Class _ Book. Copyrights Hz COPYRIGHT DEPOSIT. Synopsis of Lectures on Obstetrics BY CHARLES SUMNER BACON Professor of Obstetrics and Head of the Department of Obstetrics In the College of Medicine of the University of Illinois ^ CHICAGO: NINETEEN HUNDRED AND THIRTEEN Q* ip ** Copyright 1913 BY Charles Sumxer Bacon American Medical Association Press CHICAGO, 1913 ©C1.A357338 THE PURPOSE OF THIS SYNOPSIS AND SUGGESTIONS CONCERNING ITS USE This synopsis was originally a collection of catch-words that I used in my lectures to recall the most important particulars of the subject to be presented to the class. It occurred to me that a copy of these catch-words in the hands of the student might help him in following the lectures and in review- ing the subjects for quizzes, and that it might also be of some value for hasty reference in subsequent obstetrical practice. In printing the synopsis it seemed desirable to add at times some data not easily remembered or such as were given differently by different authors; also, some subjects were somewhat elaborated when I found it necessary to present views not given in text-books or in those accessible to the students. Examples are: the discussion of position and station, of the mechanism of labor and of the physiology and pathology of lactation. "It" was first published in 1904 and a revision made two years later. In bringing it up to date I have rearranged the matter, separating normal obstetrics from abnormal for the convenience of the classes. As before, blank pages are left for notes which may be made in ink. To facilitate the use of the four text-books especially recom- mended I have also given the pages where each subject is dis- cussed. These books are by De Lee, 1st edition (marked D) ; Edgar, 3d edition (marked E) ; Hirst, 7th edition (marked H). and Williams, 3d edition (marked W). The excellent works of Webster and Davis and the symposiums edited by Jewett and Peterson are also recommended to the students, but not here referred to as no recent editions have been issued. The habit of arranging one's knowledge in logical order is desirable and such a skeleton or framework as this little synopsis should aid in such arrangement. Where two or more students room or study together it is desirable that they pro- cure for common use books by different authors. It is well for the student to get the views of two or three of the best authors and compare them with those presented in the lecture room, for in this way he will obtain broader views of his own and begin to form independent judgments. This will offset any possible danger that he may become confused when he finds conflicting authorities and enable him to make the most of the theoretical study which is the best possible founda- tion for practical work. Charles S. Bacon. Chicago, August, 1913. CHAPTER I— NORMAL PREGNANCY EMBRYOLOGY D. 1-69; E. 27-73; H. 72-131; W. 9^-168. Ova. — Origin and development in ovary; primordial ova, number, distribution and growth; formation of Graafian follicles, growth, cells, discus, fluid; rupture of follicles, ovulation; size, 60 to 200 microns. Structure, protoplasm, nucleus 30 microns, nucleolus 9 microns, zona pellucida. Corona, follicle cells. Maturation, formation of female pronucleus by extrusion of polar bodies, relation of process to parthenogenesis, relation of polar bodies to embryomas. Unfecundated ova, destroyed in peritoneal cavity, pass through tube and uterus, may live several days. Menstruation. — Cyclic changes in the uterus and other parts of the body, premenstrual, menstrual and postmenstrual periods, endometrial changes during each, dependent on the ovaries but not on ovulation, relation to conception and nidation, corpus luteum of menstruation and preg- nancy, puberty, menopause. Spermatozoa. — Number, nuclei, spontaneous movements, in- semination, migration, penetration of ovum, male pro- nucleus. Fertilization. — Formation of segmentation nucleus by pene- tration into ovum of one spermatozoon which as male pronucleus unites with female pronucleus, in tube or on surface of ovary, beginning of germinal period which lasts about eight days. Segmentation. — Karyokenesis, morula, blastodermic vesicle, germ layers, viz: epiblast or ectoderm, mesoblast or mesoderm and hypoblast or entoderm, trophoblast. Blastodermic Vesicle. — Embryonic area and shield, primitive streak and folds, medullary groove and folds, neurenteric canal, somatopleure and splanchnopleure, coelom. Migration. — Into tube, through tube, through uterus, dura- tion, forces. Embryology Implantation or Nidation. — Three to seven days after fertil- ization, phagocytic action of trophoblast, erosion of epi- thelium and vessels, fibrin plug at point of entrance, nature and function of primitive chorionic villi, origin of first maternal blood sinuses, placentation begins. Decidua. — Vera, serotina or basilaris, reflexa or capsularis. compact and spongy layers, decidual cells. Chorion. — Formation from the extra -embryonic portion of the vesicle wall that does not enter into amnion, com- posed of epiblast and mesoblast. Villi originate as trophoblast projections into which meso- blast tissue and vessels penetrate, covered with syncy- tium and Langhans cells. Meaning of frondosum and leve\ Amnion. — Development of sac, ectoderm and mesoderm. Liquor amnii — origin: transudation, secretion; amount: 200 c.c. to 2,000 c.c; function: protective and nutritive. Allantois. — From hindgut, carries vessels to chorion in some animals, in man only to umbilical stalk. Umbilical pedicle. — Belly stalk, found early in man, carries vessels to chorion, forms basis of cord. Yolk sac. — Umbilical vesicle, persists between membranes, its stalk in cord; intra-abdominal portion generally dis- appears, sometimes persists as Meckel's diverticulum. Cord. — Structure, umbilical stalk, allantois stalk, yolk sac and stalk, vessels, Wharton's jelly. Placenta. — Structure, maternal and fetal parts, syncytial buds, lacunar, invasion of stroma and vessels; function, nourish child, remove waste, filter. Embryo. — Development from second to sixth week inclusive, organogenesis, especially heart and blood-vessels, limbs, eyes, ears, nose and mouth, intestinal tract. Fetus. — Development of organs, circulation, functions, size at various four-week periods, age determined approxi- mately by length, 1, 4, 9, 16, 25, 30, 35, 40, 45, 50. Physiology, circulation, respiration, digestion, renal secre- tion, motion, mental action, rest and exercise, sleep. Heredity. — Galton's law of ancestral heredity. Biometrical method. Mendelian heredity. Character units or factors, gameto- genesis, zygosis, dominant and recessive characters, segregation, allelomorphism, homozygote, heterozygote, 4 Changes of Pregnancy purity of type, difference in filial generations, discon- tinuity, number of unit characters. Mendelian inher- itance in man of abnormal and pathological characters. Ettles for collecting evidence. DURATION OF PREGNANCY D. 112-113; E. 127-131; H. 139-164; W. 201-207. How to determine probable date of labor: exact time of fertilization unknown; determination of end important. practically and legally; reckoned in days, weeks and months; disadvantage of the term month. Conception: two hundred and seventy four days. Menstruation: two hundred and eighty days; use tables; count back. Nausea: thirty-four to thirty-seven weeks from date of beginning. Fetal movements: one hundred and fifty- four days from first appearance. Individuality of period, therefore value of previous records. Size of uterus especially after twenty-fourth week when fundus reaches navel. Prolonged pregnancy; missed labor, uterine inertia. CHANGES OF PREGNANCY D. 70-111; E. 73-103; H. 131-139; W. 168-188. UTERUS. Enlargement. — Surface increased from 1 square decimeter to 20 square decimeters, or twenty times. Weight increased from 45 gm. to 900 gm., or twenty times. Capacity increased from 2 c.cm. to about 5 liters. Vertical diameter increased from 4 cm. to 32 cm., or eight times (including the cervix from 7 cm. to 35 cm., or five times ) . Transverse diameter increased from 4% cm. to 22% cm.. or five times. Antero-posterior diameter increased from 2% cm. to 22% cm., or nine times. Walls remain about the same thickness, thin in latter part of pregnancy. Changes of Form and Consistence. — First pyriform, then spherical, then development of the upper portion so that round ligaments come from some distance below the fundus. In early pregnancy there is projection at site of egg; also Hegar's sign. Later, development of lower 6 Changes of Pregnancy segment; posterior portion also develops more so that round ligaments converge above. Frequently irregular and asymmetrical shape. Changes of Situation. — First sinking, anteflexion; rising out of pelvis at twelve to sixteen weeks, fundus reaching navel at twenty-four weeks, sinking at thirty-eight weeks. Inclination: frequently to right. Longitudinal axis of uterus depends on position of patient and distension of abdominal walls or pendulous abdo- men. Rotation: anterior face to right. Cervix. — Slightly elongated. Situation or direction: early to one side, later somewhat posterior. Softening. Effacement: last two weeks. Muscular Wall. — Fibers increased in number and size, 50 microns to 500 microns in length and 5 to 10 microns in thickness. Arrangement hard to determine, generally described in three coats, a. External: transverse, longitudinal and circular fibers passing from ligaments and tubes, b. Middle coat, fibers surround vessels, c. Internal coat, fibers surround tubal and cervical openings. Upper or contracting and lower or dilating uterine segments. Elastic Tissue. — Greatly increased in amount, especially in the outer part of the wall. Interstitial connective tis- sue is thicker, juicier and the fibers farther apart. Mucous Membrane. — Decidua. Serous Membrane. — Greatly increased in surface, thicker. Vessels. — Arteries, veins and lymphatics increased in number and size. Properties and Functions of Uterus. Contractility: increased especially in last half of preg- nancy. Distensibility : also increased. Menstruation : cessation. LIGAMENTS. — Elongated, hypertrophied, more vertical, more vascular, broad ligament unfolded. OVARIES. — Elevated with broad ligament, nearer uterus, en- larged, cessation of ovulation, function of corpus luteum important: Born-Fraenkel theory. 8 Diagnosis of Pregnancy TUBES. — Changes in position, enlargement. PELVIC FLOOR.— Some hypertrophy, sinking. VAGINA. — Hypertrophy, congestion or dilatation of capil- laries, changes in color, increased secretion, bacteriology. Secretion: quantity, consistency, color, reaction, flora, bactericidal. VULVA. — Congested, change in color. PELVIC ARTICULATIONS.— Softened, lengthened, more elas- tic, allowing more movements of bones. ABDOMINAL WALLS. — Distension, influence of position and bandage, striae, linea nigra, diastasis of recti. BREASTS. — Enlargement, Montgomery's glands, secretion, areola both primary and secondary. HEART. — Displaced, increased in size ( ? ) . Pulse not changed in rapidity, tension slightly increased in latter part. BLOOD. — Slightly changed. Amount increased, reds not changed, slight leucocytosis, slight decrease in alkalin- ity, no change in molecular concentration, presence of ovular products, Abderhalden's test. THYROID. — Increased in size in later part, especial enlarge- ment in old nephritis, no enlargement in acute albumin- uria. KIDNEY. — Urine, increased, question of toxicity; albuminuria, how frequent in pregnancy, labor and puerperium. Kidney of pregnancy, differs from nephritis. Salts and form elements in urine. BLADDER. — Displaced, frequent micturition, causes. STOMACH.— Emesis, indigestion. BOWELS.— Constipation. MENTAL AND NERVOUS CHANGES. SIGNS OF PREGNANCY. DIAGNOSIS D. 250-269; E. 103-128; H. 1^2-169; W. 188-201. Probable Signs. — Physiological and pathological changes, biologic or serum reaction. Positive Signs. — Presence of fetus: outlines, head, limbs, etc.; movements, objective and subjective; heart tones, some- times heard before quickening. Differential Diagnosis. — Tumors, pseudocyesis, extrauterine pregnancy. 10 Multiple Pbegnancy MULTIPLE PREGNANCY. TWINS, TRIPLETS, ETC. D. J,G2->,72; E. 533-o37; II. 110-120: W. 368-379. Frequency.— Twins (Veit) I: 89, Triplets I: 8,000. Influ- ence of country, heredity. Origin. — Two Graafian follicles, two ova in one follicle, two nuclei in one ovum, division of nucleus. Superimpregnation or simultaneous fecundation. Superfecundation or successive fecundation: fertilization of two ova of same ovulation or before implantation, proof. Superf etation : fertilization of two ova of different ovula- tions or after implantation of one of them, proofs. Arrangement of Membranes and Placentas. — Cords. Signs and Diagnosis. — Size of uterus, auscultation, palpation. Termination. — Premature frequent, increase disease of mother, fetal abnormalities. MANAGEMENT OF PREGNANCY D. 22.5-231; E. 170-175; H. 11,0-1 > t 2; W. 207- 213. Engagement. — Fee, should depend on (1) time consumed. (2) responsibility, (3) visits, (4) operations. Make reductions when necessary. Fees are generally too low: therefore, poor obstetric work. Physician is not obliged to take a case. Engagement creates a contract with obligations. Physician must possess necessary skill, science and information, and use due care and dilligence and best judgment. Duty to instruct patient or nurse. Must continue attendance. Right to leave practice temporarily if substitute is pro- vided. Liability for malpractice of substitute, for gratuitous services and for students and nurses. Nurse. — Physician's assistant, and should be engaged and trained by him. Examination. — Records, card system best, anamnesis, phy- sical examination, including measurements. See page 38. Patient's Outfit. — Described under labor. Baby's Outfit. — Described under infant. Exercise. — Walking, riding automobile, street car; sewing machine, sweeping, etc., should not get tired. Travel. — Railroad and ship, advantages and dangers, value of change of scene. 12 Management of Pregnancy Factory Work. — Laws in different countries, efforts to secure vacation with continuance of wages during latter part of pregnancy. Bathing. — Warm and cold baths, care of breasts and nipples. , douches unnecessary. Clothing. — Warm underclothing, light overclothing, skirt supported from shoulders, corsets, bandage, shoes. Diet. — Mixed best, number of meals, effect of antifat diet on baby, diet in emesis and toxemia and kidney disease. Care of Bowels. — Fruit and food, laxatives, enemata. Urine. — Examine three or more times, amount, specific grav- ity, albumin, sugar, indican, urea, casts, etc. Sexual Intercourse. — Care at dates corresponding to early menstrual periods on account of danger of abortion; in latter part, danger of infection. Prevention of Infection. — Notify patients to avoid auto- examination and prevent examinations by others. Maternal Impressions. — No basis, harmful superstition. CHAPTER II— NORMAL LABOR DEFINITIONS Labor, accouchement, confinement, premature, at term. retarded, missed, precipitate, slow, etc., spontaneous, artificial. Normal (eutocia) : normal forces, passenger, passages, and mechanism. Abnormal or pathological (dystocia). STAGES OF LABOR (PERIODS) D. 116-129; E. Jfl5-.' f 21 ; H. 173-182; W. 233-2 J,3. Preparatory Stage. — Precursory symptoms. Increase in the uterine contractions of pregnancy which are sometimes painful. Sinking of uterus, date, causes, effects; favorable and un- favorable. Vaginal discharge. First Stage. — Dilatation of cervix: duration in primiparae and multipara*. Second Stage. — Expulsion of child: duration in primiparae and multiparae. Third Stage. — Expulsion of placenta and membranes (after- birth) : duration in primiparas and multiparas. EXCITING CAUSES OF LABOR D. 115-11S; E. Jfl3; H. 111-112; W. 226- 231. Stimulation of nerve centers in the uterus or in the cen- tral nervous system. a. Direct; toxins, C0 2 , fetal and placental products, ovarian products, menstrual periodicity, heredity. b. Reflex; fetal movements, distention of uterus, changes in placenta by infarcts, etc. FORCES OF LABOR D. 149-151; E. J,09-J,13; H. 2^9-251; W. 231-232, 2^3-262. UTERINE CONTRACTIONS. In all stages of labor. Nature of Contractions. — Intermittent: frequency and dura- tion. 16 Forces of Lap.or General contractions of muscles of body of uterus; not partial nor peristaltic. Involuntary, yet dependent on emotions. Intensity: measured (a) by force required to rupture membranes, (b) by tocodynamometer (Schatz). Effects of Contractions on Mother. — I. Cause pain, therefore, pain is synonymous with con- tractions. Character: menstrual like, colicky. Location: in back, abdomen, thighs. Cause of pain: pressure on uterine nerves, pelvic nerves. Relation to pain caused by contractions of other involun- tary muscles. Variability in intensity, absence. II. Affect maternal circulation: congestion of face, danger in heart disease. III. Affect uterus. 1. Harden uterus, can be determined by hand on abdomen or in vagina, hardening lasts longer than pain. 2. Change situation and shape of uterus, antero-posterior diameter increased and transverse diameter decreased, ligaments also contracted. 3. Efface and dilate cervix: generally by hydraulic pressure either before or after rupture of membranes, formation of lower uterine segment, contraction ring, BandPs and Bayer's theory, Schroeder's theory. Formation of cervical funnel and gradual changes in its shape. Dilatation of os, degree, how indicated. Action of bag of waters, how formed; shape, hemispheri- cal, pyriform, glove shape. Rupture: premature, de- layed, central and lateral; diagnosis of rupture. Condition during uterine contractions and in interval. 4. Expel child: generally by hydraulic pressure, some- times by direct pressure. 5. Separate and expel afterbirth. Effects of Contractions on the Child. — Modifies the fetal circulation, probably through action on the placenta. ABDOMINAL CONTRACTIONS Of value chiefly in second stage. Voluntary but spontaneous. Passages WEIGHT OF CHILD Efficiency not very great and varies with position of mother. DIFFERENT KINDS OF "PAINS" Precursory stage, preparatory pains, may last several days. First stage, dilating pains. Second stage, expelling or bearing-down pains. Third stage, afterbirth pains. After pains, may last several days. PASSAGES D. 152-166; E. 359-391; H. 17-5.' t ; W. 1-82. BONY PELVIS. Bones. — Innominate, formed by the union of three bones. Ilium: wing, crest, anterior superior and inferior spines,, posterior superior and inferior spines, body. Ischium: body, spine, tuberosity, ramus. Pubes: body, spine, ramus. Obturator foramen. Sacrosciatic notch. Sacrum (ossa vertebrae) : bodies, lateral masses, articulat- ing surfaces, shape of anterior surface. Coccyx. United by Ligaments. — Symphysis pubis. Saero iliac articulations (not synchrondroses). Sacro cocygeal articulation (anchylosis abnormal). False or Large Pelvis. — Boundaries. Shape of crests, Distance between spines and crests, 23 and 26 em., how measured. Pelvic Cavity. — Small or true pelvis. 1. Boundaries. 2. Form, truncated, irregular curved cylindroid. 3. Inlet or brim, superior strait (not a plane). Shape. Promontory, linea terminalis or ileo pectineal 20 Passages Diameters. — Antero posterior or conjugata vera anatomica. or promento pubio superior or p. p. s. equals 11.5 cm. Effect of Walcher position in changing the length. Con- jugata vera obstetrica or c. v. obst. or promentopubio minima or p. p. m. equals 11 cm., how determined. Conjugata diagonalis or c. d. or promentopubio inferior or p. p. i. equals about 13 cm. Depends on depth and inclination of symphysis. Method of measuring. External conjugate or Baudeloque diameter or d. B. equals about 20 cm., how measured. Transverse, or d. tr. equals 13.5 cm. Oblique or diameter sacroiliaca eminentia ilio pectinea equals 12.5 cm. First oblique is German and English right oblique and Latin left oblique, i. e. from right%>os- terior to left anterior. Second oblique is German and English left oblique and Latin right oblique. 4. Obstetric strait or strait of ischial spines or strait of Bitgen or angustia. Definition. Diameters. — Anteroposterior or sacropubio inferior equals 11 cm. D. bisischiatica equals 10.5 cm. 5. Pelvic outlet or pubio-coccygeo-tuberous surface. Definition. Diameters. — Anteroposterior equals 9 to 11.5 cm. Trans- verse equals 12 cm. 6. Pelvic cavity or excavation. Depth. — Anterior wall, 4 cm. Posterior wall or from promontory to end of sacrum, 10 cm. Medium depth from brim to ischial spines equals 7.5 cm. Other dimensions. — Antero posterior and transverse diam- eters equal about 12.5 cm. Parallel planes of Hodge. 7. Inclination of pelvis: angle which p. p. s. makes with the horizon, equals about 60 degrees. Variations on account of position, e. g\, back, lithotomy, knee-chest, etc. Normal erect position: anterior spines and pubic spines in vertical plane. Inclination of outlet about 10 degrees. Normal inclination, Meyer's line, equals 30 degrees. 8. Axes: axis of inlet, axis of outlet, axis of pelvis, line of progression. 22 Passaces Variations in Pelvic Cavity. — 1. Normal. — Due to: Individuality. Sex: male pelvis is smaller especially at outlet. Race: variation in form. Age: fetal and infantile pelves straighter. changes in adult pelves due to developmental and mechanical fac- tors. 2. Pathological. — Due to: Developmental anomalies. Disease: rickets, osteomalacia, etc. Injuries: fractures, dislocations, etc. SOFT PARTS CONNECTED WITH BONY PELVIS. Connected with Large Pelvis. — Muscles, iliacus and psoas; vessels; nerves. Change shape of inlet. Connected with Pelvic Cavity. — Pyriformis and obturator internus, origin, fascia, relations. Nerves and vessels. Bladder and rectum. Viscera, including ovaries, tubes, uterus, vagina. Connected with Pelvic Floor and Outlet. — Close pelvic cavity below, forming pelvic diaphragm, and extend obstetric canal. 1. Coccygeus and levator ani, including ilio-coccygeus, pubococcygeus and puborectalis; attachments, relations to rectum and vagina, functions. 2. Urogenital trigone : attachments, functions, perforations. 3'. Accessory muscles; in anal region, sphincter ani ex- ternus; in urogenital region, transversus perinei, ischio- cavernosi, bulbocavernosi. Definitions of perineal region, anal region, urogenital region, perineum. OBSTETRICAL CANAL. STATION OR STATIO The- obstetrical canal is gradually formed during labor as the presenting part advances by the dilatation of the uterus, vagina and pelvic diaphragm and the distention of the perineum. For purposes of description it is desir- able to consider it as preformed. In this sense it is a cylindrical cavity. Its upper part, from the inlet to below the second parallel plane of Hodge is straight while the rest is curved. Its upper half is enclosed within the walls of the bony pelvis and its lower half, the vaginovulvo perineal tube. is below the bony pelvis and forms an extension of the 24 Passenger upper part. This canal is, therefore, divided into two nearly equal parts by the obstetrical straits and bounded above by the pelvic inlet and below by the vulvar orifice. Practically the vaginal tube and the vulvar opening may be considered together as forming the obstetric outlet. Both the orifice and the tube are dilated together and usually do not retain the head long after its passage through the straits. Station is a term used to denote the station, situation or location of the head or other presenting part of the fetus. It is important to determine and designate the location of the passenger in order to denote the progress of labor, to make an accurate prognosis and to decide upon operative interference. We may say that there are in the obstetrical canal four stations or sites where at any given moment the head may be located and through which it must pass. These are: 1. The inlet or aditus, contraction ad. 2. The excavation or pelvic cavity, contraction, excav. 3. The straits or angustiae, contraction ang. 4. The outlet or exitus, contraction ex. PASSENGER D. 167-180; E. 391-1,09; H. 21,6-252; W. 213-220. HEAD. Skull or cranium and face. Bones. — Especially occipital, parietal, frontal, temporal. Sutures. — Allow molding; sagittal or anteroposterior; transverse or frontoparietal or coronal; lambdoid or occipitoparietal. Fontanelles. — Large or anterior or bregma, small or pos- terior. Diameters. — Maximum, from middle of chin to most distant point of skull, 13.5 cm. Occipitomental or o. m. is 13 cm. Occipitofrontal or o. f. is 12 cm. Suboccipitobregmatic or s. o. b. is 9.5 cm. Suboccipitofrontal maximum or s. o. f. is 9.7 cm. Bitemporal or bi. t. is 8 cm. Circumferences. — Maximum is 37 cm.; s. o. b. is 32.5 cm.; s. o. f. is 33 cm. 20 Passenger Names of Regions. — Occiput is the region of the occipital bone. Vertex is the region of the sagittal suture between small and large fontanelles or between the lambdoid and coronal sutures. It may be divided into posterior, mid and anterior. Sinciput is the region between coronal suture and root of nose, includes forehead. TRUNK. Size, less than head, abnormal size rare. Diameter bisac- romial 12 to 9 cm. Diameter sternodorsal about 9 cm. HIPS AND EXTREMITIES. Diameter bicristal or bisiliac about 8 cm. Diameter bitrochanteric about 9 cm. Diameter dorsopubic about 5 cm. ATTITUDE OR POSTURE OR HABITUS. Definition. Flexed, ventral flexion usual; causes, developmental ten- dency, pressure of uterus. Deflexed or extended or dorsal flexion. Inclined or lateral flexion. PRESENTATION OR PRESENTATIO. Definition. Indicates attitude. Variations during pregnancy and during different stages of labor. Head, trunk, breech. Head. — Frequency, 96.5 per cent, at term, less common be- fore term. Cause, greater weight of head ( ? ) , accommodation to uterine cavity. 1. Skull, or cranial, 96 per cent. Occipital, rare at inlet, common at straits and outlet., denotes complete flexion. Vertical, most common at inlet and during descent. Sincipital, includes brow which is rare, considerable de- flexion. Parietal bone, anterior or posterior, not uncommon above inlet before labor begins. 2. Face, .5 per cent.; greatest extension of head, also ex- tension of trunk. 2S Passenger Trunk.— About .5 per cent. Causes, shape and obliquity of uterus. Kinds, shoulder, arm, etc. Breech. — About 3 per cent, at term. Complete, foot, knee, etc. POSITION OR POSITIO. Definition. — General or broad, relation of fetus to mother or relation of any determining point of the fetus to the obstetrical canal. In this sense includes presentation which is relation of fetus to axis of obstetrical canal. So we have longitudinal and transverse positions. Restricted or usual, relation of a determining point of the fetus to the sides of the obstetrical canal. In this sense independent of presentation and attitude. The deter- mining point may be any point on the body. We gener- ally use the back or some point on the head, generally occiput or chin. Position varies during pregnancy and during labor. Posi- tion of head and trunk may vary independently of each other. If we wish to denote the position of the trunk we use the back as the determining point. When we denote the position of the head we may always use the occiput. Designation of Position by Naming from the Back. — During pregnancy or before the head enters pelvis when by external examination we are not certain of position of head. Back left, left anterior, left posterior, anterior, posterior, right, right anterior, right posterior. Latin designations and abbreviations best. Positio dorsalis laeva anterior or dextra anterior, posterior, etc. Contractions, pos. d. a., d. 1. a., d. 1., d. 1. p., d. p., d. d. p d. d., d. d. a. Keep to proper order of modifying terms, not 1. d. a., etc. Designation of Position of the Head by Naming from the Occiput. — Positio occipitalis laeva anterior, positio occipi talis dextra posterior, etc. Contractions pos., o. a., o. 1. a., o. 1., o. 1. p., o. p., o. d. p. o. d., o. d. a. Sometimes we use occipitalis pubica for o. a. and occipi talis sacralis for o. p. Since position means only the relation of a point in the back or head of the fetus to the obstetrical canal and is independent of the attitude or presentation of the fetus. 30 Passenger we would better always use the same method of denot- ing position whether head is well flexed or completely extended, that is, whether the presentation is occiput, vertex, sinciput or face we use the occiput to name the position. It is not necessary to touch the occiput to know where it lies. That we find by examination of the sagittal suture and fontanelles. Hence we denote pre- sentation and position thus, presentatio occipitalis, ver- ticals, facialis, etc., positio occipitalis Leva anterior when we have to do with most common position. Designation of Position by Naming from the Chin. — In case of face presentation most authors and teachers use the chin as naming point. Thus we have positio mentalis laeva anterior, dextra posterior, etc., or contracted m. 1. a., m. d. p., etc. Others use other points, for instance, the sinciput, the brow, etc. This is all confusing and has no value. Designation of Position in Breech and Cross Presentation.— In breech presentation position is generally designated by using the sacrum as designating point. This is not necessary, for the dorsum answers every purpose. In cross presentation the scapula may be used, but in these rare cases we may quite as well specify the location of the head. Frequency of Different Positions. — With head presentations during pregnancy the back is directed to the left in about two-thirds of all cases. Here it is more frequently found anterior. When directed to the right it is more often posterior. At the inlet positions are approximately o. 1. a. oo per cent., o. 1. p. 10 per cent., o. d. a. 15 per cent., o. d. p. 20 per cent. STATION. The head is not a point, but a body having considerable diameter. Hence, even with good progress some portion of it will be in one of the straits or cavities for some time. To define the location of the head we say that it is in one of the straits until its greatest circumference has passed through. With complete flexion, i. e., an occipital presentation, the greatest circumference is s. o. f. Hence, the head is in aditu until this circumference has passed the inlet. It is in excavation until rotation has occurred, then in angus- tia until the s. o. f. circumference has passed this strait, and finally in exitu until its expulsion from the body. 32 Mechanism of Normal Labor With vertex presentation the largest circumference is o. f., which must likewise pass the inlet before the head has entered the pelvis, etc. In face presentation it is the s. m. o. circumference which is greatest and determines the station of the head. EXAMINATION FINDINGS. The complete designation of the practically important find- ings in an external examination includes: 1 Nature and frequency of the uterine contractions. 2. Location, nature and rate of the fetal heart tones. 3. Presentation of the child. 4. Position of the child. 5. Station of the head. 6. External measurements. In an internal examination the points to be determined are: 1. Condition of the vagina. 2. Degree of dilatation and effacement of the cervix. 3. Condition of the membranes. 4. Presentation. 5. Position. 6. Station. 7. Presence or absence of abnormalities in the pelvic dimensions with measurement of the p. p. i. diameter. MECHANISM OF LABOR D. 181-203; E. ^21-4^3 ; H. 2^5-262; W. 262-2S2. In normal or skull presentation the mechanism of labor is the way in which the passenger is moved through the passage by the forces of labor. Three kinds of movements of the fetus occur, viz., translation, flexion or extension on any transverse axis and rotation. The progress may be described in four steps. First Step, Descent. — Entrance into pelvic excavation or passage through inlet, engagement partial and com- plete, definition of. Generally the sagittal suture is in an oblique diameter. Descent is often preceded by or accompanied with flexion which is due to lever action, the long arm of the lever being the fore part of the head, or the long axis of the head elipsoid i. e., the o. m. diameter tends to coin- cide with the axis of the obstetrical canal. Synclitism, Naegele obliquity, Varnier obliquity. 34 Management of Normal Labob Molding of head, caput succedaneum. Also rotation may begin. Second Step, Internal Rotation. — Due to accommodation to canal, action of pelvic floor or levator ani and the action of the fetal body. Sellheim's theory. The fetus tends to bend in some direc- tions instead of in others. The head bends most easily backwards while the body tends to lateral flexion. These facts are proven by observations on the newborn child. When passing through the obstetrical canal the fetus obeys the law that "When a body capable of rotating, which tends to bend in one direction, passes through a bent canal it will rotate till its line of great- est flexibility coincides with the axis of the canal." Completion of flexion. Variations in rotation in pos. o. 1. a., o. 1. p., o. d. a. and o. d. p. Third Step, Exit of Head. — Passage of head through straits and vaginal outlet. Gradual change in direction. Distention of perineum, separation of labia, passage of occiput under pubes, extension of head and escape from vulva, molding of head. Fourth Step, Exit of Body. — External rotation of head with internal rotation of body, passage of straits by shoulders, passage of anterior shoulder under symphy- sis, escape of posterior shoulder, passage of body and hips. MECHANISM IN THIRD STAGE. D. 12S-129; E. .',19-',21 ; H. 290-201; W. 300-306. Duncan and Schultze, separation and expulsion of pla- centa from uterus, expulsion from lower uterine segment and from vagina. MANAGEMENT OF LABOR D. 231-2.i,9, 270-320; E. 131-170, J h ',.' t --',7 1 ; H. 170-19S; W. 311-339, 701-715. HOSPITAL OR HOME. Advantages of hospital. — Sufficient assistance and supplies, more perfect asepsis, better observation before and after labor, saving time of the physician. PREPARATORY ARRANGEMENTS. Preliminary examination, including measurements in preg- nancy, record book, choosing and preparation of room, engagement of nurse. (See management of pregnancy.) 36 Management of Normal Labor Patient's Outfit. — Twenty-five yards sterile gauze, 4 pounds absorbent cotton, rubber sheeting 11/4x1% and 1^x1% yards, 4 yards cotton cloth (for bandages), 1 bottle (25) sublimate tablets (7+gr. each), 3 ounces compound solution of cresol (lysol), 1 ounce olive oil, some prepa- ration of ergot for hypodermic use, 1 pint alcohol, 250 grams ether, 1 tube antiseptic soap, 2 nail brushes, 1 nail file, 1 bath thermometer, 1 envelope sterilized silk ligature, 1 glass irrigator point, 1 water nursing bottle. 1 3-oz. rubber syringe, fountain syringe (3 quarts), enamel bedpan, enamel douche pan, enamel baby bath tub, breast pump, nipple shield. Other necessary preparations : 8 sheets, 12 towels, pillow- slips, patient's shirt, gown, leggings or stockings. Oil cloth (2x2 yards) for the floor if carpeted, large stand or small table, 2 enamel washbowls, 1 small (finger) bowl, 1 slop jar or pail, 2 pitchers, 1 or 2 glass fruit jars for salt solution, 2 or 3 gallons of hot and as much cold boiled water. Minimum outfit which for emergency cases it may be desirable for the physician to carry: 1 rubber sheet, 2 cotton sheets, 6 towels, 5 yards gauze, 1 pound absorb- ent cotton, 1 bottle (25) sublimate tablets, 1 ounce F. E. ergot, soap, nailbrush, silk ligature, 2 basins. Baby's Outfit.— See Chapter IV. Obstetric Bag. — Sterilizer. General sack: scissors, needle forceps, long forceps, dress- ing forceps, tenaculum forceps, 2 retractors, silver catheter, intrauterine douche tube, razor. Examination sack: pelvimeter, tape line, phonendoscope, scales. Forceps sack: forceps. Rubber sack: set Voorhees dilators, bulb syringe, aspirat- ing catheter, rubber urethral catheter. Embryotomy sack: Auvard cranioclast, Braun hook. Abortion sack: dilators, curette. Case for needles, catgut, silk, silkworm gut, fountain syringe, gloves, rubber apron, rubber sheet, gown, gauze, cotton, ether, ergotole, sublimate tablets, salt tablets; silver solution, collodion, soap, brushes, file, hypodermic syringe and tablets, thermometer. ANSWER TO CALL. Arrival at house, supervision of nurse and her arrange- ments. (For legal responsibilities see Management of Pregnancy. ) 3S Management of Normal Labor PREPARATION OF SELF. Cleaning of hands, Fuerbringer method, gloves and gown, gnaze cap and mask for hair and month. PREPARATION OF PATIENT. Before labor: baths (sponge, tub, shower), laxatives, injections, washing hair, enema, use of closet. Dress of patient : shirt, short gown, stockings or long feet drawers, or leggings. Bed: rubber sheets, sheets, pads. Cleaning of genital region: on douche pan, clip hair or shave, soap and water, antiseptics, vaginal douche ( ? ) , vulvar pad, care of douche pan, stands, how placed and covered, contents, pail, douche bag, water, floor, steril- ize instruments, including thermometer. EXAMINATION OF PATIENT. General. — Pulse, temperature, headache, edema, blood- pressure. Special. — Objects: 1. Determine condition of passages, that is, pelvis, cervix, vagina, membranes, etc. 2. Determine attitude, position, presentation, station and condition of passenger. Methods: I. External abdominal. 1. Inspection: size, shape and location of uterus, move- ments of child. 2. Palpation: outline uterus, determine position, attitude and station of child; manipulations 1, 2, 3 and 4. 3. Auscultation: fetal heart tones, importance, how taken and recorded, instruct nurse. Murmur in cord, uterine soufle. 4. Measurement of interspinous, intercristal and Bande- loque diameters. II. External of genital regions. 1. Inspection: discharge, liquor amnii, blood, meconium. Distention of perineum, appearance of head. 2. Palpation: progress of head, behind anus. III. Internal examination. Examine vagina, cervix, os, membranes, presenting part, sagittal suture, fontanelles, relation of presenting part to spines, measure p. p. i., also note any abnormalities of passages or passenger. 40 Management of Normal Labor POSITION OF PATIENT. Out of bed: dress, walking, standing, sitting, etc. In bed: on which side during labor, position during deliv- ery. NOURISHMENT OF PATIENT. Food, drink, stimulants, nausea and vomiting. RELIEF OF PAIN AND FEAR. Moral support, morphin, codein, chloral, scopolamin. Anesthetics: ether during labor, for operation. Support of back, pulling of patient. CARE OF BLADDER. Frequent attention, catheterize when necessary. CARE OF RECTUM. Sponges and washing to protect from discharge. PREVENT LACERATION OF VULVA AND PERINEUM. Laceration of cervix and vagina may be unavoidable. Frequency of vaginal and perineal tears, 20 to 30 per cent, in primiparse. Method of Prevention. — 1. Flex head and bring occiput under symphysis. 2. Prevent rapid exit of head. 3. Episiotomy. Pressure on perineum useless or harmful. CARE OF CHILD AND SEPARATION FROM MOTHER- THIRD STAGE. D. 310-321; E. £71-477; H. 199-205; W. 306-311, 333-338. Wipe face, establish respiration, cleaning throat if neces- sary. See page 60. Keep warm and dry, use Crede instillation, tie cord at skin junction and cut and also cut cord close to vulva with or without ligating next to placenta, vulvar dressing. Hand on abdomen to control uterus, watch discharge, clean patient, clean the bed, inspect perineum and repair if necessary. Deliver placenta and membranes; wait one -half hour for spontaneous expulsion if no hemorrhage. Then, if secundines are in lower uterine segment or vagina, direct patient to use auxiliary muscles during uterine contraction. If necessary, reinforce the action of the Management of Normal Labor abdominal muscles by pressing - with the hand on the abdomen. See page 174 for operative expression from lower uterine segment. If the placenta remains in upper uterine segment, massage to cause uterine con- traction and expulsion. If expulsion from uterus does not occur in 2 hours Crede expression may be required. See page 172. Examine placenta and membranes for abnormal conditions and defects. Clean the genital region, apply vulvar dressing and abdom- inal binder and remove to lying-in bed. CHAPTER III NORMAL PUERPERIUM Definitions. — Puerperiuin, childbed, lying-in period. Duration.— Six to twelve weeks. CHANGES OF THE PUERPERIUM. D. 20J,-222; E. 653-667; H. 206-229; W. 339-3 J7. Xormal anatomical and physiological constitute involution. Xot far separated and often hard to distinguish from pathological. CHANGES IN THE UTERUS.— INVOLUTION. Change in Size. — Height of fundus,, gradual rise from pelvis after expulsion of placenta to above navel, descent, disappearance, sev- enth to twelfth day. Diameters all decreased. Change in Shape. — From ovoid to shape of non-pregnant uterus, concave anteriorly. Change in Position. — Abdominal to pelvic. Abnormal: anteflexion, retroversion and flexion. Treatment consists in knee chest position, manual replace- ment, pessary. Changes in Endometrium. — Degeneration, condition of placental and extra placental regions, disappearance of deciduse. Regeneration, source of new epithelium. Changes in Muscular Wall. — Atrophy and destruction of muscle cells, influence of phagocytosis. Rearrangement of muscle fibers. Changes in Uterine Vessels. — Formation and organization' of thrombi; thickening of walls of arteries. 4fi Changes of Puerperium Contractions — After-Pains. Causes. Frequency in primiparse and multipara*. Treatment, morphin. Lochia. — Nature, blood, serum, decidua, distinction from hemor- rhage, changes in character during flow. Amount, depends on hemorrhage and other factors. Duration, stoppage or retention. Bacteria, kinds, source, location, effect on odor, on infection. Change in Cervix. — At first flabby cuff, later contraction scars from infection and tears. Menstruation. — Generally absent for several months and fre- quently during entire lactation. Sometimes reappears 3 to 4 weeks after labor and continues more or less regularly. Relation to ovulation and conception. CHANGES IN VAGINA AND VULVA. Abrasions and bruises with slight infection. Involution of fundal and lower portions. Effects of tears. CHANGES IN LIGAMENTS. Subinvolution in retroversion and flexion of uterus, invo- lution after Alexander and other operations for dis- placements. CHANGES IN PERITONEUM. Involution of uterine serosa. CHANGES IN ABDOMINAL WALLS. Involution and subinvolution. Diastasis of recti muscles. Permanence of striae. CHANGES IN ABDOMINAL ORGANS. Tendency to splanchnoptosis because of lengthened mesen- tery and change in intra-abdominal pressure. URINARY SYSTEM. Kidney. — Disappearance of pathological changes in "kidney of pregnancy/' Ureters. — Disappearance of dilatation. 48 Changes of Puerperium Bladder. — Return to pelvis and resumption of former relation to pelvic and abdominal organs. Disturbed Micturition. — Causes, horizontal position, change in intra-abdominal pressure, injuries to urethra, disturbed innervation. Diagnosis, external examination shows distended bladder, overflow from paralyzed viscus should be distinguished from normal urination. Rules for management. Patient should try to urinate every six to twelve hours. She may sit if necessary unless in dangerous condition. Catheterize if urination impossible, danger of cystitis. rules. INTESTINES. Paralysis or paresis, distention, constipation. Causes of Constipation. — Constipation during latter part of pregnancy, change in abdominal pressure, lack of exer- cise, horizontal position. Results. — Toxemia, perhaps infection, frequently most im- portant complication of childbed. Management. — Begin second day. 1. Medicines, magnesium citrate, seidlitz powders, mag- nesium sulphate, mineral waters, cascara sagrada, senna. calomel. 2. Massage. Objects, mechanically move on contents of bowels, stimulate peristalsis, assist action of enemata. Methods, hands, ball, etc., direction of movement. 3. Enemata. Contents: water, oil, glycerin (glycerin suppositories), solution of salt, soap, turpentine, salts, etc. Amount, from one dram to gallons. Temperature, from ice cold to 115 degrees. Methods: piston, bulb, or fountain syringe, hard or soft tubes, long tubes, "colonic flushing" ( ? ) , position of patient. Removal of hard masses from rectum. CHANGES IN THE BREASTS, LACTATION. Importance. — Concerns mother and child. 1. Sufficient and proper secretion very important to child. 2. Danger of infection great for nursing causes abrasions on the nipples of most women. Lactation Anatomy of the Breasts. — Main ducts, lobes and lobules, acini, gland cells, distribution of lymph and blood vessels. Physiology of the Breast and Secretion. — Rest period, swelling and preparation of gland cells, filling of vessels. Active period, formation of milk by secretion or breaking clown of gland cells or both, stimulus is nursing or other excitant, analogy with other secretions or with milking in animals, most of the milk is formed during nursing. Clinical Phenomena. — Colostrum. Composition, difference between it and milk, valuable as food and laxative for child, early nursing also stimulates breast secretion and uterine involution. Establishment of Milk Secretion. Appearance of milk gradual, generally from second to fifth day. Congestion of the Breasts. Cause: distention of vessels, not curdling of milk. Symptoms: swelling, pain, tenderness, hardness, lumps, no fever. Results: not dangerous unless infection supervenes, only temporary discomfort, in nervous women loss of sleep and institution of unwise procedures. Management. 1. Support: bandage, simple jacket, double Y bandage; roller bandage used especially when necessary to dry up the milk. 2. Icebag or coil. 3. Massage. Object is to empty the vessels of the breast and not to empty the milk. Contraindication, infection. Technic, position of patient and attendant, clean hands, lubricants, direction of manipulations. 4. Pump: not necessary, may also do harm. Agalactia and Deficient Secretion. Causes: defective development of gland, malnutrition, nervous influences. Frequency: increasing in America. Treatment : mixed diet, general hygiene, medicines uncer- tain, frequent nursing at both breasts. 52 Management of the Ptjerperium Polygalactia and Galactorrhea. Analogy to salivation. Causes: open ducts, constant stimulation, failure of inhib- itory centers. Treatment, bandage, avoid stimulation. CHANGES IN THE AXILLARY SWEAT GLANDS. Temporary hypertrophy, not important, often mistaken for swollen lymphatic glands or for supernumerary mammary glands. CHANGES IN CIRCULATORY SYSTEM. Slow Pulse. — Cause unknown. Blood.— CHANGES IN NERVOUS SYSTEM. Postpartum Chill. — Common, not alarming, cause. DIAGNOSIS OF THE PUERPERIUM. Medicolegal importance. Based on normal and pathologic changes. Especially, recent tears, lochia, condition of uterus, abdom- inal walls and breasts. Probable signs in primiparse and in multipara. Positive signs, finding parts of the ovum. Problem arises more frequently after abortion than after labor at term. MANAGEMENT OF THE PUERPERIUM D. 321-328; E. 667-677; H. 231-2kk; W. 347-35 k, 853-868. REST. Degree and length depends on (a) previous condition of patient, (o) temperament, (c) length and severity and complications of labor. Movement in bed not prohibited at any time unless patient very weak. Sleep desirable, should not be disturbed by baby, nurse or family. Company, restrict or prohibit. EXERCISE AND GETTING UP. Advantages of Horizontal Position. — Prevents congestion of pelvis and splanchnoptosis. Prevents subinvolution of abdominal wall. 54 Management of the Puerperium Disadvantages of Inactivity in Bed. — Sluggish lymphatic and blood circulation, with autointoxi- cation. Weakened muscles. Object of Bed Exercise. — Overcome disadvantages and secure advantages of bed. Stimulate circulation and strengthen muscles. Character and Order of Exercise. — Tense or opposed flexion and extension. 1. Breathing, five to ten times. 2. Upper extremities, five to ten times. 3. Feet, ten to twenty times. 4. Thighs, three to five times. 5. Lower extremities, three to five times. 6. Trunk, three to five times. How Employed. — When begun, second to fifth day; frequency, three to five times a day; duration, two to twelve weeks. Walking. — When begun, fifth to twelfth day, one minute at a time at first, increase slowly, regard as an extension of bed exercise, stair climbing. Sitting.— Comes after walking, very gradual. DRESSINGS. Vulvar pad, sterile, wide, fastened at four corners, no T bandage. Vulvar toilet, external antiseptic douche or washing with sponges, use of douche pan, danger, care of. Abdominal bandage, how applied, advantages of. Breast bandage, pattern, length, width, how applied, dress- ing of nipple. Corsets, pattern, advantages and disadvantages. DIET. Vulgar errors; causes fever, etc. Amount. — Replenish loss, supply milk. Needs of first days. Frequency. — Five feedings a day may be desirable. 50 Management of the Puerperiuh Kind.— Mixed best, liquid necessary, slop diet not desirable, pro- teids necessary, fruits good, do not hurt mother's milk. CARE OF ROOM. Temperature 70 degrees, depends on presence of baby. Ventilation, window. Odors, removed by ventilation. Flowers. Cleaning. EXAMINATIONS. Daily examinations of breasts, abdomen and vulva. In two weeks a thorough examination should be made and findings recorded and again in six weeks, before dis- charging the patient. Legal bearings. Distinct under- standing of the termination of contract. The complete examination should include general condition, color of skin, condition of mouth, neck, breasts, nipples, abdominal wall, perineum, vulva, anus, pelvic floor, vaginal discharge, uterus, size, position, mobility, sensi- bility, cervix, lacerations, adnexa. CHAPTER IV-THE INFANT ANATOMY, PHYSIOLOGY AND CLINICAL PHENOMENA, BOTH NORMAL AND ABNORMAL D. 829-339; E. 75> f -830; H. 9^2-972; W. 854-859, 869-873, 93^-935. CIRCULATORY SYSTEM. Change from Fetal to Extrauterine Life. — Obliteration of umbilical vessels, ductus venosus, ductus arteriosus and foramen ovale. Establishment of pul- monic circulation. "Blue child," cause, laying child on right side unnecessary. Pulse. — Frequency. Blood. — Amount, specific gravity, reds and whites, nucleated reds, ferments. RESPIRATORY SYSTEM. Establishment of Respiration. — Cause, when, first cry. Apnoea. — Cause, diagnosis, danger. Asphyxia Neonatorum. — Definition. — Distinction from apnoea. Causes. 1. Premature stimulation of respiration with aspiration of liquids into throat and lungs, due to pressure on cord as in prolapse of cord, or to separation of placenta. 2. Gradual numbing of respiratory center, no aspiration of liquids, interference with placental circulation ( tetanic contractions ) . 3. Injury to brain, no aspiration. Degree. a. Livid or congestive asphyxia, respiration generally excited by cutaneous stimulation. b. Pallid asphyxia, respiration not excited by cutaneous stimulation. GO Asphyxia Neonatorum Treatment. 1. Hold the head down and slap the body. 2. Remove mucus with tracheal catheter. 3. Tie cord, apply hot and cold water, using tub and faucet or pitcher. 4. Byrd method. 5. Sylvestre method. 6. Schultze swinging, technic. 7. Breathe air into lungs, technic. 8. La Borde method. 9. The pulmotor. Combine 4, 5, 6, 7 and 8. Listen to heart, continue as long as any sign of heart action. After care. Rapid and Irregular Breathing. — (Cheyne- Stokes.) Causes: general infection or intoxication, head injury, respiratory affections. Treatment: find and treat cause, baths, enemas. Aspiration Pneumonia. — Cause, prevention, treatment. Actelectasis Pulmonum. — Generally in premature. Treatment, incubator, oxygen. Respiratory Infections. — Coryza. Intrapartum and postpartum. Gonorrheal, catarrhal, grip. Bronchial. Catarrhal, grip. UMBILICAL CORD. Tying. — Primary, tape or large ligature, one inch from body, immediate or after cessation of pulsation, protect child. Secondary, at junction of skin, objects. Ligature on placental side not necesary. Cutting. — Leave only enough to prevent slipping of ligature. Desiccation and Separation. — No impervious dressing. Infection. — Causes: ligature, dressing, bath. Time: before and after separation. 02 Umbilical Cord Point of entrance: generally at skin junction. Kinds: streptococcus, staphylococcus, tetanus, etc. Results. — Local, ulcer inflammation. General, intoxication, infection from septic thrombi in umbilical vein. Prevention. — Sterile ligature. Wash with alcohol, especially after bath. Sterile cotton dressing. Eczema. — After separation of cord, treat Avith protective powder. Umbilical Hernia. — Xot hernia into the cord. Causes: congenital weakness, straining. Prevention: bandage useless. Treatment: plaster. SKIN. Vernix Caseosa. — Nature, how removed. Erythema. — Reaction to external irritants, immunization. Infections. — Pimples and boils. Cause: dressing, bathing, etc. Treatment: how opened, care in bathing. Eczema. — Influence of overfeeding. "Marks," Naevi. — Vascular tumors. Treatment, when important and growing, acid. EYES. Co-ordination.— Xot at birth. Subconjunctival Hematoma.— Xo treatment. Infection. — 1. Catarrhal. Causes: various kinds of infecting bacteria. a. Intrapartum: vaginal secretion. b. Postpartum: washes, soap, etc. Treatment: boric acid wash. 2. Gonorrheal (ophthalmia neonatorum). 04 Eyes, Mouth Sources. — Cervical or vaginal discharge, disease may remain latent for years in genital tract of mother. Prevention. — Crede installation, technic, used only when gonorrhea suspected. Treatment: nitrate of silver solution, consultation. DIGESTIVE SYSTEM. MOUTH AND PHARYNX. Tongue Tie. — Effect on nursing, operation. Infection. — a. Thrush. Cause : oidium albicans ( ? ) . Mode of infection: washing mouth, nipple, "sweet teat" or "comfort." Prevention: let mouth alone. Treatment: washing, technic. b. Gonorrheal. Cause and treatment. STOMACH. Size, position, function, regurgitation. INTESTINE. Meconium. — Nature, color, amount. Invasion of Colon Bacilli. — Immigration, gas formation, colic. Bowel Movements. — Yellow stools, odor, frequency, size. Diarrhea. — Excessive vermicular action, infection may be present. Treatment: calomel, castor oil, enemas. Constipation. — Generally with artificial feeding. Treatment: change food, enemas, oil. Gastroenteric Infection ( Gastroenteritis ) . Sources : improper and contaminated food, including drink, cold. Symptoms : colic, vomiting, diarrhea, fever, etc. Treatment: diet, enemas, calomel, oil. 06 Colic Intestinal Colic. — Differential diagnosis from urinary colic, from hunger and from other pain. Not necessarily attended with passage of urinary sedi- ment, distended bowel and green stool common. Treatment: heat to abdomen, hot drinks, carminatives, enemas, castor oil, calomel, change of feeding. LIVER. Size. Infection. — From umbilical vessels, syphilis. Icterus. — Causes: infection of duct from (a) umbilical vessels, and (&) intestines. Congenital closure of duct. Symptoms: color skin and mucous membranes, color stools, fever, intoxication. Treatment: same as gastroenteric infection. URINARY SYSTEM. Uric Acid Deposit. — "Brick Dust." Cause of urinary colic. Anuria. — Frequency. Duration. Symptoms or results: intoxication, fever, irregular respi- ration, convulsions. Treatment: baths, water by mouth and enemata. GENITAL SYSTEM. 1. MALE. Cryptorchidisms. — Undescended testicle. Always note, no immediate treatment. Adherent Prepuce. — Results, retained smegma may be irritating and later cause trouble. Management: retract if possible, split prepuce or circum- cise if necessary, dressing, after treatment, when done. 2. FEMALE. Infection. — Catarrhal: common, due to handling, bathing, dressings, etc. 68 Birth Injuries Colon bacillus: may ascend to bladder and thence to kid- ney and cause pyelitis that may become chronic. Gonorrheal: diagnosis. Treatment: keep clean. Menstruation. — True and false, not uncommon nor impor- tant. BREASTS. Functional activity in both sexes. Management, let alone. Mastitis or infection, cause, interference. INJURIES. Head.— Spontaneous and operative labors. Molding, caput seccedaneum, cephalhematoma. Marks on skin from pelvic bones and from instruments. Fractures and depressions of skull. Cerebral hemorrhage. Injuries to eye. Paralysis and paresis. Upper Extremities. — Fracture of clavicle. Fracture of humerus. Birth paralysis. Dislocations. Lower Extremities. — Fracture of thigh. MALFORMATIONS, DEFORMITIES (monsters). For classification see pages 86-90. Management of spina bifida, hare lip, cleft palate, etc. ANTENATAL INFECTIONS. Acute. — Variola, measles, scarlet fever, typhoid fever, ery- sipelas, cholera, malarial fever. Chronic. — Tuberculosis, rare; syphilis. HEMORRHAGIC AFFECTIONS. Umbilical Hemorrhage. — Time of occurrence, cause, treat- ment. Gastro-Intestinal Hemorrhage, Melena. — Cause, treatment. 70 Premature Infants TEMPERATURE. At birth. Rapid decrease on account of large surface. Bearing on feeding and dressing. WEIGHT. Scales, importance of accurate weighing. Average, lessened, increased. Importance of frequent (daily) determination. First loss, rate of gain. PREMATURE INFANTS. Definition. — Uncertainty of fetal age, therefore use weight and length, length less than 48 cm. or weight under 2,500 gm. (5% pounds). Dangers. — 1. Chilling. Rectal temperature 32° C. (90° F.) or below is very dangerous, also great danger when temperature is below 33.5° C. (93° F.). Budin found 28 per cent, of all premature infants with a temperature below 33.5 degrees C. Relation of sur- face of body to weight is relatively much greater in infants than in adults and still greater in premature infants. In adults about 260 2 cm. to 1 kg.; in infants 600 2 cm. to 1 kg. Also less fat on premature infants, hence great and rapid radiation of heat. 2. Starving. Digestive system not well developed, too little food and baby starves, too much food and digestive disturb- ances arise. Amount required from second to tenth day increases from about 100 gm. to 400 gm. Amount after tenth day, about one -sixth the weight of child. Mother's milk very necessary, give with spoon, dropper or by gavage if child cannot nurse. Frequency depends on amount taken each time. Management. — Incubator. — Substitutes. History, Winckel. Tarnier, Auvard. Construction. 72 Bathing Heating: hot water tank. Air supply : from room or from outside. Course and rapidity of current. Index of air circulation. Moisture. Temperature 92 to 80 degrees — temperature of the child and its condition, sweating, etc., determines temperature of incubator. Oxygen: how given, for cyanosis. Feeding: may remove from incubator, care for regurgitation. Bathing: temperature of room 90 to 100 degrees, of bath 98 to 103 degrees according to the temperature of child. Dressing: napkins, gown. Removal from incubator: gradual, depends on weight and condition. Subsequent history: good if cared for. INCUBATOR FOR OTHER DEBILITATED CONDITIONS. Weak, sickly infants at term or later can often be treated with advantage in the incubator. FURTHER MANAGEMENT BATH. Outfit: tub of enamel ware, painted tin, papier inache or rubber cloth, thermometer, wash cloths, soap, oil, towel. Table or bench: stand or sit. Temperature: of room 85 degrees, of water 98 to 100 degrees. Method: wash and dry face, soap body, wash and dry, powder ( ? ) . Time: morning or night. Frequency : once or twice a day. CLEANING. Outfit. — Stand with wash bowl and pitcher, soap, cotton or gauze sponges, towels, napkins, pins, waste bowl or jar, rubber sheet. Table for Baby. — This table may contain the outfit or baby may be laid across the bed with the outfit on a movable stand within reach of the nurse. Baby should never be changed in the lap. Method. — Have good light, flex limbs, wash perfectly clean and dry perfectly, powder not necessary. DRESS. Objects.— Warmth, freedom, objection to pinning- blankets, short sleeves, etc., no difference between night and day. Outfit. — Safety pins: dozen large, medium and small; diapers, 4 dozen; shirts, 4 to 6, silk and wool, or cotton and wool; stockings, 4 to 6 pairs; gowns, 0; slips; jackets. 2; shoulder blankets, 2; bibs, cloaks, hoods, etc. SLEEP. Amount: three-fourths of the time. Bed: basket or crib. Mattress: blankets, sheets, pillows (?), hot water bag. FEEDING. Mother's Milk. — 1. First few days. Colostrum, nature's food. Amount, 30 to 300 c.c. or 1 to 10 ounces per day. Frequency of nursing, every three to six hours if any secretion present. Length of nursing, not more than ten minutes at each breast. 2. After establishment of milk secretion. Amount: one-fifth to one-tenth of baby's weight, 500 to 750 c.c, 16 to 24 ounces per day, found by weighing baby before and after nursing. Frequency of nursing: seven to ten times per day, every two to three hours by day, depends upon amount and quality of milk obtained at each nursing. Importance of regular feeding. Length of nursing: ten to twenty minutes, one or both breasts. Index of feeding, weight of baby. Accessory feeding: water, 1 to 4 drams every one to three hours, salt solution enemas. Wet Nurse. — Much the best substitute for mother's milk, for she fur- nishes food fresh and clean that contains proper ingre- dients and vital ferments. Supply, hospitals, dispensaries. Directory of wet nurses necessary. Examination, for tuberculosis and syphilis, supply of milk and condition of breast, condition of her own child. 6 Feeding Care, diet, exercise, work, bathing, bowels, management. Artificial Feeding. — Temporary, when the establishment of the breast secre- tion is slow or when the breast is tender or infected. Permanent, when secretion fails or condition of mother prevents nursing and no wet nurse can be obtained. Kinds: milk and artificial foods. Milk feeding. Composition of mother's and cow's milk (certified milk). Proteids. Sugar. Fat. Mother's 1 to 2 per cent. 6 per cent. 3 to 4 per cent. Cow's 4 per cent. 4 per cent. 4 per cent. Cream 4 per cent. 4 per cent. 16 per cent. Modification of cow's milk. Any composition may be made with milk, cream, sugar and water. For young infant. One ounce 16 per cent, cream, 4 ounces water, one tea- spoonful sugar. Objections to milk feeding. Lack of milk ferments (Escherich). Contaminated with germs. Essentials of good milk supply. Healthy clean cows, clean milking, clean receptacle , immediate cooling, careful transportation and distri- bution, careful use in house, keep cool. Feed with spoon or bottle. Care of bottle and nipple. Sterilizing and Pasteurizing. Objections: kills living germs but not toxins already formed. Destroys natural milk ferments. Necessity, when clean milk cannot be obtained. CHAPTER V ABNORMAL PREGNANCY DISEASES OF DECIDUA AND FETAL ADXEXA D. 5U-565; E. 177-226; H. 293-332; W. 586-61.',. DISEASES OF DECIDUA. Acute Infection of the Endometrium. — Exanthematous decid- uitis, measles, scarlet fever, etc., hematogenous or ascending, results generally in abortion or premature labor. Hemorrhagic deciduitis, cholera. Purulent deciduitis, gonorrheal, traumatic (attempts at abortion ) . Chronic Infection of the Endometrium. — Tuberculous deciduitis, maternal or fetal origin. Syphilitic deciduitis, maternal or fetal origin, pathological anatomy, effects, treatment. Hyperplasia Endometrii. — Glandular and interstitial endo- metritis, diffuse and localized, polypoid, cystic. Symptoms: abortion, hydrorrhea. Hypoplasia Endometrii. Results: abortion, cervical pregnancy (?). Hydrorrhea Gravidarum. — Decidual, rare, proven to occur, early or late, amount not generally very great ( 100 c.c.) . Amniotic, more common, generally late, amount may be great. Rupture, high and low; result, generally labor. Treatment, absolute rest. DISEASES OF THE CHORION. Hydatid Mole. — Ends of villi changed into vesicles, minute up to 1 to 2 cm. in diameter. Anatomy, proliferation of syncytium, not mucoid degener- ation of stroma, stroma changed and vessels disappear. Symptoms, rapid growth, soft uterus, hemorrhage. Frequency, 1 to 2,400. 80 Placenta Previa Prognosis, danger from hemorrhage, perforation, uterine infection. Treatment, dilate uterus, remove, watch for chorioepithe- lioma. (Nature and cause of chorioepithelioma.) Chorioepithelioma. — History of discovery, Saenger, Marc-hand. Pathological Anatomy. — Chorionic elements, malignant growth, metastases in uterus, vagina, vulva, para- metrium, liver, lungs, etc. Symptoms, hemorrhage, tumor. Diagnosis, microscopic findings, history. Treatment, hysterectomy, excision of tumor. ABNORMALITIES AND DISEASES OF THE PLACENTA. Anomalies of Size. — Variation from the normal ratio of 6 to 1, atrophy, hypertrophy. ANOMALIES OF DEVELOPMENT. Placenta Membranacea. — Covers the entire egg. persistence of villi in the reflexa and no distinct serotina, thin, decidua thin, generally previa, nutrition of ovum impaired, adherent to uterus, manual removal frequently necessary, danger of sepsis. Placenta Succenturiata and Spuria. — Origin from reflexa, vera or from the serotina and separated from the main placenta, frequency 1 to 2 per cent., danger, retention, hemorrhage, infection. Placenta Fenestra. — Cause. Multiple Placentas with Single Egg. — Duplex and bipartite, triplex and tripartite, etc. Placenta Circum valla ta. — Description, origin. Adherent Placenta. — Rare, 1 in about 200, different from retained placenta. Treatment given later. PLACENTA PREVIA. History.— Portal 1685, Barnes 1847, Hofmeier 1888. Definition. — Location in lower uterine segment or danger zone of Barnes (within 76 mm. of internal os). Complete or total and incomplete or partial. Central, marginal, lateral. Hemorhage "unavoidable" present. Frequency. — 1 to 5 per mille, complete central rare, lateral implantation without hemorrhage much more common. 82 Ablatio Placenta Pathogenesis — 1. Low implantation, a. Upper part of uterus not in con- dition for implantation (endometritis). b. Egg reaches fundus too early. 2. Unusual cleavage of decidua vera downwards. 3. Persistence and development of decidua reflexa which unites with decidua vera. Etiology. — Endometritis, multiparity. Pathological Anatomy. — Placenta thin, large, degenerated. Symptoms. — Hemorrhage, antepartum frequently without apparent cause and intrapartum, how produced, sudden, quantity. Postpartum hemorrhage. Diagnosis. — Hemorrhage, interference with presentation, palpation findings, uterine bruit over lower part of the. uterus. Differential diagnosis from abortion, separation of normal placenta, cancer of the cervix, rupture of placental Aes- sels (velamentous insertion of cord). Prognosis. — Maternal mortality, due to hemorrhage and sepsis, for- merly 25 to 40 per cent., now about 5 to 10 per cent., influence of location of placenta and method of treat- ment. Fetal mortality, 33 to 80 per cent., frequently premature, influenced by treatment. Treatment. — Considered under dystocia. INJURIES OF THE PLACENTA. Ablatio Placentae. — Rare, about 400 cases collected by Goodell and Holmes, generally occurs in later months of pregnancy, earlier separation leading to abortion more common. Causes, traumatism, nephritis, decidual or placental disease. Concealed and external hemorrhage. Concealed hemor- rhage: behind middle of placenta, retained by mem- branes, into amniotic sac, retained by head. Treatment, under labor complications. DISEASES OF THE PLACENTA. Acute Placentitis. — In acute infection of the endometrium, gonorrheal, septic, etc. S4 Hydramxiox Placental Tuberculosis. — Rare. Placental Syphilis. — Endarteritis of vessels in villi, small cell infiltration of stroma, villi become thick and degen- erate, placenta enlarged, frequently one- fourth weight of child instead of one-sixth. Placental Infarcts. — (Fibro-fatty degeneration of villi). Size, varying, minute, 1 to 2 cm., whole cotyledon, part of placenta. Frequency, small infarcts constant. Cause, obliterating endarteritis of villi and vessels, degen- eration of epithelium, fibrin formation, when several villi involved all become enclosed in fibrin wall, final degeneration of all structures. Results, when small or few no result, when more numerous growth of fetus may suffer. Treatment, none. Placenta Marginata.— Description. Placental Hematoma. — (Red infarcts). Cause not well known. Results yary with number and size. Calcareous Degeneration. — Not rare, cause not well known, results generally unimportant. Placental Cysts.— Frequency, size, location, origin: softening of infarcts, myxomatous degeneration. Placental Tumors. — Location on fetal surface. Myxoma fibrosum most common. DISEASES OF THE AMNION. Hydramnion. — Definition, 1 liter or more. Frequency, probably 5 per cent. Factors, monstrosities, twins, etc. Causes. — Amniotic, inflammatory condition. Fetal, obstructed circulation in cord or in heart, dimin- ished secretion from fetal kidney or skin. Maternal, disturbed circulation as in heart or kidney dis- ease or abnormal blood as in anemia or syphilis. Symptoms. — Acute form, rapid enlargement with pain from distention and from uterine contractions, pressure disturbances. Chronic form, edema, dyspnea, digestive disturbances, etc., resulting from pressure. Differential diagnosis: tumors, ascites, twins, mole preg- nancy. 86 Diseases of Embryo and Fetus Prognosis, some danger to mother and more to child from dystocia, for example, weak pains, postpartum hemor- rhage and malpresentations, premature labor not uncom- mon. Treatment, prevent too early labor, combat heart or kid- ney disease or syphilis, allay pain, induce labor if necessary, watch labor. Oligohydramnion. — Lessened fetal secretion, rave. Effects, pressure on fetus, causing deformities. Amniotic Bands. — Origin, inflammation of amnion. Results, malformations, amputations, etc. Amniotic Cysts. — Origin. ABNORMALITIES AND DISEASES OF THE CORD. Marginal Insertion. — Battledore placenta. Velamentous Insertion. — Danger of rupture of vessels during labor. Stenosis. — Due to torsion, knots or to syphilitic or other disease of vessels. Abnormal Length. — Too long or too short apt to cause dys- tocia. See Dystocia. Tangling.— Results. Hernia in Cord. — Treatment. ABNORMALITIES AND DISEASES OF THE EMBRYO AND FETUS D. 535-5.',.',; E. 239-257; H. 332-357; W. 614-627. MALFORMATIONS AND MONSTROSITIES. Polysomatus terata. — Double and triple monsters. Originate generally in the germinal period, pathology of the germ, frequently cause dystocia. See page 136. I. Separate twins, omphalopagus or omphalosites. II. United twins— (a) Sy metrically united. 1. Syncephalic or hyposchistos. 2. Dicephalic or ephischistos. 3. Thoracopagus or amphischistos. (&) Asymetrically united, parasites. 1. Cephalo-parasitic. 2. Prosopo-parasitic. 8 Diseases of Embryo and Fetus 3. Trachelo-parasitic. 4. Thoraco-parasitic. 5. Castro-parasitic. 6. Lecano-parasitic. 7. Melomelic. III. Triplets, quadruplets,, etc. (a) Separate. (6) United. Monosomatus terata. — Single monsters. Originate generally in the embryonic period or period of organogenesis, pathology of the embryo. I. Pantosomatus — whole body affected. 1. Microsomia — dwarfism. 2. Macrasomia — giantism. 3. Hemihypertrophy and hemiatrophy. II. Merosomatus — part of body affected. 1. Microsomia and macrosomia of various parts, e. g.. macrodactyly. 2. Anomalies of spinal column and contents. ( a ) Iniencephalus. (6) Rachischisis. Spina bifida-genesis, failure of closure of medullary canal, overdistention, etc. Location, whole canal, holorachischisis, localized or merorachischisis. Varieties: spina bifida without sac or protrusion, (a) without a covering, (b) with a covering, occulta; spina bifida with sac, rachicele, meningo- cele, myelomeningocele, most common, myelocysto- cele or syringomyelocele. (c) Congenital spinal curvature, lordosis, kyphosis, scoliosis. (d) Other anomalies, spondylolysthesis, assimilations. 3. Anomalies of cranium and contents. Anencephalus, most common. Cephalocele, subclassification like spina bifida. Hydrocephalus. 4. Anomalies of face and sense organs. Facial fissures Hare lip, labium leporinum. Cleft palate, palatoschisis. Cyclops and other anomalies of the eyes. 90 Diseases of Embryo and Fetus Anomalies of other sense organs. 5. Anomalies of the neck, fistulas, clefts, cysts, cervical rib. 6. Anomalies of the thorax and contents. Malformation of ribs. Malformation of the breast, polymastia. Congenital diaphragmatic hernia. Sternoschisis or fissure of the sternum. Sternal fissure with ectopia cordis. Malformations of the heart and vessels. Malformations of the lungs. Malformation of the thymus gland. 7. Anomalies of the abdomen and pelvis and contents. Gastroschisis, congenital umbilical hemia. Malformation of bile ducts, icterus. Intestinal diverticula, Meckel's. Intestinal stenosis and atresia, pyloric stenosis, imperforate anus. Patent urachus. Anomalies of bladder, ectopia vesicae. Malformation of the kidneys. Malformation of genitals. Male. Female. Hermaphroditism. 8. Anomalies of limbs. Sympodia. Monopodia. Amelus. Hemimelus. Phocomelus. Absence of fibula. Polydactyly. INFECTIOUS DISEASES. Acute: fetal. Variola, vaccinia, measles, scarlatina, erysipelas, typhoid. cholera, malaria, influenza, fetal sepsis, pneumonia, infections with streptococcus, staphylococcus, pneumo- coccus, bacillus coli, anthrax. Chronic: germinal, embryonic or fetal. Tuberculosis, syphilis. 92 Pregnancy and Gynecological Affections POISONING. Drug, gas, chloroform, ether, coal gas, morphin, alcohol,. phosphorus, lead, mercury, nicotin. Metabolic: eclampsia, uremia. NUTRITIONAL DISEASES. Marasmus from starvation of mother, cancer, tuberculosis and other maternal diseases, also due to disturbed placental function, embryonic or fetal. Diseases of unknown origin. Diabetes, chorea, spastic spinal paralysis, Little's disease; nephritis, dropsy; elephantiasis, ichthyosis; chondrodystrophia fetalis. TRAUMATISMS. Congenital Fractures. — Influence of fetal disease, chondro- dystrophia fetalis. Congenital Luxations. — Hip joint most important, may be due to error in development, importance of diagnosis at birth. PREGNANCY COMPLICATED WITH GYNECOLOGICAL AFFECTIONS D. 398-^16, 51Jf-516, 521—533: E. 257-273; H. 857-399; W. 567-580. VAGINAL AFFECTIONS. Vaginitis. — Non-specific, may be profuse and irritating leucorrhea, cleanliness, antiseptic (carbolic) douches., swabbing, astringent and sedative powders or solutions. Gonorrheal, symptoms, diagnosis, treatment, silver solu- tion. UTERINE AFFECTIONS. Retrodisplacement. — Version and flexion. Origin, generally antegravidal condition which persists; sometimes arises during pregnancy when uterine sup- ports are too lax or weak to maintain the enlarged organ in place. Frequency, not found very often, because there is generally autoreposition. Pregnancy also less common because of pathological condition of uterus. Symptoms, pain, nausea, bladder symptoms, infection, abortion, depending upon size of incarcerated uterus. Treatment, replace, gradual method or with anesthetic. Prolapse. — Origin, generally an antegravidal condition. 94 Pregnancy and Medical Disease Degree and complications, incomplete and complete, ulcer. hypertrophy of cervix, abortion common, danger of infection in labor. Treatment, replace, pessary, keep hips elevated. Antefixation. — Different operations, development of posterior wall, abortion, pain, bladder symptoms, dystocia. Cancer Cervix. — Influence on impregnation; effect on preg- nancy, abortion, infection, etc., effect of pregnancy, rapid growth, hemorrhage, danger of infection in delivery. Treatment. — First half, hysterectomy, abdominal or vag- inal; second half, wait for viability of child, cesarean section or Porro or total hysterectomy or vaginal cesar- ean section. Fibromyomas of Uterus. — Pregnancy more common with subserous varieties, frequently increase in growth, abor- tion common, may obstruct obstetrical canal, danger of hemorrhage in labor. Treatment. — Sometimes myomectomy or hysterectomy during pregnancy, generally labor spontaneous, rarely or never induction of abortion. OVARIAN TUMORS. Complications of pregnancy. Frequency, generally one- sided, twisting of pedicle, intracystic hemorrhage, rapid growth. Complications of labor and puerperium. Obstruct canal, rupture, twisting of pedicle and gangrene. Diagnosis in pregnancy and labor. Prognosis, depends on complication and treatment. Treatment, remove, no puncture or induction of abortion. PREGNANCY COMPLICATED WITH MEDICAL DISEASES D. $76-507; E. 300-327; H. $01-1,31; W. $89—31$. CIRCULATORY SYSTEM. Heart Disease. — Due to pregnancy, endocarditis from infec- tion, myocarditis from toxemia or eclampsia, etc. Pre-existing disease does not prevent pregnancy. Frequency, 1 to 2 per cent. ; all myocardial and endocardial affections considered together. Effect on pregnancy, cause abortion; effects of pregnancy, dyspnea, bronchitis, edema, palpitation, indigestion, circulatory disturbances; effect of labor, sometimes sudden death; effect of puerperium, danger, immediate and later. 96 Pregnancy and Medical Disease Prognosis varies. Complete control of patient necessary during pregnancy. Management. — "No marriage, no pregnancy, no nursing," applies only to grave cases. Prohibition of marriage is absolute. Prohibition of pregnancy brings up the ques- tion of sterilization (necessity for a written contract). Nursing often possible. Question of induction of abor- tion and premature labor. Always consultation and in induction of abortion a written contract. (See page 150.) Prevention of abortion and of the danger of pregnancy: spontaneous abortion occurs in about one-fourth of all pregnancies. Rest, diet, hygiene including exercise, sleep, dress, bathing, avoidance of infection. Induction of premature labor; methods, preparations. Labor, rapid delivery is important; operation, anesthetic, oxygen, third stage. Hemophilia. — Inherited and acquired. Treatment, calcium chlorid. Varices. — Legs, vulva, etc. Danger from rupture. Treat- ment, rest, bandage, collodion dressing. RESPIRATORY SYSTEM. Pulmonary Tuberculosis. — Frequency, few statistics, one in eighty. Effect on pregnancy, sometimes but rarely causes abortion. Effect of pregnancy generally increases disease, but occa- sionally nutrition is improved and the process checked to increase in the puerperium. prognosis bad, tubercular infection of child ( ? ) . Management. — Good feeding, fresh air and avoidance of fatigue, the chief factors in the proper management of all cases of tuberculosis are also of chief importance here. Sanitarium care desirable in the majority of cases. Question of marriage, pregnancy, lactation. DIGESTIVE SYSTEM. Dental Caries. — Fear of dental work common. Teeth should be put in good condition early in pregnancy, temporary work if necessary. Indigestion. — Sour stomach common, soda, diet. Constipation. — Treatment, fruit, enemas, cascara sagrada. calomel. SKIN DISEASES. Pigmentation. — Location especially on face, no treatment. Pruritus and Pruritus Vulvae. — Treatment, diet, salves. 98 Pregnancy and Medical Disease URINARY SYSTEM. Bright's Disease. — Serious, question of marriage, pregnancy and nursing. Frequent abortion. Management. — Control patient, diet, exercise, clothing. Induction of abortion and labor. Pyelonephritis. — Frequency. Cause. — C. B. infection, ascending, by penetration of intes- tine and ureter. Symptoms. — Sometimes absent, fever, chill, cystitis, tend- erness, swelling. Treatment. — Watch, position, drugs, operation (?). NERVOUS SYSTEM. Neuralgia. — Sciatica most common ( cramps ) . Neuritis. — Toxic origin. INFECTIOUS AND CONTAGIOUS DISEASES. Acute General Infections. — Small- pox, measles, scarlet fever. cholera, typhoid fever, influenza, erysipelas. Each may cause abortion, infection of child, septic puer- perium. Management, treat the disease and try to prevent abortion, never induce abortion. Gonorrhea. — Acute and chronic; effect on child; effect on puerperium. Manifestations, discharge, vegetations, granular vaginitis.. cervical gonorrhea, vulvo-vaginal abscess. Treatment, rest, horizontal position desirable, washes, tampon, suppositories, vaccines, removal of abscess. Syphilis. — a. Infection before conception, generally abortion, child diseased. b. Infection at time of conception, sometimes abortion, child diseased. c. Infection after conception, child may escape. d. Paternal infection ( Colles' law ) . Treatment of mother in different cases, nursing child, wet nurse. PREGNANCY COMPLICATED WITH SURGICAL AFFECTIONS B. 507-508; E. 352-353; H. .' f 31-.' f 32 ; TT. 512-518. Traumatisms. — Abortion may result. Surgical Infections. — Abscess, ulcers, etc., cure before labor if possible. 100 Toxemia of Pbegnancy Hernia. — Inguinal and femoral generally cause no trouble. Appendicitis. — Operation, indicated as in the non-pregnant conditions, abscess causes special dangers. DISEASES DUE TO PREGNANCY TOXEMIA. Definition. — Toxemia of pregnancy is a term applied to describe and include a variety of pathological conditions arising during pregnancy, which probably are due to the presence in tlie body of the mother of chorionic elements or of harmful ovular metabolic products. It is generally held to include the eclamptogenic disease and also emesis and peripheral polyneuritis gravidarum as well as other less well defined pathological conditions of toxic origin. Sources of poison — (a) Nonessential 1. Parasitic. Infection from air passages. Infection from intestinal canal; contributory factors, diet, constipation, lack of bile. Infection from mucous membrane of the uterus (endome- tritis ) . Infection from urinary tract; especially old infection. 2. Metabolic: maternal, from metabolism in the body of the mother. (6) Essential or specific. 1. Dislodged syncytial masses and particles of villi. 2. Ovular metabolic products. (c) Contributory factors. 1. Lack of destruction. By blood ferments, liver, thyroids,. etc. 2. Lack of elimination. By kidney, on account of lesions and disturbances to circulation and pressure on ureters. By intestines, on account of lesions in mucous mem- brane, and also fermentation distention. By skin, on account of disturbances of circulation. Effects of Poison. — Increased sensitiveness of nervous system. Disturbed circulation: condition of shock, splanchnic con- gestion. 102 Vomiting of Pregnancy Symptoms of Toxemia. — Malaise, dizziness, headache, nausea, vomiting, edema, increased blood-pressure, lowered vital- ity with diminished appetite and greater liability to infection. EMESIS. D. 3^3-353; E. 880-288; II. J, 02-.) 07 : W. 519-529. Definition. — Distinguish between emesis gravidarum and emesis in gravidis. All degrees from slight "morning sickness" to pernicious vomiting. Description of differ- ent degrees. Frequency. Time of occurrence. Pathological Anatomy. — Sometimes degenerative changes in the liver. These are pathogenic and primary. Secondary changes in the kidney, heart, muscles and eventually in the entire body occur later. Causes. — 1. Basis is increased sensitiveness of nerve centers due to gravidal toxemia or to splanchnic congestion or chronic shock of pregnancy. 2. Associated factors are unstable nervous organization, including hysteria ( Kaltenbach's theory). 3. Peripheral irritation: uterus, prolapse, retroversion or flexion, adhesions, endometritis, tumors, etc.; bowels, constipation; stomach, catarrh, yeast fermentation, displacement, dilatation; dress, corsets. Diagnosis. — Distinguish between emesis gravidarum and emesis in gravidis. Distinguish between cases with serious organic lesions and those with less organic trouble. Treatment. — Prevention: prevent toxemia, correct sources of peripheral irritation. Mild cases: correct toxemia by increasing elimination, improving circulation by use of horizontal position, hot drinks, etc. Hyperemesis, radical treatment early; bed; nursing; injec- tion of salt solution rectal (a) cleansing, (6) nutritive (addition of alcohol) ; injection of salt solution, subcu- taneous; lavage of stomach and stomach feeding; medi- cine, symptomatic; induction of abortion. NEURITIS GRAVIDARUM.— Symptoms, in legs and arms. Cause, toxemia. Frequency, quite common in mild form, generally unrecog- nized. Treatment, eliminant and symptomatic. 104 Eclampsia ECLAMPTOGENIC TOXEMIA GRAVIDARUM. D. 3.53-371; E. 273-299; H. 6> f 6-660 ; TT. 532-567. Definition. — A specific disease of pregnancy, probably due to ovular poisons which produce distinct anatomical lesions and disturbances of function and cause a definite syndrome of symptoms, the most prominent of which is convulsions or eclampsia. Etiology. — Chorionic elements or ovular metabolic products, in excess and not broken down by blood ferments or by the liver, thyroid and other organs with katabolic functions. These substances injure the organs and tissues of the body, especially the eliminating kidney and the brain. Other theories. Halbertsma, Dienst, Zweifel. Stroganov. Contributing Factors. — Primaparity, 75 per cent, of all cases of eclampsia (as about 30 per cent, parae are priniiparae the frequency of eclampsia among primaparae is about 5 per mille or one-two-hundredth, and among multip- arae, 0.7 per mille or one-fourteen-hundredth, i. e., about seven times as frequent in primiparae as in multiparae) . Twin pregnancies, 5 per cent, of all cases of eclampsia. Hydramnios, heredity, epidemic influence. Pathological Anatomy. — Liver, chorionic epiblast emboli, degeneration, necrotic areas, yellow atrophy, hemor- rhages. Kidney, constant lesions, increased weight and size, cloudy swelling, fatty degeneration of epithelium, hemorrhages; necrotic areas. Ureters, sometimes dilated. Brain, edema. Heart, almost constant degeneration of myocardium. Blood vessels, thrombosis, emboli. Placenta, generally retroplacental hemorrhages. Symptoms. — General edema, "occult." Increased blood-pressure. Albuminuria, casts, change in ammonia coefficient. Albuminuric retinitis, disturbance of vision. Xausea and vomiting, precordial disturbances. Xeuralgia, headache, dizziness, restlessness. Stupor, coma. Convulsions, eclampsia proper, description, nature, produc- tion, duration, sequelae, recurrence. 106 Eclampsia Frequency. — Eclamptogenic toxemia about one in twenty or 5 per cent. Eclampsia about one in 500, two per mille, probably about 120 a year in Chicago; therefore the eclamptogenic dis- ease is 25 times more common than eclampsia proper. Frequency of eclampsia in gravidis, intrapartum and in puerperis. Diagnosis. — Distinguish eclamptogenic toxemia from edema of lower extremities due to intra-abdominal pressure, from Bright's disease, from pyelonephritis, from valvular heart, disease with dyspnea and edema, from organic stomach, boAvel and liver disease, from emesis gravi- darum. Distinguish eclamptogenic convulsions from hysteria, epilepsy, apoplexj^, meningitis, uremic convulsions. Distinguish eclamptoge'nic coma from coma from other conditions. Prognosis — Eclamptogenic disease. Danger of convulsions about one in twenty-five. Danger of coma still less. Depends on severity and treatment. Eclamptogenic convulsions, mortality from 10 to 30 per cent. Treatment — Eclamptogenic toxemia: rest, complete or partial depend- ing on the severity of the case. Elimination, intestinal, by laxatives like calomel. salines, oil, etc., and enemata. Kidney by water, not efficient. Skin by sweats, also not efficient. Diet, water alone if condition urgent, milk, whey, etc., fresh fruits, cereals. Eclampsia: During attack protect patient, artificial respi- ration, oxygen, no anesthetic. During intervals, con- trol the attacks with morphin and chloral and eliminate. Venesection. Empty uterus if possible to do so without too much risk. See dystocia. ABORTION D. JtlG-hSl ; E. 326-3J t J,; H. J,32-.',J l H ; W. 627-6.',0. Definitions. — Abortion, miscarriage, premature labor, threat- ened, inevitable, partial, complete, missed, spontaneous, provoked, therapeutic, criminal. 08 Abortion Frequency. — Twenty per cent, to 25 per cent., criminal very common. Pathological Anatomy. — (Condition of egg). First month, generally expelled entire with deeidua vera. Second month, entire with deeidua or only with deeidua reflexa, without reflexa or sometimes sac ruptures and ernbryo and membranes are expelled separately. Third month, sometimes entire. Later generally rupture of sac and expulsion in two stages. Embryo may be alive or dead. Embryo may have been dead some time and then it is small for the period of gestation or it may entirely disappear. Hemorrhages into walls of egg help form blood and flesh moles, also tuberous mole of Breus where the hemor rhage is into chorion, making folds of the amnion project. Causes. — Uterine contractions are always excited (when no contractions and dead fetus we have "missed" abortion). Sensitiveness of the uterus varies in different women. I. Spontaneous and unintentional abortion. a. Factors which directly and chiefly stimulate uterine contractions. Drugs, ergot, quinin, etc. Massage, electricity, vaginal douches. Acute (e. g., infectious) and chronic (e. g., syphilis) dis- eases. They are generally associated with local uterine diseases which are sequela; of general condition. Diseases of the endometrium and rest of the uterus (de- cidual diseases). Displacement of uterus, especially incarceration in retro- displacement. Distention of the uterus as in hydramnion and multiple pregnancy. b. Factors which chiefly tend to cause injury to or more or less separation of the egg. Traumatism, falls, blows, strains, placenta praevia. c. Death of fetus, which then acts as intrauterine stimu- lant. Due to obstruction of circulation in cord, dis- turbed placental function, placental detachment, syphilis of placenta, infection of placenta, infarct. d. Fetal disease, which may be due to infection, acute or chronic (syphilis), or which may be developmental. 110 Criminal Auortiox II. Provoked abortion: Therapeutic or criminal. Oxy- tocic drugs, massage, electricity, vaginal injections, dila- tation of the cervix with sounds, tents, tampons, etc.; intrauterine injections, sounding, rupture of membranes, curettage. Symptoms.— Pain, especially in back, intermitting and constant. Hemorrhage, all grades. Dangers. — Hemorrhage, infection from operation and from discharge. Prophylaxis. — Care in work or exercise, travel, bathing, clothing, diet, sexual intercourse, correct uterine dis- placement, treat for syphilis. Treatment. — 1. Threatened, (a) When no infection, bed, morphin. even when hemorrhage and dilatation of cervix. (b) When infection, empty uterus. 2. Inevitable, question of diagnosis. (a) When no infection, may tampon vagina and cervix to increase dilatation of cervix and for hemorrhage. (b) When infection, empty uterus, generally curette under anesthetic, technic of operation important. CRIMINAL ABORTION. Frequency. — Great increase in all countries in recent times, international movement started in France. Reasons for Repression. — 1. Injury to fetus which, like all human beings has the right to life. Immaturity and dependency does not change this right. Fetus is not a pars viscerum that the mother can treat as she likes. 2. Injury to mother, unjustifiable risk to her health and life. Statistics collected by the French investigators of the international movement show enormous morbidity and mortality. 3. Injury to relatives of fetus and mother, questions of inheritance may be involved, father's moral and legal rights in fetus. 4. Injury to state, interested to prevent depopulation, morbidity of women and moral degeneration. Repressive Measures. — » Voluntary cooperation of citizens, churches, clubs, socie- ties, etc. Medical societies should take active interest. [12 Ectopic Pregnancy Laws, (a) Common law. Fetus not a being before quick- ening, therefore feticide before quickening no crime. Afterward a misdemeanor not punishable with impris- onment. (b) Statute laws. Differ in different states. Generally feticide, i. e., induction of abortion either before or after quickening is a high misdemeanor punishable by impris- onment but not considered murder. Consent of mother makes no difference. Intent is the essence of the crime. It is murder when death of the mother results. Publi- cation of abortionists' advertisements and sale of abortifacient drugs is equally a crime with operative manipulations. Execution of laws. Difficulty in obtaining evidence. Prac- tically no trials or convictions for simply inducing abor- tion and few trials even when murder, i. e., death of the mother, results. Coroner's inquest necessary in all cases.^ Then the case goes to the grand jury. The accused may be brought to the grand jury on sworn complaint if the coroner's jury fails to hold him. Impor- tance of correct reports of the fact of abortion includ- ing a positive diagnosis of pregnancy. Privileged com- munications not granted in Illinois. Dying declaration, the essential characteristics of which are abandonment ' of hope and voluntariness is generally the most impor- tant part of the testimony. In it a definite person should be named. ECTOPIC PREGNANCY D. 381-398; E. SH-850 ; H. Wt-fal; W. 61,0-669. Definitions. — Extrauterine, tubal; interstitial, isthmial, ampullar; ovarian, abdominal (secondary), cornual. multiple and repeated pregnancies. Causes. — Delay of the egg in reaching the uterus from exter- nal migration of egg to opposite tube, disturbance in ciliary current, disturbances in tubal contraction which may be due to adhesions. Obstruction in tubes from tumors, bendings, depressions that may result from inflammatory adhesions, which permit passage of spermatozoa only but not the return of the fertilized ovum. Favorable grounds for nidation. Anatomical Changes. — Nidation, columnar or intercolumnar, decidua vera, serotina and reflexa, intervillous hemor- rhage, placenta. Development of muscular sac. Changes in uterus, growth, decidua. 14 Ectopic Pbegnaxcy Penetration or rupture of tubal wall with hemorrhage (a) into abdominal cavity and formation of hematocele, generally retrouterine, that may be encapsulated by adhesions to surrounding organs and later, if not absorbed, become infected, (b) in broad ligament. Tubal abortion, incomplete and complete with formation of a tubal mole. When continued life of fetus, adhesions to abdominal organs, eventual death of fetus, maceration, absorption, suppuration, lithopedion formation. Symptoms. — Local pain, tumor, uterine hemorrhage, shock. Diagnosis. — Differential. Early ectopic from abortion, extrauterine tumor, sacto- salpinx. Late ectopic, child under abdominal Avail. Treatment. — Before rupture, prevent tubal abortion or rup- ture of tube by quiet until diagnosis is made, then remove by abdominal or vaginal laparotomy. During hemorrhage, immediate operation when possible, otherwise absolute quiet and morphin till patient can be moved. After cessation of hemorrhage and death of embryo or fetus expectant treatment, unless infection or other symptoms; then vaginal drainage. STERILITY Frequency. — One-eighth of all marriages, 40 per cent. male. a. Male, aspermatism, aspermatozoa (stricture, etc.), malformation. b. Female. First — Lack of ovulation; congenital, acquired defect. Second — Lack of fertilization: destruction of spermatozoa, obstruction to passage of sperm, malfor- mation, stricture, discharge. Third — Destruction of fertile ovum: failure of implantation, failure of prepa- ration of uterus. CHAPTER VI— ABNORMAL LABOR ABNORMALITIES IN MECHANISM AND MECHANISM IN ABNORMAL PRESENTATIONS D. 576-626; E. 480-533; H. 259-290; W. 282-300, 821-829. VARIATION IN MECHANISM IN SKULL PRESENTATION. In First Step.— . I. Interference with descent. a. Contracted pelvis. 1. Flat pelvis, deflexion and parietal bone presentation common. 2. Generally contracted pelvis, extreme flexion at inlet. 6. Tumor: ovarian, uterine, etc. c. Enlarged head. d. Bad attitude or presentation. 1. Deflection: brow, face. 2. Inclination: anterior parietal, posterior parietal. e. Lack of dilation of cervix. LL Inefficient forces. In Second Step. — I. Deep arrest. a. Failure to flex. 1. Inefficient force. 2. Shape of head. 3. Lax pelvic floor. 4. Tumor of neck. b. Failure to rotate. 1. Inefficient force. 2. Lack of flexion. II. Posterior rotation. — Occiput posterior. Causes: deflexed attitude, more frequent with small head, also failure of body to rotate. Frequency: 5 to 10 per cent, of o. p. positions, therefore 1 to 3 per cent, all cases. Prognosis: longer labor, greater danger of tear of peri- neum. Mechanism of third step in o. p. position. 1. Bregma presses against the border of the symphysis pubis, occiput rotates over perineum, face passes under pubes. 2. Glabella passes border of symphysis, brow appears., occiput rotates over perineum, face escapes. 118 Mechanism of Abnobmal Labor In Third Step. — a. Contraction of iscliiospinal strait. 6. Obstruction of coccyx ( ankylosis ) . c. Contraction of diameter between ischial tuberosities (funnel pelvis). d. Lack of dilatation of vagina and vulva (cicatricial). In Fourth Step.— Over rotation of head. Interference in delivery of shoulders. Failure to rotate. Failure of anterior shoulder to pass under symphysis. Excessive size of shoulders (in monsters). MECHANISM IN FACE PRESENTATION. Causes of Presentation — Primary: before labor, rare. Secondary: dolicocephalus, obliquity of uterus, contracted inlet, occiput is long arm of lever. Diagnosis. — External examination. Shape of trunk, heart tones heard through chest. Internal examination, after rupture of membranes. First Step- Long duration, molding of head, unusually great distance of advanced part from plane of largest circumference. Second Step.— Similar to skull presentations, chin anterior. Posterior rotation of chin makes labor almost impossible. Third Step.— Chin passes under pubes, occiput rolls over perineum, exit in s. m. o. circumference. MECHANISM IN BROW PRESENTATION. Rare, generally temporary, passing into face or occiput; when persistent, characteristic molding, glabella passes under pubes, occiput escapes, then face. MECHANISM IN BREECH PRESENTATION. First Step. — Bitrochanteric diameter in oblique diameter of pelvis. Frequently slow progress on account of slow dilatation of cervix. Second Step. — Rotation, back lateral, common but not abso- lutely necessary. 120 Dystocia Third Step. — Lateral flexion or inclination of breech on body, anterior hip under pubes, posterior hip over peri- neum, descent and rotation of arms and shoulders, expulsion of chest. Variation: displacement of arms. Fourth Step. — Descent of head, internal rotation of head : expulsion of face, brow, vertex, occiput. Variation: rotation occiput posterior. Dangers during fourth stage: when delay, from compres- sion of cord, partial separation of placenta, etc. MECHANISM IN CROSS PRESENTATION. Spontaneous evolution, spontaneous version, conduplica- tion, all rare. DYSTOCIA Due to abnormalities in: 1, forces; 2, passages; 3, pas- senger; 4. to accidents. Definition. Pathological Forces D. 567-579; E. 545-552; E. 471-476; W. 67 5-6S4. rATHOLOGICAL UTERIXE COXTRACTIOXS. I. EXCESSIVE. General. — Increase in intensity, duration (tetanic), frequency. Occur at beginning of labor or during labor. Irregular. — The most important irregular contractions are those which involve the junction of the contracting and dilating zones or the ring of Bandl and cause the "hour-glass" contraction of the uterus. This spasm or stricture occurs after there has been previous dilatation and the head has passed through the ring. It is diagnosed by the groove in the uterus felt through the abdominal wall, interference with labor and by internal examina- tion. It is best treated by sedatives or when necessary by vaginal cesarean section. Causes. — a. Increased irritability of uterus, b. Premature rupture of membranes, c. Obstructions to expulsion of child, for example, contracted pelves, bad presentation, etc. d. Operative interference, e. Ergot. Results. — a. Increased pain, pain not always index of con- tractions. b. Precipitate labor, distinguished from painless labor. 122 Contracted Pelves c. Rupture of uterus.