-°^""";fsffiip'f^«t?^ I RG533 .N67 18°9o''^^?. I %ry„,, ""*" Syllabus of the obst W, ^ifffffUfffiffioyyffit^^^y^..,,. saafiiZ!^ RECAP mmmmmmm imsf i ^AULB. HOEBhR ' medica'l books 57'69. E. 59th St., >J . Y. SADNDERS' QUESTIOH-GOIPENDS. OPINIONS OF THE PRESS. Extract from London Lancet, July 6tli, 1889. " Useful Adjuncts to Systematic Reading.— It is fortunate for the Student that these books should be undertaken^Dy cou^jjetent hands, by men who, being them- selves engaged in teaching, know where the subjects require most elucidation, and who^-hioreover, are careful to be accurate in their statementss" Extract from Nashville Journal of Medicine and Surgery, December, 1889. MoERis' Materia Medica. — ^A most excellent vade mecum for students; its arrangement in Questions and Answers is a decided advantage." From Collage and Clinical Eecord, September, 1*89. Semple's Pathology and Morbid Anatomy.— "A small work upon Pathology and Morbid Anatomy, that reduces such complex subjects to the ready comprehension of the student and practitioner, is a very acceptable addition to medical literature. All the more modern topics, such as Bacteria and Bacilli, and the most recent views as to Frinary Pathology, find a pla<;e here, and in the hands of a writer and teacher skilled in the art of simplifying abstruse and difficult subjects foi* easy comprehension, are rendered thoroughly intelligible. Few physicians do more than refer to the more elaborate woi-ks for passing information at the time it is absolutely needed, but a book like this of Dr. Semple's can be taken up and perused continuously to the profit and instruction of the reader." Extract from Buffalo Medical and Surgical Journal, January, 1890. Morris' Materia Medica.— -" Presented in a unique and attractive shape, and cannot fail to impress the mind in a lasting manner. It is a fine specimen of book art." Extract from Cleveland Medical Gazette, December, 1889. Hare's Physiology. — "One of the best works on the subject that has come under our notice; of great help to the eai-nest student. Such books are ever valuable,-' Extract from Southern California Practitioner, March, 1889. Ashton's Obstetrics. — " Dr. Ashton's little work is a marvel of condensation and completeness. It will be of unquestionable value to the practitioner in serving to recall some of the multitudinous facts in the obstetrical art, which will frequently escape the most capacious memory." Extract from Southern Clinic, January, 1890. Morris' Materia Medica.— '^ The arrangement and subject-matter of this book leaves -nothing to be asked for, either for the student or medical practitioner. It is a valuable substitute for larger and more expensive works." SADNDERS' QUEST|ON-GOMPENDS. OPINIONS OF THE PRESS. Extracts from Annals of Surgery, June, 1889. '* They may be used to no little advantage by the practitioner, in presenting the- main factrf of his professional work, in a suitable form for ready reference and com- plete classification. The form of Questions and Answers is peculiarly quajified. tu secure definiteness of information. Dr. Nancrede has given us a woi'k far more exten- sive in Its character than anything of the kind. The Medical Student who shall have mastered its contents, will, eertainly have acquired all the essential jwints of Anatomy." "The Essentials of Physiology are most clearly and comprehensively outlined by Dr. Hare." Wolff's Chemistry. — "The questions are distinctly .stated, and the answers^ framed with marked clearness, are fully up to the times." ~ . - : • "Martin's Surgery, comprehensive in scope: it is an unusually satisfactory con- densation," Ashton's Obstetrics. — "The book presents all the essentials of its subjects, and much other valuable matter." Extracts from University Medical Magazine. Martin's Surgery. — "The mo,st pronounced opponent of the system of ' Quizzing' in vogue at the present day, could find no ground for -objections to this excellent little book, which cleverly combines all the merits of condensation, while avoiding the errors of superficiality and inaccuracy with which such Compends commonly iibound. It is a pleasure to be able to recommend the book absolutely and without reservation, as thor- oughly fulfilling the purpose for which it was written, and, so far as Surgery is con- r-"rned, decidedly the best of its kind with which we are acquainted." Nancrede's Anatomy. — "To learn Anatomy is not merely to remember the names of muscles, arteries and nerves, but to study their origin and insertions, their course and relations, and their distribution. Dr. Nancrede has kept this necessity constantly in mind, and the student who masters the details of this little book in connection with conscientious work in the dissecting room, will find it a help for which his tired mem- ory will often sincerely give thanks. The'questions have been wisely selected, the answers are accurate and concisely constructed, but still with, sufiicient detail to free them from the criticism that they are merely lists of names." Extract from New York Medical Record, May, 1889. ^' Saunders' Series of Student's Manuals, arranged in the forni of Questions and Answers, are concise, without the omission of any essential facts. Handsome binding, good paper and clear type increase their attractiveness." Extract from St. Joseph's Medical Herald, March, 1889. "Wolff's Chemistry.— A little book that explains, clearly and simply,, the most difficult points in Medical Chemistry, so that this need no longer be the great bugbear of a medical student's efforts." PRICE: Cloth, SI.OO; Interfeaved, for Taking Notes, $1.25. Saunders' Question-Compends. Arranged in, the form of Questions and Answers, THHE ADVANTAGE OF QUESTIONS AND ANSWERS.-vThe usefulness of arranging the A Butijects in the form of questions and answers, will be apparent, since the student, in reading the standard works, often is at a loss to discoTer the important points to be remembered, and is equally puzzled when he attempts to formulate ideas as to the manner in which the questions could he piii iyi the examination-room.. No. I. — Essentials of Physiology, second Edition. Revised and greatly enlarged. By H. A. Haee. M.D., Demonstrator of Therapeutics and Instructor in Physical Diagnosis in the Medical Department, and Instructor in Physiology in the Biological Department, of the University of Pennsylvania, etc, etc. y No. 2.— Essentials of Surgery, containing also, Surgical Landmarks, Minor and Operative Surgery, and a Complete Description, together with full Illustration of the Hdndkerchief and Rotter Bandage. Second Edition, with ninety Illustrations. By Edwabd Martin, M.D., Instructor in Operative Surgery and Lecturer on Minor Surgery, University^ of Pennsylvania; Surgeon to the Out- Patients' Department of the Children's Hospital, and Surgical Registrar of the Philadelphia Hospital, etc., etc. - No. 3. — Essentials of Anatomy, including Ffscera/ .4raaSp?ef?i.— Normally 3^ of body weight. Much increased in syphilis. (e) Lungs. — One of three conditions found: — 1. Overgrowth of connective tissue, constituting fibroid pneumonia or phthisis (most common). 2. Catan-hal or White Pneumonia. By an overgrowth of epithe- lium in the air vesicles the lung dies, fatty degeneration follows, giving the lungs a dead- white appearance, with imprint of ribs. 3. Gummata — rarest. Effect of SypJuh's upon Life of Foetus.— ''In 83 per cent, of all foetal deaths the parents are syphilitic. In 657 pregnancies in syphiHtic women 35 per cent, ended in abortion, and a large number of the children expelled at terai were stillborn (Charpentier). Of 414 pregnant women, with syphilis, only 63 per cent, anived at term." Diagnosis.— By history of father or mother, and by an examina- tion of skin, long bones, liver, spleen and lungs. Tre/am.ent.—^y\)\\\\\t\Q patients should not be allowed to maiTy without a prolonged course of treatment (for a year), to be followed 40 OBSTETRICAL LECTURES. by a mild treatment of the mother throughout pregnancy, and sexual intercourse interdicted, to avoid abortion during the treatment. The time that must elapse after parents are affected before foetus may be expected to be free from the poison varies. In one case after twelve years the foetus was syphilitic. If the mother is contaminated at the fruitful coitus, or befVjre, treatment should be begun at once. Both mercury and iodide of potash can pass to the foetus and modify its syphilitic disease. Chlorate of potash (10-20 gr., t. d.) may be given in any disease interfering with the development of the placenta, to supply oxygen, as recommended by Penrose, Sir J. Y. Simpson, Barker, Bruce and others. Habitual Death of Foetus. Causes in order of frequency : — 1. Hyiildlu. — Eighty-three per cent, of all foetal deaths. 2. Metrltvi^ endometritis and uterine displacements. 3. Alterations in maiernal hlood., as anaemia or plethora. 4. Chronic diseases of the mother. — Tuberculosis, cancer, malaria, nephritis, diabetes. 5. Causes resident in foetus., as recurring deformities. 6. Chronic poisoning. — Saturnism. Tobacco. (In the Virginia factories such effects not noticed.) 7. Causes referable to fcMher^ as phthisis, albuminuria, chronic poisoning. 8. Ilahit and heredity. Treatment. — Ascertain cause, and treat that. Physiology of Newborn Infant. Respiration. Two factors to explain its establishment : — 1. Elxternal irritation, resulting from change of environment (from liquid, with temperature of 99°, to air, with temperature of 70°), gives rise to reflex action of all muscles. 2. Maternal supply of oxygen being cut off, there is an accumula- tion of CO 2, and the primary action of this is stimulant to respira- tory apparatus. Bate of respiration is 44, sinking, after a few months, to 35. PHYSIOLOGY OF NEWBORN INFANT. 41 Weight. 7. 3 lbs. There is a gradual increase, about one and a half pounds before and one pound after the fourth month, for each month. Month. Weight K)s. Month. Weight 1 7.75 7 16 2 9.5 8 17 3 11 9 18 4 12.5 10 19 5 14 11 20 6 15 12 21 Digestion. Accomplished by digestive juices except pancreatic and saHvary secretion. Partially dependent upon bacteria in stomach and intestines. Size of >SVomac/L— Knowledge of this important to avoid over- feeding. 1st week, 46 cub. cent. 3d month, 140 cub. cent. 2d " 78 " 5th " 260 3d and 4th month, 85 " 9th " 375 Position of Stomach. —Ita axis is almost longitudinal, which ex- plains frequent regurgitation and vomiting. Excretions. (a) ^rme.— Always albuminous for first few weeks. Quantity has never been estimated. Voided 6-20 times in 24 hours. Does not stain diapers, and mistake may thus be made of supposing none to have been voided, (b) Bowels.— Meeoumm for the first 48 hours. Later, it becomes light yellow, is not formed, is sour and acid. The normal frequency of evacuation is four times in 24 hours. Temperature. Peculiarities are irregularity and height, with the variations above 98°. Slight causes will produce great changes. Eyesight. Always hypermetropic. 42 OBSTETRICAL LECTURES. Pulse. 125-160, as shown by heart sounds. Blood. Total bulk to body weight 8 per cent. ; six to seven millions red blood corpuscles to the c. c. , which are more spherical and do not tend to form rouleaux. Shadow corpuscles abundant. White blood corpuscles more numerous than in adult. Liver. Blood supply diminished, capillaries distended, secretion of bile lessened. Lower pressure in hepatic veins. Capsule of Glisson swollen. Heart. Exhibits transition from foetal to infantile circulation by closure of foramen ovale and obliteration of ductus arteriosus. Cord. After 24 hours line of demarcation at its base. Necrosis of am- niotic covering. Mummification of mucous tissue. Destruction of its vessels. Cord drops ofi" about 4th day, followed by retraction of granulating button within the umbilical ring. Medico-Legal Points. Difiicult to determine whether child has lived or whether injuries on its body have been inflicted with murderous intent. Anatomical Points. To be borne in mind when making autopsies to determine cause of death of newborn infant : — The normal size of thymus gland^ the relatively large heart. Lungs should be inflated and overlap heart. Liver ^ jo of body weight. Ductus choledochus, patulous. The sigmoid and appen- dix very large and the bladder relatively large. MANAGEMENT OF NEWBORN INFANT. 4S Abnormalities in the Physiology of Premature Infants. The two main deviations are — (a) Low temperature — variations below 98°. {b) Inability to ingest and digest food. Treatment. — Incubation and gavage. Mortality of this Treatment : — At 6 months 22 per cent, saved. " 7 " 38 " 8 " 89 " 8J " 95 Sclerema. — A disease only found in these premature infants. Occurs most often in lying-in hospitals. The most prominent symptom is a hardening of the skin, beginning in the legs and" spreading, usually sparing breasts and belly. Jaundice or a hemor- rhagic condition usually accompanies it. Temperature is very low, 95°. Its pathology is not well understood. The most probable explanation is that the large excess of palmitic acid in infants solidifies at this low temperature. The condition is a grave one and apt to be fatal. Management of Newborn Infant. Clothing". A baby should be clothed in winter as follows : A binder, of flannel or knit wool, twice around stomach, a knit shirt, diaper, knit shoes, and three skirts, the first flannel, the next linen, and finally its dress. The baby basket should contain at least — 3 day dresses, 3 flannel skirts, 2 vests, 4 pairs of shoes, 1 hair brush, 19 diapers, 3 binders, 4 night dresses. 44 OBSTETRICAL LECTURES. Feeding^. Human Milk. — Secretion established at the end of forty-eight hours. Derives its origin from an overgrowth of epitheUal cells lining the glands, their infiltration with fat and subsequent rupture. Is emulsified by casein. Specific gravity 1024-35. Chemical Constitution (A. V. Meigs). Human. Cows'. Cream. Water 87.163 87.012 79.122 Fat 4.283 4.209 13.362 Casein 1.046 3.252 2.919 Sugar 7.407 5.000 4.140 Ash 101 .527 .457 Fat — Tests — {a) Chemical. — 10 c.c. milk, 20 c.c. water, and 20 c.c. ether; agitate violently for five minutes; add 20 c.c. absolute alcohol, agitate, and allow to stand. Ethereal and alcoholic solu- tion of fat rises. The residue is washed with ether, the solution of fat evaporated on hot-water bath, the whole quantity of fat re- maining. (b) Microscopical. — By counting the number of fat globules, 800,000 to the cubic millimetre normal. Not reliable. Casein. — Nutritive quality depends more on casein than fat. The quantity of casein varies according to different chemists. From recent investigations, it would appear that there are three groups of albuminoid bodies — one coagulable (casein), two others non-cogula- ble. The diff"erence between the casein of human milk and cows' milk is not as yet made out. This difference is thought to explain the difficulties of artificial feeding. Sugar. — Is lactose, and is not so sweetening as cane sugar. Quantity in Twenty -four Hours. — At the end of the seventh day, 14 ounces ; at the end of fourth week, 2 pints. The infant after each meal gains in weight from 3-6 ounces, thus showing the amount of its meal. Factors Influencing Secretion — {a) Quality. — If the diet of the nursing mother contains too little albuminous food, or too little fat, the milk is poor in fat. If it contain too much meat, fat or malt MANAGEMENT OF NEWBORN INFANT. 45 liquor, it will have an excess of fat, which the infant cannot digest. The proper diet does not differ from the ordinary diet. An addi- tional half pint of milk may be advised to be taken at eleven and four o'clock. (b) Quantity. — This may be improved by the addition of milk as advised, and to some a half pint of malt liquor may be given at dinner, watching its effect upon the child. Always see that the nurse does not interfere with the diet. Conditions Interfering with the Mammary Function. — (a) Atro- phy of glandular elements and overgroicth of connective tissue., as from ill-developed physique, pressure of corsets, refusal to nurse, etc. (b) Diseases. — Any acute, infectious disease, as the exanthemata, erysipelas, diphtheria, typhoid. In phthisis the quantity is not often affected, but the quality is impaired. There is apt to be less fat and casein, and the milk may contain the tubercle bacillus. A syphilitic mother should not nurse her child, for fear of infecting it, if it be not already infected, but a syphilitic child may be suckled by its mother without danger of her infection (Colles' Law). (c) Hemorrhage., as when much blood is lost during the puerpe- rium, or hy the early return of menstraation, etc. {d) Emotions. — How these affect the milk is not yet explained, possibly by the production of leucomaines. When the mother is influenced by profound emotions, her milk may become even poison- ous to her child. If mother ainnot nurse child., it should he fed — 1. By wet nurse, and the selection should be governed by the following considerations : — {a) She should have milk of good quality, which is best judged by the appearance of her own child. (b) She should be oi suitable age. (c) Equable disposition and absence of disagreeable qualities. {d) She should not have syphihs. 2. Artificial feeding. Asses' milk is much more like human milk than cows' milk, but as it is not conveniently procurable, the latter is used. Cows' milk differs from human milk mainly in the per cent, of casein and sugar. Used alone, it would produce indigestion, diarrhoea, etc., probably 46 OBSTETRICAL LECTURES. due to the greater proportion of casein, and to reduce this, dilution is resorted to. Meigs Formula for Artificial Food. Milk, one tablespoonfal. Cream, two tablespoonfuls. Lime water, two tablespoonfuls. Sugar water, three tablespoonfuls. (The sugar water is prepared by dissolving 171 drachms of sugar of milk in one pint of water. ) By an analysis of this formula the proportions of water, fat, casein, sugar and ash are practically the same as in human milk. In this formula, however, no account is taken of the non-coagulable albuminoids recently discovered, hence Prof. Hirst recommends that one drachm of Mellins' food be added, which supplies the amount of non-coagulable albuminoids (about IJ per cent.) required. Microorganisms and Ptomaines in Milk. — A large proportion of artificially-fed children die annually, particularly in the hot summer months, from gastro-intestiual disturbances largely due to the con- tamination of milk by various microorganisms and ptomaines. Sterilized. Milk. — To avoid and destroy such poisons the milk should be sterilized. Boiling the milk makes it less digestible and nutri- tious. Sterilizing it avoids this and a suitable apparatus or ' ' steril- izer ' ' accomplishes what is desired, if it be used with attention to all details and greatest possible care. The apparatus devised by Prof Hirst consists of an ordinary egg-holder, containing twelve two- ounce bottles, suspended in a tin bucket. Each morning the bottles are sterilized by baking them until cotton placed in their mouths is browned. The milk and cream is then added, the bottles lightly stoppered with sterilized cotton and steamed for twenty minutes, when they are placed in a refrigerator until used. The lime water and sugar water should be prepared with boiled water and kept air- tight. The nursing bottle (Starr's) and nipple should be scalded after each meal and kept submerged. The infant should be fed every two hours during the day and twice during the night (at 11 and 5). Proprietary Foods : — (a) Milk Foods. — Dried milk, as Nestle' s or Carnrick' s. Condensed milk — a part of the water is driven off by evaporation, Matzoon — PATHOLOGY OF NEWBORN INFANT. 47 is similar to koumiss, i e., impregnated with CO 2. All of these probably have their digestibility and nutritive value partly destroyed. Condensed milk apparently does not disagree, but the fat which it produces in the child is from the excess of sugar and is not healthy nor stable, and in such children rachitis may develop. ih) Liehig Foods — are digesting or semi-digested foods, as Mel- lins', etc. (c) Farinaceous Foods — as Blair's Wheat, Hubbell's Wheat, Imperial Grranum, Hood's Food, Ridge's Food, Robinson's Patent Barley, Bethlehem Oat-meal, etc. These are never to be used before the fourth month, as the pancreatic and mouth secretions of the baby cannot convert starch into sugar before that time. Cleansing. Daily bath in the middle of the day in the warmest part of the room. Temperature of water 90°. Castile soap and soft sponge. Airing. In summer the baby may be taken out after the second month. In winter after the third month, for a few minutes about noon, although each baby is a law unto itself in this respect. Resting Place. Preferably a crib. Pathology of Newborn Infant. INJURIES TO INFANT DURING LABOR. Classified according to seat of injury. 1. Brain. The injury is most frequently the result of faulty use of forceps or extraction of after-coming head. It may be («) an apoplexy, varying in extent from rupture of a small vessel to longitudinal sinus. If lesser in degree, the child may live to adult age, but is apt to have paralyses or mental impairment, {h) The brain substance may be crushexl. (c) Injuries not so grave, but affecting intellectual or X)hysical centr&i. 48 OBSTETRICAL LECTURES. 2. Peripheral Nerves. Facial and brachial plexuses most frequently damaged. The majority of cases of facial hemiplegia due to above use of for- ceps. Recovery usually in the course of a week. The brachial palsies result from unskilled attempts at extracting the shoulders, and are more likely to be permanent. 3. Skull. (a) Spoon-shaped Depressions of Parietal Bone. — A prominent promontory or forceps may cause them. (6) Fracture.s. — Kequire an antiseptic dressing, (c) Distortion. — Very common. Hesult of diiferent presentations and positions. Disappears within the first three days. 4. Scalp. {a) Caput Succedaneum. — A serous infiltration of that portion of the presenting part corresponding to external os. Disappears in three days and requires no treatment. (b) CephaJo-hematomata. — A more dangerous condition, and to be distinguished from the above. Two or three days after birth a swelling develops, rapidly increasing in size, with signs of a cystic tumor, distinctly confined to boundary of one of the cranial bones. It is due to a subpericranial hemorrhage, and is to be- treated by non-interference, except when suppuration occurs. It then should be antiseptically laid open and drained. (c) Contused and lacerated, luounds. {d) Sloughs. — The vitality of the scalp may be destroyed by for- ceps, or prolonged pressure and sloughs appear in a few days. Require ordinary surgical treatment. 5. Face. Caput succedaneum may form. Ui/es may be injured by careless examinations or extraction of after-corn ina: head. b 6. Neck. (a) Thrombus of muscles^ most frequently of sterno-cleido-mastoid, with the development of torticollis. (5) Fracture or decapitation. PATHOLOGY OF NEWBORN INFANT. 49 7. Limbs. Fractures^ which are usually a separation of diaphysis and epiphy- sis, requiring fixation and extension. 8. Trunk. Perforations of the groin may occur, as result of use of blunt hook or forceps applied to breech. ASPHYXIA. Asphyxia of the newborn child results in consequence of an insufficient supply of oxygen. Physiology of the Institution of Respiration. — The sudden change in its environment (liquid 99° to air 70°) produces an exaggerated stimulation of all muscles to reflex action. Placental respiration is abolished, and the accumulated CO 2 primarily stimulates, finally paralyzes the respiratory centre. Causes : — {a) Intrauterine. 1. Foetal inspiration. 2. Any interference with placental respiration paralyzing the brain centres, as premature detachment of placenta ; coiling, com- pression or prolapse of the cord ; diminution of the calibre of the umbilical vessels, as from syphilitic periphlebitis ; excessive and prolonged uterine contraction. 3. Prolonged pressure on foetal brain by pelvis or forceps, para- lyzing brain centres. 4. G-rave systemic diseases of the mother, including hemorrhage, uterine or pulmonary. 5. Immature development of the infant. 6. Anomalies or diseases of the foetus preventing the entrance of air into the respiratory tract, or preventing the proper distribution of blood from right ventricle to lungs, as a patulous foramen ovale or atresia of the pulmonary artery. {h) Extrauterine. 1. Placing the infant after birth in a position unfavorable for respiration. 4 50 OBSTETRICAL LECTURES. 2. Precipitate labor. 3. Interference with the access of air to respii'atory, passages, as by a caul, unruptured membranes, or maternal discharges. Varieties : — (a) Livida. Accumulation of CO2 is excessive, yet circulation and reflexes are preserved. (6) Pallida. Usually an advanced stage of the former, character- ized \}j weakness of the heart and slowing of its pulsations to a marked degree and abolition of reflexes. Treatment. — If possible, should be prevented by removing the cause. 1. Extraction of mucus from throat and fauces by holding the child by the feet and cleaning the mouth with finger, 2. Application of an exaggerated stimulus, as slapping, rubbing, immersing in warm water and pouring ice water on epigastrium ; electricity, if at hand, preferably faradic, the poles being placed on epigastrium and at the root of the neck. In the pallid variety only the most powerful of these are useful. 3. Artificial respiration. (a) Sylvester' s method. (Not recommended.) (6) Marshall Hall's, modified to suit the requirements of the new- bom infant by suspending in a towel, and thus rolling it from side to side. (c) Schultze's. (Probably the best. ) {d) Mouth-to-mouth insufflation. (e) Catheterization of larynx with soft catheter. (/) As a last resort tracheotomy and catheterization through the wound. Only required in most exceptional cases. Risks Attending Artificial Respiration. — Injuries, as apoplexies ; Schultze's method may injure the spine; hemorrhagic effusions in the pleurae and lungs ; rupture of the air vesicles in insufflation ; trachea and larynx may be injured. PATHOLOGY OF NEWBORN INFANT. 51 DISEASES OF THE NEWBORN INFANT. I. Diseases of the Lungs. 1. Atelectasis. 2. Pneumonia. 3. Tuberculosis. 1. Atelectasis. Cause. — Not known. Diagnosis. — Dullness on percussion on one side. Respiration slightly accelerated and imperfect. Absence of fever. These signs present at birth. Pathological Anatomy. — One lung is found shriveled up, is not crepitant and sinks when placed in water. Prognosis. — Not grave. Treatment. — Grentle inflation of lung with catheter. 2. Pneimionia. — {a) Syphilitic, {b) Inspiration. (a) Syphilitic. — The diagnosis can be made by a histoiy of syphilis in the parents, by the signs of foetal syphilis together with the cyanosis and physical signs of pneumonia. Treatment is of no avail, the child usually dying within 24 hours. Pathological Anatomy. — An enormous overgrowth of connective tissue is found, compressing the blood vessels and diminishing the capacity of the air vesicles. As some air has entered the lung, a cut-off portion never sinks, but does not float buoyantly. (Jj) Inspiixition Pneumonia. — May be due to inspiration of mater- nal discharges, food, or septic matter. Maternal Discharges. — Pneumonia arising from this cause devel- ops twenty-four hours after birth, in a child apparently healthy, the temperature at this time beginning to rise and respirations growing more rapid. The child is restless, refuses nipple, is cyanotic, at times gasps for breath, and there is dullness over one or both lungs. Prognosis. — Grave. Treatment. — J to 1 gr. carbonate of ammonium every four hours. Cotton jacket. Turpentine stupes twice a day. Mother's milk, from medicine dropper, eveiy hour, and with this a few drops of brandy every three or four hours. Pathological Anatomy. — Shows the features of catarrhal pneu- monia. A cut-off portion always sinks (thus distinguished from syphilitic). The cause of pneumonia resulting from inspiration of food not yet made out. It may occur any time after birth. 52 OBSTETRICAL LECTURES. Septic variety is rare since introduction of antisepsis. 3. Tuherculosis. — Rare. Caused by mouth-to-mouth respiration by a tuberculous person. Differential Diagnosis. Atelectasis. Inspii^ation Pneumonia. One lung affected. Usually both. Exists at birth. After twenty-four hours. Temperature not elevated. Always elevated. II. Syphilis in Newborn Infant. Symptoms. — ^The child is often ill-developed and ill-nurtured, but the characteristic signs do not usually develop before four to six weeks. In order of frequency these signs are — Coryza syphilitica. Maculo-papular syphilide. Roseola. Cutaneous papules and mucous tubercles. Rhagades oris et ani. Pemphigus. Cutaneous ulcers. Paronychias. Pseudo-paralyses of extremities. Hemorrhagic diathesis. Bone diseases. Fever. Disease of testicles. Treatment. — Best results from internal use of calomel with chalk or soda, ^^ grain given twice a day, gradually increasing the dose. Should vomiting or diarrhoea occur, resort to inunction, rubbing a piece of mercurial ointment as large as end of finger on binder every other day. Always carefully watch for poisoning. This treatment should be kept up for months, replacing it from time to time by tonics or drop doses of the syrup ferri iodidi. Prognosis, — If the child is well nourished by its mother or wet nurse the prognosis is very good, so long as some important internal organ is not seriously affected. In artificially fed children it is very bad. PATHOLOGY OF NEWBORN INFANT. 53 III. Mastitis. Four days after birtli the breasts in both sexes contain colostrum, which has disappeared by the twentieth day. During this period there may occur in the breast of the child pathological processes like those in the breast of the puerpera. They can enlarge, become painful, the skin angry red, secretion much increased, and even mam- mary abscess develop. Treatment— A.YO\di squeezing. Apply cooling lotions, as lead- water and laudanum, and oil the skin to reheve tension. If suppu- ration supervene, poultice and open early. IV. Specific or Essential Fevers. {a) Exanthemata. {h) Eiysipelas (c) Malaria. {d) Septicaemia. V. Treatment of Certain Congenital Deformities. Hare-lip. -The deformity prevents suckling, hence immediate plastic operation in the first few hours of life. ^ Cleft-palate.— Too serious an operation to be undertaken at this time. Tongue-tie.— '^ni]) superficially with scissors and tear with fingers. Umbilical Herma.—li the exomphalic condition be even the size of an apple an immediate plastic operation is indicated. Spina Bifida. — Non-interference, or consult with a surgeon. VI. Nasal Catarrh. Causes.— W\(in not syphilitic, usually faulty clothing, ventilation or temperature of the room. VII. Diseases of the Mouth. (a) Aphthm.—RoumlQ^^ pearl-colored vesicles seen in mouth and on lips. Washing the mouth daily with a clean linen will prevent them. Boric acid, gr. v-x to the ounce, is curative. {h) Thrush.— Coaleacence of white spots, with an areola of red- dened mucous membrane. Is often seen in hospital practice. Now 54 OBSTETRICAL LECTURES. thought to be due to the presence of a parasite, the saccharomyces- albicans. Treatment. — ^Boric acid, gr. xvj to xx to ^j of honey. 5ss of this three or four times a day. The associated symptoms of malnutrition, diarrhoea and vomiting indicate attention to hygienic surroundings and the general health of the child. VIII. Skin Diseases. {a) Gum., due to irritation of atmosphere and clothing. Is a papular eruption resembling acne, but never becoming pustular. Treatment. — Cleanliness,, cosmoline, and proper clothing. (6) Simple Acute Pemphigus. — Rare . From the second day to the fourth, fifth or sixth week, vesicles the size of a pea to a quarter- or half-dollar appear indifferently over the whole body except soles and palms, and last for twelve to fourteen days, without manifesta- tion of constitutional disturbance. Is contagious ; may be carried by nurse, and may be communicated to mother or nurse. It disappears without treatment. (c) Syphilitic Pemphigus. — Usually occurs in utero., and the child is born with vesicles, the soles and palms most often affected. The disease is associated with marked evidences of malnutrition and con- stitutional disturbance, and yields only to specific treatment. IX. Ophthalmia Neonatorum. Symptom^s. — Usually after twenty-four to forty-eight hours the eyes are oedematous and puffed out, and there appears a. sero-purulent discharge, which is soon greenish pus. If the lids can be separated the conjunctivae are red and velvet-like in appearance, and later the cornea may lose its epithelium, ulcerate, and be perforated. Treatment. — {a) Prophylactic. Crede method. As soon as head is born warm water is dropped in the eyes. When the delivery is completed the eyes are again cleansed with warm water, followed by one or two drops of a ten-grain solution of nitrate of silver. A vaginal douche of bichloride is not always effective, because the cervix is not reached. There is danger of poisoning or sending air into the uterine veins if the cervix be injected. (6) Curative. The eyes are cleansed every hour, alternating with a concentrated solution of boracic acid and bichloride of mercury, PATHOLOGY OF NEWBORN INFANT. 55 1 to 5000 or 8000. Morning and evening, nitrate of silver, 20, 40 or 60 grains to tlie ounce, is dropped in the eye. If only one eye be affected, bandage the other carefully with a pledget of lint to pro- tect it. X. Hemophilia. A disposition to bleed, which is inherited. The maimer of trans- mission is peculiar ; always through mother to male children, who do not transmit it. The female children show no evidences of it, but do transmit it. The cause is not known, and it manifests itself all through life. Treatment is of no avail. XI. Icterus. Two classes of cases : — {a) Jaundice very light in degree. Face and breast only affected. Very common. Cause. — Hepatogenic. Disappears third or fourth day after birth, and requires no treatment. (b) Whole body is jaundiced. Urine and feces discolored and may contain blood. Is rare. Cause. — Hepatogenic. Is also seen in Buhl's and Winckel's dis- eases and in septic infection. Treatment of malignant variety. If from Buhl's or Winckel's diseases or from septic infection, as is commonly the case, is usually fatal. XII. Cyanosis. Causes., in order of frequency : Pneumonia (usually syphilitic), premature birth, malformation of heart and blood vessels, inter- ference with nerves of respiration, malformations of respiratory tract, congenital pleurisy, partial occlusion of trachea. XIII. Diseases of Umbilicus. {a) Septijc Infection. — The ulcer is covered with a grayish diph- theritic membrane, has a reddened areola, and may lead to general infection. Treatment. — Prophylactic. The ulcer should be exposed at the daily bath, cleaned with soap and water and dressed with sali- 56 OBSTETRICAL LECTURES. cylic acid, 1 part ; starch, 5 parts. Tape, soaked in an ethereal solu- tion of iodoform or antiseptic Chinese silk, should be used to ligate the cord at birth. Curative. The ulcer to be touched with solution of bichloride (1 to 500), and dressed as above. (Jb) Umbilical Fungus. — An overgrowth of granulations. Cauter- ize with nitrate of silver. In about one-fifth of these cases nitrate of silver fails, the tumor is more solid, and is the remains of the omphalic duct called an enteroteratoma. It should be ligated and cut ofi". (c) Omphalitis. — A peculiar inflammation of the umbilicus, in which the abdomen is conical, skin and subcutaneous connecti-^ tissue hard, red and infiltrated. It is always septic in origin, requires disinfection, poultices and early incisions, with stimulants and nour- ishment. Prognosis is serious. {d) Disease of Vessels. — Always due to septic infection, and invari- ably ends in general septicaemia, which is fatal. (e) Hemorrhage. — (1) From the vessels. It may be primary, from careless ligation, or secondary (the vessels of the cord close from placental end, and the hypogastric arteries may be patulous after the cord drops ofi", when increased blood pressure or handling the ulcer may bring on hemorrhage). Treatment. — If bleeding vessel seen, ligate. Usually requires Monsel solution and pressure. As last resort, liquid plaster-of-Paris, or better, transfix with hare-lip pins and apply figure-of-eight liga- ture. (2) Oozing from ulcer after the cord drops ofi". Rare. Styptics or cautery will not control it. Requires transfixion and figure-of-eight ligature. XIV. Tetanus. Is infectious. Occurs almost exclusively in hospitals, and is usually fatal. XV. Melsena. An extravasation of blood into stomach and intestines. Duodenal ulcer, some congenital defect increasing intra-abdominal blood pres- sure, or hemophilia may be the cause. XVI. Perforation of Intestines and Intussusception. PATHOLOGY OF THE PUERPERAL STATE. 57 XVII. Buhl's Disease. Acute fatty degeneration of all organs. Symptoms. — Icterus, cyanosis, diarrhoea, vomiting, etc., are pres- ent, but nothing sufficiently characteristic to make a diagnosis before XVIII. Winckel's Disease. Acute baemoglobinuria with jaundice, cyanosis and fatty de- generation of all organs. XIX. Sudden Death of Apparently Well Children. Causes. — {a) Overlying by mothers, accidentally or intentionally. (b) Diseases : most commonly pneumonias, apoplexies, more rarely perforation or intussusception, or other diseases, as above. (c) Occlusion of trachea by enlarged thymus. Medication The following are some of the drugs and their doses required in the first four weeks of life. Opium, as paregoric 2-5 gtt., lauda- num i-2^ gtt., mercury, as calomel ya-s gr-, castor oil 15 gtt. to 3j, nitrate of silver 4V grain, etc. Pathology of the Puerperal State. I. Abnormalities of Involution. These may be anomalies by {A) excess, superinvolution, (B) by defect, suhinvolution. Involution. — The old theory was that by fatty degeneration and absorption the uterus was regenerated from the embryonal muscle cells in the outer layer. This has been disproved. The degeneration is chiefly fatty, but there are other degenerative processes at the same time. Regeneration is not absolute, i. e., the whole muscle cell is not destroyed, but loses its redundant tissue. The process is rather an atrophy, and stops after the musole fibre reaches its original size. This same process affects the mucous membrane, peritoneum, uterine adnexa, vagina and vulvae. Below the contraction ring it is an intermediate process, mainly retraction of overstretched tissue. {A) Superinvolution. — An exaggeration or abnormal prolongation 58 OBSTETRICAL LECTURES. of that process by which the parturient uterus regains its normal conditions. Is rare. Its diagnosis and treatment belong to Gynae- cology. (B) Subinvolution. — A retarded or arrested involution. Causes. — (a) Anything increasing bJood supply, as hypertrophy of mucous membrane during pregnancy, fibroids, inflammatory con- ditions resulting from sepsis, mechanical interference with pelvic circulation, leading to its engorgement, as heart disease. (h) Anything interfering with contraction of uterine muscle, as retained placenta, polypoid tumors, large masses of decidual tissue, uterine displacements, distended bladder or rectum, dragging adhe- sions. Diagnosis. — ^By abnormalities in the daily diminution in size of the utenis. 1st day, normally, the fundus one finger above umbilicus. 2d day, the fundus level with navel. 3d and 4th day, the fundus a trifle below navel. 5th and 6th daj^, the fundus two fingers below navel. 7th, 8th and 9th day, the fundus three to four fingers above sym- physis. 10th, ]lth and 12th day, the fundus a little above, at, or below symphysis. Involution is not complete for six weeks, and to determine the size of the uterus subsequent to its retraction below; the symphysis (12th day), the following intrauterine measurements have been made : — 10th day lOj cm. 5th week 7 J cm. 15th " 9.9" 6th " TtV" 3d week 8.8" 8th " Gj-V " 4th " 8 " 10th and 12th week 6j " 7 cm. is the normal measurement of the non-pregnant uterus, and this table shows, therefore, a physiological super-involution which is overcome by subsequent engorgement of uterine vessels. Treatment — Varies with the cause. If due to hypertrophied deciduge, polypoids, retention of placenta or placentae succenturiatae — curette. Never allow bladder to be distended, nor constipation to exist. Correct displacements, combat septic inflammation, treat any PATHOLOGY OF THE PUERPERAL STATE. 59 heart disease, and if fibroids be the cause, give a pill of ergot, strychnise and quinia, and administer faradism daily. The routine administration of ergot not recommended. It does not secure contrac- tion, and often has ill effect upon the child through the mother's milk. IT. Puerperal Anemia. A subinvolution of the blood. The physiological hydraemia of pregnancy fails to disappear. Causes. — Any wasting or depressing disease, loss of blood from post-partum or other hemorrhages, cancer, puerperal chorea, or in- sanity. Prognosis. — Yields usually to timely treatment. May progress to pernicious anemia if neglected. Treatment. — Iron (Blaud's pill). Arsenic seems to be needed in some cases. III. Repair of Injuries after Labor. Slight lacerations and tears heal rapidly. Even extensive inju- ries, as fistulas, sometimes heal spontaneously. Small sloughs should be touched with nitric acid. Lacerations of the cervix, if productive of serious hemorrhage, should be closed by suture. Always stitch a laceration of the perineum when beyond a half-inch in length, being careful to apply sutures, so that fistulse may not result. When the perineum has been torn, a douche is given after delivery of the placenta, and absorbent cotton soaked in 10 per cent, solution of cocaine is placed in the vagina, while the doctor prepares his instruments to repair the injury. If the sphincter has been torn, the two edges are united by interrupted catgut sutures. Any tear in the vagina should be repaired by continuous catgut suture. The perineal tear is united by silkworm-gut sutures clamped with shot. Any of these injuries will produce an immediate elevation of tem- perature after labor above the normal rise. IV. Puerperal Hemorrhages. Hemorrhages occurring during the pjierperium, from 24 hours after labor until the completion of involution (6 weeks). Hemor- rhage is called post-partum when it occurs within the first 24 hours after labor. 60 OBSTETRICAL LECTURES. Causes, in Order of Frequency : — {a) Retained Secundines. (h) Displaced Uterus. (c) Displaced Thrombi. {d) Emotion, (e) Relaxation of Uterus. (/) Retained Clots. ig) Fibroids. {h) Hsematomata. [i) Pelvic Engorgement. ij) Secondary Bleeding. {k) Carcinomata, Retained Secundines. — Always examine placenta to see if a part lias been retained, and remove antiseptically with the finger any fragments left in the uterus. If more than one-third of the mem- branes are retained they should be similarly removed. Displaced Uterus. — When lateral, anterior or posterior, hemorrhage is due to the congestion or retention of blood from mechanical ob- struction. In the latter clots will be discharged. This congestion, with loss of tonicity, often develops subinvolution. Backward dis- placement is frequently caused by a (1) sudden effort, especially if patient is out of bed too early (2) misplaced compress, (3) over-dis- tended bladder. Inversion and prolapse considered later. In all cases the bladder should be emptied and uterus replaced. Displaced Thromhi. — Perfect quiet should be secured to prevent dislodgement of the thrombi . formed in the uterine sinuses. The most dangerous is when they are disintegrated by microbes with the development of septicaemia. Treatment. — As hemorrhage from this cause is usually sudden, and alarming, at once apply an intra-uterine tampon of iodoform gauze. Emotion. — How it produces hemorrhage is not known. Probably by interference with blood pressure or causing relaxation of the uterus. Relaxation of Uterus. — Karely occurs. Almost never after the third day and even before this time, only in women of poor physique. Treatment. — Same as for post-partum hemorrhage. PATHOLOGY OF THE PUERPERAL STATE. 61 Retained Clots. — Rarely a primaiy cause, but (jften secondary to retained placenta, flexions, etc. Fihy^oids. — Always cause excessive lochia and usually produce liemorrhage. Treatment. — A pill of strychnia, ergot and quinine. If severe, an intrauterine tampon. Hcematomata. — Is an interstitial bleeding, submucous or subcu- taneous. The resulting tumor, which is usually globular in shape, may be situated on one or both labise, in the cervix or broad liga- ment, etc. The very small ones are more frequent. Causes. — (a) Predisposing. — Pelvic engorgement and straining during labor. Marked anteversion. [h) Exciting. — Rupture of a blood vessel, usually a vein of large size, from straining, a blow or forceps. Symptoms. — The rupture occurs during the second stage of labor, accompanied by sharp, lancinating pain and painful expulsive efforts, the tumor usually appearing after labor is completed. Pcognosh. — Death may occur from hemorrhage or sepsis, but ought to be exceptional. Treatment. — Secure absorption if not larger than one's fist, by cleanliness, rest, cooling applications and antiseptic douches. If larger, wait until it ceases to increase in size (except when it appears between the birth of twins or prevents escape of lochia), when it should be incised and turned out. Coptrol hemorrhage when sac ruptures by ligation or iodoform gauze compress. To control the bleeding into the sac when the tumor first appears, resort to cold and pressure with the largest size Barnes' bag. The danger of sepsis contraindicates an ordinary tampon. Pelvic Engorgement. — May arise from too early sexual intercourse, increased intra-abdominal pressure from liver or heart disease, sub- involution, etc., thus proloHging the bloody lochia. Secondary Bleeding. — From laceration of vessels along the par- turient tract, especially about the meatus, the hemorrhage recurring after the pressure of the child's head is removed. CardnowMta. — Of the cervix. Rarely may develop suddenly at the placental site and end fatally in a few weeks or months. 62 OBSTETRICAL LECTURES. V. Anomalies of the Breasts. Galactorrhoea. — Rarely is the milk supply excessive for the requirements of the child. Cause. — None satisfactory. Plethora, anemia, phthisis have been reported as causes. Treatment. — Unsatisfactory. The best, perhaps, is pressure, ergot and potassium iodide. Electricity and local astringents have been recommended. Anatomical Defects. — 1 . Congenital absence of or supernumerary glands. 2. Inversion of Nipple. — Rather common in modern girls, from pressure of corsets. Should always be looked for. Treatment. — Evert with breast pump, only in last month of preg- nancy to avoid miscarriage from refiex contraction of uterus. If the pump fails resort to a shield, and finally artificial feeding. 3. Fissured Nipple. — Causes. — Maceration and irritation of nipple. Mammary abscess frequently results from it. Treatment. — {a) Propliylactie. — During the latter months of preg- nancy the nipple should be washed and greased with sweet oil twice a day, and receive a daily bath with a saturated solution of alum. Avoid alcoholic astringents, and keep the nipple clean during lacta- tion. (Jb) Curative. — Apply tinct. benzoin comp. Inflammations of the Breasts. — {a) Of the subcutaneous connective tissue. (6) Of the deeper interstitial tissue. (c) Parenchymatous. Causes. — Of the first two classes a large proportion are due to sepsis. Parenchymatous inflammation need not be from this cause. Over activity of the gland with retained secretion (the so-called ' ' caked breast ' ' ) may be the cause. Treatment. — If parenchymatous and. due to over secretion empty with pump or by massage. If of the connective tissue and abscess is threatened, apply leadwater and laudanum and a mammary binder. Suckling had best be intermitted, as the secretion is apt to disagree with the child, and rarely has given rise to septic infection of the intestines. PATHOLOGY OF THE PUERPERAL STATE. 63 Abscess. — The pus may be located : — (a) Superficially. (h) In the gland substance. (c) Post-mammary. Symptoms of Suppuration. — Uncertain. The reddened skin, fever, bogginess, etc. , may be due to other causes, and fluctuation rarely detected until late. Treatment. — Be prompt ; err on safe side by making an early incision, radiating, through skin, and then locate abscess with di- rector. Wash several times a day with antiseptic solution, and apply pressure, to prevent further burrowing. If fistulae result, resort to firm pressure, drainage and antisepsis. When the abscess is post-mammary the whole breast is lifted off the chest and there are no signs on the surface. Treatment. — Incise beyond the periphery of the gland at the more dependent part, pass a drainage tube through a counter-opening, and dress antiseptically. Galactocele — A milk tumor due to occlusion of one of the lactifer- ous ducts. Usually of no pathological importance. VI. Diseases of the Urinary Apparatus. Cystitis. Pyelitis. — The use of dirty catheters a frequent cause. VII. Diseases of the Nervous System. Insanity may occur during pregnancy, labor or lactation. During pregnancy it is apt to be melancholia ; after labor, mania. Prognosis. — Tolerably good. Two-thirds to three-fourths recover. Death may occur from maniacal exhaustion or septic infection. Treatment. — Isolation. Rest cure. VIII. Puerperal Fever. Puerperal fever is an elevation of temperature during the puer- perium. Classification : — I. Infectious. II. Non-infectious. The infectious may be further classified as follows : — A. Those in which the infecting poison enters through wounds in the genital canal or immediate neighborhood. 64 OBSTETRICAL LECTURES. (a) The pathogenic agent a microbe. (b) The pathogenic agent a ptomaine. B. Those in toMch the poison enters other channels. Septicemia, a name commonly given to the disease resulting from the invasion of the body by microbes and their products, may be due to a very great variety and number of microorganisms. In the appended chart will be found a list of those discovered up to this time: — Streptococcus pyogenis. Streptococcus erysipelatis. Bacillus oedematis maligni. Staphylococcus pyogenis aureus. Micrococcus of osteomyelitis, Staphylococcus pyogenis albus. Micrococcus pyogenis tenuis. Staphylococcus pyogenis citreus. Staphylococcus cereus albus. Staphylococcus cereus flavus. Bacillus saprogenis, 1. Bacillus saprogenis, 2. Bacillus saprogenis, 3. Bacillus pyogenis fetidus. Staphylococcus salivarius septicus. Coccus salivarius septicus. Bacillus salivarius septicus. Bacillus of chicken cholera. Bacillus of rabbit septicaemia. Bacillus of pseudo-oedema. Bacillus of mouse septicaemia. Mouse-septicaemia-like bacillus. Diplococcus pneumoniae. Bacillus resembling pneumonia bacillus. Diplococcus intra-cellulosis meningitidis. Bacillus septicus agrigenus. Streptococcus pyogenis malignus. Streptococcus septicus. Streptococcus septo-pysemicus. PATHOLOGY OF THE PUERPERAL STATE. 65 Streptococcus articulorum. Bacillus necrophonis. Brieger's bacillus. Emerick's bacillus. Bacterium coli commune. Bacillus of* intestinal diplitlieria. Micrococcus botryogenus. Micrococcus of progressive lympbomata. Bacillus of rhinoscleroma. Tetanus bacillus. Bacillus of acne contagiosa (Harold Ernst). 1. Infectious Fevers. A. The more common variety of infectious puerperal fever is that due to the absorption of ptomaines through wounds in the genital canal. The microbes, which duiing decomposition generate the absorbed ptomaines, may gain access from doctor, nurse, instruments or atmosphere charged with putrescible material, and attack clois, portions of hyjoertrophied mucous membrane, etc. Diagnosis. — The symptoms of septic poisoning are — (a) Local. — 1 . Putrid discharge. 2. (Edema of vulvae. 3. Diphtheritic patches. (Jj) General. — 1. Fever, usually preceded by a chill, although a fatal case may occur without fever. 2. Peritonitis — develops with spread of poison, although it may be entirely absent. 3. Other organs infected by the microbes, as kidneys, lungs, spleen, brain, with development of corresponding symptoms. The result of treatment can alone determine whether in any case the symptoms be due to the absorption of microbes or ptomaines — i. e. , it is impossible to diagnosticate the absorption of ptomaines, as such, from the symptoms alone. Elevation of temperature during the puerperium may arise from many causes, but should be treated as septic until proven to be otherwise. In this climate it is most com- monly mistaken for malaria. Treatment. — The indications are (1) to stop the manufacture of these poisonous bodies, which is best accomplished by destroying the 66 OBSTETRICAL LECTURES. microbes and removing their habitat, and (2) sustain strength to aid the struggle between the body cells and microbes. The first is accomplished by douches, vaginal and intra-uterine, the use of the curette, intra-uterine ujipers, forceps. In skillfal hands the curette is best. Hirst' s sharp curette requires some care and skill. Munde' s wire curette is less dangerous, but less effective. Doleris' ecou- villon may be used in an emergency. The Operation. — 1. The hands and arms washed with bichloride solution, 1 to 1000. 2. Yaginal Douche. — 2 per cent, solution of creolin (five drachms to a quart of water). 3. Curette passed to fundus, and whole cavity of uterus gently scraped, using only the force of the thumb and first finger. Remove debris with forceps. 4. Intrauterine Douche. — Fountain syringe, a two-way catheter (Lentz or Bozeman), a quart of 2 per cent, solution creolin, or bi- chloride solution 1 to 4000. If the latter be used, the uterus should always be immediately washed out with sterilized water. Douches to be given once in twenty-four hours. A heavy dose of quinia should be given for the fever and to eliminate any malarial origin of the elevated temperature. When the sj^mptoms are due to the absorption of ptomaines, this treatment will be followed by their speedy disappearance. If they continue, the second indication — in which the treatment is only palliative and symptomatic — is met by a fuU diet of milk, two or more quarts in twenty-four hours, if assim- ilated ; partially digested, if necessaiy, and large quantities oi stimu- lants, one pint or more in twenty-four hours, of whisky, wine or brandy. 'EoYt\iQ peritonitis apply light poultices twice a day, with a stupe while the former are being changed. Sufficient opium to relieve pain is demanded. Bleeding and salines are too debilitating and should be avoided in septic peritonitis. Treat other complications on general principles. Prognosis. — Large majority recover with appropriate treatment. As a rule, if temperature be high, internal organs involved, if there are repeated chills, the pulse weak and fluttering, the prognosis is more grave, but death may occur without these being present. PATHOLOGY OF THE PUERPERAL STATE. 67 Phlegmasia Alba Dolens^ or Milk Leg. — There are two classes of cases : — 1. Thrombosis of veins of thigh. 2. Connective tissue of thigh affected. Symptoms. — From the tenth to thirtieth day there develops a heaviness and stiffness in the leg, soon followed by swelling, occurring in different localities, at the ankle, gradually ascending to the groin (if due to thrombosis of the veins), or at Poupart's ligament extend- ing down the thigh (if due to involvement of the connective tissue). Fever is evanescent, and usually disappears before swelling subsides. Cause. — Septic infection. Prognosis. — Grrave, death resulting from general septic infection, or embolism. Ti^eatment. — The condition is asthenic in tendency, hence treat- ment should be supporting and stimulating. Enjoin absolute quiet and rest in bed to avoid embolism. Elevate the limb, wrapped in cotton, and when convalescent resort to cautious massage. Preventive Treatment of Puerperal Fever. — Secure absolute clean- liness of doctor, nurse, patient, instruments, atmosphere, etc. Hands. — Washed with soap and water followed by immersion in alcohol and solution of bichloride 1 to 1 000. Instrmnents. — 2 per cent, solution creolin. In hospital work the bedding should be washed in bichloride solution, and the patient given a bath just before labor. Atmosphere. — Selection of well ventilated room is important. Use occlusive dressing of corrosive cotton and gauze, which should be changed frequently. External Genitals. — Cleaned when each, pad is applied, never using a sponge, but preferably baked cotton, or corrosive jute. {B) Puerperal fever in which the poison enters other channels a. e. , not through wounds of genital canal, etc. ). Includes any of the infectious diseases, as the exanthemata, etc. When these dis- eases occur during the puerperium, their course is often modified. Incubation is usually shortened and convalescence prolonged. Their diagnosis is always obscure, as it is apt to be confounded with sepsis ; the germs of any of them, when introduced through wounds in the genital canal, producing about the same symptoms. Their jDrognosis is more unfavorable. 68 OBSTETRICAL LECTURES. II. Non-infectious Fevers. The temperature of women during the puerperium is very variable, and easily influenced by causes which in health would have no effect. Non-infectious puerperal fever may be due to : — {a) Emotion. (6) Exposure to cold, (c) Constipation. {d) Reflex irritation, (e) Cerebral diseases. (/) Eclampsia. {g) Insolation. Qi) Syphilis. {i) Exacerbations of acute or chronic diseases contracted during or before pregnancy. Influence of child-hearing upon Phthisis. — The laity believe it to be favorable. This is not the fact. Pregnancy, the puerperal state and lactation are a drain on woman's strength, and can cause the development of phthisis in those predisposed to it. If already present the symptoms are exacerbated. SYLLABUS OF OBSTETRIC LECTURES. LECTURES TO THE COMBINED CLASSES. PART II. Anatomy of the Pelvis Obstetrically Considered. The false pelvis is that expanded portion situated above the Hio- pectineal line. The true pelvis is that part of the cavity beneath the iho-pectineal hne. I. Position. The obhqnity to the spinal column and trunk in the erect posture is 55° at the superior strait, 10° at the inferior strait. II. Shape. The false is irregularly fannel-shaped, exerts no special influence on the course of labor, and is accessory to the true, seizing to direct the presenting part into the true. The true is similar to a truncated cylinder, five inches in depth behind, one and a half in front, and three and a half laterally. The shape of the inlet or superior strait is most frequently cordiform. May be circular or elliptical. The shape of the cavity is chiefly noted for its irregularity, and the outlet or inferior strait is cordiform. III. Size. (a) Inlet. — The antero-posterior or conjugate diameter, measured from the upper edge of the promontory of the sacrum to a point an eighth of an inch below the upper border of the symphysis, is 11 cm. 69 70 OBSTETRICAL LECTURES. The transverse^ the longest possible transverse distance, is ISJ cm. The oblique^ from upper edge of one sacro-iliac junction to opposite ilio-pectineal eminence, is 12f cm. (6) Cavity.— Th.Q plane of pelvic expansion perforates the middle of the symphysis, tops of acetabula, and the sacrum between the second and third vertebrae. Diameters.: antero-posterior 12| cm.; transverse 12J cm. The plane of pelvic contraction passes through tip of sacrum, spines of ischia and under surface of symphysis. Diameters : antero-posterior 11 2- cm.; transverse 10 J cm. (c) Outlet. — Antero-posterior 92^ cm.; transverse 11 cm. lY. Direction of Pelvic Canal. Represented by a curved line parallel to concave surface of sacrum, and equally distant from sides of pelvis (curve of Carus). Development of Adult Pelvis. — The foetal pelvis represents a funnel, and the development of the irregularities and peculiarities of the adult pelvis may be accounted for by three factors, viz. : — (a) Weight of the body, (6) counter-pressure of the femora, (c) force exerted by the ligaments. The sacral curve and lateral aspects are thus explained. The Bony Pelvis Filled with Soft Tissues. {a) Muscles. — Ilio-psoas, obturator internus, pyriformis, coccygeus, levator ani, retractor ani, sphincter ani, constrictor vaginae, trans- verse perinei. The levator ani plays a most important part in the sexual life and physiology of woman. A vigorous contraction of this muscle pulls the rectum and vagina towards the symphysis, and when distended during labor, serves to direct the head out under the symphysis, thus relieving the strain on the perineum. It is active during the orgasm in the female, and directs the male organ toward the cervical canal. During parturition the function of the muscles of the pelvic canal (ilio-psoas, obturator, pyriformis, etc.,) is mechanical. They serve as bumpers or protectors to the bony wall, and deflect the presenting part in the most favorable direction for its expulsion. The situation of the ilio-psoas muscles diminishes the transverse diameter of the inlet, so that in the pelvis during life, the diagonal is the greatest ANATOMY OF THE PELVIS OBSTETRICALLY CONSIDERED. 71 diameter, thus explaining the great frequency of obhque positions of the presenting part. The muscles of the pelvic floor (levator ani, coccygeus, transverse perinei, etc.,) are passive, in one sense, during parturition. They yield only outward and backward, and by resisting the passage of the presenting part, are frequently lacerated, yet the direction of their resistance serves to deflect the head outward and upward under the symphysis. {b) Ligaments. — The ohturator membrane closes the foramen and serves as a cushion to protect the presenting part. The sacro-sciatic ligaments close the pelvic wall, afford protection and give direction to the presenting part. (c) Conneqtice Tissue. — A knowledge of the distribution of the pelvic fascia is of importance in determining the course of extension of interstitial bleeding or absorbed infecting organisms. From both sides of the uterus the connective tissue extends in three directions. Laterally, it is included in the broad ligament, and, traveling along the round ligament, it reaches the mons veneris and inguinal region. Anteriorly, it skirts the bladder and is continuous with the sub- cutaneous connective tissue of the abdominal wall. Posteriorly, it skirts the rectum, is included in the meso-rectum, and is continuous with the connective tissue of the posterior abdominal wall. It also follows the three canals which perforate the pelvic floor, the urethra, vagina and rectum, and thus is continuous with the subcutaneous connective tissue of the external genitalia and perineum. {d) Blood Vessels. — The ovarian arteries, leaving the abdominal aorta, enter the pelvis on either side, and passing between the laminae of the broad ligament, are distributed to the ovaries and tubes, a branch going to the fundus, another traversing the uterus to anastomose with a branch of the uterine artery. The uterine artery passes downward from the anterior trunk of the internal iliac to the neck of the uterus. Ascending the sides of the uterus, a branch meets the ovarian, and a branch, the circidar artery of the cervix, supplies the cervix. The latter is sometimes ruptured during labor, or cut during operations upon the cervix, and gives rise to pronounced hemoiThage. The venous supply to the pelvis is very abundant. (e) Lijmphaiics. — Important in their relation to septic absorption. 72 OBSTETRICAL LECTURES. The lympli spaces of tlie uterus, lying between connective-tissue bundles, and covered witb endothelial cells, empty, by means of their ducts, into the lymphatic glands. These lead to the thoracic duct. The most important glands are the uterine, inguinal, obtu- rator, hypogastric, lumbar and sacral. (/) Nerves. — Principally from sj^mpathetic system. The uterine plexus sends off the two hypogastric plexuses, and from these fila- ments] pass to ovaries and uterus. Deformities of the Pelvis. 4 (Classification of Schauta.) A. Anomalies of the Pelvis the Result of Faulty Development. (1) Simple Flat. (2) Generally Equally Contracted (justo-minor). (3) Grenerally Contracted Flat (non-rachitic). (4) Narrow Funnel-shaped. Foetal or Undeveloped. (5) Imperfect Development of One Lateral Mass of Sacrum. (Nae- gele's Pelvis.) (6) Imperfect Development of Both Lateral Masses. (Roberts' Pelvis.) (7) Grenerally Equally Enlarged (justo-major). (8) Split Pelvis. B. Anomalies due to Disease of the Pelvic Bones. (1) Rachitis. (2) Osteomalacia. (3) NewG-rowths. (4) Fractures. (5) Atrophy, Caries and Necrosis, C. Anomalies in the Conjunction of the Pelvic Bones. («) Too firm union (synostosis). (1) Of symphysis. (2) Of one or both sacro-iliac synchondroses. (3) Of sacrum with coccyx. DEFORMITIES OF THE PELVIS. 73 {h) Too loose a union or separation of the joints. (1) Relaxation and rupture. (2) Luxation of the coccyx. D. Anomalies due to Disease of the Superimposed Skeletox. (1 ) Spondj'lolisthesis. (2) Kyphosis. (3) ScoUosis. (4) Kypho-scoliosis. E. Anomalies due to Disease of Subjacent Skeleton. (1) Coxalgia. (2) Luxation of One Femur. (3) Luxation of Both Femora. (4) Unilateral or Bilateral Club Foot. (5) Absence 'or Bowing of One or Both Lower Extremities. The simple flat pelvis is the most frequent variety in this countiy. The contraction is at the conjugate diameter of the inlet. The narrow, funnel-slmx)ed pelvis occurs in those whose bony develop- ment has ceased or in those who never have walked. In the latter the three developmental factors which produce the normal adult pelvis have been inoperative. In the split pelvis the deformity is at the symphysis and is associated with extrophy of the bladder. The characteristics of the rachitic pelvis are : excessive rotation of the sacrum on its transverse axis, resulting in an abnormal projection of the promontory and increased sacral curve ; the curve of the iliac bones is exaggerated and their anterior spines more widely separated. This form is next in frequency to the simple flat in this country. The greatest contraction is in the conjugate at the brim. Osteo- malacia is very rare in this country. It gives rise to the ' ' beak- like" projection at the symphysis. The neio growths causing de- formity may be any of the tumors that can develop from bone. When the pelvic joints are too firmly united the phy.siological loosening which happens during the latter months of pregnancy can- not occur. Anchylosis of the sacro-coccygeal joint is not infrequent in old primiparae. Spondylolistliesis is a slipping down of the last lumbar vertebra into the pelvic cavity. In lajpliosis the weight of 74 OBSTETRICAL LECTURES. the body is from above downward and from before backward. The sacrum is thus pushed backward, increasing the diameters of the inlet but diminishing the outlet. The distortion resulting from scoliosis is a lateral displacement of the promontory giving rise to an oblique deformity. Lordosis is the compensatory curve seen in kyphosis. Pelvimetry. Table of Measurements. Pelvis. Iliac spines, 26 cm. Iliac crests, 29 cm. External conjug., 20^ cm. Internal conjug., diagonal, 12f cm. True conjug., estimated, 11 cm. Eight diagonal, 22 cm. Left diagonal, 22 cm. Between Trochanters, 31 cm. Circumference of Pelvis, 90 cm. An accurate measurement of the pelvis by means of the pelvi- meter will disclose any change in shape or size of the pelvis, indicate the degree of the defomiity, and thus influence the treatment. The measurements are made externally and internally between certain bony prominences. The varying factors in the external measure- ments to be taken into consideration are the thickness of the skin, subcutaneous tissue and the bones. Estimation of the Size of the Inlet. — ^An approximate idea of the transverse diameter is gained by measuring externally between the anterior superior spinous processes of the ilia (26 cm. ) ; between the crests of the ilia where they are most widely separated (29 cm.) ; between the two trochanters (31 cm.). The transverse diameter may be determined more accurately by an internal measurement called the internal ascending ohlique (Lohlein). This is measured, by the finger in the vagina, from the centre of the sub-pubic liga- ment to the upper anterior corner of the great sacro-sciatic foramen. The transverse is 2 cm. longer than this diameter. An idea of the length of the antero-posterior diameter of the inlet PELVIMETRY. 75 is derived from the external conjugate^ measured from the depression under the spine of the last lumbar vertebra to the upper edge of the sjnmphysis (20i cm.). The internal measurement for estimating the antero-posterior diameter is made by the fingers reaching from the middle of the sub-pubic ligament to the top of the promontory, and is called the iutermd conjuffate diarjonal (12j cm.). This diameter is necessarily longer than the true conjugate, and it has been found that by substracting If cm., the true conjugate is estimated. The possible sources of eiTor in thus estimating the true conjugate are found in the fact that the internal conjugate diagonal does not take into account the height and angle of the symphysis, two factors which obviously influence the length of the tme conjugate, while they have no effect upon the diagonal conjugate. Normally the height of the symphj^sis is 4 cm., and its angle 105° (conjugato-symphyseal angle). If this were always the case, subtracting If cm. from the measured internal conjugate diagonal would be absolutely correct. As a matter of fact, both the height and the angle vary, and by the follow- ing rules the true conjugate can be accurately determined. For every .5 cm. increase in the height of the symphysis above the normal, add . 3 cm. to If cm. , and subtract the sum fi"om the measured internal conjugate diagonal. The converse of this is applicable to a decrease in height of the symphysis. For every degree of increase of the conjugato-symphyseal angle above the normal, add half that number of mm. to If cm., and sub- tract the sum from the measured internal conjugate -diagonal. The converse of this is also true. The oblique or diagonal diameters may be measured externally from the posterior superior spinous process of the ilium to the oppo- site anterior superior spine (22 cm.). Estimation of the Size of the Cavity. — Xo external points ofmeas- urement. Its general size, or the presence of a tumor, is learned by a vaginal examination. Estimation of the Size of the Outlet. — As it is increased in many varieties of deformity, and but rarely contracted, external measure- ments are not required in the vast majority of cases. It is decreased in the kyphotic pelvis. The distance between the tuberosities of the ischia (11 cm.) is ascertained by Chantreuil's method: placing the 76 OBSTETRICAL LECTURES. two thumbs on tlie tuberosities, and an assistant measures the dis- tance between them. Chief diagnostic points of the commoner forms of pelvic deformity^ Simple Flat Pelvis. — The external conjugate will be less than 2O4 (19 or 18), and the internal conjugate diagonal less than 12|. Flat Rachitic— T\\Q external conjugate lessened (18 or under). Internal coujug. diagonal lessened (11 or under). Conjugato-sym- physeal angle is increased ; about 2 cm. , not If cm, , is subtracted. The relation of the distances between the spines and crests is dis- turbed. Jiisto-minor. — All the diameters less, but normal relation main- tained. Justo-major. — All diameters increased, but normal relation re- mains. In private practice it is by no means necessary to accurately meas- ure the pelvis of every pregnant woman. When, however, there exist evidences of some deformity, as rachitis, kj^phosis, coxalgia, a history of grave difficulty in previous labors, etc. , a vaginal examina- tion should be made to estimate the conjugata vera, and other measurements taken as maj?^ be indicated. Foetometry. Table of Measurements. Child. Length 50 cm. Bisacromial 12 cm. Head. Biterap.... 8 cm. Bipariet 9^ Occip. front llf Occip. mental 13j Trachelo-bregm 9j Circumference, occip. , front 34 J The weight of mature infant is 3250 grm. In connection with the size of the pelvis, a second important factor FOETOMETRY. — ANTISEPSIS. 77 influencing the difficulty of labor, is the size of the foetus, particularly of its head. Estimation of the Size of the Foe.tus. — An approximate idea of its size can be determined by abdominal palpation. Ahdoriiiiial Palpation. — The woman should be placed on her back, with abdomen exposed. The examiner, standing to one side facing her head, by a series of stroking, patting and rubbing motions, deter- mines the height of the fundus, tension of abdominal wall, irritability of the uterus, quantity of liquor amnii, size of the foetus, its position and presentation. Position and Presentation. — The palmar surface of the tips of the fingers are carried up the sides of the abdomen, and upon one side (left in the first position) is noticed firm, broad, even resistance, con- trasting with the cystic, tumor-like sensation of the other side. This resistance is produced by the back, and, to confinn thLs, the extremities are searched for by a nibbing motion on the opposite side. Having located the back and the extremities, the portion of the foetal ellipse presenting at the superior strait is next ascertained. The examiner now faces the woman's feet, and, with the middle fingers over the centre of Poupart's ligament, the fingers clip down into the pelvic cavity. If the head is presenting, it is felt as a hard, round mass. At the same time its density, compressibility and approximate size may be learned. When it has not engaged, its relative size to the inlet, which is of obvious importance, may be discovered by an efi'ort to push it through the superior strait. Antisepsis. Mortality of Septic Infection. — In large cities the average death rate of confinement cases is about one per cent. , the greater propor- tion being due to septic infection. In Philadelphia about thirty thousand women are annually confined at term, and of these between two and three hundred die fi-om septic infection. Functions of Microbrganisms. — The widespread distribution of microorganisms is now well known, and investigation has shown then* chief function to be disintegrators and destroyers of dead animal and vegetable matter. Ptomaines. — In their work of disintegrating and destroying dead 78 OBSTETRICAL LECTURES. animal matter, poisonous products are produced, called animal alka- loids or ptomaines [irrcfia^ dead body). When the latter are absorbed, they give rise to various pathological and clinical manifestations, some proving fatal to animal life, others causing a rise of tempera- ture, etc. Phenomena Resulting from Microhe Invasion. — The cells of living matter resent their invasion and a struggle for supremacy begins. By their higher specialization for greater resistance, the skin and mucous membranes ordinarilj^ serve as barriers to their entrance, but if these are passed, the more delicate and less-resisting cells take up the combat. The result is largely dependent upon the extent of invasion, the virulence of the microbe, and the individual power of resistance of the living cells. Invasion in Puerpera. — The examining hand maybe infected, and through the placental site or lacerations of the parturient canal an entrance into the general system is effected. A fatal result in every case is avoided, in two ways : As a rule, the examining hand is not infected with the particularly viralent varieties, and in many cases the living cells are able to resist the germs that may have gained access. These elements of safety are invalidated, however, by the following facts : The germs that may have been introduced, when at their work of disintegrating the dead animal matter, as clots, shreds of membrane, deciduge, etc. , grow, multiply and increase in virulence, and the power of resistance of the vital cells varies in different indi- viduals. Therefore it is impossible to predict the character of the germ that may be absorbed, whether virulent or otherwise, and in no case can we know an individual's power of resistance. With so much uncertainty surrounding every case, it is obviously necessary to apply our knowledge of germicides and endeavor to prevent the introduction and further development of microorganisms. TABLE OF COMPARATIVE GERMICIDAL POWER. BicMoride of Mercury i Creolin / Thymol I ^^ Benzoate of Sodium... J Salicylic Acid 3 Carbolic Acid 1 ANTISEPSIS. 79 The bichloride of mercury is effective but dangerous. Creolin.is probably as powerful as the bichloride ; thus far has been found much less dangerous, and is therefore recommended. Application of Antt'seps-ls to Obstetrics. — The advantages of anti- vseptic precautions in obstetric practice have been clearly demonstrated by an enormous reduction of mortality since its employment has be- come so general. At one time in the Vienna Hospital the mortality was one death in nine cases ; now it is . 3 per cent. In the Paris Maternite it has been 10 per cent., while recently in the same hos- pital there were 1000 cases without a death. At the Philadelphia Hospital the mortality has been reduced from 7 per cent, to less than 1 per cent. Semmelweis, the originator of antiseptic practice in obstetrics, accomplished the following striking reduction in mortality in his hospital by requiring students to disinfect themselves before attending the cases : — Year. Confinements. Deaths. Per Cent. 1846 4010 459 11.4 1847 3490 . 176 5. 1848 3556 45 1.27 Antisepsis in Hospital Practice, {a) Disinfection of the Patient. — When the signs of beginning labor manifest themselves, the patient should receive a bath and be supplied with clean clothes. After labor is completed the vagina should receive one douche of 2 per cent, solution of creolin by means of a fountain syringe, preferably of glass, the vaginal tube also of glass, with lateral perforations. If an intrauterine injection be re- quired, the glass tube, a two-way metal catheter or stiff rubber cath- eter, may be used, jDreferably with a fountain syringe . (b) Disinfection of the Bed. — The lying-in bed should contain the following : 1, a pad about a yard square, composed of an upper layer of flannel, a piece of blanket and a layer of mackintosh, all to be soaked in bichloride solution, 1 to 2000, before using ; 2, a sheet covering, 3, a rubber blanket ; 4, a second sheet, and under this, 5, another rubber cloth, to protect the mattress. (c) Disinfection of the Attendants. — The hands and wrists of doctor and nurse washed in warm water with soap and brush ; nails pared and cleaned ; hands and wrists rinsed in alcohol and placed in bichlo- 80 OBSTETRICAL LECTURES. ride solution. 1 to 1000, for at least one minute, after which they should not be dried on septic towels, etc. {d) Disinfection of Instruments. — If not easily corroded, soaked in bichloride solution, 1 to 1000 ; otherwise, use 5 per cent, solution carbolic acid. This applies to all instniments used in vagina, urethra or rectum. Protection after Lahor. — The pads which receive the lochia should be changed six times in twenty-four hours for three days, and less frequently subsequently as may be needful. Protect the parturient tract from invasion by the occlusive dressing.^ composed of three or four layers of sublimated gauze (boat-shaped) upon waxed paper, and corrosive cotton upon this to protect vulvar opening. This dressing to be changed si:x, seven or eight times daily for the first three days and less frequently aftei-ward. When changed, the external genitalia should be washed several times daily with baked cotton and bichloride solution 1 to 2000. Antisepsis in Private Practice. The patient, nurse, clothing, etc, are usually sufficiently clean. Avoid infecting the patient by thorough personal disinfection of doctor, nurse and instniments. An occlusive dressing should be used to prevent infection fi'om the atmosphere. The lying-in room should not contain a stationary washstand nor be in close proximity to water closet. An open fireplace is desirable. Diagnosis of Pregnancy. Subjective Signs. — Arranged in the order of their relative import- ance. {A) Cessation of Menstruation. — Is the most valuable of the subjec- tive signs, but is not always to.be depended upon. It may occur inde- pendently of pregnancy, in immigrants experiencing a sudden change in climate ; in various mental disorders, as hj^steria, mania ; as the re- sult of old peri-uterine inflammation ; it often accompanies phthisis. In i^regnancj^ the menstrual discharge may occur during the first three months. Sometimes this may be due to failure of union of the deciduje. Rarely it may continue throughout the whole period of gestation. DIAGNOSIS OF PREGNANCY. 81 {B) Nausea and Vomiting. — Are reflexly as.sociated with the de- veloping foetus, and occur usually at the 6th or 7th week. They may occur reflexly from other conditions, as a displaced utems, an organ which is badly inflamed, congestion or inflammation of the tubes and ovaries, growing tumors within the pelvic cavity, etc. They may be altogether absent, yet rarely in some individuals they appear so early, and with such promptness and regularity, as to con- stitute a most valuable sign. {C) Changes due to Increased Blood Supply to the Genitalia and Breasts. — These are tingling and a sensation of fullness in the breasts, with the development of colostrum ; leucorrhcea ; increased temi^era- ture of the genitalia. Are of comparatively little value. {D) Quickening . — Is the sensation experienced by the mother as the result of foetal movements, and usually first appears between the fourth and fifth months. {E) Alterations in the Nervous System. — Changes in disposition, mental peculiarities, perversions of taste. Objective Signs. — Are of much more importance and value. Are obtained by employing the senses of sight, touch and heanng. {A) Inspection. (a) Face. — Chloasmata, splotches of ii'regular pigmentation on brow and cheeks. Development of the dark ring under the eyes. (b) Breasts. — Enlarged; veins distended and tortuous ; nipple promi- nent ; deposition of pigment — widening the areola and developing the secondary areola. Enlargement of the glands of Montgomery ; presence of colostrum. All these signs can be manifested inde- pendently of pregnancy, and rarely may be absent, (c) Abdomen. — Is pear-shaped., with the narrow end downward ; tumor is situated in the median line, spreading with approximate equality to either side. Strige are present. The umbilicus at the sixth month is level with the surface of the abdomen and later pouts. It is suiTOunded by a ring of pigmentation which spreads above and below along the linea alba. Foetal movements can be seen if the pregnancy be far advanced. In the latter months the mucous membrane of vagina and vulva are violet or purple. {B) Touch. — {a) Abdomincd palpation. By this method is learned the size and shape of the uterus ; in advanced cases, the 6 82 OBSTETRICAL LECTURES. position of the foetal back, head and extremities ; the intermittent uterine contractions (Braxton Hicks) ; foetal movements. Braxton Hicks' sign is available by the last of the third month, and although it may be produced by any tumor which sufficiently distends the uterine wall, as a collection of blood, soft fibroma, etc., it is almost a positive sign. Foetal movements are absolutely diag- nostic. (6) Combined examination. — (1) Softened cervix. — A ready rule of practice is, that " when the cervix is as hard as one's nose, preg- nancy does not exist; when soft as one's lips, pregnancy is prob- able " (Groodell). Bapidly-growing myomata, acute metritis, haema- tometra, can thus simulate pregnancy by softening the cervix. (2) Hegar's sign. This is a softening of the lower uterine segment, which is situated between the cervix and the upper uterine segment. Can be elicited by the forefinger in the rectum, thumb in the vagina, and pressure on the fundus above. (3) EnlargemenUof the uterus. In the early months deposition of lymph upon the uteiTis may lead to an error in diagnosis. (4) BaUottement. With one hand over the fundus, and the fingers of the other in the vagina, an impulse is communicated to the contents of the uterus by the vaginal hand, when the foetus will be felt to strike the fundus, and, returning, will impinge upon the vaginal hand. This is a positive sign, and is available in the fourth month. A small cystic tumor of the ovary, with a long pedicle and an extra-uterine gestation, are possible sources of error. (C) Hearing. — {a) Foetal heart sounds. Rate, 120 to 160 per minute. Available in the fifth month. The third positive sign. Are to be distinguished from the pulsations of the abdominal aorta. The area of their maximum intensity in anterior positions of the vertex is an inch below the umbilicus, to the left or right ; in poste- rior positions, in the flanks, on a line which passes through the umbilicus. Their absence does not exclude the existence of preg- nancy, (b) Dullness on percussion. Chnically, the signs of pregnancy may be divided into three trimesters of three months each. The Isf. — Will manifest the following signs : enlargement and bogginess of the uterine body ; soft cervix ; enlargement of the breasts ; nausea ; Hegar's sign ; cessation of menstruation. PHYSIOLOGY OF PREGNANCY. 83 The 2d. — In addition to above, Braxton Hicks' sign ; feeble foetal movements ; ballottement ; heart sounds. The 3d. — All the above present to a greater degree. Estwiation of the Duration of Pregnancy. — Ordinarily the cessa- tion of menstruation is depended upon. A convenient rule for pre- dicting the date of confinement is to "count back three months from the date of appearance of the last mensti-ual flow, and add seven days " (Naegele). An approximate idea maj" also be gained by noting the height of the fundus : — 4th month, midway between umbilicus and symphysis. 6th month, on a level with the umbilicus. 7th month, midway between umbilicus and xyphoid. 8th month, at the xyphoid. 9th month, descends almost to the depth at which it was at the 7th month. Diagnosis of Life or Death of the Foetus. — The foetal heart sounds are the most valuable sign when heard. Diagnosis of the Situation of the Developing Ovum. — Whether intra- or extra-uterine (see Extra-uterine Pregnancy). Diagnosis of a Prior Pregnancy. — Of medico-legal value, (a) Cervix lacerated, usually laterally, {b) Cervical canal irregularly enlarged, usually admitting first joint of index finger. Physiology of Pregnancy. Alterations in organs and tissues in consequence of pregnancy. (A) Local Changes. I. Uterus. {a) Devehjjment of Constituent Parts. — 1. Muscle. Fibres hyper- trophied eleven times as long, five times as broad as those of the non-pregnant uteras. The theorj^ of an additional hyperplasia of these structures has never been actually demonstrated. 2. Connective tissue. Increased chiefly by absorption of fluid and consequent increase in bulk. 3. Peritoneal covering. Increased by both hypertrophy and hyperplasia of the constituent elements. 84 OBSTETRICAL LECTURES. 4. Blood vessels. Arteries increase in calibre, length and tortu- osity. Veins grow to a very large size ; their covering is reduced to the iutima. They are surrounded by the uterine muscle, which obliterates them after labor. 5. Nerves. Increased more by a development of the connective tissue about them (neurolemma) than by an increase of the nerve elements. 6. Lymphatics. Increased by hypertrophy and hyperplasia. The lymph spaces below the uterine mucous membrane are enormously enlarged, and the lymph tubes leading from them through the uterine muscles reach the size of a goose quill. These lymph tubes or vessels are collected in a plexus beneath the peritoneum, which is continuous with the general lymphatic system. This arrangement and development explain the remarkably rapid absorption of the uteiTis after labor, and accounts for the ready absorption of infecting material, with peritonitis oftentimes as an early symptom. (6) Anatomy of the Uterus at Full Term. — The muscle fibres of the non-pregnant utei'us have a very irregular distribution. In the pregnant womb three layers may be distinguished — an outer, middle and internal layer. The outer is continuous with the muscular fibres in the round ligaments and tubes, and is mainly longitudinal in aiTangement. The middle layer is composed of bundles, which pass from their peritoneal attachment obliquely downward and inward to be attached to the submucous tissue. Above the ' ' contraction ring ' ' this oblique arrangement is less marked, while below it is more pro- nounced. The internal layer is thin and poorly developed, except at definite points. Its arrangement is chiefly circular, and is specially developed at the openings of the tubes and internal os. (c) Changers in Volume, Capacity and Weight. — Before impreg- nation, the length of the uterine cavity is about 2 J inches ; at term, it is increased to 12 inches, while its breadth is 9 inches and depth 8 inches. The capacity changes from 1 cubic inch to 400 cubic inches, weight from about 2 ounces to 2 pounds. {d) Changes in Form., Position and Topographical Relations. — From flattened pyriform to spherical, and, finally, ovoidal. During the early months the position of the uterus is altered by sinking into the pelvic cavity, as a result of the increased weight. After PHYSIOLOGY OF PREGNANCY. 85 the third month it rises until it is almost in contact with the dia- phragm, and before term (four weeks in primiparse, ten days or one week in multiparas) sinks again into the pelvic cavity, owing to the engagement of the lower portion of the uterus with the contained presenting part of the foetus within the pelvic canal. After the third month, the laxity of the abdominal wall allows it to fall foi-ward. In consequence of the position of sigmoid flexure and rectum, it is slightly tilted to the right and rotated on its longi- tudinal axis. The topographical relation of the intestines is impor- tant. They are alwa3^s situated above and behind the uterus, thus giving no resonance over the anterior abdominal wall. II. Alterations in the Cervix. Is softened, but its canal is undilated until the first stage of labor is well advanced. III. Alterations in Yagina and Vulva. Changes due to increased blood supply, as noticed in enumerating the signs of pregnancy, as darkened color, increased secretion and over-development in the muscular and mucous walls. TV. Pelvic Joints. Loosening of their connections and increase in motility, thus facili- tating the passage of the foetal body. Y. Abdominal Walls. (a) Stretching of all the constituent parts^ with the formation of striae, resulting from cracks in the subcutaneous connective tissue and deeper laj^-ers of the skin. Q)) Separation of the recti muscles. — Exceptionally, the abdom- inal contents may be extraded. (c) Inci'eased deposition of fat, as in other parts of the body. This is probably nature's provision for sustaining the woman during the first few days of the puerperium. YI. Bladder and Rectum. The growth of the pregnant uterus mechanically interferes with their functions, hence irritability of the bladder and constipation are 86 OBSTETRICAL LECTURES. frequent. By interfering witli their blood supply, liemorrhoids may develop, not only of tlie anus and rectum, but of the bladder as well, which rarely give rise to hemon-hage. (B) Changes in the Several Systems of the Body. General Changes. I. Circulatory System. (a) Blood. — Whole quantity increased. Water and fibrin-making elements increased ; red corpuscles relatively diminished ; haemo- globin diminished ; white corpuscles actually and relatively increased. (h) Heart. — Left side said to hypertrophy, and, in consequence of unusual determination of blood to the brain, there is developed on the inner table of the skull new formations of bone, called osteo- phytes. II. Urine. Becomes more watery ; specific gravity diminished ; quantity of urea normal. The kyesteinic pellicle is no longer regarded of any diagnostic value. III. Digestive System. Nausea and vomiting ; torpor of intestines and rectum, inducing constipation. ly. Nervous System. Alterations in disposition ; perversions of taste ; disposition to melancholia ; severe neuralgias, esioecially of the face and teeth. y. Changes in Weight. An increase of y^ part of the original body weight (G-assner). This estimate is not uniformly correct, as irregularities are frequently met with. yi. Changes in the Respiratory Apparatus. Lungs are shorter but broader, leaving the capacity unchanged ; alterations in the expired air of no clinical importance. PATHOLOGY OF PREGNANCY. 87 Pathology of Pregnancy. I. Diseases of the Genitalia. 1. Displacements of the Pregnant Uterus.— It may be dis- placed forward, backward, to either side, downward. It may form part of the sac contents in inguinal and ventral hernia, and may be twisted upon the cervix. (a) Anteflescion. —LhuoWy the growth of the utenis replaces the organ spontaneously, but when bound down by bauds of adhesive inflammation, pain and difficulty in urination result, until finally the uterus expels its contents, or forces its way up into the abdomi- nal cavity. Treatment.— M^sssige, and efi'orts to replace it through the vaginal vault. Late in gestation the whole body of the uterus may fall forward in consequence of greatly relaxed abdominal walls or separa- tion of the recti muscles, producing a pendulous abdomen. Treated by abdominal binder. (6) Retroflexion or Retroversion. — Of rather frequent occurrence. Explained almost invariably by the previous existence of such a displacement. Symptoms.— The earhest and most distinctive is dysuria, which should lead to a vaginal examination to confirm the diagnosis. In neglected cases, or where nature has not corrected the displacement spontaneously, incarceration occurs. The symptoms of this manifest themselves after the third month, and are : occlusion of the bowel and urethra, with their associated symptoms ; congestion, inflamma- tion and suppuration of the uterus, which may finally slough with the development of peritonitis and septic infection. Terminations when Artificial Means are not Emjohyecl. — Sponta- neous replacement ; spontaneous abortion ; expulsion of the uterus from the body as a whole ; rarely by sacculation of the utems. Prognosis. — Always satisfactory as regards maternal life when treatment is adopted early. Treatment.— KdYAd^atmewt. If undertaken early, manual means, pressing fundus in the direction of one or the other sacro-iliac joints, the patient in the lithotomy position. Failing, resort to knee-chest posture and a repositor to press upon the fundus. The cervix 50 OBSTETRICAL LECTURES. should next be drawn downward with tenaculum, at the same time continuing the efforts to replace the fundus. If successfal, a large sized pessary or tampon should be applied until the growth of the organ maintains it in the abdominal cavity. When bound down by strong inflammatory bands, steady and long-continued pressure should be supplied by large tampons in the posterior vaginal vault. Failing, finally, abortion should be induced. Treatment when Incarcerated. — Attempts at reposition as above. These unavailing, as is usual, induce abortion. If it is impossible to effect an entrance into the cervix for this purpose, it is justifiable to puncture the uterine wall through the vaginal vault, and thus draw off the liquor amnii. The organ may now respond to efforts at replacement, or permit the cervix to be drawn down and its canal dilated, to accomplish the evacuation of its contents. If the bladder is seriously distended it should be emptied by the urethra, or supra-pubic puncture with an aspirating needle may be necessary. As a last resort, vaginal hysterectomy is justifiable. (c)' Displacements to Either Side. — Include latero- position, latero- version, latero-flexion. Latero-position is usually a congenital defect due to abnormally short broad ligaments, placing the whole uterine body more to one side of the abdominal cavity. Latero-flexion is also congenital, due to imperfect development of one side of the uterine body. These malpositions complicate labor more than preg- nancy (see Dystocia). {d) Prolapse. — Causes. — Impregnation in an organ already pro- lapsed, or the consequence of retroversion, relaxed vaginal walls and outlet ; the increased weight leads to prolapse in the first few weeks of ]jregnancy. Terminations. — (1) Complete spontaneous reposition, which is most frequent. (2) Incomplete reposition, continuing in that state to fall term, (3) Failure of retraction, inducing incarceration. (4) Failure of retraction, inducing abortion. Pregnancy will not con- tinue to term in a completely prolapsed organ. Treatment.— KQ^osiiion and application of some variety of baU pessary, retained by a firm T-bandage. When incarcerated, attempts at reposition should be cautious, but if they fail, owing to adhesions and oedema, abortion should be induced and the organ replaced. (e) The Pregnant Uterus forming a Part of a Hernial Protrusion. PATHOLOGY OF PREGNANCY. 89 — Occurs exceptionally, in inguinal and ventral, but never in crural hernia, the uterus getting into the sac before or after impregna- tion. The ventral variety is most frequent, and may occur between abnormally separated recti muscles, or, more rarely, is seen on the lateral aspect of the abdomen. When it occurs in the very excep- tional inguinal variety, the pregnancy is apt to be in one horn of an abnormally developed uterus. Treatment. — Attempts at reposition. These failing, entering the hand in the uterus, version and extraction are to be considered. The last resort is Caesarean section or amputation of the pregnant uterus. (/) Torsion. — kSlight degree of torsion from left to right, phj^sio- logical and constant. A more exaggerated degree may be due to some abnormal condition, usually inflammatory, near the uterus, • which results in twisting it upon its longitudinal axis. An ovary may thus be brought in front and be subjected to traumatism during manipulation of the abdomen. 2. Diseases of the Uterine Muscle. — («) Bheumatism. — Most common ; occurs in those of rheumatic diathesis. Symptoms. — Great pain, localized in the uterine walls, lasting throughout the latter months of pregnancj^ and increased periodic- ally by the intermittent uterine contractions. The therapeutic test is, perhaps, the most valuable factor in the diagnosis. Treatment. — Administration of salicylate of sodium. (6) Metritis. — Is almost invariably acquired before impregnation, exercises a most deleterious influence upon gestation, and usually results in abortion. Symptoms. — When pregnancy continues, there is great pain, a feeling of weight and heaviness, and usually distressing and obstinate vomiting, which, in some cases, may indicate the induction of abor- tion. Treatment. — Glycerine tampons maybe tried, although verj^ likely to induce abortion. (c) Neio Growths. — Complicate labor more than gestation. — 1. Fibroids — are the most frequent, grow rapidly, and in exaggerated cases some operative interference is demanded. The same is true of other i:)elvic tumors to a less degree, as (2) ovarian cysts. 3. Malformations of the Uterus.— -Complicate labor more than gestation (see Dystocia). 90 OBSTETRICAL LECTURES. 4. Diseases of the Cervix. — The same may be said of these, except bad cases of laceration and eversion and carcinoma, which very frequently induce abortion or premature labor. Minor com- plications may arise from inflammatory processes within the cervical canal, giving rise to mucous or even bloody discharges. Supposed menstruation i^ersisting throughout i^regnancy is probably thus accounted for. 5. Diseases of the Vagina. — Due to increased blood supply or specific infection, (a) Leucorrhoea : feeling of heat and discomfort, (b) Specijic infection. Affects rather the newborn infant and mother soon after delivery. Requires energetic treatment to elimi- nate such complications. Bichloride douche, 1 to 2000 b. d., and a ■ tampon dusted with tannic acid, (c) Hemorrlioids. Gruard the part from traumatism, which can jiroduce alarming hemorrhage. 6. Diseases of the Yulva. — Also largely due to increased blood supply, {a) Hemorrlioids. (Jb] Vegetations. Require no treat- ment beyond protection, (c) Pruritus vidvce. May be a neurosis, or due to the vaginal and cervical discharges. Is oftentimes in- tractable. Treatment belongs to gynaecology. 7. Peri-uterine Inflammation and Adhesions. — May be benefited by massage. Appropriate treatment during the inteiTals between pregnancies is required. 8. Loosening of Pelvic Joints. — When pronounced, interferes with locomotion. The diagnosis is made by a vaginal examination, the patient in the erect posture taking a few steps. Treatment : Application of a firm binder about hips and pelvis, or rest in bed if exaggerated. 9. Breasts. — (a) Mammary Abscess. Its cause, course and treat- ment same as when it occurs during the puerperium. (b) Eczema of the Nipples. Is very obstinate and resists treatment. Relief only occurs after delivery. II. Diseases of the Alimentary Canal. 1. Mouth. — (a) Canes of the Teeth. — Is of rather common occurrence, particularly in the upper classes. As a rule, it is best not to advise interference, as dental operations might provoke abortion. (b) Toothache. — Develops with or without other pathological PATHOLOGY OF TREGNANCY. 91 changes in the mouth, and resists treatment. Usually subsides when pregnancy has advanced beyond the first half of gestation. (c) Ptyalhm. — Cause not known. Astringents, etc, may be employed. Disappears usually in the latter months. 2. Stomach. — Pernicious Vomiting. — Causes. — (l)Ileflexly, from irritation of the uterus and its contained nerve endings by the stretching of the uterine walls. It is thus more common in primi- parae, and when chronic metritis or displacement of the uterus exists. (2) Inflammation of the lining membrane. (3) Engorgement of neighboring organs, as inflamed tubes or ovaries. (4) Some patho- logical condition of the stomach, as chronic gasti'itis, gastric ulcer, etc, pregnancy increasing the irritability already present. (5) Rarely some pathological condition of the intestinal tract. (6) Increased in- dulgence in sexual intercourse. The latter is a not infrequent cause. Diagnosis. — Of the cause is difficult ; of the condition easy. There is fever, great emaciation and loss of strength, which maj^ prove fatal. The worse cases occur between the second and fourth months. Treatment. — Remove the cause, if ascertainable. (a) Hygienic. — Includes regulation of the diet, etc. Advise a light breakfast of tea and bread or milk, taken in bed before getting up, the patient lying flat upon her back. Sexual intercourse should be restrained. Oftentimes there is improvement when the sensation of swallowing is removed by a cocaine spray or oesophageal tube. Rectal alimentation in extreme cases, the enemata being non- irritat- ing, so as not to provoke an exhausting diarrhoea. The ' ' rest cure, ' ' combined with other treatment, has proved efficient in some cases. Some tolerance of the stomach may at times be established by allow- ing apparently unsuitable articles of food when specia% desired by the patient. (b) Medicinal. — The drugs that have been used are innumerable. Nervous sedatives, as bromides, chloral and opium, are the most reliable. Sodium bromide, gr. x, in aq. camph., 3iv, four times a day. If necessary, resort to enemata of sodium or potassium bro- mide, gr. xl, and chloral, gr. xx, two or three times a day, dissolved in water. (c) Gynaecological. — Replace a displaced uterus. If the cervix or canal is inflamed, api^ly with a cylindrical speculum a 20-gr. solution of nitrate of silver. If api)lications in the canal are used, abortions 92 OBSTETRICAL LECTURES. may result. When due to metritis, treatment does not accomplish much at this time. Grlj^cerine tampons may be used after simpler plans fail, as they may induce abortion. Empirically, a 15 per cent, solution of cocaine may be applied to cendx and vaginal vault, and, similarly, dilatation of the cervix with the fingers has been successful in certain cases. {d) Obstetrical — Induction of abortion or premature labor ; should be done as the last resort, and yet not too late. 3. Intestines. — (a) Constipation. — Should be guarded against to prevent overwork of the kidneys. Cascara sagrada, the weaker mineral waters and pulv. glycyiThizae corap. may be used. Active purges may interrupt the course of gestation. R. Ext. cascarse sagradse gr. j-ij. Confection sennse gr. x-xx. (h) Diarrhaa. — When the ordinary remedies fail, nerve sedatives may control it, as it is sometimes explained by intestinal irritability, resulting from pressure of the gravid womb. 4. Liver. — Jaundice may result from a mild catarrhal condition of the bile ducts, which may have existed before pregnancy. This class of cases is of little clinical importance. It should be remembered that a serious condition may develop as the result of excessive work thrown upon the liver — namely, an acute degeneration of the whole hepatic stmcture. Another explanation is that poisons (such as may produce eclampsia) circulating in the blood act ujDon the liver, pro- ducing acute yellow atrophy. Treatment. — The simple catarrhal jaundice is treated by regulation of diet and bowels, and securing a free discharge of bile. The graver form is rapidlj^ fatal. 5. Hemorrhoids — Guard against constipation. Astringent appli- - cations may be made. Operative interference is likelj^ to inteiTupt pregnancy. III. Diseases of the TTrinary Apparatus. 1. Kidneys. (a) Kidney of Pregnancy. — Pathology. — Angemia, with fatty infil- tration of the epithelial cells, and without any acute or chronic inflammation. PATHOLOGY OF PREGNANCY. 93 Cause. — Obscure. Has been attributed to pressure on the blood vessels ; to the compression of the gravid uterus ; serous condition of the blood in pregnancy ; influence of the weather, and to spasmodic contraction of the renal arteries. It is most probably due to a diminution of the blood supply. Symptoms. — xllbuminuria. Hj^aline and granular casts, with epithelium filled with fat, may be found. Frequency and Course. — About six per cent, of all pregnant women have albumen in the urine. Occurs most frequently in primi- parae ; nins a subacute course, manifesting itself most plainly in the latter months of gestation, and can influence the general health, course of pregnancy, and occurrence of eclampsia, the same as inflammatory renal diseases. Upon the foetus, also, it exerts practi- cally the same influence in the production of placental apoplexies. The dangers are greatest when the condition develops suddenly. It disappears with the cessation of gestation. Treatment. — Practically same as for true nephritis. (h) Acute and Chronic Nephritis. — These may occur at any time during, pregnancy, with their usual sjTnptoms. The extra amount of work thrown upon the kidneys at this time makes the prognosis more grave, and demands the most energetic treatment. Premature expulsion of the ovum and outbursts of eclampsia are frequent. The chronic variety is more frequently a complication, and may be acquired before or during pregnancy. Differential Diagnosis. — If the kidney disease existed before pregnancy, marked symptoms will develop in the earlier months. If these develop in the later months, the disease has had its origin during pregnancy. It is often difiicult to distinguish between the following : — Chronic Nephritis. Kidney of Pregnancy. Historj'- may point to its exist- Kidneys normal at this time, ence before pregnancy. Urine likely to be increased. Urine likely to be decreased. Presence of albuminuric reti- Absence of same. nitis. Symptoms apt to be pro- Same in latter months, nounced in earlier months. 94 OBSTETRICAL LECTURES. Chronic Nephritis. Kidney of Pregnancy. Autopsy gives evidences of in- Anemia and fatty degencra- flammatoiy changes. tion. No inflammatory changes. Persists after deliverJ^ Disappears after delivery. Treatment. — It is always of paramount importance to know in any case of pregnancy what the condition of the kidneys may be, hence in all cases the urine should be repeatedly examined, at least every ten days during the latter weeks. If the quantity of albumen is small, if there are no casts, no history of a previous nephritis, and no symptoms of general systemic disturbance, dietetic and hygienic management may be sufficient so long as the case is kept under care- ful observation. When considerable quantities of urine, casts and oedema are found, the patient should be put to bed for the greater part of the day, and milk diet and Basham's mixture given. Finally, induction of abortion or premature labor may be necessary. This should not be delayed too long. Serious eye symptoms always indicate it. Eclampsia can occur after the expulsion of the foetus. (c) Renal Tumors. — ^Rare. Are to be diagnosticated and treated according to the individual features of the case. {d) Dislocation of the Kidney. — The right is almost always the one afiected. Not infi-equently associated with displacements of the gravid womb. Abortion may result if it happens to become twisted upon its pedicle, and from pressure the kidney of pregnancy may develop. (e) Diseases of the Pelvis of the Kidney. — (1) Pyelitis. Premature expulsion of foetus apt to occur. It is met with much more fre- quently after labor. (2) Hydronephrosis. A displaced and adherent gravid uterus may occlude the ureters with this result. Requires reposition of the uterus. (3) Stone. Apt to induce abortion. Renal colic is to be treated in the usual manner. 2. Diseases of the Bladder. {a) Irritability. — Is ftmctional, and occurs in hyperaesthetic indi- viduals from pressure of the gravid womb. Treatment. — Reposition of uterus if displaced. When neurotic, nerve sedatives are indicated. PATHOLOGY OF PREGNANCY. 95 (/>) Incontinence of Retention. — Is the most common symptom of a backward displacement. (c) Vesical Hemorrhoids. — Due to increased blood supply and pressure of womb. Haematuria may be a symptom. If extreme, astringents may be injected. {d) Cystitis. — More frequent after labor ; complicating pregnancy, it may be due to gonorrhoea. (e) Vesical Calculi. — Important that it be discovered before labor, and removed through the urethra or by vaginal lithotomy. (/) Cystocele. — Complicates labor. {g) Injuries., Tumors^ EMropliy. — Are very rare, and should be treated as their individual peculiarities may indicate. 3. Anomalies of the Urine, {a) Polyuria. — An exaggeration of the physiological alteration. Q)) The urine may be diminished in quantity and more concen- trated, as the result of errors in diet and inactivity of skin and bowels. (c) Idpuria. — Explained by the unusual quantity of fat in the blood of some pregnant women. An oiled catheter may be the source. {d) Cliyluria. — Is of no pathological import. (e) Peptonuria. — Occurs very rarely in pregnancy. Said to be diagnostic of foetal death. (/) Hcematuria. — Produced by vesical hemorrhoids. (g) Glycosuria. — Ranks next in importance to albuminuria. May be found in fifty per cent, of cases. Is probably hepatogenic. Diabetes mellitus occurs more frequently in pregnant than in non- pregnant women, and when it exists before pregnancy, the latter condition increases its severity. In seven out of nineteen cases the disease determined foetal death, and in four out of fifteen cases the mother died shortly after labor. IV. Diseases of the Nervous System. 1. Brain. (a) Inflammatory Diseases. — Are accidental complications and rare ; exert no special influence upon pregnancy, nor do they specially modify the course of gestation, except cerebro-spinal meningitis, 96 OBSTETRICAL LECTURES. wliicli is infectious, and therefore lias the same influence upon and is influenced in the same way by pregnancy as the other infectious fevers. (5) Anemia and Congestion. — (See Eclampsia). Apoplexy result- ing from congestion has no influence upon the course of pregnancy or labor. 2. Spinal Cord. Inflammatory Diseases. — Also accidental and without influence upon pregnancy and labor. 3. Peripheral Nerves. Obstinate neuralgias, which are little benefited by treatment, and disappear after labor. 4. Neuroses. (a) Chorea. — Milder grades are not uncommon. Sixty per cent, of cases are in primiparse. Heredity, chlorosis and rheumatism are predisposing causes. In the graver variety, premature expulsion of the ovum is apt to occur, followed by death of the mother in about thirty-three per cent, of cases. Treatment. — Fowler's solution, iron, and nutritious diet for the milder cases. The graver cases may require an anaesthetic, and finally induction of premature labor, which is usually followed by sponta- neous recovery. (h) Epilepsy. — Comparatively rare. Usually does not influence unfavorably the course of gestation. It is most hkely to be confused with Eclampsia (see Eclampsia). The infant frequently dies after birth, presenting the symptoms of the maternal disease. (c) Hysteria. — Occurs frequently in its minor grades, and, as a rule, does not exert an unfavorable influence. 5. Organs of Special Sense. (a) Eyes. — Failing vision should always indicate an examination for advanced kidney disease. Occasionally there occurs complete temporary bhndness, associated only with anaemia of the eye-ground, due to reflex contraction of the retinal artery. (b) Hearing. — Disturbances of this sense are rare, usually tem- porary, but may be permanent, and up to the present time are in- explicable. pathology of pregnancy. 97 6. Psychical Alterations. Melancholia^ raarua^ dementia. Frequenqj. — Of all cases of insanit}^ in women, about eight per cent, have their origin in child-bearing. About one in four hundred confined become insane. Causes. — {a) Fredisposing. — Strain of gestation in those predis- posed by hereditary influence , temporaiy causes of mental disturb- ance ; great reduction in physical strength . (&) Exciting. — Exaggerated anaemia, asfi'om prolonged lactation ; septicaemia ; albuminuria ; profound emotions, as exaggerated fear of impending danger ; dystocia, as hemorrhage after labor ; great exhaustion, etc. Chorea results rather from the same predisposing causes, and should not be considered an exciting cause. Symptoms. — May be maniacal, melancholic or demented, i. e., exaggerated stupidity, fatuity and mental confusion. Time of Occurrence. — Most frequently during puerperium, next in lactation, and least during pregnancy. Mania is the most frequent form, melancholia next, dementia last. Diagnosis. — Easy. Important to distinguish puerperal insanity from ( 1 ) the temporary delirium of labor, (2) delirium tremens, (3) the delirium of fever, especially septicaemia, and (4) preexisting insanity. Temporary Delirium, of Lahor. — Exceedingly^ common. Is usually momentary, and varies in degree from hilarity to exaggerated mania. Deliriwm Tremens. — Labor, like an accident or surgical operation, can precipitate an attack in hard drinkers. Delirium of Fever. — Most commonly due to septic infection. Often- times it is necessary to wait until the fever subsides to determine whether it be the cause of the mental symptoms. Freexisting Insanity. — Determined by the previous histoiy. Frognosds. — About two-thirds recover their reason ; of the other third, from two to ten per cent, die of septic infection or exhaustion ; the rest remain permanently insane. Treatment. — Rest cure, combined with administration of iron, arsenic and nutritious diet, together with careful supervision to pre- vent any injury to themselves or attendants. 7 98 OBSTETRICAL LECTURES. V. Diseases of the Circulatory Apparatus. 1. Endocardium. Valvular disease of the heart usually has its origin prior to preg- nancy. It may originate from septic infection . Prognosis. — Abortion is induced in about twenty-five percent, of cases as the result of placental apoplexies, or stimulation of the uterus to contraction by the accumulation of CO 2- Pregnancy also increases the danger of the heart lesion. In fifty-eight serious cases twenty-three died after premature delivery of the child. In milder cases the prognosis is not so grave, yet the danger is increased. Complications to be dreaded during gestation are : {a) a fresh out- break of endocarditis, fatty degeneration of the papillary muscles, and especially congestion of the lungs. If the disease be of long standing and advanced degree, about half the cases will die. If recent and limited the symptoms may only be aggravated. Treatment. — Same as under other circumstances. If maternal life is threatened induce abortion or premature labor, guarding against a fatal result after the expulsion of the contents of the uterus by venesection should other organs become engorged, and by the application of pad and binder to prevent the ill effects of sudden diminution of intra-abdominal pressure. 2. Heart Muscle. {a) Suppurative myocarditis, only seen in connection with septic infection ; (b) brown atrophy ; (c) fatty degeneration which may occur acutely inconsequence of septic infection, or the accumulation of poisons in the blood when the kidneys are inactive. 3. GrRAVEs' Disease and Goitre Are unfavorably influenced by pregnancy. 4. Blood Vessels. The only disease of clinical interest is varicose veins, in rectiun, anus, pelvis, bladder, external genitalia and lower extremities. Causes. — Changes in the investing muscular sheath of the veins, increased quantity of blood, and mechanical disturbances by the growing uterus. PATHOLOGY OF PREGNANCY. 99 CompUcatiouH. — llujjture with possibly fatal lieuKjiihage, or extensive extravasation of blood under the skin. Thromboses and phlebitis with suppuration and septic infection may occur. As the result of itching and scratching, eczema or even erysipelas may develop. Treatment. —Elastic bandage or stocking when'in the legs. Small doses of heart tonics may be given and constipation avoided. Absolute rest in cases of thromboses, to prevent embolism. Lead water and laudanum when there is any inflammation. Abscesses should be opened. A mechanical protection should be applied to aiFected part to prevent the development of eczema or erysipelas, and. itching may be relieved by weak solutions of carbolic acid or cocaine. 5. Blood. Pregnancy very often has a direct influence in producing those blood diseases which are characterized by a marked alteration in its constituent parts. Pernicious anaemia and leucocythsemia can have their origin in gestation, and should they already exist their prog- nosis is rendered more serious. The anaemia of pregnancy may be so exaggerated as to simulate these , yet arsenic, iron and nutritious diet after delivery will usually efi"ect a cure. VI. Diseases of the Respiratory Apparatus. 1. Nose. The sense of smell is more acute, and peculiarities in this sense are developed, as abhorrence for certain odors, which may excite nausea and vomiting in neurotic individuals. More important is the disposition to epistaxis, which may be so severe as to threaten life. Mqre frequently, however, this complica- tion occurs during labor. It can only be relieved by the rapid termi- nation of labor. 2. Larynx. If a tumor, tubercular or syphilitic disease be present, there is a constant danger of oedema of the glottis which wnll require trache- otomy. 100 obstetrical lectures. 3. Bronchi and Lungs. (a) Bronchial Catarrh ordinarity is not liannfal, but constant coughing can cause abortion, and the hydrgemic condition of the blood predisposes to pulmonary oedema. (b) Pneumonia. — Symptoms are much aggravated, mortality increased, and in the vast majority of cases the foetus is expelled prematurely. (See Pathology of Puerperium. ) (c) Emphysema.. — Quite common. Symptoms aggravated and abortion apt to occur. Inhalations of oxygen may be given to coun- teract the accumulation of CO 2. {d) Phthisis. — The influence of pregnancy upon this disease is most unfavorable, and in those predisposed gestation may be the determining factor which brings on an attack. Treatment. — Cod-liver oil, iron and nutritious diet. After labor forbid nursing the child, as lactation is a drain on the mother's strength and the infant may be infected. »(e) Miliary Tuherculosis is rapidly fatal and may be mistaken for septic infection. (/) Pulmonary Embolism is a possible accident. {(/) Pleuri'iy. — Exerts no deleterious influence upon, nor is it afl"ected by pregnancy. VII. Infectious Fevers Are always more serious when complicating pregnancy, their symp- toms being more severe and mortality greater. Even measles at this time may become a deadly disorder. Upon pregnancy their influence is, as a rule, unfavorable. Sixty- five per cent, of typhoid cases are complicated by abortion. Syphilis rather exerts its influence upon the foetus. If the mother is diseased before impregnation the foetus and appendages exhibit characteristic pathological alterations. If the mother acquires the disease from the foetus she may exhibit all the secondary signs without the appearance of a primary lesion. If she be infected during gestation, as a i-ule, the mother is affected, the foetus escap- ing, although the latter is not so absolutelj^ exempt from infection as at one time claimed. Should infection occur at the time of impregnation the primarj^ sore may become almost malignant, PATHOLOGY OF PREGNANCY. 101 ulcerate into the vagina, resist treatment and complicate the puer- peral state. Treatment. — All the infectious diseases are to be managed with little reference to pregnancy. If abortion is threatened it should not be combated, as it is an effort on the part of nature to improve the maternal condition. VIII. Skin Diseases. The following are said to have their origin in pregnancy : — L Impetigo Herpetiformis. The favorite seat of the eruption is in the groin, around the umbilicus, on the breasts, in the axilla. Th-e small pustules become cmsts, around which new pustules develop until the entire surface of the skin in the course of three or four months becomes covered. Rigors, high intermittent fever, great prostration, delirium and vomiting accompany the eruption. The disease ajDpears, as a rule, during the second half of gesta- tion. Modern observation has shown that it is not absolutely confined to pregnancy. Of twelve cases ten terminated fatally, but thej^ exercised no influence upon the course of gestation. 2. Herpes G-estationis Is characterized by a pemphigoid efflorescence, exhibiting erythema, papules, vesicles and bullae. It appears early in pregnancy, con- tinues during gestation, and disappears during the puerperal state. Neurotic symptoms are associated with it, showing its probable nervous origin. 3. Pruritus. Its usual seat is the external genitalia. It may be general. Causes. — Neurosis ; irritating discharges ; parasites. Rarely in the general variety it may be necessaiy to induce premature labor. IX. Injuries and Accidents. Severe injuries usually result in abortion. The most serious accidents are those which cause rupture of some of the larffe blood- vessels of the external genitalia or lower extremities. One of the 102 OBSTETRICAL LECTURES. rarest accidents is spontaneous rupture of the uterus. It may occur in consequence of a previous Caesarean section ; chronic inflammation of the uterine walls, reducing them to little more than connective tissue ; traumatism. X. Surg^ical Operations. When hfe or health are seriously threatened by delay until recov- ery from the puerperal state, surgical operations upon pregnant women are justifiable, and permission may be given for their per- formance without very great fear of inducing thereby an abortion. XI. Abortion, Miscarriage and Premature Labor. Abortion. — Expulsion of ovum before the fourth month. Miscarriage. — Expulsion from the fourth to the sixth month. Premature Labor. — Delivery of a foetus that has become viable. Frequency. — Correct estimate dif&cult. One to four or five preg- nancies. Causes. — (1) Death of the foetus ; (2) abnormalities and diseases of the membranes including the deciduge ; (3) pathological condi- tions of the placenta and apoplexies of the ovum ; (4) traumatism ; (5) certain diseases of the mother directly affecting the product of conception (see Diseases of the Membranes and Foetus) ; (6) condi- tions of the mother causing contraction of the uterine muscle and premature expulsion of the normal ovum. The last cause includes the following : — {a) Irritable Uterus. — The expulsion, in such cases, results from a trivial cause, as, a long walk, purgatives, jolting, congestion of the pelvic organs, chronic constipation, reflex irritation as from suckling, extraction of a tooth, pruritus, ovarian disease. At the menstrual epoch these causes are most liable to produce abortion. (Jj) Spasmodic muscular action in the mother. 1. Chorea. — Less than half the cases go to term. The prema- ture expulsion of the ovum explained by physical exhaustion, blood stasis and excess of CO 2 in the uterine muscle stimulating to con- traction or by choreic movements of the uterus . 2. Eclampsia. More than one-half the cases abort as the result of asphyxia of the uterus, accumulation of urea, carbonate of ammonium or ptomaines, or PATHOLOGY OF PREGNANCY. 103 due to the convulsive action being shared by the uterus. 3. Uncon- trollable vomiting and cougJdng. Of 51 cases 20 were dehvered before term. 4. Epileptic^ hysterical^ cholmmic and tetanoid con- vidsions. (c) Conditions of the maternal blood ivhich stimidate the uteriiji to expidsive efforts. 1. Poisons of all the infectious ferers. It is yet undecided whether the abortion is due to irritative action of microorganisms, leuco- maines, or to a diminution of the oxygenating power of the blood. When there is an accumulation of CO2, as in pneumonia, heart dis- ease, emphysema, etc., inhalations of oxygen may be given with some hope of success. 2. Fever. (d) Local conditions. ]. Tubal or ovarian diseases., tcith perimetritis and adhesions. 2. Fibroids., polyps. 3. Uterine displacements. 4. Laceration of the cervix in irritable uteri. 5. Over-distention from hydramnion or midtiple pregnancy. (e) Placenta prwvia, obesity., contagious abortion. These are rare causes, and the last are really cases of septic infection. Clinical Phenomena. — 1. Hemorrhage. 2. Pain. 3. Expul- sion of some portion of the ovum. All three are rarely typically manifested in every case. Their duration varies from almost in- stantaneously to days or weeks. In early abortions hemorrhage is more pronounced than pain, and the blood is extmded in coagula. The appearance of the substance expelled varies with the period of pregnancy and entirety of the product of conception. The chorional coat may be entire, the deciduae alone may surround the embryo, or it may be surrounded by the amnion. Most frequently the decidua vera remains behind, and hence the danger of sepsis. Mortality. — In 926 cases there were 13 deaths, a mortality of 1.4 per cent. Diagnosis. — {a) Threatened abortion. Hemorrhage, and more or less pain in a patient with signs of early pregnancy. (6) Inevitable abortion. Persistent hemorrhage ; dilatation of OS ; ovum presenting ; considerable pain ; portions of ovum ex- pelled : effacement of the angle between the upper and lower ute- rine segment (Tarnier). Exceptionally one or more of these may be present and the case go to term. 104 OBSTETRICAL LECTURES. (c) Incomplete abortion. Examination of fragments discharged by floating them in water. Digital examination will usually find the OS patulous, and detect shreds of deciduae, the placenta or foetal membranes in the uterine cavity. {d ) Complete abortion. Uterus is firmly contracted ; os retracted and digital examination of the uterine cavity difficult or impossible. The diagnosis must depend upon the history ; the examination of the discharge ; the enlarged uterus ; lochial discharge, and possibly the establishment of milk secretion, which is more marked the later the date of pregnancy. Finally, the disappearance of the presump- tive signs of pregnancy which had previously existed Diagnosis of Miscarriage. — Escape of liquor amnii indicates rup- ture of the membranes. As the result of the death of the foetus, there is a cessation of foetal movements and growth of the uterus, a disappearance of the reflex and psychical disturbances characteristic of pregnancy, and possibly the appearance of the milk secretion. The pain is greater than in. abortion and is more like labor pain. At this stage of pregnancy the placenta is intimately adherent to the uterine wall, and often fails to become detached. For this reason the hemorrhage is apt to be serious and the danger of sepsis great. Prognosis of Abortion and Miscarriage. — The ovum is inevitably destroyed. The dangers to the woman are hemorrhage, particularly its secondary efi"ects, and sepsis. Retained fragments may develop into polypi. Treatment. — (a) Preventive. Includes the treatment of the causes that may exist in any given case. Enjoin rest at menstrual epoch, and restrain sexual intercourse where there is an irritable uterus. Replace a displaced uterus ; repair a lacerated cervix ; treat any inflammatory condition about the uterus. If it be due to any of the general diseases, do not attempt to interfere and prevent the occurrence of tbe abortion. Q)) Threatened Abortion. Absolute rest in bed. Drugs to diminish nervous sensibility and muscular action, as opium, potas- sium bromide, chloral. Opium should be given in full doses by the mouth, hypodermatically, or by the rectum. The fluid extract of viburnum prunifblium in drachm doses is very efficient. It may be combined with opium, administering the latter by suppository. PATHOLOGY OF PREGNANCY. 105 (c) Inevitable Abortion. If the hemorrhage is profuse before dilatation of the os occurs, control the bleeding by vaginal tampons of antiseptic wool or baked cotton. Remove in eight hours and re- apply if required. Often when the first one is removed, the ovum or foetus may be found extruded, when the urgent symptoms may subside. Intrauterine tampons of little balls of iodoform cotton or strips of iodoform gauze maybe used if required. Deciduous mem- brane in the earlier months, the placenta in the later, are apt to remain behind. The best method to employ for their removal is a disputed question. The expectant plan combines the use of ergot, tampon, and great care to avoid rupturing the membranes. If the abortion be incomplete, rest in bed, small doses of ergot, vaginal, and, if possible, intrauterine, antiseptic douches. At the first indication of sepsis the uterine cavity should be cleared out. The active treatment, which is the better jjlan, involves the use of the tampon to control bleeding, and as soon as the os is sufii- ciently dilated, the removal of the uterine contents by one of the following plans : The finger ; the curette in experienced hands ; the method of expression (Hoening) ; the ecouvillon (Doleris) ; after which an intrauterine douche of a two per cent, solution of creolin should be given. If needed, Hegar's dilators may be used to stretch a retracted os. After- Treatment. — Very little required after active treatment, beyond confinement to bed until involution is complete. When the expectant plan has been followed, antiseptic douches are to be used, and the earliest sign of sepsis looked for. XII. Extrauterine Pregnancy. Frequency. — The exact proportion to intrauterine gestations is difficult to determine. In the larger cities a large number occur annually. Many cases are never diagnosticated. Classification based upon the SituMtion of the Developing Ovum. J. Tubal. {a) Tubo-uterine or interstitial. (6) Tubal proper, (c) Tubo-ovarian. 2. Ovarian. 3. Abdominal. 106 OBSTETRICAL LECTURES. Cause. — Obscure. Any disease of the mucous membrane of tbe tube depriving it of cilia, forming mucous polyps or otherwise ob- structing its calibre predisposes to its occurrence. Clinical Hktory. — In each of the situations noted above, the course of gestation is somewhat different, and presents a different clinical picture on account of the difference in the surrounding ana- tomical structures which are involved. Changes in Uterus and Vagina. — In all forms these changes are rather constant. Most of the alterations characteristic of intrauter- ine pregnancy are found, i. e. , hypertrophy of the vaginal mucous membrane, with increased blood supply (purple tinge) and increased secretion ; cervix softened and os patulous ; uteras enlarged, and, in the vast majority of cases, deciduous membrane developed, which undergoes the same change as in intrauterine gestation preparatory to its separation and extrusion, which occurs in extrauterine gesta- tion between the eighth and twelfth week. The other changes in the maternal organism vary with the situa- tion of the developing ovule. Clinical History of Tubal Pregnancies. — The most frequent situa- tion of an extrauterine gestation is about the median portion or outer third of the tube. In this position it may grow upward into the abdominal cavity distending the tube walls to the point of rup- ture, or it may grow downward between the layers of the broad ligament. The tubal walls grow thicker from the development of their muscle fibres, except at spots, especially on upper and posterior surfaces, where rupture may occur, the individual, perhaps, expe- riencing severe cramp-like pain followed by symptoms of profound shock and death in a few hours. Exceptionally, the gestation may proceed to fall term, which is more common when the ovule has grown downward. When rupture occurs it usuallj^ takes place between the eighth and twelfth week. If upon the upper or posterior aspect of the sac the contents are extruded into the peritoneal cavity with an intraperitoneal hemorrhage. If rupture occurs on the lower aspect, the contents and hemorrhage find their way between the layers of the broad ligament and pelvic fascia, giving rise to an extra-peritoneal hagmatocele. The first variety is usually fatal ; the last is not always directly dangerous to life. PATIIOLOUY OF PREGNANCY. 107 Clinical History of Interstitial Pregnancy. — The ovule develops in the uterine wall, the inner side of the sac often projecting into the uterine cavity, and having on the outer side the round ligament and the greater part of the tube. The usual termination is mpture into the peritoneal cavitj^ Rupture into the uterine cavity and expul- sion of the ovum through the cervix is jxjssible. Clinical History of Tuho-ovanan Pregnancy. — The ovum devel- ops between fimbriae of tube and ovary. The sac in-xy mpture with the usual consequences of such accident. It is possible, however, to see a development of the ovule to maturit}'. Clinical History of Ovarian Pregnancy. — The ovule, impregnated while it is still within the Grraafian follicle, reaches some degree of growth and development in this situation. Is exceedingly rare. At least one undoubted case on record. Clinical History of Abdominal Pregnancy. — x\lso rare. Two authenticated cases. Is likely to go to full period of gestation and mature development of foetus. Terminations of Extrauterine Pregnancy. {a) Rurpture of tJie Sac and Profuse Hemorrhage. — Occurs most commonly in the tubal variety, where the growth is upward toward abdominal cavity. May occur when the ovule grows down between layers of broad ligament ; also in tubo-uterine, tubo-ovarian, ovarian and abdominal. Up to second month the extruded embryo may be absorbed. (h) Rupture of sac tcith extrusion of contents, and interstitial hem- orrhage into sac tcalls icithout escape of blood into peritonecd cavity or between layers of broad ligament. — This is followed by atrophy of ovum and sac. (c) Death of the Foetus after its Maturity. — Occurs most often in abdominal or tubo-ovarian, though possible in pure tubal. 1. The foetus may be converted into a lithopgedion. 2. The soft parts may macerate, leaving the bones, which may remain as an abdominal tumor or ulcerate into bladder or intestines. 3. The foetal body may putrefy from contiguity of the intestines and their contained micro- organisms and access of germs, {d) In the case of ovarian preg- nancy, arrest of development of the ovum at an earl.y period oc- curred, and the small cystic tumor containing the foetal bones was 108 OBSTETRICAL LECTURES. retained, (e) lu tuho-uterine, the ovum and embryo may be dis- cbarged into the uterine cavity and evacuated by the natural pas- sages. (/) In one case of so-called tubal abortion there was an internal rupture of the ovum, and blood was poured through the fimbriated extremity of the tube into the abdominal cavity, {g) It is asserted that a tubal pregnancy may nipture in its early stages, the embryo be expelled into the abdominal cavity, retaining its con- nection with the tube by the cord and placenta, and the foetus con- tinue to full development. This is called a secondary abdominal pregnancy. Rupture in these cases has probably not occurred, and the sac wall carefully examined would probably show enormous dila- tation of the tubal wall. (A) G-rowth and development of the placenta after foetal death has been asserted. This does not occur. Symptoms. — («) Subjective. In the early months may be indis- tinguishable fi'om those of intra-uterine gestation. In the tubal variety, which is more common, there is usually no indication of any abnormality until nipture occurs. In some cases this may be preceded by severe cramp-like pain, accompanied or followed by the discharge of deciduous membrane. When advanced development occurs, as in abdominal and some cases of tubal, no symptoms may arise until the time for labor has passed, when pain and other com- plications may arise. (6) Objective. 1. Tubal. Tumor felt to one side of the uterus, which is smaller than would be expected from the duration of the pregnancy. The uterus is usually displaced forward, backward, or to the side opposite the tumor. * 2. Interstitial. Diagnosis difficult or impossible . The uterus en- larges to a greater degree than in any other variety, and it may be impossible to determine whether or not it is symmetrically enlarged. 3. Abdominal. When the ovum occupies Douglas' pouch, the foetal parts may be made out. A sacculated uterus may be mistaken for this. Diagnosis. — In spite of a most careful history and physical exami- nation, the diagnosis is occasionally impossible. Usually it is not made until rapture has occurred. At this time a history of early pregnancy, sudden collapse and symptoms of internal hemorrhage, with a vaginal examination showing effusion into peritoneal cavity, makes the diagnosis and indicates immediate laparotomy to prevent PATHOLOaY OF PREGNANCY. 109 further hemonliage and peritouitis. Should tlie cvamp-like pain cause a patient to consult a physician, and should she give a clear history of impregnation — all the earlier signs of pregnancy, the dis- charge of blood and membrane, which the micrr)SCOpe shows to be decidual, with the detection of a tumor in the neighborhood of the uteras, on whicli balhjttement may perhaps be practiced* and the uterus not very mucli enlarged — the diagnosis is justified, and treat- ment also, even if it involve a serious operation. Among the con- ditions in the pelvis that may make the diagnosis impossible are abortion, in consequence of, or coincident with, some growth near the uterus ; pyosalpinx, with an indistinct or untrastworthy history of pregnancy ; intrauterine pregnancy, with rapid development of a fibroid on one side of the uterus ; development of an impregnated ovule in one horn of a two-honied utenis or on one side of a double uterus. Treatment. — Differs as it is met with in its early stages, or after Tupture ; whether interstitial, tubal, ovarian or abdominal ; whether the foetus has reached advanced development, as in abdominal ; whether the conditions f(jllowing foetal death require the treatment. If the diagnosis has been made early., electricity or laparotomy and removal of the foetal sac. The ordinarj^ practitioner should first tiy electricity. Thefaradic current seems to be the most efficient. One electrode in rectum, the other over Poupart's ligament, on the side occupied by the sac. The fall strength of a single-celled batteiy may be passed through the sac, and if the growing contents of the •sac are destroyed, the whole ovum may ultimately disappear. A galvanic current of 10 milliamp^res may be employed. Electricity fails in a certain proportion of cases, and laparotomy is the only resource, which, in these cases, is almost always a difficult opera- tion, not to be undertaken by an unskilled operator. After rvpture the indication is for immediate laparotomy, evacua- tion of the blood from peritoneal cavity, ligature of the sac, and its entire removal. Kupture followed by hemorrhage is, however, not invariably fatal. In interstififd little can be done until mpture and hemorrhage have occurred, when laparotomy may be performed, ligating the bleeding point, and, if possible, clearing the sac of its contents, along with the placenta. Where this is impossible, supra-vaginal 110 OBSTETRICAL LECTURES. amputation of the uterus is indicated. It mi^ht be well, the diag- nosis being established, to try to effect evacuation of the foetal sac into the uterine cavity after thorough dilatation of the cervical canal. A mistaken diagnosis, however, would lead to a premature termination of a normal intrauterine pregnancy. Tubal. and ovarian are to be treated as outlined above, when dis- cussing the treatment of early extrauterine gestation and after rup- ture. In the ahdominal variety, always delay until just before the natural duration of normal pregnancy, when the foetus and foetal sac should be extracted by abdominal section. Five such operations have been done, with five maternal recoveries. In advanced cases, ill tvhich death of the foetiis has occurred, it is best not to subject the woman to the danger of the several possible terminations, but to perform laparotomy and remove the foetus and its entire surround- ing sac. If the exsection of the sac is found to be too difiicult or dangerous, it is permissible, some weeks after foetal death, to cut off the cord short, leave behind the atrophied remains of the placenta, stitch the sac wall to the abdominal wall, and thus drain the sac externally. Labor. Physiolog'y. Labor occurs usually 280 days after the appearance of the last menstrual period. Causes of Occurrence at this Time. {a) Periodicity. — The muscular action at the periods is especially- marked at the tenth. (6) Over-distention of Uterus, followed by Retraction. (c) Maturity of Ovum (fatty change of attachment). {d) Heredity, or Body Habit, which is perhaps the most powerful. At this time slight causes, as exercise, purges, excitement, may begin the process. Signs of Beginning Labor. (a) Subsidence of Uterus. — This is a premonitory sign. Occurs about four weeks before term in primiparae, two weeks or less in multiparae. LABOR. Ill Cause. — Over-distention of abdominal muscles. It may occ-ur suddenly, and be followed by relief of pressure symptoms above, while those below may be increased, as excessive vaginal secretion, oedema, etc. If it does not occur, it indicates a malposition of the foetus, or some obstruction, as contracted pelvis. {h) Pains. — Are colicky, intermittent ; felt over the sacrum, or beginning in front and passing back to sacrum. (c) Blood-tinged Mucus. — Due to expulsion of the mucous plug in cervix and torn ceiTical vessels. {d) DiIatatio7i of Os. — The most important. Clinical Signs of Labor. (a) Contractions of Uterine Muscle. — At each contraction the uterus drives the liquor amnii through the cervix, diminishes the area of intrauterine space, and produces an expansion of the birth canal. The contraction lasts about a minute, recuning at intervals of ten to fifteen minutes, which decrease as labor advances. (6) Behavior of the Fatient. — For about the first ten hours the sacral pains are increasing in frequency and severity. During the second stage the voluntary muscles are brought into play, as shown by her straining and bearing-down eiForts, the pains increase in frequency and strength, and there is a desire to emi:)ty bladder and rectum. (c) Phenomena of Birth of Head and Shoulders. — The head retracts after each pain, and there is an intense pain and outcry as the head passes the perineum. Restitution is followed by birth of anterior shoulder. A condition of contentment and happiness succeeds the birth of the child. Phenomena of Placental Separation and Expulsion. — Theories of its separation : — (a) Placental area diminished. (6) Placenta pushed off. (c) Separated by retro-placental clot. The first probably correct. Theories of Expulsion : — (a) Edgewise (Matthew Duncan). (6) Like inverted umbrella (Schultze). The last probably correct. 112 . OBSTETRICAL LECTURES. The pouch-like dilated lower uterine segment often contains the placenta, hence artificial aid in its complete expulsion often required. A slight elevation of temperature is normal after labor. Manag-ement of Labor. Summons to an obstetric case should receive immediate attention. (a) Arinamentarium. — Ether, brandy, vinegar, a large new sponge, pads, clothing for mother and child, should be provided before confinement. The obstetric bag should contain : soap, nail- brash, tablets of bichloride, iodoform tape, or antiseptic Chinese silk, pocket-case with sutures and needles, ergot, hypodermic syringe, iodoform gauze, absorbent cotton, a ten per cent, solution of cocaine, forceps. (b) The Exammation. — Abdominal palpation and auscultation should determine the position and presentation, touch should ascer- tain the state of the perineum, dilatability of vagina, and its secre- tions, roominess of pelvis, condition of cervix, effectiveness of pains, and should confirm diagnosis of presentation. (c) Treatment of the First Stage. — The bowels should be evac- uated by an enema, urine voided, patient allowed to remain out of bed, examinations to be made at intervals of an hour or hour and a half, and when the os is the size of a silver dollar the patient should be put to bed, lying on that side toward which the back of the foetus looks. (d) Ancesthema. -^CoGMne and belladonna are not effective. Chlo- roform is not dangerous. Ether is preferable, except in eclamjDsia. By giving it only in the second stage its administration for too long a time is avoided, and bj^ producing only analgesia an excessive amount is not employed. (e) Rupture of the Memhranes. — In a primipara the membranes should never be ruptured, and in multiparas only in the second stage. Finger, match, hairpin, etc., may be used to break them, the operation being performed in the absence of a pain, with the assurance that membranes are present, and not the lower uterine segment, thin from pressure of the head. (/ ) Treatment of the Second Stage. — Examinations should now be made every five or ten minutes. A puller may be employed to in- crease the abdominal force. LABOR. 113 The Perineum. — Bad lacerations of the perineum are avoidable. In primiparae the fourchette is torn in 61 per cent, of cases, the perineum in 34 per cent. ; in multipara?, the perineum in 9 per cent. Causes : — {a) Relative disproportion between the size of the head and out- let. (6) Precipitate expulsion. (c) Faulty mechanism. Preceative Treatment. — Depends largely upon the cause. If the disproportion be great, episeotomy may be required ; if expulsion precipitate, retard the head by hand or forceps; in some faulty mechanisms the forceps can be used to correct them, as by elevating the handles when the head is overflexed, etc. A routine treatment, based upon the most frequent cause, is to retard e^rpuhion by resist- ing the head and pressing it toward the pubes, restraining voluntary eiforts and using them during the absence of pains. The Head. — When the head is born avoid traction, support it, and if the cord be coiled around the neck, loosen and slip it over the head, allow the shoulders to pass through it or cut it between two ligatures. The Shoidders. — Avoid increasing any tear the head may have made. Treatment of the Third Stage. — Indications are, (1) prevent hemorrhage, and (2) deliver the placenta. Secure contraction and retraction of the uterus by external and internal stimuli : externally, by frictions through abdomen, continued for fifteen minutes and fol- lowed by the application of a pad and binder : internally, by admin- istering 5j of the fid. extract of ergot. The binder should be 12 in. by 1\ yds., preferably many-tailed, and the pad should be placed over the umbilicus. The placenta is separated by a diminution of the placental area, and its delivery should be accomplished by resorting to the Crede method fifteen minutes after the birth of the child. Remember that the movement of " expression " should be tcith a xjain. The Infant. — After pulsations in the cord cease, apply two liga- tures, for cleanliness, and cut between them across the palm of the hand. The ligature should be tied with the surgeon's knot, followed 8 114 OBSTETRICAL LECTURES. by an ordinary bow-knot, to permit tightening after the child has had its warm bath. Before the cord is dressed it should be stripped. The vernix caseosa should be removed by some oily substance, fol- lowed by soap and water. Salioylated cotton should be used to dress the cord, and the binder then applied. Puerperium. Physiology. The child-bearing process is divided into four periods, viz. : Preg- nancy, Labor, Puerperium and Lactation. The puerperium is the period from birth to the time when the uterus has regained its normal size, which is six weeks. Dimensions of uterus at 9th month, 2 lbs., 12 X 9 X 8i^ in., 400 cu. in. Dimensions of uterus 6 weeks after labor, 2 oz. , 1 cu. in. These changes in the uterus, its lining and adnexa result from the process known as Involution. Anatomical Development of the Pregnant Uterus. — Subsequent to impregnation the muscle cells take on a new growth, and in their development hypertrophy into muscular fibres four times as broad and eleven times as long. There is a similar increase in blood ves- sels, connective tissue, lymphatics and nerves. Anatomical Changes During Involution. — As a result of the de- crease in blood supply, which normally repairs tissue waste, the superabundant uterine tissue undergoes degeneration, chiefly fatty, and is carried away by the blood vessels and in the discharges, in part as peptones. The process is really an atrophy, which ceases after the enlarged muscle cells have been reduced to their original size. From the anatomical arrangement of its fibres the parturient nterus is composed of two segments, the upper muscular, with its fibres arranged crosswise, the lower largely fibrous, arranged longi- tudinally. In the process of involution the upper undergoes the greatest change, while the lower, including the vagina, is mainly a retraction of overstretched tissue, which never completely regains its tone. The lining membrane of the uterus, or decidua, is composed of an upper cellular and lower glandular layers. The upper is partly removed when the ovum is delivered, and the remainder dis- integrates as the blood supply diminishes, until the epithelial struc- PUERPERIUM. 1 ] 5 tures of the glandular layer are exposed, and from these epithelial cells in the glandular layer the mucous membrane is renewed. Lochia. — {a) Lochia Rubra. Bloody, last four to five days. (6) Serosa. Composed of disintegrating tissue, pus cells, mucus and water, (c) Alba. Composed of healthy pus. Quantity. — First four days, 1 kilo., or 2.2 lbs. Next two days, 280 grams, or ]5 oz. Until the ninth day, 205 grams, or 7 oz. —31 lbs in all. Quantity is estimated by the number of napkins soiled. In the first twenty-four hours the pads should be changed six times, during the next four daj^s three times a day, raid after the fifth day twice a day. A personal examination by the physician should always ascer- tain their odor, which is at first bloody, later like that of the genitalia. A putrid odor is the danger signal of decomposition and sepsis. Conditions modifying the force and frequency of pains which secure involution : — (a) Individuality. (b) Always greater in primiparae. (c) Over-distention of the utenis. After-pains. — Uterine action is excited by retained blood clots. They occur most frequently in multiparas, and may be distinguished from periuterine inflammation by being cramp-like, intermittent and not increased by pressure, the pulse and temperature not influenced. Paregoric 5j with ergot ,^ss, every 2 or 3 hours, will usually control them. The Circulation. — The pulse, which is accelerated during labor to 80 or 90, falls to 60 or lower, as a result of the diminished arterial tension after labor. The heart is found to be hypertrophied and dilated, the result of the increased demands made on the circulation during pregnancy. Secretions and Excretions. — All are more active to diminish the hydraemic condition of the blood, get rid of eff"ete material and prevent rise of temperature. (a) TIrinanj Function. — The urine is increased in amount, is more watery, all the solids except the chlorides being decreased. Sugar is found in 50 per cent, of cases. . Peptonuria. The kidneys are hypertrophied. There is frequently difficulty in emptying the bladder, which may be due to the following causes : — 116 OBSTETRICAL LECTURES. (1) DuriDg pregnancy the bladder can only expand upward, and this liabit is acquired at that time. After labor it expands in all directions and admits of greater distention before the walls respond and contract. (2) The abdominal walls are relaxed, and this factor in emptying fails. (3) (Edema and over-stretching of the soft parts from pressure of the head may diminish the calibre of the urethra and make its course tortuous. The difficulty in such cases often passes away when the catheter is used once. (Jj) Skin. — Sweat is increased. (c) Lungs. — Capacity increased. The expired air contains more water and effete products. {d) Boicel. — Sluggish, from pressure. (e) Thirst. — Increased by the large amount of liquid lost. (/) Appetite. — Diminished. Two pounds of muscle (uterus) and the subcutaneous fat developed during pregnancy are being ab- sorbed. {g) Weight. — There is a loss in weight (i to xS" of the body weight). (A) Temperature. — No rise of any consequence. Developjiental Changes. Mammary Function. — Each mammary gland is divided into 15 or 20 lobes, and these are farther subdi^^ded into lobules and vesicles. Each lobe has a duct, dilated before reaching but contracted when entering the skin. Forty-eight hours after labor the breasts enlarge, the veins engorge and become painful and tender. At this time the secretion changes from colostrum to milk. Colostrum is the secretion which appears after the fourth month of pregnancy. It contains no casein, albumen taking its place, which is a laxative to the foetus. Diagnosis of the Puerperal State. — Some of the more important signs are : (a) the presence of milk in the breasts, (6) the enlarged uterus, (c) lacerations along the birth canal and {d) the lochial dis- charge containing decidual cells. PUERPERIUM. 117 Management of the Puerperium. 1. Avoidance of Septic Infection. — Accomplished by securing (a) chemical cleanliness of patient, doctor and nurse, and ih) removal of all bloody cloths, excretions and food ; (c) secure ventilation, and look for possible insanitary plumbing. 2. Visits. — If the labor has occurred in the moraing, the patient should be visited in the afternoon, and daily for one week, subse- quently every other day. At each visit examination should be made of the temperature, pulse, nipples and breasts, and the lochia. The uterus should be palpated, and the passage of urine inquired for. The child's umbilicus should be examined for any bleeding and pas- sage of its urine and faeces noted. The nurse should receive direc- tions as to diet, catheter and the recording of temperature three times a day. 3. Secure Rest and Quiet. — The patient should lie on her back for three days, and without a pillow for the first six hours, to avoid syncope. She can be made more comfortable by moving her from side to side and alcohol rubbings. She should be kept in bed until the fundus is at or below the symphysis, usually in ten daj's, when restricted exercise should be enjoined, to prevent uterine disorders, as flexions, etc. In the better classes, until the fourteenth day, and restricted to room for four weeks. Involution is best hastened by promoting the natural process and a suitable diet. The prolonged use of ergot is rather unfavorable, because of its effect upon the milk secretion and stomach of mother and child. The degree of quiet should be absolute, and the mother and husband the only visit- ors admitted while the patient is in bed. 4. Secure Emptying of the Bladder. — Xever trust anybody s statement of the passage of urine. After twelve hours, if needed, the meatus should be cleansed with cotton dipped in bichloride solu- tion and a soft and antiseptically clean catheter i^assed at least three times a day. 5. Diet. — Opinion differs. Alight, easily-digested diet gives least disturbance, and is ])referable. 6. Bowels. — On the third day castor oil. Compound licorice pow- der may be used, and if the inflammatory changes during the milk formation be great, an active saline should be given. 118 OBSTETRICAL LECTURES. 7. Breasts. — For threatened inflammation during the develop- ment of lactation give a brisk saline, and if the breasts are too fiiU, empty by the infant, pump or massage. If the pain and inflamma- tion continue, apply lead-water and laudanum and mammary binder. Mammaiy abscess is always septic in origin, and should be consid- ered in every case. To prevent it, the nipple, after each nursing, should be washed with soap and water, and sweet oil applied. In some cases astringents may be used. The mammary binder is preferably T-shaped, one arm passing around the back, one-half of the remaining arm above, the other below, the breasts, and the two halves brought together between the breasts. 8. The Child. — Sleep, cleanliness and regularity in feeding should be secured. For the first two days it may be fed every three hours, then every two hours during the day, and from one to three times at night. A daily bath, 90° F. , should be given at nooij. Directions to Nurse. Before Lahor I. Have ready towels ; ether J lb. ; brandy (2 oz. ) ; vinegar (4 oz.); hot water; a bottle of antiseptic tablets; a large new sponge ; a roll of narrow tape ; a fountain syringe ; bed-pan ; new, soft rubber catheter ; 4 clozen pads, small package of salicylated cotton, absorbent cotten. II. Grive a rectal injection as soon as labor pains are well estab- lished. After Labor. III. No vaginal injection to be given unless ordered. TV. Take the temperature three times a day — morning, noon and evening. V. Place pad wider patient. No occlusive bandage to be used unless specially directed. VI. The external genitals to be washed ofi" four or five times a day with a warm corrosive subhmate solution 1-2000. Use absorbent cotton for this purpose. VII. If, at the end of 12 hours, the bladder cannot be emptied naturahy, use a catheter. Afterward, if necessary, catheterize patient three times a day. MECHANISM OF LABOR. 119 VIII. The patient is to lie on her back ; she may be moved from one side of the bed to the other several times a day : her limbs may be rubbed with alcohol and water or bathing whiskey once a day. IX. The Nurse's hands are to he washed in a 1--3000 suhlimate solution before catheterizing the patient, cleansing the genitals or breasts. Diet. — First ^8 hours. — Milk (11-2. pints a day), gniel, soup, one cup of tea a day, toast and butter. Second ^8 hours. — Milk toast, poached eggs, ponidge, soup, com starch, tapioca, wine jelly, small raw oysters, one cup of coffee or tea a day. Third If8 hours. — Soup, white meat of fowl, mashed potatoes, beets in addition to above. After sixth day, return cautiously to ordinary diet. Child. — I. After being well rubbed with sweet oil, the child is to be bathed in water of 90° ; this should be the temperature of the daily bath. II. The cord is to be dressed with salicylated cotton. Obsei-ve carefully for bleeding. III. It should be bathed daily, about mid-day, in the wai-mest part of the room. Use castile soap and a soft sponge ; avoid the eyes. TV . The bowels of a healthy infant are moved 4 times a day ; the diapers must be changed at least this often. Xote the color of stools. Nursing. — The child is to be put to the breast eveiy four houi-s for the first two days. No other food is to he given it. After the second day it should be nursed every two hours, fi-om 7 A. m. to 9 P. m., and twice during the night (1 A. m. and 5 a. m.). After every nursing the nipples are to be careftilly washed with a piece of absorbent cotton, warm water and castile soap, and then smeared with a little sweet oil. Mechanism of Labor. Definition. — The manner in which a foetus traverses the birth canal and is expelled. It takes into account the complicated struc- ture of the maternal and foetal parts, considering their movements and the mechaiiisms of their motions. 120 OBSTETRICAL LECTURES. Presentation. — That part of the foetal body which presents itself to the examining finger in the centre of the plane of the superior strait. Position. — May be applied to the position of the child in utero, whether longitudinal or transverse ; or, in another sense, it is the varying relations which the presenting part bears to the surrounding maternal structures at the plane of the superior strait. Presentation and position are determined by abdominal palpation, auscultation, and vaginal examination. Palpation and auscultation have been referred to. By vaginal examination the finger detects the varying portions of the foetal body which may jiresent at the superior strait, as cranium, face, shoulder, buttocks, knees, feet, and, exceptionally, elbow or hand. The position of the foetus in utero is longitudinal in 99J per cent, of all cases. The cephalic extremity presents in about 95^^ per cent. , 95 per cent, being vertex cases. In about J of 1 per cent, the face presents ; the brow very rarely. In about 3 per cent, of all cases the breech presents, and in about J of 1 per cent, the foetus will be transverse. Explanation of the Great Frequency of Cephalic Presentations. — Assumption of that position by the foetus, because it afibrds it the greatest degree of comfort and the best opportunity for growth and development. Explamation of the Great Frequency of Presentation of the Vertex. — Mechanical arrangement of foetal head and body, diagram matically represented by two bars attached to one another ; that representing the head joined to that representing the spinal column, not at its middle, but at a point nearer one end of the bar (T). An equal force exerted upon this mechanical arrangement will result in the greater flexion of the longer bar, which represents that portion of the foetal skull in front of spinal column. Positions of Vertex Presentations. — There are four : 1. L. 0. A. , left occipito-anterior, the occiput looking to left acetabulum. 2. R. O. A. 3. R. 0. P. , right occipito-posterior, the occiput looking to right sacro-iliac joint. 4. L. 0. P. Of all vertex cases 70 per cent, are L. 0. A. , 30 -per cent. R. 0. P. Explanation of Frequency of L. 0. A. and R. 0. P. — The posi- sition of the rectum shortening the left oblique diameter and the MECHANISM OF LABOR. 121 projectiuM of tlie spinal column to which the foetus' adapts*its ante- rior concave surface, the back thus looking forward and turned a little toward the right because of the right lateral version of the pregnant uterus. Forces Involved in the Mechanism of Labor. 1. Forces of Expnhion : — Uterine muscle. Abdominal muscles. 2. Forces of ReMstance : — Lower uterine segment, cervix, vulva, vagina. Pelvis. Foetal bodJ^ The forces of expulsion are furnished hy a great part of the uterine muscle (upper uterine segment) and muscular action of the abdominal walls. (That portion of the uterine canal which must be dilated to allow the escape of the foetus is called the lover vteriue segment ; that portion above the point at which the dilatation ceases, ?'. e., the contracting muscle, is called the tipper nterine segment; the boundary line between these, often marked hj a perceptible ridge, is called the contraction ring). The Manner in ivhich the Uterine Muscle Exerts its Force upon the Foetal Body. — By a diminution of the intrauterine area. The abdomi- nal muscles diminish the area of intra-abdominal space. The degree of force exerted by their combined action has been given as fi'om 1 7 to 55 pounds. The forces of resistance are famished by that portion of the parturient tract which must be dilated, i. e. , from contraction ring to vulva, including {a) the lower uterine segment, cervix, vagina and vulva. The dilatation of lower uterine segment and cervix is not simply mechanical, the serous infiltration of lymph spaces lessen- ing the tendencj^ to contraction and retraction. The dilatation of cei-vical canal is also assisted by the longitudinal fibres drawing the cervix up over the presenting part. Below the cervix, dilatation is effected mainly hy the mechanical stretching of its walls. {})) The hony walls of the x>elvis. — Only offer sufficient resistance to so delay the progress of presenting part as to insure gradual dila- tation of the soft resisting structures. (c) Fmtal hody. — Head most important. The foetal head maybe 122 OBSTETRICAL LECTURES. divided -into yielding and unyielding portions. The yielding con- sists of the cranium, composed of the frontal (2), temporal (2), parietal (2), and occipital bones. These are separated from one another as follows : The two frontals by the frontal suture ; the frontal from parietal by coronal suture ; the two parietal by sagittal suture ; the two parietal from occipital by the lambdoidal suture. At junction of lambdoidal and sagittal sutures there is a membranous space called the posterior fontanelle, triangular in shape. At junc- tion of frontal, coronal and sagittal sutures there is also a mem- branous space called anterior fontanelle, kite-shaped, larger than the former. This portion of the skull yields by overlapping of the bones. The unyielding portion comprises face and base of skull. The bones here are fixed. A transverse vertical section of the skull is wedge-shaped, taper- ing toward the neck. Possible Presentations of tlie Head. — Vertex. That conical por- tion with apex at smaller fontanelle and base at the plane of the biparietal and trachelo-bregmatic diameters. Face. Brow. Larger Fontanelle. Parietal Eminence. Mechanism of the Several Presentations and Positions. L. 0. A. Diagnosis. — By abdominal palpation, auscultation and vaginal examination, the back is found to the left, extremities to the right above, head below, heart sounds one inch below and to the left of umbilicus ; the examining finger detects vertex presenting, occiput toward left acetabulum and sagittal suture in right oblique diameter of pelvis, and smaller fontanelle, recognized by the junction of lamb- doid and sagittal sutures, the top of occipital bone overlapped by parietal bones. 1st Stex>. — Accommodation of size of foetal skull to pelvis by flexion, and accommodation of shape of foetal skull to shape of pelvic inlet by moulding. (Occurs before the onset of labor.) 2d Step. — Further flexion and moulding. (Occurs at the begin- ning of labor. ) 3d Step. — Lateral flexion of the head, the right parietal bone presenting. MECHANISM OF LABOR. 123 Ii.th >SVe/).— Dilatation of lower uterine cavity and cervical canal. 5th iS'^ep.— Descent of head to pelvic floor. 6tli Step. — Anterior rotation of occiput. Cause. — The head driven through the funnel-shaped parturient canal and meeting the resisting pelvic floor moves in the direction of least resistance, i e. , anteriorly t(jward median line. 7th Step. — Extension and propulsion of the head. 8th Step. — Restitution. 9fh Step. — External rotation. 10th Step. — Descent, rotation and birth of shoulders. 11th Step. — Delivery of remainder of the body. Abnormalities. (a) Flexirm at Inlet. — Imperfect vertical flexion in flat pelvis. Conservative on the part of nature to bring bitemporal diameter (8 cm.) in relation with contracted conjugate. Associated with this we find anomalies of position and lateral flexion, i. e., the occiput situated transversely, the sagittal suture in transverse diameter of the pelvis and the lateral flexion exaggerated as the result of the increased obliquity of pelvis to trunk and increase of conjugato- symphyseal angle. This is accompanied by overlapping of the right (anterior) parietal bone. Q>) Direction. —In anterior displacements of the pregnant utems, there is an abnormal backward direction of the presenting part. (c) Rotation. — Abnormal weakness in resistance or propulsion result in incomplete rotation. {d) Vertical Flexion at OwtZe?.— Incomplete when head does not encounter normal resistance in pelvic cavity. (e) E:cte.nsion.—F-<\J\[viTQ of extension of the head occurs as the result of weakness or destruction of the levatores ani muscles. (/) ReMitution.—W\\^ when neck is a long time twisted or tightly gripped by the vulva. {g) External Rotrxtion.—Due to failure of rotation of shoulders. Is of frequent occurrence. (h) Anomalous Dejicent and Rotation of Shoulders. 124 OBSTETRICAL LECTURES. K 0. A Diagnosis. — Palpation reveals back to the right anteriorly; extremities to the left above ; head below. Heart sounds near median line below umbilicus. Digital examination shows small fontanelle toward right acetabulum ; sagittal suture in left oblique diameter. MechanisTn. — Does not differ from the mechanism of L. 0. A., except the occiput being directed toward the right acetabulum, rotation of head and face occurs in the opposite direction. K 0. P., andL. 0. P. Posterior j^ositions of the occiput are primary or acquired. Primaiy when head enters inlet with occiput posterior (common) ; acquired when head rotates from anterior position at the beginning of labor to a posterior position at its close (rare). Diagnosis. — Palpation reveals back in the flank (right, in E,. 0. P. ; left, in L. 0. P. ) ; extremities to the opposite side in front ; head below. Heart sounds in the flank below a transverse line through umbilicus. Digital examination shows small fontanelle toward right or left sacro-iliac joint ; sagittal suture in an oblique diameter. Meclianistn. — Similar to mechanism of anterior positions includ- ing anterior rotation of the occiput to symphysis. As a consequence of this prolonged rotation a peculiarity is the rotation of the shoulders at the superior strait through a quarter of a circle, a movement not seen in anterior positions, and in consequence of the greater distance which the occiput has to traverse the clinical mani- festations of this stage are different, i. e. , there is greater pain and labor is more prolonged. After rotation has occurred the shoulders descend and rotate on the pelvic floor, as in anterior positions. The ftirther mechanism is identical with that of anterior positions. Cause of Forward Rotation of Occiput. — Same as in anterior positions, i. e. , whatever portion of the foftal head first .strikes the pelvic floor .^ whether it encounters this structure behind or in front of the median transverse line., will he directed forward under the sym- physis pubis. mechanism of labor. 125 Abnormalities in Mechanism. Backward Rotation of the Occiput complicates labor by protracting its course, increasing the danger of foetal death, and subjecting the mother to increased risk of injury. Causes. — 1 . Anomalies of Force. — Anterior rotation is the result- ant of the forces of expulsion and resistance, hence any condition disturbing the normal relation of these forces will interfere with the normal rotation. Thus backward rotation occurs when there is diminished expulsion, increased resistance, or decrease in resistance as occurs in cases of very large pelves, relaxed pelvic floors, small and yielding heads. 2. Anomalies of Flexion. — When flexion is imperfect the anterior vault of the cranium (as in those rare cases of presentation of the large fontanelle), the brow, or chin first strikes the fjelvic floor and is therefore directed forward, and the occiput thus directed back- ward. 3. Insuperable Hinclramces to Forward Rotation. — In some cases when flexion is only partially disturbed and the occiput first strikes the pelvic floor, the occiput will rotate backward, because the large diameter of the head (fronto-occip. llf cm.) engages and rotation from one oblique diameter of the pelvis, through the smaller transverse to the other oblique, is impossible. The occiput will also be directed backward for the same reason when the foetal head is over size, or accompanied by a prolapsed extrem- ity ; when the pelvis is deformed, particularly kyphotic, generally contracted and Naegele's ; when there is an abnormal projection of the lumbar and sacral vertebrae interfering with rotation of shoulder. Mechanism when Occiput Rotates into Hollow of Sacrum. — The occiput is propelled forward over perineum by increased flexion until the face is finally born under the symphysis by partial exten- sion. This mechanism subjects the cranium of the foetus to danger- ous pressure, and increases the danger of perineal rupture. Abnormalities in Mechanism just Descnbed. — x^bnormal resistance to de.scent of occiput, resulting in conversion into jDresentation of large fontanelle, brow, or face. Causes. — Projecting ischiac spines, central tear of perineum. 126 obstetrical lectures. Treatment of Posterior Positions of Vertex Presenta- tions. Bear in mind tlie causes of rotation backward, and try to prevent its occurrence, {a) Secure perfect flexion of the head hy placing patient on that side toward which the foetal back is looking, {b) Secure normal action of expelling and resisting f3rces. If the pelvic floor is weakened and does not supply sufficient resistance, reinforce it by two fingers in tbe vagina or single blade of. forceps. If expul- sion is faulty administer a single large dose of quinine, or forceps may be resorted to. If backward rotation occurs in spite of preven- tive treatment, extra precautions should be made to protect vaginal walls and perineum from laceration, and to avoid a protracted second stage. These can usually be accomplished by judicious use of for- ceps. It may be necessary rarely to first convert into a face presen- tation. Prognosis. — Not so favorable as in anterior positions of occiput. Forceps often required. Laceration of soft parts more frequent. The mortality of the foetus increased from 5 per cent, (normal vertex), to over 9 per cent. Luckily backward rotation occurs in only about IJ per cent, of all labor cases. Face. The bead is extremely extended. The chin is the most dependent part presenting, hence the classification by its situation, left mento- anterior, right mento-anterior, etc. Frequency. — Occurs about once in 250 labor Cases. Diagnosis. — Bulk of cranial vault felt to one side of hypogastric region ; a deep groove between occiput and the child's back may sometimes be made out. Heart sounds loudest over anterior surface of foetus, i. e. , on that side of abdomen upon which the extremities are felt. The diagnosis, however, must usually rest on digital exami- nation, which shows before onset of labor high situation of present- ing part ; flattening of anterior vaginal vault ; the contrast between the smooth outline of foetal forehead and irregular contour of the face. As soon as the os is dilated the characteristic features of the face can be felt. Has been mistaken for the breech. Should be considered an abnormality and entails greater danger upon mother and child. MECHANISM OF LABOR. 127 Cames. — Conditions preventing flexion, as tumors of the neck; increased size of thorax ; constriction of cervix about the neck ; coiHng of cord around neck. Conditions favoring extension, as mobiht}^ of foetus ; obHque posi- tion of child and uterus, especially when abdominal surface of child is directed downward and pelvis is flat : altered shape of head. After the head has reached the pelvic cavity it may be due to the conversion of an occipito-posterior position into that of the face, as already described, Meckaniwi. — Comprises the following steps : — 1. Extension. 2. Moulding. 3. Descent. 4. Anterior rotation of cliin, 5. Its engagement under symphysis pubis. 6. Delivery of head by flexion. 7. Restitution. 8. External rotation. 9. Delivery of body as in vertex presentation. Ahnormalities in Mechanism. — The most common is delay in forward rotation of chin under symphysis. This is due to the differ- ence between the lateral depth of the pelvis (3J inches), and the length of the foetal neck (U inches), /. e., the chin does not meet with sufficient resistance. Should the chin be directed posteriorly, where the depth of the pelvis is even greater, the delay is absolute, and such cases can only be terminated by artificial assistance. If left to nature the upper portion of thorax (9 cm. ) is forced into the pel- vic cavity, along with the posterior half of the child's skull (9J cm.), and it is impossible for these two diameters to pass through the pelvis. P/-o,^?io.svs.— Foetal mortality 13 to 15 percent. Maternal, from less than 1 to 6 per cent. Treatment. — Before labor begins, convert into vertex by the method of Schatz. If this fails and labor is in progress, guard against rup- turing the membranes, that the os may be more thoroughly dilated and the liquor amnii not drained away. If anterior rotation of the chin is delayed, it may be hastened by two fingers pressing on the cheek and chin ; or, if necessary, pressure may be applied with a 128 OBSTETRICAL LECTURES. single blade of the forceps. These failing, straight forceps may be used to effect rotation, and if the chin is directed anteriorly traction may be made. If the chin is directed backward traction should not be employed. Finally, craniotomy may be necessary. When the case progresses with or without assistance care must be exercised in the final delivery of the head, not to push the neck too forcibly against symphysis when trying to prevent laceration of the peri- neum. Brow. Head midway between^complete extension and complete flexion. The largest diameter of the head presents. Of all presentations of the head it is the most unfavorable for mother and child. The four positions are classified according to the direction of the chin. Diagnosis. — Is made by a digital examination. Mechanism. — The steps are similar to those of face presentation. When the chin is directed posteriorly the case is an impossible one for the same reason as in the posterior position of the face. Prognosis. — Foetal mortality, 30 per cent. ; maternal, 10 per cent. Treatment. — Before labor convert into vertex. This can some- times be accomplished by external pressure on the occiput to secure flexion. If this fails, insert hand in the vagina and pull occiput down. Next, try to convert into face if the chin is anterior. If this fails, version should be tried. It should not be resorted to if the waters are drained off, or the presenting part is fixed in the superior strait. Finally, if the chin is anterior, apply forceps ; if posterior, craniotomy is indicated. In face and brow presentations the cardi- nal rule is, not to use forceps except as rotators ; if traction is resorted to at all, it should be employed with the greatest caution and gentleness. Very rarely the head may be brought down far enough to meet with resistance, and thus be rotated anteriorly, but unless the head yields to moderate traction, embryotomy is pre- ferable. Breech. Presentation of any part of the pelvic extremity of the foetal ellipse. The classification is according to the direction of the sacrum, left sacro-anterior, right sacro-anterior, etc. Frequency. — Occurs in 3 to 4 per cent, of all cases. MECHANISM OF LABOR. 129 Causes. — ]. Abnormalities in shape of foetus or uterine cavity. Includes reversal of uterine ovoid (the lower uterine segment larger than upper) ; foetal monstrosities ; twin pregnancy (in 25 per cent, of cases the breech presents). 2. Increased mobility of the foetus. Diagnosis. — Head above, breech below. Heart sounds are heard on a transverse line above umbilicus. Digital examination shows high position of the presenting part ; absence of dome-like projec- tion of vaginal vault which is found in presentation of head ; the bag of waters projects as a pouch-like protrasion ; by pressure on the fundus with the other hand the characteristic features of the breech may be detected, ^, e. , the nates and sulcus between them, tip of sacral bone and coccj^, the thighs, external genitalia and anus, evacuation of meconium, which in breech cases is not of serious import. Mechanism. — Comprises the following steps : — 1. Descent of breech to pelvic floor. Occurs veiy slowly because the soft breech is an ineffectual dilator of the cervix and ineffectual irritator of reflex uterine contraction, hence many hours may be required. 2. Rotation forward of anterior hip. The anterior hip first stiikes the pelvic floor, but owing to the insufl&cient resistance which the soft breech encounters the rotation is imperfect. 3. Birth of anterior hip, posterior hip, thighs and trunk. 4. Engagement and descent of shoulders in oblique diameter. 5. Rotation foi-ward of anterior shoulder. 6. Birth of anterior followed by posterior shoulder. 7. Descent of head in oblique diameter. 8 . Rotation forward of occiput, which is always the part to first strike the pelvic floor. 9. Delivery of head in the following order : Chin, face, forehead, anterior fontanelle. Prognosis. — Foetal mortahty 30 per cent., including badly man- aged cases. TrexLtment. —Before labor, external version. After labor has be- gun, inaction until body is born to umbilicus, unless maternal or foetal life threatened. At this time interfere and deliver by press- ing upon fundus with one hand, the other hand in the vagina to y 130 OBSTETRICAL LECTURES. favor anterior rotation of the shoulder, flexion of the head, and to direct the head through the vagina. Abnormalities in Mechanism. — The most frequent and important are (1) backward rotation of the occiput and (2) excessive rotation of the breech. Backward rotation of the occiput is very excep- tional, and the mechanism now difi"ers as the head remains flexed or becomes extended. When flexed, the chin, face, forehead, anterior fontanelle slip out under symphysis in the order named, and the head is delivered. When extended, the chin catches upon the symphysis, the head is extremely extended and is born by the oc- cipital protuberance, small fontanelle, cranial vault and face slipping over the perineum. The following rules for managing these cases should be remembered : If flexed, the body of the child should be carried downward. If extended, the body should be carried up- ward over the mother's abdomen. Excessive rotation of the breech occurs as the result of prolapse of posterior extremity, and is of no great practical importance. Shoulder. Transverse position of the child in utero resolves itself into a shoulder presentation as the result of uterine contraction when labor begins. Shoulder presentations are classified according to the posi- tion of the back and head. When the head is to the right, the back can be in front or behind. The same is true when the head is to the left. The back is directed anteriorly twice as often as poste- riorly, and the head more than twice as often is found toward the left. Diagnosis. — Abdominal palpation reveals the foetus in a trans- verse position. The heart-sounds are more distinct at a point cor- responding to the interscapular region of the child, and sometimes cannot be heard. Digital examination shows the characteristics of the shoulder, viz., axilla, clavicle, spine of scapula, acromion pro- cess, head of the humerus, ribs. Causes. — 1 . Abnormalities in the shape and position of the uterus, as pendulous abdomen ; uterus bicornis ; kyphotic spine ; uterine fibroid and other abdominal tumors ; multiple pregnane}^ (in twin pregnancies the shoulder presents once in 22 cases). OBSTETRIC OPERATIONS. 131 2. Conditions preventing engagement of ceijhalic or pelvic ex- tremity, as deformity of the pelvis ; abnormally large child ; mon- strosities ; placenta praevia. 3. Abnormal mobility of the foetus, as occurs in hydramnion, after fcetal death, or in premature birth. Mechanism. — Strictly speaking, there is no mechanism of shoulder presentations. The course of these cases is impaction of the shoulder, ascension of contraction ring, death of the mother by rupture of the uterus or exhaustion, and destruction of the foetus by prolonged pressure. As a matter of ftict, however, nature can in exceptional cases effect delivery in one of three methods : — 1. Spontaneous version. The transverse position converted into a longitudinal by uterine contraction. 2. Spontaneous evolution. The breech slips past the shoulder and is delivered. 3. Body doubled up (corpore reduplicate). Treatment. — Version. Obstetric Operations. Induction of Premature Labor and Abortion. Abortion. When performed before viability of child (180th day). Indications.— When the patient is a subject of disease originating in or aggravated by pregnancy, and life endangered thereby, viz. :— 1. Pathological Vomiting. — Only after all known remedies and rectal alimentation fail. 2. Grave Albuminuria. — As when oedema, headache, casts, etc., threaten eclampsia. 3. Certain Nervous Diseases. — As acute mania, melancholia, or associated inflammatory changes in the brain. Rarely chorea. 4. Certain Blood Diseases. — Pathological hydraemia (pernicious anaemia), leucocythemia. 5. Displacements of Gravid t^/'eras.— Retroflexion, prolapse, her- nia, resisting other treatment. Always secure consultation and share responsihility. 132 OBSTETRICAL LECTURES. Methods. — Many have been resorted to, but have been found either too dangerous, slow, or ineffectual. Such are the use of ergot, cotton-root, injections upon cervix or between membranes, inflated rabber bags in vagina or uterus, rapid or gradual dilatation of the cervix, perforation of the membranes. The method recommended is a combination of the good features of some of those mentioned, and is as follows : — 1st. Disinfect canal by antiseptic douche and pledget of mercurial- ized cotton in cervix. 2d. Dilate cervix to size of thumb with Hegar's dilators. 3d. Antiseptic wool tampon in cervix and lower uterine segment, and a similar tampon in vagina. Remove at the end of 8 hours. If the ovum is not discharged from the uterus, remove it, using, with strict antiseptic precautions, the finger, or with greatest care, curette. Premature Labor. When performed after viability of child. Indications. — 1. For diseases as above. 2. Special Indications., as («) Contracted Pelvis, (b) Advanced Phthisis, Grrave Heart Disease, etc., threatening mother's life, (c) Habitual Death of Foetus just before term. Method. — Sims' position, aseptic hard rubber bougie passed in for 7 or 8 inches between deciduse vera and reflexa. Labor begins after a variable period, 3 hours to a wieek, the average being 36 hours. If the mother's condition demand immediate deliveiy, the method is as follows : — (a) perforate the membranes, {h) forced dilatation of cervix with Barnes' bags or Hegar's dilators, (c) for- ceps, or version and extraction. Forceps. Uses and Functions. {a) Tractor — most important. (6) Eotator. (c) Lever. (cZ) Compressor — dangerous. Indications . 1 . Anomalies in Expulsive Forces — as uterine or abdominal inertia. 2. Anomalies in Resistance — in the pelvis, soft parts or foetal OBSTETRIC OPERATIONS. 133 body, as minor degrees of contracted pelvis, abnormal rigidity or large foetal head. 3. Threatened F(jetal Life — as prematurely detached placenta, compression or prolapse of the cord, prolonged pressure on foetal head, feebleness of foetal heart, sudden death of mother. If the heart sounds sink to 100 for a mirmte forceps should be applied. 4. DebiUtatmg diseases^ acute or chronic^ rendering the ordinary forces insujjicient — as phthisis, tj'l^hoid, heart disease, etc. In such the forceps should be applied at the beginning of the second stage to avoid asphyxia or to save the mother's strength. 5. Life Endangered — as in heart clot, eclampsia, hemorrhage, rupture of uterus. 6. Abnormal Positions and Presentations and Anomalies in the Mechanism of Lahor. As a general rule, they should be applied when the head, during the second stage, has been stationai-y for two hours. Contraindications : — 1. Os must be dilated. Exception. When maternal or foetal life is threatened, it is allowable to apply them to a partially dilated OS, as when rupture of the uterus is threatened, as shown by the ap- proach to the umbilicus of the groove over the contraction ring. 2. Head must have engaged at the superior strait. Exception. To bring head down as a tampon in marginal placenta praevia. 3. Membranes must be ruptured. 4. Must not be used as tractors in faulty positions. 5. Should not be emjployed unless head be of average size. If too small or too large, apt to slip and lacerate the soft parts. 6. Shoidd not be employed ivhen the disproportion between the head and canal is too great. Forceps in Contracted Pelves. — Two factors, size of foetal head and degree of contraction, must be considered to determine between the use of forceps at term and induction of premature labor. The determination of the size of the foetus must be left to each indi- vidual's skill and experience in abdominal palpation. In contracted pelvis, if justo-minor, with conjugate 9 J cm., or over, it is justifiable to deliver with forceps at term . If the conjugate be less than 9^, induce labor preferably at 36th week. In the simple flat or rachitic flat, 9 cm. is the limit in primiparaB ; 134 OBSTETRICAL LECTURES. 9i cm. in multiparse, whose uterine and abdominal forces are not so strong as in primiparae, and in whom rupture of uterus is more apt to occur. Forceps Recommended. — Simpson, for the low operation, Poullet V. Hecker or Tarnier, for the high operation. Sawyer's, to protect perineum as the head emerges. Rules for Apx>lication. — In using the Simpson forceps, the left blade is always applied first. The left blade should be held in the left hand and introduced into the left side of the pelvis. Right blade right hand, right side of pelvis. With the diagnosis of the presentation assumed, the steps in the application of the blades may be summarized as follows : — 1 . Having introduced two fingers of the right hand into the vagina, the left blade, grasped at the lock by the left hand as a pen, is held almost perpendicularly, with the tip of the blade opposite the vulva. 2. The tip of the blade should enter the vagina and traverse the perineum toward the sacrum. 3. Rotate the blade outward in its long axis, to bring it in apposi- tion with the posterior inclined plane of the pelvis, and thus escape the promontoiy of the sacrum when the handle is depressed. 4. Depress the handle, carrying it to the left side, the fingers of the right hand in the vagina guiding the blade and protecting the soft parts. 5. Introduce the right blade in a similar manner, substituting right for left in the above description. 6. To grasp the head properly and facilitate locking, rotate for- ward the Hght blade in the first and third positions, the left in the second and fourth. Too great compression of the head may be avoided by placing a folded towel between the handles. Tractions should be made in a line parallel to the axis of the parturient canal — with the pains when present, at corresponding intervals when absent. During the inter- vals between the tractions the grip on the handles should be relaxed to release the head fi-om compression.^ * The skill and manual dexterity required in all forceps operations can only be acquired by actual practice, bence the student must avail himself of the opportunity to learn the technique of all the operations in the Laboratory of Operative Obstetrics. OBSTETRIC OPERATIONS. 135 Preliminaries to the Operation. — An anaesthetic always renders the operation less difficult. The lithotomy position at the edge of the bed is the most convenient. The blades should be immersed in a 5 per cent, solution of carbolic acid or boiling water, rubbed with a 50 per cent, solution of carbolic acid in glycerine and folded in a clean towel. Just before using them vaseline should be applied to their outer surfaces. Version. Version is an operation or manoeuvre to change the position of the foetus in utero. Varieties : — (a) Version by the head (cei)halic). {h) Version by the breech, (c) Podalic. jb Methods (a) Postural. (b) External manipulation. (c) Internal manipulation. {d ) Combined or Bi-polar. Indications for Version. 1. Presentations of the trunk — usually shoulder. 2. Deformity of pelvis. 3. Sudden dangers, when the head is not engaged, as eclampsia, heart clot, etc. 4. Malpositions of the head, as presentations of the ear, parietal bone, brow or face. 5. Placenta praevia. 6. Prolapse of cord. In all cases combined version should be tried first, followed by podalic if combined fails. Contraindications : — 1 . The presenting part should not be engaged nor out of os. 2 . High position of contraction ring. Conditions rendering the operation difficult., dangerous, or impos- sible : — (a) An undilated and undilatable vagina. (b) A similar condition of cervix, as in placenta praevia, where 136 OBSTETRICAL LECTURES, the operation is performed early. Always anaesthetize and overcome the rigidity gradually. (c) Inability to effect an entrance into the uterus, as occurs when the liquor amnii has been lost and the uterus is retracted, when the uterus is permanently contracted (tetanus of uterus so called), or when there is obstruction by the foetus, as hydrocephalus, spina bifida with meningocele. {d ) Inability to bring the feet down after they are grasped. (e) Conditions interfering with external hand, as excessive amount of fat in abdominal wall, hysteria, chorea, epilepsy, eclampsia. Conditions 3Iost Favorable for the Operation. — {a) Uterus distended by liquor amnii. (h) Os dilated. (c) Uterine muscles not irritable. (d) Abdominal muscles flexible and thin. (e) Cervix not rigid. Postural. — This method msij be used in deviated vertex presenta- tions. Ear presenting, turn the patient on the side, so that breech may face to that side and thus bring vertex over os. Brow present- ing, turn to that side toward which the face looks, and thus secure flexion and cause veitex to present. Combined. — The patient should be placed in the lithotomy posi- tion and anaesthetized. Externally use the hand nearest the part acted upon, operator facing the mother. Head is preferably brought to superior strait because it is usually nearer centre of pelvis, is more easily manipulated externally and vertex presentation most favorable to foetus. Podalic. — Preliminaries: {a) Secure relaxation of uterus and abdominal muscles by anaesthetic, (b) Secure lowest position of foetal^ feet by turning mother on that side toward which the feet point, (c) Use that hand, made aseptic, which midway between pro- nation and supination corresponds to abdomen of the child. The hand reaches the anterior foot first, and the advantages of resting content with traction on a single foot are : — {a) A further entrance into uterus is unnecessary. (b) Easier to hold. (c) The other doubles up along the abdomen and thus dilates cer- vix more thoroughly. OBSTETRIC OPERATIONS. 137 {d) Secures sacro-anterior position of breech, which is desirable. When the knee is born cease traction, unless there exist some indication for immediate delivery, stop the anaesthetic, turn the patient on her back, listen to foetal heart-sounds and leave the further delivery to nature until the head is about to be born, when it should be extracted by the following methods, in the order given : — {a) Wiegand. {h) Veit-Smellie. (c) Prague. {d) Forceps. Not more than five minutes should be consumed in the operation. When rapid delivery of breech cases maybe required, it is afcom- plished by means of the fillet or flexible blunt hook. Embryotomy. Embryotomy is mutilation of the foetus and comprises several operations : — {a) Craniotomy. (Jj) Decapitation, (c) Evisceration. {d) Amputation of extremities. Craniotomy. — Comprises opening the head, diminishing its size, and its extraction. Indications ivhen the Child is Dead. — When the mother can be saved risk or sufiering by the child's deliver3^ Indications when the Child is Living. (a) When the head is very large. {h) When the pelvis is very small. Many authors advise the operation when the conjugate measures 6-8 cm. , but the size of the head, its compressibility and the muscu- lar power of the woman are elements to be considered. Premature labor, when possible, should be the treatment. At term, forceps, version, Caesarean section are alternatives. Alwaj^s secure a consul- tation to share responsibility. Instruments for Operation. 1. Perforator. Blot's, Smellie or Hodge scissors. 2. Large catheter, and carbolized solution for washing out brain substance. 138 OBSTETRICAL LECTURES. 3. Cephalotribe. Karl Braun's, Tarnier's Basiotribe. 4, Cranioclast. Karl Braun's or Hirst's. The operation consists of the following steps : — (a) Etherization. (b) Vaginal douche of bichloride solution. (c) Yolsella forceps to steady scalp. ((^) Perforation of cranium. (e) Contents of cranium washed away. (/) Crushing with cephalotribe. ig) Extraction with cranioclast. Decapitation. — Indication. — Impacted shoulder presentation. Instruments. — Braun's hook, or Bamsbotham's sharp hook. Amputations., and Evisceration are very rarely indicated. Some forms of monsters may require them. Symphyseotomy. The operation is a division of the joint, allowing diastasis of the bones during labor, the child being delivered by the natural passage. Was performed for the first time on a dead woman in 1665, on a living woman in 1777. In 1866 the operation was revived, and from that time to 1881 it was performed fifty-three times with a death rate of 18 per cent. Not much space is gained and the operation is no longer employed. Caesarean Section. When the escape of the child by the natural passage is impossible, it may be delivered by an abdominal and uterine incision (Ceesarean section). If by an abdominal and vaginal incision the operation is called laparo-elytrotomy. Caesarean section may be performed ante- or jDOst-mortem. Post-mortem Ccesarean Section. —When the death of the mother is assured, cut open the abdomen and uterus with any instrument at hand. A living infant has been extracted twenty minutes, three quar- ters of an hour and even two hours after the death of the mother. Ccesarean Section upon the Living Woman. — Performed for the first time in 1500. Five years ago, in England, the death rate was 99 1^0 per cent. OBSTETRIC OPERATIONS. 1 ol> Varieties : — Porro-Ccesarean. — In 1876 Porro modified the operation by per- forming, in addition to laparo-hysterotomy, a laparo-hysterectomy, i e., removal of the uterus. The stump is fixed in the abdominal wound preferably by Koeberle's noeud. In 150 cases the death rate was 54 per cent., but since 1884 to the present time it has fallen to 20 per cent. The operation is performed to obviate any discharge into the abdominal cavity through the uterine sutures. Porro- Milller. — In this a long abdominal incision is made, the uterus is lifted out and then incised. The application of an Es- march around the cervix to control hemorrhage was also a modifica- tion of Miiller. Sanger. — The modifications of Sanger have given an operation which is the most successful and the one to employ, except when certain conditions indicate the PoiTO-Caesarean as preferable. The mortality with the best of German operators is 5 per cent., for mothers and less for the children. In general, it has now been re- duced to 20 per cent. ; for continental Europe to 12 per cent., and there have been six consecutive operations in Philadelphia without a death. The main feature of Sanger's discovery is the introduc- tion of two rows of silk sutures to close the uterine incision, one through the uterine muscle down to the decidua (two to the inch), and the other superficial (Lembert suture) to tuck in the peritoneal covering of the uterus which unites in twenty-four hours, and thus prevents leakage into peritoneal cavity. Another element of success is to be found in the fact that the operation is now undertaken in time, before forceps, version, embryotomy or other operations have been tried. Indications. — Are relative and absolute. (a) Absolute. — Some condition which admits of no other method of treatment. 1. Pelvic deformity. In flat pelves when conjugata vera is 6.5 cm. (2J inches) or less. It may be required in osteomalacia and spondylolisthesis, also in Nsegele'sand Roberts' pelves. 2. New growths obstructing the pelvis, as a large fibroid, bony tumors of the sacrum, carcinoma, etc. (h) Eelative. — When the condition admits of s(jme other method of treatment, but the question arises whether Cesarean section will 140 OBSTETRICAL LECTURES. not give the best result for motlier and child, i. e. , it is selected as likely to give best results. 1. Pelvic deformity. Conjugate vera 6.5 cm. {2^ inches) to 8i cm. (3^ inches). When the conjugate measures 83^ cm., the opera- tion is indicated only when the child is abnormally large. 2. Rupture of the uterus may often require the Sanger operation. The Porro operation is indicated when the pelvis is so choked up as to interfere with drainage of lochia ; when the woman has been long in labor and is septic, or when other methods of treatment have been unsuccessful, and the danger of sepsis thus increased ; when the uterus fails to contract, or when hemorrhage is profuse. Technique of the Operation. — (Sanger, or improved Caesarean.) [a) Time. — The most favorable time is from 250th to 265th day after conception. The introduction of a bougie into the uterine cavit}'^ to institute labor pains is an advantage. The operation should be performed after labor has begun. ih) Instruments. — Those ordinarily used in a laparotomy. (c) Preparatory Treatment. — ^Includes disinfection of abdomen and external genitals, evacuation of bladder and bowels, etc., as for laparotomy. (c?) Abdominal incision should extend one-third above and two- thirds below umbilicus. (e) EsmarcTi tiihe should be placed around cervix to control bleed- ing. (/) The uterine incision should be long enough to allow the escape of the child's head, and the child extracted, grasping it as may be most convenient. {g) The placenta is next extracted., followed by the Sanger method of suture to close the uterine wound. The abdominal wound is then closed after the toilet of the abdominal cavity has been completed, and the after-treatment combines the features of management after labor and laparotomy. Laparo-elytrotomy. In ] 806 Jbrg devised an operation which consisted of an incision over Poupart's ligament, dissecting up the peritoneum until the va- gina is reached, when the latter is incised transversely, the cervix dilated, and the child thus extracted above the inlet. In 1820 this operation was performed by Ritgen, with a fatal result. In 1822 it DYSTOCIA. 141 was proposed by Physic, of Philadelphia, and in 1823 done by Bau- delocque. In 1876, Thomas and Skene, of New York, performed it, and it was called by them laparo-elytrotomy. Since 1876 its mor- tality has been 50 per cent., and therefore it shcjuld not come into general use. Laparo-cystectomy. An operation performed in advanced extrauterine pregnancy for removal of foetus and entire sac. It is performed like an abdominal section for any cystic tumor in the abdominal cavity with dense adhesions. The sac is to be evacuated or not, as indicat€d, and adhesions separated, if necessary, after ligation. Dystocia. Causes : — A. Anomalies in force, expulsive or resistant. B. Accidents. C. Disease. (A) Anomalies in Force. /. In Expulsive Power of Uterus or Abdominal Muscles, (a) Excess of expulsive power. (h) Defect of expulsive power. (a) Excess of Expulsive Power. (1) Uterine. — Excessive uterine contraction is rare. Occurs most frequently in primiparse, and does not seem to be dependent upon the muscular development of the patient. Diagnosis. — iibdominal palpation shows frequent and forcible uterine contraction. Vaginal examination shows rapid advance of presenting part. Cry of patient is exaggerated. Difficulties. — The severe pain and precipitate expulsion of the child. Treatment. — Anaesthetic. Resist advance of presenting part. In the earlier stages if the pains be so fi-equent as to threaten exhaus- tion, lessen nerve action and muscular power by chloral, gr. xv every fifteen minutes, until three doses are taken. Bromides or opium may also be used. (2) Abdominal — Excessive abdominal power occurs in the second stage, and should be similarly treated. 142 OBSTETRICAL LECTURES. (3) A relative excess occurs when the opposition is less, as in a roomy pelvis, a pelvis with straight sacrum, relaxed or lacerated perineum, foetus very small or premature. The dangers of rapid expulsion thus likely to follow are, laceration of the perineum, syn- cope, post-partum hemorrhage, rupture of the cord, premature de- tachment of the placenta. When due to such a cause, treatment should supply resistance by holding the head back with the thumb or small, straight forceps. (4) Excess occurs when there is a gradual decrease of the intervals hetiveen the contractions^ until a final condition of tetanic spasm may result. This may be due to a serious obstruction, as deformity of pelvis, abnormal presentation, fibroids, cancer of cervix, ovarian tumor, agglutination of external os, etc., or there may be a true spasm of the utenis, as may develop in an irritable primipara with liquor amnii drained ofi^. Diagnosis. — Bj^ palpation above and below the contraction ring. Treatment. — Remove the cause. If a true spasm, chloral and opium. (b) Defect of Expulsive Power. Uterine Inertia — Causes. — (1) Weakness of mu.scle., as occurs some- times in multiparae, exhausted primiparae, general diseases, as pneu- monia, typhoid, phthissis, cancer, over-distention from twins or hydramnion. (2) Ajyathy of muscle. (3) Emotion. Dangers. — Relaxation predisposes to septic infection, pressure necroses, post-joartum hemorrhage. The child may become asphyx- iated by pressure on its brain centres or compression of the cord. Treat nient. — ^Rise of temperature and other signs of exhaustion demand interference. It is always best to err on the safe side and terminate the labor. If due to weakness of muscle, stimulants, quinine gr. xv, forceps. If to apathy of muscle, introduce a bougie ; if to emotion, administer an anassthetic. If it occurs early, termi- nate the labor by rapid dilatation of ceiTix and' version. Ergot should not be given, as it excites tetanic spasm and contracts the cervix. The foetus is often semi-paralyzed, its blood supply partly shut ofi", and if an obstmction to labor exists, rupture of the uterus may follow its use. DYSTOCIA. 143 // Anomalies in Force of Resistance. Maternal Obstructions. 1. Contracted Pelvis. Treatment. — Differs with grade of deformity. Conjugate 9j to 11 cm. — Can allcjw to go to term, expecting the labor to be rather difficult and prolonged. Complicatifjns are frequent, as abnormal positions and presentations of child, which are four times as frequent as in normal pelves. Prolapse of cord is also a frequent complication. The most frequent abnormality is transverse situatior of the head at pelvic inlet, as described under abnormalities in the mechanism of vertex presentations. Prolongation of labor and exaggerated com- plaints of patient must be expected. Increased expulsive powers are demanded, and if insufficient, forceps or version must be resorted to. In primii3ara3 spontaneous termination is more frequent. In multiparse, or when muscular force is diminished, avssistance is often needed. When forces are normal and child not ovei'-sized, non-inter- ference with nature's mechanism is the cardinal rale. Forceps inter- feres by preventing partial extension, favorable moulding and lateral inclination, and should not, therefore, as a nile, be applied until head has entered pelvic cavity, when it is not usually required unless inertia uteri develops. Conjugate heloic 9 to 9 J cm. — Indicate induc- tion of premature labor from 2 to 4 weeks before expected delivery depending upon degree of flattening. After labor has begun, the head in flat pelves is apparenth' low down, from shallow depth of pelvis and low position of caput succedaneum, and this mis- taken idea may induce one to apply forceps. In such a case, either non-interference or version and extraction are indicated, — the former in primiparae or in women with strong expulsive powers, the latter in multiparas or in women with deficient expulsive powers. Forceps may be applied after the head has entered the pelvLs. Con- jugate so contracted as to he impassahle. — Accurate and precise diag- nosis of the degree of deformity should always be made in order to spare the women the dangers of futile attempts at extraction with forceps or by version, when craniotomy or Caesarean section are indicated. (See Craniotomy and Caesarean section.) 2. Congenital Anomalies of Development in Genital Canal. — As double uterus. May interfere by its bulk or contractions of the 144 OBSTETRICAL LECTURES. empty uterus. If placenta is attached to septum, alarming post- partum hemorrhage may occur. 3. Closin^e and Contraction of Cervix. — As atresia., cicatricial contraction or rigidity. Atresia is never complete, and may be over- come by pressure on the small opening with the tip of a sound or finger. Cicatricial contraction may require incisions, controlhng the hemorrhage temporarily by clamped sutures. Rigidity usually yields to copious hot douches. Chloral, morphia, belladonna ointment have been recommended. 4. Closure and Contraction of Vagina or Vulva. — As by. con- stricting bands, cicatrization, haematomata, requiring incisions. 5. Displacements of Uterus. — Anterior, lateral, sacculation, hyper- trophic elongation of cervix. The first requires a binder, the second side position, with compress under fundus. Version or forceps to bring head into pelvic cavity for sacculation. Incisions radiating from OS for elongated cervix. 6. Tumors of Genital Canal. — Carcinoma of Cervix. — If exten- sive may require Caesarean section. Fibroids. — If low down and diagnosed during pregnancy, remove by abdominal section, induce abortion, or perform Csesarean section at term. If movable they maj^^ be pushed out of the way during labor. Polypi. — Ligate base and remove at term. 7. Tmnors of Neigliboring Organs. — Ovarian Cystoma. — Usu- ally cause abortion. Ovariotomy during pregnancy is justifiable. If they obstruct during labor aspirate per vaginam. Cysto-colpocele or Rectocele should be replaced until forceps are used to bring the head past them. Calculi or fecal masses should be removed. A decomposed foetus in utero, as result of obstructed labor, should be removed antiseptically. FcETAL Obstructions. 1. Overgroictli. 2. Malformations and Tumors. — Treatment varies with each case. Version or embryotomy usually required. 3. Diseases. — As cystic kidneys, eifusions into the serous cavities, anasarca, enlarged liver, etc. 4. Malpresentations and Faulty Positions. — As shoulder, face, brow, compound. DYSTOCIA. 145 5. Multiple Birtlis. Twins. — Head of one, feet of the other, most frequently present. If both engage, retard one and extract the other. The cord may be coiled around one. The chins may lock, when an effort should be made to push back the one presenting by the head. Failing, ampu- tate the head of this one and deliver the one presenting by the breech, or push the latter back and deliver the fonner with forceps. In any case, when one is born, do not follow the expectant plan, as sometimes advised, but at once determine the position and presenta- tion of the one remaining in utero. Correct it, if necessary ; give ergot and terminate the labor. 6. Abnormalities in Foetal Appendages. Membranes. — If too thin, an early rupture precedes a dry labor with irritable uterus ; if too thick, child apt to be born with a "caul." Liquor Amnu. — If too little, consequences are similar to those of premature rupture ; if too much, there is inertia, as result of over-stretching. Cord. — If short, may cause premature detax^hment of placenta or prevent advance of the child. Placenta.. — May be adherent, from syphilis or endometritis during pregnancy. The alarming hemorrhage resulting requires removal of the adherent portion. (B) Dystocia due to Accidents to Child or Mother. {a) Accidents to the Child. — 1. Prolapse of Cord. Causes : lack of conformity of presenting part with shape and size of pelvis, as small head, malpresentations (face, shoulder, breech), contracted pelvis. Less commonly hydramnios, too long a cord, lateral devia- tion of uterus. Diagnosis. — Easy. Has been mistaken for prolapse of intestines. Prognosis. — Mortality 53 per cent. Treatment. — Postural and manual, i. e. , knee-chest posture, and endeavor to replace with fingers. Instrumental, a catheter with counter-opening used as repositor. If these fail, resort to version or rapid extraction with forceps, placing the cord at that sacro-iliac joint where it would be least pressed upon. 2, Rupture of Cord. Rare. (h) Accidents to the Mother. — Hemorrhage occurring before, 10 146 OBSTETRICAL LECTURES. during or after labor. Ante-partuiji hemorrhage may be due to pla- centa praevia, premature detachment of placenta, rupture of uterus. (1) Placenta Prcevia. — The placenta is said to be praevia when it is attached to anj^ portion of the lower uterine segment. Causes. — It is the result of a low situation of the ovum, but why this occurs is not yet satisfactorily explained. It is more frequent in multipar^e and those of the poorer class. Varieties. — Central, Partial, Marginal, Lateral. Symptoms. — Hemorrhage, occurring as early as the second month in the central variety, during labor or not at all in the lateral. The characterivStics ol the hemorrhage are, sudden onset without pain, the ])atient often finding a gush of blood while in bed, and return of tlie bleeding, with progressively increasing quantity at de- creasing intervals. Rarely, the hemorrhage is controlled by nature, a clot forming or syncope occurring, and a fatal hemoiThage before the 7th month has not been recorded. Treatment. — Prior to 7th month, expectant. After 7th month, mduction of premature labor by forced dilatation of cervix and com- bined version. The breech should be brought down, as it controls the hemorrhage and does not cut off the blood supply to the foetus. Use the right hand internally, as the smallest segment of the placenta is usuall}^ on the left side. In the central variety perforate the placenta if necessaiy. Wiegand's treatment is placing an antiseptic tampon in the upper third of the vagina, allowing the head to push it out. Incubation and gavage should be used if the child is born early after 7th month. (2) Accidental Hemorrhage. — Hemorrhage from premature de- tachment of the placenta. May be one of four classes : — 1. Centre of placenta detached. 2. Upper margin detached and blood extravasated between mem- branes and uterus. 3. Membranes rupture and blood passes into amniotic cavity. 4. Cervix obstmcted by clot, membranes or presenting part, when it is concecded. Causes. — Similar to those of abortion, as decidual apoplexy, violent exercise, emotion, etc. Occurs more frequently in the latter months of pregnane}^ and in multiparae. DYSTOCIA. 147 Diagnosis.— The symptoms are similar to rapture of utemp. There is hemon-hage, with sudden excraciating pain and shock in both, but in rupture of the uteras the membranes are broken, the presenting part recedes, the uteras is well contracted, while in accidental hemorrhage the membranes are not always broken, the presenting part does not recede and the uteras is distended by the accumulated blood, particularly in the concealed variety. Progjiosis. — Grave. Treatment. — Perforate membranes, thus securing some control of hemorrhage by the contraction of uteras, fVjllowed by forced dilata- tion of cervix and version. (3) Post-Partum ^e^norr/ior/e.— Nature's mechanism of controlling hemorrhage : — 1. Leucocytes beginning to block up sinuses in latter months of pregnancy. ^. Contraction. 3. Retraction. Cau,ses : — 1. Those which interfere vnth crmtraction, as {a) weakness from general disease, bad hygiene, mental anxiety ; {h) muscle fibre at fault, as when undeveloped, fatigued, overstretched, or inactive by reason of surrounding inflammatory products ; (c) anomalies in innervation of muscle fibre. 2. Mechanical— Rttmnecl placenta, clots, old adhesions, tumors, as fibroids, ovarian cysts, distended bladder or rectum. Symptoms.— ^uMen gush of blood, or four or five ounces lost eveiy few seconds. Uteras relaxed. Constitutional signs of severe hemorrhage, as, vertigo, air hunger, pallor, etc. Treatment.— {a) Propliylactic. When there is any probability of its occurrence, as soon as head is born inject into thigh a syringefal of ergot, properly manipulate uteras and apply binder. (b) Curative. — Always have in readiness, water 1 12°-120°, empty basin, vinegar, ice broken size of fist, clean handkerchief, hypoder- mic syringe, ergot. The indications are : 1. Control the hemorrhage, and 2, treat the after condition. The first indication is met by the following in the order given : — (a) External stimulation of uterus. 148 OBSTETRICAL LECTURES. (b) Cany the other hand into the uterus and remove any clots, placenta, etc. (c) Ice applied internally and externally, but not persisted in. (d) Handkerchief soaked in vinegar squeezed at the fandus. (e) Hot water. (/) Electricity. ig) Intrauterine tampon of iodoform gauze. (h) Drugs, as iodine, styi:)tic salts of iron, etc., are dangerous, as the coagula produced by them may extend into the vessels, are firm and must be broken up by putrefaction, exposing the patient to septic poisoning. Treatment of the After-condition. — While controlling the hemor- rhage, nurse should administer hypodermic of ether. When the bleeding has ceased administer an enema of hot water and fre- quently repeated small doses of coffee, milk, brandy, etc. Auto- transfusion by bandaging extremities, compressing abdominal aorta or actual transfusion {^jj of 1 per cent, of ordinary NaCl solution). When reaction is established, a hypodermic of morphia may be given. (4) Hemon-Tiagefrom Injuries. — Exceptionally may be fatal. The most common source is in the anterior wall of vagina near the urethra, where it should be controlled by antiseptic catgut or silk ligature. Exceptionally an anomalous artery may be torn in the cervix or perineum requiring immediate operation. (5) Rupture of Uterus. Cause. — Obstruction to labor. Diagnosis. — Placenta Prgevia, Accidental Hemorrhage, Rupture of Uterus are the three causes of grave antepartum hemorrhage. In the latter there is shock, great alarm on the part of the patient, the membranes are broken, the presenting part recedes, the examining hand finds the rent, and perhaps feels coils of intestines. The child may be felt in the abdominal cavity with the uterus small and firmly contracted. The danger signal is thinning of the lower uterine seg- ment and a high position of the contraction ring. Treatment. — Varies with the cause. Deliver by podalic version. If the hemorrhage ceases and there are no clots, no meconium and good drainage, no active treatment required beyond irrigation with 2 per cent, solution of creolin, otherwise open abdomen and suture DYSTOCIA. . 1 49 after the Sanger method. During the puerperium the uterus may- rupture as result of septic ulceration, pressure necroses, or more rarelj^ from malignant septic degeneration of the chorion. (6) Inversion of the Uterus — The rarest of all accidents to the mother, and happens before or after delivery of the placenta with equal frequency. It may be partial or complete. Cause. — It may arise spontaneously in the so-called paralysis of the placental site, or it may be due to too vigorous traction on the cord or compression of the fundus. Symptoms. — Occurs suddenly and is usuallj^ associated with shock and hemorrhage. Physical exammation per rectum reveals a cup-like body containing, perhaps, the prolapsed tubes and ovaries. Treatment. — Occasionally spontaneous reduction occurs, particu- larly when the inversion is partial. Remove the placenta if still adherent and reduce as Lusk advises, or by placing fingers just inside the constricting cei"vix, and while spreading apart to relieve constric- tion the thumb pushes fandus up. (7) Other accidents to the mother are Rupture of Symphysis., re- quiring a binder or plaster bandage ; Separation of Sacro-iliac Joints; Fracture of Sacro-coccygeal Joint ; JjCicerations and Per- forations icith Instruments ; Diastasis of Ahdominal Muscles. (C) Dystocia due to Disease. (1) Puerperal Convulsions. — Causes. — Hysteria, epilepsy, tumors of the brain, meningitis, profound anaemia following post-partum hemorrhage, apoplexy, or the convulsions may arise in that curious nervous condition after labor or during pregnancy so easily respond- ing to reflex disturbances. (2) Eclampsia. — Is the name given to the most frequent variety of puerperal convulsions. Causes. — Obscure. Theories of causation : (a) Urea. (Jj) Car- bonate of Ammonium, (c) Uringemia. id) Trauber-Rosenstein. (e) Prof Hirst approves the following : Angemia in the deeper por- tions and congestion of the surface of the brain, due to the sudden rise of arterial pressure resulting from the accumulation of poisons in the mother's blood (probably leucomaines generated in the foetal body), her kidneys being unable to excrete them. Insufficient ex- cretion may be produced by occlusion of ureters. 150 OBSTETRICAL LECTURES. Frequency. — Occurs once in three hundred cases; most frequently in primiparse, and during labor ; least frequently duringthe puerperium. Symjjtoms. — (a) Prodromal. — Sharp pain is sometimes felt in the head, epigastrium or under clavicle ; muscae volitantes with failure of vision and rolling of the head. (h) Of the Attack. — A few moments after the above the attack comes on with a stare, pupils at first contract, eyelids twitch, eye- balls roll, mouth pulled to one side, the neck is then afi'ected, and the spasm finally spreads to trunk and upper extremities. The lower part of lower extremities are rarely spasmodically affected. Consciousness is lost for a minute or two, and during the varying length of interval between the attacks there is more or less stupor. Prognom. — 30 per cent. die. Influenced by the violence and fre- quency of the attacks, the character of the pulse, degree of coma, and perhaps the height of temperature. Mortahty of the child, 50 per cent. Treatment.— [a) Preventive. — The urine of all pregnant women should be critically examined. If there be evidences of nephritis or the kidney of pregnancy, a restricted diet consisting largely of milk should be advised. Colds should be avoided, diuretics administered, and cathartics to prevent constipation. If the symptoms fail to respond to this treatment, the induction of premature labor should be considered. (Jb) Curative. — Indications are to eliminate the poison and combat the spasm. Includes the treatment of the spasm during the inter- vals, and the obstetric treatment. During the spasms, inhalations of chloroform. In the interval between the spasms, venesection, a pint or more ; croton oil, two or three drops ; an enema containing a drachm of the bromide of potash and forty grains of chloral. In severe cases, a hot bath, 100° or more, with ice or cold cloths applied to the head. Morphia, elaterium, veratrum viride, may be used. Gruard the patient from injury, especially the tongue, which may be protected by placing between the teeth a brush handle wrapped in a handkerchief. 1. Obstetric Treatment. — If the os is dilated, terminate the labor with forceps or by version. If the convulsions occur early, and the OS is not dilated, wait until partial dilatation occurs, and complete the delivery by combined version and extraction. DYSTOCIA. 151 2. Shock. — Lowered temperature and other symptoms of shock may develo]) after kibor. 3. Typhoid. — Rare. Premature labor occurs in 65 per cent, of cases. 4. Pnetononia or otJter Adynamic Diseases. — Require stimulants. Whiskey, digitalis, carbonate of ammonium administered in the first stage and labor terminated. 5. Vahular Defect in Heart. — Extensive mitral disease fre- quently causes death. The heart is embarrassed during pregnancy or labor, and manifests its weakness directly after the expulsion of the child or placenta. When the discharge of blood is profuse, car- diac failure is rare in these cases, thus indicating the treatment : Venesection, removing 8-16 oz. , if there is not much blood lost after labor. Digitalis should be given in the first stage, and forceps or version and extraction resorted to in the second. Sudden Death during or directly after Labor. Causes. — 1. Pr< found Mental Impressions., as sudden joy, grief, fear, exaggerated shame. 2. Thrombosis, resulting from excessive pains. 3. Heart failure, most frequently due to fatty degeneration. 4. Some Complications, as accidental, unavoidable, or post-partum hemorrhage, ruptiu^e or inversion of uterus. 5. Rupture of Hcematoma, externally or internally. 6. Syncope. — This is not usually fatal. It is favored by the deter- mination of blood from the brain, as by hemorrhage. Thromboses in the heart may form, and those in the uterine sinuses may be pro- longed and embolism result. 7. Embolus. — Maybe the result of syncope, or it may be caused by entrance of air. Symptoms. — Sudden shock, heart failure, death. 8. Ruxjture of Gastric Ulcer. Effect of Maternal Death upon the Foetus. — The foetus sui-vives rarely more than a few minutes. It has lived for two hours. When making an autopsy on a jjarturient woman, it is convenient to split the symphysis and remove the genital tract in one piece. APPENDIX. Selection of Wet Nurse. In addition to qualities enumerated (page 45), she should, pre- ferably, be a multipara ; her child approximately the same age as the one to be nursed ; nipple should be well shaped, and it is of advantage to have made a chemical analysis of her milk. Artificial Feeding. The disadvantages of substituting cows' for mother' s milk may be accounted for by three factors : — 1. Difference in Chemical Composition (see Table of Analysis, page 44). — This difficulty is overcome by preparing the milk as fol- lows : To make four ounces, take 3 tablespoon fuls of weak cream or 2 of ordinary cream and 1 tablespoonfal of milk, 4 tablespoonfiils of sterilized water, 1 tablespoonfal of lime-water, 102 grains of sugar of milk. 2. Bacteriological Contents. — Cows' milk, particularly in the hot summer months, is infected with microorganisms and theu- poisonous products, ptomaines. Tyrotoxicon is the most viralent animal alka- loid found in milk. To destroy these poisons, sterilization by steam is necessary. Boiling changes the chemical constitution and renders the milk less nutritious (3 per cent, of CO 2, oxygen, nitrogen driven ofi", and 20 per cent, of albuminoid constituents found as a thick scum on the surface). Two steamings for twenty minutes each will absolutely sterilize the milk ; one is usually sufficient. 3. Quantity. — Overfeeding is a common mistake. The following- table indicates the proper quantity : — 11 153 154 APPENDIX. Age. Interval. Number of Feedings in 24 Hours. Amount of Food at Each Feeding Total Amount in 24 Hours. 1st week. 2 hours. 10 1 oz. 10 2d-6th week. 23^ hours. 8 1-2 12-16 6th-12th week. 3 hours. 6 3-4 18-24 6th month. 3 hours. 6 6 30 12th month. 3 hours. 5 8 40 The greater the weight, the greater the gastric capacity. Grastric capacity = x^ of body weight + 1 grarame each day (Ssnitkin). It takes a baby fifteen minutes to empty the breast, and this time, therefore, should be consumed in emptying the bottle. The plain rubber nipple should be used, not the feeding tube. Preparation of Artificial Food. — 1. Have ten small Rotch bottles prepared clean every morning. 2. Put in each of them, by means of a funnel, to secure dryness of the neck of the bottle, cream 5iv, milk 5ij, water ^j, milk sugar gr. 1. 3. Steiilize. 4. Add 5ij lime-water to each bottle before use. This mixture lacks by 3^ of 1 per cent, the same amount of non- coagulable albuminoids as compared with mother's milk. Should the chUd, by weekly weighings, fail to show the normal gain, add one and a fourth drachms of white of egg to ten ounces of water, and distribute this among the ten bottles. Proprietary foods should not be used. Condensed milk, under some circumstances, may be employed, diluted with nine parts of water, and 3j cream added for each ounce. DATE DUE M/IR2 5 7m APRlsZf 18 z\m «"••■. Wr'i 7 nt}i FflM/. I*.. " '^IM ~ ' Demco, Inc. 38-293 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RG 533 .N67 1890 C.1 Syllabus of the ob^.tetncal lecture- in 2002254859