ; lu-atl iiiovcim-iit ; doceiit ; llfxidii ; inleriKil rotatimi ; exloiisidii ; ivstitiitioii or eMenuil rotation; delivery of tlie trunk; jiains; sufRTiii;;s of woman; aftor the birili of the I'hild ; nioiildini^ of tin; fo'tal head; capnl succedanenin ; anatoniy I(»7 Hi; Laijok — Tjiiuu Staok: Separation of placenta; separation of nieinlwanes ; expulsion of placenta and inetnhranes ; retro- p'.acental heniorrhaj,^e ; eoinpletion of labor; hlood lost in labor J Itl ll.s MANAGEMENT OF NORMAL LABOR. OliSTHTUu; Antiski'.sis: Antiseptic a<^ents ; chenncal antise|)tii's ; the obstetrician; inetliods of sterilizing hands; the nnrse; tlie patient 11 '.M'JX I'KErAUATloNS FoK I.ahoH: On the part of the j)h_vsician ; obstetric bag and contents ; labor room ; linen; vnlvar pads; binders; labor-bed; anasthetics in labor 124 127 Managkment oi" Tin-; First StA'se: Preliminary conduct of the physician ; obstetric examination ; palpation ; auscultation ; vauinid examination; succeeding the examination; rupture of M embranes 128-13G Manackmknt of thk Skconij iSxAtiK: Position; in rapid cases; aniPsthesia; perineal stage; laceration of perineum; at moment of delivery; delivery of head ; delivery of shotdders ; immediate care of child; the cord 137-140 MANA(iKMKNT OF TiiK Thiut) Staof, : To insure lirm uterine contract!. )n ; lacerations; e.\])ulsion of placenta; Crcde's method of expression; retraction of uterus; final measures . 141, 142 THE PUERPERAL STATE. Anatomy of thf Parts immkoiaiklv aftkk Lahoi! : Tiie uterus; vagina; vulva; bladder; peritoneum; abdominal walls 143-140 PiiYsioi.OfJY OF THE PrERi'ERAL Pehioii : Involution; circula- tory system; urinary system; skin; digestive apparatus; lactation; mammary glands; colostrimi ; milk 145-150 Manauemext OF THE PiERPERiUM : Lying-in room; genitalia; care of breasts; nursing; nipples; contraindications to suck- ling; after-pains; visits of the physician; infant's tempera- ture Io0-lo4 '?< 8 CON TESTS. PATHOLOGY OF FllEGNANOY. PAOK 'I'liK I)i;( IDIA : Aciiti- and clironuMlcfidual nidoiiii'tritis; atrophy 154-ir)t» Tin; I'd/iAi, A l'i'i;M)A*ii:s: ( Hinoliydraimiios ; liydraniiiios ; amuiniic l.iiids; prciiiatiirc' riiptiiiu of aiiiiiioii ; alterations in ('liarat'liT of iiijiior anniii ; vi'siciilar nioK'; anomalies of pla- (vnta ; disi-asi's of plact-nla ; plarcntal apopk-xy ; placiMitilis; tumors and odema of placenta; aijiiornial lenj^tli of cord; coils and knots of cord; hernia into cord lotl-Ki.) TiiK lAivrfH : Tlof,'y ; fo'tal mortality ; elciihantiasis; a'la- sarca ; ii-hthyosis; rachitis; syphilis; tubcrcidosis ; contagions disiuses; fo'tal death Kio-ltJl) l'A'rii(),.()(iV OK TIIK I'i!i:i!!iy of thehladder; hietnaturia; alhuminui'ia ; kidney of jireynaney ; acute and chronic nephritis; coutih ; dyspna'ii; pneumonia; phthisis; cardiac ilisease ; heart nnir- nnirs ; eid;ir^ement gf thyroid ijlaud ; neuralgia; neuroses; infectious diseases 109-188 ToXilCMiA — Kci. A.Mi'siA: Symptoms; definition; frecji Micy ; pre- monitory symptoms; the lit ; etiology; path()lof>^ical anatomy ; treatment 188-101 AnoirnoN an'd Pi;i;MATiitK Lahok: Detinition; symptoms; patludogy; etiolo^'y ; diagnosis; treatment; missed ahor- tion ; miscarriage ; missed labor r.)4-201 1m roric Gkstation : Detinition; frecpiency ; varieties; tubal pregnancies; terminations; tubal abortion; etiology; path- ology ; symptoms ; treatment ; removal of sac ; techni(pie of operation 202-2(1'.) PATHOLOGY OF LABOR. Dystocia due to Malpositions of tiik F(Ktis: Occipito- posterior cases ; face presentations ; brow presentations ; breech presentations : arrest of breech at the brim ; rapid I'xtraction of trunk ; delivery of tlie after-coming head; transverse pres- entations ; prolapse of the fietal liMd)s ; ))lural Itirths . . 20'.* 218 V(fSTh\\TS. 9 I'AtiK I)YST()C1A Dl'K TO A N(»M A 1,1 i:s ol' I'tKI'AI, I )|:Vi:i.' H'M i:n T : OviT- ;;r(i\vtli of I'm 1 1 IS : |Hiiii;iliiri' ()>HirK;ili()ii nl' >kiill ; liy(lr(i(r|i|iii- liis; i.'iut.'l>liiilti(i'lf ; inciiiii^' ; |ifiviiiK'l'y ; aiioiiialic^ of iilfriiit' di'Vflopiiic'iit ; alri'.sia and rigidity of cervix ; iiii|i:ii tioii of anterior lip of cfrvix; (lispL.t'i'int'iils of llu- ntcriis; pro- laphc; aliiu>rmal coiKlilioiis of vagina, vnlva, and Madder; tumors of u:eiiital canal ami neiy:lil)oriiij,' or^ians; rupture of litems; inversion of the nterns "JtiS-lU'J PATHOLOGY OF THE PUERPERAL PERIOD. IIemoiujii AiiKs in i!iNt-partum lie.liol- riiaije; secondary liemoiriiaii:e ; lia'mat.una 312-318 SiT.iNVoi.i iiox : l';tiolo,iry ; diagnosis; treatment 31H-320 Anomai.iks and I)iskasi:s of tiii: Xiitj.ks and I>I!i:asts: Supernumerary nipples; inversion of the nipple; ahsence of inamiiia'; liypenropliy of mamma'; supernniiKMary mamma'; defii'ient milk-secretion ; polygalactia ; ualactorrlnea : eng-orye- inent of the hreast : sore nipples; mastitis; mainmary ahscess ; arrest of lactation 320-332 I.\Ti.i!( I I!I!i:nt Diskasks IX TiiK I'rKKi'iiiiif.M : >[iscellaneons diseases; malaria; piKM']K'ral ana-inia; liemorrlioids ; diseases of the urinary ortfans ; neuritis ; myelitis ; cerebral heniorihage and embolism ; i)uerperal insanity; snd, ;{, (litt'erent parts of stroma; 4, Graafian follicle (tunica fibrosa) ; 5, Oraatian vesicle or ovisac ; 6,6, tunica granulosa ; 7, liquor f'olliculi ; «, vitelline membrane, or zona pellucida; 9, granular vitellus, or yolk ; 10, germinal vesicle ; 11, germinal spot. conception it has a diameter of about two-thirds of an inch (1.5 cm.). At term it is still present, has shrunk to half an in(!h (1 cm.) in diameter, and is of a distinct lemon-yellow color. A month after delivery it is reduced to a small mass of fibrous tissue. Ovulation and menstruation : Neither ovulation nor menstru- ation is dependent on the other. Both depend on the same cause, a periodic nervous excita- IMPREGNATION AND CONCEPTION. 21 tion and (•()ii<>;(.'Stion. As a r\\\v, they do occur synclironoiisly ; but Lo()})ol(l liavS j)r()VO(l tliat ovulation has taken place in the intcrinonstrual ju'riod. Pregnancy has been icnown to take place before the onset of menstruation and after the climacteric. PREGNANCY (Normal). EMBRYOLOGY. Impregnation and Conception. The propagation of tlie species re(piires the union of the vital elements of the two sexes. In the act of copulaiioii the male deposits within the female a fluid, tiie semen, which contains the vitalizing element. The semen is a white, viscid, dense fluid having a peculiar odor, secreted by the testicles of the male. It consists of water, albuminous matter, salts of lime and sodium, and contains numerous peculiar organisms called Hpeniiatozoidn. These spermatozoids form tiie essential fecundating part of the semen, are about g ,\,j inch in length, and resemble tlie tad])ole of the frog. p]ach one is made up of three parts ; head, middU> })iece, and tail, and is capable of very rapid vibratory move- ment (Fig. 3). After emission, if in ])roper surroundings, ^Ki. 8. the organisms retain their vitality for a con- siderable time. Plxcessively acid or alka- line fluids destroy them. While })regnancy has been known to follow the (lej)osition of semen on the ex- ternal genitals of the female, as a rule, the acid mucus of the lower vagina })roves fatal to the spermatozoids. At the crisis of the sexual act the semen is usually deposited in the upper portion of the vagina, into which the cervix ])rojects. spermato/.oi.is. Hence the sjx'rmatozoids And their wav into the cavity of the uterus, and ultimately reach the Fallopian tubes. They have been found on the surface of the ovary. 22 PREGNANCY. As a rule, tlie meeting-place of tho speriratozoid.s r.nd ovum is ill tlio I'^illopiaii tube. Many chiiin tliat the normal place of inot'tiiiu; is the upper portion of the uterine oavi* ; and it is not infVcijtient that tliev come in contact on the surface of tiie ovary or in the abdominal cavity (ectopic gestation). If the ovum is discharged at the height "f tlie menstrual conges- tion, it probably does not reach the cavity of tlie uterus fir some days, llyrtle found the ovum in the uterine extremity of the tube in a girl who had died on the fourth day of men- struation. Pregnancy is more Hkchj to occur after copulation during the first eight days succeeding the cessation of menstruation. Fertilization of the ovum: Of the large munber of sper- matozoids deposited in the vagina, but few ju-obably come into Fig. 4. .'-f'n Lb * « M J \ • , • <* • *ir N-i: »• •• '» / Formation of polar globules in artoria glacialis : Sp, nuclear spindle ; Pg, first ])()lar globule ; Spg, seconii polar globule; /p, female pronucleus. (After 0. Hert- wig.) contact with the ovum ; and of these, but a single s})ermatozoid actually takes part in the fertilization of the ovum. By friction with the walls of the tube the cells of the discus ])roligerus disa])})ear and the zona pellucida becomes surrounded with an albiuninous covering which seems to attract the sper- matozoid. The successful spermatozoid, after penetrating the zona pel- DKVELOPMENT OF THE DECIDUA. 23 liicida, coiues in t.'ontact witli a projection oi'tlie j)r<)to})la,sin of tlu' ovum and its tail disapjx'ars. I'lic head then penetrates the cell-contents and (lisaj)pears, to reappear subsequently as a sn-iall round body, the male j>r()imcl<'un (Fiji;. 4), Finally the male pronucleus and the female ])ronucleus unite, and concej)- tion has occurred, 'i'hus the lii'e-history ot" the embryo, i(etus_, and infant be, zona pellucida; ep, epiblast ; hy, hypoblast; b«, cavity of blastodermic vesicle. 28 PREGNANCY. coUeots, and tlio ovum m w forms a (listeudcd Vv icle, termed (lie f)/(isf<)(lcnni(' vrnir/c. At this Htii^o tli(! cpiblastic cells completely line the blasto- dermic vesicle, while the mass of hypohlastie cells having becon)e distended by the accumulation of fluid is flatlencd and pressed out over c small area of the epiblastic cell-lining, the central portion being thicker than the periphery (Fig. JM. This thicker |)art is tlie commencement of the embryonic area. It is only this part of the blastodermic vesicle which is con- cerned in the formation of the embryo; the remaining portion being the non-embryonic part, and concerned only in the for- mation of the amnion and the umbilical vesicle, as we shall see lat(.'r. The primitive epiblastic cells peripheral to the thickened layer of hypoblastic cells now disappear, leaving tliis portion of the Fig. 10. Transectidn of eiKhteen-hour cliif'k embryo, showing beginninp of medullary groove and the three layers: a, ectoderm; b, mesoderm; c, entoderm. (Manton collection.) wall (if one could look, as it were, through the vitelline mem- brane) somewhat clearer (area pellucida). The hypoblastic cells now appear as a darker streak in the area pellucida, termed the primitive streak; which then devel- ops with a groove known as the primitive groove, which is t)ie first evidence of the formation of the embryo, indicating, ap- proximately, the position of the future vertebrae. Cleavage of the hypoblastic cells : If a section be made througii this streak, or .^ove, at this period (Fig. 10), the hypoblastic cells will be foiuid to have separated into two layers, termed respectix'^ely the ectoderm (permanent epi blast) and the ento- DKVKLOPMKyr OF TUI<: MEM BRAS ES. 29 (hi'in (pcriiiiiiicnt li\ jxtMiist) ; wliiN- Ix'lwccn (liiMii aiiotlu'r liivcr i«:i-> tniiiud, doiivcd in part tV(»iii both, Icnnod tlin uhho- derm (im'sohhist). Cleavage of the mesoderm: In tlu' coinsc of tinio this inoso- (lorin develops latend redu|»iieiiti(>ns and divides into two layers, tli(! parietal and the visceral layers, inrlosint:; spaces. The parietal laver unites with the; cctoderni to form the Hoinato- j,/rnir ; and the visceral layer unites with the entoderm to lorin th( xpfdiu'/niopkurc. '•: ii'j space included between tlu* two leaves of the deft meso- derm is the primitive hody-cavity, or c(elom, which afterward becomes the pIeiu'oj)eritoneal cavity. Development of the Membranes. The amnion : The embryo now sinks toward the centre of the ovum, and as it does so the somatopleure grows up all Fiu. 11. Fig. 12, /EiiihIatI Ki^r. 11.— //, lit'iKl (if emhryn; pp, tnil-portinn f)f [)lonrnpcritoncal onvity ; omr, t)iil-i)orti()ii of primitive amniotic cavity (the ;*/•/«*////> Mmiiintic ciivity is tlic hollow space inside the donble folds that rise over the hack of the fcetus) ; (U.f., tail-fold of amnion; nhf. head-fold of amnion; ,w, sonintoplenre ; .v/>, splanclinoiileiirc! ; rVr, false amnion ; h>j, hypoblast ; at, alimentary canal, coinninnicatintc witii cavity of nv, the umbilical vesicle; ZP, zona pullucida; A, conunencinji projection of alla'ntois. Fiff. I'J.— The amniotic f()lds have united, inclosing hmcj, the trni' amniotic cavity :/a, false amnion, whose cavity fnnr,f(mr./>, iscrintinuons with the ph-nroperito- neal cavity; (if, alimentary canal, s"till communicating with »r, the nmbilical ves- icle ; A, sti'm of allantois dilating into a vesicle at x ; ////, hypoblast ; «;>, sphmclino- pleure, c( nposed of mesoblast and hypoblast, and continuous with splanchnoplcure of intestine ; ZP, Mwa. pollucida. around it, while the pplanchno])leure sinks with it. These somatopleuric folds thus present two surfaces, one looking 30 PRE3 NANCY. toward tlie embryo, tlie other toward tlie outer surface of tlie ovum (Fig. 11). As these :'"oids meet over tlie back of the embryo they coa- lesce, and thus fbru; two distinct membranes (Fig. 12). The inner membrane, that next the embryo, forms a complete sac, the amniotic .sac, having its origin close to the cephalic; and caudal ends. This membrane is termed the amnion, and its inner surface is derived from the epiblast, and is continuous with the skin of the embryo, which is also epiblastic. The outer membrane, which has its outer surface composed of epiblastic cells, then retires toward the outer surface of the ovum, to form the chorion. Primitive gut- and yolk-sac : While these changes are in progress in the somatopleure, the sj)lanchnopleure, sinking toward the centre of the ovum along with the embryo, com- })letely envelo})s the yolk. By bending sharj)ly inward at a point some distance from its origin the splanchnopleure forms a second canal, which is thus lined with liypoblast. The upper canal eventually becomes the fdinientary tract; while the lower is the yolk-sac (Figs. 11-14). This latter gradually disappears, though it sometimes persists as a blind sac leading from the ileum, known as Meckel's diverticulum. The allantois : A portion of the splanchno])leure forming the wall of the primitive intestine very early buds outward, projects into the pleuroperitoneal cavity, and approaches the chorion. This is termed the allantois ; in its sibstance the foetal blood- vessels develop (Figs. 11-14). These allantoic bloodvessels line the chorion and dip down i^jto the villi. The urachus : In the course of development, that part of the allantois in connection with the body becomes obliterated. A part forms the urinary bladder, while a portion of it persists as a fibrous cord running from this viscus to the umbilicus, termed the urachus. The umbilical cord : Both the yolk-sac and the allantois are at one time included in the tube formed by the meeting to- gether of the amnion on the ventral aspect of the embryo, termed the abdominal stalk, which becomes the umbilical cord. The chorion is the permanent outer membrane of the ovum, and is formed, as we have seen, from the somatopleuric layer, its outer surface being epiblastic and its inner mesoblastic. DEVELOPMENT OF THE PLACENTA. 31 Tlie wholo superficial area of tlie chorion soon becomes cov- ered with littk' projections, termed villi, wiiich *' dip down " into and soon become attached to tiie deeidna (serotina and reHexa) at all points of contact. Each villus thus has an outer surface of epiblastic tissue, while its core is formed of mesoblast. The>«e villi, as we have seen, receive a vascular eq"oj)ment from the allantois, th()njj;h the more recent view is that the capillaries are simply formed from the mesoblastic tissue of the chorion. Subsequently those Fio. 13. Fi(i. 14. Fig. 13.— to, true amnion, its cavity, amc.t, bi'«iniiing to extend witli liquor anniii:/rt, fiilso amnion, its oavity, (i»»r', eontinuons witli iileiiroperitoneal cavity; *'o.s, folds ,,(!— are loathed in it; bnt there is no actual connection Ix'tween the iu'tal and maternal circulations, as tlie walls of the lu'tal villi and their coverings are still interposed. The maternal blood is carried through the decidua by means of spiral twigs derived from the uterine arteries ; and is carried away by veins having an oblique direction toward the perito- neal layer of the uterus. This formation of the arteries and veins in the decidua results in the absolute cutting off of the blood-supply, when uterine retraction and contraction bring about the expulsion of the placenta at birth. Placenta and Membranes at Term. a...' placenta at tern^ -/. c, the end of the period of preg- nancv — is a soft, spongy, vascular mass, circular in outline, thi( kest at its centre, where the umbilical cord is inserted, as a rule, rts surface is six to nine inches in diameter; it is from one-half to one and one-half inches in thickness; and weighs from one to one and one-half pounds. The placenta is fully formed r.t the third month, though its dimensions increase steadily toward term and bear a propor- tional relationship to the size of the child. There are two aspects of the placenta to be described : first, the fetid, that side directed toward the fa'tus; secondly, the maternal, that directed toward the uterus. The foBtal aspect of the placenta is covered with a smooth shining membrane, which is continuwus with that covering the umbilical cord and lining the amniotic sac, the amnion. Beneath this may be seen the large umbilical vessels running tortuously on the chorion, and dividing into brandies, which dip down at right angles into the villi, forming the mass of the placenta. Deeper down the darker chorion may be seen through the transparent amnion. The remains of the yolk-sac may occa- sionally be noted, looking like a })iece of putty, lying a short distance from the insertion of the cord. The maternal aspect of the ])lacenta is of a dark grayish-red hue, and is divided by deep sulci into lobules of irregular out- line, termed cotyledons. Its surface is covered by a grayish, 3— Obst. 34 PREGNANCY. <;'listening, tmusparent membrane, wliicli is the maternal por- tion of tlie placenta, and is composed of the superficial layer of the decidua serotina. Therefore tiie line of cleavage, when the placenta separates from the uterine wall, is through the mubUe or S])ongy layer of the decidua. Around the periphery of the placenta runs a large vein, the circular sinus or vein, which returns a portion of tlie maternal hiood from the organ. Tlie site of the placenta in the uterus varies, though it is generally on the anterior or on the posterior wall. The functions of the placenta are many. It is at once the lung, the alimentary apparatus, and the kidney of the f(etus. In it the fuetal blood parts with its carbonic acid gas and its otiier waste-products, receiving in return, from the maternal blood, oxygen, and the materials necesFiuy for the nutrition of the f(etus. The epithelial layers of the chorionic villi seem to have certain })owers of both selection and resistance; since cer- tain bacilli and drugs pass readily into the foetal circuhition, while others do not. The umbilical cord, which unites the fa^tus with the placenta, is formed about the fourth Mcek of gestation. It averages at term about twenty inches, varying from four to eighty inches, in length. Its thickness varies from the size of the little finger to that of the tlunnb. Its sheath is composed of am- nion ; it contains two arteries carrying blood from, and a rein carrying blood /o, the foetus, which are ind)eddcd in a mucoid substance known as Wharton^s jelly. Tiiese vessels run in a spiral manner, the twists usually being from right to left. The amnion and chorion, with the slireddy remains of the decidua and the placenta, when they are examined after de- livery, are seen to form a sac, which has been ruj)tured at one spot, usually at the site of the internal os, to permit the escape of the fcetus. The decidua on the membranes is somewhat thicker than that on the maternal aspect of the placenta, since it consists of the atrophied reflexa and the superficial layer of the vera. It is reddish in color and very friable. The chorion can be readily separated from the amnion, each of these forming a distinct membrane as far as the edge of the THE OVUM AT DIFFERENT PERIODS OF PREGNANCY. 35 placenta. The cliorion will be noted to be thieker, more opaque, and less tough than the amnion. The amnion, which is the membrane next to the fciotus, is a clear, translucent membrane whose chief characteristic is its tougiincss. This toughness permits tlie sac, when distended with liquor amnii, to withstand considcraMe ])ressure, and eiiabl(!s the bag of nuMubranes to act in an ("flKcient manner as a hvdrostatic dilator durinu; the first staije of labor. The liquor amnii, which fills the amniotic sac and in which the fietus is suspended, is a light-colored turbid fluid of a specific gravity of about 1010. Its quantity varies from one to two pints in the normal state. Its source is not (U'finitely known, ^y many it is believed to exude from the maternal vessels in the uterine walls, but it is ])robably of fassinn; thence into the right auricle anteriorly, it finds its way into the right ventricle. It is then forced into the pulmonary artery, whence it [)asses by another "short circuit," termed the ductus arteriosus, emptynig into the aorta just beyond where the cai'otids bi'anch to the heas (''J.7 cm.) ill the uii impregnated state, to 12 inches (;}().o cm.) ; the width, from 1] inches (3.2 cm) to 9 inches (23 cm.) ; the dej)tli (anteroposterior), from nothing to between 8 and 9 inches (20-23 cm.). The capacity is increased from nothing to about 500 cubic inches (8300 c.cm.). The weight of the organ increases from 1 ounce (30 gm.) to about 24 ounces (720 gm.). These measurements varv with the size of the foetus, the quantity of liquor amnii, and in multiple pregnancy. This increase in size is a growth, and not a mere distention, UTERUS. l\\) for ill ectopic o;cst;ition tiu' utcni.s is touml to go on grow i lit;, up to Mild Ix'voiid tli(> ioiii'tii iiioiitli. 'J'lic changes in shape :iiv clianu'tcristic. In tlic noii-prc<:,- iiaiit ('oiiditioii the uterus is pyrilonii, tiie large end being nppcniiost ; and flattened aiiteroposlerioriy. In the earlier niuntiis of pregnancy tiie lower part seems to increase in capacity ta>ter tiian the n|)per, so that the shaoe of the uterus becomes roughly spherical ; wiiile at the tit'ih month, accordinir to Webster, the oruaii is once more ovrilbrm in shajK', but the wid(,'st part is lowennost. At the end of ])re<'nancv the uleriis assumes verv mtieji the shape of tiie non-pregnant organ, the roomiest part being again U[)permost. Thus uj) to the fifth month the increase in the capacity of the uterus is chiefly in its lower part; and from tiien till term iiKiinly in its nj)])er portion. Muscle-fibres : The marked increase in the bulk of the utroportion to the nuiscular. There exists a true hyperplasia of the con- nective tissue, which begins in the neighborhood of the blood- vessels. The arteries of the ut|)I:i('((l upward l)y tlio utonis as it asceiuls, so tliat ouie- wliat to the rijiht as a nde. This i-i are two conditions of the cervix during pregnancy which are jwculiarly characteristic. B(»tii are diK' to a partial obstruction in the; venous return which leads to softening and Ji marked blue or violet discoloration. The softening of the cervix l)egins, as a rule, about the second month. It is lirst ai)parent about the tip, but spreads upward as ])regnan(n' advances, so that in the later months the \vhol(! cervix becomes so soft that the fingei", if unaccustomed to vaginal examination, may have difliculty in finding the os uteri. The cervix in pregnancy has been likened in feel to that of the ])outed lips. The violet discoloration is due simply to the venous engorge- ment, and it may be j^resent even in the first few weeks of pregnancy. The canal of the cervix remains throughout preg- nancy unaltered in length. Its mucous glands secrete a peculiarly t(jugh mucus, wiiich stops up the canal like a c(-rk throughout pregnancy (mucous ping). Vagina, Vulva, and Breasts. Tlie vagina and vulva become somewliat hypertrophied during pregnancy. The color of the mucous memi)rane becomes bluish. There is a slightly increased secretion of nuicus, and the parts become lax and soft. Changes in the Breasts. With the onset of pregnancy there is an increased deter- mination of blood to the breasts ; and certain alteiations pre- paratory to the function of lactation begin. 42 ritl'JGXANCV. Tlit'sc glands attain roinplctfi (Nivclopiucnt in the first pro^- naiK'v. The lobules ciilarp' and liccoinc distinct tVoni one another. Tiie epithelium lining tiu; acini h<'cunies active, kjadinjj;' to a certain amount of desipianiation of th<' nj>i»er layers. These cells undei'ii'o tatty de<:;cneration and are set i'rec, con- st it ntint; colostrum-corpuscles. Very early in pregnancy a small quantity of serum may he expressed from the nij)ples. The fat and connective tissue snrroimdinji the lobules hyper- trtiphy, and the hreasts l)eet)n>(! eidar<;('d and more prominent. Coincident with these ehauj^es there is increased tenderness on pressure. The skin heconies stretchecl and striie develop, havin'j; a radial disti'ihution and diicction. The veins on the surface b(>come more obvious. The areola becomes darker from dejMisit of j)igment, this being more marked in brunettes than in blondes (Fig. 17). Fio. 17. -17- '■■:,:h..Ji^ ■*.^^£.!^ ^B^^^t; '■ ■mm ■'■■fmm w y,;^ IP- |si.^ -3^ ''"w.'ntrtl — i •^ 1 Brunette: Wrinkling of iiriniary areola; x. ,1., well-defined secondary aroula. (Itii'kinson.) The ftchaccous fnUiclr.'^ of the areola, ton or twenty in num- ber, become more prominent, being of lighter color. These follicles at the margin of the areola licing uncolored, stand out prominently as white spots, forming the so-called secondary areola. The nipples become more prominent as a rule, and are softer ALTKIiATIONS IS OTUKR THAN GKNICIiATlVJJ ORCiASii 43 than ill tlie n<»n-j)i('p;iiaiit state. In tlio later inontlis of pre^- naiKy dried cakes (if secretion may be found encrusted on tlieir surface. Alterations in Other than the Generative Organs. Nervous system: 'I'lien; is present durin<:; prej^iiaucy a condi- tion of cvidfrd in'rrr-tciisioii. Hence there is an increased tendency to nervous instability. The woman is more prone to hysterical attacks. There are often present juMversions of taste, smell, etc. ; also neuralgia, especially of the face and teeth. Mental affections are apt to develop during this period. This condition of increased nerve-tension causes about two- thirds of all pregnant women to suller from vomUin signs of pregnancy; it may reach from the pubes to tJie ensifoi-m cartilage. The skin around the eyes is darkened, and frequently irregular s[)ots of pigment aj)pcar on the surface of the body, chiefly in the face. Linese albicantes : Certain skin-cracks are to be noticed, chicHy as a result of ON'cr-stretching. They are termed Ktri(r, H)ic(v (ifhicdufci^, linar inafcvi> white, and form strong presumptive evidence when present of previous preg- nancv. DURATION; DIAGNOSIS; HYGIENE AND MANAGE- MENT OF PREGNANCY. Duration of Pregnancy. As a rule, it is impossible to predict exactly the date \\]wn labor will take place. If the date of fruitful coitus can be fixed, then labor will most likely set in two hundred and seventy-one days later, according to Ahlfeld. The common rule is that labor will occur on the day of the tenth menstrual period — /. c, two hundred and eighty days after the first day of the last menstruation. Allowance must always be made for the short month February. As a rule, one seldom predicts the exact day of labor, and the variation of a week or two is far from common. When pregnancy occurs during a period of amenorrhoea, as FIRST TRIMESTER— SUBJECTIVE SYMPTOMS. 45 lactation; or if the date of the last iiionstniation cannot lie ascertained, then th(^ probable tlato of labor may be fixed by noting the height of the fundus : The .tollowint;' table has been giv n by >Satugin and Galabin : Weeks Inches Cm. . 16 4 10 t>0 5.4 13.0 04 *- * 28 32 34 36 38 6.0 7.S 8.7 9 9.3 9.6 16.5 li».5 22 23 23.5 24 S 40 10 Tiiis method can oidy be employed in cases M'here the head pr(>.sents at the brim of the ])elvis. Tiie vicd.sKrcmenf is made bv placing one tij) of a pair of calipers on the syniphysi.s pnbis and the other on the fundns nteri. The date of quickening — /. c, the first occasion on whicli the mother feels the mov(!ments of the fcetus — is of .some value in estimating tlu; dnration of pregnancy. Quickening occurs in the twentieth week as a rule in jn'imipara*; and in the twenty- first or twenty-.secoud week in multipane. Diagnosis of Pregnancy. The recognition of pregnancy is not always an easy matter, especially in tlu! earlier months of gestation. Careful, systematic, and, if necessary, rej)eated examination camiot fail to j)ermit a certain diagnosis being made. Failure in diagnosis is nearly always the result of careless and unsystematic examination. For convenience of study the nine calendar montli.s of j)reg- nancy may be divided into trimcsfn-fi ; and a classification of the symptoms and signs as to these three periods be made. First Trimester — Subjective Symptoms. The suppression of menstruation constitutes, as a rule, the first evidence of pregnancy. This function is usually su.s- ])ended throughout gestation ; but this is not invariable. Some women menstruate at least once, and occasionally several times after the occurrence of pregnancy. The value of this sign as evidence is less in women who are very irregular in menstru- ating. Cavfies: Suppression may result from exposure to cold; 46 PREGNANCY. from the presence of debilitating disease, as tuberculosis, anaemia, etc. ; over-anxiety or marked fear of pregnancy may produce this result, as may also sudden mental shock ; change of climate or surroundings occasionally act in the same way. These exceptions should be held in mind ; but suppression of menstruation in a healthy woman of regular habit usually means })rcgnancy. Nausea and vomiting, occurring in the morning especially, form one of the most common symptoms of pregnancy. The sensation usually comes on when the woman fir^t as- sumes the erect position in the morning, hence the term " morn- iny .sickness " commonly a})plied to it. These sym})toms, as a rule, appear in the fourth or fifth week ; but may occur even earlier. They cease, as a rule, about the fourth month ; but may persist throughout pregnancy. The causation has already been referred to. The mammary changes l)egin as early as the second month, the congestion of the parts causing a sensation of fulness, with tingling and tenderness. Increase of pigmentation about the areolae and the presence of serum in the lacteal ducts become apparent during the third month. Vesical irrit. lion is often complained of very early in preg- nancy. As a result of the increase in the normal anteversion of the uterus, the bladder is pressed upon and its functions in- terfered with ; this usually persists till the fourth month. Frequently digestive disturbances arise early in pregnancy, having a reflex origin. The appetite becomes capricious, and ncidity is common. Nervous disorders, which are purely functional, are not infre- (Tjuent. Ptyalism is not uncommon, and may persist throughout gestation. Neuralgias, cardiac disturbances, mental perturba- tio;. and irritability frequently manifest themselves very early and are oftc:^ very persistent. First Trimester — Objective Signs. These are confined chiefly to the uterus and the breasts. The softening of the cervix uteri begins in the first month of pregnancy. The whole cervix, beginning first at the external OS, gradually softens as a result of the physiological uterine FIRST TRIMESTER— OIUKCTIVK SIUSS. 47 congestion. This change is most marked in the primipara, but is also present in the multipara. The cervix becomes plugged with nnurus as a result of the increase in the activity of the cervical mucous membrane. A violet discoloration of the mucous membrane of the cervix, vagina, and vulva may be noted on insj»cction of these parts, beginning as early as the fiftli week in many cases, i'liis discoloration, being due to a certain h hue. Tiie softening and enlargement of the body of the uterus consequent upon pregnancy may b(! readily made out by care- ful combined examination. JI(yi.stnrh(niccfi of difjcstion and of rcKpiration are common, both resulting from the great abdominal distention. The movements of the foetus can be plainly seen through the abdominal wall. The skin on the abdomen frequently shows linear markings, which apj)ear as red radiating striae, chiefly on the lower quad- rants. The umbilicus becomes prominent, and there is an increase in the deposit of pigment in the middle line. " Settling " : Within two weeks of labor the presenting ])art of the foetus partially enters the brim of the pelvis, becoming more accessible to the examining finger. The cervix also be- comes somewhat thimied out and feels shortened. At this tiine the prominence of the abdomen becomes less marked. To these changes occurring in the last two weeks prepara- tory to labor the term ".sv/////k/" has been a})[)lie(l. The mammary changes continue to become more marked, and colostrum can be expressed from the nipples. Summary of Diagnosis. The presumptive evidences of pregnancy are: (1) menstrual suppression; (2) morning sickness; (3) irritable bladder; (4) mental and emotional phenomena. The probable evidences are : (1) manmiary changes ; (2) abdominal changes (e.g., size, shape, markings); (3) uterine changes (size, shape, color, and consistency of cervix) ; (4) uterine contractions and bruit. The only positive signs tire f(etal: (1) foetal heart-sounds; (2) foetal movements ; (3) ballottement. 52 PREGNANCY. Differential Diagnosis of Pregnancy. The pliysician is not infrequently called upon to make an examination wliere the patient either feigns, desires, or, more commonly, conceals the condition of pregnancy. The diffi- culties of diagnosis are much greater before the fourth month of gestation ; but careful systematic examination will scarcely fail to establish a certainty in the majority of cases. Care nnist be taken not to express an opinion until a reasonable cer- tainty of the condition p.eseut is obtained. First Trimester. In this period the following conditions may resemble preg- nancy : amenorrhooa ; subinvolution ; metritis ; uterine fibroid ; retained menses; malignant disease; tumors in the neighbor- hood of the uterus, as ovarian growths; salpingitis ; and ectopic gestation. Simple amenorrhoea accompanied by symptoms of gastric irritatit)n may very closely resemble pregnancy ; but a careful bimanual examination will demonstrate the absence of uterine changes. In subinvolution the uterus does not increase in size, and it is not globular ; while its texture is harder than that of the organ in jiregnancy. In metritis the uterus, while enlarged, is sensitive to the touch, and is hard and dense. Its shape is that of the unini- pregnated organ simply increased in size. An interstitial fibroid of the uterus may be distinguished by its denseness and by the irregular contour. Menstruation, in- stead of being absent, is, as a rule, increased. Retained menses may cause an enlargement of the uterus; but in such cases the fact that menstruation has never been established, and a history of abdominal pains occurring at monthly intervals, will indicate the nature of the case. In malignant disease of the uterus the menstruation is, as a rule, increased, and intermenstrual hemorrhages occur. In ovarian tumors the uterus is not affected and menstrua- tion persists as a rule. The tumor is usually situated to one side of the uterus and causes some displacement of that organ. ■^ DIAGNOSIS OF VAIUTY OR NULLirARlTY. 53 Ectopic gestation may simulate uterino pivj^iiancy ; but caro- ful c'xauiiiialiuu will ivvoal tlio pivsonce ul' a tuuior outside the uterus. In the Later Months of Pregnancy the I'olluwino; conditions may load to an error of diai^nosis : (.JM'sity, ascites, tympanites, phantom tumor, and lar<>,e ovarian or fibroid tumors. \\\ obese women with irregular menstruation it is not infre- <|iicutly dillieult to establish a diagnosis of pregnancy ; but the absence of mammary changes and auscultatory signs will clear up the case. In ascites a diagnosis may I)e made by j)lacing the patient in the dorsal decubitus and percussing the abdomen. Both Hanks will give a dull note, while tlie middle area of the abdomen will be clear. Fluctuation may be obtained ; and on changing the })osition of tlu; |)atient the area of dulness will alter. In tympanites, the whole abdomen, while enlarged, gives a clear note on percussion. The bimanual examination in both the above conditions will reveal the unimpregnated condition (»f the uterus. Phantom tumors, which are occasionally met with in hysteri- cal women, can be recognized on applying the usual tests of auscultation, pi'rcussion, etc. Pseudocyesis, or spurious pirf/iKinci/, is a very interesting condition met with usually in women about tbe time of the menoj)ause. The woman imagines herself tt) be pregnant, and develops many of the characteristic symptoms of that condi- tion. Eidargement of the abdomen, fulness and tenderness of the breasts, may mislead the careless examiner; but in both the above classes of cases tbe administration of an aniesthetic, to permit of a thorough examination, will clear up the diagnosis. Ovarian and fibroid tumors, if large, may cause distention of the abdomen ; but in these cases the absence of all signs of a Hetus will suflice to (bstiuguish the conditions from pregnancy. Diagnosis of Parity or Nulliparity. Certain mechanical effects are produced on the abdominal wall and birth-canal of a woman who has previously borne a 64 PRIX! NANCY. f'lill-tcnii child, wliicli timc! fjiils quite to eradicate. On these depends the di;i<2;iiosis of parity or iiulli|)!irity. If tlie ovum has heeii discliarf^ed befon; it was siifhcioiitly hirnc! to pro(hu'e those changes, tlieii it is j)ractically impossible to be certain as to parity. These signs consist of changes in the breasts, perinenm, vagina, and cervix, as well as laxity and strise of the abdom- inal wall. In the parous woman the hrcadu are a|)t to be well developed a. id somewhat pendulous, the ni])ples being large and promi- lujiit. Occasionally striiemay be noticed. The (ifxIoiiiiiKif vuill is lax and yielding, the skin being marked with white strije. The perineum may show marks of laceration and be some- what lax ; the fomchelte being absent. Tlu! ni(/iiia Is eapaeioiis and lax, the walls being somewhat smooth. The remains of the hymen may be noticed as forming numerous small caruncles (carunculie myrtiformes). The rervi.r is short and broad; very often it is lacerated, generally on the left side. Diagnosis of Life or Death of Child. Jt is not always easy to decide that th(» child is dead. The woman may suspect this to be the case because of certain vague sensations of coldness about the ])ubes, and because of a feeling of weight or dragging. She may cease to feel the movements of the f(Tetus. The matter can only be settled if after repeated examination the physician fails to hear the ffotal heart or feel foetal move- ments. If at the same time the uterus ceases to grow, and the breasts l)ecome flabby, it may be inferred that the child lias perished. Hygiene and Management of Pregnancy. While the condition of the pregnant woman is a purely physiological one, it must be borne in mind that tlie border- line between health and disease may be very easily passed. Hence it is the duty of the physician to give every woman engaging his services for her confinement such hygienic instruc- tion as she may require. In fact, a certain degree of pro- T^V lIYdllCSI': AND MAyAdKMENT OF rUEaNASCY. bh ro-ioiuil Jit(on(ion slutiiM l)o ^Ivon to all women throiij^hout I lie Nvliolc jM'riod of j)r('i;ii;mcv. Diet: 'I'lic diet diiiiiiti' ))r('}i;niiii<'V sIiomM Ik' |)lain. Simple, ci.-ilv (li^tstil)le, aiul lii<;lily milritioiis food slididd he tuken at i( <:iil:ir intervals. Overeating;, espeeiaily in the later month^, shoidd he Li'iiarded aai pari of all meals. Exercise: All violent exercise should he avoi«led. ^^'all^s ill the o|)en air and simj)l(! jrymnastics within doors should he indiilu'eil in daily. All liftin The use of drugs should ho avoided as much as possible dur- ing pregnancy. Large doses of quinine and calonud should not be administered. The all too common habit of taking drugs of the coal-tar series by women, to relieve headache, etc., should be especially discouraged during pregnancy, on account of their deleterious action on the heart. Many of the cases of severe cardiac failure following labor may be set down to this pernicious habit. The physician should make a careful general examination of every })regnant woman under his care about the eighth month of the pregnancy. A careful external and, if thought neces- sary, an internal examination should be made. The pelvis should be measured and the attitude of the fo'tus noted. The breasts and nipples should also be examined. Inquiry shoidd also be made as regards the presence or absence of vaginal discharge. If present, its character should be noted and a bacteriolog ^ 'examination made. OBSTETRIC ANATOMY. Foi detailed anatomy of the female pelvic structures the student is referred to special works ; or to obstetric systems, such as Jewett's " Practice of Obstetrics." The chief anatomical elements concerned in labor are three «P»V; THE UTKRVS. 67 ill mitulMT, namoly: (1) tlio iit«'rns ; (2) llic pclvi-^cnitul ciiiial ; (.'{) tlio Di'tiis. Ill tln' act of parturition the iimtiiiil reaction of these elo- iiiciits is coMcenied. Tlie iifii-n.fi may l)e coiicoivcil of as a iiiiiseiilar sae (i|)eiiiiin into a tMirv<'ists of two ovoids, the trunk and the head ; the forincr plastic, the latter more or less rigid, and therefore the more important as regards its relations to the birth-canal. The Uterus. At . .'rm the uterus is an ovate viscns; it is less part of the birtii-ianal than it is the engine by which the [)assciigcr — the fu'liis — is exj)elled. The cavity of the uterus at term has been stated as measur- ing 12 inches in length, 9 inches in breadth, and 8 inches in depth. The walls of the uterus vary in thickness from one-fourth to one-fiftii of an inch ; the posterior being tliicker than the anterior. Tlic muscle-fibres of the uterus mav be distinunished at term as forming roughly three layers: an outer, a middle, and an inner layer : In the outer layer there are two sets of fibres : (1) longitudi- nal and (2) transverse (Fig. 21). The /oiif/ifuduial Jibre.s, posteriorly from the junction of the; body with the eerv'x, pass in the form of a broad band verti- cally upward over the fundus and down the middle line ante- riorly to the cervix ; the marginal fibres toward the fundus branching off to interlace with those of the round and broad ligaments. The tramverse fibres arranged at right angles to these pass across the uterus from side to side ; at the fundus passing from one cornu to the other. These fibres interlace in great part at 5,S OB.STm'RIC ANA TOMY. tlic sides of tlic iitoriis, l>iit some of tlieni are prolonged along tlie broad and the round ligaments as well as along the tubes. Via. '1\. External muscular layer of the posterior wall nf Uio uterus. In the middle layer the tibres have no delinite direction on account of the numerous bloodvessels traversing them. They Fig. 22. Middle muscular layer nt the fundus : a, a, superficial layer dissected back ; I), branches belonj^ing to the inner layer ; t, t, tubes. pass in every direction — longitudinal, transverse, and obli(jue — twisting and curving about t.ie vessels. Freely ; while others j)ass do\vinvii"d longitudin;illy to the cervix, in the middle line of the anterior and posterior walls. Uterine segments : These layers an; not all distiiK-t, but shade imj)ei'ceptil)ly into one another. In the hjuh'i' part of the uterus the arrangement in lavers is fairly distinct; but i»i the loicer |)art the fibres are moie loosely arranged, passing ^ chiefly in a longitudinal diree- internal surface of the uterus as i.: ,, shown after ineisiou in the median •^^ '"• line of the anterior wall. (I'arvin.) Hence tlie uterus may be divided into two portions, the upper of which lias a frmer muscular arrangement than the lower. These })ortions are termed respectively the upper and th(i loirrr ntcriiie sec/vienf.s. The line of separation between the segments lies nearly at the level of the uterovesical fold of the peritoneum, and is termed the irt)'((ctio)}-ri)i(/, or ndiid/'.^ i'i))f/. The uj>per segment plays an active rd/c in labor, while the lower has but a passive rofc. The lower segment along with the cervix must undergo dilatation preparatory to the exi)ulsion of t.ie fietus. The upper segment includes roughly the upper two-thinls of the entire body of the uterus ; while the lower segment and the cervix, which are nearly of ecpial lengths, form the remain- ing one-third. The round and the broad ligaments, which have become 60 OBSTETRIC ANATOMY. hyportrophiod diiriiii; j)r('u;niui('y, s('rv(> as ^iiys to steady tlie uterus during its contract ions, so that its long axis corresponds to that of tlie ])elvic inlet. The peritoneum covering the uterus is finnly attached to this organ as far down as tlio retraction-ring; below this its attach- ment is loose and it may easily he stripjx'd oil'. Thus the site ol' the retraction-ring, or Bandl's ring, is at the lower border of lirm peritoneal attaclunent. The peritoneum at term has in front of and behind the uterus the same relations as iu the non-[)regnant condition ; but at the .svV/c.s it lias been so lifted uj) by tiie enlarged uterus that it does not desc'end into the ])elvis. Tiie broad ligaments have become so elevated that theii' bases are only at tlu! pelvic brim, extend- ing on either side from the ilio})ectineal eminence to the sacro- iliac joint. Thus there exists on either side of the uterus at term a large triangidar area uncovered by j)erito)'eum. Owing to the drawing U[) of the uterosacral ligaments the pouch of Douijhix becomes nuich dee[)er than iu the non-pregnant con- dition. The Relation of the Full- term Uterus to Contiguous Structures. The intestines do jiot descend behind the uterus at all, and iu front oidy as low as the umbilicus. A j)ortion of the rectum lies behind the uterus, ;ind occasionally a looj) of the sigmoid flexure of the colon. The urinary bladder lies wholly within the pelvis before the onset of labor, its highest ])oint being below the symphysis pubis, except when distended. The cellular tissue about the uterus exists as a thin layer behind; but in front there is a broad band between the cervix and the bladder. At the sides of the uterus it is enormously increased as compared with the non-pregnant condition. At the bases of the broad ligaments (defined above) there exists only cellular tissue (no peritoneum) between the uterus and the })elvic wall ; this de})osit extends u|nvard and backward between the layers of the broad ligament into the iliac fossa'. The ureters enter the ju'lvis just in front of each saero-iliac joint and pass downward, forward, and inward to the neck of the bladder in such a way that they are not in the least liable to pressure between the uterus and the bony pelvis. 1 BONY PELVIS. 61 The shape and position of the uterus as well as the direction of the axis of its cavity chant;*' as tlie organ passes from its rchixed state to one of active contraction. Tliese will tliere- fore be discussed later. The Pelvi-genital Canal. Bony Pelvis. Definition: Tlie pelvis is the bony basin, or canal, which foiMiis the most important part of tiie l)irth-canal (Fig. 24). Fto. 24 I'lie ft'iiiale pelvis. (JewcUj Tile leiMH is derived from the liatin p(/ri.'<,'A bowl. The pelvic canal is irregularly funnel-shaped, flattened from before back- ward, the larger end looking uj)wai'd and forward, the smaller downwai'd and backward, when the woman is in the erect j)osition. It contains in the non-pregnant state the essen- tial organs of generation, and in labor the child is expelled through it. 62 OBSTETRIC ANATOMY. An intimate knowledge of the pelvis as related to the mechanism of labor is essential to complete understanding of the problems of the art of obstetrics. ' General description : The pelvis is composed of the sacrum, the coccyx, and the two ossa innominata. Each of these bones is made up of separate parts which become united by the twentieth year of life. The articulations of the pelvis, wliich are of considerable obstetrical importance, are the sacro- iliac joints, the sacrococcygeal joint, and the symphysis pubis. The sacro-iliac joints : The opposed surfaces of each bone forming these joints are covered with thin plates of cartilage. These become separated by spaces containing a small quantity of glairy fluid, but no synovial membrane can be demonstrated. Each of these joints has anterior and posterior ligaments and intercartilaginous bands; of these, the posterior are by far the most important. Each of these posterior ligaments is formed of three fasciculi ; the two superior run nearly horizontally from bone to bone; wliile the inferior passes obliquely down- ward and inward from the posterior superior spine of the ilium to the third and fourth sacral vertebrae. The sacrococcygeal joint has an interosseous fibrocartilage which permits recession of the coccyx. Its ligaments are of no importance. The symphysis pubis : The slightly convex surface of each pubic bone is covered with a thin plate of cartilage sufficient only to fill out any irregularities in the bones forming the joint. The opposed surfaces are held together by an intervening mass of fibrocartilage, which constitutes the interpubic disk. A small cavity is frequently present in the centre of this disk, the result of absorption of the fibrocartilage ; it is non-syn- ovial in character. The lujaments of this joint are four in number — anterior, posterior, superior, and inferior ; of these, the most powerful is the inferior, often termed the ligamentum arcuatum. It is a strong fibrous bundle passing across from one descending pubic ramus to the other, blending at the median line with the interpubic disk. Besides the ligaments which are associated with the pelvic joints, we have the sacrosciatic ligaments, which play a very important part in the mechanism of labor. BONY PELVIS. 63 The greater sacrosciatic ligament arises from the posterior inferior spine of the ilinni and irorii tlie side of the sacrum and coccyx. It narrows and thickens in its middle part, be- comintr broad a^ain at its anterior attachment to the inner sur- face of the ischial tuberosity. The lesser sacrosciatic ligament takes its origin from the side of the sacrum and coccyx, and, passing in front of the greater, is inserted into the spine of the ischium. Mobility of the pelvic joints : Toward the end of gestation there obtains a certain degree of swelling or oedema of all the interarticular structures of the pelvic articulations, which per- mits of some slight expansion of the pelvis during labor, under the wedge-like advance of the fnetal head. The sacrum })er- nn'ts of a slight rotation on its transverse axis. There is also a hinge-like motion of the coccyx on the sacrum which permits an enlargement of the anteroposterior diameter of the pelvic outlet. The pelvis presents two divisions, the false and the true pel- vis, the dividing-line being at the plane of the brim — /. e., the plane cutting the upper end of the sacrum, the top of the sym- })hysis pubis, and the iliopectineal line on either side. The false pelvis has but little obstetric interest ; it simply forms with the vertebral column and the abdominal walls a funnel-shaped approach to the true pelvis, and is included iu the abdominal cavity. The true pelvis constitutes that portion of the pelvis lying below the iliopectineal lines. It is a deep basin-shaped cavity, the ■posterior wall, formed by the sacrum and coccyx, being shar})ly cm-ved with an anterior concavity. The anieriov wall is formed by the sym})hysis pubis and is short and straight. The lateral walls, which are formed by the lower portions of the ilia, the rami and tuberosities of the ischia, the sacro-iliac ligaments, and parts of the descending 'ami of the pubes, are irregular in outline, sloping inward, so that the transverse diameter of the pelvis is less at their lower than at their uj>per extremities. The true pelvis may be divided into three portions: 1, the inlet, or superior strait; 2, the outlet, or inferior strait; 3, the extiavation, or cavity. (1) The inlet, or superior strait, of the pelvis, sometimes termed the 6rm, is usually described as beiug heart-shaped, though iu 64 OBSTETRIC ANATOMY. the fresli state it is more nearly circular. Its boundaries are defined by the toj> of tiie sacrum behind, the iliopectiucal lines on eitlier side and the top of the symphysis j)ubis in front. (2) The outlet, or inferior strait (Fig. 25), is bounded by the subpubic ligament, the descending rami of the pubes, the rami, tuberosities, and spines of the ischia, the sacrosciatic ligaments, and the coccyx. Its outline is roughly triangular in shape, i)ut when distended by tiie advancing head in labor, it becomes ovate, owing to the distensibility of the sacrosciatic ligaments and the yielding character of the coccyx and sacro-iliac joints. Fio. 25. Outlet of pelvis. (Leischman.) (3) The excavation, or cavity of the pelvis, is bounded by the su})crior and inferior straits, and comprises all that portion of the j)elvis between them. J\jiitci'ior/i/, the cavity is bounded by the sacrum and coccyx ; antenorhi, by the })ubic l)ones and their rami ; iaieralh), by the lower portions of the ilia, the bodies, tuberosities, spines, and rami of the ischia, and by the sacrosciatic ligaments. Tlie jMfifcnor wall is concave from above downward ; its depth, following tho sacral curve, is 11.5 to 12.5 cm. (4| to 5 inches). The anterior wall is concave from side to side ; its depth at the symphysis is 4 cm. (1 1 inches). The lateral wall is about 9 cm. (3^ inches) in depth. BONY PELVIS. 66 For description each must be divided into three portions, wlii<'h may he mapped ont in Fi«;. 2(1. 'I'he A'/'^/ jKH'tuni is triangular in sliape, its hase heini:; a Une (h-awn from tiie iliopectineal eminence (o the top of the sacro- iliac joint, its lateral boundaries meeting, at the iliac spines. This portion is bony thrcMighout, and is smooth and ciu'ved. The second ixtH'um lies forward and somewhat below the first, and has but little bone in its comjjosition, being ciiietly made up of the membranous tissues of the foramen ovale cov- ered bv the obturator muscle. These structures are at term somewhat softened and more elastic than in the uon-pregnaat condition. When the pre- Fio. 20. Side view of pelvis. seating part in labor, in advancing, impinges on these structures their recession converts this j)()rtion of the lateral wall into more or less of a groove, with bony edges and elastic floor ; this groove d(?epeus as it descends, and its direction tends towar pubis at a point just above the lower margin (l''ijj,-. 2S). Via. 28. Ohstftric (liiinit'tiTS of the pelvic oiitU't : S. P., snoroimhic (liaiiutcr; Hi. I., liis- ii^chiiil diameter; IJi. S., bisischiatic diamctiT. (.k-wttt.) Plane of the cavity: The middle plane of tlie pelvic cavity lies at the level of the up])er end of the thii-d ])iece of the sacrum, the middle of the symphysis ])ubis, and tlie centre of the acetabular (javitics (Fi^. 25)). Internal pelvic diameters : The dimensions of (ricJi plane are measured in four directions : the aiiter()])()stcrior, the transverse, and the two oblique. At the plane of the brim : The auicropoderior dUiineler of the brim is the least distance between the sacral promontory and the symphysis pubis. It is measured from the middle of 68 OBSTETRIC ANATOMY, the sacral promontory to the jjosturior surfaco of tlic symphy- sis, at a point 1 cm. (f inch) below its upper margin. It is Diagram showing axes and planes of pelvis : A B C D, axis of entire parturient canal; X, anus as distended at acme of expulsion; E F, plane of brim ; K L, mid- plane of cavity ; M N, plane of outlet ; O P, axis of brim ; Q R, axis of mid-plane ; S T, axis of outlet ; // H. horizon ; E N, diagonal conjugate diameter. termed the conjugate, or true conjugate, and measures 11 em. (4f inches) (Fig. 27). I BOXY PELVIS. <>U rianes of the pelvis with horizon : A B, horizon ; C D, vertical line : A B 1, niigle of iiicliiiiition of jielvis to horizon, e " or 12-12W /> 0, left obli(Hie, 4.7 to 4.9 " OT \2-V2% The circumference of the inlet is l'),b inches, or 40 centimetres. 70 OUSTKTIHC A ^A TOM Y. Tlio frii(ffi' {F\^. ^\) is tlio jrroatcst distance Ix'twooii the iliojH'ctiiical lines, and measnros 13.5 cm. (5| inclK's). Tlie o/>//Vy//fw//V/;/*f^'/'.s' (Fi^. .■)! ) are ineasnred one fVotn the riji'lit and the other tVoni tlie left .-aero-iliae joint wliere it inter- sects tile iliojM'etineai line, to tlie opposite iliopeetineal emi- nence. Tlie ri«;ht oi)li([nc sprinjjjs from tlie I'iiiht, and the left ol)Ii(pie from the left, sacro-iiiac joint. Thay each mcasni'e Mi)ont 12.-") <'nK (5 inches). At the plane of the cavity: The notlcrojiosftrior lili(|iu;. 11.5 oni. (4.\ inches"!. 11.5 " (1.1 " ) 11.5 " (A] " ) TriinHVurHc. 12.5 cm. (5 inclieH). 11.5 " (li " ) ino " (-1 " ) Inclination of the pelvis: Tlio inclination (!'^i^. .*)()) of t lie plaiicof the jx'lvic brim lo the liori/.on, with tiu; \V(»nian in the erect po-ition, may hcstati'd ais tit'ty-tivc (Icjrrcos. Tiio inclina- tion of the jK'lvis, of conrso, (lilfcrs witli changes of postnrc. In the erect position tho ,syni[)liysis pubis is nearly !) cm. {l>\ inches) below the level of the promontory ; and the coccy.x is 2 cm. {'I inch) above the level of the lower border of the .•^vmj)hvsis pnbis, the pnbococcygeal line making an angle of ten degrees with the horizon. The Soft Parts of the Pelvic Canal. The lower sognu.nt of the nterns and the cervix form a part of the birth-canal ; while the nj)per segment is the chief sonrce of the j)roj)elling jxjwer. This portion of the soft parts has already been deserib(!d. Th(! soft partH irliirh luw- tlie houi/ ^x'/rifi and thos(> which contribute; to the formation of the pe/ricjfoor ai'e of great ob- .stetric importance. Tlie former diminish somewhat the diame- ters of the bony cavity ; the latter form the lower portion of the birth-canal. The psoas and iliacus muscles, which lie at the brim, dimin- ish the transverse diameter o^' this ])oi'ti()n of the ])elvis a quarter of an inch on either side, thus bringing this diameter down to about the size of the oblique diameter. The external iliac vessels run along the inner borders of these muscles, and the main trunk of the lumbar plexus fol- lows the course of the psoas, the crural nerve running between the psoas and iliaeus muscles. The obturator internus, which is but a thin muscle-sheet, covers ])ortion.s of the anterior and lateral walls and a j)art of tiie small .sciatic notch. Thus it practically covers the anterior inclined groove of the pelvis, and is by many thought to make the groove of but little value obstetrical ly. The pyriformis, which is a thin fan-shaped nuisele, lies a little over the edge, of the .sacrum and conipletely fills the great 72 OBSTETRIC ANATOMY. scijitio notcli, thus r()iitril)uting to the formation of the floor of the so-called posterior j)elvie groove. Tile anterior wall of the jx^lvis is not eovererises tlic soft structurL? which close the outlet of the bony pelvis. Its function is to support the pelvic viscera. Its upper limit is the peritoneum, its lower, the skin ; it is ])crforjited by the rectum, vagina, and urethra. Hart has divided the pelvic floor into two segments, as follows: the j)osterior vaginal Mall and the soft structures behind it constitute the mcvdl segment ; the anterior vaginal wall and the soft structures in front of it compose the pubia segment. In labor the ]>nbic segment is drawn uj)ward and the sacral segment is pushed downward and distended as the foetus descends. The resiliency of the sacral segment holds the fa?tal mass in close relation with the ischiopubic ran. i during the latter part of labor, and assists in its final expulsi )n. The pelvic floor when stretched by the fietus measures, from the tip of the sacrum to the anterior border of the ])ubic segment, about 5 inches (12.75 cm.). It is mainly com- posed of nniscles and fascia-. The muscles forming the pelvic floor are the levator ani, the sj)hincter ani, the transverse muscles of the perineum, and the sj)hineter vagimic. The levator ani nniscle, which is the most im|)()rtant, takes its origin from the posterior layer of the triangular ligament, TIIK SOFT PARTS OF xlIK I'FLVIC CANAL. 7;> from tlie spine of tlu? iscliimn, and from tlio wliole kinp:th of tlio "wliltc lino'"' (Fi^r. ^>,2).^ Those fibres wliieh arise from the puhes pass baeUward to \)v inserted into the last two {)ieees of tiie coccyx, and on Fig. 32. Drnwinji from ii iihot(inra])li of a dissectioti iiukIc nt tli<' I-oiifr l^liiiid College Ilnspital : 1, symiihysis : J, coccyx: :'., anus; 1, suiici licial (itiri's fiuin tlu' )aihic; oriuiii of the levator aiii : .">, deeiier titiics from the iniliic oriKin ; 'i. Iil>res from the " white line"; 7, tibres from ilu' .spine of the iseiiium ; ,s, gluteus maxinuis muscle, (iirownin^'.) tlu'ir way send fibres to tlic urethra, vajj^ina, and the internal sj)hineter ani, and a f • to unite with those of the opposite 74 OBSTETRIC A NA TOMl. side behind tiie anus. Tiiat jmrt arising from the " white line " and the rest of the line of origiii whieh forms the greater bulk of the musele, runs backward, downward, and inward to the side of the cocevx and lower end of the sacrum. I'he muscle thus forms a diaphragm with the concavity uj)ward. Fio. 33. (Coronal siM'tion of tlio jK-lvis: .1, ilium; 7', iscliiiiui : r, n(H't!il)\ilinii ; D, ]ts(ms miiKniis uiiisch^ ; K, ()))turntor interims : F, loviitor ani : (i, .sphincter ani oxtcrnus ; a, transvcrsiilis fascia : /), iliac fascia ; c, obturator fascia ; (/, " white line" ; e, recto- vesical fascia ; /, Aleoek's canal. (Browning.) The other muscles entering into the formation of the pelvic floor form a second layer thinner than that formed by the levator ani. They all meet at the (Central ])oint of the ])eri- neum. The fascia forming the pelvic floor is j)rol)ably a more THE SOFT PARTS OF THE PEE VIC CANAL. 75 iiiij)orlant clement ol)stetrically tliaii tlic- muscle layer. It iiia\' l)c (lcscril)e(l in two })()rtions, a parietal and a visceral layer (Fi^. -i-i). The parietal layer, wliieli is the less imj)()rtant, covers the iiiiiscles, paddiiiji: tiie sides of the j)clvis ; in front it forms the j)(»sterior layer of the; trianj>;ular liii:;ament, and is perforated hy the urethra and vagina; at the hack it helps to cover the sciatic notches. The visceral layer is continuous with the fascia covering the sides of the pelvis. J''rom its line of origin at the "white line" the visceral layer passes downward and inwai'd to the middle line, where its lihrcs fuse with the connective tissue at the hase of the bladder, the vagina, and the rectum, thus slinging thes(! striictinvs in the pelvis. On its lower surface is the levator ani muscle. The perineum may be defined as that portion of the body lying between the anus and the orifice of the vagina. Jt is formed by the perineal bod ij (Fig. '34), which is the aggrega- Fi(i. 34. TIh' cxtci'iml KC'iiitals, us seen in uicsjnl section; k. iiiius; /), pcriiifiil body; c, v,i','iu!i : (/, urctlira: r, Inliiinii minus;/, clitoris; ,7, fossil niivicularis, in front of wliicli is tiic liynicn. (Ucnle.) tion of the tissues lying between the rectum and vagina below their point of contact. On sectioji the perineal body is tri- angidar in outline and pyramidal in form. Its skin surface (base) from the anterior ))art of the amis to the i)osterior part of the vaginal orifice measures about 2.0 cm. (1 inch). 76 OBSTETRIC ANATOMY. The parturient axis : Tlio niatlicniatioal axis of the pel- vic canal is a line Avliich pierces eadi pelvic ])lane per- pendicularly at its central point. This axis is a curved line with its concavity for- ward, and re})resents very closely the course the fo'tal head follows in its descent through the pelvis in normal labor (Fig. ;i5). The axis of the brim if pro- longed would strike the tip of the coccyx below, above it would touch a j)oint on the abdomen near the umbil- icus. The axis of the bony outlet, if prolonged upward, would pass innnediately in front of the sacral promontory. The axu of the plane of the ndvo- vdc/iiKil rhicf at the moment when the head is exj)elled, is a line directed upward almost parallel with the lower part of the abdominal wall of the mother (Fig. 29). Hirst points out that the direction of the pelvic canal depends entirely on the curve of the sacrum, and that this Axis of the birUi-onnal : r, anus; ah, plnnc of outlet of conipleted canal; r, ))erpen(licular to plane or axis of ex- pulsion. differs in every pelvis. The Foetus. The third anatomical element concerned in labor is the body to be expelled. This consists of the whole ovum, viz., pla- centa, membranes, and foetus. The anatomy of the ])lacenta and membranes has already l)een described, therefore this section will be concerned with the footus only. THE FCETUS. 77 The mature foetus: At term the fn'tiis virdsiircs usually iH'tux'ou 40 and ol cni. (l(S-20 iuchos) iu Icu^^tli. Its irci(//il jivorages from 3150 to o21)0 grainmos (7-7| j)ouu(ls), uialos beint'" soiuewliat licavier than females. Not rarely ti>e weight may reach as high as 5400 grammes (12 j)()un(ls), the phe- nomenal weight of 9000 grammes (20 pounds) has been recorded. The hf'dd bears a much larger proportion to the trunk than in the adult. Its diameters are greater than those of any part of the trunk, and are more incompressible. It therefore offers the principal resistance to the passage of the child through the pelvis. In the mechanism of labor it is with the head that obstetric problems are mainly concerned. The icho/e bodij of the fcetus before and during labor forms a roughly ovoid mass. So long as the long diameter of the f(etal ovoid coincides as nearly as possible with the axis of the parturient canal the mechanism is a normal one. This is the case whichever extremity, head or breech, the fa'tus presents. The head : Obstetrically, the f:. 'J'lie (liniiK'tors of tlie fiutiil heiiil: O V, Mcci|iitofii)iital ; O B, i-ulxicciiiito- hrcjrniiitif: ; B 'J', c'c'rvicobreKiiuitio. The iiiaxiinuiii diiiiiR'tcr, (icci|iitomciital, is imiicati'il by the luiifj dotted urrow, Meusureineiits arc euiitiuictrcs. (Furubeuf iiml Vurnit;r.) Fi(i. 30. ^^^-"^ • ^^^V^ y/^ * >v^ / - ^ / 1 2? ^ i//^-^ \ ^ ^ \^ y KiiWKiiij,' (linmotiTS of the flexed liead : /' /', Hii)arietal diameter, '.M , cm. (After Faralieuf and N'ariiiur.j 80 ORSTETRKJ ANA TO MY. the piirictal and occipital hones, on cither side of the head, tiiere exists a small (jiiadrilateral t'oiitanclle. Fd/.se f()>itaii('//r.s are occasionally ohserved either in the hody of tlie hone or in the conrse of a sutnre. These are due to some defect in ossilication. A (|[uadrilateral false fon- FiG. 40. Vertex. Left occipitu-aiitcrior position. (Ribemont-Dessaigncs and Lepage.) ,7 tanelle is not infrequently to he felt in the line of the sagit- tal puture a .short distance from the usual small fontanelle. Obstetric landmarks: Certain landmarks ahout the Ja'ta/ head are of considerable obstetrical imj)ortance. The vericx is that portion of the head between the anterioi- THE F(ETUS. 81 and posterior fontanelles, and extending laterally to the parie- tal eminences. The orclpal is that portion of the iiead behind the posterior f'ontanelle. 'riu' slitcipiU is that portion of the head in front of the bregma. Fig, 41. Vertex. Right occipito-antcrior position. (Ribemont-Dessaignes and Lepage.) The (jlahcUa is the spaeo over the root of the nose and between the supra-orbital ridges. Five jirotuberant'e.H are j)resented by the cranial bones : The occipitdl profuhcnincc situated in the middle of the squamous ]K)rtion of the occipital bone about 2.5 cm. (1 inch) behind the ]K).sterior fontanelle. The jxirktal protubenmce is the boss or eminence in the centre of each parietal bone. 6— Obst. 82 OBSTETRIC A NA TOMY, The fronUil jjrotubercmce is tlie eniiiieiice in the centre of each frontal l)onc. Diameters of the foetal head : OcclpUofrontdl, extending from tlie ghihclla to the tip of tlie occij)ital protuberance ; 1 1.5 cm. (4^ inches) ; posterior end, Fig. 38, too high. Fig. 42. Vertex. Right occipito-posterior positijii. (Ribemoiit-Dessaignes and Lepage.) Occipitomental, extending from the tip of the occipital pro- tuberance to the centre of the chin. Mea.sures 14 cm. (5tV inches). The posterior end, Fig. 38, is too high. SuhoccipitohregmaiiCy extending from the junction of the neck and occiput to the centre of the bregma. Measures 9.5 cm. (3| inches). SubocGipitofrontal, extending from the junction of the neck THE FCETUS. 83 uikI occiput to the suininit of the brow. Measures 11 cm. (4jJ iuclies). ll'qturidal, measures through the ceutre of the parietal ('inineuces. Measures 9.0 cm. (3.^^ inclies). l-'r(m(<)iiH')it((l, exteiuliug from tlie sumuiit of the brow to the centre of the lower border of tlie chin. Measures U cm. (3,V inches). ^ ^ Fiu. 43. Vertex. Left occipito-posterior position. (Ribemont-Dessaigncs and Lepage.) Cervicobregmatic, extending from the junction of tlie neck and cliin to the centre of the bregma. Measures 9.5 cm. (3| inclies). The above diameters (Figs. 38 and 39) are all of them more or less compressible. The remainder are incompressible. Bimastoid, measured through the mastoid processes, 7 cm. (2f inches). 84 OBSTETRIC ANATOMY. Bimalary measured throiigli the malar eminences, 7 em. (2f inches). Ilitemporal, measured through the lower extremities of the coronal suture, 8 cm. (.'3^ inches). The follov^iufj tnhle is suiliciently accurate for all practical purposes and should be memorized : Fio. 44. Face. Loft mcnto-antorior poKition. (Farabeufand Varnier.) Diameters of the Foetal Head (Jeivett). Biparietal, 9 cm. (3^ inches) Suboccipitobregmatic, 9 cm. (3^ " ) Frontomental, 9 cm. (3| '' ) Occipitofrontal, 11.6 cm. (4^ " ) Occipitomental, 14 cm. (5^ " ) TIIJ'J V(ETUS. 85 In the followinf; taMo the circumferences of the most iin- jud-taiit planes of the f(et;il liead are ^Hven : Circumjerenvct* of tliv Phinca of the Fon, generally the one in rela- tion to the promontory, always slips nnder the other. The Fia. 47, Face. Lift •uentD-postcrior position. (Fiirabtnif and VariiiiT.) itwo halves of the frontal bone follow the same rule as the parietal hones. Thi! wliole volnme of the head is rediieed bv compression, tile greater j)oi'ti' ii of the cerebrospinal Hiiid and of tiie con- tents of th(! cerebral bloodvessels being forced out of the cranial cavity during labor. 88 OBSTETRIC ANATOMY. The foetal trunk : The (Jiameters of inij)()rtance in the trunk are few, as tlie whole body is very incompressible. The hi.s- (icroiaidl is the longest and measures 12 cm. (4| inches), and is reducible to tlie extent of 2 to 3 cm. The hitrnchfinteric measures about 10 cm. (4 inches). The dorsosternal measures 9 cm. (3| inches). Fi«. 48. Breech Left .sacroanterior position. (Farabouf and Varnier.) Thv f(')i(/th of the fcetal ovoid, that is, from the vertex to the breech, may be given as 24-24.5 cm. (9^ to 10 indies). Mobility of the foetal head and trunk : The movements of flexion, extension, and rotation of the JwUd hciid are of great imjmrtance in the mechanism of labor. Flexion is limited by the pressure of the chin upon the chest. THE FCETUS. 89 Extension is limited by compression of tlic oeeiput against tlie back. Jioddion is safe tiiroiigli an are of 90 decrees on each side, till the chin points over the shonlder. The trunk permits of a certain anionnt of rotation which is limited by the rotation of the vertebral bodies. A certain Fig. 49. Breech. Right sacro-anterior position. (Farabeuf ami Varnier.) ('('irree of lateral flexion is also possible as Avell as ordinary He.xion and extension. The posture of the fetns is the relation which the trnnk, head, and limbs of the child have to one another, independently of the relations of any part of the fa'tus to any part of the mother. The normal posture of the fcetus during pregnan(!y and 90 OBSTETRIC A NA TOMY. piirtnrition is one of Hexion, the liead heing flexed on tlie trunk, tlio tliiglis on the abdomen, and tlie legs on the tliiglis, the amis heing fohled on tlie ehest. The relation of the uterine and foetal axes : Dnring the lattei* part of pregnane}' and in partnrition the long axis of the i\vU\\ ovoid may eorresj)ond to the long axis of the uterus (longi- tudinal) J or may be at right angles to it (transverse). Fig. 60. lirioch. Kiglit sacro-posterior position. (Farubeuf and Vaniicr.) NontutJIji the long axes {'orresp')iid ; any deviation from this relationshij) leads to serious coinplie;itions i!i labor. ( ommonly, obstetrieians aj)j)ly tiie term presentation to denote the relation of the long axis of the fcetal ovoid to the uterine axis. In our opinion the use of this term to denot<' THE FCETUS. 91 this rolationsliip is a misnomer. The term prcficntation should onlv he used to denote tlie part of the lu'tus which presents at the' pelvic hrim and is accessible to the examining Hnger. Presentations: Under the definition just given there are three forms of fa;tal presentation : the ccplialicy i\\G iielvicy and Fi(i. 51. Bnccli. l.t'ft saiTu-ixisttTior jKisition. (Farabeuf and Varnicr.) the soiiKifir. There occur distinct varieties of each of these forms, as will be noted in the following table : T((b((' of Fa:ft) shoulder, (h) elbow, (c) hand. 02 OBSTETlilG ANA TOMY. Tlin hiftvr form of presentation is often termed transverse or crossed birth. Position: Tiie pelvic brim is divided l)y tlie conjugate and transverse diameters into Jour qtiddraiif.^. Position may be defined as the relationship of the presenting part of the fwtus to the quadrants of the pelvic brim. Thus for each presentu- Fio. 52. Shoulder. Left sonimlo-nntcrior jiositidn. (Farabeuf and Varnicr.) tion there arc four positions. They are named according to the ])articular quadrant confronted by the [)resenting ]wrt. In vertex, face, and breech presentations the long diameter of the presenting part engages in (.>ne of the oblique diameters of the pelvic inlet. In vertex presentations when the occiput confronts the left .V THE FCKTUS. 93 antorior quadrant of the pelvic brim, tlio pofiitlon is loft (K'oipit()-aiit(MMor, and so on. luii-c prcKcidiit'unin arc named similarly according to tlio direction of the chin, left niento-anterior, etc. Ilrcri'h ptu'soitdfions are named according to the position of the sacrum, left saero-anterior, etc. Fi(i. 53. Shnuldcr. Ri,i,'lit seai)nlf)-aiitori()r position. (Farabcuf luid Viiriiii'r.) >'^ho}dj)()sU'ri()r, \l. S, 1*. jjot't sacroposterior, L. H. P. Somatic or shoulder presentations : Left s('a|>iilo-ant(>rior, L. Sc. A. Ixiii'lit scapiilo-autcrior, R. Sc. A. Iiin of the centre of gravity of the fietus ; 2, the relative shapes of the uterus and of the f been obtained its alteration is not likely to occur provided no abnormal conditions are present. THE MECHANISM AND COURSE OF NORMAL LABOR. Definition : The term cutocia, indicating normal labor, is applied to labors which terminate \vithout artificial aid and without injury to the mother or child. Under this definition, in this work, only uncomplicated vertex presentations will be classed as normal. At this point it may be mentioned that a woman pregnant TUi: r.ir.s'/'.'.s' of the osset of lauor. \)7 I'lir tlic first time is ItTinod a jtrinilf/roridd ,- one in labor or in . ' the pncrjx'riuiM tor tiu' first linic, a inhiiijtitrd. ' It' a woman lias lia«l several cliildrcn or miscarriages pre- ij | viuiislv slie is termed a iiniffij» enstomary to divide hibor itself into three distinct sta«»'es : The first sfof/c, or stage of dilatation, ends with the fnll (lilatati(tn of the os nteri, with which the rnpture of the j membranes is usnally coincidctnt. The second sf(t(/c, or stage of expnlsion, ends with the complete birth of the child. 'J'lie third sttrual period. it is known that three motor centres exist which preside over uterine contractions; a centre in the medulla ; the cervi- cal ganglia; and the ganglia in the anterior vaginal wall and the uterine walls. Labor is not the result of the operation of one, but rather of a number of concurrent causes. These act In' increasing the painless rhythmic contractions of tiie uterus present thruugliout tlie whole period of pregnancy. 7— Obst. I i IMAGE EVALUATION TEST TARGET {MT-3) /. i// « :/- 's? 1.0 I.I 11.25 ■1° 1^ 1^ m 12.2 U Hi IS 110 U 11.6 Photographic Sdences Corporation 23 ?;:iT MAIN STREET WEiSTER.N.Y. 14580 (716) 872-4503 V y '^ <^ ^ -''-is ^ 98 THE MECHANISM AND COURSE OF NORMAL LABOR. The following are among the most probable causes :^ 1. Loosening attachment of the ovum, thus converting it into a foreign body ; 2. Excess of carbon dioxide in the blood ; 3. Distention of tiie uterus by the ovum ; 4. Mental impressions. 1. Loosening attachment of the ovum: It has l)eon observed that toward the end of pregnancy the trabecular in the spongy layer of the decidua vera decrease in size, causing this layer, as it were, to shrivel up, and thus easy separation of the ovum is permitted. Also slight hemorrhages, wh' h occur as tiie result of violent uterine contractions, tend to ' in detaching the ovum from tlie uterine walls. The ovum tnus becomes a foreign body and excites the uterus to further action. 2. Excess of carbon dioxide in tho blood: As the fwtsis develops it demands i«. nourishment, and there is at the same time an increase in its tissue-waste, M'hich includi-s carbon dioxide. This gas has been proved by Brown-Sequard to excite uterine action by stimulating the nerve-centres men- tioned above. Certain changes are supposed to take place in the placenta leading to an increase in the (juantity of carbon dioxide. When the venous blood has accunuilated a hufticient quantity of this gas, uterine contractions are stimulated to such an extent that labor is established. 3. Distention of the uterus: All hollow viscera when dis- tended to a certain limit contract and expel their contents. Witness the distention of the bladder, the rectum, and the overloaded stomach of the infant. 4. Mental impressions : The emotions play a large j)art fre- quently in inducing uterine contractions. (Jreat grief, joy, or severe fright experienced toward the end of ])regnaucy fre- quently precipitate labor. The Forces of Labor. The expellent forces of labor are : 1. Contractions of the uterus and of the vaginal and pel- vic muscles ; 2. Contractions of the abdominal nuiscles and diaphragm ; 3. Gravity. CONTRACTIONS OF THE UTERUS, ETC. 99 1. Contractions of the Uterus and of the Vaginal and Pelvic Muscles. Uterine Contractions, These are by far the most important factor in bringing •ihoiit the expulsion of the ovnm. riie contractions are involuntary, ocmrring iiuh'pcndcntly (.1" the woman's will ; tliough they nndonbtedly are weakened i\v even iidiibited by varions agents. Emotion, such as the (head of pain, or nervonsness caused by the entrance of the |(hv>ician or a stranger, may inhibit them. A loaded rectnm or a full bladder may reflexly inhibit nterine contractions. They are peristaltic, the wave of the contraction being from the fimdns to the cervix, and lasting from one-third to two- thirds the length of the labor pain. They are intermittent. The contraction begins gradnally, rapidly reaches an acme, and tlien slowly j)assos off. This may be demonstrated clinically by keeping the hand on the woman's abdwminal wall thronghont a contraction ; the nterns will be felt to harden gradnally ; then, remaining in this con- dition for a short interval, to relax and b,ecome soft again. Their duration averages abont one minnte. In the earliest stage of labor they occnpy but a few seconds ; bnt in the ex- pulsive stage they last longer and are stronger. The con- I pactions are rhythmical in their intermissions. There is a certain regnlarity in their appearance and disappearance. The i:i'<'ater their freqnency the longer their duration. At the l)('ginning of labor the interval is long, say a (piarter of an hour; toward the end the interval between the pains may be l»iit a few seconds, so that the contractions seem to be almost continuous. The contractions are painful, hence the term " pains " usually apjdied to them. This pain is due to the forcible ^•tictching of the cervix and its attachments, and of the vagina and vulva consecutively ; also in j>art to the fact that the uterus is contracting against resistance. A parallel to this latter occurs in the intestine when an obstruction exists. The pain is usually referred to the sacral region, especially in the earlier stages; later, when the sacral nerves are pressed U])on by the advance of the foetus, the pain is felt down the limbs. 100 THE MECHANISM AND COURSE OF NORMAL LABOR. | The individual musde-jihrcs of the uterus during contryction I become shorter and thicker than they are during relaxation. Retraction is a process peculiar probably to all involuntary muscle-fibres ; but is most marked in those of the uterus. Retraction enables a muscle-fibre which has shortened dur- ing contraction to relax without returning to its original length. The fibres after contraction do not quite return to their original length, but remain persistently somewhat shorter and thicker. Retraction is due in part also to a rearrangement of tlu; fibres. These are assumed at the beginning of labor to be nearly end to end ; in the course of retraction they come to lie almost side to side. J^etraction is practically limited during labor to the muscle-fibres forming the upper idcrine .scc/vwiif. This portion of the uterine wall as the ovum is ])ushed down becomes gradually thicker ; thus its propulsive force during contraction augments, and it is enabled to remain constantly in contact with the upper end of the ovum until its expulsion from this segment. The hnrer vtcrlne segment^ not possessing the power of retrac- tion, becomes progressively thinner and dilates as the ovum is forced down through it. Retraction thus enables the uterus to preserve the exj)ulsive results of contraction. Polarity is a useful term to express the fact that throughout labor the expelling part of the uterus — the up])er segment — is in a state of opposite function to the sphincter part — the lower se;z:ment and cervix. During ])regnancy the muscle forming the l)ody of tlic uterus is practically at rest, while the cervix, especially the internal os, is in a state of tonic ccmtraction, it is active. During labor this relation is inverted, the body contracts while the cervix is relaxed. This relation is takei advantage of when it is necessary to induce labor for any cause — that is, to set up active contractions in the muscle forming the body of the uterus. This is usually accomplished by dilating the cervix either manually or by instruments, which brings about the desired result. Effect of uterine contractions: In chaiH/hig the ,shapc (t)i(l ])<)f not alfected. Thus throuu;hout the whole of pre*;'nancy tiie circulation of blood in the uterus is assisted by the regular ihvthmical uterine contractions. Oh thcfivtal heart: The fcetal heart is slowed because the pressure on the placental site raises the general fetal blood- pressure. On the iiKifenHi/ pii/.se : The maternal j)ulse-rate increases ten to twenty beats, thus contrasting with the f(jetal pulse- rate. Vaf/iu((/ (did Pelvic 3fu.selefi. These muscles play but a very unimportant part in bring- ing about the expulsion of the ovum. They act only in the later stages. 2. Contraction of the Abdominal Muscles and Diaphragm. The muscles entering into the formation of the abdominal walls, along with the diaphragm, wh'Mi simultaneously in a state of contraction, increase the intra-abdominal j)ressure and thus render very important aid to the uterus. The?se muscles taken altogether form, as it were, a second layer of nuiscular ti--ue external to the uterus. Their mode of action is as follows : A deep ins|>iration is taken, thus flattening out and depressing the diaphragm, w hich is then fixed by the closure of the glottis ; then the muscles in the abdominal walls contract. The descent of the diaphragm pushes the fundus forward; this is resisted by the contraction of the muscles of the abdominal wall, so that the resultant of the combined pressure of these muscles is in the direction of the long axis of the uterus — that is, down- ward in the axis of the pelvic brim. 102 THE MECHANISM AND COURSE OF NORMAL LABOR. The action of tlioso muscles is not exerted until the second or expulsive sta<^e, and is at first entirely voluntary. Jn the later stages of the expulsive period their action is entirely involuntary. At first they act only during the acme of a ])ain, when the woman voluntarily hears down ; hut later, when the pain lasts longer, the woman is compelled to o})en the glottis to respire, thus I'elaxing the j)ressure ; hut innnediately another hreath is taken, they act again, so that there are often several abdominal contractions to one pain. 3. Gravity. The weight of the child and of the waters contained in the niemhranfts exerts but a small influence in ding ex- j)ulsion, except perhaps during the first stage of lauor, when the woman is more or less in the erect or semirecumbent position. LABOR— FIRST STAGE. Premonitory Signs and Symptoms of Labor. The events which indicate the approach of labor are varia- ble in their duration and may be so slight as (piite to escape observation. The change of position of the uterus which takes place during the last weeks of pregnancy has been referred to already. Irregular pains, usually felt low down in the abdomen in front, are frequently complained of by patients for some days before the onset of true labor. They are sometimes severe, and may cause nuich suffering to sensitive women. These "false pains," as they are termed, may be distinguished from true pains by their irregularity and by their site ; true labor-pains being felt chiefly in the sacral region. These false pains have absolutely no effect on the cervix, and no in- crease in the vaginal secretion accompanies them. Frequency of micturition and, less often, of defecation, niiiy be troublesome during the last few days, and are probably caused by increase in the nervous excitability of the pelvic structures usually present at this time. MECHANISM OF THE FIIiST STAGE. 10:3 Characteristic Signs and Symptoms of the Onset of Labor. Regular uterine contractions: Tlic interval iH'twccn tlu'se is loiiu' at first, but sliortcns steadily as the labor in-ourcsses. The j)alns at this period are always referred to the sacral rcnioii. Appearance of the "show": This is the term eonunonlv ;i|»]>lied to the imieiis tinged witii blood which escajx's IV( in the cervix and vagina at this time. The mnciis comes I hiclly from the cervix, and the blood fr(»m the separated -urfaces of the membranes and the uterine walls just above the internal os. Softening and shortening of the cervix : These changes can only be noticed by making a vaginal examination. The softening of the cervix is due to infiltration with serous exu- date resulting from the interference with the return circula- tion caused by the uterine contractions. 'I'he shortening of tlic cervix results from tlie yielding of the internal -os, whicii is undoubtedly a physiological relaxation analogous to that which takes place in sphincter nuiseles. Mechanism of the First Stage. The uterine contractions during this stage are occupied en- tirely with dilating the cervix, there being little or no expulsion of the ovum, this being limited to the slight advance of the i)a<:' of membranes throuii:!! the internal os. Dilatation of the cervix results from: (1) the yielding (.f tjic internal os, which is a physiological relaxation ; (2) the hydrostatic pressure of the bag of waters ; and (3) the action of the lomr muscular fibres in the outer muscle-laver of the uterus. 1. The first of these lias already been discussed. 2. The hydrostatic pressure of the bag of waters: The first result of uterine contraction is an i)i(')r((f(;Iizr one (iiiofhcr if: (I) the utei'ine wall were of e(|iial thickness throu(>l/i l/icsc coiHlifioiis fdif in that : Jir^f, the uterine wall is not of e([ual thickness throui;houl, the lower selace as a result of the increase in the general intra-uteriue fluid pressure. Afi (llf((f(ifion proeeedfi the membranes, having become loosened from their attachment to the uterine walls, insinuate themselves into the opening. Since the fluid within the mem- branes transmits the force of the uterine contraction ecpially in all directions, the bag of waters is distended laterally as well as downward, thus exerting an expansive action directly on the walls of the cervix, and finally on tiie margins of the external OS. As the cervix and external os dilate this lateral pressure of the bag of waters increases proportionately. 3. The action of the longitudinal muscle-fibres of the uterus : The contents of the uterus being practically incompressible, the [)ull of the longitudinal fibres will result in drawing the lower uterine segment and cervix, whoina. The (|iiMntity eseapinf waters. In these cases the lonM of the cervix not yet taken up may be felt as a soft apju'ndagc to the spherical surface of the (listended lower ])ole of the uterus. l*ossil)ly the external os may be sufficMcntly solt and dilated to j)ermit the insertion of the Hnger-tip. tinder the same circumstances in a inultipdrd the os may be quite patent long before the cervix is taken uj), so that the finger may easily be inserted into the uterus. Tnder these circumstances the only way to be certain of the extent of cervix still remain- ing to be taken up is to insert the linger till the membranes can })e felt, then, while withdrawing it making firm ])ressure on the ]X)stcrior wall, note the length of cervix before the mar- gin of the cxt(;rnal os is reached. Later, when the cervix is completely taken up, during a pain the sharp edges of the external os can be ^^'> COVllSE OF NORMAL LAIiOli. Till' most important |»art of the mcclianlsm is that rclatiiij^ to till" hctnl^ on account of its si/c and (ii<' incomprcssihility ol' its (liamt'tci's as co]nj)arc(l with tlic trnnk. The Head Movements. 'rhcs(> arc : descent; Hex ion ; int<'i'nal rotation; extension; and finally, after expulsion, I'csiilutiou or exlcrnal rotation. Descent: HesciMit of the head Ite^ins, as already nicntione*!, with the rupture of the membranes, or as sooi' as it (!onies into complete contact with the lower uterine segment, or os. It is (•(iii.scti hy the uterine contractions i-cinforced hy the action of the abdominal musch's and diaphra;j;m, and persists through- out this stage, r<'.sulting in the other movements about to be describetl. Flexion: Tlie position of the head is naturally one of par- tial tiexion, as it lies in the lower uterine segment at the ital than the sin- cipital pole. The head is so attached to the trnnk that its sincipital is longer than its occipital pole ; it corres})onds to a lever with unequal arms, the occipito-atlantoid articulation being the MECHASUiM OF THE SKCOM) STAdE. lUi) itivntal point, and the sin('ij)it:»l ^Ik' l(tn<; arm of tlie lovor. lIoiK'cllu' sincipital pole is nutro acted on by the resistance otl'ered to descent, \vi:ile tlie oc'cipital pole receives tlie iiiaxinmn pressnre iV(»ni al»ove (V\ix- '"'^J') linis is flexion prodneetiiiti(iii of ju'lvH' llnnr. Ki|u;itnr (if head about to jiiiss. (Farabeiif and \'iinii(.'r.) scends along one or otlier, as tlu; case may be, of the posterior grooves of the jH'lvis, and impinges on the pelvi<' floor beliind flic transverse line of the ])elvic outlet. Ivotation thus is longer, being through thre(!-eighths of a circle instead of one- ciglith, as in anterior positions. Thus the main (net or in causing rotation of the head is the icsistance ofllered by the pelvic floor. By the time the peri- neum is well distended rotation is completed and a portion of 112 THE MFCHANISM AND COURSE OF NORMAL LABOR. the liairv soalj) over the occiput is in view between the dis- tended labia. Extension : At the moment when tlie next movement, exten- sion, begins, the sagittal suture is directed anteroposteriorlv and the sinciput lies in the hollow of the sacrum. Descent goes on in this positioa until the occiput clears the lower border of the subpubic ligament, and the neck is ])ressed firmly against the back of the symphysis. The base of the occiput then pivots on the lower edge of the symphysis, and at each pain the head extends, stretching Fig. 59. Occiput rides u]> in front of symphysis. Pelvic floor retracts. (Fnrabeuf and Vnriiier.) the perineum and vulvar ring as it does so. Gradually the vertex, brow, and face successively glide from under the peri- neum, Avhich retracts over the chin and the head is born (Figs. 57-59). Restitution or external rotation: Directly after the head is born it resumes its usual relation to the shoulders, namelv, with its occi})itoniental diameter at a right angle to the bis- acromial. The shoulders enter the brim in the opposite oblique to CLIMCAL PHENOMESA OF THE SECOyD STAGE. 113 the iioml ; thus in L. O. A. position tlioy enter in tlie left ,,l)li(jiie diameter, and as tliey descend tiie ri^ht shoulder •uiiios to the front. Hence the head wiien it escapes from he vulva turns so tiiat tiie occiput points to the left side of lie mother, whicjj is the same position it occupied at the trim. This movement of the head is termed refit lint ion, and s of interest, as it indicates usually its primary position fur. GO). Fio. GO. I'd'tiil liead after restitution. Shows also caput succedaneum. (Ribemont- Dessaigues and Lepage.) Delivery of the Trunk. The anterior shoulder is, as a rule, arrested at the lower border of the symphysis, so that the })(>sterior passes over the |KM'inetmi and appears at the vulva first. After the po.sterior -houlder escajies the anterior descends and is delivered. The hips emerge with the bisiliac diameter in the anteroposterior position. Clinical Phenomena of the Second Stage. At the conclusion of tlie first stage the pains not infre- (|iiently cease for a time, and the more or less exhausted 8— Obst. 11-1 THE MECHANISM AND COURSE OF NORMAL LABOR. woman has a few moments of rest and possibly of sleep. Especially is this tlie case if ehlonil has been administered. The ])ains are more severe during the second stage and last longer; but the ])atient becomes more ]K)])el'nl as a rule, for she realizes tliat with each pain definite })rogress is being made. \Vlien the j)elvic floor is reached the perineniii begins to distend from the pressure of the head, and the sphincter ani relaxes, so that not infre((uently a (piantity ol' faecal matter or mucus esca})es from the anus. At this time the contractions of the abdominal muscles arc inxoluntary, and the patient is forced to strain down with each pain, holding her brcjath as she does so. As a rule, tiic woman grasps any support near by firndy w'th her hands and braces her feet, to assist her expulsive efforts. In the intervals between the pains she rests quietly and may fall asleep. When the vulvar ring is being distended the sutl'erintrs of the woman may become so intense as to result ii- a condition bordering on delirium. At this period tlu; head advances rapidly with each pain, coming plainly into view as it ole, so tiiat it is more (■;i-ily directed forward. Elongation: In L. C). A. and Ij. (). I*. j)ositions tiie clonga- ii(»ii of tiie head is -along a line joining the chin to the posterior upper angle of tlie right ])arietal hone. in K. C). A. and Iv. O. P. positions tiie elongation of the; head is along a line joining the chin to tiu; posterior upper iiiigle of tlie left })arietal bone. Tiiis deformity is accentuated by the capiif ,snc(r. Caput Succedaneum. Definition: The oaj)ut succedaneum is an o'dematous swell- ing which is developed on the |)resenting part in the course of hii'th, usually after ruj)tui"e of the membranes. The vessels of tlie presenting part become engorged during the pains, and serous exudatit)n takes place into that [)orti(»n of the fetal surface wliich escapes the pressure of the girdle of resistance. Its size varies with the degree of force producing it ; hence it is large in difficult and jirolonged labors. Its size is an indication of the degree of obstruction encountered by tiie flit us in its passage through the ju'lvis. Its location indicates the position in which the head has descended. In anterior positions it is situated on the posterior, and in the posterior positions on the anteri(U' asjiect of the siimniit of the head, in left positions it is on the rigiit ; and ill right ])ositions it is on the left of the median line. riie exact position of the caput may be modified if the iicad has been subjected to prolonged [iressure at the outlet or at the vulva. Anatomy of the Second Stage When the head is in tiie distended perineum the shoulders ii(! just within the dilated cervix. 116 THE MECHANISM AND COURSE OF NORMAL LABOR. The uterus has retracted on tliat part of the foetus remain- ing inside it. The differentiation between its upper and lower segments has become marked ; and if the hibor is a difficult one, the retraction-ring may l)e felt running obliquely across the uterus a sho"t distance above the ])ubes. The higher thi> ring is felt the more serious " , the obstruction which has been encountered by the f placenta will sli}) down sideways as detachment ^oes on, bcino- detached by the expulsive force of the uterine con- tiactions. As separation advances uterine vessels are torn across and -iii aiul tlu' (>« ; lieiioe this part is and fluid blood, these coming from the j)laeental site. After expulsion of the after- birth the uterus is found re- tracted and contracted to about the size of the fo'tal head. Its .size varies with the amount of retraction and with the size of the child. The position of the fundus immediately after labor is about half-way between the pubes an appl'v'ation of the antiseptic method to the man- agement of prirafc lliition, which blinds them to the fact that asepsis is more important tiian antisepsis. 'I'he j)h'ntifiil ns(! of soaj) and hot water accompanied by muscle and common sense would ij:reatlv reduce not ouK- mortalitv, but also morbiditv in obstetric work, even if anti- septics had never been heard of. The use of these agents should always precede the employ- ment of antisej)tics. Heat, eitijer dry or moist, is the most general and available germicide. All utensils employed about a jmerperal woman should ix- at least scalded thoroughly with liot water, and where j)ossi- ble should be boiled. All dressings or material A\hich it is intended to use as vulvar pads should be boiled or steamed before labor, and kept carefully wiappcd up until used. All instruments should be boiled for at least five minutes in a 1 per cent, soda solution, after which they may be placed in sterilized water. All water used in the labor-room should be boiled, and then kcj)t covered until wanted. In fact, cleanliness in all that ])ertains to the woman, not oidy during labor, but for two weeks subseciuently, is abso- lutely necessary if it is desired to have fever-free obstetric cases. In all details the method followed should be as simple as })ossible. Chemical Antiseptics. The most useful chemical germicides are mercuric chloride ; Cfwholic (icid ; and forma /i)i. Creolin, lysol, and permanganate of potassium are also very commonly employed in obstetric practice. It should be remembered that soap decomposes mercuric chloride and permanganate of potassium, rendering them inert ; that carbolic acid and permanganate of potassium are incom- THE OHSTETRIi IAN. 121 |)jitil)l<' ; tl'Jit nuTciirii! clilorido is deoonijioscd in tlic jncs- ciicc of albumin, f'ormiiiji; tlicivwltli an iiuTt allxinrmatc (it" iiicn'iiry. T/icrcJnrc wiioii tlic /atfcr is used in a solution for douciiinj;', it .-liould 1)0 conihincd with tartaric, acetic, <»r hy(ln»clil(tric acid in the proportion of live parts of the acid to one of I he iMercnrial. ("onvenienee and accuracy are secured hy nsini:: tablets ■ niit:iininpei' pro- |M»rlion of the acid. Sublimate solutions are used in strengths ,.f from 1 : 5000 to 1 : 500. Formalin solutions are now re|)lacinc home and a olii tion of atli, lu'lorc assimiiiin' cliarn'c (if a jtaticiit in lal)«»r. Her (.•Intliin^ slioiild !)(• alisolutcly clean, and .slic whoiilU wear \va>li-r duty t(t inform the physician of the fact In-foro taking charge of a case of labor. I)('foro attending to the vidva of the patient the inirse >ji(tiild sterilize her hands ihoronghly, and the process slionld he repeated each time she has occasion to cleanse the parts. The Patient. The aseptic preparation of the patient should begin weeks before the expected ('y'.s;/)ur/ r/<'(niflin,ss. .Any (li.scd.scd, (•(tiidUioufi of the rectnm, vulva, or bladtler should receive li'eatment. At the onset of labor the ])atient shoidd take a warm l)ath and then j)nt on clean linen. The lower bowel should bo (■in|»li('d by an enema. 'file nurse should then thoroughly scrub the lower part of the abdomen and thighs with green soap and hot N\ater, making use of a soft hand-brush, or a jute swab, for this pur- pose. The vuh'dr Jtair shouhl be cli])ped if it be too long. Then these parts should be washed with a warm solution (1:500) of formalin or of (1:2000) mercuric chloride. After the parts lure been dried ^vith an ase|)tic towel a sterile vulvar pad should be applied. The pad should be worn during the Hrsi and second stages of labor. The nurmal vaginal secretion of a pregnant woman has been j)roved to be germicidal ; therefore in normal cases no ante- partum vaginal injections shoidd be permitted. Xsthetie \\hen the pains are IK it >vell l)orne without it. The degree of ]>aiu Avhich some women can endure is wonderful, wiule in other cases the limit of endurance is soon reached. Ana>stiietics are usually indicated toward the end of the -ccond stage of labor. At the acme of expulsion surgical aiuesthesia should be induced, as a rule. Chloroform or ether may be employed. Chloroform is nciiei'ally ])referred, as the necessary quantity is less bulky, ,111(1 it is pleasanter to take. When partial auiesthesia is all that is desired chloroform is the more satisfactory ; but in cases requiring surgical auicsthesia for any length of time ether is undoubtedly the safer and the better. Chloroform is said to weaken, an, .iCrine contractions. Kthcr should not be employed when bronchitis is present, or when the patient is the sub- ject of atheroma. In eclampsia and tetanic contraction of the uterus chloro- form is to be preferred. Administration : In cases requiring only jHirfiaf (nia'.slhc.^id the administration can be entrusted to the nurse, acting under the physician's direction. A mask or folded towel is held over the patient's face, and at the approach of each pain the nurse is instructed to sprinkle a few drops upon it. It is well in all cases to smear the ])atient's face with a light coat- ing of vaseline, as the anaesthetic may occasionally fdl on -kin and cause considerable in'itation subsecpiently should tliis ])!'ecaution be overlooked. (are should also be taken to remove any false teeth before coiiunencing the a globular outline, which can be readily defined. The ])reecli, on the other hand, is soft and bulky, and its outline very difficult to define. Should tlie head of the fcetus occupy the pelvis in the nor- mal condition of flexion (Fig. 62), it \\'\\\ be noted that one hand is arrested above the brim, while the other sinks to a lower level before meeting with resistance. The part of the head wdiich is thus most accessible is tli(> brow. This condition is most marked in occipito[)osterior positions of the head. Hence if this fact be noted the posi- tion of the fcetus is pretty well indicated. If the head be located at the brim and the excavation of the pelvis not be accessible, it should be noted whether it is engaged — that is, fast in the brim — or whether it is movable. If the head be found to be freelv movable, an attempt should be made to engage it by })ressing it down- ward and backward in the axis of the pelvic inlet, and thus to estimate the relative proportions of these ])arts. The upper pole of the uterus is palpated by gras])ing tin fundus firmly between both hands, having the finger-tips di- rected toward the head of the mother. By thus steadying the MANAGEMEXT OF THE FIRST STAGE OF LABOR. 131 luiidus between tlie hands, by flexin^; tlie liiio;crs tlie ii|»i)er I < lit d pole can be palpate*! f<»r the ()sitions it is not ])(>ssibk' to feel the back, but in this case th(- lateral plane of the fietus can be felt ; it is narrower than tlie back, not convex, and the 132 THE MANAGEMENT OF NORMAL LABOR. shoulder can generally be located without difficulty. B\ making firm ])re.ssure downward on the fundus with one hand, the back, if directed to the front, can l)e more readily })al|)at('(l with the other. This pressure in the long axis of the f(etf!> increases the convexity of the dorsal plane and renders it more accessible. The limbs are felt as small nodules, knees, heels, elbows, etc., which slip about freely under the touch. If the small parts are muuerous and found near the middle line of the abdomen, a ])osterior position of the fcetus is indi- cated. Finding of the small parts in one section of the abdo men confirms the location of the dorsum in the opposite region ; thus small parts to the right indicate a left, and small parts to the left indicate a right position of the fcetus. Auscultation. Auscultation is best practised with the binaural stethoscope. It is a mistake to press the bell of the instrument firmly on the abdominal wall ; it should be allowed to rest lightly upon the skin, being steadied by the slightest touch of one finger on the cross-bar. The first object is to locate the point at which the fuetjil heart is heard with maximum intensity. The foetal heart-sounds are transmitted most loudly through the back, generally about the lower angle of the left fii't:il scapula. In antrriuv vertex presentatiovs the heart-sounds are hearliy,si('iiiii havini; coinplctcd tlio external cxatuiiiation i)i' tlu! patient, sIioiiUl tlieii ascertain the condition of tin N'lilva, the va fJic juifirnf in hcd, and /o si(tiiiii<)>i tJic pJii/sicidii when the membranes ruj)ture or on the occurrence of bearing-down pains. After an interval of two to four hours, should the mem- branes not have ruptured, a second vaginal examination may be ma kept III h('(l. Iler ordinary nij^ht-elothin;^ sliouhl he tt'rned up ;iiitai'(' in which she can secure the greatest j.mount of comfoiM, provided tiiere is no reason wliy slie shouhl he constantly ivcpt ill one; |)osition. She shouhl he enctoura^ed to hring all her expidsive ell'orts into operation, and to this end her feet may he hraced aj^ainst >oine oi)ject, and she may he allowed to assist herself hy either piillinij:: upon the hands of a hystander or on a sheet-slin(ene(l to the foot of the hed. I n rapid cases these measures shoidd he avoided, and the jKitient instructed not to hear down, hut to relax her muscles l)V sliort, pantiuij^ hrcathiiifj^ or hy cryin<^ out aloud duriui;; the ai-me of the uterine contractions, in this way too rapid dis- li'iition and rupture of the perineinn may ho avoided. The phvsician shouhl l)(> in (ionstunt attendance duriuii- this stai^e. 'Piiere is hut little occasion to maUe a vaginal examination when the second stage of lahor is eshU)lished. Should it he found that advance does not occur in spites of apparently good uterine action, then a vaginal examination should he made to ('-(ahlish if possihie the cause of delay ; hut frecpient examina- tions should he avoided. During the second stage an anaesthetic may be employey exerting ])ressure with this hand too early extension of the head can be prevented, and any of tlie soft structures of the pubic segment of the pelvic floor, whi'^^h may be caught in front of the occiput, can ' '\ pushed I)ack in the interval- between the pains and held out of the road, so as to j)ermit its early escape under the arch of the j^ubes. The fingers of the right hand are held on the 1ow(M' side ol" the vulva, and the thumb on the upper, while the palm covers the perineum. As the occiput escapes under the pubic arch pressure is .VAXAdl^MI^yT OF THE SECOND STAGE OF LABOR. 139 iiKulo witli tlio fiiii^crs and thumb of the right hand, so as to l»iisli the liead lorward, and at the same moment tlie left liand lii-mly iii;ras|)s it in order to moderate the rapidity of its eseaj)e ; I hen tiie right iiand is free to prevent the perineum slipping too raj)idly over the face. As the head escr^pes from the vulva it is well to have the nurse extend the lind)s of the patient somewhat, which movement results in a certain degree of relaxation of the perineum. Fig. 65. Protection of pelvic floor and delay of fietal head. (Davis.) With the hands placed as directed above to control the di- livery of the head, this exten.-;ion of the limbs interferes in no way with the physician's work. l)uring the moment of delivery the anjesthetic should l)i> j)ushed so as to induce surgical auicsthesia, in order to prevent any unexpected movement of the mother and also to spare her agonizing ])ain. Having delivered the head, the physician may now quickly cleanse his hands in the antiseptic solution before proceeding to 140 THE MANAGEMENT OF NORMAL LABOR. examine tlie neck of the child to see if it be encircled by the cord. Slioiild this he the case, lie may drawdown tlie cord and loosen tlie loop sutHciently eitlior to ])ass it over tlie child's head or to deliver tlie shoulders througii it ; if this be impossible, it must be tied, cut, and the chihl rapidly delivered. No effort for a couple of minutes should be made to deliver the shoulders after the head has been born, except when tlie labor has been lon«r and dillicult. Should they not advance, then the anterior shoulder should be rea(;hed if possible by passing two fingers over the dorsal surface till the arm is reached, when it is delivered by flexing the fingers, so that it moves over the chest. The physician should then j)lace his left hand over the fundus of the uterus, making firm j)ressure upon it, while at the same time with his right he ])ushes the head and body of the child forward toward the pubes as it escapes from the vulva. Immediate care of the child: The nurse should then take charge of the fundus, while the physician attenhysiological, borders so closely on the pathological that conditions of disease may very readily arise. rience during this period the woman is so beset with diffi- euhies and dangers that accidents and comj)licjitions are likely to occur unless she is guarded and cared for with knowledge and skill. Anatomy of the Parts Immediately After Labor. The Uterus. Position: This organ lies in an anteverted and anteflexed state with its fundus in contnct with the anterior abdominal wall. Its shape is usually an irregular ovoid. The upper uterine segment is thick-walled (1| inches, ."> to 4 em.), and is pale pink in color (m section. i'he lower uterine segment is separated from the upper by a well-marked line. Its walls being much thinner, are thrown into folds by the weight of the upper segment. »•». 144 THE pvebpehal state. The cervix can roughly be made out, its walls bein^^ rather thicker than the lower i^egnient. The lips are usually everted, resting on the posterior vaginal wall, and are flattened bv the weiijht of tiie uterus. The lower segment and cervix are much congested, and thus contrast with the bloodless body of the uterus. The placental site, which measures roughly 4 by 3 inches, has a ragged surface, and is somewhat elevated. It shows tli( openings of the sinuses tilled with clots. The area of the at- tachment of the membranes is paler in color and smoother tlitin the placental site. Shreds ofdecidua are scattered over the surface. The oaTity of the uterus measures 6 to 6^ inches (15 to ll! cm.) in length. The Vagina. It retains its usual shape, but is much distended. Its walls are thickened and their surface smooth and (edematous ; they also present more or leso evidence of contusion or abrasion. The Vulva. The vaginal orifice is stretched and torn to a variable degree. All the external parts are frequently somewhat bruised and lacerated, and may also present more or less cedema. The pelvic floor is greatly relaxed and not infrequently torn, the edges of the wound in this case gaping somewhat. The Bladder. This lies in its usual position, and is once more a pelvic organ. The Peritoneum and Broad Ligaments. The peritoneum over the body of the uterus is smooth ; but at the fiides and at Douglas's pouch it is thrown into folds. The broad Ugamcnts lie folded and to a certain extent compressctl between the body of the uterus and the pelvic walls. This compression of the broad ligaments must retard tlie circula- tion in the vessels contained in them, and so lessen the en- gorgement of the uterus. INVOLUTION. 145 The abdominal walls are relaxed and the skin usually thrown into folds and wrinkles. Physiology of the Puerperal Period Involution. The uterus : Imniodiately after the expulsion of the placenta the fun(his of the uterus may be felt about half-way between (he umbilicus and the pubes ; but in a short time, from one to -ix liours, it will be found to occupy a position at or slightly ;ilM)ve the umbilicus. The dilatation of the lower uterine seg- nuMit and cervix necessary to permit the passage of the child results in more or less com})lete loss of tone, so that the weight of the upper segment compresses them ; but as tone is re- trained they become capable of sup])orting the superimposed ueiglit and the fundus becomes elevated slightly. From this time the uterus diminishes rapidly in size, so that the fundus gradually sinks, and at the tenth day may be found at the level of the pelvic brim. Involution of the uterus ])roceeds most rapidly between the third and the twelfth day of the puerperal period. The uterus never quite returns to its virginal condition, its cavity in the parous woman being about half an inch longer than in the virgin. Changes in the muscle-cells : The firm contraction and retraction of the uterus, after labor, cut oil' its blood-supjily to a very considerable extent, and thus being deprived of nourishment the muscle-cells rapidly undergo fatty degenera- tion. At the same time a porticm of the cell-contents is con- verted into a peptone, which is absorbed into the blood and discharged through the kidneys. It is doubtful if anv cells are destroved in toto ; for Sjinger's observations prove that reduction of the uterus after labor is effected by a diminution in size of the individual cells and not by their destruction. Changes in the uterine vessels and nerves : The bloodvessels, lyinj)hatics, and nerves have all participated in the general uiowth during pregnancy. These all take on retrograde changes. The bloodvessels, which are closed by thrombi, are 10— Obst. 146 THE PUERPERAL STATE. coinprcsst'd, tliiis l)riii<::iii(i^ their walls in ajn)().sition. I'arth by ()r attached to tlu; chorion, and leaves behind on the uterine wall the lower cellular layer and the ^huuhdar portion. Diminished blood-suj)[)ly from uterine retraction soon results in loss <»f vitality in the lower portion of the decidu.i, fatty de'>;eueration and disinte^iation of the cell> rapidly ensue, and they are cast off in the loch'ud (Ji.scliaiyi . This pr()ci!ss soon lays bare the g;Iandular layer from which the new niu(!ous membrane ori<^inatcs. The epithelial cells ol' the glaiuhdar layer as well as the interglandular connective tissue rapidly proliferate and form the new mucous m- of clots, mucus, and quantities of harmless micro-organism-. It begins after the placenta has been delivered, and lasts from ten to fourteen days. Its character changes as the pnerperium advances. At first it mainly consists of pure blood mixed with cervical mucus and small clots — f/ic /ocliia nihrd. In two or three days it becomes paler and consists of serum and mucus — tlie (oc/iln serom. About the sixth day it becomes thicker and is choco- late colored ; but as the blood disappears and leucocytes become more abundant, it is white, having the ai)j)earauce of thin pus, which it practically is — the Inch'ui (ilba. Frequently when the patient first assumes the erect posture the lochia again becomes tinged more or less with blood. Its quantity was formerly greatly overestimated by Gassner, who gave it as about fifty ounces. Recently Giles, from care- ful measurement in a large number of cases, estimated the total quantity as being only ten and a half ounces. Its odor is peculiar. The lochia rubra has the odor of fresh blood; but later the mucus from the vulvar glands gives it a peculiar and somewhat penetrating odor. Practically the odor CJfANai'JS IN THE URINARY SYSTEM. 147 ii: IV he (Ic'fiiK'd as an a('iiitiircd, heal hy ^rannlation and cicatrization, occasionally leavinjz; extensive scars. The vagina rapidly becomes smaller and narrower; its walls from being smooth, gradually boeonie rngated though the nigjo are never so marked as in the nullipara. As the liyper- it'iiiia of the parts passes off, the vulva and vagina assnme more their previons color and proportions. Involntion also takes place in the uterine ligaments, ovaries and tubes, abdominal walls, and pelvic joints, all gradually returning more or less to their condition as before the occur- rence of pregnancy. Changes in the Circulatory System. Pulse : The pulse-rate shortly after labor falls to about 00, or even lower. The cause of this lies in the reduction of the ii'eiieral blood-pressure due to changes in the constitution of the blood and also to the ^!ii;is should he ( haiiired at least every three hours during the first twenty- lour; alter this as ol'teu as soiled, or three ov lour times daily. \Vheii the pad is removed the (.'Xternal genitals should he cleansed of lochia hy means of swabs dipped in a saturated -ohition of horic acid and s(pieeze(l dry, hefore a fresh dress- iui:' is applied. Alter thehed-pan has heen used the lips of the vulva should he o;('ntly sej)arated and a stream of warm horie-aeid solution poured over them from a doueh ha^ or small juti'. The parts >li()uld then he carefully drie A. m. to 10 \\ M. Tsuallv it is necessary to fjive one nursiuij: during the nijjht for the first six weeks. The imj)ortance of re^ulai'ity in nursinji; should bo impressed upon the iuother, for without re<:;ularity it is scarcely possible for mother or child to do well. ( )verfre(pie!it and irrciLcular nursing- deran»^es the infant's disxostion and imj)airs the (piality of the milk. The nipples should be cleansed with a saturated boric;- aeid solution, both before and after sucklinj;. In (lryin<»; the nij)})les only absorbent cotton or soft p;auze should be employed, and care should be taken not to rub them. Should they become icuilvr any antiseptic emollient may be aj)plied. The followinpi; makes a very satisfactory ointment for this purpose : 152 THE PUERPERAL .'TATE. 1|. Acid, boric, 3J ; Bisniiitli. subnit., Ol. ricini, da .5ss. — M. Ft. uiig. Sig. To be applied after nursing, and covered with a small square of white waxed paper. It may be necessary to us:' a well-fitting f/lnss nipple-shield for a short time, should the act of suckling give rise to irrita- tion of the nipples. Not infre(piently, usually in women with large, pendulous breasts, considerable discomfort, even amounting to pain, is suffered when the glands become distended with milk. In these cases a snugly fitting hredd-hinder will afford great ease and comfort. Either the Murphy or the Y binder may be employed. Contraindications to suckling : While suckling benefits the mother by promoting involution through refiex nervous ac- tion, and while there is certainly no food so suitable for the infant as mother's milk, there are still certain conditions which may render it unwise for the patient to nurse her child. A feeble state of health, tuberculosis, and persistent albu- minuria all contraindicatc suckling. The same applies to cases in which syphilis has been contracted late in pregnancy, for it is possible the child may have escaped infection. Inversion of the nipples, or severe and painful fissures, mastitis, or defective secretion, all act as contraindications of suckling. Nourishment: As the process of digestion is usually im paired during tlu; first days of the ])ucrperium, the diet at thi- period should consist chiefly of fluids. Milk, clear soup, gruel, cocoa, week tea, toast, stale bread, and soft-boiled e^^^i;^ may be permitted. After the third day a gradual return to the usual diet may be made. ISIalt liquors and wines may be permitted in small quantities if patients are accustomed to their use. Rest: Everything about the patient should be so disposed that she may obtain absolute mental and physical rest. It is not necessary, provided, uterine refraction he firm, for the patient to remain constantly on her back ; she may gently turn ,; CARE OF BREASTS, NURSINO, ETC. 153 over to one or other sido should she so desire. After tlit; jirst day she may l)e allowed to rise almost to the sittiu}^ i)(jses, eom- hiiied with caffeine cit., gr. ij, may be given. Shoidd the uterus remain lax and soft, involution mav be ])i(»nioted by friction of the fundus ten minutes two or three times daily, and a j)ill containing: ergot., gr. ij ; (piin. sulph., gr. ij ; strych. sulph., gr. -r^jj ; may be given twice or thrice in tiie twenty-four hours. After the fifth day a hot vaginal (louche, night and morning, may prove of value in this condi- tion. Visits of the physician : The first visit after labor should be made within twelve hours, and afterward one or two visits daily, as the case may require. While the patient may be allowed "out of bed " when once the uterus has become a |)('lvic organ, still she should continue under the physician's observation until fully convalescent. The nurse in charge of the case should record, morning and evening, the temperature, pulse, and respiration, as well as evacuations of the bowels and bladder, and the condition of the lochia. At each visit the physician should note the record of the pidse, temperature, respiration, etc. He should also exam- ine the condition of the uterus, the bladder (bearing in mind the danger of distention of the latter), the breasts and ni])ples, the skin, the digestive a])paratus, and the lochia. The bowel having been pretty well clearenrulent discharge. Deciduitis accompanying the develoj)ment of infectious dis- eases during ])regnancy usually results in abortion. This I'esult is j)rol)ably due to the hypertrophied mucosa, because of its vascularity, becoming the seat of an intense inflamma- tion and particij)ating in the eruj)tion which usually afi'ects the mucosa of the body in exanthemata. The treatment in these cases consists in controlling hemor- CHRONIC DECIDUAL ENDOMETlllTIi^. 155 rliage, favoring abortion, and attending to complications jis ihey arise. Chronic Decidual Endometritis. Occurrence : Chronic inflaniniation of tlie decidna is very Mtiiinion ; and is tiie canse of a vast majority of early alxn*- lions. Usually the inflammation of the endometrium ante- dates the pregnancy. Two forms are commonly observed, a chronic (liff'iD^c cndo- iiirfrili'S, or |)olypoid degeneration ; and a vulelv 1)V the fdetus, either as an excretion from the kidnev and skin or by a process peculiar to the amnion. Symptoms: As a rule, hydraninios does not develop before the fifth or sixth month of gestation, though it may occur as tiirly as the tentii week. Usually the first sign to attract the patient's attention is the undue enlargement of the abdomen, which is usually out of proportion to the period of pregnancy. Thus at the sixth month the uterus may reach the diaphragm. Tliis great distention gives rise to oHlenia of the lower limbs, |)alj)itation of the heart, and dyspnwa. Locomotion becomes (lilficult, the functions of the liver or kidnev may be inter- fered with, and icterus or albuminuria develop ; sleep may also be interfered with, and the patient becomes worn and haggard. On palpation the uterus is tense, and the ftetus, if felt, will he found preternaturally mobile ; while on auscultation the heart-sounds may be feeble or inaudible. Diagnosis : The condition is to be differentiated from twin })regnancy, ascites, and ovarian cysts, as follows : In tirin prcf/nant'i/ the enlargement of the abdomen begins earlier and not abruptly at about the sixth month ; the preter- natural mobility of the foetus is not present. Two fcetal heart- sounds in different ])arts of the abdomen may be heard. It may be possible to palj)ato two fcrtal heads and bodies. In ascifcs the symptoms of pregnancy are absent, but it is (|uite possible that both conditions may be present in the same case. On ])ercussion a dull note is obtained in the flanks, while the central portions of the abdomen are tympanitic. In hydraninios the dulness is in the central region of the abdomen whi'o th flanks are tympanitic. In ascites change in the patienr s position alters the location of the tympanitic areas. In ascites organic disease of the heart, liver, or kidneys Avill be found to exist. Ovarian cyst is to be distinguished by the history and ])hys- ieal signs; the growth is more gradual and longer in develop- ment. Menstruation is generally present. The fluid wave is 168 PAT no LOGY OF PREGNANCY. more pronounced. Xo fn'tal }>art.s can he palpated. A bimanual examination will permit tiie uterus to he differen- tiated from the tumor. The enlargement of the abdomen is not, as a rule, as symmetrical as in hydramnios. Prognosis: For the mother this is usually favorable, but probably one-fourth of the children are born dead or non- viable. The risk to the mother is increased by the tendency to malposition of the (ihild, by overdistention of the uterii> leading to changes in its stnu^ture which render hemorrhages during and subseciuent to labor more fre(|uent, and by the increased liabilitv to collapse following the sudden escape of fluid. Treatment: The abdomen may be su])ported by a properly fitting abdominal binder ; the patient should be kept at rest as much as possible. When the distention becomes extensive and serious symi)toms develop then the membranes should be ruptured. When this is done the li(pior amnii should be allowed to escape slowly and i)recautions should be taken to avoid syncope. Strychnine (gr. y^^) and fl. ext. of ergot (.^ j) should be administered after the placenta has been delivered, to insure good uterine contraction and to avoid the risks of post- partum hemorrhage. Other Affections of the Amnion. Amniotic bands : Karly in embryonal life should there not be sufficient liquor amnii ])resent to separate the amnion from the early formed skin of the embryo, adhesions may form between the skin and the amnion. As the anniiotic cavity becomes distended the adhesive material becomes stretched, finally forii:ing bands of greater or less length and thickness. Xo satisfactory theory has been advanced to explain the pathology of this condition. Braun regards the adhesions as resulting from folds of amnion, inflammation of the amnion being impossible, as it contains no bloodvessels. The bands thus formed result in producing grave defi)rm- ities in the fetus, such as eventration, anenceplialus, amputa- tion of the limbs, etc. The foetal cord mav be artificially shortened, or even completely severed by such amniotic bands. HYDATIDIFORM DEGENERATION OF CHORION. 159 Premature rupture of the amnion : Sovoral casos liavo beon imported wliorc later on in piv^nancy the amnion lias nnder- Moiie rnptnre and yet the intet2;rity of the ovnm has been pre- served by the ehorioii. The amnion in these eases is nsnallv toimd rolled nj)on itself and forming a sort of ontf abont the jilaeental en sot)n as a diagnosis is established. The patient should be aiiit'-theti/.ed, the os dilated, and the growth slowly removed, I lie hand only being used for this purpose. Should it be im- possible completely to clear the uterus in this way, then the l)hmt curette may be emi)loye(l ; but it must be borne in mind that the uterine wall mav be so thinned out in areas as to be vcrv easily ))enetrate(l. This shoidd be followed by a hot uterine doiiclu! and, if uterine retraction fails, the cavity of the uterus may be packed with iodoform or plain sterilized equally. Crescentic, or horseshoe placenta: This is a very rare form. Battledore placenta: In this form the cord is inserted at the margin of the placenta. Occasionally an accentuation of this form is seen, in which the vessels from the cord branch out before reaching the placenta — this is termed a velainentous insertion of the cord. Placentae succenturiatae : There may occasionally be found two or more distinct masses of placental tissue produced by the growth of isolated patches of chorionic villi. The vessels 11— Obst. 162 FATIWLoar OF PREGNANCr. of each patch course alon^ the inenihnines to unite with tljost going to the cord. In multiple pregnancies each chiUl may have its own placenta. Diseases of the Placenta. Calcareous degeneration of the placenta: Deposits of linn salts in the placenta are not nncommon. TJiese deposits only occur as tine sand-like ])articles, or as scales. Tiiey usnall\ occur at the edjjfes, though they may he found in the suhstaiKv of the cotyledons ; and consist of amorphous phosphate- and carbonates of lime and magnesia. They cannot be saiil to have any pathological significance. White infarctions: Yellowish or grayish masses of degener- ated placental tissue are to be found in nearly every pla(;ent;i. When small and few in number they have no pathological significance ; but if extensive, fietal death may result. Fatty degeneration of the })la(!enta may occur as the rcsiili of some local obstruction of blood su])ply to the parts affected. Small areas are commonly observed close to the margin of tlic placenta. If extensive degeneration occurs the function of the placenta may be interfered with and the fuetus perish. Placental Apoplexy. Definition : This is an eifusion of blood either within or l)o- hind the placenta. If it takes place before the third montli the effused blood may force its way between the loose attach- ments of the decidua and chorion and thus result in abortioD, a very common occurrence. Joncquemin described three well-marked forms of placental apoplexy as follows : (a) The effusion takes place directly into one or more placental cotyledons forming here and there small soft clots. (b) The effusion leads to destruction of portions of placenta forming irregular cavities which are surrounded by infiltrated and reddened areas. (c) The effusion may occupy a number of clearly defined irregular cavities of varying sizes, from millet seed to a pigeon's egg, which are not surrounded by areas of infiltra- PLACESTITIS. IQ'l ti(»n. In tlino these iij)()j)lo(!ti(^ areas lose their color, become denser, and form yellowish-white masses. Causes: IMacental ai)()i)l('xv is determined hy diseased states of either the maternal or the fo'tal strnetui'es enterini^ into the formation of the ])laeenta. Most eommonly the e;inse is niafcrnal in origin, as nephritis and allmminuria, which prodnee increased arterial tension and venons oon- -fc-tion. Ti-anmatism, as a hlow or kick nj)on the abdomen, iii;i\' produce it. Uarcly tiie cause lies in diseased conditions of the ffrtdl rill'i ieadiiii:: to rupture; Avhen the umbilical vessels are dis- eased, rupture ol' one or nu>re of their branches may result in exsauuuination of the f()r(ion or jiremature labor. Jf the effusion is large and the placenta situated low down, the blood niay dissect its \\;iv down to the os and escape, constituting (uridental lionov- rli/o//w/.s'/o» ot* some of till' al>dominal viseera into the sheath of the umhilieal cord is asionally met with. It is due to imjK'rfeet development ot' the alxlominal wall at the seat of the hernia. THE FCETUS. Anomalies and Monstrosities. Teratology, whieh is the seienee ])ertaining to f(etal malfor- mations and monstrosities, forms a special hrancrh of pathology, icferenco to which must he ha:ravc' cliaracter are usuallv associated with tlii- disease, the .-ubjccts of it are usually boni prematurely iimi scarcely ever survive the birth. Anasarca: General anasarca of the fcrtus Is occasionalK seen. The et>ndition is usually associated with collections ni fluid in the plem-al and abdominal cavities. The subjects (t this disease are usually born preniaturely and seldom sur\iv( . Ichthyosis: This disease is observed in two forms, tin grave and the mild. Thv, (/rare fonn is characterized by the existence over tin whole surface of the body of horny c])idermic plates separated from each other by fissures and furrows, and associated \\iili deformities of the face and extremities which lead to death of tlic infant soon after birth. '.'he iiu/d form is characterized by the presence of a col- lodion-like substance ovci the whole body of the fo'tus which later, by a process of descpiaination, forms into flakes. Jt i- usually associated with e(!tropion and eclabium. Jt does not. as a rule, prove fatal, but may ])ersist more or less throughoiii life, or mav terminate by complete cure. Witli regard to the |)er cent, of premature and stillbirtiis have tiicir cause in s\ j)liilis of one or both parents. Infectnn : The ovule may be diseased before impregnation, wliere the woman is a syphilitic. Infection may occur along with impregnation where the male is a syphilitic. Tiie ftctus mav become irfected at any period of intra-uterine life, should tlie mother contract syphilis while i)regnant. When the infection is directly paternal in origin, the syphilitic j)()ison may be conveyed from the fietus to the mother, and she may thus develop secondary symptoms of the disease witliout a primary lesion. It is undoubtess to O j ; an ointment composed of chloral hydrate, camj)hor, aa 3ss, ung. aq. rosre, ^ij, may give relief. In severe cases it may be necessary to aj)ply solutions of cocaine, 4 grains to the ounce, in order to obtain any relief. Vaginal leucorrhoea may be very troublesome during preg- nancy. In all cases where the discharge is profuse it should l)e examined for gonococci. Simple leucorrhoea usually yields 170 PA TIIOL G Y OF PREGNA NCY. to niikl antiseptic iistrinf»:eMt douclies which should be given with great care, c.(/., Coiidy's fluid, 5J to Oj. Shouhl (/onocorri he found in the vaginal discharge the treatment sliouid he energetic : hi(;]dori(le (1 : 2000) or perman- ganate of ))otassium (oj to Oj) douches should be given twice (laily, and an occasional a])j)lieation to the walls of the vagina and urethra of a solution of silver nitrate (gr. x-xx to 5J) will ])r()l)ably give good results. Vegetations of the vulva sometimes reach excessive size dur- ing pregnancy. Tiie iradmenf consists in washing with liquor sodie cidorinatic, afterward dusting with calomel, and keeping them perfectly dry. The Uterus. Tiiis organ may in pregnancy be displaced forward, back- ward, to either side, or downward. Retroversion of the Gravid Uterus. Causation : Tiie displacement is of frequent occurrence and may have existed before the onset of pregnancy ; or it may occur as the result of a fall or sudden jar. Anatomical results: As long as the uterus is less than foni- inches in length it may lie; across the axis of the pelvis. As its bulk and lengtii increases, it becomes too large for the pel- vis. \i upward movement be prevented by the projecting promontory incarceration occurs, and pressure symptoms begin to develop. Incarceration usually occurs about the end of the third or the beginning of the fourth month. The (lis tended fundus will on examination be found to occupy the hollow of the sacrum causing a bulging downward of the pos- terior vaginal wall, while the cervix is ])ressed upward and forward against the pubes, thus displacing the anterior vag- inal wall and urethra. The bladder is thus displaced upwaril. Tiie uterus may regain its normal position by growing u])ward in the direction of least resistance ; or it may remain incar- cerated and give rise to serious trouble. Symptoms : The earliest and most distinctive symptom is dysuria, accompanied by sensations of weight and bearing- i . I '■■■\ TREATMEXT OF RETROVERSION. 171 (|(t\vii pains. If tlio coiKlition bo overlooked or noj:;lecte(l the bladder symptoms become rapidly more marked. Ivetention ct' urine from pressure on the urethra brings about overdis- icntion of the bladder, and a more or less severe cystitis results. While the urinary symptoms are the most characteristic, ihc condition also skives rise to rectal tenesmus and obstinate (•i»Msti])ati()n. ( lOdcma of the vulva and of the uterine walls iiiav develop from interference \vith the pelvic circulation. Tli(> abdomen becomes distended and vomiting; may occur. Diagnosis : \\ here the retroversion is suspected the bladder must first be catheterized before makinu; a vaginal exanuna- tion. The condition will then be readily ascertained. The history of retention of urine and dribbling in a woman who has been pregnant for three or four months, the round (IdUghy-feeling mass occupying the vagina, and the position (if the cervix make the diagnosis conclusive. Tiie condition may be siDiuhtfcd by ectopic gestation, sub- involution of the uterus, intraperitoneal luematocele, uterine (ibroid, and ovarian cyst; but careful examination, if neces- MH-y, under an ana}sthetic, will clear up the diagnosis. Treatment of Retroversion. In mild cases the bladder having been catheterized and the jKiticnt placed in the knee-chest ])osition, the uterus can be i( placed by ju'essure upward on the fundus in the direction (if one or the other sacro-iliac joints, so as to avoid the promontory, two iingcrs being placed in the posterior vaginal iornix for this purj)ose. If necessary the cervix may at the same time be drawn down with a tenaculum. If the attempt succeeds, as it usually does, a large tam))on should be ])laced ill the posterior vaginal fornix to retain the uterus in position. Tliis may be replaced later by a large-sized pessary. If the attempt fails, the patient should be placed under ether and a second effort made to replace the uterus. In severe incarcerated cases there is occasionally great dif- Hculty in emptying the bladder. If, after drawing down the cervix with a tenaculum, the catheter fails to pass, then the l)laddcr must be aspirated by suprapubic puncture. If all 172 PATHOLOGY OF PREGNANCY. attempts at reduction fail, then abortion must be induced. If tlie cervix cannot lie reached for this purpose tluMi the uteriiu wall must be |)nncliired through the va_;inal hysterectomy may be necicssary in rare cases where suppuration or gangrene of the uterine wall has occurred. Prolapse of the Gravid Uterus. Causation: This condition may occur in the early months of ])regnancv as the result of accident or from violent strain- ing when the vaginal walls and outlet are greatly relaxed. Treatment consists in the replacement of the prolapsed organ and the adjustment of a perfectly fitting pessary to retain it. Endocervicitis ; Tumors. Endocervicitis : This condition is frequently found during ])regnancy. It may be the origin of a leucorrhooa and is fre- quently associated with hyperemesis. It is best irccded with ap])lications of fairly strong solutione of silver nitrate (gr. xx to 3 j) through a cylindrical speculum. The speculum is pushed up against the cervix and the solu- tion then jioured in and allowed to remain in contact for at least five minutes. Uterine fibroids and cancer usually com])licate labor more than pregnancy, and will therefore be dealt with under thai head. Diseases of the Breasts. Mammary abscess may occur during i)regnancy (see Disecms of Puerperal Period). Excessive secretion : Occasionally during the latter part of pregnancy the breasts secrete excessively, causing a serous flow which gives rise to considerable inconvenience. Appli- cations of belladonna may afford relief. Eczema of the nipples may require treatment, though the condition is very obstinate. s PTYALISM, OR SALIVATION. 173 DISEASES OF THE ALIMENTARY CANAL. Gingivitis is an unpleasant tliongh sonicwliat infrequont ailection of the pregnant woman. Tliis and other eon(litit)ns iibout to be mentioned are due, not so much to nncleanliness, ;is to an alteration in the seeretions of tiie Luecal eavity eon- -('(juent upon pregnancy. The (/nm.s l)eeome spongy and soft, p'd or violet in color at the margins, and occasionally ulcera- tion occurs. Pain on eating, foul breath, and bleeding are svmptoiAs of this condition. Treatment: Sometimes ain on swal- lowing; and the submaxillary and sublingual glands become swollen and tender. Treatment is most unsatisfactory in most cases. Co])ious rinsing of the mouth with wealc solutions of potassium cldor- ate, ash bark, cinchona, etc., may be employed. In tlie ex- 174 PATllOLOdY OF PREGNANCY, perience of the author, local measures afford but little if any relief. The condition is a ncnro.sis and nnist he treated ;i> such. Therefore chloral and sodium hrtimide in large do.se^ may be tried ; atr()|)in(! in doses of gr. ,,\^ t. i. d. may give re- lief. What rarely tails to give tenijyorary relief is morj)hiii( (gr. J) with atro])ine (gr. jlu)) ^^^^'^^ administered together give better results than either alone. Tiie latter nnist not be given as routine treatment, but oidy occasionally to permil rest and sleep, while the patient should always be kept in ignorance of what she is given in order to guard against tin formation of the morphine habit. Antij>yrin (gr. v, t. i. sia, gastritis, etc. (c) Too frequent sexual intercourse. (/) IMental or ))hysical shocks. {(f) Toxic conditions of the blood, urremia, saprfemia, etc. Recently I have advanced the view that probably the essen- tial exciting cause of the nausea and vomiting of pregnaiicv is the phjislological uterine contractions. It is well known that the uterus is subject to rhythmical contractions through- out the whole period of pregnancy. The purpose of thc-c contractions is probably the acceleration of the circulation of blood through the uterine sinuses. The enormous dilatation of the veins of the uterus which occurs as the result of preg- nancy brings about a retardation of the blood flow through them. As the result of contraction of the uterine muscuhir fil)res these sinuses become emptied of blood and thus the uterus may be said to supplement the action of the heart, to wdiich it may be compared, as its nervous supply is very simi- lar in arrangement. The nerve suj)ply of the uterus is chieHy derived from the ovarian and hypogastric plexuses of the I PERNICIOUS VOMlTISa OF I'liKGNANCy. 177 ,v\ iiijKitlu'tic systoin, wliicli to a limited cxti'iit have an iiulo- iKiidciit action ; while in tlie inethilhi there exists a eentre |iicsi(lin<:; (»vei' uterine contraction. The tle\(lo|>inent oi" the ciiihryo and its envelopes, as well as the hy|ter|»lasia (d'the uterus and its lining-, are accoiiijtanied by tremendous ehemi- (■;d changes. Jt is eertaiidy I'roni the venous sinuses at the itLicciital site that the embryo dei'ives its chi(!t' nourishment ;iii(l into which its efVete mateiMal is emptied. The ordinary circulation of the blood throut be a certain rcsiduiun, which, as it becomes surcharucd with ell'ete material, probably acts as an irritant and stimu- lates the uterus to contraction, and thus to a cerlain deoreo the orjj^an may be said to empty itself. It is tliese contractions, so brought about, which probably prtuMpitate the paroxysms of nausea and xomitiu^. UMie nausea is seldom constant, but is usually rhythmical in its occiu'rencc. As has already been stated it is usually most severe in the morninfi; when after a lou^ fast tiie patient as- siunes the erect ])osition. Jt is ])robable that the occurrence (»f the retching at tliis tiiue is due to the eu^'orlni«: table as jircdisjmxitif/ to pernieiiiijj: in (lit' iiioniiii^- the j)ati('iit sIkmiM tal\(' a ^lass of iced milk (»r somo li<»t clear coH'cc or wc;i|< tea. Ill sonic cases a t^lass of sherry and ii dry biscuit aiisw. r tlie purpose \-ery well. It is a g'ood |)lan to order small <(uaii(ities of plain food :it two-lioiir intervals dni'iii^ the day, instead of allowing ilsc patient three regular iiuals. If the nausea he trouhlesoinc the ])atieiit should he kept reclining as niiich as possihle, when the weather permits, out in the opt'ii air. (lose, wjiiiii I'oonis and tiuht clotliiii»i,' should he avoided, and atlentidii should he ^iven to the condition of the howels. \\ hen vom- iting; occurs only in the ni(»rnini; such uieasur<'s will euallc tho ]>atient to ])ass the day in comparative coml'ort. When vomitinii' takes |)Iace several times a day, some simiijc sedative mixture should he ordered, such as the followint>:: 1^. Sod. hrom., gr. xv ; Aq. camphorjc, ,5ss. — M. O Sig. t. i. d. "H l; Kifervescent hromocalTcine in drachm doses three or four times dailv often I'enders y^ood service. Iodine or carbolic acid in minim tloses, well diluted, may he tried. Patients who do not yield to the above treatment should he contined to bed. A thorough examination should be made to ascertain if any of the ))atliological conditions above enunur- ated as ])redisp()sing to hyj)eremesis gravidarum are present, and if so appro])riate treatment should be inaugurated. \\'here nothing can be discovered to account for the con- dition beyond pregnancy, the stomach should be given n rest and rectal alimentation resorted to. Predigested ini!k and eggs, nutrient broths, and beef peptonoids may be ad- ministered per rectum every six hours. The rectum should be washed out at least twice daily, nnd immediately afterward a pint of normal saline solution should be introduced by means of a catheter attached to the no/.zic of the syringe, high up into the bowel, in order to relieve the KTEiirs. 170 tiitiihic.'somc thirst wliu^li is usually ju'csciit iu tlicsc cax's. Tlio uutrit'iit cnt'iuata should lK'«:;iveu very slowly, ainl should inaT consist of more than live or six ounces. Twice daily an eui'Mia containinij; chloi'al hydrate. ( palliative. Laxatives, rest in ind, and the fre(|nent assumption of the knee-chest posture will afford i-elief. Locally, unir. ualke cum opio, or hot sunt. of all cases <»f pregnancy ; but it is probable that a far larger pro))ortion of cases liave some degree of icnal iii-ulli(!iency, though albumin may not be j)resent in the iii'iiic. Pathology: The kidneys are usually amemic, and ])resent evidences of fatty infdti'ation of the epithelial cell.- \\ilh(»ut intlammatory changes. Symptoms: The condition is not infreipiently met Avith in |)iiinij)ane. The symptoms usnally manifest themselves in the latti'M- half of the pi-cgnancy, and ai'c generally mild, ilcadaciie, j)allor, weakness, and slight shoriness of bi'cath arc usually the oidy subjective mainfestations. The irr'na is lessened in (piantity, is cleai", .ind its spc<'itic gravity is re- (liicrd ; it contains from a (pun'tcr to one-half its bulk of allHiinin, and a +'ew granular casts ; the albumin is mainly paraglobnlin. The >ircatient's sympt(»ms. Delivery is followed by diuresis, which is most marked from the third to the fifth day. Etiology: The cause of the condition is pi-obably a diminu- tion of the l)lood-sup|)ly due to inci'eascd inti'a abdominal tension ; and to irritation froir the excess of effete substances contained in the maternal blood. Treatment is as that ibr true nej)hritis. 182 PATHOLOGY OF PREGNANCY. Acute and Chronic Nephritis. Tliese diseases are more prone to occur during pregnane v oil account of the extra amount of work devolving upon the Uiduevs at tliis period. Tile symptoms are tlie same as in cases not complicated l.\- pivguaney. Differential diagnosis: It is not always easy to differentiiiio between the kidney of pregnancy and chronic nephritis; hiii the following ditferential signs may jirove of aid: History. Kidney of Pregnancy. Chronic Nephritis. Kidneys normal before Existed before pn^'- prej^nancy. nancy. Quantity of urine. About normal or slightly lessened. Increased. Specific gravity. Low. I.,ow. (Jasts. Few and only with severe Numerous and appiar symptoms. early in pregnancy. Retinitis. Absent. Very often present. Grave symptoms. Generally appear in later May be pronouncd months of pregnancy. in early months. Ceases with parturition. Persists after parturi- tion. Prognosis: Tlie possibility of complications renders tlio prognosis for the mother doubtful, while as regards the child it is decidcdlv s;rave on account of the tendencv to the forma- tion of })lacental infarctions. Premature interruption of tlie pregnancy is also of frecpient occurrence. Treatment: As it is important to know the condition of tlio kidncivs in jiregnancv, frecpient examinations of the urine should be made. Should evidences of renal insufficiency ))resent themselves, the patient should at once be placed u\^nn a dietetic and hygienic regimen. Meat should be excnidc*!, and the diet consist of milk and farinac;'oiis foods; lariic draughts of water, preferably Poland or lithia water, slioiiM be systematically taken. The patient should be guarded against fatigue and exposure to cold or damjmess. A saline laxative should be administered two or three times a week. (!'( DISEASES OF THE RESPIRATOIiY SYSTEM. 183 Should the (jiiantity of tl»o urine excreted not increase, and Icnia appear, the jjatient should then i)e placed on an ex- clusively milk diet and he put to l)ed ; a diuretic mixture should he ordered, such as Jkisham's mist, ferri et annnon. iiif'tatis, U. 8. P., in 5ss doses after meals. If un- taiued by avoiding tigh*^ clothing, and having the patient sleep with the head and shoulders elevated. Pneumonia is a disease much to be dreaded when complicated h\ pregnancy. The Hij^nptoms are always aggravated and the mortality for both mother and fictus is high. Phthisis pulmonalis : Pregnancy has a most unfavorable in- tliience on this disease. Rarely, patieiits sutfcring frouj j)hth- i-is seem to improve during pi'egnancy ; !)ut the disease only advances the more raj)idly after delivery has occurred. 184 PATHOLOGY OF PREGNANCY. AVomen alreiuly affected niul j)re(li.s[)osed to tuberculosis should he strongly advised against maternity. DISEASES OF THE CIRCULATORY SYSTEM. Cardiac diseases in pregnancy are not rare ; the danger of the heart lesions is increased by pregnancy ; abortion is api to occur from tiie formation of infarctions in the i)lacenta ; not infrequently the child is l)orn badly nourished. Tlic cotiiplications to be dreaded are failure of comjiensation due to fatty degeneration; and })ulnionary congestion. 1 1 compensation is good, no untoward symj)toms are likely to develo]), beyond fi'dema and albuminuria, the latter boiiiu due to renal congestion. Hirst states that witli proper treat- ment he has no fear of heart disease in pregnancy. Treatment: All women sutlei'ing from cardiac disease should be kept under constant observation tlu'oughout gesta- tion. The urine should be frecpiently examined. Sliould symptoms of failure of compensation arise, digitalis and stropiumthus should be exhibited, combined with strychnine ; the bowels should be kept open, and rest and moderate ex- ercise ordered. Hirst states that pregnancy should not be allowed to con- tinue longer than the thirty-sixth week in a woman who ex- hibits any symptoms of imperfect compensation. Cardiac diseases do not contraindicate the employment of ana?stiietics during labor. These benefit by preventing the injurious effects of straining and by quieting the action of the heart during parturition. Functional heart-murmurs in pregnancy : In the later montlis of pregnancy soft, I lowing murmurs can occasionally be heard, both over the mitral and aortic areas ; these are usually sys- tolic in rhvtiim, but mav also be diastolic. They mav he ex))lained by the hydrjcmic state of the blood in pregnancy, and may in ])art be due to a certain amount of displacemein of tlie organ resulting from overdistention of the abdomen. They disappear completely shortly after labor. The bloodvessels : Varicose conditions of the ven.. of the NEUROSES. 185 ixlvis, alKloniinal walls, and lower limbs are froquont during ])ii'j)hthalmic goitre pregnancy exerts a very inifavorable | influence. The growth of the gland may progress to such a \ degree as to cause pressure ui)on the trachea resulting in dysj)- | mea, and even threatening maternal death from asphyxia. In | rare cases tracheotomy has been resorted to in order to save \ the patient's life. | DISEASES OF THE NERVOUS SYSTEM. Neuralgia in various portions of the body is a fref|uent af- fection of the pregnant woman. The most common situations arc the head, hands, face, teeth, and breasts. Pelvic neuralgia is usually due to j)ressure of the growing uterus uj)on the j)elvic nerves; occasionally neuralgia occurs in the uterus. f n the frcdfiiinif of these troublesome neuralgias, tonics con- taining iron, fpiinine, and arsenic are j^articularly valuable. Attention should always be paid to tiie matter of diet, sleep, and the state of the emunctories in these cases. Any of the coal-tar derivatives, combined with the citrate of catfeine to prevent depression, usually ])romptly relieve the severe pain. All sources of local irritaticm should be sought for and re- moved. Neuroses. Chorea : Mild grades of chorea cannot be said to be uncom- mon in pregnancy. Chorea is more common in primipurge. 186 PATHOLOGY OF PREGNANCY. Rh(niinati.sni, clilorosis, lioredity, and tlio previous ocnurronr of tlu! disease in ciiildliood are considered as predisposing: causes. Jt usually a[)j)ears early in pregnancy and is a})t tu persist throughout its cronrse. As a rule, in the milder ca<(< it does not manifest itself dui'ing sleep. In the grave forin it may result in the j)atient's death, after causing preniatm ■ exjndsion of the ovum. The treatment is the same as when not complicated hy pr(>o nancy. Epilepsy is a rare complication of pregnancy. It does noi, as a rule, exert an uni'avorahle inlluence upon the course ol' gestation, and it can usually he controlled by the free admin- istration of ])otassium iodide. Hysteria is frequent during pregnancy. Vomiting and coughing occur as neuroses during pregnancy, and have already been referred to. Psychical disturbances : Not uncommonly a complete change in the disposition and mental character of the woman m:iy occur during j)rcgnancy. Insomnia may be ti'oublesome toward the close of j)regnancy. A warm bath on retiring, a glass of milk, or a cup of warm broth, taken at the same hour, may be sufficient to induce sleep; sidphonal or trional in 10- to 15 grain doses may he resorted to if recpiired. Insanity is of but rare occurrence during gestation, beiiiL: much more likely to develop during the puerperal ])erioil. jNIelancholia and mania are the more usual forms, the former being more frecpient. The j)rof/)i()sis in the maniacal form is more grave than in the melancholic. Insanitv mav recur in successive i)i'eu- nancies. It may be stated that gravidity exerts usually an unfavorable inHuence upon insanity. The treatment can only be expectant and symptomatic; in- duction of labor, when marked symptoms liave developed, only tends to aggravate the condition. Temporary delirium may occur during labor, and is far from common. A woman rendered delirious from acute suH'ering in labor may do serious injury to her child, for which she cannot be held responsible. INFECTIOUS DISEASES. 187 DISEASES OF THE CUTANEOUS SYSTEM. Herpes gestationis is a peculiar neurotic skin affection usu- ally met witii in early pregnancy. It generally ])ersists throughout gestati(»n in spite of treatnuMit. The eruption is iiiiiltitbrin, exhibiting erythema vesicles and hulhe. lis treat- ment consists in the administration of nerve sedatives and the 1. julation of the diet and mode of life of the patient. Impetigo herpetiformis is rare. It usually occurs toward the close of pregnancy. It generally locates itself in the folds of the body around the groins, the und)ilicus and axilla', and iiiider the mamnife. It occurs as small ])ustules forming crusts ; it tends to spread raj)idly and may cover the whole Ixxly. It is generally accomj)anied by marked syni])toms of -ystemic disturbance, high fever, chills, vomiting, and severe piostration. Hirst states that of twelve cases ten terminated iiitally. The disease did not terminate gestation prior to the maternal death. The ii-cidmeni is symptomatic, with the apj)lication of sooth- ing remedies locally. Pruritus is usually a local affection limited to the vulva ; i)nt it may occur as a general affection. It may cause intense siilfering to the patient, and eases have been reported in which it was necessary to induce labor in order to relieve the ])atient. Treatment consists in alkaline baths (o ounces of bicarbonate (if sodium to the bath), and frictions with sedative lotions, as the camphor or chloroform liniment. Usually this treatment must be combined with the internal administration of chloral aiifi bromide. Exaggerated pigmentation : Dark spots of ]iigmentntion may aj)j)ear on the breasts, thighs, and abdomen, and occasionally on the face. The condition is not amenable to treatment, and usually disappears shortly after labor. Infectious Diseases. Certain of the infectious diseases are more prone to attack the pregnant woman than are others. Variola is ])r»)bably the most virulent of the infectious dis- eases attacking the ])regnant woman. It generally results speedily in both fa'tal and maternal death. 188 PATHOLOGY O. PRKaNAydY. Scarlatina is upt to ho exocodiii^ly virulent, hut it is moiv prone to attack the puer|teral woiiiim. Measles in tiie prei>ii;uit woniaii usually assumes a s(,'vr'r( ty|)e and re tyi)e when it attacks the |)resia occurs without any premonitory syjiiptoms. The urine is diminished in (|uantity to from one-half to one- third the average in bealth. The K}>ccijic f/nirifii is very high, from 1030 to 1045 ; in rare eases it may be lower than nor- mal, 1010 ; and the cpiantity of urine undiminished. ECLAMPSIA. 189 Alhnmin is, :is ii rule, pivsciit in tlu iii-iiio in very lai'ara- 'jlitlmlin. riic presence ot" lai'ue <|iiantilies of serinn-alWuinin ill the urine indicates verv extensive dainatie to tlie renal ceils, i:i wiiieii case tiie j)r()n;n()sis is rendered more sei'ions. I'o distinguish the relative amoiuits of the two kinds of .illnunin, the urine nuist lirst he saturated w.th mairnesium -iilphate to precipitate the paraiilohidin. After lilterinu-, the liltrate mav be tested ior senmi-alhiunin i)v the niti'ic-acid or licat test. The j)recipitate obtained iVom the; filtrate may then be compared witli that thrown down by lieat oi* nitrlt; ;iiid in a spi'cimen w liich has not been satiM'uted with magne- siimi sulphate, and the dilference noted. rrca is, as a rule, largely diminished, not only in quantity, but also in })ercentag:e. ( '«.s/.s may or may not be found in the urine. LeiU'in and fi/rosiii, if sought for, will usually be found in the urine of eclamptics. The eclamptic fit usually begins with a fixed expression of the (yes, the hea(Ml-.-.ei'iini of e<'lain|)tics. It has l)een fonnd that in those oases tlie toxicity of the hh)od- siiiini is in inverse proportion to th<' toxicity of the urine. As to the formation of these toxins l)nt litth- is known. It is -iippi)S(!d by some that they originate chielly from the pres- ence of the fetus in tiie uterus ; hut the most generally ;i |)ti'd vi(i\v is tiiat they originate from the decomposition (if lood within the bowel. The liver probably |)lays an iin- |) iriaiit part in the destru(!tiou of the toxins, while the kid- iirxs and skin are chari:;e(l with tlieir elimination. It is a welbknown fact that the pregnant wotnan rarely ex- cntes a normil amount of urea. Urea is the most jjowcrfid (liiu'etic known, and it is probable that its function is to sli;iiidate the kidneys to the elimination of the toxins. I leiice wiien the urea is diminished the kidneys are (K'jU'ixed i)f rheir stimulus to th(^ excretion of these jioisons. The elfect of tin; elforts of the liver and the kidneys to break up and eliminate the toxins is to brin^ about certain chanu^es in their structure which exj)lain the presence of albumin, as well as of leu(;in and tyrosin, in the urine. Pathological Anatomy of Eclampsia. The kidneys : In most cases in which necropsies have permit- ted the examination of the kidneys, these oi'gans jircsented ma(n*oscopic evidences of cither acute or chronic nephritis, fii some cases the kidu(!ys have appeared |)erfectly healthy. But in all cases in which the kidneys ha\'e been microscopically cxamiiied, certain chano^es in the structure have been found \vlii(!h are not those of inflammation, but I'ather (»f deo('nei'a- tioii, and very similar to those changes associated with blood- poisoning. Phis ihyencrdflo)} seems to he of a colloid nature, and is ii>ually most marked in the epithelial cells of the tubules of th(! cortex. To the naked eye, kidneys which have under- i,^oiie this degeneration have very much the ap])earance of p:u'enchymatous ne])hritis, and it is only by means of the iiiieroscope that the true character of the change present can be made out. IMAGE EVALUATION TEST TARGET (MT-3) // 1.0 !i:l^ 1^ I.I UUi. 2.0 1.8 1.25 1.4 1.6 ^ 6" — ► Photographic Sciences Corporation 23 WEST MAIN C^REET WEBSTER, N.Y. MSCO (716) 872-4503 'o" .^ '^U ^ ^^ mi 102 rATiioiJxiY or vregnascy. Tims ill ('('laiiij)sia the Ic-idii prcsciit in tlic kidneys is iiDt ii(ij)liritis, but :iii acute (lenciieratioii due to toxins in tin- Mooil. The liver: I I(iuorriiau;es into the siiUstaiiee of tlie liver aii.' the most marke(l ehaiiu'c t(» he noted in these eases. 'I'hrv oeenr as dark-red stains or hlotehes, and may he very ( \- teiisive ; or so sliu'iit as only to he revealed hy the microsen|ic. JJetween the sites of the hemorrhau'es the liver-e(ll> >li(i\v either fatty ile can onlv re-iilr iVom severe c( ntaiiiination of the hlood. 'J'lie spleen presents, as a rule, veiy much the same chaiiurs as those fmnd in the liver. 'I'he lungs and brain u>i!ally show certain changes uliii h prohahly residt chieHy iVom the eonviilhioiis. Diagnosis. Eclampsia has to he distintiuished from coir idsioiis due to (?pilej)sy, hysteria, and oriranic hrain disease. The distiiietinii may he made by an examination of the urine. Prognosis of Eclampsia. Maternal mc/rtality is ahoiit ''^0 per cent., wliile tlie fn tal mortality is ahoiit oO j)er cent. The earlier in pret;naney tlie eclamj)ti(' condition occurs tli" worse is the proi»;no>is. Pro<2;nosis is favorable w hen : The attacks are infre(|ueiit and mild ; The ])atient reuains consciousness hetween the attacks ; Tlie skin, howels, and kidneys can he stimulate(l t(» func- tionate fi-eely. Proonosis is unfavorable when : riie attacks hecome j)rou;ressively more severe in spite 'il treatment ; The urine is completely suppressed, and j)iir(|uent examination of tlu^ urine, with special retrard to the (piantity secreted, the j)ercenta*re of urea and of aihuniin, and the presence and character of sediment. J 772^. 1 TMI'jy T OF I A 'L A MPSIA. 193 The hoicrfs jiinl shin slioiihl he kc))t active hv the internal aihl external use of water, and mild laxatives shonld be ciiiployed rcuiilarly it' n'(|uii'('d. The patient should he ordered a reailily oxidized and non- (iiDstipating diet, and outdoor exercise in moderation, and (lii-eeted to avoid i'.\j)Osure to cold and dampness. Medical treatment: Shonld the urea present in the urine t';i!l to 1.5 per cent., then treatnicnt shonld he inauixurated, as till- indicates renal inade' of calomel and soda, (7^7 gr. x, will be fdimd to stimidate the action of the liver. When this treatment fails to improve matters, the patient should he put to bed, and the diet limited to //////; as far ;is |)its>ii)l(>. The eliminative treatment already sufrgested may be iviiiforced hy the daily lavage of the <'olon with at least two iiiillons of noiMual salt solution at a temperature ot" 100° F. Till' pill of aloes and colocynth may he replaced by Epsom or Hochelle salts in these more serious cases. The kidneys being already overtaxed, the eni})loyi^ient of sliinulating diuretics should be a\iu'ing the convulsion administer chloroform, and also when- ever for any reason the patient is to be disturbed, shoidd it be fMimd that such disturbance tends to ]>recipitat(^ a convulsion. Then inject hypodernneally ext. veratr. viridis (ITlxv) and irive an enema containing chloral hydrate (.^j in four oinices nt' water), and place two drops of croton oil on the hack of the tengue. Have the patient's clothing entirely removed, and envelop her body in blaide with several dry ones. Then inject into the colon by means of a large-sized catheter attached to a fountain-syringe several ([uarts of warm saline solution. Where possible a 13— Obst. 194 PATHOLoar OF ruEaxAycy. pint or more of sterile saline solution should also l>e inject ( I under the breasts, using a large exploratory needle for tins purp;)sc. Should the convulsions recur and the j)atient be a fu!i- bloodcd, strong woman, a pint or more of l)l()od may Lm drawn by opening one or more of the large veins of the arii. The veratrum, in TTLv doses, may be injected at short inter\;il^ till the pulse is reduced to 70 ])er minute. The chloral cnena should be repeated every four hours, ])rovided the conditi .11 of the pulse is satisfactory. As soon as the patient can swallo" , dessertspoonful doses of a conct utrated solution of i^psoiu salt may be administered every fifteen minutes till the bow' Is are acting freely. The hot ])a(!ks should be renewed sut- ficiently often to keep up free dia})hore>is. The obstetrical treatment : When should ])regnancy be ti 1- minuted in those cases in which eclampsia i< thrcateiK il ? When, in spite of active treatment, the })atient's conditi 11 gets steadily worse, or where improvement is oidy trau>i( nt and relapses occur, the only safe course is to terminate the pregnancy. When eclampsia occurs during parturition interfereiK c with the progress of labor should be avoided until the (k is fairly well dilated. Accouchement force is to be cdii- demned, except in very rare instances. The convulsions mii~t first be combated, and as a rule labor comes on spontane(.Mi-l\ . It maybe terminated by forceps in order to j)revent its undnr prolongation, as soon as the os is moderately di'ated, the patient always being deeply anjesthctized for this pii'-oose. The after-treatment consists in keeping uj) free action •! the emunctories. Daily doses of Epsom salt should be givrii. The patient should be encouraged to drink large (juantities ul' cream of tartar water, oj to the pint. The diet should Kc limited to milk until the kidney condition has improMd. Heart tonics may be required, and none is better than str\ ( li- nine in full doses. ABORTION AND PREMATURE LABOR. Definition: Abortion is the term used to denote the exjtiil- sion of the ovum up to the end of the third month of i)icg- SYMPTOMS OF AliORTTOX. 195 nancv. Premafinr Uihor ,-in it the ovum hetweeii the fourth aud sixth months ol" prcj^- nanry. Frequency: It is iinpossii)le to estimate <'orr(>ctly the fre- (jiienoy of abortion ; hut it is ])rol)al)le that the ]>r(»|)ortion of ahortions is about one in every three or four pregnancies. Symptoms. The cardinal symptoms of abortion are, )Hi'n\, Ji(iiion'}i(i(/i\ ami the expulsion of tlu; ovinn. The pain is due to uterine (untraetions ; anf a painful and rather ])rofuse menstruation. Siicli it is often supposed to be by the patient. In some cases tlic uterine colic may be so severe as to cause V(»miting or nei-- viuis eiiills ; the o\'i ni usually passes unnoticed with blood- clnts. On bimanual examination the uterus will be foui.d enlarged and the os more or less patulous. When the abor- tinii is not complete fragments of the ovum may be I'elt vithin the cervix. At the third month, which is the most common period for ahtirtion, the process generally occurs in two stages : first, the exjMilsion of the fo'tus ; and second, the expulsicm of the n(n\ ly formed placenta and membranes. The ])rocess is more pfulonged and more painful than in the earlier months. In )iimp cijfni and severe emotional distiirliancis iiiav j)ro(iuce aWoi'tion. ( 'eiMain diai^s, a> (piinine, savin, erixot, Mini a host of others, are said to canse abortion ; hnt it is (l.iihtfid if this is the case when the nterns is in a normal (Miidition. Li)C((l : J)isj)lacei!ients of the nterns, pelvic inflammations (.1 adhesions, cervical lacerations, endometritis, nieti-itis, filiro- iiivomata, and abnormal development of the nti'nis may be mentioned as conditions which predispose to abortion. fhore are women who abort constantly in whom no reasoii- ;il'le cause can be tbund ; to this condition the term ''' hdhihatl iih'iiilnii " is applied. Foetal: Svj)hilis, which acts by j)rodnciniji: chano;es in the ovum or in the placenta, leadinir to the death of the lietus, is jn'obablv the n)ost common lo'tal cause of al)oi'tion. DeiTcneration of the chorion, hydramnios, and vicious inser- tion of the placenta fre(piently result in abortion. Diagnosis. In caocs of suspected abortion it is necessary to detennino tlie existence of |)i'en;ii;incy. The abortion may be flirr(ifr)n(l ; (inrifdh/c; or wholly, or |>ai'tially arconijt/is/Kd. Threatened abortion: If the patient h:is been exposed to the j)o-sibility of impreu'iiation and the menses jiave be<'n suj)- |»i-cs>ed ; if a hemorrhage from the uteiMis occur, associated with more or less pain ; then it is j)robable that an abortion is thi'catened. nysmenorrh'ca may be mistaken for ifn|)endinu^ abortion ; hut in this case the cervix is clos(>d and firm to the feel. Ilcinorrhau'c, associated with the j)resence of a stiff jto/i/jtoiil I'ltiinr ill the uterus, may simulate the condition of tlir<'at- cin'd abortion very closely ; but a careful local (examination w ill uenerally establish the nature of the condition ])resent. Inevitable abortion: When the membranes have ruptured, or tlie fetus is dead, or wluMi any fetal part is enpi^ed in the cer- vix, the abortion may be said to be iiirvifdh/c. Cases have iHciirred in which large portions of decidua have escaped from 15J8 VATllOUHiY OF I'RIJuyAyCY. tlio uterus, associated witli eouslderable lieinorrlia^e, nud vr i have ;tfter\\ar]acenta are followed bv decomposition of these sid)stanei's in iitero, and acute or ciironic septic infectio!i is the result. Hemorrhage very rarely leads to a fatal result in eases nt' abortion. When neglected, abortion may be the starting-point of vaii- ous uterine diseases, as subinvolution, metritis, etc., whidi may lead to invalidism. Treatment of Abortion. Prophylactic : When any of the conditions are present whicli may tend to premature expulsion of the ovum, all precaution- TllEATMEST OF AnoRTinN. li><> I , list 1)C takon to provont siu-Ii an accident. Ai)i)r<)|)riatc --tcniic treatment should he imdertakeii wlien indicated, and ; the same time the patient slionhl he instrncted to (fhsei ve -jicciid precantions, snch as the avoiihmce of o\'ei-e.\ertion \triire for the patient ahsolute I'cst, mental and physical. This is obtained hy puttini:' her to bed, in a cool, darkened ii II iin, where she can he ke|)t in ahsolute (juietne.ss ; and hy till' free use; of opium, hro: lide, and chloral. (J|)ium is hest admini,->tered hy the rectum. A supjxisitory cniitaining ()j)inm, gr. ss, should he gently inserted every eight ii.iiu's, or at least sunieiently often to kecj) the patient well under the in(luence of the drug. At tiie same time a ndxture (•(intnining sodium hromide, gr. xxx, and chloral hydrate, gr. x\ , Uiay he given three times daily. Many |)i-efer the lluid extract of vihurnum prunif(»lium in drachm doses, t. i. d., iii-tead of the hromide and ciiloral nuxture. Inevitable abortion : 'I'wo methods of treatment are avail- ;iMe, the cxj)ectant and the active: The expectant treatment: Should tlie hleeding he severe hefoi-e the OS is dilated, it must he c(»ntrolled hy means of a vnginal tanijmn of sterile or iodoform gauze. To apply va- Liiiinl tamponage pi'operly the ])atient should he ])laced in the let'i semiprone ))osition, with the hi|)s resting on a ruhher >lieet or Kelly jiad at the edge of the hed. '1 he vulva and v.iuina should then he waslied with s])irits of green soap and liut water, and tlien swahhed with a 1 : oOO formalin solution. It' the vulvar hair is long, it should he clij)ped. The only iii-truments recpiired are a Sims speculum, a pair of uterine rnivej)s, and a |)air of scissors, wliich may be sterilized wliile the patient is being pre))ared. riie sj)eeulum is then inserted and the perineum reti'acted so as to expose tlie cervix to view. A strip of gauze (sterile 200 PATUOiJK'.Y OF PIlF.dNASCY. or iodoform), about two indies wide and a yard lon<;, is then seized ai>ove hy means of tlie uterine forceps and |>ael<(il lirndy around tlie .ervix. As the j^au/e is beinjj: inserted tin speeulnni is gradually withdrawn. A snilieient (piantity u\ \f\\\\/.v. siiouhl be inti'o(hi(!ed to distend tlie vagina. IIm patient is then made eomfoi-tal»l(!, and should remain in bed, '1\) facilitate tlie emptyiiiu:; of the uterus, the lluid extract (•! eru:ot may be administered in hall-drachm doses three tim< - daily. If the uterine eontraetioiis are |)aiiiful, an opiate ma\ i)e combined with the erj^ot. The vauiual tampon should l>r renioveHtient'> temperature. Often when the first tamjum is removed tli. ovum comes with it, or tlu; cervix will be found softened and tlu; OS sufficiently dilated to permit the intn»(hietion of the finjrcr, with which the ovum may be extracted. If the o\ iim rupture and a |)art be rettiiiied in the uterus, the woman must 1)0 kept in bed, the eri!;ot continued, and the vagina (hiily douched with a solution of formalin, 1 : oOO. In many cases this treatment will be sufficient; but in spite oC eveiv ])recaution the discliarires may become foul and the tempera- ture rise, in which case the uterine cavity must be tlioroui;lily curetted. Active treatment : This is the treatment to be reeomnuMidcfl, in preference to the exj)ectant plan, in the larixe )>roportion <>r cases. The va<;inal tampon may be eni])loyed, as recommended above. If at the end of twenty-four hours the os is lu-t ])atid()us, the patient should be antesthetized, and the cer\ i\ dilated with Il"u:ar's or Barnes's dilators, and the uteiii> emptied, as recommended i)elow. As soon as the os is sufficiently dilated to permit the intrn- ducti(;.i of the for(^Hn<>^<>r the ovum should be nvept out ami the decidua or placenta removed by scrapin<>:. The forefiniici' of the rii^ht hand is the best instrument for tl s purpose. It can be made to reach all parts of the uterus, with the assist- ance of the left hand pressing on the fundus tliroui>h the abdominal wall. When the secundines cannot all be removed in this manner the interior of the uterus may be pMitlv scraped with a blunt curette. In all cases, after emptyiuir tlie uterus its cavity should be thoroughly douched with i>laiii MISSED LABOR. 201 -toriIi/o(l wjitor or formalin solution, ux'd hot. l-'or (his pur- [lose the Frits('h-l)o/.('m;ui uterine catheter is l»y lar the l>e~t iiistninient. The I*]Mimet :'iirette fltn-eps will he loiind (n l>e ;i verv valnahle adjuvant to the etirette in reinovini; shreds Iroin the uterine cavity. After-treatment of abortion: 'I'he woman shoidd hi- Ue|»t iu hed for at least a week or ten days, the temperature should he watched, and, ii' necessary, a|)|)i't»|>riate treatment to prevent die onset of lactation should he ap[)lied. Missed Abortion. It occasionally happens that the fictus jierishes, symptoms (il inipendin;; alxtrtion develop only to roduet of conception is retained in utero for months, or even years. The fiit>ial)ly al)out oii. < ill o(K) cases of |»re^iiaiicy. Varieties: 'I here are //wee priiiKiri/ Jonus of rcfojtic (jtsfit- ti(jii : (1) hihiil ; ['!) nrtii-ifiii ; and (.'i) dhdoviiiid/. Many authorities classily the \arious terminations of tlie>( primary forms of ectopic gestation as .scccnidfiri/ fonns^ earli heiiiij: (K'xi^nated accordiiio' to tlie location of the disj)lae((i ovum. Tlu! term "secondary" as thus empioyed simpK means siiffscfjiiciif to nijifm-r or dis])laeement. AV'hilo |)riniary ovarian and alxlominal ]>ref2iiaiicies (|m occur, they are iindoiihtedly extremely rare, and are dilliciih of ahsol'.ite demonstration ] as a general rule, ectoj)ic gestation- are filfxl/. Tubal pregnancies are classified according to the site of the attachment of the ovum, .'is: (1) / iifcrsf/fia/ when the o\'um develops in that ))'>rtion ol' the tnhe which j)asscs through the Mall of the utei'U, , or in a diverticulum '>^' this ])ortion of" the tiihe. (2) True tiifxi/, or amj)ullar, when the ovum develops in the free portion of the tube. (.')) Iiif'ini(li/)ii/(ir when the ovum develops in the infiindili- uliim of the tube, and j)revents the closure of the td)doniinal ostium. Cases of this varietv are also termed fitbo-ordrtcii. Terminations of Ectopic Gestation. Interstitial pregnancies usually terminate al)out the thinl month by rupture into tlie j)eritoneal sac. The patient g( ii- erallv succumhs to hemorrhage and slioek. Ivuptni'e into tin- uterine cavity, with ex])ulsion of the fcetiis through the c(>rvi.\. is possible, as is also rupture into the base of the broad liga- ments. True tubal pregnancies terminate by rupture cither (<() u\)- ward into the abdominal cavity, or (l>) downward ')etwc( n the layers of the broad ligament. When the rupture occurs TKIiMIXATI(L\S OF hCTOl'lC (U-.STATION. 20;] lih the ahtloininal ravUtj tlu> licinonliM^o Is usually severe, iiml may l)e fatal in from sixteen hours to three or four days. When rn[)tnre occurs early and the heniorrhap' is not severe, tiie fu'tus ujav bo ahsorlied, as the enihrvonic; sac; usually I iptures at the sanie time as the tuhe. When the ruj»ture occurs (loinniuird, between the layers ol' till' broad li»;ainent, the ovum may perish and all trace ol" it (li*ap|tear, while; the blood eit'used may be i-etained, Ibrmini; a p 'Ivic hiemato(;el(;. The ovum may develop ibi' a time, ami then burst into the peritoneal cavity, or continue to full term liv slrii)pin<^ the; peritoneum I'rom thi' pelvic wall as it en- l;u'ixcs. In either ease the ovum develops tor a tim<' and then perishes, and is either absorbed or macerated, when it iiKiv ulcerate throu<^h i' ^o the bow(;l, bladder, or vagina, and ('-(■ape. In still other cases the gestation-sac may undergo putrel'ac- tinii from access of bacteria from tlu; bowel, and be converted iiiio a broad ligament ab'.cess, which may rupture into the jH'ritoneal cavity, or into the bladder, rectum, or vagina. In other cases the f(etus aft( r death mav be conveiMed into a liiliopicdion or may be mummilied, and thus remain for ycai's. Infundibular pregnancies may either rupture into the perito- neal cavity or develop to full term. Ovarian pregnancies may terminate by rupture of the sac and profuse hemorrhage; or arrest of (h'velopment may occur at an early period and the sac remain a cvstic tumor. Advance to ftdl term is j)ossible, but not ))robable. Abdominal pregnancies may advance to full term ; or the sue may rupture early, and the fetus be either absorbed or mummify. Tubal abortion : This term is aj)plied to a certain rare con- dition in which blood is effused into the ovum, destroying it and its attachments to the tube-walls. The ovum may re- main as a inlxil mo/c, forming a solid tumor of the tube ; or it may esca))e with the blood from the timbriated extremity of the tube into the abdominal cavity. 204 PATIIOLOUY OF rEKGNAiWY. Etiology of Ectopic Gestation. As has been stati'd, tlio ovum usually Ix'conu's iuipro^- natcd while still in the l''all(»j)ian tuhc. 1 1' the tube is in a iiornial coiKliliou. tlio iinprcjiiiatcd oviiiu is uiovcd alou.; il iiniil it liuds its rcstiun-jdacc iu the titcriuc cavitv. It i- th(!i"etoro pi'ohahlc thai the most important liictor iu pfodiR-iiiM eciojtiir *iC'statiou is some abnormal condition of the tubes. Sueh abnormal conditions may arise either from liiflnut- i.Ktlioii of the tissues of the tubes or from |»arametrilir exudations, which lea di- verticida, accessory tubal canals, etc., and iiave been noticed in connection with ectopic gestation. Any diseased condition of the mucous memhranc of the tubes, or any condition which iuterfeivs with their noruKii peristalti(^ at^tion, may be said to favor the (U'veloj)ment oT ectopic iLj;estation. 'J'he coniUtion is generally encountered iu women who present a history of a protracted period of sterility. Pathology of Ectopic Gestation. The uterus: With the establishment of prcirnancy flic uterus begi'is to enlarge ; (he enlai'gement continues througli- out the pregnancy, though at a much slower rate than is tlir ease in iutra-uterine gestation. As a rule, this organ begin- to involute when the fetus j)erislies. A dccidua f)rms in all cases of ectopic gestation, which is erishes or not. 'fhe shredding of the (Ku'idua is invariably accompanied with nietrorrhagin. The de(!i(hia varies in thickness from one-eighth to one-fourili of an inch ; it is sliaggv on its uterine side, while its imici' surface is quite smooth and shows no trace of either the decidiia serotina or rcHexa. Changes in the tube and ovum: As tlie tube eidarges its relation to surrounding pai'ts becomes greatly nioditied. 'flic first change iu the tube is a turgesccuce, (hie to in(!rease in size of the vessels, the result of the stimulus of pregnancy. SYMPTOMS OF ECTOPIC GESTATION. 205 Tho imiscle-fihrcs of the tube's walls tlicn iiicroase in si/.c, Imt later ali'ttpliy a- the result of iniiuite ruptures due to small jicniorrliaiics into llieir >iil»taii<'e. Tlieii lollows tree develoj)- iiu'Ut ol' eonueetive tissue, w liieli replaces in threat part the iiiiisele-Hhres. As the o\ inn eiilarii'o the tnhe-walls heconio iliinned out, the thiekesi jtait Iteinn' '*t the >ite oi" the placental ;iltachinent, and the thinne>t ortion ol" the ther change it< charjicter, converting it into a liver-like mass. When the tube rujtturcs the torn walls nt" the tid)e sprea- sivelv severe and cause collapse. Not infre(picntly the.-c attacks are ac(!omj)anied by dysuria and rectal tenesmus. The amount of blood lost varies from a mere show to :i severe hemorrhage; with the blood may be found small shreds of mucosa, or even a comi)lete cast of the decidual lining of the uterus. The pelvic pain is usually of a sharp, tearing character ; when excruciating, and accompanied with collapse, it indicatt -« a serious rupture. A vaginal examination in such a case will reveal the pres- ence of a mass in close ))roxiniity to the uterus, which may be found somewhat (Milarged. The character of the mass de- pends uj)on the situation of the ovum and whether it has rupi ured or not. In cases in which rupture has taken place early into the general peritoneal cavity no mass may be felt. [f the first attack be survived, other similar attacks mav follow and the internal hemorrhages be fatal. Jn other oases the effused blood may be absorbed after the perishing of the ovum. The ovum if it survive may go on developing, in which case signs of pregnancy will continue, an abdominal tumor develop, and finallv evidences of a livinj; fa>tus will manifest theni- selves. Such cases may go on to full term and a spurious labor occur. In other cases secondary rupture takes place at a later ])eritMl when the patient usually dies of hemorrhage or peritonitis ; of if the patient survive, the foetus becomes mummified or form- a lithopa}(lion, being retained for some time, and finally is cas: out piecemeal thropgh a fistulous opening. Diagnosis. To make a positive diagnosis of ectopic gestation previous to rupture of the sac, while possible in a large majority ol' TREATMEXT OF ECTOPIC CESTATIOS. 2()7 cases, is ahvavs a niattiT (»t' (lilliciiltv. Tlic liistorv of the hiij^ns of early prejiiiancv, a>s(i<'iatc(l uitli airirravati'd rcllcx luTVous phenomena; tlie early aj)j)earanee of sliai'|), crainj*- iike pelvic pain increasing in severity, make a diagnosis pos- .';il>le. Usually the condition is not recognized until rupture has taken place. At this time the history of delayed menstrua- lioii, the occurrence of a paroxysm of frightful pain, sudden (.ilhipse, and symptoms of internal hemorrliage make the diagnosis very sim})le. A microscopical examination of the shreds contained in the \aginal blood will reveal their (lecidual chara<'ter, and make a (litl'erential diagnosis from al)ortion ])ossil)le, as no chorionic \illi will be found unless the pregnancy is intra-uterine. In cases of advanced ectopic gestation the diagnosis is, as a \'\\\e, not ditiicult. Owing to the great displacenuMit of con- tiguous organs, abdominal pain is often excessive. This j)ain i- due in part to j)rcssm(', and in |)art to the development of" jH'ritonitis of a chronic type. Prognosis. Ectopic gestation is one of the most serious obstetrical condi- tions. If left to nature, the mortality is over (K) per cent., the remainder recovering by d(\ath of the ovum and absorj)tion of the consents of the gestation-sac. When treated by abdominal section, Mirst states the mor- tnlity should be alxMit 5 per cent, or lower, if the operator sees the patient in time. Treatment. As soon as a diagnosis of ectopic gestation is established the only rational treatment consists in the immediate removal of the gestation-sac, whether it has ruptured or not. Abdondnal section is the most satisfactory method of operat- ing:, though some operators prefer th<; vaginal route, The latter method has many disadvantages, and should only be n-orted to by those operators having sj)ecial exj)erience in ()|H*rating by the vaginal route. As it is a matter of considerable difficulty in many cases to 208 PATHOLOGY OF PREGNANCY. control the licinorrliage and to sej)arate the gestation-sac, tho operation of dhdoniiiid/ .section for the removal of an ectopic gestation should not he undertaken hy an unskilled ojierator. The technique of the operation: Tliough the o})eration has fre(]uently to be jx'rformed in an emergency, })lenty of lime shoidd he taken to secure an aseptic condition of the ahdoincii of the patient, of the operator, of tlu; assistants, and of ihc instruments and dressings. The oj)erator, liaving oi)ened the abdomen by a medinn incision, should at once insert his hand and seize the afl'ectcil tube at its uterine end, so as to control the hemorrhage. 'Jlic broad ligament should then be transfixed by a pedicle-needle to the inner side of the roinid ligament, and the tube ligatdl been removed the cori should be cut as close as ])ossiblc to the jdacenta and the e%es of the sac stitched to the edge o{' the abdominal wall, and the sac drained by packing it light Iv with iodoform gauze. The after-treatment in such cases consists in daily irrigatimi of the sac with antiseptic solutions, dusting it well with :tii antiseptic powder, and introducing fresh packing. For further information on this subject reference should be Iiad to standard gynaecological Vvorks, as ectopic gestation has DIAGXOSIS OF OCCIPITOPOSTKIUOR VASES. 209 ]) isst'd from tlie domain of oh.sti'trics to that of gynax'ology, since tlic treatment of the condition is pnrely snrgical. PATHOLOGY OF LABOR. The term eutocia is api)lied to normal hibor which termi- n ites easily without serious damage to m- ther or fetus and AVitiiout artificial aid. Dystocia is the term aj)i)lied to abnormal labor. If the al'iionuality of the labor lij:CJHiient and the iimhi liens. The f'cetal heart-sonnds mav in- heard in the Hank at abont the level of the und)ilicns. Vaginal examination : If the eervix '-• dilated sntlieieiitiv, the saijittal sntnre may be felt in fhe line of the oblicjiic diameter of the j)elvis, while the })()sterior fontr.nellc is directed toward the righi. or left sacM'o-iliae joint. Labor in oceipitoposterior positions is generally tedions dne to the iri'egnlar and inetfe(^tiial pains which eharacteri/e the fn>t stage in these eas<'s, and also Ix'cansc! of the long internal idii- tion which mnst take place before the oecipnt is direcinl under the pubic arch. Mechanism of Occipitoposterior Cases. In normal cases the mechanism is much the same as in anterioi' positions of the occiput. Flexion is more ditliciih on account of the maladaptation of the head to the ju-lvis in these posterior ])ositions, as the widest ])art of the head, tlic biparietal, is in relation with the narrowest part of the inKt, the diameter between the iliopectineal prominence and the Fig. 67. Fig. 68. Riglit nrcipitopnstorior position of licnd. 'I'lie arrow sliows tho erniit ic (v-capo of tli<' <»('( ipiit over tlu- p<'riiu'iim. Wlicn the occipn i^ (l(;livt'i*c'(l tlw li('aul)es(Fi<^. ()!)). Sj)ontanoous(leliverv in a t'ae(.' to pulx's ea>' i> only a('(;om|>lislu'(l witli ditlieiilty, ami re(jiiires stronjr paii*, lax maternal [)arts, jiiid lu t too large a head. After the hi ih of the head the nieehaiiism is the same as in other eases. (o) In other cases the head may enter the pelvis po. 1\ l]exeitolVontal diameters of the fi- tion of the fcetns some time bcturc the expected onset of labor. If at this examination the fa'tns be Inmid to occupy a posterior position, it i- possible to rectify it by })ostural treat- ment in many cases. The woman should be instructed to assume the knee-chest ])osition as frequentiv a- possible, and to remain in this jwsitidii for some time before turning iiimhi the side to which it is desired [>> direct the occiput. In this po>tiirc the tendency is for the child to siii away from the brim under the iiitlii- ence of gravity, as the fundus and anterior uterine wall become the lowest ]iortions of the uterus. Tlif child thus becomes free to rotate upon its own axis, aii i IN Oi'ClJ'ITorOSTEJtKJii (Vl^AX 213 ii is hroiiulit into apjio-^itloii with the anterior wall of tiic iiurtis. IIciico as tiio woman assumes the erect posititm the child's head tends to settle tlown a<^ainst the brim in iui anterior j)osifion. At the Peldc Inlet. Fre((nent examinations should be n)ade to ascertain wliether ll \i(>n is heino' maintained as the head descciid> into the brim. Sliould extension of the he;'.«l take jdace without descent, iiiterl'erenee is demanded, as tliere is l)ut little likelihood that the head will pass the brim by natural etlbrts. Tlircc iiHthods of dc/lrcri/ are possible : 1st. Version : Tiiis is probably the most popular as well as the easi(,st method of dealing with these cases, because, as a rule, the general practitioner can perform thi> operation with LTcater ease to himself and less danger to the |)atient than citiier of the other methods. 2d. Normal restoration of flexion and rotation of the foetal head and body to an anterior position, with the subsequent ap- plication of the forceps : This is a rather ditlicult oj)eration, and >hould only be undertaken by tiiose who are thoroughly skilful in the use of force])s. To perform this operation |)i(i|)erly the patient should be placed under the influence of cliioroform, so as to relax thoroughly tlie uterus. '^Phe opera- iov, after the usual anti;n'j)tic ])rccautions have been observed, sliDuld then ])ass his whole hand into the uterus so as tirmly to giasp the brow and face of the child. The head having been raised slightly, so as to free it from the brim, is then gently rotated to an anterior position. The external hand of the opci'ator should be used to ])romote rotation of the trunk, which should accompany rotation of the head. The rotation should be carried out slowlv and with the utmost i»;entleness. After this lias been accomj)lished the head should be urged into the brim by external pressure, and shoulil be maintaine rotate spon- taneously. As the head emerges it should flex and the root oi' the nose ])ivot under the pelvic arch. It should be delivciid slowly and with extreme caution, so as to favor moulding ;iiij;ht obli«pie diameter of tin- jx'lvic brim ; hence tiic most common positions are : Iv. JNI. 1*. and L. M. A.; rarely, R. M. .V. and L. M. I*, jxtsitions may be met with. Causes : Any condition which tends to interfere with proper th.'xion of the head may be set down as a cause of face pnis- ontation. The most common causes are : 1. Oblicpiity of the uterus, which acts by altering tiie line of fetal-axis j)ressure. 2. Tumors of the fetal neck, thyroid, or thymus. .'». Coils of thick e«)rd around the neck. 4. Dead fetus, 5. Kxeessive li((Uor anmii. 6. Small size of fetus. 7. Deformcid pcilvis. 8. Tumors of uterus or nei<^liborin<»; structures. 9. Tumors upon the ba(!k, as meningocele. 10. Dolichocephalic head. 11. Occipitoposterior positions, in which there is a tight fit at the brim. Diagnosis of Face Presentations. Abdominal examination: It is sometimes a matter of difh- culty to make a diagnosis of face presentation when the abdominal wall is thick or tense. Usually the bulivy cranial vault can be felt in one hypogastric I'cgion, and a deep groove may be made out between it and the fietal back. On the opposite side of the abdomen the fetal members may be dis- tinguished (Fig. 71). As the fcetal back is displaced from the uterine wall by the extended head, the hi'drt-Hounih are to 21lar marjjiiis. It'tlu! caput siu'cedancjim has loniied ovei" liie (ace, it may he mistaken ior a hreech, unless can- he taken |.i distini^niish clearly the relationship of the parts within nach «»1" the linger. Mechanism of Face Presentations. The first stage of labor is delayed hecanse the head does iiiit lit the lower nterine segment so well as in vertex presen- taiions. The mechanism of face cases differs fr(»m that of the V( rtex in that : 1. The chin takes the j)lace of the oc''ij)nt in heing the l(;i(liiig ))art of the head in descent. It osition, which may be accomjdished by arranging an ordinary wooden chair (first sawing off the legs close to the wooden seat) on the bed so that its back forms an inclined plane, covering il with a folded blanket and 220 PATHOLOGY OF LABOR. dravving tho patient up over it so that iier huttoeks rest on tlie back edge of tlie seat. Tlie operator tlien presses on tli oceiput of the eliihl \vith one hand, so as to force it into tli pelvis, while he presses the other against the child's neck o ■ the opposite side, thus Hexing tlie head and straiglitening tli • vertebral .'olunin of t' ^ fcetus. When flexion has thus been accomplished, ])ressure is then maintained upon the fundus, >n as to for(!e the head into the })elvic brim in the flexed ])ositi()ii. If this !)e found impossible, the case may be left until tin OS has dilated, when, after ruj)turing the membranes, an etlort Fig. 73. <-«« Schatz's meUiod of rectification by external nianiinilatiun. may be made to restore flexion by introducing the hand into the uterus. If it be found im])ossible to maintain the head in the flexed position after this manauivre, the forceps should be ap- plied and the head drawn down into the cavity in a flexed j)osition, when the bla('l\ is it will be found empty, while at the brim a large, bulky, incouliir, movable mass may be distinguishe the UKMiibi'anes if they I)e found intact, in niaiving tlie vagiir 1 examination. Generally the hreeeh is situated so higli i :i that it cannot be reaehed without risk of ru})turinjr the h; .r of waters if the examination is made early in labor. Aft v labor has advanced and the membranes have ru[)tured tl ■ breecli may be recognized by feeling the sa(;rnm, coccyx, a. I ischial tuberositi(!s of the fetus. The anus mav be rec(»<;n!/ I 1)V the grasj) of the sphincter ani, and ' y the presence of in - eonium on \\u\ examining finger. If the child is a male, tlic scrotum and penis may be felt. Occasionally the former iii.iv be fedematoiis and may then be mistaken for the bag of w ati r-. One or both feet may be felt; the foot may be distinguished from the hand by the projections of the heel and the malleoli. The knee may be distinguished from the elbow by the pn >- ence of the ])atella and by the larger size. Care must In- taken to distinguish the breech from the face, for which it is often niistidicn. Mechanism of Breech Presentations. The first stage of labor is very prolonged, for the brc" rh forms a poor dilator of the cervix, and s along the i)<)dy of the child preventing its lateral flexion. lM(i. 7C). Passage of buttocks over perineum iu ii breech case. (After Barnes.) .'). The (ii'inx may become extended and cause arrest of the luad at the pelvic brim. This accident may be due to an iiiiixrfectly dilated os or to pelvic contraction. It is very apt t(i occur if traction is made upon the body of the fretus to accelerate delivery. I. The hf(uf may become arrested at the brim or in the pelvic cavity, as a result of extension or from ])elvic deformity. Occasionally when the ftice is directed anteriorly the chin may catcji on the upper border of the pubes and cause delay. Moulding of the foetus : The breech is generally swollen and ot'toii discolored from eechymoses ; the discoloration is generally 15— Obst. 226 PATJiOlJjaY OF LABOR, more nuirkccl over tlio anterior liip. If the child is a male, tin.' scrotum is jreiierally (edematous. Prognosis of Breech Presentations. The foetal mortality varies from 10 to .'50 j)er cent., depeml- iu<; upon the skill of tlu; physician. The risks to the eliil I are orcat, due to the prolapse of the cord and the j)ressure df the aiter-cominjij head uj)on it. Fractures and dislocations may he caused by etforts at rapid delivery. The risks to the mother are increased only hy tiie tenden. v to laceration and to bruising of the soft parts on account dl' the necessity for rapid and sometimes violent extraction of the after-coming head. Management of Labor in Breech Presentations. General: Very earlv in lahor, before the membranes have ruptured or the breech has bet;ome engaged in the brim, it may be j)ossible to perform an external version. The o|)cra- tion is not always practicable, and therefore shoidd not he attempted unless there is certainty that it can be successfully accomplished. The position (►f the ])hysician in charge of a breech case should be one of armed ex})ectancy. As long as th(,> natinal processes are progressing satisfactorily lie should be watclit'iil but inactive, and should be prepared to interfe^ ' promj)tly (ui the appearance of danger to the child. Wlien ]K)ssible a skilled assistant should be obtained, whnsc duty it is to give the an.'esthetic and attend to the maintenance of pressure upon the finidus, so as to prevent extension of tlic head during the delivery. Preparations should be made for treating asphyxia of tli( newborn infant. At hand should be placed, sterilized and ready for use, the ligatures for the co»'d, scissors, two pairs of artery-forceps (to be used instead of ligatures in cases in wliidi speed is demanded), a basin containing warm sterile water in which are a couple of sterile towels for wrapping arr kept in Ix'd, and >li(»iil(l 1)(! caiitioiicd aijainst strainiiiii- diiriiiLr tlic lir;ion of the cord. IiTej^ularity of the heart-heats is suf- liiicnt cause for interference. When delivery is imminent the j)atient should lie in the il.irsal j)osition, with the thit^hs flexed. In cases in which it is iit'ccssary to etVcHit a speedy delivery the paticiit shoidd he placed across the bed in the lithotomy position. As soon as the buttocks enieru;e they should be wrapped inajvui'ni ;?t<'rile 'I. to prevent the child inakinir eiu)rts at rcsi)ii-ation. pro 'V lowe , .__»_———_ t . ..._ Kroin the moment the buttcx'ks appeaFat tlie viTIva till the placenta is delivered the fundus u teri shoidd be consdnil/i/ under the control of an assistant. The trunk, as it emer<;es, should be suj)ported, so as to prevent undue strain upon the perineum and traction upon the after-coming head. As soon as the feet apj)ear the le^s may be gently drawn down in su<'h a wav as to make no traction upon the bodv of the child. As soon as the umbilicus comes within reach of the fm^'cr, a loop of cord may be ^ontly drawn down and examined. If it is j)ulsarin^ well, the case may be allowed to deliver slowly ; hilt should there be evidence of compression upon it, then the revent aspira- tion of mucus should the child attempt to breathe. Then the head should be delivered slowly and carefully, so as to avoid ruj)turing the perineum. 22« PATUOLOdY OF LAliOR. Treatment of Arrest of Breech at the Brim. Arrest of the breech at the brim immv he due to tin- cxccssiNc size of tlic <'liil(l or to pclvicr dcfoniiity. 'I'lic jH'ccniitiiii should idwiiys he taken of incasiiriiijr the inollicr's pclxi-. uidoss tlii.s lias boon done, bef'oiv any o}){'rativ(' nicasMrcs ;iii atlo|»t('d. 'I\) srcnrc descent five methods are available: (1) l,\ l)rin- cnga<»:e it from the brim befon; seizing; a foot. The antcTJj^ foot should always be selected, and when firmly grasped may M.\S.\(;rMl':ST()F LMKUl IS ItllEECll PllEShSTATIOSS. 225) l.r "rciitlv (Irawii tliroiit'li tlic os mid vniiiiia. < )cfa>itmallv the IrM's may l)c liumd extended aloiij;' the clicst <»f tin' cliild ( l^'ij;. 77). Ill siu'li a case tlio i'oot iiiav hv \)Vo\\\A\{ witliiii rcacli l)V |iassin<; two liiij^crs al«»n<; the liack oi' \\\v tlii^li, at the sanu; tiiiic abdiictinjjr it .<() as to press tlic kiu'c to one side; tims tlio loot tends lo di-o)) down in tii(> median line oi' the eliest, and may be grasped by sli|)|)inp: th(; lingers down alon^ tlie le^. I'rovideii there are no iiulieations neeessitatin^ speedy (hdivery, ! lie ease may be left to natnre as soon as the foot has been (liMwn down to the vnlva. Siiotdd the patient be exhansted. delivery may be hastened liv eombined traetit)non the foot which has been bron^ht down, and pressure on the fundus from above. The latter slionld be managed by the assistant, so that the operatoi- may ^ive his whole attention to the child. When it is hoMld 1)0 wraj>ped in a warm sterile towel, and then as much (if the limb as [)()ssible slioidtl be orasjied in the whole hand. The ojH'rator should introduce the forelin^'cr of his free hand into the vay^ina and hook it into the ])osterior ^roin as soon as it comes within reach, in order to distribute the tractive force iH widely as possible, and thus reduce the risks of injury to tlic child. As the breocli distends the perineum it should bo (hawn forward against tlio ))id)es, so as to avoid laceration. A- soon as ]>ossil)le the posterior limb should be gently drawn tMit, in doing this, pressure on the thigli should be avoided, care being taken to seize the foot and draw down tlio leg in such a way that the knee comes down in the median line of tile child's bodv. W hen it is impossible to bring down a foot it may be pos- sil)le to hook the forefinger in the groin, which may be done in iniy manner convenient to the o])erator. Traction may then lit' made downward and backward, care being taken to avoid jiH'ssure on the shaft of the femur, on account of tlie danger of its snapping. rhe blunt hook or fillet may be used as a tractor. Tlie latter 230 PATHOLOGY OF LAliOJi. yliould Ik! ii.s(!(l l)y prelViviiee as imicli U'ss liable to do damage to mother or child. TIk; fillet is usually couiposed of a strij) of stcrili/cd cotton or ^au/c haiida^^c. The hcst iiistnuiicut lor plaiMut; tiiu lilici is a ^uni clastic! catheter. The catheter should he thread* d with a loop of striujjj and then, with its stihft, should he hent so as to form a lar^e hook. After it has heen sterilized tin- hook should he guided over the anterior hip and rotated .-u that its point |)asses between the child's thif^h and alxlotneii. The finder should then he passed between the thighs, and tlir loop of striiifi^ dra<;^e(l thighs. This gives the most secure grasp. Tracticm is then made downward and backward with both hands, while the assistant presses firmly on the fundus. As soon as the cord can be reached a looj) should be drawn down, as is done in normal delivery of the breech. When the angles of the scapulae come into view the delivery M^NAaKM^:^T of lauoh is unEEcii viiESEyvATioMi. 2:U (.f the arms slioiiM Ik; attcmpti'd. To tlo this, two liiif^ers of tlio ojM'rator's hand which coiicsjhiikIs to tlic arm it is di'sircd t(» roacli, should Ix' passed n[) over the shouhlri* and (h)wn the arm to the elbow, wliicii may then he swept aeross the chest >.() jis to l>rin^ (h)Wii tiie forearm and hand, the chihl's hody being luild in such a position as to give \\w greatest freedom Fio. 78. Delivery of child in a breech case by traction made with fingers placed in groin. (After A. R. Simpson.) of movement possible to the operator. Having released one arm, the operator should then change hands and deliver the other arm by a similar manwuvre. Upward displacement of the arms : Not infrequently the arms are found to be displaced upward alongside the head. This is generally indicated by greater resistance to traction 232 PATIIOLOGY OF LABOR. after the scajmhe have wmie into view. Wlien this coniplicii- tion is found the body of the fo'tus should be [)usiied uj) i the axis of the brim, so as to diminish the pressure on th. arms at tliat level. The body should then be rotateil until it- back is directed to one or other side of the mother. Usuall the posterior arm is most accessible, and is therefor j bronchi down first. Holding the child's body up against the pubt ■ the operator presses two fingers up over the posterior should* !• to the elbow, and sweeps the arm down across t!:e face ami chest, as directed above. Having released the posterior arm. the child's body is pressed over against the perineum, and tli" anterior arm is brought down by a similar maufeuvre. The anterior arm may be so firmly caught between the heal and the pubes *hat it may be impossible to dislodge it. In this case it should be rotated so as to come into a posterior position. This rotation is accomplished by grasj)ing the trunlc of the child's body firndy with both hands, lowering it so as in bring its long axis to correspond to that of the pelvic brim, and then shoving it up so as to release the anterior arm from pressure. As soon as the arm is loose alongside of the head, the child is rotated about its long axis, so that the arm wliicli has been anterior passes along the same side of the pelvis backward and rests in front of the sacro-iliijc synchondrosis. By this manipulation the back is moved from one side to tlic front, and then to the opposite side. Tlie arm is then deliv- ered as was the posterior arm in the first instance. Occasion- ally the anterior arm may be folded behind the occiput. In this case the revolution of the body must be made in the opposite direction. First turn the abdomen of the child for- ward and then to the opposite side, thus causing the shoulder to rotate through three-quarters of a circle. Constriction of the head by the cervix : Occasionally the cervix may become tightly constrictt ^ about the child's neck ; a condition which generally endangers the life of the child. The patient should be deeply anaesthetized, and traction made on the shoulders with one hand, while the fingers of the other, placed in the child's mouth, give what assistance is possible. I ilASAdEMl'JST OF LA Unit fX liltEEi'lI PRKSKSTATloys. 2.33 Delivery of the After- coming Head. Deventer's method : IVobably the oasicst nu'tliod of ctlwt- iu\r a speedy delivery in a ease in wliich the pelvis permits tiie descent of tiie iiead with the arms extended alongside is Ih'irnter^s. Tiie body of the ehiUl is dropped downward, ihe feet are grasjjed witii one iian-). Flexion is then made downward irWi both Jiands until the oc(*ij)iit appears under the pnbes. Th( ii the right hand swings the bodv upward, at the same time makiiiir traction, while the left hand is held firmly in position, being used as a fulcrum around whicli the lieail moves, until it is finally forced otit of the parturient canal by this lever-like movement of the body. The force exerted by this metlnxl is very considerable, and therefore it shoidd be used only af(< r the foregoing methods have been attemj)ted. 5. Forceps : Manual efforts at extraction having failed, the forceps may be used. To permit the application of the blades, Prague grasp. TRAXSVKfiSI': PRI'JSESTATroXS. 237 I 'ir child's licad must Ix' held up toward the motlicr's jilulo- ii (11 l)y an assistant. Properly diivctcil suprapul)i(' j)r(>ssure h\ an assistant incivascs the I'llicacv of al! nu'tliods ot" di'Iiv- ( linu: tlie aftoi'-coining head. Six minutes is the maximum time at tiie operator's dis|)osal onee tlie placental eireulation Ills heen completely cut oiV. Therefore it is advisable to have tlie assistant call oif the minutes as the time |)asses, so that liie last two may be utilized for the application of the f()rce|»> >hould recourse to these instruments l)e re(iuired. TR AN8 VE RS E Pli ES ENT ATIONS. Definition: Any presentation of the trunk of the child's liiidy is termed a transverse presentation. As the result of uterine action after the onset of labor transverse presenta- tions resolve into shou/dcr ^>yc.vcH/(f//oy<.s-. The term c/'o.s.s- hirf/i is frecpiently apj)lied to a transverse presentation. Frequency: Less than 0.5 per cent, of all cases of labor l»i\'si'nt transverse j»resentations. Causes: The same causes that residt in breech j)resentations iilso act in producintz: transverse presentations. Varieties : The lon^ axis of the trunk is very rarely trans- Vvi'se, but is usually obliijuely placed as re<2:ards the lonji: axis of the uterus; thus any part of the fresentation becomes altered to that (►f the breech or the head, the delivery then taking place accord- ing to the new presentation, S})ontaneous version may take 240 rATllOLOGY OF LABOR. ))l;i('e before or after rupture of the menihraues, and is wv, likely to oceur in multipara! and wlien the ehild is livinj:. 2. Spontaneous evolution: This nieehanisui is favored ex(.'essively strong uterine eoutiaetions, a roomy pelvis, am: small fcetus. By the strouj^ uterine contractions the anterior shoiddci forced down into the pelvis, and rotates to the front, while i head lies ahove the brim and over the puhes ; the breech :i; truidi ar(! then compressed, and gradually forced jKi-t i head and anterior shoulder, which pivots on the j)ul>ic air Fio. 84. ro IS IC 1(1 IC ll. Spontaneous evolution. First stage. Thus the chest and breech slip ])ast the shoulder, over tlio perineum, and are delivered. Finally the head enters the p( 1- vis and rotates, so that the occiput pivots under the pubic nidi and the face sweeps over the perineum, thus completinsr the delivery (Figs. 84-88). 3. Delivery with the body doubled up {Kvolntlo con (Jup/i'-'it'i corpore) : The conditions favoring this mechanism are stioiig I MECHANISM OF TRANSVERSE PRESENTATIONS. 241 Ki(i. 85. Spontaneous evolution. Second stage. Fig. 86. -|Mintiiir.'ous evolution. Third stage. ]6-0b.-t 242 PATHOLOGY OF LABOR. Fio. 87. Spontam-ons evolution. Fifth stnpc. MECIIAMSM OF TRASSVEnsE rilESESTATlOSS. 'l\'^ utciino contractions, a roomy jxlvis, an«l a small dca*! fo'tiis. 1'lie presenting HJiouUler is (Irivcn down into the pelvis and is Via. 89. Hirtli of child doublcrl. Kvnlutio con cluplicato onrporo. (Klcinwiirhtor.) (lolivored first, tlie head and ehest of the fo'tus are eom])ressed tnsrctlier and forced throuii^li the eanal, being tiius delivered, ami are followed by the breech and legs (Fig. 89). 2M I'ATiioLoay of lajwr. Management. 'I'raiisvcrsc prcsciitatioiiK should never he h'ft to Nntiir. to h(iiil(| he |)erlornie(l. It' seen late, when inij)aeti<)n has taken place anortaiic(' in bivccli pi'i'.senlutions, ami no attention net'(l be paid to it. In Transverse Presentations. Tlic prola|)se of a foot is, of course, favoral)le. Sliniild a hand or arm be found prolapsed, il' it cannot be |iii-;li('d up out of the way, it may be tlrawn down snllieiently |m fasten a broad piec^e of tape about the wrist. After version 111- been performed the tape may be lu'ld so as to j)revent the ;irm from rising alongside the head and ('om|)lieating its descent. PLURAL BIRTHS. Twin Labors. These are usually easy and uncomplicated. Twin pregnancy occurs about once in l.">() cases of gesta- tion ; while triplets occur about once in 5088 cases. The tendency to twin pregnancy is very frecpiently Jicirdi- Itii-jl. The greatest number of reported cases have occurred in According to the origin of the ova will arise the various peculiarities in the development of the placenta' and mem- hr.ines. If the two ova have bee'/ derived from separate Graidian follicles, each will have its own |)lacenta, cord, chorion, and amnion, eairh being in(i( pendent of the other. Sjiould the two ova have been derived from a single (iraafian follicle, the amniotic sacs will be distinct, but the choricm and phu'enta will be in common, the two cords aris- iiiu" from the same placenta. I sually twins arising from ova fiom a single (Jraafian fi»llic!e, are of the same sex ; while when the original ova are distinct each is of an opj>osite sex. 3Iii/e twins are slightly more common than female twins. Diagnosis: Very frecpiently the diagnosis of twins is not made until after the birth of the first child. The oidy ccrtuhi 246 PATHOLOGY OF LABOR. signs of twin pregnancy are tlic presence of two f(x?tal lioar!- sounds, lieard at dittereiit ])()ints over the alxloniiiial snrl':i< !•, and liavin overdistention of the uterine walls; dbnormal prexentntion ; ulbaminurid and ecUwip.sitt, more fre(|uent in j)lural |)r( te- nancies ; Jiemorrhaxje in the third stage of labor from tnMil)l(' in the delivery of the placenta. The fd'tdl pro(/n<),si.s is always more serious tlian in simple births. The ddiif/er.s are : deficient develo})njent from ovri- crowding in the uterus; via Ijmj-s it ion dnd nidlprefientdtion ; and hydranitiios. Mechanism: The following table from Spi"gelberg, bastd on 1138 lab.trsj gives the combined presentations in tin ir order of frequency. Both heads presenting 40.00 per cent. Head andhreech 31.70 Koth pelvic presentations 8.00 " Head and transverse G.18 " Breech and transverse 4.14 " Both transverse 0.37 " The order of de/ireri/ varies. When both heads present, usually the larger is delivered first. If one twin presents by the breech and the other by the head, usually the latter is delivered first ; if one presents transversely and the other longitudinally, the latter is usually expelled first. Management of labor: AVhen the presentation of the liist child is normal no sj^ocial treatment is indicated. AVhen the first child has been delivered and its res])iratory function well established, before cutting the cord the physician should pil- pate the mother's abdomen to ascertain the position of the second child. If any abnormality exists, it should be at (Hice corrected by external manipulations and the fundus uteri gently kneaded to stinudate retraction. The fundus may then be placed in charge of the nurse or assistant while the phy«^i- 2'U7iV LABORS. 247 (ian attends to the cord of tlio first cliild. This shoidd be tied in two phices and then divided l)etween the ligatures, in case there siiould be eonniiunication between the phieental Iicnlations and the second chihl bl(>ed to deatli. Friction on tiie iunchis siioukl be sustained until the uterine lontractions are firndy established. Jt is not advisable to wait more than halt' an hour for the birth of the second chihl. Tiie second amniotic sac shouhl then be ru|>tured and the uterine contractions reinforced by firm pressure on the i'undus so as to expedite the delivei-y oi' the second child. From this time until retraction has been firmly established, after the complete emptying; of the uterus, the fundus shouhl b( kept constantly under control in order to ])revcnt its relax- ation and the occurrence of hemorrhage. Should hemorrhage follow the delivery of the first child, the sect»nd should be delivered as rajiidiy as ])ossil)le, either by forceps or version, and the uterus emptied artificially. It is not advisable to infoi'm the mother during labor, shouhl a diagnosis of twins be established, as the shock may iidiibit uterine action. Complications of Twin Births. Compound presentations : Occasionally both fietuscs tend to engage simultaneously in the brim. \\ hen hoflt liaid.s tend ti» j)resent at the same time, the highest should if ])ossiblc be ]>usiied uj), and the foi'ceps then aj)plied to the lower head and traction exerted until it is firndy engaged. During the traction an assistant may be able to hold the heauld be replaced and the head drawn down by means of the forceps. Interlocking twins: Occasionally both heads enter the pelvis, one being generally well in advance of the other. The upper head then becomes jammed against the neck and thorax of the first child. 248 PATHOLOGY OF LABOR. Trcdtmcid: The most advancod head should l)o delivend by forcei).s, as unlocking is generally out of the question. The second head should then be delivered, and when this i^s done the Ixxiy of the first child may be extracted, the head of the second being held out of the way by an assistant. Sometimes it is ne(!essary to perforate one of the heads in order to permit the delivery of the other. When this opera- tion is required it should be })erformed on the head of the lii-i (ihild, because the second is more likely to be alive, there beinu; less risk of compression of its cord. In cases in which the breech of one child and the head of tlic other become impacted in the pelvis an endeavor shouKi he made to push up the head and deliver the breech. The body of the child presenting by the breech should only be delivered as far as the neck, as the two heads u ually become locked at the brim by the overla|)|)ing of the chins or of the occiputs, ur by the face of one child being pressed against the back of the other child's neck. Should it be im|)ossible to push back the head of the secoiwl child or to apply forceps and deliver it, the head of the breech child sliould be perforated and extracted before attempting to deliver the other. Triplets. As a rule no difficulty is encountered in the delivery of trip- lets, as the greater the number of fietuses tiie greater tlic tendency to ])rematurity of delivery. The labor is generally jM'olonged on account of delay in the first stage from imperfect uterine contractions. The third stage must be very carefully managed, and it is advisal)le to empty the uterus artificially in order to insure that no portions of placenta are retained. DYSTOCIA DUE TO ANOMALIES OF F(ETAL DEVELOPMENT. Overgrowth of the Foetus. Definition : A child may be said to be overgrown when it weighs eleven pounds, or over, at the time of birth. It is but very seldom that a child is born weighing twelve pounds; Imt PREMATURE OSSIFICATION OF THE SKULL. 249 ( uses are rceorck-d in which tlie ])irth-\V('iglit was over twenty jMillluls. Cause : Notliinjj^ (lofinito is known as to tlic cause of I his overgrowth. Mnltiparity, advanced a»;c of one or ])otli parents, and ])roh)nji^ation of [)regnancy are generally regarded ;;- the probable causes. Mechanism: When the hea»y>/< //.s/o/o//e accident is also more liable to occur in cases of multi- ple pregnancy. Diagnosis. Before the rupture of the membranes it is a somewhat dittl- cult matter, as a rule, to recognize a prolapse of the cord on account of its non-resisting nature and the ease with which it recediis before the examining finger. After rupture of the membranes it may be generally recog- nized without difficulty, on account of its twists and the pulsa- tions of its vessels. It has been not infrequently mistaken for a ])rola])sed looj) of intestine ; and occasionally a portion of intestine has been mistaken for the cord. Care in examination should make such an error in diagnosis impossible. The position the cord usually occupies is at one or other PROLAPSE OF THE CORD. 255 side of tlio pelvis somewhat posteriorly ; rarely it may lie cither in front of the promontory or behind the sym})hysis |»iil»is. When the foetal heart-sounds grow progressively weaker :iiid no cause is apparent, prolapse of the cord should be ^llspecte(l and a})propriate treatment inaugurated. Prognosis. This complication rarely influences the prognosis for the mother, save in so far as the operative treatment exposes her to risks of shock and sepsis. For the child the prognosis is somewhat grave, the mortality ri-'ing to somewhat over 50 per cent. The cause of frd to settle slowly toward the fundus, and thus the j)ro- lapsod loop is gradually withdrawn. Diiriiif/ the infcrrdfx be- tween the pains this may be gently pushed back with the iiaiid, care being taken not to rupture the membranes. When the romJition has been corrected, the ])atient may be permitted to recline on the side ()j)}><).site to that occu])icd by the cord. The change of position should be made slowly and carefully, so as to avoid forcino; the cord down again. Tlic mend)ranes may then be ruptured, care being taken to force the head down by pressure from above while this is being done. 250 PATIIOLOGY OF LABOR. r( - 111- \< till II' After rupture of the membranes: Rcforc attomptinjr to j)lii('o the prolapsed loop of cord after rupture of the \m brano.s, eare should he taken to find out whether the ehihi alive. If [)ulsation has eeased in the eord, the heart niav s he heating ; if this is tin? case, the presenting j)art siiould piished up, and the eord replaced after j)uisation returns. The woman should he [)laced in the Sims position on ;l;c !-ide opposite to the prolapsed cord. The hips should he ( 1. - vated hy means of a folded pillow. The oj)erat()r should tin n push hack the presenting part so as to release tlie cord. TJiis Fio. 92. Postural trentmcnt of prolapse of the cord. may then he loosely twisted, care heing taken not to interfi re with its pulsations, and the twisted mass gently pushed ii|» beyond the ])resenting part. If it he found im])ossihle to replace the cord with the woiiinn in the Sims position, she should be placed on her knees and chest and another attempt made, if necessary giving an aii.i s- thetic so as to relax the uterus com])letely. The objection to the knee-chest position is the tendency for air to enter the uterine cavity ; if this accident occurs, the subsequent lahor should not be inididy ]>rolonged. Should maiHial efforts fail, a suitable instrument for replac- VROLAV^E OF TUK LORD. 257 iiitr the cord may Ix' improvised wltli a No. 10 or .No. I'J^iim chistic cjitlu'tcr mimI some tajtc. A loop of tajx* is made to encircle the eonl loox'Iy, and its free ends are attaeiie the uterus, carrying the cord with it (I'igs. 03, 94, and UO). The stylet is then withdrawn and the Fig. 93. Fm. 94. Reposition of cord. (Witkowski.) Braun's ronosition of cord. (Witkowski.) catheter left in the uterus to come away with the child. Care should he taken to remove the bone button from the end of the catheter. If all attempts at reposition of the cord fail, then either vrrsion or forccpK, with rapid delivery, must be resorted to ill order to save the life of the child. Befon; either of these operations the loop of the cord should be ])laeed opposite the saero-iliac joint, where it will be least pressed upon. 17— Obst, 2'iH I'ATIIOl.iKlY OF LMiOIt. ^X\ Coiling of the Cord about the Foetal Neck. Quite frequently (lie fulul cord is foiiixl to 'oc coiled alxtnt tli(! iicciv ol' tlu! child. It iiiiiy cncircK; tlic neck several tiim -, and thus |)i'odi;ce a relative shorteiiiiiLr 1" 1(1. l»"). ol' the ('(trd. 'i'he condition is dillicult to diagnose before delivery of tlu; head. It niiv l)e suspected if the head descends will witii each pain, hnt rapidly recedes in the interval hetween the contractioi!>. Results: Occasionally the traction is .so severe as to interfere with the fold- placental circnlation ; and has hci n known to cause; premature detachini in of the placenta. The only treatment that can he .-iil"^- ^ested is the a])plieati()n of the for('(|ts and the rapid delivery of tlie he:iil ; when the cord may he cut and un- coiled from the net^k before the biiili of the trunk takes place. Pla centa Prsevia. The placenta is normally implanted entirely within the upper uterine m'^:^- ment. When it is im])lanted, in wh(>le or in part, upon the lower uterine .segment tin condition is known as placenta praevia. Varieties: Three varieties are de- scribed : (1) Placenta prievia centralis: The placenta is so situated that its centre corresponds with the internal os (Fiir. 96). (2) Placenta prjcvia marginalis : 'Die placenta is situated so that but a ])ortion of its margin ov far as the internal os (l'i^^^>H). In the central and niarj^inal varieties the hemorrhage may lic^dn early in prejjjnaney ; it is repeated frecjUently, and in lahor is niueh more serious than in the lateral variety. Flu. %. Fui. i»7, riat'fiitti pr.i'via centralis. I'liiccnla praviu iiiarKiiialis. Fig. 98. Placenta pravia lateralis. (After Dakin.) Frequency: Placenta pnevia centralis is very rare; lateral :iii(l marginal placenta prjevia are the commctnest varieties. Placenta pnevia occurs about once in 1000 cases. It is more i'n'(|uently met with in multipane than in |)rimipar{e. Etiology: A satisfactory explanation of the occurrence of i-f 2G0 PATHOLOGY OF LABOR. ])l5icenta j)ncvia lias never been advanced. Clironic inHaminu- tory <'liantj:es in the mucous nicinhrane certainly prcdisjKisc i,, its occurrence;. Other probable causes are: subinvolutinn. atrophy of the decidua, new growths, and inalforniations ol the uterus. Symptoms and Physical Signs. 'I'lie symptoms of placenta pra'via do not usually prcx m themselves until after the sixth month of nre<2:nancv. The first indication of the condition is a sudden gush of blood from the genitals, usually without apparent cause and without pain. The bleeding then recurs at intervals as pii l-^- nancy advances. 'V\\i\ amount of blood lost is proportionaU' to the extent of the placental separation. \\'hen hemorrhage takes ])lace during pregnancy it is j)robably due to a i)ai!ial separation of the placenta in the lower uterine segment, wluiv its attaciiinent is im])erfeot. This separation is caused by ilic normal uterine cc/Utractions which constantly occur throuuh- oiit pregnancy. The first hemorrhage wlien it occiu's during la})or may be so severe as to threaten the patient's life. As a rule, the blecdir i; is most profuse in the intervals l)etween the pains; but this cannot be said to be diagnostic of the condition. \\y abdominal examination the location of the ])lac(>nta mav be re<'ognized, uhen the implantation is on the anterior uterine wall, by feeling its edge, which presents as- a resisting y\\\)i. Below this point the uterus feels soft and boggy, and the fo'tal parts can oidv be felt indistinctlv, while elsewhere thev mav be readily made out. Over this boggy area the placental hniif is to be heard with great distinctness. If the larger portion of the placenta occupies tlw lower uterine segnunt, mal|»ic— entations of the fu'tus may occur, a-; the presenting part is thus prevented entering the pelvic brim. Wy vaginal examination the cervix and lower uterine scnf- ment are found to be softer than usual. If the insertion of the placenta is marginal, one side of the cervix and lower seiz;- mont may be softer and more bogiry than the other. Pul- sating vessels may be felt around the cervix. Tlie external os is usually patulous, and through it the finger may be pushed till the internal os is reached, where the I'LACJ'jyTA PR^JVIA. 261 matornal siirfaoe of the placenta may be felt, a gritty feel (.lis- tiniriiishiiiir it from a blood-clot or the membranes. Diagnosis. When homorrhaj>:o takes place in the later months of preijj- iiancv a careful examination siiould be made to ascertain its cause. The ruj)ture of a varicosed vein in the vagina and pi'cmature detachment of the normally situated placenta may icail to severe hemorrhage in the later months of pregnancy. A carefid and s.stematic examination will generally permit u tliagnosis to be made. Treatment of Placenta Praev^.a. The control of hemorrhage is the principal indication of treatment. In the rare cases in which the condition of placenta j)rievia is recognized before the fetus is viable it may be j)ossil)le to carry out an expectant plan of treatment imtil the seventh month of the ])regnancy is reached. The patient must be kept in bed, not being permitted to rise for any purpose. It may be well to administer chloral (gr. xv) or li(|. opii sed. (nixv) two or three times daily to t utrol the nervous system. When the seventh mont h has been reached labor shoidd be induced, as after this j)eriod the woman may bleed to death he fore medical aid can reach her. Being satisfied that the condition of placenta pnevia is present, it is the duty of the physician at once to empty the uterus if the child is viable. The ])atient should be an.Tstheti/ed and ))laced in the lithotomy position, with her hips at the edge of the bed. A Kelly pad should be ])laced inulcr her. The vulva and vagina should then be scrubbed and doucled with formalin or bi- iias licen a great loss of lilood and the cervix is found to be rigid, it is better to ])ack the cervix and vagina \\\\\\ sterile iodoform gauze, whicii may be left in ))lace until the patient lias had time to rally under appropriate treatiiK nt (see l\ist-partum Hemorrliage). The gauze tampon not only ciiecks the hemorrhage, Imt also assists in softening and di- lating the cervix and os. ]\Iany authors recommend the cmjiloynient of hydrostatic dilators instead of the gauze tampon. Tiic Ciiampetier dc Ribes i)ag is the best for tiiis ])urpose. It is claimed that the bag controls the hemorrliage and dilates the cervix more elV( « t- ually than does tlie vaginal ])acking, while it as a rule causes less discomfort to the patient. For the introduction of the imu tiie patient is placed in the lithotomy position, the anterior lip of the cervix is seized witii a tenaculum and drawn will forward, being thou held by an assistant. The dilating bag i- folded into a cylinder, grasped with a pair of forcojis, and guided carefully into the cervix and tiirough tiie internal os. Before withdrawing tiie forceps the distention of tiie hau sliould be commenced in* injecting into it boiled water hy means of a syringe attached to the tube of tiie bag. Tiien as the bag distends the forceps may be unlocked and carefnlly withdrawn. As a precaution against rupture of the bag, the PREMATURE SERA RATIOS OE RLACESTA. 26^ iiperator should ascertain heforcliaiid li()\v many hiilUfiils of natcr are rtMjuirod to dilate it completely. The most rigid precautions a^ ret;ards asepsis should he observed in the treatment of ])lacenta pnevia, as the risk of infection is greater than in ordinary cases, on account of the low position of the placental site. After the child has been delivered the operator should intro- duce his hand into the uterus to remove the j)iacenta and any clots that may he fouiul there. 'I'his shoid<' l)e followed hy a prolonged hot intra-uterine douche of stei'iK salt solution or 1 : 500 formalin. A full dose of the fluid extra(;t of ergot should he administered as soon as the uterus is em[)tied, or else a hypodermic of ergotin. Prognosis : Placenta ])r{evia constitutes a most serious com- plication of pregnancy or labor for both mother or child. I'lider prompt and aseptic treatment the maternal mortality should be practically nil. As premature delivery is frecpient, the infant mortality-rate is high. Pre mature Separ ation of a Normally Sit uated Place nta : ' "A ccidental Hemorrhag e . The hemorrhage associated with premature detachment of a normally situated placenta is termed "accidental," to dis- tinguish it from the "unavoidable" hemorrhage of placenta j)r;evia. Varieties : Accidental hemorrhage may be apparent or con- rrtiled. Fn apparent accidental hemorrhage the blood dissects its way between the membranes and decidua, and escapes through the cervix. In concealed accidental hemorrhage the blood fails to find a way of escape, and may collect Avithin the uterus in sulli- cient ([uantity to cause serious symj)toms, or even death of tlu; patient. In this form anv of the followin"; conditions mav obtain and prevent tJic escape of blood : 1. The placenta may be detached only at the centre, the margin remaining adherent ; 264 PATHOLOGY OF LABOR 2. The upper margin may be detached, so that blood accu- mulates between the membranes and the uterine wall ; »5. A portion of the ed-rc t'i*^'. 99. • of the placenta and of the adjacent membranes may he detached ; the latter m;i\ rupture and permit the bhx.il to mingle with the licpioi amnii in the sac. 4. The cervix mav be oh- .structed by a clot, the de- tached membranes, or the j)resenting part of the ftetiis (Fig. <){)). Etiology : The predis])()s- ing causes may be given a>, tubercular and syphilitic [aternite de Beaujon. (I'inard and Varnier.) Symptoms and Diagnosis of Accidental Hemorrhage. The symptoms resemble those of rupture of the uterus, but are not so severe. In the appa' mt variety the fact of hemorrhage is obvious. It usually takes place early in labor or during the later months of ])regnancy. Severe localized pain at the placental site is not infrequent. The uterus may bulge at this point. PRKMATVRE SKPAIiATIOX OF PLACKXTA. 2(55 Placenta pnevia is readily distingiiished by a careful vaginal examination. Concealed hemorrhage is generally revealed by the systemic ctVects. Rapid pulse, pallor, cold extremities, restlessness, sighing respiration, and collai)se may be j)resent. Jf labor has begun, the uterine contractions cease or become weak, though the patient may com])lain of inon.' or less continual pain at the placental site. ()n abdominal examination the uterine wall may be found bulging at the seat of the hemor- rhage and the ffctal heart-sounds are feeble and irregular. llii|)ture of the uterus may be distinguished from concealed accidental hemorrhage bv the fact that the former occtu's late in labor, usually after rupture of the membranes, and that the presenting part of the fcetus recedes. Prognosis. In apparent hemorrhage the prognosis is good for the mother, but not favorable for the child. If labor does not come on at once, there is danger of infection of the blood- tract between the edge of the placenta and the os, residting in sej)sis. In the concealed hemorrhage the percentage of mortality for hoth mother and child is high. Death results from hemor- rhage, shock, extreme ansemia, or sepsis. The f(etal mortality is due to interference with the uteroplacental circulation. Treatment. External variety : If the external hemorrhage is moderate ill amount, a full dose of o])ium (li(j. opii sed., lllxxv) and rest in bed for a few days will be the only treatment recpiired. The patient's temperature shoidd be taken twice daily for a week or ten days, and if evidences of infection of the blood- tract occurs the uterus should be emptied. When the blood- loss is alarniins: it inav be necessarv to induce labor. The os should be dilated digitally to ])ei-mit ru]>ture of the mem- hranes. A Barnes or Champetier de Kibes bag may then be introduced into the cervix and left there till it is expelled, when forceps may be apj)lied, should the Ibrces of Nature fail in promptly effecting delivery. When it is recjuired to empty 2<;() rwTiioLoay of lahoh. tlu! utcni.s iiiiiiuidiati'ly, the cervix sliould he dilated r:i|>i(||\ • if necessary, it siioidd l)e incised and version performed. Concealed variety: If tlie patient's condition is sndi us tu forhid active obstetric interference, the treatment sliould li' directed to combatinjj; the etlects of the shock and iienioi- rhajre (see Treatment of I\)st-])artnm Hemorrhage). The fnn(his should he compressed hy means of a suu<:lv fittinjjj l)inder and pad. Tiie loot of the bed sliould he el< - vated. When the patient's condition })ermits, tlu! uterus should Im emi)tied hy means of manual dilatation of the cervix and vii- sion. The ))lacenta in these cases should he remove*) inaiui- ally, and a hot intra-uterine injection should be given afi* r the uterus lias been emptied. Tiie after-treatment should be directed to controlliuix the effects of severe hemorrhage, and to securing good uterini' contraction. Retained Placenta. This condition is of frequent occurrence. The j)lacenta is usually completely detached, and lies in tiie dilatef the vagina. Causes: Feeble uterine contractions, or, more frefpientU . improper methods of placental expression, generally give ri-c to the condition. A full bladder or rectum may lead to reten- tion of the placenta. Treatment: The ])roper apj>lication of Crede's method ..t' expression is usually all that is re(iuired in the way of tnni- ment. The uterus may be steadied and held in ])osition liy laying one hand across the sujirapuhic; region of the abdoimii, while the other firndy squeezes the fundus and at the same time exerts pressure in the axis of the pelvic inlet (lurin;/ le of fingers into the vagina, so as ht rtnich the lower edge of the placenta and hook it forward. Adherent Placenta. In this condition, which is rare, the placenta is not onlv retained, but is also adherent to the uterine wall. The adlu - AhllEREST PL A ( 'KXTA . '2i\: -ion is riuvly complete ; a part of tlie placenta is usually detached. The turn siiuises bleed [)r(»f"usely, as the uterus Fig. 100. ii Artificial removal of adherent placenta. (Modified from Ribemcnt-Dessaigncs and Lei>af,'e) "luuiot contract properly on account of the portion of the jihicenta which remains adherent. Causes : The most frecpient cause is a placentitis (or de- cidual inHammation) of specific ori<^in. Chronic endomc.'triti.s 2-ii( have been retained. A hot intra-iiterine douche should then be given. It is advisable to administer a full dose of ergot as soon as the uterus has been emj)tied. MATERNAL DYSTOCIA. The subject of maternal dystocia may be divided into three headings : 1. Anomalies in the forces of labor ; 2. Anomalies in the pelvis; 3. Anomalies in the maternal soft structures. 1. ANOMALIES IN THE FORCES OF LABOR. Precipitate Labor. Excessive power in the expulsive forces of labor may result in the very speedy comjdetion of the act. Etiology : The condition is usually due to undue e.vcltahUifii of the .sympathetic nervous system, rather than to excessive FliECIPITATJ': LAHOR. 2G!) imiscii];ir dovelopmont. It may tlu'rofort' be met with in \i)imidly, it may be lie/d hack by inserting the fingers in the vagina and resisting the advance of the pre- senting part, while at the same time chloroform is administere remains firmly contracted. Delayed Labor; Uterine Inertia. When the expulsive action of the uterus is unable to over- come the normal resistance of tlie maternal j)assages, labor is delayed and the pains are said to be " weak." Causes : The commonest causes of uterine inertia are pre- mature rupture of the membranes, rigid os, a distended bladder or re<'tum,and general debility of the patient. Oblicpiity of the uterus; overdistention,as in multiple pregnancy or hydramiiids; degeneration of the uterine muscle-fibres from inflammation or too fre(pient childbearing ; malpresentation ; uterine tuniois or tumors of neighboring structures ; and low attachments of the placenta, may all be mentioned as causes of uterine inertia. Diagnosis: Before making a diagnosis of uterine inertia care should be taken to ascertain if the bladder and rectiiin have been emptied. By external examination the contraction of the uterus may be felt to be weak, for the organ will not assume the intense hardness associated with good uterine action. By vaginal examination in the first stage the bag ot' waters does not become tense during a pain, or if the mem- branes have ruptured the presenting part does not descend. Examination should then be made to ascertain that the labor is not delayed by some obstruction. The prognosis depends on the stage of labor and the canso of the inertia. In the first stage there is little danger to either mother or child unless the membranes have been lonir rnj)tured. In the second stage of labor there is danger to both mother and child from prolongation of the labor. DELAYED I.MlOli; VTERISE ISEliTlA. 271 No hard-and-fast rule as to liow loiii; delay nilu^lit l)o with- <'iit danger can l)0 lainis n .sfcri/izcd hoiif/ir may he inserii ,] into the nti-rus, and the vajz^ina paelced lightly with iodot'iinn i;auzo, as for the induction of premature lahor. 'I'he iniio- duction into tlu; cervix of a Champetier de Ivihes l»ataiii c olfered by the os. 'V\w /)(((/ of iralers should not bo ru])tured until the o-; is dilated, unless it is evident that tlu.'re is an ex(X'ss of licpior anmii j>resent, and that this is the probable cause of inelliciciit uterine action. When inertia is j)resent in the second .sfaf/c of labor the patient may be allowed to walk about, in the hope that the descent of the head under the influence of ^I'avity will set up uteriiu! action by rcHex stimulation of the |)elvic floor. Pressure on the fundus with the patient in the dorsal jxisi- tion may i)rov(! of value when employed durinji^ uterine cdii- tra(!tions. When other measures fail resource must be had to the forcej)S to terminate labor. 2. ANO.NrAIJKS OF THE TELVIS. The ^reat majority of anomalies of the pelvis arc of the nature of contraction. Contractions in the diameters of tlic ])elvic brim give rise to the most serious conseciuences both to mother and to child, in proj)ortion to the degree of ob- struction olfered to the passage of the fport»Ml, llic ditltToncc oxtcudin^' from 1.2 |iir <'(Mit. ill Iviissiii, to *J l.."> |)('r ('ciil. in S;i.\ouy. \'oii \\ inckcl ('oMsioston, 1.1.'} per cent.; ( 'rosseii, in St. lioiiis, 7 percent.; Dolihin, in Haltiinore, 11.1.") per cent.; and W'illiains, in ilailiniorc, 1;>.1 per cent. Davis, fioni tiic records of 1221 patients, ((inclndes that 2') per cent, of the women in tlie Ignited Slates have pelves smaller than the avera;i,(', while 7 per cent. have pelves Iar<^er than the averaj^e. Hirst states that detoiMned pelves are hy no means rare anionic: native-horn women in the Eastern States. Classification: \"arions classifications ol' pelvic^ anomalies have heen employed in dilTerent countries, hut the following-, taken from Jewett's Pntcfior of ()/>s(c(ri<-s, will he fonnd snf- (iiiciitly comprehensive to meet all re(|iiircments : I. Pelves normally proi)ortioiied Init ahnormal in size: 1. Fniformly enlary kyphosis of the spine. 5. Compressed pelvis : (d) JVfalacosteon ; (b) PseuiloiMalacosteon rachitic. 6. Sj)ondylolisthetic. 7. Pelves distorted by injnry, tumors, anchylosis of joints. 8. Deformity due to spinal curvature : {(i) Kyphotic ; (/;) Scoliotic ; (<') Kyphoscoliotic ; ((/) Lordosis. Diagnosis : Theoretlealh/ it is the duty of the physician to take careful measurement of tlie pelvis of every woman li(> is calhsd ui)on to attend in labor; practically, this is rarely doDc until delay in the progress of labor calls attention to the ilict that possibly some obstruction exists in the pelvis. Deformity of the pelvis is most frcqnerifli/ met with in those women who in childhood have suffered from malmitiilidu, rickets, or tuberculosis of the vertebne or joints of the lower limbi-", or who early in life have suffered from accident to a limb which has resulted in shortening, dislocation, etc. Maldufrition and lutnl vorl: early in life not infre(|iictitly result in flattening of the pelvic brim. Rickrt,^ may lead to various serious pelvic deformities. A Jiixfofi/ of late dciiti- tii)n, ])rolonged indigestion, of not walking after the second vear, v^ould suti^irest this disease. An examination of sncli a patient might reveal the square head, ])igeon-breast, head- ing of the ribs, or bending or twisting of the long hones common to this disease Usually these patients are of short stature. /)/,s'cr/.sr.s' or acriih'iifH resulting in (h'formity of the s|)Iiie or lower limbs when they have occurred c\' of the head in descend info the pdrifi at or before tlie onset of labor, associated with undue proni'nence of the alxlo- rh'LVIMKTRY. 27 rj i;ien, sliould always .siijj^gorit oUstniftion at tlio pelvic brim wlu'ii these conditions are found present in a pi'imij)ara with a vi'Vtex presentation. Pelvimetry. Deformities of the pelvis may be detected by rrfrrnaf and infernal pd/jHitioii ; and by inraimreinnds, both external and internal, of those diameters of the pelvis which are accessible. l'\)r inkiiHj jM'frir nu'af-'Ui'einciif.s the examiner's Hn<2;ers, a ta|H'-measnre, and a jiair of modified calij)crs, known as a i)el- vimeter, are usually employed. The jK'lvimeter devised by r»;iii measurement should be about lOj inches (2Bimi.) ; the knni,s of the })elvimeter are then moved along the cvtcrnal ahjix nf the i/iao crests until the greatest distance I.: found, the measure- ment of which should be about 11 inches ( 28 cm .), 'flic length of these measurements, as well as any im])()rtant dilHr- ence between them, enables us to draw our conclusions as i- urement of the external conjugate, to allow for the thickness of bone and soft tissues; this would give the normal true conjugate, 4 inches (10 cm.). The ohli/jue diameters of the brimmay be measured by ])la(iiiLr one knob of the })elvimeter in the depression marking ihc posterior suj)erior spine of cue side, and the other knob on the anterior su])erior spine of the opposite side. In sym- metrical pelves these measurements are usually equal, and should be about inches ( 22.5 cm .). The circumference of the pelvis may be measurc<'l by jtlacii'^' a tajie-line around the body, so that it will ])ass jus<" over the symphysis, under the iliac crests, and over the middle of iIh' sacrum behind. In a woman of average development and with a normal })elvis this measurement should be about 'loi inches (DO cm.). PELVIMETRY. 277 The otlicr oxtoriial nicasurcnu'iits of iinportaiicc arc tliosc tt' tlic (H((/<1 oj' the jH'lvis. Tlic (rdii^svcrHC didincfcr ot' tlic otit- !i't is uicasiired by placing tlio kn()l)s of the pelvimeter on the inner sides of the ischial tiilxtrosities. The (tiifcroposfcrior 1 1 idiacter \m\y be measured l»y jilacing one kiioh of the pelvim- rtcr on tile under border of the symj)hysis pubis and the other knob on the skin over the lower border of the tip of the acrum. i^'rom this l.;}em. nuist be deducted to allow for iliicknessof the bone, etc. This measurement can be better (il)tain(!d by placing the tij) of the middle linger of the left hand, inserted into the vagina, against the end of the sacrum :iiid pressing the edge of the hand against the lower bolder of the symphysis, the point of contact being marked by the iiidcx-Hnger of the right hand and the distance measured niter the left han the length of the diagonal conjugate. From this mcasiire- iiu'iit I inch (1.75 cm.) should be deducted to obtain the true 278 PATHOLOGY OF LABOR. coiijiij^ato (liamotor. This average (liircronoo bctwoou t\u>< two cliamoters (lepciids upon tlie licight of tlio syinpliysis ( 1 ', inches, 4 cm.), a normal angle between tlie axis of the ])u1ms and the true conjugate (105 degrees), a normal thickness of tli^' symphysis, and a normal height of the promontory. When the height of the symphysis is greater than l^ inclu^ (4 cm.), about 'j inch (2 cm.) should l)e deducted from tlic diagonal conjugate. The true conjiu/dte may be measured with almost perfect accuracy by means of a special pelvimeter invented by llir>t, Fig. 102. Internal pelvimetry. Measuring the diagonal conjugate with the hands. (Jewctt.) of Philadelphia. Hirst's measurement is from the promoiiduv to a })oint one-eighth of an inch below the uj)per, outer boidf r of the symphysis pubis. Plirst's pelvimeter corisists of a iniilo)ifj<'(J, and the head undergoes much 111 )nlding, the caput succedaneum being unusually large. 1 hi; suboccipitobregmatic diameter of the head is com- jtressed and the occipitomental elongated (Fig. 105). Treatment: If the heaf He\i(^n DiaRram showinpr head iiii- n(!cessary to permit the CUiJ^agenicill iiKiiildcd ami inoiildud by lalxir p ,i /•■ • i i •' fi i ill ajiist()iiiiii..icasf. ot tlic aiter-comiug head m tlie pd- Red, mouldi'd. VIC DUm. Pelves with Anomalies of Size, Shape, Inclination; or Combinations of These. Mir^cT Developmental Peculiarities. Masculine pelvis: Tn this pelvis the bones are heavy and strong, and the whole ])elvis is masculine in character. Labor may be ])rolonge(l and difficult on account of dehiy either in the brim or the outlet. Forceps are frequently re- quired to accomplish delivery. Shallow pelvis : The distance between the brim and tlie outlet is relatively less in this form of pelvis than in tlie normal. As a rule, labor is easy, though occasionally forcejo are required. Deep pelvis: There is an abnormal increase in tlie distance between the inlet and the outlet in this form of ])elvis. Pro- vided the diameters are normal, labor is not interfered with. Funnel-shaped pelvis: In this form of pelvis the .sacrum is narrow and has little perpendicular curve, and thus the depth of the canal is increased (Fig. lOG). In this form of pelvis the contraction is nicst marked at the outlet, and may Ix' in VKI.VES WITH ANOMALIES OF SIZE, ETC. 28.'} \\\i\ anteroposterior (liainctoi', or in llic latoi'al, or in hotli. Tlic pelvis tlius approaclies tlic niascuiinc in type. Injlunur <,ii Lahor : Tlic lueelianisin of lai»or is interfered will) and tlie head tends to Ix'cotne extended in tlie cavity of ;lie pelvis; tliiis backward rotation of tlie oceij)nt is likely to oei'ur. Jiahor is usually prolonged, tlie delay oceurrinu- v. lien I he head is at the outlet. There is j^nater risk of extensive rupture of the ju'rineinn. The soft parts at the ju'lvic outlet are likely to be injured by undue pressure of the head. Flu. 100. Funnt'l-shaped pelvis. (After Winokel.) Treatment: Tn the lesser fjrades of contraction the 'woman may be delivered spontaneously or l)y force])s. In the higher LH'ades the C^esarean ojieration may be recjuired. Sym])hy- siotomy may be employed Avhen the contraction in the outlet is not marked and efforts at extraction by means of the for- ceps fail. Flat Pelves. Shortening of the conjugate diameter of the brim is the main characteristic of flat pelves. Simple Flat Pelves; Non-mchitic. Schroder states that this variety of deformed ])elvis is more frequently seen in Euro})e than all the other forms put liSl I'ATIIOIJXIY OF LAIlon. tojj^cllicr. In Anicrica th(( sliiij)l(' flat, and tlic ^;('n('i'allv coii tractod, ai'c; tlic two varii^tics of pcKic (Icroniiity mo.st lic- (jiictitly met witli. Hirst, ill a scries of .'{KJ pelves in women of American hirtli, found flatteninfj^ to exist in 5.<) j)cr cent. Davis, in a series of 1 1224 pelves, found the simple Hat in 5.7 \)vv cciii. Characteristics: The sacrum is small, and pressed down- ward and forward between the iliac bones; as it is not rotatnl Fid. 107. Flat nonrachitic pelvis. (After Kleinwiichter.) forward on its transverse diameter, the anteroposterior diam- eter of the pelvis is therefore contracted throughout its wlinlc extent. The transverse diameter remains as great as in the normal pelvis (Fig. 107). Frequently in flat pelves there is a dnuhlc prnmoiifori/, m) that a line drawn between the second sacral vertebra and the symphysis is often as short as, or shorter than, the true con- jugate. PKLVKS WITH AS OM A LIES OF i>lZh\ ETC 285 'PI)o he has had dilli- culty in previous labors. \W pelvimetry the transverM' measnrements will ho fonnd to he normal, while the antero- posterior diameter will be diminished. The Flat Rachitic Pel r is. Characteristics: Rachitis loads to increased condensation in the hones; hc^nce in the flat rachitic pelvis they are heavier, thicker, and somewhat smaller than in the normal. Tiie sacrum is wider than in the normal pelvis. The i/inc crests are more or less everted at their anterior ends, so that the interspinal diameter is eipial to or lireater than the intercristal. "^I'he ilia are flattened, so that the fossie are not so distinctly hollowed ont nor are the iliac winujs as (•xj)anded as in the normal pelvis. The y>c/r/c hriin is kidney- shaped, not heart-shapc.'d, as in the normal pelvis. '\\w coii- jii(/(itc is diminished ; and the traiis- rcrsc (lidmetcr relatively or ahsolntely increased. At the outlet the transverse diameter may he widened and the antero])()sterior he eitluir normal or increased (Fig. 108). The pnhic arch is wider than nor- mal, and the symphysis is deejx'r and is rotated on its transverse • liameter, so that its npj)er border converges toward the j)romontorv. Tims the relation of the trne conjngate to the diasxonal conjngate is not the same as in the normal pelvis (Fig. 109). I)ia;,'riiiii shdwiiiu outline of liriiii !>(' iKiriiml and of Hal racliitic [)clvi.s. Hhick, normal. Itud, flat. IMAGE EVALUATION TEST TARGET (MT-3) J^:^ % // y. X* >> ,.. 'mis- v.. 1.0 I.I 11.25 1^ no US US Ui 1^ IIM tei Ilia 2.0 ■ 40 14 mil 1.6 V] <^ /a ^>. PhotogranFiic Sciences CorpoMon 23 WEST MAIN STREET WEBSTER, NY. M580 (716) 873-4503 28 (i PATHOLOGY OF LABOR. Fig. lOU. In tlu' rachitic })elvis the coxjiif/dta vci'(( may be diniiiiislK (i to any extent, dcjicndin^- on iIk (lc<>;rcc of dcfoi-niity pi'o.-cMt, Etiology: liadiitis in its cjnU stages causes a softening (»f tin bones and bgaincnts. Tlic wcigln of the body tends to pnsii tin ])roniont()ry of the sacnnn dowii- Mard and forward ; tiiis causes ;i rotation of the sacnnn on ii- transv' rse diameter, and teiids to eh , te the h)\vei part of tlii> bone aiivl the coccyx uj)\vard and backward. Thestr(»ng liganuiits attaclied to the h)wer part of ilic sacrnni prevent its niovenicni u{)war(l and l)ackwar(l, and tin residt is a sharj» bending of tin' nin>:mm sliowinp (lillVrcnoc be- Ixino pnxhiccd ill tlie n('iuhi)or- twfi'ii iioniml iiiid nichitic iu'lvis , i n i /« i i on vtiti'iii niLsiai siciiim. Iiood oi the lourth saci'al VCltc- l)ra. iJesides tlie weigiit of tlie body, tlie action of the imischs attached to the jH'lvis lielj)s to bring about the (k'ibrniity. Tlic increased sepai'ation of tiie ischial tuberosities is thie to tlic action of the abchictor and rotator niusck's of the tliigiis. 'I'hc (k'gree of (k'formity pnxhiccd by ra<'hitis depends on tlie dat( of its appearance, its severity, its duration, and the habits ol' the child. Diagnosis : The history of the woman, her appearance, and the examination and measurements of her pelvis will permit the establishment of a diagnosis. The rachitic woman is usually nnder-sized. She may li:i\i' a s(pia re-shaped head or deformed thorax (pigeon-breast), bead- ing of the ribs, and curved long bones, which may beenlarg((l at the ends. When she lies on a Hat surface with the liiiili- well extended lordosis is generally jiresent. Pi'lric invdSKi'onnif will show that the relation of the spines and crests of the ilia is altered. The external conjugate ami the diagonal conjugate diameters will be found diminished. On account of the increased depth of the symphysis and the divci- PELVES WITH A SO MA LIES OF SIZE, ETC. 287 iTcncc of its lower mar^iii, ^ iiK-h (2 cm.) wnx^i bo dcdiicttHl iVoin the diagonal conjugate, instead of the average j? inch ( 1.75 cm.). Care must he taken to ascertain if a doiihlr pr(»notil())i/ is present; and if so, the conjugate should he measured from the projection of the sacrum which is nearer the symphysis. j\ [cell (til is}ii of Labor in Flat Pr/irs. The contracted condition of the conjugate j)revents the entrance into the jwlvic inlet of the j)resenting part ; hence the ahdonien is usually more or less pendulous. The |)resenting part, if it is the head, is usually found at the onset of lahor to he restintj in one or otiier iliac los>a ; or it may he tirndy pressed down upon the hrim in a transverse position, so that its longest diameter is accommodated to the li ingest diameter of the jjclvic inlet. Malpresentations are common, and piolapse of the coi\; and of the extremities is not infre(|Uent. The first stage of hihor is usually ])rolonged, because of the non-descent of the head. The membranes protrude from the OS in a cylindrical pouch. TTnfortunatelv the \)\\\i of waters nsnally ruptures early ; annds, and thus extension of the head occurs ; this brings the small bi- tcni]>oral, insteatl of the larger biparietal, diiuneter of the lu'ad into relation with the contracted conjugate. The movement "rounding the promontory" then takes place. The posterior parietal bone becomes arn'sted on the ptomontory, so that the head becomes oblicpiely displaced by tm-ning on Its anteroj)oslerior diameter. Thus the sagittal >iitiu-e, instead of remaining in the middle of the ju'lvic inlet, :ipj)roaches the promontory, as the anterior parietal bone slips past tlie uj)per border of the symphysis and enters the cavity i»i the pelvis. Then the posterior parietal bone slips past the >^- 288 PATHOLOGY OF LABOR. Fic;. 110. pronioiilorv, and the licad outers the pelvic cavity in an extcndc.! position (Fig. 110). Once tiie obstruction at the superior strait is passed, tin head usnally descends with ease and rapidity, tiie rest of tin nieclianisin going on normally. Occasionally rotation of tli^ head fails, and owing to the widtii of the transverse diani'ti i of the ])elvis it is expelled from the vnlva in its original ti-an - verse or in an ohiiqne position. Head-moulding: The caput snccedaneimi is gencrallv wa exagg<'rated. Usnally the cliildV head shows what is known as tin- " j)romont()ry mark." This nuiv 1m' only a red mark on the parietal iv- gion, between tiie anterior fontiuiciji' and the parietal eminence which was in contact with the promontory. Or- Moulding of head duriiiK casionally thcrc mav be an actual dc- Kif ""'""''''' ""' ™""'"' pression of the i)arietal bone in tliis region. Sometimes a gnttcr-lil-c groove may be noted in a lin(^ running outward and forwaid on the child's skull. Usually the posterior parietal bone i-; depressed below the anterior, which overlaps it at the sagittal suture. Treatment of Lahor in Flat Pelres. Care should he taken to keep the membranes intact as Iniitr as possible, by keeping the pntient in bed during the first stanv of labor, and by warning her Ttrainst "bearing down" dnriiii: the pains. If the conjugate is not greatly diminished, the head will usually engage, provided it be given ])lenty of time to nionM. To this end the uterine contractions should be controlled by means of hypodermic mjections of niorjihine or of Battley's S(ilu- tion. The patient's strength should be maintained by ;lio administration of nourishing broths, egg-noggs, ect. If tlio child's head be not iniduly ossified, this treatment in the lai^e proportion of cases will j>rove successful. Should the head not descend, interference should not \>o delayed too long, for there is danger that the pressure of ilio head may residt iii , necrosis of the cervical tissue over the PELVES WITH A yoM A LIES OF SIZE, ETC. 2^1) promontory and of the anterior va(i:iiial wall behind the .syni- [ihysis. J)elivery hy the eMij)l()ynu'nt of axis-traetion fitrccjis tnu^t ;hen bo attempted ; for this ()j)eration the patient shonld be |ilac'ed in \\ ulchci's position. JShould the Ibreeps operation fail, delivoiy of a iivinjij child ean only be effected by recoiii'se to sym])hysiotomy or to C'tusarean section. Obliquely Contracted Pelves. ()l)li(juely contracted ])elves result I'rom : («) Imperfect develo})ment of one sacral ala; Via. 111. Sin<,My (il)li(HU'ly coiitriictiMl ]p(i\ is. (AftiT ^■■ill(■kel.) (h) Imperfect or abolished nse of one limb; or (/') Lateral ciu'vatnre of the spine. 19_0bst. 290 PATHOLOGY OF LABOR, fn tlicso pelves tlu; jK'lvic inlet 1ms an oval shape, with tli small point directed to the atrophied side of the pelvis {Fvj;. 111). The diagnosis is based upon the history of the woman, an I a earefiil examination and measurement of her pelvis. Influence on labor: The mechanism of the head in passiiiL: throni^h an ()l)li(jnely contracted })elvis is the same as in tin' case of a justominor pelvis. The head usually enters the briin Fig. 112. Transversely contracted pelvis. (After E. Martin.) in extreme flexion, with its long diameter in relation to the long, oblique diameter of the pelvis. The long, ol)Iii|iii' diameter is usually that of the diseased side. As the hcnl descends rotation may fail and the occij)ut may turn toward the sacrum. Treatment: The long diameter of the head should alw:ivs be brought into relationshij) with the long oblique diameter of the pelvis by manual rotation, should Nature have failed to accomplish this before the onset of labor. Should descent of the head be delayed, the axis-traction forceps should be tried. Should these fail, Cfesarean section is the oidy operation available. Should the condition be diagno.sed early in pregnancy, pn-- PELV/'JS WITH ANOMALIES OF SIZE, ETC. 291 iiiiitmv liihor may ho iiulucwl, provided the deformity of the iK'lvis is not extreme. Transversely Contracted Pelves ( Fig. 1 1 2). Transverse contraetion of the pelvis results from: {(i) I nipt' r feci (hvclopmcnt of both sacntl ahv (Robert pelvis): {/>) Ki/plio.si,s of the sj)inc. This is a very rare (U'formity. As delivery "per vias naturales" is impossible, Caesarean .^ection must be employed. Compressed Pelves. Two varieties of compressed peKes have been described, the liiiilacotiU'on and tiie pscudomalacoKffon. 3f ,i hcak. 'I'lic curve of the sacrum is ij^reatly ex auge rated ain! the coccyx }»oints upward into the pelvic canal (Fi^s. ll.'>, 11 I and 1 \i)). Etiology: 'i'he condition is l)rou<;ht ahout hy ^reat softenin- of the hones resullin<; from osteomalacia (mollities ossiiuiii. This disease is met with chiefly in Euro[)e, and is chnracteri/i lvis to the lower limbs. Diagnosis: This is based npcsn the history of the wnmaii and an examination of the pelvis. Treatment : When the bones are soft delivery may be efticli il by means of forceps ; when the bones are hard and the deronn- ity ))ermanent, Ca3sarean section must be performed should tlic j)clvic contraction be extreme. IWuiJoutdlcK'oxffon (Rachitic). This deformity of the pelvis, produced by severe rachitis, may closely apj)roximate that produced by osteomalacia. PELVES WITH ANOMALIES OF SIZE, ETC. 2S>;> Wiiilo the (k'toi'inlly of tlic tnio [u'lvis is very imicli as in the iimlacostt'on, the iliac wings aiv widoiy sepaniU.'d as in tlu' typical rachitic condition. Spondylolisthetic Pelves. Definition: 'I'lic name applied to this variety of pelvic uall\ congenital, rarely produces such deformity of the pelvis a- s<'rio',isly to obstruct labor. Tumors: T'^9 commonest tumors which occur in connection with the ])elvis are crnstoscs of the joints. Fibroma, sarcoma. carcinoma, and (Michondroma of the ])elvic bones may distoit the pelvis and so lead to obstruction (Fig. 117). Treatment: When the growth is not excessive delivery 1»\ the natural passages may be possible. When such is not ilic case Csesarean section must be performed. Symphysiotoiii\ may be employed in suitable cases, when the sacro-iliac joints are not involved in the tumor. Fractures of the pelvis: Deformity the result of fracture ol' the pelvic bones is rare. Separation of the symphysis pubis : This accident may occiw rKLVES WITH ANOMALIES OF SIZE, ETC. oor; 95 as IX result of^ioat force l)einion lias been pel loiMiied. Osteomalacia, rachitis, syj)liilis, and tiihei'ciiiosis, or any |)r(t- lound cachexia, may predispose to the occnrrenci- of this aci'i- ilent. DidgnoaiH : The ])atient fjjenerally com|)lains of sharp pain at tlic! moment of sej)aration of the joint. The con«lition may he iccoy-nized l)v introdncinti* the index-fmijccr into the vagina behind the joint and grasjying it between the tinker and tin. nib. Fig. 117. Malignant growth of posterior wall of jiclvis wliicli nccossitated Ca-harean section in a case of i)r. Canierdn. Ti'catmeni: This consists in the ap})lication of a firm pelvic uirdle as recommended for use after the operation of sym- |>liysiotomy. Anchylosis of pelvic joints: This condition may affect any of the pelvic joints. When the symi)hysis is att'ected it lias l)nt little influence on labor. Anchylosis of the sacro-iliac joints may result in serious pelvic deformity. Not uncom- monly the sacrococcyj:^eal joint is affected, in which case ob- struction may occur at the outlet. Fracture of the coccyx is tiic usual result. 21)0 PATHOLOGY OF LAliOli. Split pelvis: Want of ('(iiiiplctc (Ic.'vcldjuiicnt of tlic aiitcrinr wall «»f" iIk! jic'lvis n-sults in this condition. It docs not caii-f any olistriK.'tion to labor, but is likely to be associated with precipitate delivery. Pelvic Deformities Due to Spinal Curvature. Kyphosis: 'I'lie derniity resulting; from kyphosis dep(!nds on the situation of the hump; the nearer tlii- is to the sa(!niin the greater ':. the deformity of the ju'lvi-. (jrcnerally th(^ kyphosis occurs about the junction of the doixil and lumbar vertebne. Trcctiiind: i^ the degree of contraction is sligiit, labor i> us'ially easy. Tiiere exists an old saying that " hunchl)acks Fig. 118. Lordotic pelvis. (After Kleinwiichter.) have easy labors." AVhen delay takes ])]ace fofoeps may be required to effect delivery. In extreme contraction the Oesarean operation is demanded. Lordosis is a rare condition, and is usually secondary to spinal disease or pelvic deformity. To a certain degree it afi'ords Ay()MALU:s OF rTF.niSE DEVh'LorMhWT. 21»7 ('()iii|M'iisati()H ; hut, as a rule, il i- not siiniciciil, and a I'dla- lioii (»r t!i(j .sicniin occurs, x) that the iippci- end is llirowii hacUNvard and downward ( Fin'. ILSj. 'I'lic pelvic canal tends to become t'niniel-sliaped on accoinit of tlie projection lorward ol' tlie l.»\vc'r |)art <»(' the sacrum and the partial ohliteration of the piH)mont«»iT. At the iii/<( th(! conjiinate is increased while tiic^ antero- posterior diameter is dimini-hed. The diameters at the oiifdf are usually more or less diminished. Scoliosis: 'I'heett'ect oi' scoliosis on the pelvis depends on tlie -iluation and extent of the spinal curvature. 'J'he lower it is and the earlier it occurs, the more serious are the efllects pro- duced in the ])elvis. There is usually some deoroe of oMicpu; contraction present in the pelvis of a j>atient the subject of .■scoliosis. 'J'he condition is fre}ii/.^it< is thus pushed toward the oj)posit<' side. Thus the ijreatest degree oi' pelvic contraction is on the side of flic spi)ia/ ronrexifi/. In (ahor the largest part of the head generally descends on the roomier side of the pelvis, through which it may pass when in a state of ijood Hexion. In cases in which the pelvic deformity is extreme the Csesa- rean operation nuist be resorted to. Kyphoscoliosis: Rachitis may j^roduce both kyphosis and scoliosis in tlie same woman. If the kyphosis is situated high up, but little effect may be produced on the pelvis. 3. ANOMALIES OF THE MATERNAL SOFT STRUCTURES. Anomalies of Uterine Development. Varieties: Tiabor may be complicated in many ways in a jiaticnt who has a double or se])tate uterus. ]Mal))ositions of the ffrtus are common. The unimj)regnated half may caus(! obstruction by its bidk, as it usually imdergoes considerable it/ 298 PATHOLOGY OF LABOR. increase in size in sympathy witli tl:'j impregnated iialf. ]i tiie placenta is attaclied to the sejHum, severe hem()iTlia}:;e ni;i\ take j>lace owing to imperfect (;ontractiou. Kupture of tlie septum or of tlie uterus may occur. The decidual membrane which has formed in the imjiroo- nated half of the uterus may be retained, and, undergoing pio- liferation after delivery, may give rise to scj)tic infection. In all cases of anomalous development of the uterus labor- pains are usually short and inefficient. Pregnancy in a rudimentary horn is a most dangerous coiidi- tiou, and when diagnosed it should be treated as a case oi ectopic gestation. Treatment: Forcej)s or version must be resorted to in nid-l of these cases in order to efleci delivery. The former shoiiM be chosen in })reference lo the latter when possible. Cesarean section may be necessary. Abnormal Conditions of the Cervix. Varieties : Atresia, cicatricial conditions, contraction, aiul rigidity of the cervix, may all give rise to more or less ob- struction in the first stage of labor. Atresia is a very rare condition, and it is very seldom com- plete. The situation of the external os may be recogni/cd :!,- a dimple. Pressure upon this with a blunt instrument, sikIi as the tip of a uterine sound, is usually all that is rcqniicd to perforate it, after which dilatation usually jiroceeds raj)idly. Cicatricial contraction of the cervix is usually due to old laceration, or it may arise from a repair operation, from cautir- ization, or from syphilis or cancer. Rigidity of the Cervix. Etiology : When not due to orgnnic chariffes, it is said to be funcfio)ifil. Functional rigidity is common in highly sensitive young women and in elderly primiparre. It is usually due to some imperfection in the nerve-supply of the uterus, and i> frequently associated with inefficient uterine contractions. Treatment: When tiie rigidity of the cervix is function..! in origin it may usually be overcome by the employment of ncivo DISPLACEMENTS OF THE IJTERf'S. 29{» sedatives and hot douchos. Syr. chloral, hydrat., siss, should he administered in warm milk. Ten minutes later a hot vajr- inal douche (110° F.) should be «riven, at least two (juarts of water being used. Every succeeding ten minutes a dose of chloral and a hot douche should be given in alternation, till the patient has received three doses of cidoral and three hot douches, should the cervix not yield befui'e. In the autiiors ex})erience this plan of ti'eatment has rarely failed. In some eases a hypodermic injection of mor{)hine, gr. ], is all that is required. Painting the cervix with a 2 per cent, solution of cocaine has been hi<;hlv recommended, (k'casion- ;dly a few whiffs of chloroform with each pain act like a charm in relievino; this condition when it occurs in a hiirhlv nervous patient. When these methods fail, artificial dilatation by means of the fingers or by the introduction of a Barnes or Cham[)etier (le Ribes bag may be necessary. In extreme cases it mav be necessarv to make several small incisions, one-quarter to oui'-half inch deep, in the cervix be- fore proceeding to artificial delivery. Impaction of the Anterior Lip of the Cervix. Occurrence: This condition may occasionally obstruct the advance of the head at the outlet. The anterior lip in these cases is caught between the head and })ul)es, and, becoming swollen and cedematous, may actually protrude at the vulva. After labor it mav slou";h. The proper treatment is to attempt to j)ush it uj) in the intervals between the pains. If it be v(My (edematous, it mav l»e necessary first to make a number of small incisions into it to permit the escape of serum, when its reduction may be ac- complished without difficulty. Displacements of the Uterus. Anterior displacement of the uterus at the time of labor is not infrequent. It is generally due to a lax C(»ndition of the abdominal walls. Treatment consists in the application of a tight abdominal :]{)() pATiroLoay of labor. hinder, and in k(.'('j)ii); version, the danger of this operation being rupture of tli* thinned-out posterior wall of the uterus. The writer in oiif case was able to push the anterior wall out of the way siii- ficiently to permit tin; application of the forceps to the head, which was then drawn down. Abnormal Conditions of the Vagina and Vulva. Longitudinal and transverse septa may be present in tin' vagina and obstruct the advance of the presenting part of the fetus. They are seldom very dense in structure and are ea-ilv ruptured. If they do not yield, they may be divided between ligatures. Unruptured hymen : This conditi(Hi may be found present in labor; it causes but slight obstruction; occasionally it may he necessary to incise it. Atresia of the vagina: Narrowing of the vagina mav ho due to maldevclopment or to cicatricial contractions after ])n- vious injury. Trcdtitiod: Hot douches followed by injections of sterili/cd sweet oil may be employed to soften the part. Dilatation may be eflfected by the use of Champetier de Ribes's bag. Rigidity of perineum: The perineum mav be so rigid as to prevent advance of the fetus. This condition is common iii muscular women and in elderly priniipar«3. Ti'catmoit : In these cases the forceps maybe recpiired to draw down the fetus. During delivery the perineum may lie softened by the free use of hot fomentations, care being takin to smear the parts with vaseline, to prevent burning. Wlun laceration is certain, episiotomy may be performed. Hsematoma : This condition is, when present, found at flu' vaginal orifice. Treatment: If large enough to obstruct labor, the tumor should be excised and the contents cleared out ; after delivery, if hemorrhage from the cavity takes place, it should be packed with iodoform gauze. TUMORS OF THE GENITAL CANAL, ETC. 303 Varicose veins wlien prosent seldom (»l)stru('t labor. They iiiiiy rupture or bo so bruised i;s to slouijh alterward. CEdema of the vulva due to heart or kiduev disease uiav ob- struct labor. Multinle puuetures shoidd only be resorted to in extreme cases, as there is great risk of sepsis or gangrene fol- lowing delivery. Abnermal Conditions of the Bladder. Distended bladder: This is a not un(!ommon cause of delay in labor, and should always be borne in mind. The urine .-hould be removed with a sterile, long, soft catheter, the pre- senting part being pushed up so as to j)ermit access to the 1 -ladder. In cases in which it is impossible to pass the cathe- t( r perforation through the abdominal wall may be re(iuired. Cystocele : In this condition the bladder may j)rotrude through the vulva. Treatiiif)d : The urine must be drawn by means of a soft (Mtlieter, and the prolapsed jxirt afterward pushed gently up :il)ove the presenting part of the fcetus. If reduction prove imj)ossible, the part must be held up while the child is ex- trncted by means of the forceps. Vesical calculus : If small, the calculus may not obstruct labor. If possible, it should be pushed up above the sym- physis. When large, it may be extracted after dilating the ure- thra; or it may be necessary to incise the bladder through the anterior vaginal wall. After labor the incision may be sutured. Tumors of the Genital Canal and Neighboring Organs. Carcinoma of the cervix : It may be said that, as a rule, when this condition is present at full term serious obstruction to labor results. Spontaneous delivery may occur if the dis- ca-o is limited to the anterior lip and is not surrounded by a large area of cicatricial infiltration. Hemorrhage and sepsis are likely to arise during the puer- pcrium. ( ^jesarean section is the proper treatment, if the disease is fairly extensive. 304 PATllOLOdY OF LAIiOR. Fibromyomata. Tlu'obstriu'tiors to hibor rosiiltiiiLj from tlio pmsciice of'lil)i..- myomata dciKiid on tljo situation of tlie new <:;ro\vtli. If it s{)rin0. ^fc'/i'/r> Per/neum Myoma uteri complicating pregnancy. (After Spiegclberg.) Effects: They lead to mal presentations and malpositions (d' the f(etus, to prola})se of the cord, to adherent placenta, and in hcmorrha2:e. The lal)or-pains are likely to be inefficient. A tetanic condition of the uterus is not infrequently met with in these cases. The pressure of the tumor may j)roduce severe contusions oi' fractures of the f-siblc! to push it u|)0ut of harm's way by placint]^ the patient ill tli(! knee-chest [)osition. If this fails, it may be possible to extract the child by means of the tbrcej)s with the woman in W'alcher's position. If this be impossible, C^iesarcnui section imist be performed, or else Porro's operation. if the tumor is suh)imi'nus and attached to the cervix, it may be possible to remove it by enucl(>ation evcMi after labor lia^ begun. After labor the tumor cavity . hould be packed with iodoform gauze. In all caseti iu which delivery takes place through the natu- ral ])assagos there is great (hiuf/rr of Jirmorrliar/c from imper- fect contraction of the j)lacental site. Should hot intra-uterine douches and iiypodermics of ergot fail to control the hemor- rhage, the cavity of the uterus must be packed with sterilized iodoform j>;auze. The ijauze mav l)e left in the cavitv for three or four days, and if necessary it may then be renewed. Polypi. Mucous polyps usually spring from the cervical canal or anterior lip of the cervix, and wlien present may obstruct labor. 20— Obst. l){)6 PATIIOLOdY OF LABOR. Even if small, these polyj)i sliould be removed at the tini' of labor, by transfixing and tying the palicle, and cutting them away. Ovarian Cysts. These rarely complicate labor. \i' discovered diiriiig ])'(•-- nancy, they should be removed. Small ovarian tumors m:i\ prolapse and cause obstruction in the pelvis. Treatment: If the tumor be foimd below the brim at liir time oC labor, efforts should be made to push it u[) into liif abdominal cavitv. To do this it mav be necessaiv to :iii;i-- thetize the patient and to place her in the knee-ehest po>iti<»ii. If it be impossible to reea|ic of the contents into the peritoneal cavity. It is better to ju'ilo! m Csesarean section, and at the same time remove tiie tumor, h the cyst only partially occludes the j)elvic inlet, it may be |h)-- sible to effect delivery by version or forceps. Vaginal cysts, dermoid cysts, swellings of the tubes jiikI broad ligaments, prolapse of a floating kidney to the jteK Ic inlet, hydatid cysts of the pelvis, and tumors of the liver ur spleen may be found to cause obstruction in labor. Rupture of the Uterus. Occurrence: Rupture of the uterus may take place dnrinir pregnancy, labor, or the puerperal period. In the vast major- ity of these cases the rupture takes place during the seccpinl stage of labor, and consists of a laceration of some ])ortioii ot' the uterine wall. Frequency: This accident is said to occur about once in 4000 cases, but the writer is of the opinion that it ociins much more frequently than is generally thought, as ])ra<- titioners are not prone to report these cases M'hen they occiii' in private practice. Etiology: The most frequent cause of rupture of the uiriiis is overdistention of the lower uterine segment, the result of some obstruction which prevents the descent of the present iiiir part of the child. RUPTuiii: or Tin-: uterus. 307 Thus pelvic (leformity, overgrowth of the cliild, liydro- cepluiliis, a tumor llockiiifj^ tlie pelvis, rii^idity of the soft ))art.s, or malpre.scntations, result in eontraetions of tiie uterus lureini^ the child's body iiUo the \o\\vv uterine setiinent, wiiich liei'onies enormously distended, while the upper sconicnl, with its walls (greatly thickened, is drawn up until it forms a dis- linet t(i(nor, wliieii can be felt throuj;h tiie abdominal wall ;i1m)V(> the child. There is n>uaily a irrU-dcfliud line between the thickened ii|)jter segment and th<,' distended lower segmeiif. This line is Livnurally visible, as well as palpable, running ()bli(|nely across the abdomen somewhat below the unibilii'us. U'liis is tlu; ivtraction-ring, or so-called "contraction-ring of Jiandl." W hen the limit of the capacity of the lower uterine wall in siniching and thinning is reached rn])ture takes ])la( \ When the utvrhic trail Is iraikoicd from any cause, such as a Mow or tall during j)regnancy, fatty or other d(\generatif)U, or iVom malignant or other disease, ruj)ture may take place early, ( Acn without UHich distention of the lower segment. I'^inally, rnj)ture may occur during unskilful (iflnuj)fs at ver- sion, the high a[)plieation of Ibrceps, or separation of an adher- ent ])lacenta. Ikupture of the uterus has been reconled as lollowing the (uliiilnisb'afion of cr(/ot to hasten the exj)ulsion of the child, -hilly has collected thirty-three such cases. Site of the rupture: The tear usually begins in the wall of tiic lower uterine seo;nient and runs transversely, ^\'hen the rii|iture is spontaneous it usually occurs in the Literal wall. ^\ lien due to traumatism the anterior wall is usually the site 111' the laceration. The c.vtcnf of the tear varies from a small rent limited to the niiiseular coat to complete penetration into the abdominal cavity. Usually the edges of the wound are jagged and irreg- ulai', and infiltrated with blood. When only the muscular coat is torn, the peritoneal covering of the uterus may be stripped off for a considerable distance hovond the tear, the sac thus formed becoming filled with blood-clot. The foetus and placenta may escape into the peritoneal cavity 308 PATIJOLoaV OF LABOR, wlit'M the rent is extensive, and the iiitestiut's may prolapse iiiln the vjit^iiia. Symptoms: Rupture of the uterus wlien extensive is usn:illv actioinpanied witii alariMiii<^ syniploins. Tlie uterine e()iitr;i< - tioiis iiavc probably been vij^orous lor some time, and tli^ woman's snireriniii>< until after the birth of the child. There may be a moderately severe hemorrhage before the placenta comes tiway. Utciinc action is usually poor, and there may be uerperal period iIh' patient developed a slight temperature, and on the third a severe hemorrhage took place. On making an intra-nlciini' examination a rent, sufficiently large to admit two fingoi- \\a« found in the posterolateral wall just above the external <>-. The prognosis depends on the site and extent of the laci la- nrVTL'llE OF THE riEiius. 3li!> lion as well as upon tlic treatment. The maternal mortality under the host treatment runs as liij^h as (10 per cent., while ihe mortality of the infants is as hitjh as OO per cent. Complete rnptnre is nmeh more liUely to j)rove fatal than is pai'tial I'nptiii'e, on aeeonr.t of the involvement of (he peritoneal .;i\itv. Moi'e than one-haif of the cases perish within Uventv- I'uur lionrs of the ae<'i(lent. The causes of death ari' .sepsis, licmori'hai;'e, anhoel\'. Treatment: When vi>i;orons uterine contractions fail to <'an>c ;id\ance of the pi'e.-entinu- j)art, the condition of the; lower iiiei'ine segment should Ih' a->eerlained. When the retraction- riiii; of IJandl is to he felt half-way hetween the jxihes and tlu! iinihilicus lahor should be terminated as rapitily as posslMe, in older t(» ^uard ai;ainst the occuri'ence of rupture. Tlu^ pro- (cdurc to he adoj)ted will depend on the conditions [)re>enl. r.clore (»peratin_!j; the patient should he antestheti/e the -iH'Liical de;ato the cavity (if th(! rent with a hot antiseptic solution, such as formalin (1 : -jOO), and to pack it gently with iodoform gauze. This tivatment shoidd be repeated at intervals of from twenty-four to forty-eight hours until the rent has healed. When the rupture is found to be ('o)npl(if the treatment (It pends on its site and extent. WIh.'u it is small and situated ln\v down, and but little if any I'oreign mattei* has escaped into llir pei'itoneal cavity, the rent may be irrigate*! and j)acleritouitis ; and if such develop the abdo- 111(11 should be promj)tly opened, the ])eritoneal cavity cleansed. Mild tliorough vaginal and abdominal drainage provided. When the rupture is (wfcnsit'c the abdomen should be l)r(»mptly opened and the peritoneum cleansed of all clots and otlier foreign matter. If the edges of the wound are ragged all) PATIIOLOUY OF LABOR. iiiid inlillrated with hlood, no sutures will hold ; in tlii- ci c some aiiliiors rccomniciKl that tho uIci'Uh be removed, wiiilr oliiers claiii. rxcellriit results [hnn merely jjrovidiug lor «;(iii,| vaurfaee of the body. In th(! author's exj>eiieuee, limited to four eases in wliiii treatment \vas j)()ssil)le, most excellent re.>tdts followed cart In I irrijijatiou and ^auz(! paddnj;'. In two of these eases tin; jn r- forations, though small, extended e(»mpletely hron^h liic uterus. The hemorrhage was severe in all f) 'i eases, Im could be faii'ly well controlled by pressin<^ tiic uierns fu'inlv down into the pelvis iVoin above. Al'ter the hot douche the blood ceases to flow for a slmit periotl; this time nuist be utilized by <|uiekly j)ackinn- the cavity of the rent with ^au/e, which may l)e fz;uided into phi" aloui; tlie fin<;ers of the left hand jdaeed in the cervix. (ireat care nuist be exercised in removing the gauze packing. when this is necessary ; it must be drawn out bit by bit, slowlv and ge.itly, in order to avoid start iuii' Ji hemorrhage. The nn.-i rigid asej)sis is recpiired in the j)erformance of each dressing n\' the laceration. 'J'he gauze ])acking should not be too linn, though sufficient should be inserted to prevent bleeding, I mi not so tightly packed .'is to prevent free drainage. Inversion of the Uterus. Occurrence : This accident is fortunate! v extremelv rare. It is met with more frequently in pilvate than in hospital j)i;i(- tice. Inversion of tho uterus may be acute or clirooic. Ii i- wiili the acute form the obstetrician has to deal. The iii\'i- sion may be jHinidf or compldc. In partial inversion the fundus may be the site of a dip- shaped depression, or it may actually prolapse sufficiently to protrude from the os. In complete inversion the uterus is turned inside out, mid may protrude from Uie vulva, appearing as a rour led ni;i>s between the ])atient's thighs, Etiology : Complete inertia uteri, or uterine paralysis, at the iNVFiisioy OF Tin: ("n':iiijs. :MI close of the set'oiul stat impoitnut \)\v- (lisposiiii; c'liiist'. It may occur spontaiu'dii-ly, aiul imnicdiatclv Inllnw the hirtli of the cliiM. It lias boon |)roioii, Tructinii (HI till' cord, to aid the cx|uilsioii of tlie |»l:i- ceiita, has brought about inversion. When thero is an actiial or rehitivo .shorteninj^ of the cord it is possibU' that the trnc- tion on the placental site njay drag down the I'nndns so as nlii- niately to j)rodnce inversion. Symptoms: 'J'he inversion nsnally takes place siiddeidv, and is associated with sevci'e shock, pain, and heinorrhaiz,t'. N'csical and rectal tcnesmns may be present. The pain is usually severe, while the hemorrhai:;e is rarely proluse. liy abdominal exam- ination the absence of the uterine tinnor will be noticed. On inakinii; an internal examination the inverted I'nndns will be found either {)rotrudinj^ from the os(n' pos-ibly completely till- ing;- the vay-ina. Diagnosis: Inversion of the uterus can usually be diagnosed by a careful external and internal examination. The only con- dition from which it nuist be diiVerciUiated is i)rolapse of a uterine polypus. The most important |)oint in (li:>tin<;uishinrivate piac- tice than in well-organized maternities, the reason being that In these institutions the attendants are individuals of sj)ecial skill. Vte/inc inertia is a frequent cause of post-j)artiun hemor- rhage. The uterus fails to retract properly after tlie expulsion of the placenta; hence the placental sinuses remain patent, ami blood is poured out into the uterine cavity, where clots form. which acting as a foreign body may stimulate contraction-. These contractions are usually weak and inefficient, while tin intra-utcriue clots are more or less firmly attached to the walls, POST- PA R TUM U KM GURU A GE. ?) 1 ;) and licnoo (lifHcult to dislodge. In tlio intervals between tlie contractions more blood is poured out, nntil liiiMlly by this j)roc- ess the uterus may become distended to its lidl capacity. The external hemorrhajie mav be insi»inilicant in amount, tliouirli it is usually o;reatlv in excess of the normal. Of/icf coiKlHioiis which predispose to liemorrhalaced in tlu^ ujijier ]>art of the vagina to keep the cervix in place. The gauze may be left in ])lace from twenty-four to forty-eight hours and then gently removed. It is seldom necessary to repeat the intra-uterine packing. As soon as the uterus has been emptied of clots a hypodei'- niic of ergot (aseptic, Parke, Davis (Vr Co.), .^ss, should be given, and repeated in half an hour if required. \i' aftc^r the first hot douche no acetic acid is available, a j)iece of sterilized gauze, or even a clean pocket handkerchief, may be saturated with vinegar, carried to the fundus, and there s((ueezed out. The vinew-ar should be strained throtii>;h cotton- wool before being used for this purpose. Having checked the hemorrhage, the physician's duty is then to combat the evil effects of severe loss of blood. Treatment of Acute Amvinia. The pillows sliould be removed from beneath the patient's head and the foot of the bed raised on some books t)r bricks. 316 PATHOLOGY OF THE PUERPERAL PERIOD. Hot-water bottles should ho applied to the extremities of the patient, and s'lie should he covered with warm hlaukets. It tliere is a tendeiiev to syncope, a hypodermic injection of strychnine nitrate (or. .^) and nitroglycerin (gr. yj,,) should be given. As soon as possible a (piart of watei- at 110° F., containing: two teaspoon t'n Is of c )nunoii salt, should he injected into tin I'ectum. For this purpose a soft-rubber catheter shonhl 1h attached to the noz/lc of a fountain-syringe, so that the injec- tion may be carried as far u\^ as })ossible. \X the heart's acition fails to improve, hypodermic injections of ether, strychnin, and nitroglycerin may be employed. Nausea and vomiting are frequent in these cases, and there is but little absorption from the stomach until these cease. As soon as the stomach will retain anything, small (juantities of hot coffee, hot brandy and water, or warm milk may be gixcii and frefpiently repeated. A\'hen reaction has been estabhshcd a hypodermic of morphine (gr. \) should be given to quiet th(( patient. In desperate cases the saline solution may be sterilized, and inj(M^ted beneath the breasts or directly into the median ba>ili(' vein : To insert the salt solution beneath the breasts a large ex- ploring-needle may be used. A ghiss funnel and a ])iece of rubber tubing com])lete tiic apj)aratus. These should be ster- ilized after bein-entle friction of the fimdus through the abdominal wall for ten minutes or so, three or four times daily. A pill containing ergotin, gr. j; ([uinine, gr. j ; and strychnine, gr. T^^^y, may be given three times daily. Should tliis treatment tail to improve matters and ther^ is no dimipMtion in the loss of blood, the cavity of the uterus should be explored with the finger. If neces.-ary, the curette and placental forceps may be used, being followed by a douche of hot formalin solution (1 : oOO), and the introduction of a wick of iodoform gauze to the fundus. The latter acts by stimulating the uterus to contraction and Ivy favoring drainage. The gauze slioidd be removed at the end of forty-eight hours and a hot vaginal douche once or twice dailv mav be ordered. Daily free evacuation of the bowels should be secured. If the uterus be displaced, it should be put in proper position and retained tliere by means of a pessary. Occasionallv the condition of subinvolution is not discovered until late in the puerperal period, after the woman has been walking about for some time. In such cases the cavity of the 320 PATHOLOGY OF THE PUERPERAL PERIOD. uterus sluuild be painted witli Clun'cliill'.s solution of iodiiit , and a vai^inal tampon oi* wool saturated with boroglyeeriii should be inserted two or three times a week. ANOMALIES AND DISEASES OF THE NIPPLES AND BREASTS. Anomalies of the Nipples. Supernumerary nipples are of frequent oeeurreuce. Defects of the nipples are chiefly imj)ortant as they mny interfere with nursinj^. Inversion of the nipple is a very common condition, whi( h may be congenital or acquired. This defect may constitute ;iii absolute impediment to lactation. During the last month of pregnancy attempts should be made to draw out the nipples by means of a l)reast-punip. When the nipples are small or imperfectly (levelo})ed daily gentle traction upon them by the nurse or physician may rcsuli in improvement. If this fails, a nipple-shield must be em- ployed to enable the child to nurse. Anomalies of the Breasts. Absence of mammae: While imperfect development of the mainniie is coiumon, their complete absence is a very rare con- dition. It is usually associated with deformities of the pelvic sexual organs. Hypertrophy of the i ^ammae : This condition is also rare. When present it does not of uecessit}; contraindicate mn-siiiii;. Supernumerary mammae: Supernumerary breasts are to l)c met with comparatively frequently. They occur with no regularity of situation ; the most frequent position is below the true mararase; they have been found over the pubes, on the buttocks, shoulders, and in the axillae. In most cases no hereditary influence can be traced. Anomalies in Milk Secretion. Deficient Secretion. Complete absence of milk-secretion is a rare condition ; but deficient milk-secretion is only too frequently encountered. ANOMALIES L\ MILK SECRETION. 321 Etiology : Lttck of derr/()j)in(nt of the ^laiuliilur tissue of tho hreasts is tlie most common cause of deficient secretion of mili<. This lack of development niav he due to hereditary causes, or to c'Mitiniious pressure from tiuht clothing; or it may he associated with maldevelopment of the otiier sexual orgaus of (he body. The ,sizr of the hrm.^ts is no indication of their ability to furnish milk. This function depends entirely upon the aiiionnt of glandular t'ssue present in tlui breasts. Some women with well-developed breasts have but little glanduhu" tissue, and therefore make poor niu'ses ; while others with :i|)])arently but poor develo|)ment of these organs have a rich and abundant supj)ly of milk for their otlspring. The secretion of milk may be diminished by the occurrence iA' fever, hemorrhages, chronic; diarrhcea, jnid insufficient nour- ishment; serious oi'ganie diseases also result in diminished milk-secretion. Emotions j)rofoundly atVect the secretion of milk ; prolonged grief is a well-known cause of deficient -ccretion. The return of mensfrnation, while it may affect the quantity and (jualitv of the milk secreted, cannot be said invariably to |ii()duce this result. Tt may be stated that, as a rule, tlie re- turn of this function has but litth; influence on milk-secretion. Treatment : But little can be suggested in the way of treat- luont ; good, plain food and ])lenty of it ; moderate exercise in the open air ; three or four glasses of milk daily betw<'en meals, and a wineglassfid of extract of malt thrice daily, con- stitute about all the treatment ]iossible. There is no medicinal galactagogue of any value in the experience of the writer. Excessive Secretion — Polygalactia. In this condition, ^vhich is not infrequently met with, the secretion of milk is in excess of the demands of the child. Treatment : The bowels should be kept relaxed and the quantity of fluids imbibed reduced. The breasts may be coiiq)ressed by means of a tightly fitting breast-binder. The woman should take plenty of hard exercise daily in the open air. If this treatment fails, the excess of milk must be pumped out at regular intervals. 21— Obst 322 PATUOLOOY OF THE PUERPERAL PERIOD. Galactorrhoea. This term is applied to an excessive secretion of milk which persists! after weaning. Tiie flow of milk is not necessaril\ ex(!ited by suckling the child. The milk is thin and wat(i\ . the quantity being excessive. One or more breasts ma\ In alfccted, and the condition seriously impair tiic general heahli, The condition may last foi* years. Etiology: Nothing definite is known as to the causation oi" this condition. It has been attributed to a relaxation or paial ysis of the circular muscular fibres surrounding the milk- ducts. Treatment: These cases frequently offer very stubborn re- sistance to all treatment. Firm comj)ression of the breasts li\- means of a breast-binder and the administration of potassiiim iodide (gr. x t. i. d.) and of fl. ext. ergot (Til x). for a consid- erable period constitute the usual treatment. General tonic.s and iron should be administered. Engorgement of the Breasts. Etiology : Reference has already been made to the fact that occasionally with the establishment of lactation the breasts may become congested and engorged. Tiiis condition of en- gorgement may occur at any time throughout the period of lactation. Exposure of the breasts to cold air and hypersecre- tion of milk are the most common causes of this condition. Ssrmptoms: The breasts quite suddenly become engoriMd with milk, to such an extent as to occasion very consideialile distress to the paticiit. The pain and tenderness may be the o» .ion of more or less elevation of temperature. Treatment. To relieve the patient it is necessary to remove the excessive amount of milk and to prevent further engorgement of the breasts. The breasts may be emptied by permitting the infant to nurse ; by the hreast-pump ; and by mascage. If the child fails to empty the breasts, the milk remaining may be drawn off by means of the breast-pump. Probably ANOMALIES rX MILK SECIiETIOX. 323 the most satisfUctoiy Invast-pump is that known as tlie "Enj^lish" piunj). That part of tlio pump which is applic*! to the breasts sliould he free iVom ja<:!;<>;('(l, roiij^h od^os, other- wise these may pnKliiee some al)rasions. Massage of the breasts: W'lien properly performed this is a verv ellieient aid in relievinji; eonm'stion and enirortjement. It shouhl never he empK)yed if there is eviilcnee of interstitial inHammation of the breasts. 'file patient, bein<»; in the dorsal position, is directed to sup- port her l)reast by placing; her Ibrearm under it and drawin*;' it lip. The breast is then anointed, witii warm oil, afier which the operator begins the manipulations by phicinj:; his finjjer- lips, separated as widely as possible, at the ])erij)hery of the iireast. A rapid thoui^h j^tMitle strokinii; luovement is then made toward the nipple, the fino;er-tips beini; brought ; at the nij)|)lc. The pressure exerted by the finger-tips should be gradually increased, short dl" producing severe j>ain. This stroking movement in about (Ive minutes usually ceases to cause ])ain. Then the operator sii|)j)orting the breast in the palm of one hand, with the iinger- tips of the other hand selects a nodiifc of induration, which he strokes toward the nipple, gradually employing deeper and liiiner pressure. Each nodule of induration is thus treated in succession. Xodules M'hieh this mapii)ulation fails to soften may then !)(• compressed by placing the hand flat ui)on them and exerting st( ady gentle pressure downward against the chest-wall. The pivssure thus exerted should be greatest at the periphery of the i;l;iiid. After a few moments of steady j)ressure, gentle rotary movements of the hand may be made over the lum])s. If pain is complained of, the stroking movements should be resumed. The breast should then be grasped with both hands so as to encircle it completely ; and the whole gland gently raised and (oinpressed, while the two index-fingers are quickly stroked toward the nipple to favor the escape of milk. These various manipulations should be repeated at short intervals until the glands have been softened and emptied of their contents, when a pressure-bandage should be applied. 324 PATHOLOGY OF THE VVERPERAL PERIOD. The most satisfactory breast-bandage, in the opinion of tlio writer, is the Y-han|i((| under the patient's baciv at tiie lower part of the scM|iiil;ir region until the apex of the fork is just external to the oiilcr edge of the left breast. The [)Mtient then lifts her brea-ts upward and toward each other, while the lower arm of the fork is drawn tightly across the chest beneath the breasts; \\\v inferior border of this arm shotdd extend at least an inch below the lower margins of the breasts. The upper arm of the fork is then drawn across the chest above the breasts in such a way that its upjter border exteixU an inch beyond the u])per margins of the breasts. The iVeo ends of the two arms of the fork should thus meet at the outer margin of the right breast, where they shoidd then be drawn tight and securely pinned with safety-pins to the strip wiiicji lias been passed l)eneath the back. The free end of the l);i •!< stri]) may then lie over the apices of both breasts. The >tii[) passing underneath the breasts is then pinned to the binder to keep it from slipping up; shoidder-straj)s may then be pintud to the upper arm of the fork and fastened behind to the l»:i(k strij)s, thus kcej)ing the upi)er arm of the ibrk from sli|>|»iiig down. The hollow between the breasts may then be filled with cotton, and this held in place by two safety-])ins joined togetlicr and pinned to the u})per and lower arms of the fork. In place of this the Murphy binder may be employed. It is made of a strip of thick gray c<)ttt)n, forty inches long and ton inches wide. In the upper border of this stri]) a narrow notch is cut for the neck, and two deep notches for the arms. The soiii': MrrLix 32.") hinder is a|)|ili(' l)reasts, and repeated at Intervals of live minntes, soon gives relief and permits the ipplication of the bi'east-binder. In these cases a frrc aclion of the hoiir/.s shonld be obtained hy the administration of teaspoonfnl doses of Jxochelle salt in warm water, at intervals of fifteen minutes till ])nrgati(»n is i I III need. Sore Nipples. Etiology and symptoms: The child in mirsing may niacer- ;ile the sni)erficial ej>ithelinm of the nipples. Small superficial ulcers may thus be formed at the apices or at the bases of the nipples, which arc dillicnlt to heal because the child in nursing Mjiarates their edges. The j)ain cansess) sliould there be evidence of abrasion. 326 PATHOLOGY OF THE PUERPERAL PERIOD. Painting the nipples, by means of a camel's-liair l)riit^li, with the coiii|)(tuii(l tincture of benzoin, or a 10 grain to tiie ouik. solution of silver nitrate, will be fount! very satisfactory treat- ment in more severe oases. Deep fissures are best treated li\ daily touching them carefully with the solid stick of nitrate of silver. In some cases extreme tenderness of the nipples niav li complained of, and yet the most careful examination fail i . reveal any trace of either erosion or fissure. In tluw.' ca- > extract of witch-hazel (ext. hamamelidis) will be found vli just before each application of the child to the nipple. Cer- tain writers claim to have had severe inflammatory react inn follow its employment, so that it should always be used wit!i caution. In all cases in which the ni})ples are tender a glass and iiili- ber nipple-shield should be employed while nursing. The shi(^M should be kept surgicaliy clean. In some cases it may bo necessary for the mother not even to attempt to nurse tlie child for twenty-four hours, or e\eM longer. In these cases the breasts may be emptied by menus of massage, the breast-pump not being used unless it piovo absolutely necessary. In very exceptional cases nothing but weaning will result in permanently relieving the condition. loflammation of the Breasts — Mastitis. Varieties: Three forms of mastitis are usually dcscrilMil: the most frequent variety is the parencJnpnafoKi^, or (f/an(hi/j»l( . This form of inflammation is very difficult to abort and u.-u- aiiy results in abscess formation, though if the breast be opened early but wry little pus may be found. Treatment of Mastitis. Abortive : The iuelications are to secure complete rest for tlio affee;ted glanel by (a) absolutely prohibiting nursing from cither breast; {h) removing by means of massage and the brca>t- pump the contents of the glands, and (c) reducing the local blood-supply. It is imjiortant to decide if possible whether the inflamma- tion is of the parenchymatous or of the interstitial form. The mode of onset, condition of the nijiple, appearance and feel of the breast, anel the fact that the parenchymatous form occurs most frequently, will afford assistance in making a diagnosis. If the type of inflammation present is parenchymatous, the routine of treatment may be given as follows : the breasts aic emptied by means of massage and the breast-pump, all manipu- lations being as gently carried out as possible. The nij)j)l(> are then cleansed and an antiseptic dressing applied, as pre- viously re^commended. A tightly fitting Murphy binder is then applied so as to secure as firm compression of both breasts as is })ossible, without increasing the j)ain i.i the affected parts. Then an ice-bag may be placed outside the binder over tlic affected portion of the gland. The ice-bag should be kejit constantly applied for from twelve to twenty-four hours, the length of time being eletermined by the relief of pain and sub- sidence of temperature. The lessening of the local blood-supply of the gland may be obtained bv the derivative action of saline cathartics, which should be freely administered as previously recommended. INFLAMMATION OF THE BREASTS— MASTITIS. ;}29 If after twenty-four hours tlie temperature lias dropped and the paiu disappeared, tlie pressure on tlie breasts may he re- duced by loosening the binder somewhat. The ice-bag may then be removed for an hour or two, but should be used inter- mittently till all tenderness of the breast disappea/s and the flow of milk has been re-established. In rare instances the ice- l)ag is not well borne by the patient, in which case a com|)ress wrung out of a solution of lead and opium (1 : 40) should be applied over the affected portion of the gland and (;overed with oiled silk or a layer of non-absorbent cotton, over which the Murphy binder may be lightly applied. The treatment of the interstitial form of mastitis differs somewhat from the preceding. In this form massage should ))(> avoided, as only tending to aggravate the condition. The Murphy binder should be applied so as merely to support the breasts, but not to compress them ; otherwise the treatment of the two forms is the same. In spite of all treatment a large proportion of these cases terminate in abscess tbrmation. Mammary Abscess. The pus may be located in the gland-substance or in the >ul)mammary connective tissue. Symptoms: It is not always possible to be certain that sup- |)>u'ation has taken place from the symptoms given. Fluctua- tion, the most certain sign of abscess formation, is rarely to be jinnid until late. Severe throbbing or stabbing pain suggests abscess forma- tion, especially when accompanied with chilly sensations, a iiigher grade of temperature, and greater ra])idity of pulse. Tsually a bluish discoloration and some oedema of the skin mark the locality where the abscess will " point," especially in the more common parenchymatous form. In the interstitial fomn the pus tends to burrow extensively, and no actual abscess may be discernible though the whole ^dand is found to be riddled with pus-tracts. If such a case be left too long, the pus will be found " pointing " in several })laces. Surgical Treatment. Preliminary: The patient should always be anresthetized before attempting to open or treat a mammary abscess, unless ;i30 PATHOLOGY OF THE PUERPERAL PERIOD. it be superficial and about to point. The wliole breast should b(,' well scrubbed with soap and hot water, followed by solii tions of permanganate of potassium and oxalic acid. Incision: By carel'ul palpation the pus collection is located, and an incision is then made in the skin over its most de[)(ii dent portion in a line radiating from the nipple. Through tiiis opening a grooved director is then inserted and passed in all directions until pus is encountered, when a pair of arterv- forceps is introduced and opened so ps to dilate the ti^siK - sufficiently to permit the introduction of a finger iiiiu the abscess-cavity. All adjacent cavities should then lie searched for and freely opened, and all friable tissue britkcn down. Additional openings should be made to secure five drainage. The walls of the abscess-cavity should be geiiilv scraped with a Volkmaun spoon. All the openings shoultl then be irrigated freely with an antiseptic solution, such us formalin, 1 : 500. Drainage: Instead of employing rubber tubes for drainage, gutta-percha tissue which lias been stei'ilized by soaking in formalin solution, and then folded in strips about half an inch wide and six or eight inches long, will be found much more serviceable. Several of these strips should be drawn throiiuli the openings, so as to secure drainage in all directions. An antiseptic surgical dressing is then applied, and the breast firmly bandaged with a broad roller bandage, so as to secure even compression throughout, or a Murphy bandage may I)o applied. After twenty-four or thirty-six hours the dressings should ho removed and the abscess-cavity thoroughly irrigated with boric- acid or formalin solution. The gutta-percha tissue drains should be reinserted and a fresh dressing applied. As soon as the discharge has almost ceased, the gutta-percha tissue drain- age may be dispensed with and firm compression of the walls of the cavity secured by means of antiseptic compresses placfd under the bandage or binder. The most equable pressure is secured by means of a large bath-sponge which has been boiled and then wrung out of 1 : 5000 bichloride solution. Tliis should be slightly hollowed out so as to fit over the breast, to which it is directly applied and covered with oiled silk and the bandage or binder. This dressing should be removed daily ARREST OF LACTATION. 331 and the sponge cleansed in ii solution of 1 : 5000 l)iehloride. The breast should also be washed with the same solution before the dressinj^ is reapplied. Nursing: The child may be applied to the sound breast to keep up the flow of milk, provided the mother's general health is such that it is not desirable to discontinue nursing. In the interstitial form ci" abscess but very little pus may be found on incising the breast. All nodules should l)eopened> as the pus tends to burrow very extensively in this form, and special care should therefore be given to providing for free drainage. Abscesses of the areola : The glands of Montgomery may become infected and result in the formation of small superficial abscesses in the areola. Trcotment : Each suppurating gland should be o})ened, and its walls curetted and then swabbed with strong bichloride or formalin solution. Galactocele : This is a milk tumor which may form as the result of occlusion of one of the lactiferous ducts. Beyond causing a little pain these milk tumors are of no importance. 7yT«^w<'7*/ .•; Massage may result in causing the milk to flow and thus relieve the condition. Karely these tumors persist for a long time, and may become so large as to necessitate their being tapped and drained. Arrest of Lactation. Indications: When the child has perished at birth or when the constitutional condition of the mother is such as to pre- clude the possibility of nursing, it is necessary to prevent the activity of the mammary glands. Method : Before the first aj)pearance of breast engorgement a tightly fitting Murphy hinder should be applied. Free jiiirgation should be induced by means of salines when the patient's strength will permit. The amount of fluids ingested -liould be restricted, the patient's thirst being relieved by rinsing the mouth frequently with weak tea. If the engorgement of the breasts tends to become excessive, ;}32 PATHOLOGY OF THE PUERPERAL PERIOD. the binder may be removed once or twice daily to permit of mcmmf/e or the u.se of the bread-pwinp. Tlie breasts may tlioii be covered with glycerite of belladonna and tiie binder or bandaj^e reapplied. Usnally under this treatment the breasts become inactive in less than a week. To arrest lactation when the woman has been narshir/ for some time, firm compression of the breasts by means of tlic Y-binder combined with the use of salines will be sufficient. Tlio milk usually flows away readily under the compression exerted by the Y-binder, and there is no disposition of the breasts to become engorged and caked. Massage and the use of the pump siiould be omitted as long as the milk flows away freely. In a few days the breasts will cease flowing, when a Murphy binder may be applied ami worn till the breasts become soft. After prolonged lactation there is but little difficulty in drawing away the milk when the child is weaned gradually. Should secretion ])ersist it may be necessary to employ com- pression and to give atropine internally. INTERCURRENT DISEASES IN THE PUERPERIUM. Miscellaneous Diseases. Scarlet fever : This is a rare complication of the puerpcriiim. It almost always appears within three days of labor ; tlie throat complications are slight, the rash appears quickly, is rapidly diffiised, and is usually of an intense dark-red color. Convalescence is usually tedious. Occasionally the pelvic organs are profoundly affi.vted by this disease, and when this is the case the prognosis is very grave. When the attack is a frank one and the genitalia are not much involved the prognosis is not unfavorable, though the condition is a grave one. Measles : The puerperium is rarely complicated by this dis- ease unless the attack has occurred during ]>regnancy and has led to premature expulsion of the ovum. The condition pre- disposes to hemorrhage and also to pneumonia. Variola : This is a very grave complication of the puer- perium. MISCELLANEOUS DISEASES. 333 Rotheln : This disease does not markedly aifect the puer- periiim. In two or tlireo cases which have come under my notice the disease was very mild in character, though in one the rash was very marked. Erysipelas: This disease usually affects the genitals when it occurs during the puerperal jjcriod. It is seldom mani- fested by a cutaneous eruption. When the genitals only are aife(^ted the prognosis is very grave, and it is imjH)ssil)le to distinguish the case from one of ordinary streptococcus infection. Erythematous rashes : Puerperal erythema is not an infre- quent condition. In rshnplc cases there is apt to he a moderate elevation of temperature, and the lochia may become offensive. There may be some uterine or pelvic tenderness. The condition is therefore looked upon as a mild septic infection. Iodoform when freely used about the genitals may set up an extensive erythematous rash ; in this aise the temperature and pulse remain unaffected unless the skin irritation causes the patient much distress. Erythema may be mistaken for scarlet fever, and it is not infrequently associated with grave septicaemia. Diphtheria : This disease may affect the throat or the genitals, in the latter case a variety of general sepsis ensues. Pneumonia: This disease constitutes a very grave complica- tion of the puerperium. It not infrequently occurs secondary to septic infection. Its treatment will be discussed in the section on puerperal infection. Rheumatism; arthritis: The diagnosis between septic arthri- tis and simple acute rheumatism is a matter of great difficulty during the puerperium. Sim])lc rheumatism tends to affect several joints, while the arthritis is septic in origin and usually only one large joint is affected. In the latter case there may be little evidence of general septic infection. Simple rheuma- tism usually runs its ordinary course and does not affect the puerperium, nor is it affected greatly by it. The treatment of acute rheumatism is the same as when it occurs at any other time. In septic ai'thntis recovery is the rule, but with a greatly damaged joint. Local treatment only is of service^ general medication being of little use. 334 PATHOLOGY OF THE PUERPERAL PERIOD, Malaria. The puerperal state, it is generally admitted, predisposes to malarial attacks. Women who are subject to malaria usually manifest the disease after delivery, probably as a result of tlie traumatism of labor. The malarial attack is usually of a mild type, but occasion- ally it may be extremely severe. The disease, which usual Iv manifests itself about the third day after delivery, prcdisposi s to puerperal hemorrhage; it also modifies milk secretion, espe- cially during the exacerbation of fever. It is not general Iv admitted that the germs of disease can be transmitted in thf milk to the nursing infant. Diagnosis : Malaria occurring during the puerperium nni>t be differentiated from septic infection or typhoid fever. Tlic diagnosis is occasionally a matter of considerable difficulty. The fever in malaria is frequently continuous at first, but soon becomes remittent in type. In doubtful cases the blood should be examined for malarinl organisms, and Widal's test for typhoid reaction should he applied. A bacteriological examination of the uterine locliia should also be made, for it is quite possible that malarial pois- oning may be associated with septic infection in some cases. With these tests at one's disposal we should not remain long in doubt as to the origin of the fever in any given case. Treatment: Usually it is necessary to give large doses of quinine to control the fever during the puerperium. When the daily dose of quinine is 20 grains or under, it is seldom necessary to remove the child from the breast ; but when this dose is exceeded the infant is likely to suffer from the effects. Puerperal Anaemia. After delivery the blood begins to undergo a change in con- stitution by which it is converted from the hydrsemia of pre<;- nancy to the normal proportion of its constituent parts in the non-gravid condition. This change is usually completed by the end of the second week of the puerperal period. Many causes may interfere with this process of involution :( M DISEASES OF THE VRTXARY ORGAXS. 335 of the blood, such as sepsis, severe blood-loss at the time of labor, or any wasting or depressing disease. In such cases the anaemia tends to assume a pernicious form if treatment ib neglected. Careful blood examinations should be made from time to time in these cases in order to judge of the effect of treatment. The treatment consists in the administration of tonic drugs and careful feeding. Iron and arsenic, in the form of the com- pound .Bland pill, usually give satisfactory results. In some eases in which iron is not well borne ai*senic alone will succeed. Hemorrhoids. Great discomfort is frequently caused by an attack of hem- orrhoids during the earlier days of the puerperal period. Treatment : The bowels siiould be freely opened, and great relief may be obtained by the application of hot compresses wrung out of hot lead-and-opium solution (1:40). In some cases the application of ice is more comforting to the patient. An ointment composed of equal parts of ung. gallfB cum opio, uug. stramon. and ung. bellad. will further relieve pain. Diseases of the Urinary Organs. Retention of urine : Patients not infrequently complain of inability to urinate after delivery. The condition may be the result of injury to the urethra or the anterior vaginal wall during labor. Many women are unable to empty the bladder while lying in bed. In others the flow of the urine over small abrasions of the vulva sets up irritation, which they seek to avoid by holding the urine as long as possible. The relaxed condition of the abdominal walls and the consequent diminution of intra-abdominal pressure to some extent inter- fere with the function of micturition during this period. Treatment: The nurse should be instructed to see that the patient empties the bladder at least twice daily. For this pur- pose, if unable to pass water otherwise, the patient may assume a kneeling posture, or may be raised carefully so as to be able to sit on the bed-pan. Hot applications may prove of assist- ance, as may also the stimulus caused by the sound of running ii.J() PATHOLOGY OF THE PUERPERAL PERIOD. water. If tliese means fail, the nurse should be instructod to ])ass the catiietcr into the bladder, and to observe the strietcst antiseptic pi'ccautions in so doinj^. Incontinence of urine : Tiiis condition may result from ovt r- distention ol' the bladder from retention of urine. This is tin- commonest cause. Other causes of tlie condition are paresis of tile spiiincter muscle and vesicovaginal or vesico-uterine fistula. A ('(irrevent the infection spreadinji; to the ureters and kidneys. The bladder should be irrigated daily with a waiiii solution of boric acid (gr. xv-.^j). The diet should consist of milk only, and the following mixture should be ordered : ^. Sod. bibor., Ac. benzoic, aa .fss ; Inf. buchu, 5vj. — M. Sig. A tablespoonful in a wineglassful of water three times daily. If the condition persist after irrigating with boric solution, the bladder should be distended with a solution of silver nitrate (gr. ss-^j), all of which should be allowed to drain away with the exception of about an ounce, which may be left in the bladder. Pyelonephritis : This condition may follow an infection of the bladder by extension of the disease along the ureters, or it may result from a general septic infection. Diacpiosls can usually be made by an examination of the urine. Treatment: Stimulation, support, the administration of DISEASES OF THE NERVOUS SYSTEyf. Il'i? hliiiid diuretics, and daily iirit;ati()ii of* the bladder constitute tlio treatment of tiiis condition. Hsematuria : Bloody mine is sometimes seen af'tef labor, and may tbllow severe contusion ot'tlic bladder either l)y the child's head or the forceps. Not intVe(|iiently tlie condition is due to the jx'rsistence of vesical jjeniorrhoids wiiich develo|)ei(ni;i is not intre(|Mcnlly found to follow an attack of celamp>ia. Cerebral embolism wiien it is not within th(! pnerjxriuni j^enerally follows an endocarditis or phlebitis of septic origin. Puerperal Insanity. Occurrence: Mental derantjement manifests itself in connec- tion with childhearinn;; most fre i'en the biiili of the child and the termination of lactation. '; he condition is most likely to occur in connccition with the first confinement, thony-h in a small number of <'ases mental (leranif(fl an.vktji in connection with domestic worry, desertioir. and illegitimate pregnancy may be mentioned as an exciting cause. Forms : Two forms of insanity are ordinarily met with, the mankwal [\n(\ thin mrlancholic : the former occurs much more frequently during the puerperal period ; while the latter is generally associated with lactation. Puerperal insanity — symptoms : In both forms prodromdl nisi': ASKS OF the iXervous system. 339 ni/)n]itoiiiK usually niaiiil'cst thciusclvi'S. 'I'ljcso arc irritahilily, restlcssurss, coiMplaints oi' |>(i(y auuoyanccs, aud pci-io'ls of (l('|)r('>si(m, altcniatinii; with conditions of nt rvous tension. A coutlitiou of ucncral ill-health is usuallv manifested hv loss of appetite, iudip-stion, const ipatioii, and llatulence. The patient is usually pale, the pulse is irritahle and quick, and sho is incliueti to sudden outhreaUs of tearfulness. The condition n)ay dctepen rapidly, and fevci" develoj), and delusions aud halluciualious heconie luaiiil'est. 'I'he lauunaue hecoines ohsccne, aud fre(piently orotiti niaiiifestations Ih-coimv evident. The patient hecoincs uucouti'ollahle, aud is vi()lent ill her actions; she may attempt to destroy her infant (»r attack her attendants. In the iiirlduc/io/ir form the patient hecoiues morose, de- pressed, and listless; delusions of |)ersecutiou are of frecpieut occurrence. She accuses lier husband of inlidelity, or ol' even worse ci'iiucs. She hears voices tellin<;' lu;r to kill herself, which she may attempt to do iniless closely watched. In some cases the jtrodroiiia/ si/iitj)fninfi may he y" ;(/i(/lif as to escajx} ohsi'rvatlon ; or the condition may he rej^ardcd as one of ordinarv neurasthenia, when suddenlv th<' ])atient mav attack and destroy her infant or attendant, or may accomplish suicide. When a woman (hn'ing the puerperal period manifests ex- cessive irritability or unusual kxpiacity or tacitin'uity, associated with sleeplessness aud constipation, a close watch shoidd b(» kept on all her actions, and she should on no account be left alone \'\th her infant. Diagnosis: Usually this can be made without diffieidty. i'!ie d(>lirium of mania must be distinotiished from that of fever and that of delirium tremens. Prognosis : About two-thirds of all cases recover their reason ill from two to six months. Of the other third, 10 per cent. (lie of sej)sis or exhaustion, and the balance remain i)ernia- neiitly insane. ^^ania is less likely to result in permanent insanity than is melancholia; but it maybe said, that the j)atient's lif(; is in greater danger from mania than from nudaneholia. The; older tli(! j)atient, the more rapid the pulse, and the more persistent the elevation of temperature, the more grave is the prognosis. .340 PATHOLOGY OF THE PUERPERAL PERIOD. WIkmi eclampsia boars a causal relation to the condition the jnognosis is distinctly more f'avoiable, for these pat'ents re- cover much quicker than in any other variety. Treatment of Puerperal Insanity. When possible, patients suffering from this affliction should be removed to special institutions for treatment, and the earli( i this is done the better. When this is impossible the jialii i i should be isolated with two or three attendants who an strangers to her. She should never be left for one niiiiuif alone, tiie windows shoidd be securely fastened, and ail un- necessary fui'uiture removed from the room. When in mania it is necessary to keep the patient in bed, this may be done by covc^ring her witli a strong sheet fastenc d at tlie sides and foot of the bed; otherwise instruments ol restraint should never be employed, but a sufficient inimlx r of attendants should always be at hand to control the patient if this be necessary. The treatment otherwise should be largely symptomatic. Nutrition should be promoted by every means possible, but sedation shouM be avoided. It is alwavs well to begin by securing a free action of llx' bowels. This mav be accomi)lished bv the administration of a mercurial with a subsequent saline. The regular adminis- tration of intestinal antise])tics, as salicylate of sodium (ir naphthalin (gr. v t. i. d.), is advisable. Sleep may be promoted by giving paraldehyde (.^j-ij) at night. Instead of this, sulf'onal or trional in 20 grain doses may be em])loyed. Hydrotherapy is of advantage both as controlling the tem- perature and in securing sleep. The diet should consist of milk in generous quantities at first; later, eggs and meat may be added as digestion im])r<»\('s. Stinmlants should be emj)loyed when necessary. ISlalt ex- tracts are valuable adjuvants to the diet. Forced feeding by means of the oesophageal tube may be re(juired in rare instances, and it may be replaced at intervals by nutrient enemata. Iron and arsenic should be given regularly in full doses, as SUDDEN DEATH IN THE VUERVERIVM. 841 soon as tlie condition of tlie digestive Iract permits of tlieir employment. As soon as possible the patient shonld be kept constantly in the open air during tlie daytime ; and exercise short of fatigue shonld be encouraged. The fact that pelvic conditions have nnich to do with the development of this condition renders it necessary to make a careful -jxamination of the state of these organs in all cases. All abnormal conditions shonld be corrected as far as possible. In nuuiy cases operative treatment has been followed by bril- liant results; but to accomplish this, such procedine should i)e ado})ted early in the history of the case. Sudden Death in the Puerperium. The most common causes of sudden death in the puerperal ])eriod are pulnionarji emholistn, cnfrance of air into the uterine fiinuses, and heart-J'aUure. Pulmonary Embolism and Thrombosis. Etiology: Some authorities claim that primary and sponta- neous coagulation of blood may take place in the pulmonary artery. The most generally accepted view is that pulmonary em- bolism results from the separation of a }>ortion of a tiirombns which has formed in some peripheral vein. Thrombosis most commonly takes place either in an iliac, femoral, or uterine vein. Symptoms and diagnosis : This accident may o'^cur at any time during the earlier weeks of the puerperal period. The symptoms usually (kn'elop with great suddenness^ and their severity depends on the size of the embolus. When the ob- struction of the pulmonary artery is complete, death may be practically instantaneous ; or it may be preceded by precordial <;))pression, great dysjmrea, and cyanosis. Usually the patient utters a sharp cry ; the respirations become shallow, gasping, and irregular, and in a few seconds cease altogether. In cases in which th(? embolus is small the onset of symptoms is not so sudden ; but they are similar, though not so severe. Death 342 I'ATIIOLOOY OF THE PUERPERAL PERIOD. iiKiy not take place for several days, and very rarely recovery may follow. The symptoms usually follow some sudden UK)vement, such as sitting- uj), laughing, straining at stool, etc The following may he cited as an illustrative case : the patient, a multipara, had made a perfect (!onvales(Tence after iui uneventful labor, when on the morning of the thirteenth day. after being gently moved to a sofi j)laced alongside of her bed, she suddeidy gave a gasp, fell back on the pillows, and in a moment lost consciousness. CVanosis rapidly developed, and the resjiirations became labored and ceased inside of five min- utes. The ])ulse at first was rapid and strong, but (piicklv became thready, and ceased shortly after the fail • of respira- tion. At the (uitopai/ there were found in certain of the larger veins in connection with the uterovaginal plexus large, well- formed thrond)i ; a thrombus was found to extend into tlic right internal iliac vein, where it ended abruptly with a trun- cated and ap[)arently broken-otf' end. Both right and left nulmonarv arteries were found absolutelv occluded with firm red clot at their very origin. Nothing abnormal was found elsewhere in the body. Treatment : Usually death takes place befl^re any treatment can be inaugurated. In all cas(>s in which there is evidence of venous thrombosis prolonged and complete red should be en- joined. From an examination of the records of four of these cases which came under the observation of the writer, in none of which there existed any evidence of thrond)osis before the onset of the fatal symptoms, the only abnormal condition com- mon to all was a somewhat increased pulse-rate. In all four the ])ulse-rate is never recorded as being below 80, though death took place in each between the tenth and the fifteenth days of the ]Mieri)eral ])eriod. In view of this fact the writi r is in the habit of keeping all cases having an unusually higli pulse-rate as quiet as possible for at least four weeks after the birth of the child, or until the pulse-rate becomes normal. In mi/d eo.srs in which treatment is possible the indications are to keep up the body-temperature by the application of heat externally, to stimulate the cardiac and respiratory organs by the administration of ap})roj)riate remedies, and to secniv the most absolute physical and mental rest for the patient. FEVER DUELS a THE PUERPERWM, ETC. 343 Entrance of Air into the Uterine Sinuses. Causation : Tliis is ii very rare accident. Air may tiiul entrauce into the uterine sinuses in the course of intra-uterine manipuhitions, sucli as the introduction of the hand, the givin*; of an intra-uterine douclie, or by aspiration following a change in ])Osture of the patient. Symptoms: These are practically tiie same as in pulmoriary embolism. Treatment: This consists in the hypodermic administration of stinudants and the employment of artificial respiration. Inhalation of oxygen gas, in order to inflate the lungs and to ex})el the air emboli, has been suggested. Fever during the Puerperium due to Other than Septic Causes. Elevation of temperature may occur in the course of the puerperal period quite indc})endently of t^rptic hifci-tioii, from such causes as ex|)osure to cold, constipation, emotion, or reHe;^ irritation of any kind. Emotional fever: Profound ]isychical im])rcssions, such as grief, anger, fear, or even excessive joy, may give rise to some elevation of temperature, especially when exj^ericnced during the early puerperium. The mechanism of this elevation of' temperature is not susceptible of explanation in the j)reseiu state of our knowledge. In maternity hos])itals emotional fever is frccjuently met \\'\{\\ in cases of iUff/ithiidtc jtirf^Koicy about the tenth day of the puerperium, as a result of anxiety on the part of such jiaticnts in regard to their ability to j>rovide for themselves and their children in the immediate future. In emotional fever the temperature may rise to 104°-105° F. ; but the cause being usually transient the temperature quickly falls to normal. Exposure to cold: Elevation of tem])eratnre may follow exposure of the breasts or abdomen to cold ; too low a tcm- jwrature in the lying-in room or insufficient bed-clothing may expose the patient to a chill, which is usually followed by some elevation of tem})erature. The administration of some warm drink and the application of external heat usually cause the fever to disaj)pear promptly. 344 PATHOLOGY OF THE PUERPERAL PERIOD. Constipation: This is a not infrequent cause of elevation of temperature during the earlier part of the puerperiutu. Tiic fever is probably due to the irritation of retained aninml alkaloids. The administration of a dose of castor oil will probably result in a drop of the temperature to normal as soon u^ the bowels have been evacuated. Fever from reflex irritation : The effect of constipation when it occurs in the puerperium is an example of reflex irritation of the nervous system producing fever which at other times would have no such result. Irritation from engorrjenient of the breasts frequently result- in elevation of temperature, as has been mentioned elsewhere. Several times we have met with cases of fever in which no cause could be found to explain the condition until segments of a tapeworm or a round worm aj)peared in the stools. Fol- lowing the administration of appropriate remedies the worms were expoUed and the temperature promptly returned td normal. Tympanites : Tympanites, or overdistention of the intestines with gas, is not infrequently met with in the earlier part of tin- puerperal period. This condition may or may not be attended with fever. When this condition is associated with elevation of the temperature care must be taken to distinguish it from peritonitis. Treatment : Turpentine enemata at short intervals, com- bined with the internal administration of small doses of calo- mel, usually relieve the patient. Usually it is necessary to start the treatment with an enema of hot soap-water and turpentine (^ij to Oj). Then calomel (gr. Y^jy) should be given every hour. At the end of six honrs a dose of Epsom salt (.iss, in two ounces of hot water) may be given ; and if this is not effectual in an hour an enema con- taining glycerin (,lj), turpentine (^ij), ICpsom salt (Iss), and water (.?iij) should be given. The calomel should be kept up for two days, and then reduced to two or three doses daily. As these cases are due io p:\ralysis of the muscular coats of the intestine, a hypodermic of strychnine (gr. ■^^) should be given every four or six honi's until the condition improves. PUEtiPKRAL Sh'PTIC IMKCTKiS. .'M;') Puerperal Septic Infection. The general term puerperal septic infection is lierc employed to designate the many and vaiietl tliscaMcd conditions resulting from infection of the female genital tract during labor and the puerperium, by microiu-ganisms. Frequency: Previous to the introduction of the antiseptic method of conducting labor the mortality -rate from septic infection varied between 10 and 15 per cent, in the large maternity institutions. As the result of the application of rigid antisej)sis and asepsis to h(>sj)ital practice the mortality from septic disease has been reduced to a low fraction of 1 per cent. lu private practice the beneficial residts of the antiseptic method are much less marked than in hospital practice. Epi- demics of puerperal infection are now but rarely heard of, but the mortality-returns still show a large proportion of deaths following parturition. That septic conditions frequently c()mi)licate the puerperium is evidenced by the overcrowded condition of the gvnjrco- logical clinics in all parts of the country. A very large pro- portion of these gynaecological cases ]>resent conditions which owe their origin to febrile affections arising during the puer- peral period. Bacteriology. The streptococcus is the microorganism most frequently associated with the occurrence of j)uerperal sepsis. It is to be found in nearly all fatal cases. The staphylococcus aureus is the next most freque; ' cause of puerperal septic infection. Not infrequently mixed infec- tions with streptococci and staphylococci are encountered. The gonococcus, bacillus coli communis, bacillus diphtheriae, bacillus aerogenes capsulatus, pneumococcus, and bacillus typhosus may be mentioned as rare causes of puer])eral sej^tic; infection. These may be found pure or mixed with strepto- cocci ; M'hen the latter is the case the infection is generally exceptionally virulent. T\\Q gonococcus ]>lavs an inijiortant part in the production of puerperal sepsis. Kronig has found it to be present in 50 346 PATJiOLOay OF THE VVKRVKIIAL PERIOD. out of 179 cases |)iesonting febrile piierperia. Il ajjpears mmi ally to cause a mild infection, unless associated with a streptd coccus, in which case tlie infection is usually very virulent. Saprsemia: There is a considerable class of cases in Mhicli the symptoms are due to the absorj)ti()n of toxic j)ro(lu('ts pro- duced by organisms witiiin the genital tract which do not make their way into the blood-current. These are mostly ol an anaerobic nature, l)elonging to the pufrcfdctivc class of microorganisms, of which little is known. They usually pro- duce gas, and hence give rise to frothy, foul-smelling di- charges. Recently a great deal of bacteriological work has been carried out in the study of the vaginal secretion. Jt has been prac- tically })roved that the normal vagina in pregnancy is ficc from pathogenic microorganisms, at least in its upper third. The vaginal secretions are commonly strongly acid in their reaction, due to the })resence of a so-called vaginal bacillus, which in its life-processes j)roduces lacti(! acid. It is probably this acid condition of the vaginal secretions, associatetl with a certain leukocytosis due to chemotaxic aetion, which results in the rapid destruction of the })athogenic bacteria shoidd tluy find entrance fo the vagina. It has been proved that pathogenic bacteria introduced into a normal vagina perish in from eleven to twenty hours througli the germicidal action of the normal secretions. Preliminary antiseptic vaginal douches have been ])roved to iidiihit the germicidal action of normal vaginal secretions. Pathogoiic bacteria have been found to flourish from eight to sixt(, and yet the patient may succumb with extreme rapidity. It is the cndometrinm which is affected in the majority of cases of puerperal septic infection. This cndonicfritis may be septic or [ndrid, according as it is the result of infection by pyogenic or putrefactive microorganisms. The mildest form of pu('r[)eral septic infection is the puer- peral ulcer. These puerperal ulcers are simply infected lacera- tions of the vaginal outlet and vulva. Tiny usually present a dirty, greenish-yellow appearance and are bathed in a purulent secretion. Formerly these were termed diphtheritic ulcers, but it is very rare that they result from infection with the Klebs- Loffler bacillus. Usually they cause but little symptomatic ;, necrotic layer, which is hathcd in bloody discliar ■ is (jitcn considei'able, and it recurs vvitli urcat ra})idity ai'lcr ji removal by the curette. It consists of necrotic decidual (lei»r;- FlG. 121. uterus from yiiitient dyiinrcni tlic tenth tlay from iiiiiirc strt']ito('oecus iiifcction, and fibrin-exudate loaded with microorganisms (Figs. Til and 122). When the infection is due to the sfr('ptoco('cii,s or to tlif Kf(i/iln(looocci(.'< the odor of the lochia may not be affectid. Thus in the most virulent cases the lochia may remain swict throughout; but when the colon bacillus or any of the jjittn- VVEnVKUM SI'H'TfC isfectios. ;mo ffir/it'c (/cniis arc |)rt'S('iit tlic discliariics hccoinc luiil in tlic (Xiri'iiic. Ill a lai-<;(' iiiiiiilx'r ot' (•a>os Xatiirc succeeds in liiiiitin<; the iiite(;tive process to the eii(h»nietriuin, wliich it does hy lorniiii^ I'Ki. 122. tunis from patient dying on the tenth day frnni a mixed infection— streptococcus and coluii bacilli. a l)arrier or ohstnictioii inimediatelv l)eh)W the necrotic laver. I Ids barrier consists of a layer of small-cell infiltration, desig- nated the zone of rcdcfion. JJeneath thi.s zone the tissues are u-ually (|uite normal. ;350 I'ATiioLoar of tiii': pukiiperai^ period. 'riiiis o)i sccfioii \v(! find an internal layer consist iiijr of necrotic dc'cidna and HUrin-exudate swanninjj; witli niicro- oi'franisnis; below this is a layer of small-cell inliltrati(»n, tli<' •'zone of reaction," containini^ few if any bactei'ia, while inidcr this is the normal uterine tissue. Such is the condition found when the infectittn is due tn putrefactive mi<'roorjj;;anisms, as in jnifrid ciHlonictrilis, f^o-vnWvd by IJinmn and I)os throui^hout the uterine wall, though usually most marked Jiisi beneath the peritoneum. Parametritis: This inflammation of the oonnootive tissue contiguous to the uterus frequently follows intra-uterine infec- tion tluring the j)uerperium. The extension of the microorgan- isms usually proceeds along the lymphatics from the endomet- rium to the peri-uterine (tonnectiv^e tissue. Occasionally the infection may originate in laceration of the cervix. The infective inflammation of the peri-uterine connective tissue produ(!es extensive preads down the limb. in both fonn.s the ail'ected limb becomes (Miormously swol- Irn. In the first form there is usually more or less tenderness alou": the course of the femoral vein, which is usuallv marked l)y a line of inflammatory redness. Modes of infection: The most common mode of infection is the introduction of septic material into the genital canal, on tiie h((nds or instniniods of the j)hysician or midwife ; con- Ixid iidh secretion from wounds of any kind, such as infected .'352 PATIIOLOdY OF THE PUIAtPKIiAL PERIOD. altiasioiis on tlic hands of a nurse or physiciian. Air-in/evtion may account lor a vci'v small proportion of casi^s. The iiuffcr used to donclic the patient after lahor rimy carrx |)atho<;enie j;ernis into the ^<'nital canal. Conlttct of the vuls.i witli dirty hed-clothes or personal linen, or with infected vulvar pads, may account for some «'ases. In one case in the untli(tr's experience infection was pi'ohnliK due to the r///7// liand of /he jMificnt, who coidd not be re.'?trainMl from scratclniii:; the vulva. As has been shown, tlie nornml vagina is j)ractically sterile, so that when inl'ecti(»n occurs it is ^ have been introduced from without, during or after laiior. The inicrooriianisms may be lodged in the vagina, cervix, nr urethra, as in cases of gonorrlxea. Endometritis antedalinii conception may accomit for the lodgement of germs in the uterine mucous mend)rane, which in the favorable conditions existing after delivery may become virident and set U]) sejitic infection. In the same way an old pus-sae in one of the tubes may rnpture during labor and cause a sc})tic peritonitis. Symptomatology. The symptoms of septic infection may develop within the first twenty-four hours after delivery; but, as a rule, nothiiii: out of the ordinary is to be noted until the third or fourth day. The onset of infection may be attended with a sen,>-e of malaise and j)ossibly a slight headache. As the temperatiiic begins to rise the patient develops a more or less severe chill. which may amount to an actual rigor. The tem))eratnre (juickly rises to 103° F. or higher, and the pidse beconn- very rapid. Usually there is only one chill, but the temjxin- ture remains persistently elevated. PLJEltrKllM SEVTIC ISlEt'TIoy. 35.'i Tli«' loi'liUt may hccoinc scant, hiil as a rule tlic discliai'^c in- creases in anionnt. It niav i-einain Moudv <>r niav rapidiv he- coino purulent. In tli(! most virulent ca>es and in those due to pun; Htrentoeoccus inllrtion, very little, if any, odor is to he noticed. Profuse fonf-tintclliiif/ locliial discharge indicates a putrid endometritis; or a mixed infV'ction due to pyogenic as wi'l I as putrefactive orjjjanisms. Witli the onset of enri;anismH. li' the infective |)rocess extends beyond the uterus, the symptoms which then develoj) depend upon the tissues in- volved. Symptoms indicative of peritonitis, parametritis, or pysemia mjiy thus ensue. Peritonitis: The onset of this complication is indicated by the occurrence of intense pain, which is at first limited to the lower zone of the abdomen, hut "gradually extends as the whole- peritoneum becomes alfi^'cted. As paralysis of the in- testine; takes place marked tympanites occurs. In fatal cases deatli usually takes })laee within the first ten days of the puerperiiim. Parametritis: This complication, as a rule, develops when the endometritis is apparently snbsidinjr. Its onset is fre- ([uently attended with a chill; the temjM'rature, which has probably fallen, aj^ain becomes ele.ated and pursues a more or less irrej^ular course. The extension of the inflammatory proc- ess to the parametrium may usually be detected by a vain;inal examination. The infiltrated tissues surround iuij^ the uterus become hard and tense to the feel. This iuHammatioi' may end in resolution or in (ihs^ccx.^-foiiiKition — one lariie or several small abscesses may form. The pus may burrow about and make its way into the bladder, re(!tum, va*»;ina, or peritoneal cavity. Oceasionally such an abscess may jioint at Poupart's liiiament, or even above the crest of the iliinn. Pyaemia: In cases of pyjemia the initial symj)toms of in- flection are not so marked as in the other forms. The temper- 23— Obsf. 3-54 PylTIIOLOGY OP' Till': PU Eli VERA L PERIOD. atiirc (Iocs not rcninin r<»nst;uitly clovntcd, hut assumes tlic li('(;ti(^ \.y\K\ ( "liills arc usually of fV((jU('U( occiUTeMcc, Tlio sul)so(|uc'ut ,syuij)touis (Icpoixl upon tlic organs invadcij l)y the infected tlu'oniWi. Most coninionly with jn'jvinia we liavc syiuptoHH of an infectious i)roncliopueunionia develoj)in^-. Tiiis generally j)roves raj>idly f;.lal. In true septicasmia, wliicli is tiie most viridcnt form of sept ii' inlection, the organisms make theif way so rapidly into the general blood-current tiiat tiioy fail to become localized in anv one organ. 'I'his is the most rapidly fatal form of infection ; death may occur on the third or foin'th day of the puerperiinn, the j)oison being so viridcnt as to induce a condition of [tro- foiind shock. Diagnosis of Puerperal Septic Infection. If on tlu^ third or fourth day of the puei'peral period a woman develops a temperature of 101° F,, or more, which j)ersists for twenty-four hoiu's, the condition present is almo>t certanily one of septic infection pro^'ided ther<; is no otlior ap- parent cause to accoinit satisfactorily for the symptoms. The most common causes of an elevation of tcmjx'ratmc early in the ])uerperiiim, not (ixxociafctl irith septic infection, are : consti|)ation, ii-ritation from the breasts, and emotional excitcmcMit, fright, o" grief. Malaria and typhoid fever niav complicate the puerperiinn, and may be confounded with septic infection. A diagnosis of malaria is only possible when the ])reseii<(' of tlie ])lasmodium lias been demonstrated in the blood. A diagnois of typhoid fever is not jiermissible in the ab-enco of ^^ idal's blood-serum test. l^eforo making a diagnosis of septic infection, careful, syste- matic physical examination of the })atient should be made. A careful examination of tiie characters of the lochial dis- charge may render possible a diagnosis of which variety ol' endom(>tritis is j)resent in a given ease of puerperal septic in- fection. In all cases the ])hysician should make an ocular examination of the viih'dj vaf/iud, and crrvix in a good light, employing for tiiis purpose a largli>lie(l with hut little (iinieulty \)y the method ree<»mmeii(le(l Ity Professor W illiams, ol" I>alti(n(»re. The apparatus necessary eon>ists of a iila>.s tuhe, "20 to 2") cm. in leUiith and .'> to A mm. in diameter, with a sliiiht heiid at one end .so as to facilitate its intr(.(hiction into the uterus. I'his may he stei'ilized after j)lacinu' it in a lonti; te>t-tuhe u\' thick glass, which contains in its lowci- exticmity a pledget of cotton-wool, wjiile its U})i)er end mav he closed hv a cotton plug (Figs. 12;}-12o). Williams thus describes the method to he followed in oh- taining a cidture froe.i the uterine cavity: "A\'hen we wish to make cultures from the uterus, our hands and the external genitalia shoidd he thoroughly disinfected, the [)atieut placed in the Sims position, and a sterilized Sims or Simons speculum introduced so as to retract the postei'ior vaginal wall ; then the cervix is caught with a volsellum forceps anrotrudes from the vulva a syringe, which draws well, is attached by means of a I'ubber tube. Suction is made whereby a certain amount of the uterine contents is drawn u|) in the tube. The tube is then withdraw n and its ends sealed with .sealing-wax, when it can be carried to the laboratory without fear of contamination. On reaching the laboi-atory it i> broken in its uiiddle portion and cultiu'cs are taken froiu its inntents, which we know represent the uncontaminated lochia iVom the u|)jK'r part of the utei'us." When there is iDKlonhfcd rr/V/rocc of <'ndonietritis the interior Mfthe uterus should be explored by means of the sterile finger. This procedure can be can'ievl out w lieu the culture has been ehiained. \W this means important information may be ob- tiiued which will indicate the line of treatment to be |)Ui'sued. \\ hen the ira/Zs of the uterine cavity are ro//r///, the jti'obability is that we have to deal with \.\ patrcfadive cmlomdritis ; or 35G PATHOLOGY OF THE PUERPERAL PERIOD. Fig. 124. Fig. 123. I; II Fig. 125. one due to a pyogenie organism of a low degree of viruli'iicv. When the cavity is perfeetly smooth the infection is probal»ly due to virulent .sfrcptococci or daphyfococci. PUERPERAL SEPTIC INFECTION. 357 Treatment of Puerperal Septic Infection. Prophylaxis: The oocurrcnoe of puerperal septic infeotion is to be pr(,'vente(l by tlu; observance ol' llie most scrupulous «.svy).v/.s' in the inetiiod of conducting labor. This subject lias been fully dealt with in the section on the management of labor, to which the reader is again referred. Proj>hylactic (IcicJics should not be ein[)loyed except when the vaginal secret! n presents marked evidences of abnormality. ViKjinal ('xamm<(tividcnces of infection, the stitches should be removed in order to secure free drainage. Endometritis is the condition most U'equently present in puerperal septic infection. As previously mentioned, the cavity of the uterus should be exj)l( red and a })()rtion of the lochia removed for examination. The method of treatment to be followed will depend in a large measure on the conditions ])resent in the uterine cavity. The indications are to remove all debris and shreds of broken- down tissue, and to cleanse thoroughly the interior of the uterus. The routine use of the curette in all cases of puerperal endo- metritis is mentioned only to be condennied, as in certain con- ditions this treatment may result in the jn'oduction of far more iiarm than good. When the walls of the uterine cavity are found to be perfectly 358 PATHOLOGY OF THE PUERPERAL PERIOD. smooth there is absolutely no iiulication for the em])loyment of the curette, as tliere is uothino; present that can he reiuoved l)\ it. Tlie cavity siiould he douciied thoroii^idy with a oaljon (u- two of hot yterile formalin sohition (1 : r>()()j, alter which a strip of sterilized iodoform jiauze, rolled so as to foi-m a double wick eij>ht to ten inches long-, may be introduced as liiLih as the fundus. This wick of gauze favors drainage, and by ii> jiresence in the cavity stimulates the utci'us to conlraet. Some obstetricians prefer to ])a('k lightly the uterus with strips (if gauze after douching, but this rather tends to interfere with free drainage, and therefore the gauze wiciv is to be prcfcri'cd. If the bacteriological examination of the lochia reveals that the infection is due to .strqtfococci, further local treatment is to lie avoided and the gauze removed in forty-eight hours. If the interior of the uterus l)e foinid rough and jagged, and covered with more or less ialse membrane, the walls of the cavity should be systematically scrajied with a blunt cnrcitc (Mimde's), though many prefer the fingers for this puri»-c. Affrr cinrffiiir/ the walls should be explored by the fingei-tijis to make sure that all debris has Ixeu removed by the curette. A (loucJic of hot formalin solution (1 : 500) may then be (>iii- })loved to cleanse the cavity thoroughly, after which a Ijougieor two comj)osed of iodoform (.^ss) and suilicient ol. theobrom. to make a bougie two inches long, of the thickness of an ordinary lead-})ral use in this countrv, but is common in Germanv and Austria. Indications : These are : 1. Threatening central rupture of the perineum. 2. Great narrowness of the external genitals. 3. Rigidity of the perineum, especially when due to cica- tricial tissue. ;J(J2 OBSTETRIC OPERATIONS. 4. Faulty position of the advancing part of the Actns at the onth't. 5. ITiidiu! size of the fo'tal head. Operation: Tarnicr lias rccoMuiicndcd an oblicpio incision passing to one or other side of llic anns. Tiie (ierinans pil- fer lateral ol)ii((M(! incisions directed toward tiie ])osterior com- niissnn!. It is stated that such an incision 1 cm. (j^ inch) in lenglii increases tiie circninterenee of the vulvar orifice 2 em {jl inch). The inxfnininit used is a l)liint-])ointed scissors. During a ])ain one blade of the open scissors is slipped sideways between tiie iiead and the vulva, and then turned and the tissues cut. Tiie advantage of e|)isiotomy is the substitution (►fa clean cut of definite size, in a i)iaco where it (!an do no harm, for an ir- retfuhir laceration of indefinite size which mav cause iieniia- nent injury to the patient. Also a clean incision is much mon; easily sutured than a jagged laceration. IMMEDIATE REPAIR OF VAGINAL AND PERINEAL LACERATIONS. Wliether the pelvic fascia or the fibres of the levator aiii muscles are the all-important structures concerned in the suj)port of the internal pelvic structures is still a matter of debate. It is, however, certain that the wedge of tissue between the vagina and rectum comjwsing the perineal body has practicallv nothing to do with the sui)port of the j)elvic contents. According to Kelly, the "real sujiporting mechanism " nl' the outlet is the (itiferior portion of the levator (inl nvixclc. Tln' more generally held o])inion, however, is that \\w pelvic fttscia is the supporting miit is ahsolntelv iieeessarv. Wlien an ex- tenial superficial tear is found it may be rej)air('d at oiiee, as directed below. Jt", however, an extensive laceration should be present, l"urther examination may be deiayetl until preparations have been com- pleted tor a repair o])eration. Injuries to the vaginal outlet the result of ehildbirth may be classified as follows: 1. ivxternal supei'licial tear. 2. Internal tear, or eond)ined internal and external tear. 3. Complete tear of the rectovaginal septum. Fk;. li^G. 1. External Superficial Tear. This form of injury from parturition is the most frequent and also the least important, as it in no way atlects the suj)- porting structures of the j)elvic outlet. The tear involves siniply the sui)erHcial portion of tiie wedge of lax tissue between the vagina and rectum. It begins at the introitus vaginte and extends backward through the skin in the median line; occa- sionally it may extend inward as far as the ])osteiMor column of the vagina (Fig. l-li). This laceration can be inspected through- out its whole extent bv merelv se|)aratinss under the influence of chloroform. During the slight operation the uur.se is placed in charge of the fundus. S\ipor(icial tear cx- tiist'd by liiifxiTS parting al)ia niiiKira. 304 OBSTETRIC OPE It AT IONS. Instead of fijlng (he sufiirc.^ at once, the ends may l)e eaiiixln in a |)air of forceps and tlie tying completed after the dehvc r\ of the placenta. Necessary for the operation: A conple of small cin-ved iici - dies, a needle-holder, three oi" four silkworm-^nt or silk suture-. and a pair of scissors shoidd be sterilized. Many jncfcr tn employ an Kiniiuii pcrinvHin-nccdle in suturing these lacera- tions; it consists of a needle with a large curve, niounled on a handle; the needle is passed, threaded, and tlu!n withdrawn. The rule is to place the patient across the bed with the but- tocks over the edge, the legs being flexed over IIh; backs of two chairs properly arranged. In many cases it is possible ti- suture these simple lacerations without disturbing the patient beyond sejiarating and (,'verting her thighs. Suturing: The })atient being j)laced as most convenient, lli. lips of the tear are held aj)art by the fingers of the left liaii is then placid near the lower angle, and both sutures tied after the wound has been cleansed. If the apjti'oximation is not ([uite sat is fact oty, one oi- two superficial sutures may be re(|uire(l. The end of the siitin-t- shoidd be left fairly long, so that they may be easily liiuiid and })reventcd from causing the ])atient inconvenience bv pricking. The sutures may be removed on the eighth day. 2. Internal Tear, or Combined Internal and External Tear. Conditions : An mfcrmtl tear when present is found to ex- tend from the fourchette inward from one to two inches, in- volving one or both lateral sulci (Fig. 127). This tear alway- destroys the integrity of the i)clvic suj)porting structures, and if neglected leads to seric^us residts. Such an internal laceration may be present wiihnut an ex- ternal wound ; but usually the external injury (already de- scribed) is to be found afo^oclafefl irith the internal tear when it is present. On inspection a ragged bleeding wound will bo nEiwin (tF vAcisM. AM) rimisKM i.M.'EiiATioys. )M\r) fomid in tiie posterior vMiiiiml wall, associiitcd probably with iiioi'c or loss external laeeratioii. Method of Repair. TIk! |)atieiit should be placed aeross the bed with tiic but- tocks over the edge, as previously deseribed. I'Ki. l-i7. Superficial combined iuturniil and externiil tear, slidwiiig: portion of tear in vagina that may cscain.' notice. The illumination of the field of operation should be the best obtainable. Unless the patient is prej)ared to suffer a little pain, an an- aesthetic, preferably ether, should be administered. Thi-ouo;!!- out the oi)eration an assistant should guard the fundus uteri to prevent relaxation. The instruments recpiired are th(> same as before mentioned, with the addition possibly of a couple of vaginal retractoi*s. :]«() OllSTF/niK' OI'IHtATIoyS. Fi(i. i'2ri. 'I'lic first step ill llic oiicnitimi is to ascrrfMlii tlio mifiirc mid extent of the l;ic( nilioii. To ohtain a ii»ty means of iii< finiLJ<'f> ol' the left hand or by a retractor held hy an assi.-taiii 'The suturing sh(»iil(l eommenee at the upper anule (»t" tli^ tear, and the sutures should he ahoiit a centimetre ajiart ; a> many shoiihl l»e eiiiployeideral»le importance, as the oi)ieet i- to .secure the union of the >ii|>- ))ortinii'striictiii'esol' tlie peUic floor ( l-'iu'. \'2^). The needle should he introduced on the nnieoiis surface ().") cm. ( !, inch) from the margin of Same as Via. V2~, with iiitcTiiiil sutures passed, ready to tie. Internal stitctH>s tied ; external .stitclics in jiositiun. tlie wound and directed lhroiiL::li the tissues in the direction of the outlet, bronijlit out at tlie base, then reintrcxlueed, and directed inward and uj)ward so as to emerixe on the miicoii- surface at a point oi)posite its insertion. Tlius the hiop of IlKVMll OF VAdlSAL ASD ri.IilSF.M LACEIIATIOSS. Wiu enoh siitim' wlu'ii in place is diicctcd touaiti llic oju ratof (l"'iir. Kacli stitiirc >li(»iil(l i)(' licil l(cl'(»rt' the next i- iiilrodiiccd. Till' last suture thus iutioiliiccd >li(»uluj>er- lirial sutures introduced iVoui the ,-kiu >urraee. Kiu. i:;o. Conii)li.'te tiiir, i!i\(ilviiion may then lie removed, a vaiiinal doiiehe u'iveu. and the wound dusted with an anti- septic powder hefore the vulvar pad is a])|'li((l. After-treatment: The wound should he lliould be avoided, aiul the patient forbidden to strain while 3G8 OJiSTJ'JTRlf OrERATIONS. Iiiiviiijj^ a motion of tlio bowels. Jf there 1 c mueli tension oi, the sutiiiv, eatlicterization may be necessary in order to relicM the bhuhler. Tlie .siitnres may be removed on the eitdith oi tentli day, but the patient should be kept in bed for at leasl fourteen days. 3. Complete Tear. Conditions: A complete tear of the perineum is one extend- ing; from the fourchette back .vard through the sphincter ani, and involving the rectovaginal septum to a greater or less Fiu 131. Complete tear ; closing the rent in the bowel. extent (Fig. KIO). Such tears involve destruction of the fu'iction of the sphincter ani muscle, and result in inconti- nonee of faeces and flatus. The condition of the patien' thus becomes most distressinsr. Operation. Anaesthesia in this instance is imperative for the proper 'Per- formance of the operation. REPAIR OF VAGINAL AND PERINEAL LACERATIONS. ;i()9 Tlie position of the patient sliould be as for tlie previously described operation, Tlie natur;j and extent of tlie wound sliould be first ascertained and the field of operation thor- oughly cleansed. The rectum is first repaired by means of interrupted catj>;ut sutures introduced from the nuicous surface. The ends of the sphinciter nuist be carefully approximated by means of buriitd catgut sutures. The vaginal rent should then be repaired as before recom- mended ; and, finally, the r!evia may render necessary the termination of pregnan(n' befi)re the ])ei-iod of tiie viability of the child is reached. Tlie attending j)hysician should considt with a colleague luifore deciding the question of interference, and a full ex- r. 372 ORSTKTRW OPERATIONS. pliination of tlie circumstances of tlic case should be made to tlie members of the family most directly concerned. Methods of Inducing Abortion. The administration of drugs internally for the purpose of inducintj: abortion is onlv mentioned to be condemned. I'licii action is slow and uncertain, and their use is not infre(|U('nti\ attended with danjj;er. Up to the end of the sixteenth week the quickest and most certain method of terminating the pregnancy is the following : Dilating the Cervix and Curetting the Uterine Cavity. Advantages: The operation can be done in from ten to twenty minutes ; it is certain in effect, and when properly car- ried out it is practically unattended with danger to the patient. Th(; instruments required for this operation are, a volselhiin forceps, a Simon perineal retractor, a set of Hegar's dilator-, a pair of branched d'lators, such as Goodell's, an Emmet curette-force])s, a sharp curette, and a pair of long uterine dressing-force])s. Some strips of iodoform gauze (10 pci- cent.) for packing the uterine cavity and vagina should alsc be prepared. Preliminary to operation : The patient, aft( r being anaesthe- tized, is placed in the lithotomy jmsition on a table which is in a good light, the limbs being held in position by means ol' a rolled sheet or by a crutch. The vagina and vulva are then scrubbed with s])irits of green soap and hot water, cotton-wool swabs being em]>loyGd. The parts are then disinfected 1>\ niv..;?^^ of a douche of 1 : 500 formalin solution. The hand- of the operator an? then sterilized. The operation : The perineal retractor is placed in the v;i- gina, and the anterior lip of the cervix seized with a volselhiin and drawn well down. These instrimients may then be lieM by an assistant. The cervix is then diUdcd by means •'(' Hegar's and (4oodell's dilators till it easily admits the fore- finger. The Ennnet curctte-forcep'"^ is then inserted into tlie uterine cavitv and the ovum seized tnd crushed before the rNDUCTION OF PHKMATVRE LABOR. ;J7o iiistriinu'iit is witlidrawii with wliatovcr may iiavc lurii ^raspiMl. 'I'lic fu'tus and as miicli of tlic rost ot" tlio ovum as is possihlc should ho removed hy these forceps ; after which tile uterine walls should he carefullv and svstematicallv curetted^ hut without much force. After operation: The uterine cavity is then douched with hot formalin solution, and afterward packed with iodoform <>;auze. Tiie volsellumand perineal retractor are then reiuoved and tlie operation is completed. Some operators prefer not to empty the uterus at one sitting, hut after removing the fietus to ])ack the cervix with gauze and to tampon the vagina with antiseptic wool, which are left in place for twenty-four hours. On their removal, if the remainder of the ovum is not discharged I'rom the os, the cer- vix being softened hy the tampon, is further dilated and the uterine cavity is thoroughly curetted ; and is then douched and ])acked with gauze as ahove. recommended. This gauze j)acking should he removed in from twenty-four to thirty-.six hours. The ))atient should he kept in bed from one week to ten days after this operation. Abortion, when in(hiced after the sixteenth week is accom- plished by means of the methods to be reconnnended for the induction of prcniaturc labor. INDUCTION OF PREMATURE LABOR. The indications for the induction of ])remature labor are much the same as those given for the induction of abortion. In addition, however, may be mentioned (•(mtr ^<'t the handles of tlu.' ordinary forceps hack far enonjrh on aceonnt of resistance offered hy the perinenm This diflieulty has been overcome by the invention of the (ixis-iradioii forceps by Tariiier, iu 1877 (I'ig. Vil). By Fio. 137. Tarnier's axis-traction forceps. means of traction rods attached to the base of each blade, tittinoi; at their lower ends into a sj)ecially curved ))erin<'al bar, to which is attached a cross-bar as a handle, the line of the traction force is brouM(l in detail. Other indications : Insnnieient expulsive power, as nteriiu inertia from whatever cause ; increased resistance in the pil- vio canal from moderate pelvic contraction or from unusu;il ri'i'idity of the soft structures; over-size or undue ossilieiitioii of the fcetal head ; ahnormal presentations or positions of the fetal head, as lime presentation and occipitoposterior position.-; (Ku-idnifdf rondidoxN, such as eclampsia, placenta pra'via, pro- lapse of the funis or of a fu'tal member. Exhaustion of the mother is evidenced by a steady increase in the raj)idity of the pulse-rate, rising temperature, and a proirressivc failure in the force of the uterine contractions. Danger to the child is indicated by the fetal heart beats becoming rapid and weak or slow and feeble. If in the course of the second sfaf/c of labor the head fails to advance, and, either because of feeble contractions or from increased resistance, is arrested for half an hour, the labor should be terminated by forceps. When forcej)s are indicated the following conditions must be present to render the application of the blades permissible : 1. The OS must be com])letely dilated or easily dilatable; 2. The membranes must be ruptured ; 3. The child must be livinji; and viable; 4. The head must be engaged in the brim ; or it must be ]>ossible to crowd the head down to the pelvic inlet by external j>rcssure; 5. The head must be of average size and consistence, or else the blades will not retain their hold ; 6. The relative ])roportion between the head and the pelvis must be such as to make extraction possible with safety to mother and to child ; 7. The position of the head must be favorable ; for instance, FOnCEPS. .']79 it is prnctically iinjMtssiblc to cleli'cra inciitoposltiior pusitioii of tiic i'ace. Preparation for the Forceps Operation. Instruments, etc. : Tlic oljstctric forceps, as nvcII as siicli iii- stniinciits and siilinH's as may Ix' rcfjiiircd (or llic rcjtaii' of lacerations snl>sc(|nent to delivery, siionld he \vi-:i|t|)ed in a clean towel and boiled for ten ininntes, aftei* \vlii(li tliey niav be placed in a basin containini:: cold sterile water, to cool «ili'. Preparation of the patient: The h/sihle. If there be reason to susjx'ct contamination of the r«//V/(/'.s' (imhs should then be Mrapped about with freshly laundried or ster- ilized sheets. The operator's hands and forearms should be sterilized, and he should wear either a sterilized apron or a sheet, to protect his clothing. Preliminary to operation: The t)perator should then sit down facing the genitals of his patient, ("lose to his hand should be ])laced his instruments and a basin containing a weak formalin solution (1 : 1000), as avcH as some ])ieces of sterilized gauze or a ])lentiful suj)ply of clean towels. Before proceeding to apply the force])s the (juality and fre(piency (;f the faidl hearf-heafs should be ascertained aiul an exact knowledge of the poxiilon and vJtardcier of the jOial Jirad obtained. For this latter it may be necessary to j)ass the entire hand into the uterus; hence the ])atient sliould be anjesthetized before making this examination. Any mal- ])osition of the head should then be altered if j)ossible before the application of the blades is attem])ted. Anaesthesia : It is rarely possible to employ the obstetric IMAGE EVALUATION TEST TARGET (MT-3) i.O I.I 1.25 JA^IM 12.5 1^ 1^ |_2.2 ! ■- IIIIIM 1.4 1.6 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. M580 (716) 873-4503 1% \^^ 'v- 380 OBSTM'Rrc OPKIiATfOXS. forceps satisfactorily unless tiic patient is under liie iuHuencc of an an:estlietic. For j)rolon^^e(l or dilTiiMilt cases ether should he used in preference to chloroform, and its adminis- tration entrusted to a medical assistant. Posture of the Patient. The application of the obstetric forceps is possible with the patient cither in the dorsal or in the left lateral position. Many consider that the application of the forceps is more difficult in the left lateral than in the dorsal position ; but this difficulty is more appa'v-nt than real Generally speakin*^, the lateral position o . s many advan- tages, especially if tli(; oj)erator lacks a skilled assistant. In this position the patient's limbs do not re(iuire to be sup- ported. Tiie application of both blades is accomplished with the right hand, while the Hngers of the left hand places! within the vai^ina serve to j^uidci both th*' blades into position. During traction the perineum is undcjr constant observation, and extraction is easier and safer. Walcher's position: On account of the increased mobility of the sacro-iliac joints in the latter months of ])regnan('y a certain limited amount of rotation of the sacrimi is possibh on a transverse axis passing throiigii its second vertebra. After experiments with the live subject and with the cadaver, Walcher demonstrated that by placing the woman at full term on a table in the dorsal position with the buttocks close to its edge, and the lower limbs hanging unmipporfcd. the coniuffate diameter is len<>:thened bv from one half to one centinHitro. This posture of the patient is known as Walcher's position. The posture may be utilized to advan- tage ill high forceps operations or in difficult versions. The Forceps Operation. There are two methods of aj)plication of the forceps. That known as the Knglhli mrfliod is to apply the blades so as to correspond to the sides of the pelvis, (juite regardless of the position of the head. The Continental method is to apply the blades to the sides of the child's head regardless of the pelvis. FORCEPS. 381 The |>olvi(^ application of tlio blades — /. r., tlie Enjxlish method — is on tiie whole safer and l)etter, as less (hunaii;e is possible to the niattrnal soft parts. The eej)halie aj)j)lieation of the blades — /. f., the Continental method — shonld oidy bo emj)loye(l by experienced and expert operators, as it is the more complicated and ditficnlt. The o])cration is divided into the A////*, the iiioliinn, and the /orr, acu'ording to the position of the head in the pelvis. In the hifj^h o|)eration the head is arrested at or Just eniiajjcd in the pelvic brim. In the iiiedhuii oj)eration the head is arrested well within the pelvic cavity. In the /o/r operation the head rests npon the pelvic floor. In high operations the axis-traction forceps should be em- ployed, and the i)atient shoidd be j)laced in W'alcher's j)osition until the h"ad has been drawn down into the |)elvic cavity. As a rule, it is more convenient for the operator and better for the ])atient if she be placed on a table for the high forceps o|)e ration. fn medium and low operations the patient may be j)laced either in the left lateral or in the dorsal position, whichever is more convenient for the operator. Forceps Operation in the Dorsal Position. The )>atient havinc; been ])re})ared for the o|)eration, is placed in the dorsal ])osition, across the bed with the buttocks projecting slightly over the edge. Support of the limbs : When assistants are not obtainable to hold the limbs, they may be supported as in the lithotomy position by means of a rolled sheet passed under the neck and over one shoulder, having the end" fastened at the patient's knees. A better metJwd is to ])lacc two ordinary wooden chairs a short distance apart with their backs to the edge of the bevi' bliidc is then held in the right hand in similar fashion, and is guided along the fingers of the left hand within the vagina, the handle being de])ressed along the mother's right thigh. The forceps are then locked by depressing the handles toward the ])erineum and gently rotating the bhules into i)osi- tion. Care should be taken not to include hair or a portion of the vulva in the bite of the lock. In guiding the blades into position it is important to have the fingers of the internal hand introduced as far as possible and t(» press the maternal tissues well to one side. After locking the forceps a careful internal examination should be made to ascertain if a good grasp of the head ha,-; been obtained, and that nothing but the head has been in- cluded in the bite of the forceps. The luindla^ are fJieii (/fdsjjed near the lock with one hand, the fingers being hooked over the projecting shoulders while the back of the hand is directed upward. Extraction is effected by steady jmlling, or, better, by exert- ing a slight pendulum movement at the same time. The line of traction should corres])ond to the axis of the plane of the pelvis in which the head is engaged ; thus in hif/h operatinna the line of traction is directly backward to cor- respond to the axis of the brim ; in medium operations tlie FOR< 'EPS. ;is;] line of traction is directly liorizontal ; wliilc in /air oprrafious it is npwanl, so tliat tiie handle's are directed toward the mother's abdomen. The tractions shoidd be intermittent, like tlic natural pains. A ^ood rule is U) pull for oiw minute and then to rest for two. nurinji^ the intervals it is better to inifocl: f/ir forcrjis, so as to relieve the head from pressure and also to favor its rotation as it descends. Traction, when once the perineum begins to distend, nnist be made very carefully in order to avoid the sudden descent of the head. The line of trdcfion should be pretty nuich horizontal until the occiput pivota under the pubic arch. After this has occurred no fnrther traction \a necessary, l)Ut the head is slowly and carefully extended by pushini^ the luuulles upward in the direction of the mother's abdomen. When the licdd can he retained iti f/ie perineitm by pressure aj){)lied from behind in the (^occyneal reji'ion, the forceps may be gentlv removed and tin; head delivered without them. The liead in lield in position bv i^raspinir it throuji;h the perineum with the left hand. On no a(?(!ount should the lingers be inserted into the anus for this piu'pose, as it is unnecessary and dant^erous to do so. When the head can he lielu in ])osifion the blades may be removed in the reverse order of their application. The utmost gen' Mioss should be employed in their removal, and no force should be exerted if anv obstach* be encountered. A\'hen gentle manipulation fails to release a blade, it should be left in place until the head is delivered. After the forceps have b^en removed the iiead can be delivered by pressure over the perineum. As a general rule, forceps o])erations are performed with excessive speed, hence the frequency of lacerations of the maternal soft j)arts following their employment. Axis Traction. Tn high operations axis-traction forcaps should be used, though a certain degree of axis traction may be obtained witii the ordinary forceps; as will be described later. 384 OliSTKTRK ' OPERA TIONS. The patient having hec^n j)lac'e(l on a table in the dorsal position, with the buttoeks at the <'(!<:;e and the limbs held by assistants, or supported by ehairs, the blades are inserted in the ordinary manner with the traetion-bars fastened ( Fi^. 138). After insertion the blades are loeked, and, if Tarnier's Fu:. 138. Guiding-hand and forceps blade ; high application. (Farabocuf and Varnier.) instrumc it is used, the lock-pin is screwed moderately tiaht. The bar conneeting- the handles is then thrown across, locked, and the screw tightened nntil the blades have secured a firm but not too tight grasp of the foptal head. The lower ends of the traction-bars under the shanks are then loosened and the perineal handle adjusted to them and locked. FORCEPS. ;»8r> After riHcortainlng tnat a jn'opor jj^rip of tlio luad lias hrcn obtained and that the various screws are properly adjusted without the inclusion of portions of vulvar tissue the patient can be placed in the Walcher position hy reniovintji; the sup- ports from her linihs. J^y plaeinj^ large Mocks or hooUs under the table-legs nearer the o})erator the table can be Fig. 13y. ^^fft'-'^^^Wff-^' Traction with axis-traction fnrcci>s. inclined in such a manner that the buttocks will \vA be ])ulled too far over the edge when traction is exerted. 'I'lic line of traction should be downward and backward as far as possible, the traction-rods being kej)t about a (piarter of an inch from the shanks throughout the pull (Fig. l.'^Ol Between the tractions, the connecting-bar between tlie 25 -01)St. .">86 OnsTETIUa OPERA TIONS. Imndlcs should he unscrewed and tlic piii-l()(!k loosened in order to relieve the fu'tal head iVoni continued pressure When the head has been drawn down to the pelvic floor there is no further need either for ti'.e W'alclier position or for the axis-tra(!tion rods. The patient may then he placed in the ordinary position, the p(!rineal handle may he removed, and the traction-rods fastened in their places heneath tlic Idades, the force|)s then heinj;; used as the ordinai'v instru- UK^nt. Some operators prefer to remove the Tarnier instru- ment as soon as tlu; head reaches the [xdvic floor, completinjr the delivery by means of Sawyer's small forceps. In hii^h operations a certain amount of axis traction can he exerted with the ordinary long forceps. By l*aoet's or (lalal)in's manoMivre the line of traction can Ixj broiii^ht to correspond fairly well with the axis of the pelvic inlet. Tiuis hy pressinj^ or pullini^ downward with one hand ])laced as near the shanks as invssihle, and by pressini; or pulling u])ward with the other h.and on the handles, two forces are brought into action, with the elfect that tlu,' resultant acts in the line of descent of the head. The forcei)s by this manoeuvre is used as a lever, the hand grasj)ing the siianks beinijj the fultM'um. In em])loying this man(JMivre the greatest care must be exerci.sed to prevent the blades slip})ing. Forceps Operation in the Left Lateral Position. The patient is placed somewhat obliquely across the bed, lying on her left side with her thighs well flexed, the hips being brought well over the right edge of the bed. A folded pillow may be placed between her kriees to keej) the thighs separated. The oj)erator sits facing the ])atient's buttocks. The preparations for the ojieration are otherwise the same as mentioned in dealing with the application of forceps in the dorsal position. Insertion of the blades: Two fingers of the operator's left hand are inserted along the posterior wall of the vagina, through the cervix when possible and well over the present- ing ])art, pivoting the finger-tij)s upon the head globe, while the cervix, the posterior vaginal wall, and the perineum arc pressed back as far as possible out of the way. /•'OAv •i:rs. ;;h7 The loircv hhnlc hciii^^ licld in the ri^iit lunxl witli tlic pelvic curve directed hackward, so that tlie tip of the instni- nient is in contact with the left hand, is thus introduced within the vajrina. To facilitate tlic intro(hiction of tiie tip of tlie bhide in this j)osition, the liandii' must he held h>\v down, correspond i no; to tiie direction of the ^hiteal fold of the patient's left buttock ( Fiir. IKM. As soon as the //y> of tiio blade has been guided by the lingers of tiie left hand over the Fig. 140. Position of imtiont for forceps delivery und mode of introducing lower blade. (I'liiylair.) convexity of the head the InnxJ/c is raised, Ix'ing swept up- ward over the mother's right thigli, and Hnally l)ackwar(l and downward, until the shank falls behind the operator's left wrist. The handle thus sweeps through nearly three-cpiarters of a circle as the blade is being introduced and pushed up. This movement of the handle causes the tip of the blade to sweep around and under the head. The fi)i(/('rs of flic left luiml remain in contact with the head throughout the insertion of both bhules, the first blade being 388 OBSTETRIC OPERA TIOXS. held ill j)<)sliioii aftor its introduction by rostiiip^ ap;ainst tlio back of llu; left wrist wliilc the second is hcing nianii)nlatc(l into ])osition. TIk- iiji/xr hhulc is then j,n-asjK'd in the rigiit hand and its tip intnxhiced into the vulva above the shank of the first blade with the pelvic curv(! directed forward. The i'n^ is guided into position over the convexity of the head by the fingers of the left hand (Fig. 141). The handle is then swept Fig. 141. Introduction of the upper blade. (Tlayfair.) do'/nward and backwan^ cdong the mother's left thigh, thus causing the blade to move around the iippn' surface of the head to take its position opposite the right ilium. The second blade, having been placed in position, is used as a guide in locking the handles. It is held steady while the first blade, which may become displaced during the intro- duction of the second, is manceuvred into position so as to lock (Fig. 142). Extraction: After examination to .see that all is secure, the operator, grasping the hauvlles over the projecting shoulders FORCKPS. :wii witli liis rijrlit haiul, exerts traction as far l)a<'k\vanl as pos- sihle, at tlic same time stear«)j)er moii/ditif/ ol' the lieiul to < 'cur. 'Die normal nieehauisin of deliverv in face to puhes cases must be home in mind, and the forceps so used as (o aid iiatuH!. Tiic line of traction should he in the axis of the pel- vic cavity — that is, hori/ontally — until tiie forehead emerges sutticiently for the glabella to pivot r.nder the pubic arch ; tlu! iian(l'>s are then I'aised so as to bring the o(!ciput over the perineum, after whi(;ii tlu; face generally dtilivcis itseif by cxtfMision of the head. ()n(!e the (jUihiihi /iose. The grasp of the breech may be obtained by placing the tip of the blades over each trochanter and below the iliac crests. When this hold cannot be obtained, the blades may 1)0 iiifrixliicod so tliat one is in (MtntiU't with tlio sju'rum Mild OIK! iliiiin of llie child, wiiih- the other is in <'oiit:ict with lh»' posterior surface of the ()])j)ositc thi^h, as recom- meiuh'd i>y Oiiivier. 'J'lie after-coming head lias occasionally to he delivei-ed hy forceps al'tei- the failure of other methods. 'I'he application of the hiades is not dillicidt, j»rovieration. The manoeuvres: '^J'he operator ])laces a hand on each end of the fir'tal ovoid, with the palms facing and the fingers of one hand dire(!ted toward the wrist of the other. \^\ the alternate fiexion of the fingers of either hand the version i^ accomplished. One hand gives a movement of ascent and the other a movement of descent, each acting alternately. The extremity of the fa»tal ovoid it is desired to bring down is made to follow the shortest route which will bring it into proper relationshij) witii the |)clvic brim. Should uterine contraction occur during the mani|>ulations, the o|)eraior must be content to hold the fVetus in the ])osition gained until re- laxation occurs, when the operation may be proceeded with. AVhen the fcetus has been placed in the desired position a vaginal examination should be made to ascertain whether the presenting part is ])ro]ierly over the iidct. To irfain flicfa'fii.s in ))osition until the presenting part lias engaged, longitudinal pads comvtosed of folded towels, may be placed on either side of the fetus and a fii'm abdominal binder apj^lied. Occasionally, when external version has been carried out after the onset of labor, it is advisable to rupture the mem- branes, so as to favor the retention of the fu'tus in its new position. Bipolar Version. The chief advantage of the bipolar method is that complete dilatation of the cervix is unneeessarv, as bv this methoidic<(fio)i.'< for this method are : abnormal j>resenta- tions or ])ositions of the head, such as face or brow presenta- tions and prolapse of the cord, when diagnosed early in labor. It is also very useful in transverse cases, whether it is desired to bring down the breech or the head. Conditions for bipolar version: The membranes should be intact or so recently ruj)tured that the child is still freely movable. The cervix should admit two tingers, and the vagina be capable of containing the operator's hand if neces- sary. The uterine and abdominal walls should be lax. Preparation: 'J'he patient should l)e ])repared as for a for- ceps operation. She should be placed in the dorsal position, across the bed, witli her hips at the edge, the legs being suj)- ]K)rted by chairs. The operator sits between the ])atient's thighs, after having well sterilized his hands and forearms. The external hand can be kept from contamination by wra[)- ])ing it in a sterilized towel. Anaesthesia is desirable, but not necessary, provided th(> vagina and vulva are lax and the patient not nervous. Method of operation : Before proceedivg in operate, the diagnosis of the position of the fietus should l)e confirmed by careful external and internal examination. The details of each movement of the operation should then be })lanned so il VERSIONS. :]9r) that the operator has clearly in mind exactly wiuit he wishes to accuniplish by his nianceuvres. In head preacnUitionn, in which it is desired to bring down the breech, the head shonld be moved in the direction in which the occipnt points. The fingers of the hand, the palm of which points in the direction in which it is desired to move the presenting part, are then introdnced through the cervix. Thus, if j)resentatii-^ / ' tiie a^lrt hand presses down the breech, through the abdominal fr^y.JL wall. The version is accomplished by a series of alternate pushes with either hand. Vaxyh should be taken not to rupture the membranes, should they be intact, until a foot or leg is within reach of the internal fingers at tiie pelvic brim. In correcting an abnormal presentation of tlie head by combined manipulation the fingers of the internal hantured, th(\v should be broken as soon as the position of the head is altered. Pressure should then be maintained upon the fundus until the vertex has become firmly engaged in the brim. Internal Version. This method of version is most commonly employed, as it is probably the most rapid and effectual way of securing delivery when the head is not engaged in the pelvic brim. It is the most dangerous method of version, as the hand must be placed into the uterine cavity in order to seize one or both feet. Indications : Eclampsia, placenta prjevia, threatened sud- den maternal death, prolapse of the cord, and accidental hemorrhage may be mentioned as indications for this method of version, especially when rapid delivery is desired. Other indications are transverse presentations, moderate pelvic contraction, prolapse of fietal members, and rupture of the uterus. 396 onSTETRW OPKBATIONH. Conditions for internal version : Tlio crrvix must l)o dilatcc!, or . (). A. or \j. O. P. positions the left hand is introduced into the uterus. In such cases the anterior foot should always be seized. In ease of doubt both feet may be brought down. VERSlOyS. 397 Wlion tho long axis of the fu'tiis is transvorso to the axis of tho uterus t/ir /kiikI to be introdiaud is the one irliich rorrr- sj)(>tnl.i to the side of the mother to irhich the hreeeh is direeled. When the breeeh is directed to the mother's right side the operator sliould introduce his right liand. In dorso-anterlor positions tiie near foot should ho sei/ed and brought down, and in dorsopoi terior positions tli<' remote foot. Thus when the child's hack Is directed to (he front, seize the /yon^ (near) ^'jot ; when the back is directed to the back, seize the back (remote) foot. Before introduction the hand and arm should be dipped in creolin solution or smeared with sterilized oil. The hand, with the tips of the lingers and tlnuub placed together ,s'o as to form a cone, is then introduced through the vagina and cervix with a rotary motion. The uterus shouhl always be entered with the jialm of the hand directed toward the abdomen of the fretus. The hand should be ])ushe(l steadily though gently n])ward to the fundus, where the feet are usually to be found. A conunon mistake of inexperienced operators is to feel about for the feet before the hand has been introduced far enough. The foot can be easily recognized by the prominence of the heel and malleoli. The e.vternal Itaiid, j)rotected with a sterilized towel, should co-operate by making counter-pressure on the fundus, in order to steady the fetus as well as to press tluj breech down, so that the feet may more easily be reached. If the membranes be found intact, they should be rvjdnred and the hand pushed (piickly uj), in order that the forearm may plug the vagina and so prevent escape of the licpior amnii. Should nterinc contraction occur, tlu^ hand with the fingers extended should be held quiet until relaxation has taken place. If the shoulder he found impacted in the ])elvis and an arm prolapsed, a noose of gauze bandage or ta])e shoidd be slipj)ed over the child's wrist, and then the impaction may be reduced by gentle upward pressure upon the body of the fVetus, In reducing an impaction of the fcetus the same rule ap- plies as in the reduction of an impacted hernia, " The part that has come down last should b'^ returned first." Thus the upward pressure should first be ap})lied to that portion of the 398 OBSTETRIC OPERATIONS. fu'tus nearest tlio pelvic brim, and then successively along the body until the apex of the siioulder is reached. \Vhen (I xccarc (/r(t,sp of the desired J'oot has been obtaincjd it is drawn steadily down toward the pelvic outlet, the external hand at the same time bein^^ employed in directing the head toward the f'ui;dus. This turning movement should only be made when the uteius is eh rely relaxed. The operation may be con-sidcrrd . Rationale of symphysiotomy: Tlio scpiiration (A' the sym- physis (uusos a k'nii^tiicnin*:; of tlic diamcti'i's of t^ic pelvis, llie conjnii'ate lu'inj; the one atfeeted most in conseijiicnee of tiio ends (»f the pnWie hones moving downward as well as outward when ^e[>ar"iited. The (h'seent of the ;5ei);irated ends is (hie to the fact that each of th*' sacro-iliac joints roljitcs upon an oi)li(|ne line rnnnint; from above downward and tVoni without inward. A separation of .'jcm. (li inches) (pauses a descent of 2 cm. [l incli) ; still further descent being canse.5 to 7 cm. (2.5 to 2.7 inches). After delivery has been completed the patient's thighs should be extended and her knees brought together. The oj)eratoi', after having washed his hands, removes the gau/e packing 26— Obst. 402 omTKTRK' OPKRATloyS. from tlie woiiiid iind ]>ass('s liis left indcx-fin^or hcliiiid the joint to make sure tliat the Idaddcr has not hccii cautilii Ix'twceii tlic boiu's ; tlu'ii liavin*; clMcUcd all liciiiorrliajxi', lu' siitiiros iIr' wound with three or t'oiir deep sllUworin-mnt sutures. Most operators consider it unneeessary to attempt to suture the hones to<:;etlier ; on(! or two sutures, however, may be placed so as to include the Hlwous tissue on the ante- rior surface! of the joint. Vaginal and vulvar lacerations, if present, are then re- |)aired, and the bladder and urethra examined for ])ossible injuries. The abdominal wall is then drc^ssed with a sti'ij) of iodofoiMu ti:auze and covered with lavers of absorbent cotton. 'J'his dressing is iield in phuic by means of one or two bi-oad strips of rubber adhesive plaster which pass well behind the wings of the pelvis on either side. A firm cotton binder is then aj)plied, or a broad canvas belt whi(;h can be fastened by means of straps and buckles. The patient is then removed to a bed witli a firm level mat- tress, sucii as would be used for a fracture case. It is ad- vantageous to su]>port the sides of tlie ])elvis with sand bags reaching from the knees to above tlie waist. Tlie patient's knees should be tied togetiier. French method : The chief advantage of this method is that on account of the long incision the operator can see what he is doing at each step. The operation ; An incision three inches long is made begin- mintr on the abdominal wall one and one-half inches above - the symphysis and extending downward to the clitoris. The edges of the wound are separated by retractors and the exact location of the symphysis d(4ermined. By careful dissection first th(> lower and then the upper margins of the symphysis are exposed. An index-finger is then inserted behind the joint so as to detach the retropubic tissues. A broad, flat, grooved director is then guided along the index-finger behind tlu; joint, either from above down- ward or from below upward. The joint is then cut fr(»ni without inward by means of a Farabceuf knife. During de- livery the wound is })acked with iodoform gauze to prevent possible infection. After delivery the wound is sutured with strong silkworm- .S' YMPIl YSrn TOM Y. 4 Oli ^iit, tho sutures hciuii^ ^'» pnsscd as to include tlie Wvux tihrous outer (!()veriu^- of the ends of the hones. After-treatment : 'I'lir atter-enre of a svtni)h\>iotoinv ease is usually very trouhlesoiue, the dillicidlits hciu^ to keej) the wound from infection and to prevent separation of the ends of the pubic hones. 'I'here is usually very considerahle u'di'Uia of the vidva j)r('seut for several days after the ojx'ratiou. Special attention should he i)aid to the f(>i/lu(e or rclntiir : An absolute indication is the presence of some condition which renders im])ossil)le any other method of delivery — e. //. — extreme degrees of pelvic contraction (conjugate under 6.5 cm.) ; marked ])elvic deformity resulting from osteomalacia, kyphosis, and spondylolisthesis ; foreign grow'ths obstructing < '.fASVl RIJA iV .SAY "11 ON. 405 tlio |)olvI(' canal ; cicatricial <'(mh'a»'ti<»ii of llic vaiilna ; and carcinoma of tiic cervix or ol' llic rectum. A relative indication is tlic jn'cscncc of some condition wlii<'h makes y tlic natural |)assa^es. In some cases tlie v'apsuds (.^j to ()j) may be given. Before the })atient is ])laced on the operating-table siie should be catheterized and the abdomen, vulva, and vagina 400 OBSTETRIC OVERATIONS. fiipilly .sterilized. Tlio vagina is tlien liglitly packed with iodoform gauze. After tlie patient is placed on the operating- table the chest and thighs are covered with blankets j)rotected by sterilized towels, and a large piece of sterilized gauze coni])osed of four thicknesses is arranged so as to cover the whole body from chest to knees. The usual dresshigH and acce.sHorics for an abdominal opera- tion should be provided in addition to the following instru- ments : 2 scalpels, 1 pair of ordinary scissors. 1 dozen artery-forceps, 1 pair of retractors. Curved and straight needles, 1 needle-holder. A large thin-walled rubber tube as a uterine ligature, Silk, silkworm-gut, and catgut for sutures and ligat.ires. Four assistants are required — one to give the ansesihetic, one to compress the cervix and control hemorrhage, one to receive and attend to the child, and one to assist the operator throughout the operation. The Csesarean Operation. The operator first cuts a slit in the gauze extending from the pubes to a short distance above the umbilicus. An incision is then made in the linea alba extending from a ])oint 4 cm. (1| inches) above the pubes to a point the same dista» ce below the umbilicus. The peritoneal cavity is then opened with the usual precautions. Such an incision is sufficient for the introduction of the hand and the withdrawal of the child. Many operators prefer, however, to extend the abdominal incision to a point above the umbilicus, and to turn the uterus out of the cavity before incising it. The advantages claimed for this laffer method are : a saving of time, better control kS the uterus, and that it is easier to ])revent the entrance of fluids into thc^ general peritoneal cavity. Its disadvantages are : the great length of the ab- dominal incision, which predisposes to hernia later; and the CMS A RE AN SECTION. 407 greater extent of adliesions oecurriiig later between the ab- dominal wall and the nterns. For these reasons the shorter ineision is generally to he preferred. Having exposed the uterus to view, the operator then passes a piece of rnhber tubing over the fundus and down to the lower segment, so that it will encircle the uterus below the presenting })art of the child ; the ends are given to an assist- ant, who, l)y exercising traction, compresses the uterus and steadies it against the symphysis, thus eontrolling hemorrhage. An incision is then made into the uterus extending from tlie fundus to just above the retraction-ring. This incision must be made quickly and boldly in spite of the severe hemorrhage whicii occurs. Extraction of child: The operator then plunges his hand into the cavity of the uterus, pushing to one side the placenta if it be encountered, seizes the chi'd by a foot, and extracts it as raj)idly as possible. While the uteri le incision is being made the assistant should press the abdominal wall to the sides of the uterus, to prevent the entrance of fluids into the peritoneal cavity. As soon as the child is extracted the utarus usiially contracts. When the child is withdrawn from the uterus it is given to an assistant to hold, while the o])era- tor clamp-i the cord in two places with artery-forceps and cuts between them. The placenta is then grasped on its foetal surface; and loosened from its attachment by simply squeezing it. The membranes peel off from the uterine wall as the placenta is withdrawn through the incision. Should the uterus fail to contract properly, it may be stimulated by the applicaticm of hot cloths and friction. It is then lifted out of the abdominal cavity and a large piece of gauze slipped under it, to hold it and also to prevent the intestines protruding. After some iodoform powder has been dusted into the cavity the uterine wound is closed bv means of silk sutures. These si *^ures are placed at intervals of about 1.5 cm., or about half an inch, and should include only the muscular coat. The peritoneal edges are then approxi'.nated by a second layer of interrupted silk sutures, placed at shorter in.tervals than the first layer. After the sutures have been tied there 408 OBSTETRIC OPKIiATtONS. shoukl l)e no lionK)i'rlmf2;(> oitlior from tlio wound or from tlio utHMlle-pimctiirt's. When tlic utorine wound has been sutured the clastic ligature around the cervix may he withdrawn. Closure of abdominal wound: The abdominal cavity should then be sponged dry with cheesecloth sponges, particular attention being paid to the renal fossjc. Having returned the uterus to the abdominal cavity and placed \^ in proper position, the omentum is then to be brought down and carried behind instead of in front of it, in order to avoid omental adhesions. The abdominal incision is then closed in the usual manner and a surgical dressing applied. The vaginal gauze is then removed and a vulvar pad applied. After-treatment: The after-treatment should be much the same as after any abdominal operation. During the first twenty-four hours it may be necessary to give a hypodermic injection of morj)hine for the relief of ])ain. The child r-^'^w be put to the breast after twenty-four hours have ela .. Special attention should be given to the care of the vui.a, in order to prevent infection of the vagina. The abdominal sutures may be removed from the tenth to the fourteenth day, and the patient may be allowed out of bed at the end of three weeks. An abdominal support should be worn for six months after the opeiation. Porro Operation. In 1876 Porro suggested that the ordinary Ciesarean opera- tion should be supplemented by the amputation of the uterus along with the tulies and ovaries. After amputation of the uterus, two methods of treating the stump, are available. Ry the extraperitoneal method the stump is transfixed by long needles and retained in the lower angle of the wound. By the intraperitoneal method the stump is sewed over in such a manner as to cover it completely with ])eritoneum, after which it is drop])ed into the abdominal cavity. The advantages of the Porro operation ar(> that it rend(>rs subsequent uterine hemorrhage or conception impossible, and decreases the risk of puerperal infection, while it adds nothing to the danger of the operation. SELECTION OF OBSTETRIC OPERATIONS. 409 Indications : Orlioliystcn'ctoniy, or Porro-Ciosjiroan soction, is indicated when labor lias hoeii |)rolon<::('«l and nianipidations have been attempted to .secure delivery, hut have tailed and sepsis is j)rol)ahle ; when the uterus or its apj)enda^es are so diseased as to require a subsequent operation for their •enioval ; and when any condition is present which will make it impos- sible for a child to be delivered subsequently by the natural passages. The preparations are the same as for Cttsarean section, except that the following indrurnenfx should be added to the list given previously : 1 large pedicle-scissors ; 4 curved large pedicle-clamps ; 2 large volsellum forceps; 2 right and 2 left aneurisrr>-needles ; and 1 right and 1 left sharp-])ointed pedicle-needles. Operation : The abdominal incision should extend from two inches above the umbilicus to just above the symphysis. The uterus is drawn up out of the abdomen, and a sterile towel is packed into the peritoneal cavity to jirevent the escape of the intestines. The assistant then draws the edges of the alxlomi- nal incision close about the cervix, whi(!h he grasps tirndy with both hands so as to control hemorrhiige when the uterine incision is made. The uterus is then incised an 1 the child and placenta removed as quickly as possible. The ovarian arteries are then sought and tied, as also the arteries of the round liga- ments. The broad ligaments are then clamped and cut ; peritoneal flaps for covering over the stump are tin n pre- pared, the uterus amputated, and the uterine arteries tied. The stump is then oversewn and dropped, the peritoneal cavity is washed out, and the abdominal wall closed. GENiSRAL RULES GOVERNING THE SELECTION OF OB STETRIC OPERATIONS IN CASES OF OBSTRUCTED LABOR. Conjugate of 9.5 cm. or less: The best method is to induce labor at or about four weeks before the ex])ected termination of pregnancy. Tf the condition of the pelvis is only discov- ered after labor has begun, the labor may be allowed to go on for twenty-four hours. Atter^ion should be paid to the 410 OnSTETRW OPERATIONS. woman's general condition and tlie distention of the lower uterine segment, 'llie (choice of operation then lies between for(!ej)S, version, symphysiotomy, and Cjesarean section. Forcepti may 1)6 applieossibly can be avoided. On the other hand, Ctesarean section should not be rashly undertaken by an oj)erator unskilled and iuex- ])erienced in abdominal surgery. As before; said, the final decision should be left to the ])atient or her nearest dila- tions. When the pelvic canal is obstructed by a tumor which can- not be dislodged or which would be subjected to dangerous kMBUYOTOMY. \\\ |)i'essiire during tlic passa'i;^ of llio child, tlio safest inctlio! of delivery would be Ctesarean seeti(»n or the Porro operation. EMBRYOTOMY. Definition: Etnhri/ototni/ is a generic, term which includes all the destructive operations by which the volume of the fo'tus is reduced to permit of its extraction throuj^h the natu- ral })assages. The term thus includes crdiildtoini/, dccdpita- tioUy evuHceratlon, and wnputation of the extmnit'u'x. Indications : Emhrvotomv should never be i)erformed on a liv'uKj child when any other obstetric operation otfers a reason- able chance of savinu; its life. The patient and her friends may decline any conservative operation and insist on embryotomy. In such er- forator, a cranioclast, and a ceplia]otril)e (Fig. 147). Tliis instrument is composed of a perforator, two heavy fenestrated i)lades of uneijual lengtli, and is provided witli a })owerful compression screw. Method of use: After disarticulating tlie instrument tlie pei'forator is pushed tlirougli a suture or fontanelle, the short bla oriuiii, fu'tiil. 197 iiiatcnial, liKi pati'iiiiil. l!M> fn'(HUMic,v, !!•■") iiuluction of (see lion), ;{7l iiiovitablc, 197 missed, 'J('<1 labor, 201 partial, 19.S pathology, 19') blood-mole, 19(5 cast-off decidiia, 19(5 effusion of blood, 196 prognosis, 19rt symptoms, 19.") expulsion of the ovum, 195 homorrhage, 195 pi.in, 195 threatened, 197 treatment, 198 active, aOO after-, 201 expectant, 199 of inevitable, 199 projjhylactic, 199 of threatened, 199 tubal, 203 Accidental hemorrhage, 263 apparent, 263 concealed, 2(53 etiology, 261 symptoms, 264 treatment, 265 Albuminuria in pregnancy, ISl Alimentary system, chaTiges of, pregnancy, 43 Allantois, 30 in Amnion, 29, 35 liijuor aninii, 35 function, 35 I)ath()logy, 156 dropsy, 15(5 hydranmios, 156 oligohydramnios, 156 lircmature rupture, 159 sac, 30 Amniotic bands, 15H Anasarca of fo'tus, 166 Anatomy, obsti'tric (see Obstetric atiat' omif), 5(5 !Ki Apojdexy of placenta, 162 Area pellucida, 2H Areolie, abscess of, 331 Arrest of lactation, 331 indications, 3:51 method, 331 Atresia of vagina, 302 Axis of bony outlet, 76 of brim, 76 parturient, 76 of plane of the vulvovaginal ring, 76 relation of uterine to fcetal, 90 B. Ballottcment, 50 Bladder, calculus, 303 cvstocele, 303 distended, 303 Blastodermic vesicle, 26 Blood-mole, 196 Bloodvessels in pregnancy, 184 Breasts, abscess (see Mammary abscess), 329 absence, 320 changes in pregnancy, 41 diseases of, 172 abscess, 172 eczema of the nipples, 172 excessive secretion, 172 engorgement of, 322 419 420 INDEX. Breasts, engorgement of, treatment, breast-handiigi', ;{24 breaat-i)uniii, ',VZ2 massage, '.V2'i Murphy binder, 324 nursing, ;}2'-i hypertrophy, 320 inflammation of (see Mastitis), 326 mastitis (see Mastitis), 32(i supernumerary, 320 c. Csesarean section, 404 liistory, 404 indications, 404 operation, 406 Porro, 408 Calculus of bladder, 303 Caput succedaiM'um, 115 '*, rcinonia of cervix, 303 Cardiac diseases in i)regnancy, 184 Cerebral hemorrhage in puerperium, 338 Cervical lacerations, repair, 370 operation, 370 Cervix, atresia, 298 carcinoma, 303 cicatricial contraction, 298 impaction of anterior lip, 299 polypi, 305 rigidity, 298 treatment, 298 softening of, 41, 46 violet discoloration, 41, 47 Chorion, 30, 31, 34 hydatid i form degeneration, 159 pathology, 159 villi, 31, ''<2 Circulatory system, changes of, in pregnancy, 43 Climacteric, 18 Ccelum, 29 Colostrum, 149 Conception, 21 Constipation in pregnancy, 174 Cord (see UmhiUcal cord), 30, 34 Corpus luteum, 20 of pregnancy, 20 Cough in pregnancy, 183 Cutaneous system, changes of, in l)regnancy. 44 Cystitis in puerperium, 336 Cystocele, 303 D. Decidua, 23, 34 Decidua, cells, 25 coalescence, 23 development of, 23 layers, 23 pathology, 154 atrophy, 156 decidual endometritis, 154, 155 acute, 154 etiology, 154 treatment, 154 chronic, 155 catarrhal, 155 difl'use, 155 occurrence, 155 treatment, 155 reflexa, 23 serotina, 23 vera, 23 Dental caries in pregnancy, 173 Development, 23 decidua (see Decidua), 23 f(Btus (see r^etiis), 25 l)lacenta (see Placenta), 3 Diagnosis of pregnancy, 45-51 Diarrhreu in pregnancy, 174 Diphtheria in puerperium, 333 Ductus arteriosus, 38 venosus, 36 Dyspnoea in pregnancy, 183 Dystocia, 209 due to abnormalities of the foetal appendages, 253 accidental hemorrhage, 263 adherent placenta, 266 coiling of cord about neck, 258 placenta prsevia (sec Pla- centa prievia), 258 prolapse of cord, 254 retained placenta, 266 short cord, 253 anomalies of foetal development, 248 encephalocele, 252 hydrencephalus, 252 hydrocei)halus, 250 meningocele, 252 monstrosities, 253 overgrowth of foetus, 248 premature ossification of skull, 249 tumors of foetal trunk, 252 malpositions of the foetus, 209 breech presentations, 221- 237 brow presentations, 221 INDEX. 421 Dystocia, due to malpositions of tlie foitus, face presentations, 21o-^'21 occipitoposterior cases, 209- 214 plural births, 245 prolapse of the foetal limbs, 244 transverse presentations, 237-244 triplets, 248 twin labors, 245 maternal, 2G8-;J12 anomalies in forces of labor, 268- of the maternal soft structures (see Uterus, Vagina, etc.), 297- ;J12 of the pelvis (see Pelvis), 272- 297 E. Eclampsia, 188 course, 190 definition, 188 diagnosis, 192 eclamptic fit, 189 duration, 189 etiology, 190 toxaemia, 190 frequency, 188 pathological anatomy, 191 kidneys, 191 liver, 192 lungs, 192 spleen, 192 prognosis, 192 symptoms, 188 premonitory, 188 termination, 190 treatment, 192 during attack, 193 medical, 193 obstetrical, 194 prophylactic, 192 urine, 188 Ectoderm, 28 Ectopic gestation, 202 definition, 202 diagnosis, 206 etiology, 204 frequency, 202 pathology, 204 primary, 202 secondary, 202 tubal, "infundibular, 202 interstitial, 202 Ectopic gestation, seco)idary (ubal. true, 202 tubo-ovarian, 202 symptoms, 205 terminations, 202, 203 treatment, 207 varieties, 202 abdominal, 202 ovarian, 202 tubal, 202 Eczema of nipples, 172 Elephantiasis of fa'tus, 165 Embryology, 21 Embryonic area, 28 Embryotomy, 411 dangers of, 417 definition, 411 eviscerat^-.a, 417 indications, 411 instruments, 411 basiotribe, 413 blunt-pointed scissors, 415, 416 Braun's hook, 414 cephalotribe, 413, 416 craniodast, 412, 416 hook and crotchet, 413, 416 perforators, 412, 416 operation, 415 perforation of after-coming head, 416 Encephalocele, 252 Endocervicitis, 172 Endometritis, decidual, acute, 154 chronic, 155 in puerperal septic infection, 347, 350 Entoderm, 28 Epiblast, 26, 28 permanent, 28 primitive, 28 Episiotomy, 361 advantage Ci, 362 definition, 361 indications, 361 operation, 362 Erysipelas in puerperium, 333 Erythema in puerperium, 333 Eutocia, 96, 209 F. Fibromyoma of uterus, 304 Foetal circulation, 36 head, flexion of, 85, 108, 109 moulding of, Hti heart-sounds, 132 movements, 96 trunk, 88 diameters, 88 422 INDEX. Fd'tal trunk. mol)ility, 88, 89 Fd'tus, iiiiasartii, l()(i aiioiiialifs, Ki") centre ()f gravity, !»(> circulation (sec Fn'tol circulation), 3(i contagious diseases, 1G8 death of, 1()8 causes, 168 se()uela!, 169 development, 25 elephantiasis, 165 head of, 77 l»ase, 77 diameters, 82-84 flexion of, 85 Klahella, 81 nobility of, 88, 89 mouldinji of, 86 occiput, 81 planes, 85 circnmfereucos, 85 protuberances, 81 frontal, 82 occipital, 81 sinciput, 81 vault, 77 fontanelles, 78 false, 80 sutures, 78 vertex, 80 ichthyosis, 166 mature, 76 monstrosities, iS5 mortality of, 165 ossification of skull, 249 overgrowth, 2 ts treatment, 249 positions (see Positions), 93 posture, 89 normal, 89 presentations (see Presentations), 91 rachitis, 166 shape relative to uterus, 96 syi)hilis, 167 diagnosis, i67 infection, 167 manifestations. 167 treatment, 168 tuberculosis, 168 tumors of trunk, 252 Fontanelles. 78 false, 80 Forceps, axi.s-traction, 377 description, 375 operation, 371 ill breech cases, 390 dangers of. 391 iu dorsal position, 381 Forceps operation in dorsal )>ositi(m, axis-trai^ion, 377, 3'^.3 with ordinary forcejis, 3H() distention of iicrincuiii, .{H.'J extraction. "! ".* introduction of blades, .381 support of liml)s. 3f^l in face jiresentations, 390 high, 37(i, 381 history, 374 indications for. 378 iu left lateral position, extraction, 388 insertion of blades, 386 low, 37(), 381 medinin, 381 methods, 380 Continental, .380 English, 380 in occipitojiosterior cases 389 jHisture of patient, 380 pr(^paratioiis for, 379 , Funic souffle, 133 G. (lalactocele, 3.31 (ralact(>rrh(ea, 322 (ringivitis in preijiiancy, 173 Graafian follicle, is membrana granulosa, 18 number, 18 ovum (see Ovum), 18, 19 tunica fibrosa, 18 propria, 18 H. HaMiiatoma of vagina, 302 Htematnria in pregnancy, 180 in ])uerj>erium, 337 Heart inurmurs in pregnancy, 184 Hegar's sign, 48 Hemorrhage, accidental {see Accidental hemorrhafie), 263 hsematoina, 317 post-partum, 312 definition, 312 diagnosis, 313 etiology, 312 symptoms, 313 treatment, 314-316 puerperal, 317 secondary, 315 Hemorrhoids in pregnancy, 180 in puerperiuni, 3.35 Hernia into umbilical cord, 165 Herpes in pregnancy, 187 INDEX. 42;i Hydniimiios, I'lfi diaj;ii()sis, ir>7 fti()l(i;;y, lot) syniptdins, laT troatiiKiit, l.")!-i Ilydroi-eiilialus. 250, 252 llvnicu, unruiitmi'd, ;}02 Hypoblast, 2fi, 2.S cleavajri', 2H permanent, 21) I. Iclithyosis of fo'tus, Kifi Icterus in iJrt'fjnant-y, 179 Iinpetifjo in prctrnancy, 187 lni])rcgnation, 21 Indigestion in pregnaney, 174 Induction of abortion, 371 definition, 371 indieations, 371 methods, 372 dilatation and curetting, 372 drugs, 372 of premature labor, 373 indieations, 373 methods, 374 Krause's, 374 Tarnier's. 374 Infectious diseases in pregnancy, 187 Insanity in puerperiuni, 33S-341 Inversion of uterus, 310-312 K. K Kluey of pregnancy, 181 Labor, delayed, 270 causes, 270 diagnosis, 270 treatment, 271 missed, 201 normal (see Normal Inbor), 96 pathology (see Dystocia), 209-212 precipitate, 268 etiology, 268 treatment. 269 premature, induction of (see Induc- tion of premature labor). 373 Lacerations of cervix (see Cervical lareratioii.s), 370 of perineum (see Perineal lacerations), 362 Lactation, 148 arrest of (see Arrest of lactation), 331 colostrum (see Colostrnm), 149 Lactation, establishment of, 150, 151 nianmiarv glands, 1 19 milk (see Milk], 149 Lcucorrlnea of vagina, 169 Li(iuoraninii, alterations in character, 15i» Lochia, 146 alba, 146 character. 146 composition, 146 odor, 146 (juantitv, 146 rubra, 146 serosa, 146 M. Malaria in i)uerperium, 334 Maniniie (see Jireasl.t), .320 Mammar.v abscess, .329 of areola', 331 location, 329 sympl(»ms. 329 treatment. 329 incision, 330 Mastitis, 32() etiology, 327 symptoms, 327 treatment, 328 abortive, 328 varit^ties, 326 glandular, 326 parenchymatous, 326 ])ost-maniniar.v, 326 subcutaneous, 326 Measles in puerperium, .332 Membranes, 29 rupture of, 1.36 at term. 33 Meningocele, 2.52 Menopause, 18 Menstruation. 17, 20 cause. 17 cessation. 18 character of flow, 17 duration, 18 onset, 17 and ovulation, 20 quantity, 18 structural changes, 17 suppression, 45 Mesoblast, 29 cleavage, 29 Mesoderm, 29 Milk, 149 chemical composition, 149 quality, 150 quantity, 150 424 INDEX. Milk, secretion of, 150 deficient, :J-JO excessive, .'Wl giilactonho'a, .322 polygalactia, 321 Miscarriage (see Abortion), 194, 195, 201 Mole, blood-, 196 fleshy, 155, 196 tubal, 203 vesicular, 159 symittoms, 159 treatment, 161 Monstrosities, 253 Multipara, 97 Myelitis in puerperium, 337 Nephritis in pregnancy, 182 Nervous system, changes of, iu preg- nancy, 43 Neuralgia iu pregnancy, 185 Neuritis in puerperium, 337 Neuroses in pregnancy, 185, 186 Nipples, anomalies, 320 inversion, 320 sore, 325 treatment, 325 supernumerary, 320 Normal labor, 96 antesthetics, use of, 126, 127 antisepsis, 119 agents, 120 nurse, 122 obstetrician, 121 patient, 123 blood lost iu, 118 duration, 97 first stage, 102 anatomy of soft parts, 107 clinical phenomena, 106 initial labor-pains, 106 reflex vomiting, 107 dry labors, 105 management, 12H examination, 129 auscultation, 132 palpation, 129 vaginal, 134 preliminary cond uct of phy- sician, 128 succeeding the examina- tion, 136 mechanism, 103 action of uterine fibres, 104 dilatation of cervix, 103 hydrostatic pressure, 103 Normal labor, first stage, os uteri, 106 rupture of membranes, 105 signs and symptoms, 102, 103 characteristic, 103 premonitory, 102 forces of, 99 contractions of abdominal mus- cles, 101 of uterus, 99 duration, 99 effect of, 100 intermittent, 99 involuntarv, 99 painful, 99' peristaltic, 99 of vaginal and pelvic mus- cles, 99, 101 gravity, 102 polarity, 100 retraction of uterus, 100 management of, 119 onset, causes of, 97, 98 preparation for, 124 nurse, 126 patituit, 125 labor-room, 125 physician, 124 obstetric bag, 124 second stage, 107 anatomy, 115 clinical phenomena, 113 moulding of head, 114 management, 137 laceration of perineum, 138 perineal stage, 137 position, 137 rapid cases, 137 mechanism, 107 delivery of trunk, 113 head movements, 108 descent, 108 extension, 112 external rotation, 112 flexion, 108, 109 internal rotation, 110 restitution, 112 stages, 97 third stage, 116 management, 141 Crede's method of expres- sion, 141 final measures, 142 lacerations, 141 retraction of uterus, 142 mechanism, 116 expulsion of placenta, 117 separation of placenta, 110 of membranes, 117 INDEX. 4-2.' O. Obstetric anatomy, r)<)-96 operations, ;it)l-417 Ciesarean section, 404-409 embryotomy, 411-417 episiotomy, 3()1 forceps, 374-391 general rules governing selection of, 409-411 induction of abortion, 371 of premature labor, 373 repair of cervical lacerations, 370 complete tear, 3(W external superficial tear, 3G3 internal tear, 361 vaginal and perineal lacera- tions, 362 symphysiotomy, 398-404 versions, 391-398 (Edema of placenta, 164 of vagina, 169 of vulva, 169 Oligohydramnois, 156 Ovarian cysts, 306 Ovulation, 18, 20 and menstruation, 20 Ovum, 18, 19 at different periods of pregnancy, 35, 36 discus proligerus, 18 fertilization, 22 germinal spot, 19 vesicle, 19 immature, 19 impregnated, 25 maturity, 19 nucleolus, 19, 26 nucleus, 19, 25 polar bodies, 19 pronucleus, 19, 26 segmentation, 26 yolk, 19, 25 zona pellucida, 19 P. Parametritis in puerperal septic in- fection, 350 Parotitis in pregnancy, 173 Parturient axis, 76 Parturition, 57 Pathology of amnion (see Amnion), 156 of breasts (see Breasts), 172 of chorion (see Chorion), 159 of decidua (see Decidua), 154 of foetus (see Foetus), 165 of placenta (see Placenta), 161 of pregnancy, 154 Pathology of the pregnant woman, 169 abortion (see Abortion), 194 albuminuria, IMI bloodvessels, 184 cardiac diseases, 184 constipation, 174 co'igh, 183 dental caries, 173 diarrhoea, 174 dysi>ntea, 183 eclampsia (see Eclampsia), 188 ectopic gestation (see Ectopic (jesttttiou), 202 gingivitis, 173 hiematuria, 180 iieart murmurs, 184 hemorrhoids, 180 herpes, 187 icterus, 179 impetigo, 187 indigestion, 174 infectious diseases, 187 kidney of pregnancy, 181 nephritis, 182 acute, 182 chronic, 182 difierential diagnosis, 182 treatment, 182 neuralgia, 185 neuroses, 185, 186 parotitis, 173 phthisis pulmonalis, 183 pigmentation, 187 pneumonia, 1H3 premature labor (see Premature labor), 194 ptyalisni, 173 salivation, 173 scanty urine, 180 thyroid gland, 185 toxaemia (see Toxaemia), 188 vomiting, 174 perniciou?! (see Pernicious vom- itina), 175 simple, 175 of umbilical cord (see Umbilical cord), 164 of uterus (see JHerus), 170 of vagina (see Vagina), 169 of vulva (see Vulva), 169 Pelvic canal, soft parts, 71-76 muscles, 71-74 floor, 72 fascia, 74 measurement, 72 muscles, 71-74 segments, 72 426 INDEX. Pelvio floor, segments, pubic, 72 sacral, 72 Pt'lvi-p'iiitu) canal, 57, (il I'dvinictry, 275 nicHsiirenu'Uts, 275-279 external, 275 internal, 277 Pelvis, (il anomalies of, 272-207 classification, 27.'} (leei), 2ri2 diagnosis, 274 due to injuries, tumors, or dis- ease, 291 spinal curvature, 29() kyphoscoliosis, 297 kyphosis, 290 lordosis, 290 scoliosis, 297 flat, 283 mechanism of labor, 287 non-rachitic, 283 rachitic, 285 treatment of labor, 288 frequency, 272 funnel-shai)ed, 282 justomajor. 279 justominor, 279 mulacosteon. 291 inasc\iline, 282 obliquely cor.tracted, 289 pseudomalacosteon, 292 shallow, 282 s])ondylolisthetic pelves, 293 transversely contracted, 291 diameters, 67-70 of the brim. 07-70 conjugate, 08 measurements, 70 oblique, 70 transverse, 70 false. 03 inclination, 71 joints of, 02 mobility, 03 lateral grooves, 05, 06 planes, 00 the brim, 00 the cavity, 07 the outlet, 07 true, 03 cavity, 04 boundaries, 04-60 inferior strait, 64 inlet, 03 outlet, 04 superior strait, 03 Perineal body, 75 Perineal lacerations, complete (ear :{()8 conditions, 308 operation, 3(i8-370 external tear, 303 internal tear, 304 conditions, 304 method of repair, 305 308 repair, 3()2 Perineum, 75 rigidity, 302 Peritonitis in puerperal septic iiilVc tion, 351 Pernicious vomiting, 175 duration, 175 etiology, 170 physiological uterine contrac tions, 17() prcdisjxising causes, 176 symptoms, 175 treatment, 178 ., dietetic, 178 digital dilatation of cervix, 179 drugs, 179 hygienic, 178 induction of abortion, 179 rectal alimentation, 178 Phlegmasia alba dolens. 351 Phthisis pnlmonalis in pregnancy, 183 Pigmentation in pregnancy, 50, 187 Placenta, 31 adherent, 164, 266 (;auses, 207 treatment, 208 anomalies, 101 of position, 101 of shape, 101 of size, 101 of weight, 161 apoplexy, 102 causes, 103 definition, 102 forms, 102 results, 103 symptoms, 103 treatment, 103 as[)ects, 33 battle-dore, 161 circular sinus, 34 cotyledons, 33 degeneration, calcareous, 162 fatty, 162 functions, 34 horse-shoe, 101 inflammation (see Placentitis), 163 intervillous spaces, 32 nniternal blood, 33 , tuembranacea, 161 INDEX. 12: Placenta, CBclema of, 164 ])olyi)i, 19(i 1 lie via, 258 centralis, 258 etiology, 259 lateralis, 258 marginalis, 258 symptoms, 2G0 treatment, 261 premature separation of (see Acci- dental hemorrhage), 263 retained, 266 sinuses, 32 site, 34 structure, 31 succenturiata, 161 syphilis of, 164 at term, 33 tumors of, 16\ white infarctions, 162 Placentitis, 163 pathological changes, 163 Plural hirths, 245 Pneumonia in pregnancy, 183 in ])ueri>eriuni, 333 Polygalactia, 321 Polypi of cervix, 305 of placenta, 196 Porro operation, 408 Position, 92 Positions, 93-96 breech, 95 face, 94 occipitoposterior, 209 diagnosis, 209 management of labor, 212 at the pelvic inlet, 213 in the pelvic cavity, 214 mechanism, 210 abnormal, 211 prognosis, 214 somatic, 95 vertex, 94 Pregnancy, ballottement, 50 changes in alimentary system, 43 circulatory system, 43 cutaneous system, 44 maternal organism, 38 uterus, 38 nervous system. 43 respiratory system, 43 urinary system. 44 corpus luteum of, 20 diagnosis, 45-51 differential, 52, 53 of life or death of child, 54 of nulliparity, 53 of parity, 53 Pregnancy, diagnosis, saniuiary of, .")! triiiR'sters, 45-51 first, 4.5-48 objective signs, 4 caiis'-s, Jilfj (liaKOosiK, 2\Ty nianageinent, 219 niechaiiisni, 217 occurrence, 215 positions, 215 peivi(\ 91,9;i shoulder, 95 somatic, 91, 93 transverse, 92, 237 causes, 2.'i7 diagnosis, 238 fretjuency, 237 iiechanisiu, 239 spontaneous evolution, 240 version, 239 with body doubled up, 240 positions, 237 dorso-anterior, 237 dorsoposterior, 237 Primigravida, 97 Primipara, 97 Primitive groove, 28 streak, 28 Prolapse of cord, 254 of fietal limbs, 244, 245 of uterus, 172, 300 Pruritus of vagina, 169 of vulva, 1(59 Ptyalism, 173 in pregnancy, 173 Puerperal period (see Puerperal state), 143 pathology of (see Uterus, Breasts, Hemorrhage), 312 state, 143 anatomy of parts, 143 bladder, 144 broad ligaments, 144 peritoneum, 144 uterus, 143 vagina, 144 vulva, 144 beginning, 143 duration, 143 management of, 150 after-pains, 153 care of breasts, 151 of genitalia, 151 contraindications to suckling, 152 lying-in room, 150 nourishment, 152 rest, 152 physiological phenomena, 143 physiology of, 145 I'uerperal state, jUiysiology of, invo- lution, 145 abdominal walls, 147 circulatory system, 147 digestive api>aratus, 148 lactation (see Lactation), 148 ovaries, 147 pelvic joints, 147 skin, 148 tubes, 147 urinary system, 147 uterus, 145 lochia (see Lochia), 146 mucosa, Mfi muscle-cells, 145 vessels and nerves, 145 vagina, 147 vulva, 147 septic infection, 345-361 bacteriology, 345 cervix, 346 ^ saprsemia, 346 vagina, 346 definition, 345 diagnosis, 354 culture from uterus, 355 lochia, 354 fretjuency, 345 pathology, 347 auto-infection, 352 endometritis. 347 modes of infection, 351 parametritis, 350 peritonitis, 351 phlegmasia alba dolens, 351 pyaemia, 351 salpingitis, 350 ulcer, 347 vaginitis, 347 symptomatology, 352 onset, 352 param(>tritis, 353 peritonitis, 353 pyaemia, 353 septicaemia, 354 treatment, 357 general, 359 serum-therapy, 360 local, 357 prophylaxis, 357 Piierperium (see Puerperal state), 143 fever other than septic, 343, 344 intercurrent diseases, 332-361 anaemia, 334 cerebral hemorrhage, 338 cystitis, 336 diphtheria, 333 erysipelas, 333 INDEX. 429 Piicrpcriiiin, intcrrnrront diseasos, I'rytliL'ina, :{■'{:{ liiciiiatiiria, WM hemorrhoids, ;{:>i> iiicontinciu'o of uriue, ;53() insanity, :{:5rt-341 malaria, 334 muscles, 33'i myelitis, 337 neuritis, 337 pneumonia, 333 pyelonephritis, 336 retention of urine, 335 rh(iuniatism, 333 rotheln, 333 scarlet fever, 332 septic infection (see Puerperal septic infection), 345 sudden death, 341 entrance of air into uterine si- nuses, 343 pulmonary embolism, 341 thrombosis, 341 Pyaemia in puerperal septic infection, 351 Pyelonephritis in puerperium, 33t> Q. Quickening of pregnancy, 49 B. Rachitis of foetus, 16fi Respiratory system, changes of, in pregnancy, 43 Retroversion of uterus, 170 Rheumatism in puerperium, 333 Rotheln in puerperium, 333 Rupture of uterus, 306 S. Salivation, 173 Salpingitis in puerperal septic infec- tion, 350 Scarlet fever in puerperium, 332 Segmentation, 26 morula stage, 26 Semen, 21 Somatopleure, 29 Spermatozoids, 21 meeting-place with ovum, 22 Splanchnopleure, 29 Subinvolution, 318 Symphysiotomy, 398 dangers of, 403 Symphysiotomy, definition, 398 French method, 402 history, 39.H indications, ;'>99 Italian method, 400 rationale, 399 Syi)iiilisof fo'tus, 167 of placenta, 164 T. Thyroid gland in pregnancy, 185 Toxiemia (sec Kcliinipsifi), 1H8 Treatment of abortion, 19rt of accidental heniorriiagi', 2(i5 of adherent placenta, 268 of apoplexy of placenta, 163 of decidual endometritis, acute, 154 chronic, 155 of delayed labor, 271 of eclampsia, 192 of ectopic gestation, 207 of engorgement of breasts, 322 of mammary abscess, 329 of mastitis, 328 of nephritis in pregnancy, 182 of overgrowth of feet us, 249 of pernicious vomiting, 178 of ]»ost-partuni hemorrhage, 314-316 of precipitate labor, 269 of prolai)sc of umbilical cord, 255 of i)uerperal septic infection, 357 of retroversion of uterus, 171 of rigidity of cervix, 298 of rupture of uterus, 309 of sore nipples, 325 of subinvolution of uterus, 319 of syphilis of fretus, 168 of vesicular mole, 161 Triplets, 248 Tubal mole, 203 Tuberculosis of ftctus, 168 Tumors of placenta, 164 of uterus, 172, 304-306 Twin labors, 245 complications, 247 u. Ulcer in puerperal septic infection, 347 Umbilical cord, 30, 34 anomalies, 164 coils, 164 knots, 165 of length, 164 coiling about fcetal neck, 258 hernia into, 165 430 INDEX. Uniliilical cord, prolapse of, 251 diagnosis, 255 treatment, 255 sliort, 25U vein, ;{({ UracliiiH, 30 Urinary system, cliangcs of, in preg- nancy, 44 Urine, incontinence of, in pncrperinm, retention of, in pnerperinm, 335 scanty, in pregnancy, IHO Uterine l)ruit, 133 contractions in pregnancy, 49 inertia, 270 sonffle of pregnancy, 49 Utcrns, arteries of, 39 cavity of, 57 cliangcs from jircgnancy, 38 contractions, 40, 99 dextro-rotation, 41 diagnosis, 171 displacements of, 299-302 double, 297 endocervicitis, 172 fibrorayoma, 304 full-term, relation to contiguous structures, GO inversion, 310-312 ligaments, 59 lymphatics, 39 n'lusclc-fibres, 39, 57 layers of, 57-59 nerves, 40 peritoneum, 60 prolapse, 172, 300 relation to pelvis and abdo."oen, fourth month, 40 ninth month, 40 seventh month, 40 sixth month, 40 third month, 40 retroversion, 170 anatomical results, 170 causation, 170 treatment, 171 mild cases, 171 severe cases, 171 rupture of, 306 etiology, 306 site, 307 symptoms, 308 treatment, 309 segments of, 59, 100 lower, 59 upper, 59 Uterus, septate, 2f)7 subinvolution, 318 diagnosis, 319 etiology, 318 treatment, 319 tumors, 172, 304-306 walls of, 57 V. Vagina, atresia, 302 luematoina, 302 lacerations of (see Perineal lacera- tions), 362 leucorrlKea, 169 oulema, 169 pruritus, 169 septa, 302 varices, 469 violet discoloration, 41, 47 Vaginitis in puerperal septic infec- tion, 347 Varices of vagina, 169 of vulva, 169 Vegetations of vulv.', 170 Version, spontaneous, 239 Versions, 391 definition, 391 methods, 392 bipolar, 393 indications, 394 method, 394 external, 392 indications, 393 method, 393 internal, 395 indications, 395 method, 396 varieties, 391 cephalic, 392 pelvic, 392 podalic, 392 Vesicular mole, 159 Vitellus, 25 Vomiting of pregnancy, 43, 46, 174, 175 Vulva, oedema, 169 pruritus, 169 varices, 169 vegetations, 170 w. Wharton's jelly, 34 Y. Yolk-sac, 30 ALPHABETICAL CATALOGUE OF PUBLICATIONS OP LEA BROTHERS & COMPANY, 700, 708 A 710 NaiiMoin 8t., FhllHdelphla 111 Firth Av«., New York The hooks in the annexed list iire for siilti by all bookseller!" d will be «ent oiirriaue paid, to aiij liddreHN In tb« United Ktates, on receipt of the printed priceR. ANATOMY, (iiav, (itrrisli,\Vonlsev, lliiiitint;! Kck lev, Treves, Rockwell. nA(;TI<;ilI<)IiOC;Y. AI.Ik.U, I'm-k, /apHe, Aroiiinanl. ' BliOOl). Ewiiiu'. CHKMISTIIY. Sinion iVV.), Simon (('. Iv), Altfi.id, Martin it Rockwell, Reinsen, VimikIihii it Now, Me( ilaniiiin. CMMATOIiOGY. Soiiv, I In vera it Hare. DKXTISTIIY. Essi>r{l»rostheiic), Kirk (Operative), Unrchard, Ehsik it KoeniK (Metaliiirtrv), Lonu', Amcriean Hvstein, roleman. DF.IlMATOIiOCiY. Hyde & Montgomery, .la.'kson, Pye-Smitli, .lamieson, flardaway, (Jrindon, Scliiilik. DIAGNOSIS. Mnsser, Jlare, Simon, Ilerrick, Le I'evre, Findlev, Arncill. DICTIONAKIKS. 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An exceediiif^ly useful hand-book anlain and concise. We for the student, prepared to be used rei,'ard it as a most excellent book, in connection with the most popular Xashrillr .lonnial of Medicine ami text-books of the day, (irai/ and Siirgrrj/. Grrrish. The arrant,'ement is good ECKLEY (WII.LIAM T.). REGIONAL ANATOMY OF THE HEAD AND NECK. Octavo, 240 pa<,'es, with ;<6 engravin'TH and 20 plates in black and colors. Cloth, ^2.50, net. A most excellent work of especial that chai)ter. The engravings, and interest to the dentist. It is seldom especially the colored plates, are one sees a book .so well arranged and fine and if the student cannot (jet a so concisely written as this one. At correct understanding from their the end of each chapter (juiz (pies- study it must certainly be his own tiona are given covering the text in fault. — The Deidal Suniniari/. EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDI(;A. In one 8vo. volume of 544 pages. Cloth, $3.50. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings. Cloth, $.S. EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. New (.'5rd) and revised edition. In one 12mo. volume of 467 pages, with 86 illustrations. Cloth, $2.25, net. A concise, comprehensive manual, lay reader. It deals with personal alike suitable for the medical stu- hygiene as well as public health. — dent, sanitary inspector and for the The Siiiiitdrian. ElililS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25. EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6. ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octAvo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSTG(CHARI.ES J,), PROSTHETIC DENTISTRY, Sec American Text-Booh of Dentistry, page 2. ES9IG (CHARLES. I.) aii2.0o, /mV. .///s/ rKuh/. 10 Lea Brothkrs & Co., Philadki.phia and Nkw York. EVANS (DAVID. I.). A I'OCK KT TEXT-HOOK OF OIJSTKTIlirS. in one handsorne I'imo. volmiic of 4()!t paj^'es, with \4H illustrations. Cloth, .^l.rr., iirf ; limp IciithtT, $_'.'2r), mf. Lra'n Strict oj IWkrt Ti\rl-h(i()lcx, edited hv I5KKN !?. (lAl.l.AlDl'.r, M.D. Sec pn«e is. \\'rittcn foi' the iiicdictal sliidi'iit i It isciiinpcndioiis, (Miricise and readi- and praplitioncr l)y one whose e\- i ly intelliyihle, giving; the essentials erience, l)(»th /(« Mnliad Journtil, EWINC. (JAMES). CI.INICAI, PATFIOLOdY OF TliK ISLOOD. A Treatise on the (ieneral Principles and Special Appli<'ations of Fteinatolouy. New (2d) edition, thorou!,dily rcivised. Handsome octavo, 4!i2 pafi;es, l.'{ en;,'ravin;;s, 18 colored jdates. (Moth, $.'{.r)0, )ii(.. In all of those medical colleges in certainly made it a reliable giiide which heniatoloyy is taufjht the hook for all those who desire to enter up- hefore US has been recommended for on tiie work of blood examination, a text-book, and no lietter one cotild — St Loiiix Midlcal itnd Siiniinil have been chosen. The author has JminKil. EXAMINATION SERIES (STATE BOARD). See page 2(5. PARQUHARSON (ROBERT). A (^UIDE TO THERAPEUTICS. Fourth American from fourth English edition, revised by Frank WooniUTRY, M. D. In one 12nio. volume of 581 pages. Cloth, $2.50. PER(iUSON (J. B ). AN EPITOME OE NOSE AND THROAT DISEASES. See L,a\s Srrirx of Mrdiail Epitomes, page 18. FIELD (GEORGE P.). A ]\IANUAL OF DISEASES OF THE EAR. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. FINDLEY (PALMER D.). A TREATISE ON GYNECOLOGI- CAL DIA<;N0SIS. Octavo, 4!t;{ pages, 210 engravings, 15 plates, in Idack and colors. Cloth, .$1.50; leather, !^5.r)(i, net. This elaborate work will occupy and will be found of the greatest a uni(|ue place in gynecological value to both. It is thoroughly illus- literature inasmuch as it is the lirst trated with excellent cuts and on the subject in the English colored engravings. The text is full language. It is adapted to the needs and j)lain — Xoshrille Journal of of both student and practitioner. Medicine and Simierii. FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Frkdrrick P. Henry, M.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5.00 ; leather, $fi.OO. FLINT (AUSTIN). A PRACTICAL TREATISE ON THE DIAG- NOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of .550 pages. Cloth, $4. ON PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, ETC. A Series of Clinical Lectures. 8vo. 442 pages. Cloth, $3.50. -ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. 12mo, 214 pages. Cloth, 81.38. FORl^IUIiARY, POCKET. See page 32. FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. Sixth and revised American from the sixth English edition. In one large octavo volume of !>23 pp., with 257 illus. Cloth, $4.50; leather, .$5.50. Unquestionably the best book that ! busy physician it can scarcely be can be placed in the student's hands, i excelled. — ThePhila. Polyclinic. and as a work of reference for the i Lka Brothkea a Co., Phii.adei.imiia and Nrw York. 11 FOTHERGIIili (J. MILNER). THE PRACTITIONKR'S IIAND- nOOK OF TIIKATMKNT. Tliiid cditiDn. In one handsome octavo volume of 6M pa^es. Cloth, J."?.?') ; leather, $4.75. FOWNES (GEORGE). A MANUAL OF KLFMFNTARY CHKM- ISTRY (INOI{(wVNI(; AND OIKJANK"). Twelfth edition. F,m- iMxiyin^,' Watts' I'hysical and Inorganic ChrmiHry. I'Jmo., 1061 pa^e.s, 168 enKravint;s, and 1 eolored plate. Cloth, lf2.7.'') ; leather, $.'{.25. FRANKIiANl) (E.) AND JAPP (F. R.). INOIKUNK^ CHEMISTRY. Ill one handsome octavo volume of 677 pa^'es, with 51 enj,'ravinf;s and 2 plates. Cloth, $.'?.7r) ; heather, $4.7.".. FUIiliER (EUGENE). DlSOllDEUS OF THE SEXUAL OR- QANS IN THE MALE. la one very handsome octavo volume of 2,'<8 pa^e-s, with 25 enj;ravinj,'S and 8 ftill-page i)lftt«'fl. Cloth, $2. GAIil.AUDET (RERN R.). A I'OCKET TEXT-HOOK ON SUR- GIORY. In OIK' handsome TJmo. volume of about 400 pajjes, with many illustrations. S/ior/li/. See Lfii's Srrirs of /'ockrl Te.vt-l>i>ok)<, page 18. GANT( FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one aiiuare oetavo volume of 845 pages, with 159 engravings. Cloth, $.'5.75. GAYIiORI) (HARVEY R.)aiul ASCHOFF (lilTJ)WIG). THE PRINCIPLES OF PATHOLOGICAL HISTOLOGY. With an in- troductory note by William H. Wki.ch, M. D. Quarto, 364 pages, with 81 engravings and 40 full-page pliites. Cloth, >;7.50, 7iet. Admirably arranged and beauti- tion of a work which should be in fully illustrated. The authors are the hands of every student of morbid to be eongratulatefl on tlie produc- histology. — London Practitioner. GERRISH (FREDERIC H.). A TEXT- BOOK OF ANATOMY. By American Authors. Edited by Frederic H. Gerrish, M. D. Second and revised edition. In one imperial octavo volume of i».S7 pages, with lOO.'i illustrations in black and colors. Cloth, $().50, ;((/. leather, $7.50, net; half Morocco, .*8. 00, //r/. The illustrations far outnumber The text is accurate, concise, and find exceed in size and in profusion gives the e.s.sentials of descriptive of colors tliose in any previous work ; anatomy with less waste of words and and they can well claim to be the better emphasis of important points most successful series of anatotnical than any similar text-book with pictures in the world. — The Amrri- which we are familiar. — The Boaton can Practitioner and News. Mrdinil ntid Snrriicit/ JourxnI. GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GRAY (HEXRY). ANATOMY, DESCRIPTIVE AND SURGI- CAL. New (fift<'enth) edition thorouLdily rcvi.sed. In one im|)erial octavo volume of lL'4!) j)ages, with 780 large and elaborate engrav- ings. Price with illustrations in colors, cloth, .$6.2.">, «onk, tolliip,' and it is proportionately valiialde. " not only what to do, luit liow to do Thr hook is vveil written Miid is a il." Under "Treatment," Itie author serviceahle and praotieal addition to is very evidently pnd sincerely yiv- the literature of the siilijectH treated, ing, not compilations from other —Mnlical liccitrd. men's work, i)iit hisown experiences, ORFKN (T. HENRY). PATIIOLO(JY AND MORIUD ANATOMY, Ninth edition. In one handsome octavo volume of 'ul paijes, with 3.S!t engravings and 4 colored plates. Cloth, %'^.'l^>, nrf. The work is an essential to the date text-hooks. — Virginia Medical practitioner — whether as surjjeon or Monthly. physician. It is the hest of iip-to- , GREENE (WILIilAM H.). A MANUAL OF MEDICAL CHEM- ISTRY. For the Use of Students. Based upon Howman's Medical Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. CiRINDON (JOSEPH). A POCKET TEXT-HOOK OF SKIN DISEASES. In one handsome 12mo. volume of ;5tJ7 pages, with 39 illiLStraiions, Cloth, .-?L'.(»0, urt ; flexihle leather, $'2,.")(), net. See Lea\9 Serie.'i of Pockrl Text-hooks, page 18. A compentlious and tru.stworthy tologv. Asa thera|)eiitic adviser for guide hook for the practitioner as the doctor it is replete with direc- wpII as student, emhodying the tions and valualde formuhe. — 'I'ltr. most recent developments in derma- Virqinia Medical Scnii-Monthli/. GROSS (SAMUEL. I).). A PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORM.\TIONS OF THE URINARY BLADDER, THE PROSTATE GLAND AND THE URETHRA, Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. GUE\THER(A.E. ANI>T. C). AN EPITOME OF PHYSIOLOGY. 12mo, 22.") l)age8, illustrated. Cloth, $1,00, vet. Lca'ti Series of Medi- cal Epitomes. See l>age IS. HABERSHON(S. O.). DISEASES OF THE AI'.DOMEN. Second American from the third English edition. Octavo, 554 pages, with 11 engravings. Cloth, .•^3.50. HALE (HENRY E.). AN EPITOME OF ANATOMY. 12mo., 3H!t pages, 71 engravings. Cloth, -SI. 00, net. Sev Lea's Srricft of Medical Kpitonits, pau'e 18. HAIili (WINFIELl) S,). TEXT-BOOK OF PHYSIOLOGY. Octavo of 672 pages, with 343 engravings, and 6 full page colored plates. Cloth, $4.00, net ; leather, $5.00, net. Students and teachers may j)ur- j The clearness with which chase the work with the certainty ; physiological facts are tlemonstrated that they will olitaiii a thorouehly makes il of special value to the sound and reliahle exposition of the , medical student. Western Medical present state of physiological know- i Review. ledge. — 'iiic London Lanccl, I Lea Bkotmkuh & Co., Puri.ADKi.PniA and New York. 13 HAMII/rON (AliliAN MCliANI-:). NKIIVOIKS DISKASKS, THKIH DKSCUn'TION .VNI) TIlK.VTM KNT. Stcoiid and reviHed edition. In one octavo volume of 5i»8 pag»!S, with 72 engravings. Cloth, $4. HAMILTON I Ml LDllKD). A POCK KT TEXT- MOO K OF MAS- 8A(iK. I 're paring. Hi'ti /.ki's Sm'rfi of I'nckrl 'I'l .rl-Hi>i)l,:-<, page Is. HARDAWAY (W. A.). MANUAL OF SKIN DISKASKS. Second edition. In one llinio. volutne of ')ti(l pages, with 40 iihistnitions and 2 plates. Cloth, $L'.2:), »>■(. Till' l>est of all the small liooks to recractical, he appreciates the needs or the gen- eral practitioner ; and in presenting the symptoms as met at the hedside and discussing disease as it actually appears, he has no peer. The new etlition has heen carefully revised, and its scope has iiecn widened to in- clude not only symptoms but also HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. Ninth and revised edition. In one octavo volume of 851 pages, with 1(»5 engravings and 4 colored plates. Cloth, $4.00, h^<; leather, $5.00, net; half Morocco, $r).50, nrt. .lust the book the active physician for administration are given. A most needs. He generally needs com{)lete index of diseases and the information he seeks quickly, remedies makes it an easy reference day elinical experience. His great strength is in diagnosis, deMCi'i]>tions of lesions and especially in treat- ment. — Jitdinna Medicnl Journal, PRACTICAL DIAGNOSIS. THE DIAGNOSIS OF DISEASE. Fifth of (J!I2 pages, with 240 engravings . Cloth, $.■■).( )0, /(^« ; leather, $(1.00, physiea! signs and clinical tests. Thi« makes the treatise a complete guide for the purposes of diagnosis. The chemical and microscopical ex- amination of the t)lood is described in detail. Directions as to urinary diagnosis are concise and complete. — Nf. Louis ('i)uriir iij Malicinv. too, and here he finds it, accessible clear and adeiiuate. On every occasion we have ct)nsulted its i)ages, and tney are many, we have never turned away in disappointment. This must continue to be the text- book, par excellence, of therapeutics. — Hnfjalo Mcdicid Jonrnrd. We know of no book which is its eciual in practical therapeutics. — Hoxton Mcdicid and Siiniicid d mir ntd. The great value of the work lies work. It has been arranged so that it can be readily used in connection with Hare's Practical Diagnosis. For the needs of the student and general practitioner it has no equal. — Medical Sentinel. The best planned therapeutic work of the century. — American Prac- titioner and News. It is a book precisely adapted to the needs of the busy practitioner, who can rely upon finaing exactly what he needs.— TAe National Med- in the fact that precise indications ical Review. HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- TIONS AND SEQUEL.E OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full-page plates. Cloth, $2.40, net. A very valuable production. One read with great profit. — Cleveland of the very best products of Dr. Journal of Medicine, Hare and one that every man cau 14 Lka Brothrbs & Co., Philadri-phia and Nkw York. HARE'S SYSTKM oK l'U.\(TICAI. TH KllAlMCUTICS. Inn seru-s of ooiitribiitioiiH by <>tiiiiieiit itractitionerH. >Si'(;(iii(l edition. In three lar^'e octavo volnnu'H oontuininj,' LT)!*.'! pn^es, with 457 enyravinKS ami 2(5 full-pa,i,'«! plates. I'rioc per volume, cloth, .'f.'i.OO ; leatlier, $ 1 pages. Cloth, $1 7r>, ml. The lectures are eminently prac- hody, hut rather an ae<;()unt of the tioal. A great variety of suhjects altered chemical changes which take is dealt with i>'. a most attractive place in the ditl'ereiit organs and se- nninner. Thtt volume is not a de- cretions in various di.seases. The Ncriptionofthe notnnil |)hysiologi<'al hook is full of interesting, practical processes going on in the iiealthy points. --./o/jyix llojikiiis linlhliu. Hllili (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 47y pages. Cloth, $3.25. HIIililER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PIERSOL. (GEORGE A.). IIU^iAN MONSTROSITIES. Magnificent fidio, containing 220 pages of text and illustrated with 12.S engravings and .'W large photographic plates from nature. In four parts, price each, $5. HOBLiYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. Thirteenth edition. In one r2mo volume of 845 pages. Cloth, $3.00, lift. This is a volume of almost Poo that it has gone through 12 editions pages, printed in easily-read type, is an evidence that the medical pro- and is fully up to date, enihracin!,^ | fessiou has found it meets their practically all the terms. The fact wants. — Cantida MnlinU litcord. HOLIilS (A.W.). AN EPITOME OF MEDICAL DIAdNOSIS. See Lvn's SvricK oj Medical !•'. pitinnis, Pi'g'-' l''^- HOLiMES (TIMOTHY). A TREATiSE ON SURGERY. Its Prin- ciples and Practice. Fifth edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo volume of 1008 pages, with 428 en- gravmgs. Cloth, $6.00 ; leather, $7.(iO. HOLMES (TIMOTHY). A SYSTEM OF SURGERY. With notes and additions by various American authors. Edited by John H. Packard, M.D. In three 8vo. volumes containing 3137 pages, with 979 engravings and 13 plates. Per volume, cloth, $6.0(J ; leather, $7.00. 16 Lea BROTHKua & Co., Philadelphia and New York. HUNTINGTON (GKORGK S.). A TREATISE ON ABDOMINAL ANATOMY. Quarto, 590 i)aKis including 300 full-paije plates in black and colors, coiitainiii!,' 'i.sij lij^urcs. I)e luxe binding, $10, net. The njvstt'rics of the Peritoneum ancl Abdnninal Cavity |)articularly concern anatomists, sur>(eons, gynecologists and obstetricians, and in- terest the i,fenenil i)ractitioner to a degree scarcely less. This compre- hensive and authoritative work will therefi;re a})peiil to an unnsuaiiy wide constituency of readers. Dr. Huntington V.as approached the sul)- ject in the lii,'iil tnrown upon it liy eniliryoloi,'y and ^omparative anatomy, thereliy clarifying the hitherto diliieult and complicated morphological |)r(>l)lems preseiiti'd l)y these regions. The hook is uni(|iie in its marvelous wealth of illustrations, amounting nracticaliy to an Atlas, with fuil ex- planatory text. Th" structural details of the Human Cacum and Appendix are considered very fully by reason of tlu; extensive material available and the paramount clinical importance of these suiyects. HYDK (.FAMKS NKVINS) AM) ]>10NT<;0M1:RY (V\ H.) A PRACTICAL TREATISE ON DISEASES OF THE SKIN. Sixth edition, thoroughly revised. Octavo, 832 pages, with 107 engrav- ings and 27 full-page plates, !) of which are colored. Cloth, $4.50, net; leather, $5.50, net; half Morocco, $().O0, iift. This is beyond doubt the most A complete exposition of our successful work on skin diseases, knowledge of cutaneous medicine as This work is now looked upon as ] it exists to-day. The teaching in- tlie American authority. — St. Lohik \ culcated throughout is sound as well Mf.lical n,ul NKrfiical Journal. as practical. — The American Jour- The first American ^ txi-hook.— ^ '>^^''^ ^f (.he Medical Sciencet. Xorthwrfitrru Ixuirit. It is the best one-volume work The work answers the needs of the , tli'it we know.— Virginia Medical general practitioner, the specialist, ''*"'^' "-"'"' '"'y- and the student. — Tkr Ohio Med- A full and thoroughly modern ieal Journal. text-book on dermatology. — The A treatise of exceptional merit Pittsburg 31ediud Revieiv. characterized by conscientious care The most practical handbook on and scientific accuracty. — Jiu/Jalo dermatology with which we are ac- Medieal a)id Suri/iral Journal. quainted. — Chicago Med. Recorder. JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK OF DISEASES OF THE SKIN. Fourth edition. In one 12mo. volume of 617 pages with 82 illustrations and 3 colored plates. Cloth, $2.7."), vet. Without doubt forms one of the The work is especially rich in best guides for the beginner in der- forniuhe and practical methods of matology that is to be found in the treatment. — Medicine. English language. — Medicin\ \ JAMIESON (W. AIiLA^). DISEASES OF THE SKIN. Third edition. In one octavo volume ot 656 pages, with 1 engraving and 9 double-page chromo-lithographio plates. Cloth, $6. .IKWETT (CHARLES). THE PRACTICE OF OBSTETRICS. By American Authors. Second edition. Octavo, 77") pages, with 445 engravings in black and colors, and 35 full-page colored plates. Cloth, $5.00, net ; leather, $().0(), net ; half Morocco, $»;.50, net. furnishes a concise, comprehensive The most complete of the recent obstetric text-books The illustra- tions are superb and possess the merit of clearness and accuracy. — Jiujjalo Medical and Surgical Journal. It is pre-eminently a practical treatise suited to the needs of medical clauses, while, at the same time, it and trustworthy guide to the prac- titioner. We regard this as being one of the most scientific and thoroughly modern treatises upon this irn))ortaiit sriiject in useto-oay. — .1 ///('/•. (i !/iieco ■H/ierd anil (Htstet- rical Juurnid. Lea Brothers & Co., Philadelphia and New York. 17 JEWETT (CHARIiES). ESSENTIALS OF OBSTETRICS. Si-coiid edition. In one 12tno. volume of 385 pages, with 80 engiiivi'tgs and .') colored plates. Cloth, $2.25, net. This is the best epitome of ol)stPt- students and j)raetitionersand to lee- rics with which we are familiar. It ; turers who need to review salient is sntticiently illustrated to make pointsofolistctrics in preparinii their clear its text. Its contents are well instruction. — The A mrricdii .1 ounuil selected. It can be recommended to of the Mrdicul Sri(iin;<. JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. New (.Hrd) edition. In one octavo volume of 7;iS pp., with 1!'0 engravings, 25 chromo-lithographic plates. Cloth, s5.25, /((/. KELLY (A. O. ,I.j. A MANUAL OF THE PRACTICE OF MEDI- CINE. Octavo, about (iOO pages, illustrated. Pnpurituj. KIEPE (EDWARD J.). AN EPITOME OF MATERIA MEDICA AND THERAPEUTICS. See lint's Srrirs„f Mrdical /'Jpitomcs,^. is. KINO (A. P. A.). A MANUAL OF OBSTETRICS. New (!»tii) edition. In one 12mo. volume of 621) pages, with 275 illustrations. Cloth, $2.50, 7ief. The bestmanual thiit li;isever been The most succinct, reliable andat oti'ered tons. It has a wonderful the same time individual book for a fund of information in •: very small student or practitioner. — Mitlical space. — A'. O. Mai. (uid Sunj. Jour. Xnrs. KIRK (EDWARD C). OPERATIVE DENTISTRY. See Ameri- can Text-Books of Dentistry, page 2. KLEIN (E.). ELEMENTS OF HISTOLOGY. Fifth edition. In one 12mo. volume of 506 pages, with 296 engravings. Cloth, $2.0U, net. See Student's Series of Manuals, page 27. It is the most complete and con- This work deservedly occupies a cise work of the kind that has yet first place as a text-book on his- emanated from the press. — Med. Age. tology. — Canadian Practitioner. KOPLIK (HENRY). THE DISEASES OF INFANCY AND CHILDHOOD. Octavo, <)75 pages with 16ii engruv^igs, and '62 plates i. black and colors. Cloth, .■^.").00, //(/ ; leather, .■<(). (H), net. Certainly the best book for stu- with the treatment, which is not dents we have seen for some tiu'e, as complex, but simple and positive, it is clear, concise, ejjigrammatie ind with proper reyani to dosage, so certain to make an imj)ression on often neglected in books of this kind, the mind of the reader. It is fully to the detriment of the student. — up to date. We are specially pleased Chicago Medical Record. LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. liEA (HENRY C). A HISTORY OF AURICULAR CONFESSION AND INDULGENCES IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each. Per volume, cloth, $3.00. CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN ; CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINA- TI OF THE J:NDEM0NIADAS ; EL SANTO NI^O DE LA GUARDIA. 12rao., 522 pages. Cloth, $2 50. THE MORISCOS OF SPAIN, THEIR CONVERSION AND EX- PULSION. In one roval 12mo. volume of 425 pages. Cloth, $2.25, net. SUPERSTITION AND FORCE; ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Fourth edition, thoroughly revised. In one hand- some royal 12rao. volume of 629 pages. Cloth, $2.75. STUDIES IN CHURCH HISTORY. The Rise of the Temporal Power — Benef'' of Clergy — Excommunication. New edition. In one handsome 12m(i /olume of 605 pages. Cloth, $2.50. 18 Lea Brothers & Co., Philadelphia and New York. Iil<:A'S HKRII<]S OF MI'IDK'AIi KPITO^IFS. Ivlited by \ K roi; C. Pkdkkskn, M.I). Coverinj,' tilt' entire field of niediciiie and sur- gery in twenty-two convenient volumes i)f idxiut 2'>i) pages each, amply illustrated and written by jtroininent teachers and specialists. Compendious, authoritative and modern. Following each (diapter is a series of ([uestions which will be found convenient in (|uizzint;. Price per volume, cloth, $1, tid. The following vrduniesarenow ready: ]Ia[.K's Anatomy (JUKNTHKlts' Phyk.iology. McGlaxna.n's Phys- ics and Inorganic Chemistry. M( ( Ii.annan's Organic and Phys- iological Chemistry. Na(;kl's Nervous and Mental Disea.scs. Watiii;n's Histology. Akchinakk's I'acteriology and Microscopy. MA(ii:K iV: .Iohnso.n'.s Surgery. Ai.mnm; and (iKiri'KN on the Kye and Kar. SciiMIiri'.s ( ienito-Urinary «nd Venereal Diseases. Sciiali:k's Dermatology. Manto.ns Obstetrics. Tii,i:y'.s I'edi- atrics. DwKiin's Jurisprudence. DwKiiiT'.s Toxicology. Tlie following volunus are in press: KiKl'K's Materia Medica and Therapeutics. Dayton's Practice of Medicine. Hoi, lis' Medical Diagnosis. Akniiili.'s Clinical Diagnosis and Urinalysis. .Stkn- HorsE's Pathology. FKUiii'soN on the Nose and Throat! Pkukkskn and Pahkkr's Gynecology. liEA'S SKRIES OF POCKET TEXT-BOOKS, edited by Bern B. Gallaudet, M. D. (^vering the entire field of Medicine iu a series of !?< very handsome l2ino. volumes of 350-525 pages each, profusely illustrated. (Compendious, clear, trustworthy and modern. The following volumes are now ready : Rockwell's Anatomy. Collins and Rockwell's Physiology. Maktin and Rockwell's (^Chemistry and Physics. Nichols and Vale's Histology and Pathology. ScHLKiF's Materia Medica, Thera- peutics, Medical Latin, etc. MALSiiAiiY's Practice of Medicine. Potts' Nervous and Mental Di8ea.ses. Hay'OEN's Venereal Diseases. Gkindon's Dermatology. Ballencek and Witpehn's Diseases of the Eye, Ear, Throat aiid Nose. Evans' Obstetrics. Crockett's Gynecology. Tuttle's Diseases of Children. Za pefe's Bacteriology. The following volumes are in press : Collins and Da vis' Diagnosis ; Gallaidet's Surgery ; Wk^ks' Nursing and Hamilton's Massage. For prices and separate notices see under various authors' names. liEFEVRE (EGBERT). A TEXT-BOOK OF PHYSICAL DIAG- NOSIS. In one 12mo. volume of 450 pages, with 74 engravings and 12 plates. Cloth, $2.2."., Hrf. This book will take front rank, tailed attention, and the same nieth- It is prepared by a teacher of ex- ods as applied to the thora.x are em- perience and a clinician of acconi- ployed and explained with the varia- {)lishment. Le Fevre gives adequate tions ncx'essary. A number of en- instructicm upon all the details of graviuars and .\-ray plates elucidate diagnosis. The abdomen receives de- the text. — liiijjnio Medical Jniirnnl. I^iONG (Elil H.). A MANUAL OF DENTAL MATERL\ MEDICA AND THERAPEUTICS. 12mo, ;!21 pages, with (5 engravings and IS plates. Cloth, s3.(iO, nrt. The author's aim lias been to cover what is essential ; to treat fully all remedies that belong properly to the special field of dental medicine; to discuss brietly the action and application of the most important general remedies, emphasizing tliose of which the action may avail in dental dis- eases and emergencies, and to furnish matter for reference that will cover all ordinary demands of the dental student and practitioner as to genernl remedies, their preparations, do.ses and uses. The value of the work is much enhanced by the extensive Index of Drugs, including every drug of local or general ii.se that the dentist may have occasion to refer to. This iiide.x is, in fact, a geneial therapeutic referendum for the den- tal practitioner. Lka Brothers & Co., Philadklphia and New York. 19 LOOMIS (AI^PRED L.) ANI> THOMPSON (W. GIIjMAN), EDITORS. A SYSTEM OF PKACTK^AL MEDICINE. In Contributions l»y Various Anu-rii'an Authors. In four octiivo vol- umes of about 900 |)iit,'es eacli, f;lly illustrated in black and colors. Per volume, cloth, $5.00, ml; leather, $6. On, mt; half morocco, $7.0(t, /((/. For sale by subscription only. Full j)ro8pectu8 free on applica- tion to the Publishers. LYMAN (HENRY M.). THE PR.\CTICE OF MEDICINE. Iii one very handsome octavo volume of 925 pages, witli 170 engravings. Cloth, $4.75 ; leather, $5.75. M«->. AN El'ITOME OK ORCANIC AND I'll YSK »L0( IICAL CHEM- ISTRY, llimo.. 'J4« pages, illustrated. Cloth, $1, int. See Lea's iSirics of Mrdiail EiiilnDK s, j)age IM. .>IAGEE (.>!. 1).) ami .lOHNSON (WALIiACK). AN EPITO.ME OF S(^R(;ERY. 12m(>., a:)out .">00 pages, with IMO engravings. Cloth, ••^l, /((•/. Sfinrlhi. See Lai's Srrirs <>/ Mnlinil LpilDiiiis, page 1^. MAISCH (JOHN M.). A MANUAL OF ORGANIC MATF.dA MEDICA. Seventh edition, thoroughly revised by 11. C. C. M.\KSCH, Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 285 engravings. Cloth, $2.50, net. U.sed as text-book in every college The best handbook upon phar- of pharmacy in the United States macognosy of any j)ublished in this and recommended in medical col- j country, — Huston Med. & tinr.Jour. leges. — American Therapist. \ MALSBARY (GEORGE E.). A POCKET TEXT-BOOK OF THEORY AND PRACTICE OF MEDICINE. In one handsome 12mo. volume of 405 i)ages, with 45 illustrations, ('loth, $1.75, net; flexible red leatiier, $2.25, net. See Lea's Series of Pocket Te.rt- books, page 10, ■net ; limp leather, .^2.00, net. See Lea's Series of I'ocket Te.ct- liDoks, page 18, The work accurately reflects both sciences in their [)resent develoj)- ment. The arrangement of the mat- ter is exeellent. The Medical and Snn/ical Monitor. 20 Lka Brothers & Co., Philadelphia and Nkw York. MF]l>iC'AL l<:i»ITO>IK SERII';S. Sit y.ir/. J lint rrdilji. This subject has not previously di.seases which have been introduced been written upon in the English into the family life, and there are no language, and altiiough we are quite more dislns.singtraeedies than those familiar with the work of several which follow. Morrow discusses French and Uerman writers (m the every possible phase of the subject, relationship of 8y])hilis and gon- and he lias made many timely sug- orrho'ato marriage, we have nowhere eestions wiiich are both helpful and seen a more masterly presentation of hopeful. This book should be read this most important subject. There by every physician, and there are a is probably no medical practitioner large number of ncm-niedical readers who does not freijuently have ocea- who might read it with profit. — St. sion to see the ravages of venereal Paul Maliail Jounidl. MU88ER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAGNOSIS, for Students and Physicians. New (.')th) edition, thor- oughly revised. In one octavo volume of 1205 pages, with ,'^!i.') en- gravings and 63 full-page colored plates. Cloth, $6.50, ict; leather, $7..")0, net; half Morocco, $8.00, net. A feio ni>ticcs o/ the previons edition arc appended : Musser's Mrdiad Diagmi.sis has become the leading and standard work on its subject. In this work every accepted method of clinical and bedside investigation is de- scribed clearly and fully, and every This is the best book on medical diagnosis published in the English language. In it is found everything relating to the proper making of a correct diagnosis. It is comj)lete, practical, up-to-date, well illustrated. effort is made to render the teachings well arranged, easy for reference, of the book of such practical nature and is the best iiook on medical diag- as to be readily available to the iiosis, both for medical students and practitiont r. — M e m }> h i s Medical for practitioners. — Muriflaud Med- Monthlij. ic(d J oiinial . XA/^/. vr republished also in 2 vol- umes. Vol. I, General Surgery ami Surgical Pathology. Cloth, ■^.3.75, net. Vol. II, Special, Regional and Operative Surgery. Cloth, .S.75, net. The work is fresh, clear and practi- clear-cut, thoroughly modern and cal, covering the ground thoroughly admirably resourceful. — Johns Hop- yet briefly, and well arranged for kins Hospital Bulletin. rapid reft-rence, so that it will be of The latest and best work written special value tothestudent and busy ui)on the science and art of surgery. [)ractitioner. The patliology is Columh.is Medical Journal. )road, clear and scientific, while the It is thoroughly practical and yet suggestions upon treatment are thoroughly scientific— J/«(i. News. 22 Lka Brotheks h Co., Philapblphia and New York. PARK (WILLIAM H.). RACTERIOLOCY IN MEDICINE AND HFUGKllY. ll'mo., (iSS pn<,'es, with 87 illustrations in black and colors, Hnd 'J jilatcs. Clotli, $'■]. 00 net. This hook tills a very diatinft of view of the hyjrienist and public ^a|>. None of the te\t-l)ooks in our health ofReer. TIk; work is correct laiiuiiau'e takt> up tin; subject of hac- and very well up to date. Tkr Mon- teriolouy so tlioronLr'>ly and no (real Mcdiatf Journal. soundly as does this from the point pI':i)i:rskn (\ . c.i. am> pakker (i:. o.i. an epitome of (rYNE('< >L< )( i Y. See /.r0, }ict. ,J nxi ratdij. It is an absolute «?/(c (/(M 7(0/) for ' physician as a book of reference the practitioner who devotes atten- upon these toi)ics. — A invricaii tion to otology or rliinology, And Journal of tlic Medical Sciences, should be in the lil)rary of every | POSEY (W. C.) AND WRIGHT (JONATHAN), F]DITORS. A TREATISE ON THE EYE, NOSE, THROAT AND EAR. Hy Eminent authorities. (Octavo, 1243 pages, richly ilhiBtrated with fi.'iO engravings and 3") full-page plates in black and colors. Cloth, .$7.00, )ir(; leather, .S8.00, ?)r< : half Morocco, $8.50, ?(c<. Published also in 2 volumes. Volume I. Posey on the Eve. 700 pages, 358 engravings, !!• plates. Cloth, $4.(10, net. Volunie II. Wright on the No.se, Throat and Ear. 543 pages, 292 engravings, 1(5 plates. Cloth, .'^3..")0, vet. The book is a distinct success. It book which every specialist should will fulfil the aims of its editors and own, because he will find in it much win popularity among students and that cannot be found in any other practitioners. — .luluis llopLim^Ilos- \ work of the kind, and tlie book that liit(d liulhliii. ! tiie general practitioner should pur- This is the best book published in ! chase, for it is especially adapted to the English language upon the eye, his needs, is strictly up-to-date, and ear, nose and thiDat. In (his work because he can purchase no single every chapter is exeelb'nt. The book which will meet hiswantRas most recent theories iind methods of thoroughly as will this work. — treatment are incorporated. It is a JVorllnrc-itern Lanal. Lka Brothers & Co., Philadelphia and New York, 23 POTTS (OHARIiKS S.). A I'OCKET TEXT-1500K OF NERVOUS AND MENTAL DISEASES, [n one Imndsome 12rao. volum.' of 445 pii,t,'es, with 88 , net ; limp Iciither, $2. 25, »r<. See Lra's Srriix of Pocket. 'J'e.rl-li(inLt, pn^v. ]><. Far superior to the onlinarv work slndent to inultrstand the essential of its chiss. The autlmr lias sue- plan of his future study. The sue- eeeded in inipnssintr the l)road out- eccdinf; ehapterson the various dis- lines of the stnieturc and functions eases, althoufih co?idensed, are iiecu- of the nervous system so sinipl\ and rate and up-to-date, and give in u so coniprehenfqvely, with the aid few word.s the most important faets. )f a few well-seh'eted dia>i;rams, as — linsloii Midlnil (iinl Sunilrol ,1 mn to make it compralively easy for the noL A TE.VTBOOK ON MKDI('Ar> .\XD SI KCICAL EIKCTHI- CITV. Octavo, about .S'lO pages, limply illustrated. Shoilly. PROGRESSIVE MEDICINE. See page 32. PURDY (CHARIiES W.). BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 en^avings. Cloth, $2. PYE-SMITH (PHIIilP H.). DISEASKS OF THE SKIN. In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2, RALPE (CHARLES H.). CLINICAL CHEMISTRY. In one 12nio. volume of 314 pages, with l(i engravings. Cloth, $1.50. See Student's Series of Mamuils, page 27. REMSEN (LRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. Fifth edition, thoroughlv revised. In one 12nio. vol- ume of 326 i)ages. Cloth, $2. REYNOIiDS (EDWARD) AM) NEWEM. (F. S.). A MANUAL OF PRACTICAL OHSTK/I'RICS. Second and revised edition. Octavo, 531 pa.i,'es, illustrated with 253 engraviuLrs, and 3 plates. Cloth, $3.75, jif/. A complete text-book on ohstetrics, ' so complete, diagnostic jioinls so characterized by a distinct aceen- clearly brought out, and the line of tuatioii of the practical side of this treatment of special conditums so science. — I iiltrstdh Alcdicul Jniiriuil . graphically drawn. — 'llw \' irj/inid SeldIII)T (liOUIS E.). A\ EPITOME OF (iKN ITO-UKINARY AND VENEREAL DISEASES. l2mo., 21!i pa-res, 21 cnuravings. Clotli, .'^l, net. See Iau's Scries i>j Mcdiad I'Jiiiliinics, page 18. Lka Bbothkeh & Co., Phii.adki.pmia and New York. 25 SENN (NICHOLAS). SURGirAL BACTERIOLOGY. Second edi- tion, lu one octavo volume of 2t>S pa^es, with I'.i i)lateH, 10 of which are colored, and !) engravings. Cloth, $2. SERUCS OP CLINICALj MANUAIjS. A Series of Authoritative Monograj)hs on Important Clinical Subjects. Tiie foUowiiij,' volumes iiri' now leady : Cai;i'KK and Fkost'.s Ophthalmic Surgery, $2.25; Maksh on Diseases of the Joints, $2; OwKN on Surgical Diseases of Children, $2; I'lCK on Fractures and Dislocations, $2. For separate notices, see under various authors' names. SERIES OP MEI»I('AL EPITOMl<;S. See page 18. SERUMS OF POCKET TEXT-BOOKS. St <> page 18. SERIES OF ST ATI: IM)ARi) E\A>li\ATiON t^UESTIONS. See page 20. SIMON (CHARIiES E.). A TEXT-BOOK ON PIIYSKM.OGICAL CHEMISTRY. Octavo, 4.")3 i)a,i,'cs. Clotii. $;5.2.'), net. Tills book is a dcservintj; ooinpiin- clan. Simon has honored Anieriean ion work to Simofi's Ciininil Ding- medicitu- in his pioneer work in a 7insis, and like it will live to l>f- fii-lil which heretofore has been oc- oome a standard and recognized enpied by foreiyn authors. — 77//' te.xt-ltook for students, and a guide Mrdicnl Furtiiliililhi. for the thoui^ditful studeMt-ph\ si- SIMON (CHARL.es E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL METHODS. New (5th) and revised edition. In one octavo volume of ()95 pages, with 150 engravings and 22 full-page colored plates. Cloth, $4.00, net. JnsI nadi/. A few notices oj the previous editions are (tppended. This book thoroughly deserves its ; The chapter on examination of success. It is a very complete, authen- the urine is the most complete and tic and useful manual of the micro- advanced that we know of in the scopical and chemical methods [ English language. — Canadian Pruc- which are employed in diagnosis, j ^(7(«HPr. — A'. Y. Med. Journal I SIMON (WM.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. Seventh edition. In one 8vo volume of 613 pages, with M engravings and 8 plates showing colors of 64 tests, and a sj)ectra plate. Cloth, $3.00, net. It is difficult to see how a better students. It is clearly written and book could be constructed. No num I beautifully and instructively illus- who devotes himself to the practice trated. The fre(|uent new editions of medicine need know more about ! that are called for allow the work to chemistry than is contained between the covers of this book. — The North- western Lancet. Si/non'.s Chrniistrij has long been a favorite with teachers and with be kept up to the latest researches. As a text-book for medical students it has no sujtenor. — Dearer Medieid 'I' iines. SliADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. lu one royal 12mo. vol., 158 pp. Cloth, $1.25. 26 LKA BKOTMKKH «fe Co., I'HII.ADKLI'MIA AND NKW YoKK. SMITH i.I. lil^^WIH). A TIIKATISK ON TlIK DISKASKS OF IN- KAN(;Y and CIIILIUIOOI). Ki-hth edition, liion.iiglily revist'd aiitl rewrittt'ii and much enlaiKi'd. In one larjje Kvo. volume of W.i j)af,'es, witli '27.5 engravings and 4 fuil-jiai;e piates. Oloth, $4.r)(); leather, '^Ft.'ti). For years the leadini( text-book on A safe ijuide for students and |>hy- chiidren'H diseases in America. — sieians. — The .' in.,li>itr.oj' Obstetiiia. Vhiciujo Medical Recorder. SMITH (STKPHKN). OI'KKATIVF SURGKRY. Second and thor- oughly revised edition. In oue octavo volume of 892 pages, with 1005 engraving,s. l^loth, $4. One of the most satisfactory works 1 dium for the modern surgeon. — Hot- on modern operative surgery \'iti\toii Medical mtd SargicalJonrnal. puhlislu'd. The book is a compen- | SOIiliY (S. l-:i)WIN). A HANDBOOK OF MKI)I(L\L CLIMA- TOIvOtiY. In one handsome octavo volume of 4tlJ pages, with en- gravings ami 11 full-page plates, 5 of which are in colors. Cloth, $4.(10. A clear and lucid summary of to its iiitluence u]>on human beings, what i.« kmtwn of cliimite in relation ' — The Therapeutic ikizetle. STAKK |>i. Aiilii:\). A TRFATISF ON OIKJANK^ NFRVoUS DISFASKS. ( »ctavo, 7 10 l>agi's, 27r)engravingsand 2t! colored plates. Cloth, .Stl.OO. iii1\ leather, $7.0(1, ml: half Morocco, $7.50, net. The besi book on organic nervous It is gratifying to tiolicc thai special care has been exeici.'^ed (hroui^hout (he book to give prom- inence to the(|uestion of treatment. It deserves to lake its place among the best text books in English upon diseases of the nervous system. - Jiilnis Hoji/.in.s llosiiildl liiillitiii. Especially in regard to treatment the statements are full and precise, i .Ury/Zcu/ ./ — Clcvdmid Ml ilical .foiiriKd. I diseases. — llnfjidn Mniicid .1 niinnil , This book is easily the best that has appeared in America. l"or the student it is especially to be recom- mended and for the neurologist it j)resents in a brief and in ii very attractive way the conclusions of a vtTV wide e.\|)erience, — InlirKtatc uniiil . sTATi<: novRi) i:.vami\atio\si<:hies. ( i.assified and EDITED I'.V H. .1. E. SCOTT, A.M., M.D. Containing, with answers or references, every (luestion asked at all of the examinations held by the New York State Hoard of Medical Examiners. The best guides" to similar examinations in other States. In 7 volumes, bound in llexible cloth, each containing from 'JOO to ,S(i0 I'Jmo. ])ages, i)rinled on paper suitable for either pen or pencil, every other page, opposite text, being left blank for memoranda. Price, $1.50 per volume. The respective volumes cover the subjects of Anatomy, (rradij), Chemistry, {rcudi)), Obstetrics, (midi/), Surgery, (niidif), Practice, Materia Mediea and Therapeutics, (rcudi/), Pathology and Diagnosis, {rriidji), Physiology and IIygiiliniies, ])age IS. STIIjIiE ( AliFRED). CHOLERA ; ITS ORIGIN, HISTORY, CAUS- ATION, SYMPTOMS, LP]SIONS, PREVENTION AND TREAT- MENT. In one 12mo. volume of 16;^ pages, with a chart showing routes of previous epidemics. Cloth, $1.25. THERAPEUTICS AND MATERIA MEDICA. Fourth and revised edition. In two octavo volumes, coutainiug 1936 pages. Cloth, $10; leather, $12. Lka Bkothkhh & Co., PhiladkM'hia AM) Nkw York. 27 STIIiLK (AliFllEI*), MAIHCH JOHN M.) ANI» <'ASPAKI (CHAS. JR.). rilK NATIONAL l>lSI'KNSATnKY: ("oMtaiiiiiiK till' Natural llistoiv, < 'litriiistrv, riiariiiacy, Aftioiis and rs»'.s oC Medicines, incliidiiii,' those reeojinized in t)ie late.st I'liarnuicoineiaH of the Unitecl Stiite.s, (ireat Britain and (lerniany, with nuniernns refer- ences to the Freneh ("odex. Fifth edition,' revised and enlar^jed, including,' the U. S. I'hartnaeopa'ia, Seventh Deeennial Revision. With .Supplement containini; the Natioiml Forninlary. In one nuiijnifK'ent imperial ()ctavd volume of ahout l.'(llir» pages, with .'{liO engraving's. Cloth, $7.L'r>; leather, $8. With ready reference Thunih-letter Index. Cloth, $7. 7a ; leather, $HMK STIMSONiLiEWIS A.). A MANUAL OF OPKRATl VK SUUtiKKY. Fourth ed.'*'"ii. In one royal I'Jmo. volume of oM pages, with •-!',»;{ engravings. Cloth, $;{.0(t, lui. The hook is worth the priee for the every particular. It covers the field illustrations alone. — 0/iio Medical so ihOrou^hly as to make it a very Journal. valuable te\t-l)ook and a ready Well wrilteii, clear, concise, prae- refcrenee-hook for surgeons. — /\(f//- tical, and tlioroiighly up-to-date in sns Cihi Mi iliml h'l f(,,il. STIMSON (liEWIH A.). A TUFATISK ON FKACTUUKS AND DISLOCATIONS. Third edition. In one hand.xome (uaavo vol- ume of 842 pages, with ;'),■!(; engravings and Wl plates. Cloth, |5.0(), *(('/; leather, .iiti.oO, iift ; half Morocco, .iii.')0, 7i'7. I'reeiuinetitly the authoritative value. The work is profusely il- text-hook upon the Hid)jcct. The lustrated. It will l)e found indis- vast experience of the author gives pcnsahle to the stndentand llie prac- to his conclusions an unimpeachable litiouer alike. — 7'Ae Midical J(). nil. Ki, kin's Elements of Histology {5th edition), $2. (.)(>, mt ; Pl':flM-:u's Surgical Pathology, $2; TuEVKs' Surgical Applied Amitomy, .-;2.(i(), ml. RALFE's'Clinical Chemistry, $1.50. Hkkman's Firstl.ines in Mid- wifery, .-^1.2.'). For separate notices, see under various author's names. STURGES (OCTAVIUS). AN INTRODUCTION TO Til F STUDY OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. SUTER (W. NORWOOD). A MANUAL OF REFRACTION AND MOTILITY. 12ino., .{82 pages, 101 engravings, 4 colored plates. Cloth, $2, / >la(>CTAMilT>I (.1. Kill (i:). A TKXTI!(»(»K OK lIlsrol.tMiV oKTIIKllI'MAN I'.oDV: in- cluding' MiiTOHcopiciii 'IVclini(|ue. Octavo, -l.S? |>iii,'t'H, with 277 orJL'inul t'liu'iiiviMLrs and 57 inset platfs in hiack and colors, contain- ini,'Hl fikrnies. ('Inih, s4.7."), //,'eH, with 5-1 engravings and 8 full-page plates. Cloth, $4.50; leather, $5.50. To the student, asto the physician, he found to he thorough, authorita- we would say, get Ttiylur first, and live and modern. — Albany Laiv then add as means and inclination Jdunidl. tuiihlK you.— American Practitioner |',ol.al)ly the hest work on the and News. suhject written in the English Ian- It is the authority accepted as guage. The work has heen thor- dnal hy the courts of all English- oughly revised and is up to date. — speaking countries. The work will I'acijic Medical Journal. TAYLOR { ROBERT W.). (JENITO-URINARY AND VENEREAL DISEASES AND SYPHILIS. New (.id) himI revised edition. In one very handsome octavo volume of ahout 750 pages, with 153 en- gravings and 3!* colored plates. Cloth, $5.00, net; leather, $(I.OO, net; half morocco, $0.50, /((Y. ./ nsi rraihi. A jiic notice!^ (ij the prrrious rdilion iirr niijundcd. By long odds the best work on It is a veritable storehouse of our venereal diseases, — Louisville Medi- knowledge of the venereal diseases. cal Monthly. It is commended as a conservative, The clearest, most unbiased and practical, full exposition of the ably presented treatise as yet pub- greatest value. —6%»mj^w Clinical lisheu on this vast subject. — The Ji^view. Medical News. TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- UAL DISORDERS IN THE MALE AND KEMALE. Second edition. In cue Svo. volume of 434 pages, with !tl engravings and 13 colored plates. Cloth, $3.00, net. The author has presented to the followed, will be of unlimited value profession the ablest and most scien- to both physician and patient. — tide work as yet published on sexual Medical News. disorders, and one which, if carefully A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 1 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic plates, 85 tine engravings and 425 pages of text. Bound in one volume, half Turkey Morocco, $28. For tale by subscription only. Address the publisbers. Lka Bbothir MUNDK (PAUIi F.). A TRAC- TICAL TRKATISE ON Till-: DISKASKS OF \V0M^:N. Sixth edition. In one oetavo \()luni(' of 824 pJiKos, with H47 engraving". Cloth, $.5; lenther, $«. TIIOHI»SO\ (W. (illiMAV). A TFXT-HOOK OF PRACTICAL MFDICINF. For Students and Pnictitiuners. Second edition, thor- oughly revised. In one hiindsonio octavo volume of 1014 pages, with "f)!t engravings. Ch)tli, .f^i.OO, nrf ; leather, ifn.OO, )ift ; half Morocco, $()..'■)(), urt. Till- author has presented the rich direct and most satisfyinu' nianner harvest of his ripe experience as he has giveri in andicient detail the physiciiiu and teaclier. 'i'here is exact nnthod of treatment that hiis everywhere iimpleevidence of iiccur- commended itself to his judu'menl ate observation, profound seholiir- ami his ex|ierienci;. — Maiicul A'cirs. ship and rare trood jiidutnent. In a THOMPSON (SIR HENRY). 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It is a good work -the author liav ing condensed most of the leading points in connection with diseases of infancy and childhood into short and readable chapters. — Virginin Medical Semi-Monthl>j. 30 Lka Brothkrh a Co., Philadrlphia and New York. VAUGHAN fVICTOR C.) AND NOVY (FREDERICK O.). rKl.LUI-AU TOXINS, or the Clieniieal Fiictors in the Cauaation of Disease. New (4tli) edition. In one 12nio. volume of 180 pages, (loth, .$8.00, nrl. The work has heen hrouuht down The most exhaustive and most re" todate, and will be fousid entirely cent presentation of the Ruhject. — satisfactctry. — Joitrnn/ of the Ameri- American Jour, of the Med. Sciences, con Meiiiraf A.'^xocuttion. VEASKV (CliAREXCE A.) A MANUAL < >!' OPIITIfALMOLOG Y. 12mo.,410 pages, 194 engravings, lOcolov d plates. Cloth, s2 (lO, /mV. The best eye niiinual we havi' interesting volutne. A book that seen. 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Tht; text is clear and the pedic surgery. — \'iri/ini(i Midinil views expressed are well presented, Miiiilhlii. making the work the liest that has It is a pleasure to review a book yet been otiered in this important so well written and so clearly illus- branch.— 77/r Jinston Mxlirnl imil trated as this, presenting the last Siiri/icul .hmriKil. and best word on this active special WICKS (3IArn -K.). A POCKET TEXT-HOOK OF NIKSING. I'n jKiriiKi. Si'C l.ra's Siriis ,ij I'ocl.ct 'I'l .i-l-liiinl.-s, page 18. WIIJilAMS (l>.\WSON). THE MEDIGVL DISEASES OF GHIE- DRE.N. Second tidition. S|,ecially revised for Anu-riea by F. S. C" I'tiCHll.l,, A.M., M.D. In one octavo volume of .').'{S! pages, with ,52 illustrations, and 2 plates. Cloth, $.'5. .")(», 7icl. The descriptions of symptoms are diagnosis, prognosis, complications, full, and the treatment recommended and treatment. 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