Obstetrics ; a manual for students and practitioners

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Disease-* of the Eye, Bar
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n. \v LaUtuiron,M.O Uacmnt

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HaauaeauftaeHoaaand Throat,

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Oynacology.

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Obstetrics.

ahv Ii'vim J IV. -.s M. H ( Dwnuii'
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Derraaiology-
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ft>«ur of Dermatology, at Loui* and
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Genito-Urinary and Venereal
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OBSTETRICS.

A MANUAL FUll STUDENTS AND PRACTITIONERS.

BY

DAVID JAMES EVANS, M.D.,

Urturer On Otulrlrirt and Dixaaa of Infancy, MeQitt InivtrtUy, Montreal, Canada;
fVlote of Uu Obatett teal Society, London, England.

AERIVS KDITED BY

BERN B. OALLAUDET, M.D.,

Dcmomiralnr of Awlcmy nr'-l l&i'uctor in Surgery, S*V nf'jf>!,rtc1anl and Surgeons,
Columbia CmrmWv. Trte'J »*■; Tisitint/ «.rt*M, Ettfhw U-trpilal'scv York.

ILLUSTRATED WITH ONE HUNDRED AND FORTY-NINE
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LEA BROTHERS & CO.,

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: /:••• «ri1~1 — 7T::: -" :
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PR Kl -WOE.

T IB Him of the nuihor m writing llii- " poi ltd loxt-book "
li:i- I htm t<» -ii|i|»ly :i ibortf COQOO&tltttsdl tnttlM 00 'lie "'"'H"'
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tinu of their |Kitlmloi

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til the volume on " l'< di;M HW " bdoOnilB '" ll'i- -■■n.'..

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.via^n

CONTENTS.

MENSTRUATION.

MOB

Definition; cause; structural change*; onset; character; duration;

menopause 17, 18

OVULATION: Graafian follicle; ovum; maturation of ovum ; corpus

luteura ; ovulation and menstruation 18-21

PREGNANCY i Normal).

Embryology: Impregnation and conception; semen ; fertiliintion
of the ovum ; development of the deciduii ; reftexa ; vera ;
layers of decidua; decidual cells; changes in the ovum ; de-
velopment of the firlua; segmentation ; blastodermic vesicle;
cleavage; development of the membranes; amnion; yolk-roc;
allantois ; urachus; umbilical cord; chorion; development of
the placenta; structure; villi; capillaries; placenta and mem-
branes at term ; functions of placenta; ovum at different periods
of pregnancy; filftiil circulation 21-38

Chances in Mateiinai. Organism: Herns; increase in sire;
changes in shape and structure ; relation to pelvis and abdomen ;
alterations in cervix, vagina, and vulva; changes in breasts;
alterations in other than the generative organs ; linoe albican tea 38-44

Duration of Preonancy: Date of fruitful coitus; rule for deter-
mining; height of fundus uteri ; date of quickening 44, 4"»

Diagnosis ok Pkk<inancy: Kii>i trimester: suppression of men-
struation; nausea and vomiting; mammary changes; vesical
irritation; nervous disorders; softening of cervix; violet dis-
coloration of vagina ; softening and enlargement of body of
uterus; second trimester: fatal movement; uterine souffle ;
fiftal heart-sounds; pigmentation; hallottement ; thiol tri-
mester: pressure-symptoms; varices; dislnr1«ancesof respiration
and digestion ; fcetal movements; stria 1 ; settling; summary of

M«

l*rity or inilli|mrii.v ; ffllfnndicf 1Mb Of JMthflf ohJtd • 10 W

iiv. mat un Uanausmstx m> PjuxuteiNzy: I >i.-r . , phw;

■ ink; I'Mliinj,'. care v( urvuls; uuu u] other ti*K«in mnl
Qwotfowi aamiiMlion ■ 34-Afl

OBSTETRIC? ANATOMY.

AYATOVtCAfc BLKMBm in I.aiuih

Tin I'vti.i- VV..11-, i.ni*'lt-Iit.ir«. UfWtM *etfntcnt" ; KgiimrnU;
peritonuiiui ; rcliiuotiof lull-term litem* l"i-mii u* ini<(<ii\'-

Tiir I'mii.iMiM ( uu&i Vang petvui gaaanl dcBoriptko |

joint-; ni..l»ili(v ..i paMd fofafe; foW run! In... j-Ivih ; iritcl ;
«ii|..n..r -ir;iii ; InfaiOf »liftit, mill.t; .nvity of polvU; bl-
unil Knxivm; plain* nf jh'Ivi-; |h'1yu' •liinuvU'rw: roinuunli* ;

I Vi'l r i.l.lii|ii,< . .1 . . . I. i.f (III- |"'lv i .

i.!t |...M< ul ill. (i-lvi.- mi..! * mu- l< : r.-.-tuni : ;><l\h llih-r:
MiniMiiU «Ji lluor; hiok; piriiwuiu; pirturichl aim; otlwr

»«-.» .... m ;c

Tin: PknrtB Ktum faflmt '"•• i*. ... i twits but] «nnr«:

fan(UWllM| nb"ti'lfii'liiinliii.ifU *li juik-Utk rirfa-titl lic.nl iir-

■ 'if " "i AmbI ln»l ; ounldlof of hffftd ; to-

p in. I.. ( f iii-tii'ti >if IicikI ; RMalinmhi dUnutofi! moWHij

■ I. nl i. id imiuK , jio-iijm- of fu'lim ; (ii. -k ■. it. ih. .in. . ••-|.li«li«' l

pdrlc, -ommlr; pnrfttam; rtrttx, f.«v, tmefc, Aonldar;

ivnir.nl (.Tiivitv nl' fatal; fuliil niovi'ifirni* . .... . ?0W

MECHANISM AND OOUR8E OP NORMAL LABOR.

t)KMi< »i Diru'iTivM ure BnoiAoi I ulocEa i noomplieaiod

T#ri*x prt-"'nl.illiin« ; prlmlRravM.i , prlmlpar.i . multipara ;
»lmn» <>l Inlaw; tlunilimi of niwmiil lulxtr ; oiiipt* of l|n< uiuwt

i if U1.ii fun. ■• ..f 1 lUn nii'iihi' i-iiiirinriiniK [uitn i. i ■■

i".i i-.i.niii f..n.Hi lit .lUlnnmml Moiabi ml <li«

phruKUi; vnrily ("1-102

I.uhik— Knurr Ntaii*: rf-'t.i..nil..rv-l|rn- ninl -vinptom. ; ohwn»
tcriwic fiff»* mid MympLmim «f the unwl of lul»»r; BOahMihU
of |Im* llf"t •i«ifr ; ilJUii' ..> - I...! oUUlf |. it— mi- of

tli' ■ ' 4 nlm] mil i l..in iimliiinl uhn-'-l in. in*; rupt-
ure uf mnbllMO: [W— WllllH ptiit of (u*t'i» «» diliilor. 'Irv

kboni m. lnTttiJ I"'-" [miiwi f.'ilt-i M.injiin/. mm *

of»fi[ M rt- Idt Iff

cosrr.sr.s

PAOS

r.%Bf»H— f-tvorf Hta&r: Moihiini-m ; htoit intwnu-nt , (Went ;
II.' 1 1 "ii, toMnwl mlnlion. MMufoaf rmlilulioii or cilvrnitl
rutoiiva; Ueiivorjr «T tin mink, | i nArlri| nf vonu;

•ftw tI., blnli ..( i|„, ,lnM. rnoulilli^ <•( (h« l«4al linwl |

ai|i(il -HM..I.UH- | mi,, m | I0T"JM

I -•■ Inn D i" 1 . t : '.imtioii Of plmviili; «»|mn»Uiin of
tUUmWlUHk ; C*ptlW ( |i1di>iiI< iiil'l inniilntin,- , rolru-

itecmtol in- "Iurs; oonplfdon of btaop| Uood in*i in

IMmr , .... ,116-311

MANAGEMENT OK NORMAL LABOR

OlWTtfHlr Am I V . .1 ; ,,.!,. „...,,,(.; rlM-l0Jr.l1 1-',,!!,.,

iho oUleini.iti DMtfcodV of iUflluil^ IdihI- ,. i

"■■ puSou UK

Pi -i '■ - i. 'i' I taoHl <1ii i)i* j.iiri of lli> |-li>«irinn ;

t . i-i. in.- U| «ini watooto , Uwroan; linen, TuUnr pa«i».
bhulon i.tU.rir.1 ■-, i -.- i» i.u.i lm ju

M**a«ihmi:xi ■•» nil in' t BtaoH: Pfelli try taadud «f

llif plnn'inn i iit^lr'fiffj^Hniti.tiiiM . pJtlp*ti<iftl lU rilttlloDl

tOjflflttl niii.i'i.,1 UMOMUng ihc culmination; rupture

. I mtnhnuMi .... [28 Ltt

M»xi"»vii\i "i rnr facmo hr.s-ir. I*r*ltic.n ; in rnpW cvn»;
■n*»tl«»tn; |*>rlnnl •(«*«■, blOOflltfOn ol pflrflWMfl 'U

liminrn! OJ ihUwr.' . tMi'rn •>{ Iti'i"! . ili-luff) «>l -I !■!■ i- ,

(mninliui. mtt fn* ■ i"i'i ■ rlic cord 1ST- HO

HAnAaxnErr nf tmi Tiiiiii- Stauij T<- lawn linn mm w
<vmtr*rtjnn; bamtfaMj stpoltdon of puu-NtU I nNkft
iiwihoil of apnaiun . rati u U ii »i»n» ; fln«l m».uiiiv» . 141. 14'.'

THR PUERPERAL STATE.

Akatomy • •» mi I'mi-- UfJUMATKLY •rrr» Ltmil IV

nirnix s..,.iini • Wing |ilntl<li*t. jinrii..iKiiiiii RMOtniniU

will* 148 I 16

Pm>l..iii».% mi mh Pi'MM'litM, l'l ■ lnv.,liifi i.-illu

i"i .^-ti-in •kin. dljr»*t|™ npPHmtu*;

licfjttion; nummary ftlntvl**, oiWlnim; utill H*« I.Vi

Ifjurjamiorr o» mm Pi avnuini i..im. In room] *c»iulia ;

can of l>rvaBt*; Mining; nippl- ■ ; WOll [odlMlI<MH '■ BMl

liiu*. '0.-' i««it»". rUtt of ihr i'iir-.i. Ikaf ttnpMt

tun I -V> IM

8 contents.

pathology of pregnancy.

Phi

The Dbcidua: Acute and chronic decidual endometritis; atrophy 154.-I56
The Foetal Appendaues: Oligohydramnios; hydmmnios;
amniotic bands; premature rupture of amnion; alterations in
character of liquor amuii ; vesicular mole; anomalies of pla-
centa; diseases of placenta; placental apoplexy; placentitis;
tumors and cedema of placenta ; abnormal length of cord ;
coils and knots of cord; hernia into cord 156-165

The Foetus: Teratology; fatal mortality ; elephantiasis; ana-
sarca; ichthyosis; rachitis; syphilis; tuberculosis; contagious
diseases; fatal death 165-169

Pathology or the Pregnant Woman: Varices; tedema;
pruritus; leucorrhcea; vegetations ; retroversion and prolapse
of uterus; endocervicitis; tumors; mammary nbscess ; exces-
sive secretion of milk; eczema of the nipples; gingivitis;
dental caries ; parotitis; ptyalism ; indigestion; constipation;
diarrhoea ; vomiting ; pernicious vomiting; uterus; hemor-
rhoids; irritability of the bladder ; hematuria; albuminuria;
kidney of pregnancy; acute and chronic nephritis; cough;
dyspncea; pneumonia; phthisis; cardiac disease; heart-mur-
murs ; enlargement of thyroid gland ; neuralgia ; neuroses ;
infectious diseases 169-188

ToZjEmi a— Eclampsia: Symptoms; de6nition ; frequency; pre-
monitory symptoms; the fit; etiology; pathological anatomy ;
treatment 188-194

Abortion and Premature Labor: Definition; symptoms;
pathology ; etiology ; diagnosis ; treatment ; missed abor-
tion ; miscarriage: missed labor 194-201

Kctopjc Gestation : Definition ; frequency ; varieties ; tulial
pregnancies; terminations; tubal abortion; etiology; path-
ology ; symptoms ; treatment ; removal of sac ; technique of
operation 202-209

PATHOLOGY OP LABOR.

Dystocia due to Malpositions of the Forrua: Occipito-
pusterior cases ; face presentations ; brow presentations ; breech
presentations ; arrest of breech at the brim ; rapid extraction
of trunk ; delivery of the after-coming head; transverse pres-
entations ; prolapse of the fottal limbs ; plural births .... 209-248

.>.■-.

'•*" l''M.I. IHVi l-.l-Mt *, (I, .

,;,. Athoj r- - 1 11- : |in<iiiBUiru a»illi-niii>ii of ■kiitl ; hj i ■ ■ | ..

lua; uiKv|i}in[<Mvlt'. niuuiiu['*vl' I \>\n lavjilmlu- ; turn-

UUftV ; MMBj I tolWl P10IMI i'itS

i' 'i oAMnnuiAi m fa r*j lm 19*01

I . |'t"l.i|— •< ■•■> I . ■ 'limn i.( I obOOl fatal i

pflOttNini |»ni'vn ..iliiiil bMBorrhagBj ptfRVUUn) Of]

lion ill ft niHiMntl iiIikvoIr, rvlmiKil Jiliici nix ; nd-

• ■ ... SkMob*

Minn-" I-, mou i'm-.'i] n.if itboi (Maya Ikbor; utatM
[■ momtJla dI lb* ptftb) pcMaiaUfj umohII

iil< rUM ■!>■•.' I 'itui'ii: ; infi'i.i .iiul i S - i- ■ J ■ i . ,,r , ,-,-< . imUlCtSOB

"I aitlcrtut lip uf <■ i » i ■ . dl ; laa mnki at Um ukrat{ pro*
i..|,- , tboomuJ i ptfJtlagj ..« ragSna, vulva, and IJtddw;
Umofl of ,' -niiiii canal miJ noljrhborinj; oopuu; raplurc cd

■Mm um. i-iiiu of iit«- ni. ....

PATHOLOOY OP THE PUERPERAL PERIOD.
1 1 1 « .1 1. H m .1 ki i-.. rin l*i i an »ii *i potl |iiiintii iit'n ■-.!

rli»Bp; ■M-nmlnrr li*inorrli»ff«; liwnaiomi BlS-SIB

BjOHKVoi.i Tio.\ l.ti.-l ikiimU ; trmlmfiit "H* 330

AvoMAim avd Dmufai nr mi n:iii«h uro Hurt-**:

s , rippla . inv.r.ioti <>i Uh nlppN); taHK»af

inn hrpurtmpbT el Ruunaaa; -• « * i *• - » • t > i • >■ »■;

•Wficii'iK tulQ iteration; pntvi cat*. ftOJartorrbnia ■ ■<■ ■

hi. mi , f '|., i,i. ,, | ,, il] ■,.: , .i»iitu>; aiuiinn:if» «!»«»«• ;
orrwl of Inrt.ui <»

Ixtmh I'Iiki:nt |»i-ka*io- iv iiii I *|- i i: rmtn u : Mi».-»ll;m. ■

fflapaaai; malar! i; p nrpml aiwtuiu; lirim«nlu>i'l*. •Kmw*

bf i In- it rim r^ nrg.iii* . Miiiril!* iii \ rl! lii . i i-i.'Iii .! In i Imii-c

■ml t'inii ii.-ni . piiiT|n-i.ii i.. ... -iiiiid-n ii>-.itii |iiiini"i .1 <
rnbvlUni ami thromlmb; cntmnwnf air into ntorlnc aViunnaj

Ti «.' Miln'f limn ■•-piii- . p«H'r|»'tnl »i'|'l(i Enfottlun . . ■ ■ '■" ■ ' I

OBSTETRIC OPBRATIONa

i ■ immetlial* repair o( vapfaal and perineal If

n fdialc rvuair "f rvrvicnl lacmmESuna; Inuautfiin ■■( il-ir

li-li f |'i ■ ; ( j- .'|'.i.iIm | i

■ton*; astaraal, bipolar, InltmaJ venlon; ►•mpin [11(007;
tananana oaetf oa : Pom optmtlun; ajaniiinl rota ajeforalnf
M'ltvilr.n nf oli-ifirli operation! ; owl f) BOOB} Ml *IT

OBSTETRICS.

MENSTRUATION

StacarSVATJOOi U a periodic discharge "f blood and mucua
the uterus and the Fallopian tube* of the woman during
period of KXUftl activity — *.*.. from puberty to the tueuo-
u*e.

The caaaa of menstruation i* unknown. Many theories have
been mlvuncftl; but all thntcao beiaid i* that ntrvous injtfinruva
iui; from id. .»wn|uilietic ncrvc-ginelia in the lowtf
abdomen and iwlvi* \* rindically briWjf, about a '.fjmJitioii of
otii^mtiiin of (lip wxual OnH

It it pn-nrn. <l thsl tin function N miiilra^im* In " nil " in thr
limrr niiim-d*. rind thai from ilw •n<t |H.-iurr «il" ibc woman,
fh. paJrio UJUBMtfuu rttfiilts in bloody dbohargt.

Structural changw: According to Leopold, thn infra-uterine
•><.< mewbranr become* thick- m-o' ml *oh>noa l iKoKMl to
liq i i'i. icon, bat remain* practically iuuut throughout, while

net from the r -cular tiwne of the uterus,

'■, u,- (jfmuis are swollen and lengthened. In the -ii|»i
Beta I portion of the endometrium is an enormously iIim

of capillaries. As the venous return is slower fan
ihoarltrml supply, there occurs a diapedtwia of blood. I ln-
blood, ifong h fii :m ciee* of nocai (Von locraBcd activity

uterine ^Inml-, fnrni> \\w mcnttnwl ttftckafgc

Ihfl onMt of im-iii-Uuiitimi, or pubcrlv, \:irir- m dim-mit.

eonntrko, oeeurriofi earlier in southern Bun io northern eli-

mud-v Generally in Utn|Hr;itc diinalee ft appear* aboot lb"
fourteenth VOtr. It fa UOn likely Io come on earlier '" • Hy-
brid lhan m cDantrv-brsd girta.

Character of tfce flow: The Bow is chiefly OQIPpUBaJ of

hi — "I. hut tlw* contain* mum* :ind epithelial detritn-.

It has a |«'-uli;ir odor, which is more marked in brunette*

18 MENSTRUATION.

than in blondes, and is caused by secretions from the sebaceous
glands at the vaginal outlet.

The discharge is dark in color, as a rule does Dot clot, and is
alkaline id reaction.

Duration and quantity: Menstruation lasts from three to
seven days. As a rule, it occurs every twenty-eight days.

The actual quantity of the discharge ia from four to six
ounces.

ManopMM: Menstruation ceases in the forty-fourth year
usually; bat there are many exceptions. As a rule, a woman
menstruates during a period of about thirty years.

The cessation of menstruation is termed the menopause or
climacteric.

Ovulation : By this term we designate the process of forma-
tion, development, and discbarge of a mature ovum from its
Graafian follicle in the ovary.

The Graafian follicle is derived from the germinal epithelium
on the surface of the ovary. These cells, becoming isolated in
the stroma of the ovary, develop a s|>eoial containing mem-
brane from the theca fulliculi, which becomes divided into two
layers, the tunica Jtbrona and the tunica propria. The epi-
thelial cells develop and line this membrane, forming the mem-
brana granuloma, and n fluid, the liquor folliculi, distends the
cavity.

One of the epithelial cells of the membrana granulosa be-
comes more highly specialized, the ovum, and is surrounded by
an abrogation of cells, the dweus prolitjerm (Fig. 1).

It has Imtii ealeiilated that at birth each ovary contains
S5|0OO immature follicles. These do not develop till about the
time of puberty, when one or more rapidly mature and rupt-
ure. The escape of its contents takes place eacli month, the
process being; repented.

As the follicle matures it approaches the surface of the ovary,
the liquor fulliculi increases till it points at the surface, rupt-
ures the tunica propria nnd washes out the ovum surrounded
by its discus proligerus.

The ovum is then swept into the fimbriated extremity of the
Fallopian tube, through which it passes into the cavity of the
uterus.

Miwsmiwrt- ,

lit

The OVUm. Tin* iinmithitt >n«m ih ■ -irujilr i>|>jl ln-l ml ft>||
withuiil :. ivll-wiill, l»iil h;iv'ilij» all-OOfltfKtl — i,r., lh.< 'Ik, ;i
OUcJeu> tt'rriii'tl tin- pTtniiiitl vwucltf, Slid J DOclfOluil <.i.lni ili>'
p-niiiii.-il >|ml (Klj{. 2). I( uith UOV4 lopl ;\\<i «;iil-, tin
lcriiMv] llu- vitelline! inniiliriuir ; (lie iiiimt, tin- ■ -« ll-im inl.nwx
llrtwirii tlirw Willi- U ft Hear iiivii, Itniinl \ht tOttB [•» Ihirulu.

a- thi <"""• mcturu previotn to ill magi From tin I In
loilicU lis gvnninal npol ippnunba the cwl*iMDbnuit^ when

lr.. I

PS SB I's

m

f i.

■v

»

HO

y>

IVF

IVvW.ipmcnt -if Ih* OrniAan fnlHik • A'*".r*nnin«i iMlhcUun, fti-m which

rniiK.i ■ ..,.-..■. ma f( ,„..ii

■ i ■• i' I '. >t tin ill r* uin . .V ■!•••'• but" •• i n i.n'iiilriiil jfaiml' <• m <i OTUO) /./.
ll.MI.ir f«*l i i'«» ,.r-.li,-.--u. Pi, rlj* nvupi, »il >i» i 'III/ ami gvt

>«i •»- >t /«' irp.mvmi -i-:h.i.u »• man u:«i iimi!i..i fOUli ].. >.

brana*raiiul«*«a iwt««J«nb* I

i. Mini to dinpponr, Bad » portion of the ovum iicxtradcd,
known m i'"' /'••' pofaf oooy. After o rtagc of ^uicawenin

ill** [«*■ «•*■?■ i- r'('|M-utMl, iiim) ti -final J,,,/,/, hath, i- c.viruHrxl,
Thou apptan a new and smaller pcrniirml -|..-t. '>rme<l the

'i wlau.
When tliwc phenomena hove taken plnee the ovum i* mature

and tltc Omnium follicle rupturut.

.</> v.//;rr/7"Y

The carpua lutauin ! \ I'm- llir Mcnpc of the 07001 the rupt-
urwl (rrnnfiuii follicle Uroim-.-- tilled with blond, which dote
and n Hue <w|wih' devtlopl around it, which gradually becomea

thickened and throws into fold*. Ton fbrinatioo i* ecrmod the

,■,„-,,»»> Intrant, from it* yellow eoloi. Should prvi;imiic\ ittd
,„,.,„ , lV ||,r mvnfv-t 'ijfhlh t\i\y it hIiuhs on the mii tail- nf lliu

. v tin-rely an I lHtn.ii-> lamina in a little pit

But in iit-yo" "■-'/' l" ,Ml tfW pfoloopd CODgMtfon, the corpus
lukum ban « """'I' greater Juvclopiiteiil. forty day* after

Una *i

H i hi ftmn mn «miioii*i lo ihtm urtaan

ivfriu ■■(•nary, 2. tunTi'i allmwl (lbr>.u»i,

Mtimn I.ilUrli- rtmilni flliMwn; f.. <in»nrti«tt vr*lc|,i

fscun/uUr bll «»/ .narlitn ItRHU PHI fcftlO 0W1
MMit* 0iui mill i. ■ i"iiiiiinl oovvrln
ii i' (■ni uHtu •■( -I..II.I1 i, ii».i.n«it
.., itvuae • *.B, mntm trrttiuilma; l. liquor rttlllntul *, • u-iiii»- mi mbriM, hi »nm
im>lltiriii<> . • fnfiuiai Viii-iim, nr »«ik . lo. u> -■ruiUmt vwlclv. 11. ewrmlnal iprt

QOIlCtption il hut n diameter of about two-tlitrd>» of an inch

(i 'nin.i. At tarn it 1m m\\\\ p r a aan t, haa ahrnnfc to half an

nidi {! cm.) in d in malar, ami ih of a dUlimi b'lmui-yrllmv
it.lur. A month lAof delivery il I8 reduced to a small maa*

of lil into- !i- --in ■.

Ovulation and menstruation: Neither ovulation Iior menstru-
ation i- ilrjH'tnlciil on tin: oilier.

Both depeod on (ha name enuse, a periodic ucrvoiib eicitu-

IMPRM1SATI0.S A.M) (WCHI'TIOX

21

lioa «d<1 uHijp'Ulioii. A* :i rule, lhe\ <l -uu -\ ur!it.njou>-l_v;

IhiI LtopuM 1i:im proved tliul ovulation liiw taken pkai in tin-
iii(.-nii<ii-iiu:il ptflodi

PnglMDOy UU Wi-ii ktumti In l;iUi' pluiv Im-I'oiv tin- uiimcI

nf meiiAtrniitioii ami nftrf (lie OIlOUtCNrid.

PREONANOY (Normal).

EMBRYOLOOY.

Impregnation *uii Ooncnptfon.

Tin- unapqption of tha -j-ri.- rnqatra ilu* union of tin-

I lUl ftloOMUa of I he tVQ MM*.

In tin' :nl of roy-Wo/ion the male d«nmlui williili the female

a ilunl, tli*- ormtn, which oontahi the vliolfriog olwnot

Tll« ««ra«n i- a while. vi-nd. deiw fluid haviuj; :i jwrnliar

ndur, M Cfl I'll b) 1 1 ji ■ 1i'-1irl< - ill' thr in:ili II mil-UU of \v:iltT.

;tll,iihint.-n- rn.it:. r -.ill* t,f linn and sodium, mid OQD&UOl
DORNTOUI ptOOluU Drnflhni CuHid OJM ■''■■

Thcw f»i»rrnn»ti.»iiil- form tin- »«-eiitiiil iVfiindatinK pin nf

thoncincn, ore about 6 J,, inch in length, nn i i> i ■ l«* the tadpole

of the frog. Knoh one m made up of three parti \ Iwiid, middle
pitrc. and tail, and i* eupuble of wry rapid vihrntory move-
ment (Kit-.

A'l>T t'lni-r-iuii. if in proper »nrivrtin<1tngs,
tin? "iv..niiM!i- lelalti their vitality for n COO*
ridcraBIe time. Excessively acid or alka-
line (hud* destroy tliem.

Wliile pri-giiiim^ Ihi Uvn known to
follow lilt- ddpautloD of Miilrn tin lln: OX-
t. th.mI eonlb&H of i Jn* li-niale, m n rulr,
tht ;u-id iini<ti- ol" i In* lower vagina proves
l':tf;il to iln« HlOltPOtPBlidl

At the eri-i* t»f tin- -exiial ml mt 0000)

n H«uttiu iicju.-iini in tin- upper portion ul

(lir VKIIHtj '"'" «'l''*'l' '1"' "Tvix |>rojlN't>.

BcdocUm roonnstooonifl Sod thofi nip inn*

,vi:, of the utfi-ii-, ud ultimately noon Im Fallopiui

tubs. They have bwii found OB 'I" - Mirfswv ul the ovary.

!■'... '.

*tmn,MawoMM.

/•/.7". ^ i.vri

\- :i mil', ! In m««tini-pl&e« nf tin- Mftfrmatomidt roc own

:- in llii l'':tll<i|iiati Ultw* JM ;i « i v claim thll tbl "nriiKiI J>!lUV

of DMvtiru i- Qii upper purtion of Um ntnfa • - ■ •< I it

id iio( UUfmtll n( rluit ili< \ «-<hii< in « ontact <>n i lit' -nrliiev of

(In ovary or n Ihv ■brfointaal mvitj foctopia goititioii)i If
tin- ovum u dwdiarw) tl uiv Imigfil of tin- couMtratl •■■
liorij ii prutabjv does nol rwuu ih*- twit] of the uteru n

•OHM U*TA Il\i-; mad i In' ovum in the iit-Tinc I'Xlirmitv

of tin tube 111 4 yirl who bid died on the fourth day of rata*

Mtnciiinn.

rp'vii;iiii\ i- wort tiki-/ ij tn ui'fiti ufti-r I'l'jinliitii.ii dUfiDg the
lli -i i jglil il;iv- 'iKiiMling the oft*adon nf njcnMumtiin.

Fertilization of the ovum: Of the Iitrpc nnmlHr nf -|» r-
mutojf-'i.l- i|i-|M»iUrd in the vogina, hut few probalily com* into

n* 4

..--'V

Ffirnrnilnn of [tntor fllotiiilw in nru rin ijla< hille fto, nntflMI Iptatflfll l*g. flr-l

!"*[« flnWIt'. ^p, MCV1I«I 1-iU- r.lr.l.ilN . ,,i. I Ii< (irnrMiil ifl.-f M.-i

wlv I

contact with tin ovum ; ind of ill. ■■. , hut ft single s|w»rnintoKoi<i
nctualU rak^fl |t:ul fa lli«- tiTlih/atmij of tlic ovum.

Hy Miction Willi I lie Willi of the tnlw the cells nf the rliftciift

prongonti disappear anil tin- bum pellucklfl boconiw -uirmi nihil

\viili 3i 1 1 :ill>iiniinnu>- covering which BMQM to attract UM >jni-
HiUlo/oiil.

Tin- ftueoawful Hpvniiatosoiu, ilta penetrating t lie sona |« I-

DBfBLOPMKhT <•!' TBB bBCHWA.

!uri<l:i. ""iii- in CYHitml "itli i projection <.t ' ilu- |K\>i .ji!a-m >>l
ili«- iivuiii and 'I- tftfl -I:- «|'(» ." - The l»f*d '1"'" iwni'lr.Kr.
llie •> lUrniil.-sil- :iii'l dlMPPnUV, tO r-'Mjip' .(' -ul.-n|iiriith :<• P

mall ronml body. lha snofi pttnucfou [Fig; U l-niullv Iba

in.'ilr jir lelans and (In female i" I" "- nntto, and connip-
tion tin- noourrod, Thni the Hft bhrtoq of ll tbryoj R*tw

and iafmnl begin*

Development of the Decldua.
u In!'' ilir abovc-elcM-rib**] prmv* -■■- hnve been mUing pi

liwlilic U) ilu* licini.|:ihuli of tin- OVaiD, [ii*-|miI :ill«»li* li!Ur bpJCD

in pro .!■■ En tin l.iii-r"- r . --« |>i i >n :ni'l muin-liiuciit within

tbi ocarina ceviiy.

Tlic mucous membrane lining the body ul il>< "'■ beco HC

much iiUT»-JiM-»l in ilihl.n. --, i|- m l;n i<l - • iil;ii-itn_: in nil ilimt-n

-J..II- I'hr lining tncmbmiM « the atoms during pregnancy

U (.nihil tnO 'lir/'lmi.

Tin* ovum when it nii'-li'- iIm- ni<-ru- ihn- tliifb thai ■> nA
l»ed han boon ptvpnnil for ii. fi nan ecttla end liwnaiw
lulhcrvm. a« i renal! of ca aln iaunbn4Ike projections (villi)
which have ['I'liK'l <-ii hi wrftc*.

The ovum oooq Axed, the dcoidiia pf I to grow ui»

around a catnpletoly Imbedding it m»l thus mnttrog if »n*

frnm tin- iili-iiiK 1 •■ u it*.

Subdivisions of the decidua : The (iftridua liolng lha Otertne

cavity Ei tarraed the dfeftfaa vtta . ihsi portion on which ihe
ovum luM 'nun to anchor, the -it- of lot future ulaccnn, u
called the dteUta mtouswi; while thai portion wnlcn prowa

njt ninl itin "ni'l- tli«- iivuiii i- named tin- rltrulmi ,

(Fig. 6).

Coalescence of reflex* .\nd vera : Al ill" OVOm glOWl md

distend the ut.ni-, the daeidua rrflcsn cotnee in contact with
the dooUin vara throughout A i rcsull of prvwun- rlre
■ mi i layw of both renem end vera then undergo conaldep-

ahle atrophy Tlii- bakee place about il»<- I lE m h of

gustation

Layer* of the decidua: Tho oVvalofimanl of the disci

fftatul* u.uU to ecnnhi chan ■■:■■ in ilu- ivirii*-.nn:iii"n •(' ill**
iktndua. TOeaaghwda, dilated and airtight toward the «a>

tvrnt-tiiipTAiimnuii- omlin. oi in uittfroptmarfor HWl r tit. ^ravirt nu<nM

«ji«1 orum ^ ftv«» »,-<i|(i- * imurtnf utrrinv wall- h, prntorl^r ut«rln« wall vJk
rl.lim >.iti il ilariilllB rvftrt*. .. • Im-Mim •I'hilliiM i». Hmrl.ni with U. villi
iW.rftftprt from All«n Th. im«on.'>

ailed ■■f»'H" i<>!/"\ or mpitfhny atrabmt while below thin

again, fa contact with tbd * le-wnll « «*" the uterus, U n nmi-

JlOrt l:i'.'t hiiiiiii rln- <.t,-<)hltn ffmijiifhlhi (Kitf. (l).

The opoaiy Uyer [i of prime Importance, for ii is through

rti \ .- Of OVUM i OBYKt.orJUEXT "i i < " 'J.>

ibuiluyvr tint tUolini- of tqxiraiiun nun-, whMi thsdenldQaewo-
tiim uud the dfeddni vera arc c*«i off vrltfa 1 1 ■■ - ubotBtt ud

membrane* ni tho< duflQ KM

In fbolj flu 1 decidua may l«- norapond to i cake, which i-

i'niMH«-M-'ii ..| (vvii i',.|ihji:iri l:iy»-iv, Im1ui.ii «lu<'h i^. i |»v. r I

jam. It' tin iilloinjH i.» mmlc BO MRpwrafa il» • >two laji I of
cuke, the Hm Of MBOMtiOB «ill run thlTMgll i h< jam I wliitli

Ki... A

3£S

J,*'7

x«'lKin throiirti rtc <1c*Mnn. a niur i rtoii p AmMm: ''. utrrino

mwk' r. UMnrMnmi"! I"- wllntai u lUUi !«>.. : . .Iniui.il.i

-.-■ti I

w tinp o ftdft to ihc i"'itffy Inyrr of Ihe draidaaY icoondcnbli
portion ••' wlii'li «ul doom in 9 idhi rioo t<» tin- top I grer of

tha c:iki', wliili- Mime of it «ill "t'll be left on the lower Uyer.

Dacidimi cell* : Xot only <!«• ifce abnufa "f the doefdno
brp«rtropbv, bet tho fr/*r?2awfa&ti ../*...« i i «> U : and in

ii ire (U-vi'l<>n».i l.-irjr*' • nillii-Iinid " Ik, kin.wii U •ifi'lmil iv/U
In mfer of popig OfPBOO* of plooiata "i* mbrnnr* thc«evll>

m obinutenitio of drridiul il n.

ClmiiKtm in tho Ovum; Development of the r«tue.

The impfWlBtid uvuni i* (IT first ■ Ornplo Mil,
I . wall i- '!»• iiirititf mi norofu ; it* eoutcnte, theortrnw/nr
vikHuA ..r 1/.-.U-, ami which Utter ie • comple*

Dl»nam •howlnr Am iImw of §r#nv*ntatlnn In * mammalian ormn. lAlIrn

The fl ml division resulta in two cell*, \\hu-\i differ BOtDCWlttl

both la *ta And AppAAraMA; This diflbram \» ptrpfltotlrd,

•o that n* n nsmlr of thill further division two groups of* <*"llft
difforinit in aIm and AppAATADCA arc formed.

Tin- largn in urrrnon ijMi.*tir .•'//«, nnd tin- abuIIaf Ajpa-

bluflir oV/*,

Thn bUxlotlm-mlc vmlcla : That two «Jt8 of ndls then »r-
nagMhvron Wm in a npAofail maimer; the epihlastir wlls aoov

ly Hirrounding tOA bypoblAAlIC eells, VrblCfa collect in a

1

2$ PREOXANCY.

ouUncta, ami the ovum now form, ft diattaded vcaicl*, termed
htnttixtrrmir wsifle. ..

Al tin- Man the euiblastic wll* compleuly l.nc tbr bloato-

dtfufc vi-.-i.-L. nliilu tin: mas* uf hyjioblaatic evil* I

. diet nded by Lbc accumulation of fluid is MMenod ino
poMdoutovci i small «n» of tha wibhitic wH-iinwKf "J

ml p-.rt.oi. being thick« limn the |mnphny (I''U- ■'»■

. jmrt ■ the commencement of the embryonic we-.

It i- -c.l. ii.m part of the blMtodermic vw'ielc which i*con-

.. ti».. inrnmiinti of the embryo; ibc ronuuamg I 101 " 1 / "

0* Ihfi BOfi-ODfarrnnio port, ;.n.i mrnvrned only m '{J 6 .™**
mtlHio of lb* amnion nod the umbilical vceiolo, at> we >n,|H wt
Ut«.

TW jvUttir «pibloftic cell* peripheral to the thickened Wfw
of bypuUaatio eeUa now diaapiwir, leaving this portion ot we

Fw, 10.

Tr* *i f .-hilM.r,, it rbltk vtubryn, ■li..«lim br«l«til«K *-r u, <i''"*5'

t* i . 1^,.. ... .<.i...Iv»m. fc, BMMMtenu. r. tuwdora .M»ni»»

wiill flf one oooM look, a% it were, through the vitelline luem-

Mine) lomewbiil dearer (awa peliucida),

Tho hjrpdblaattc <v\U now appear os a darker strvuk in the
:m:i palluritln, termed the primitive streak; which then devel-
0|r» with a groove lumwn w thu primitive groovo, which is the
fir»i evidence of tin formation i>t~ the emhrTo, indicating. «p-
proximately, the po-iimn of the future vertebra?.

Olaxvag. of the bypobleHic celU : If a «cctinn be mini.- through
ilii- -ir.Tik, ur groovi al thU period i Fig. 10), the hypoblu-tn-
crlU vtill ta- found to have aeparntcil into two layer*, trrm.-d
Mtivcly the tetwterm (permanent epibJaat) and the mto-

r'rvrii<rur\r of uir \WMnn \sks

•1*

jam [-■riimin'in hypot>uet)j while between then ipoUus
\:-.\>-v lut— formed, derived in pert from both ( I'-noed the 1

Clt&vecc of the mesoderm: In the rour* of time tlii« moo-
derei developi Intend roduplionliono nod div"nle» into two I

till |.irirt;tl :m<l the vit'.vntl 111) rl in-' |>:t<.*>, Tin-

parieteJ lever unllei wfth iii«- eeiixlerm to form the tomato

phuir ; ami ibfl viwvrnl Ian:* unite;' Willi the - -ttt-HU-riti inform
(be Ajilnui'l,w>j<hiirr,

'I'll' ipeo [nolcded between tin ew©1*»vi* i»l the eU-ft me-i
dera in (he primitive botlv-eueiiv, or iirlum, whirh afterword
becomes il»' r^eortpwitoaea] oevity

Development of the MnmhrnnnH.

The amnion Hie embryo no* noloi towtrd th aire of

the ovum, efld M it <J«M3> *o the M.iiiiutu|ileuiv grow- an ill

i- 1*.. M

ho, [ft.

' ft.

y

re

r

■'•

ii A i mhrj n . , uil i mmi i.uu ....r.

(*ll-|Btnl r ■ .r 1 1 r, 1 1 (s « i,rr< ill. • ... . [...||.. ta

• |M(X Hl*lilf Hi.. .Ire. '.I.. .:<!■ (lift) ,|- ...... I...- v.-fc i.rn i fl.l.lf

inn >o ■ I i I >roId >f amnion *■■ ■-■m* -nf.i ■ , ■.. r >.

■" hyivifil.nl .». -:... ... if ■*.. n,ij

iimi.ih. V. mlvlc J(P >'.ii.i pwIliiHiUi i

t'.i'. fold" iinw united, ■ mel, tht- trm nmnlntk

-•IH nil mi Alfli i>i<- [id ur.i|

v o'limiiKft i amul. ■till i ■ -I liifl *IU. «c. 1 1 . i- hiiiI'iIIi'aI in

|rl« I -I. ». «.( ni hi lliiir Itiinii vt-tlrlr i r j.ii.in.f . - . .>.■

i'i.Mtr. i !-«•• i ..I mm idlAai *■><) ii> |> >l>U*i mm) iliiuoii«*lih ipl ' i«i»of»

if hi'.. -Uiu : //'. KOI i<c) lur l<l<i.

troood it. while Uw Pjdimehaopleure nuke with tl Phi

■MDIto|>l"iiri< f<-lU Ihiw jirwnl two -nif.n... QOQ limiting

.» PRZGXASCT.

wward the embryo, the other :->wa:xi :b* «r:er -cract of the

'/ v ij jjj F; /. 11.

A- ti**e ;*-.•!- a**? ■>v*r :he bu*k ot' :!*= *sic«eyo they ooa-
Jev*. and iwiz wrtj two discisct DW g bcaJW F:£. 12. The
iW metbirfwe, :ha: next the embryo. :V«s3$ * complete
«**-. the *uttnl'/ic *-"-. Laving it- origin do** W :i>- cephalic and
<au«lai end-. Tiii- membrane is termed :fce -.?■**•;■>»*. and it*
ibuer -urtV*- :- ■irrivtd from tiie tfEKaK. and is tvoiinooos
with the •* : .u of tt»»- embryo, whieh :> also tp;:*Iast:o.

The *>■.•/**■ njvfubrane. wLU-h ha? i:s outer stir:**.** composed
of ep: ola-t;e otilf. then retires toward the ouiir surrace ol" the
o". u:xi. to form the chorion.

Pnmrtjre pit- and jolk-sxc : While these chants are in
projrre^ in the *>ma:op!viirv, the spiancunopiiiir*. sinking
toward tiie e»-utre ".•!* [Ik ovum alone with the enibryo. «md-
|A*f«]v envelop the yolk. Bv bending sharply inward at a
j/iint tom* <J:-*aii">- fn.-u its ..ri-riu tlu- ?planehuep\ure forms
a -***/ii'J "anal, wlii-h i:- thu- liuvd with hv|«..'Uast. The upper
'anal <:Y*flt'Jaliy ljeev:ii-:« (he h'u.\i nU: ■> !•■■:•* ; while the lower
i- r|*e n'Jk-M: '.Fig*, 11-14:. This latter gradual :y disappears,
though it *>metinie* j^r-ists a< a blind -sac U-ading fr*»ni the
il'uiii. known a- Meeker* diverticulum.

The albuitois : A portion of the -planch nnpleure formic j the
•*;i)l of the primitive interfile vvtv Mflv bud- outward, projects
in'o the pI<-urop« -ritoneal cavity, mid approaches the chorion.
*I hi- i- ferrm-d the offfthtoi* ; in it?- substance the livtal blood-
y**V'l- develop fFigg. 11-14). Tluse allantoic bloodvessels
line ih<- 'horion and dip down into the villi.

The orachtis: In the mur.-o of development, that part of the
;j||;»ntoi- in r«jiiiieeti#rti with the bodv becomes obliterated. A
l*irt f«»niH the nriiiarv hlachler, while a portion of it iietsists
:i' a filinmi! i»rr| running from thi* visciu to the umoilteus,
U-riw*l the urof/uiK.

The umbilical cord : Both the yolk-sac and the allantois are
;it oih- lirn" iiM'Indcl in the tuU: furmed hy the meetinjr lo-
/'th«-r <«f th.- sitnni'iii <>n the ventral aspect of the embryo,
Mnii'-d ih<- ulffhrfuinal -mlk, which beeomes the umhilieal cord.

'I he r.htirUm \* •!•#- j'Tiiiuii'-iit (Hiter memlirane of the ovum,
iiihI \* forin'o!, :i- \m- have -<-<-n, from the soniatopleiiric layer,
il>. outer -nrfm*. UiIiK '-pihla-tie and its inner uiesoblastic.

\)KVXMPitx$T "i rrrr rr.ACEyr.i

:;i

Tin- u In >li -ii[it>iiit'I;il »n*i di' the * Ih-iii.tii i4.*ou bccomcc GOV*

end with lit lit.' proji i tiout, tari I ritfj. which "dip down H Into

ind * ! m ittaeltecl to 'I" 1 dedduo (porotlna and rcnVscoj

nt ull point- of CQUtMt

Etc* villas din- Ii;h an outer NirflMK of CpJHlftic tissue,
while tenon i" ferinoa of ioblool IIicm \iilt u m htvc

■••n, n.civi .! \,i-. 11I..1 i'ijni|ihM'ii( li tin- iil!iiiit<>i-, lliollgli

the Don rwetit virw [■ tout the capUltrlM in Kiipiv formed
from th*. 1 niiHtthluMK 1 ti«ue <>!' ill- --( ■• »«•- »ti, Siihw*|iirnily them

rV. 13.

Fki H.

■ ■ inMUanlo wiij mm f. i-dimmr I ■ Uqnu

■mnU:/n. fuluc Mfialun. . ■■ cnvin. imr, coutlmiuua •■ 1)1 i<i l*n «1 i*vli| :

. . j fniiU i.r ..i. -.1 . ■ 11 1 '■ 1 •; -u, n,, :.. 1.. mi .■ I.

■I • MUD toll . m "'" '■■ • I 1 "' 1 ■ ■ ■

IllllHM I ml ...111 .,,.... I ■ ■! nt I UK lllil.i 1 " ■

#|l UfllUUni In -I'll iiii.'l vuti h«|'"' , l>»''

fls U— ' ' ' M> ravMi »•■« "Mil mMil 11 U« i|ir> mi «Ii - •I.mihI

(I Ml . Ii|j ■ 1.. ■ '■ ■ IDI |. ,'•)„!,. 1

1 form «■ horton m rtmtmnt of tmi! .....

n«l nf •UitnUiH w Hit Mi »t«li 'ii 1. 1 m nd

l.ll'l.. lll U I lift! ■ liU'l t. I Jolll 1. .

. 1 ■ . ■ lik.:..> 1...I1I, -.1 1 Ik I 11 ■..!"! t nil . ; In i i.il < . ■ »1 I

. . j-< ii.iu >■ . itiiaa 01 tni» ftniii 1 ■> >■ ■ »ol •'rinr,nini

•U • ■111 H' I Unit Mil lltfl lrll ( l» ItB'V

nil I Ig. 1:1 1

villi iii contact wiih iIm- motion undergo rapid development
ami proliferation, forming the dmionfrorulomim .- while thoan
in oonUoi uiili ill'- roflena, termed dAoi Eon '" " . retrograde ind
finally etronhj .

Development of tho Placenta.

Structure The ulncentn » cbivfly ««iipo»«n of wrtol tuwne,
the chorion rrontlomjiiij h»i ihe miptfrfieiid lAyei •»!" dmdua

:;■'

MKt/XA V| i

•4j.i:in.i .j.n.ii.- with it. iiikI fumw it- mat. raft) HJ

Thus the putosntfl ii partly fatal ind purify maternal, both in

origin nwl structure.

The viiii forming the chorion tYonaoean are rimidy tafl o£
fatal mpJllarta ivcrcd nrUh two or more i.iv-i ■ or embryonal

cn.ih ■ ■ ■ riv-m- derived from the •piblart, tn tarmoat layer

being conned the syneiriiim iron) iu peculiar phagocytic funo-
lion.

Those villi branofa iu every di ration, and. Doming into eon-
i:i.i ^itli ill'- uneven ■ftrftr "( the deoidua lerotiua, often
:iin>r:it oo section to have notmlly dipped down into ii , but

ilii- M only apparent, and doe* not really occur (Kg. I i.

i ... i:,

**—

.

■' I I'Ui .(-.. hi. in. ii tA. ohoftnn; i, Mill' \

•IrcJ'lu* lorxiiim. I>-* ."i-| ll( i iImMiIim I,, villi |.'>| (.. icrutlu*. A,

- : I l . ni«ti;rt>«l •■oin. .*"■

The roatornal capillaries Iff th< Mpcrnt'io) layer of the
■<■' ''in i become enormously diateoded with l.u«l. tnni funning
Italian

Through toe prolmblr pha^hvii. adion uf thv ^nehid
inura "M the villi tli<- mnerfipial lever of the Bcrodne end tltt
wall- 'it id'- maternal 1 otpUisriee nro in tinn* abaorbad, ilm«

pormlldng tin- maliTiutl blood to rWJpe into the tnfn't'iflou*

epoeeii

PLACENTA ASH Vr\flti! I MS ir 7'WMf

Mi

The fftul villi an* lli«n in direct contact with Lfefl DateOn]
blood — fin- lathed id it; but there ll no actual QOOIiectiofl
between the fmiul and maternal circulations, as the wall* of
the lletal villi and their covering* art' "till interposed.

The maternal blood ia curried through the dcoidun by moan*
of spiral twigs derived from the uterine arteries; ant] i* carried
»w;i\ In vein-. li:ivni|' :in oblique direction toward the jH'i'ito-
nee I layer of the litems.

This formation of the arteries and vein- In the decidua
rraull* in the iilwilutc cutting of!* of the Moud-Mipply, when
iilcmic retraction mul contraction bring about the cAjxilsioti
uf the phuvutn :ii birth.

In,.,

Placenta and Membranes at Term.

The placenta at terni— i. r., the end of the period of preg-
nancy — is i aoA) BpoDOi vwouwi maee, tfroolar in outline,

tiili ke-l at i> centre, urban the umbilical cord U IBaWtVBj ■'• ■
rule. It* mr&OC i* *ix to nine inches in diameter ; it i« from
one-bnlf to one and one-half inolits in thickness; und weighs
from owe to mm and on* -hull' pounds.

The jibuvnia is fully formed at the third mouth, though it*
tliineu-i'in- hi. i. I-.- -li'iidily Inward term nud boat ll DCOpOl
tional relationship to the boo of the child.

There .ire two aspects of the placenta to be described : Hr»t,
the f'rtttl, thut side directed toward the tortus; secondly, the
noioma^ tint dirwted toward the uteru*.

The total aspect of the placenta is covered with a raootli

- li in i nu. membi'mie, whieh is contlnuoua a/Uh that OOVartOg; llM
umbilical cord and lining the amniotic sic, the amnion.
Beneath this may bo seen the large nntbfltfal voaaels running
(tiitiiotmly on the chorion, and dividing Into bftuaebea, which
'lif down nt right nngle* into the villi, forming the man of ili«-
plaoontn. Deeperdown thedaritei chorion may ba mm through
the transparent amnion. The remain:- of the yoll nw e mnv oooa-
f-ionatly ix.- Bond, Looking like a piece of potty, hiny; a ihofl
distance from the Emertiefl of the cord.

The maternal aspect of the placenta i- of a dark grayidi-ivd
bile, god i* divided by deep -nlei into lobule* of irregular nul-

Imi , tanned dotgitdotuk it-- Bonaol ll eovered bt » grxyi-h,

1-0 b.l.

JW'.Vt.V'T.

_ i '"'Hint;. !nttiH|nir<-ni ineinliriiuc, which is tbc mtil c-rncxl |M»r-
DOO Of the plucciilji, and i» nMiipiiwil of the miintHimii! laser

of the deoidna nrotfaa. Therefore the line o( cleavage, amen
the placenta ■epentea from the uterine wall, i- through llM
middle or Bpong) layci of the docidua.

Aroma tbc periphery of the placenta rum u large vein, the
circular ainua or veto, winch return* » portion of I Ik niatarned
MihxI from the organ.

Tin: site of the placenta in I Ik* UtVItlt vario, though n i-

generally on the anterior or on the posterior wall

Tlu- functions of the placenta in*' innnv. !l i- ;M mice the
liiiiir, the iiliincnliirv ti|i|i)initn~, nnd tin kiilncv of thti '<< !

hi it tha Ebrtal Mood parte with it* carbonic acid cat and its

other eajjte>pr<)diifi* a receiving in return, from tin- iniitcriiul
blfMMl, oxygen, ami the material- ne« -«irv tor the nutrition of

UN fotfUS.

Tl pitltdlal liivciv of the chorionic villi -- - m to huvc

certain powers of l«>tl» election und resistance; since cer-
tain Imi'illi and 'lings pass readily into tic ftctnl circnlotionij
while often do not

Tin- umbilical cord, which unites the iictn- with the placenta,
i» formed about the llmrtli week of gOBtulinn. Il :ivei:ij;c>ji|
linn about twenty irii-lii--, Varying IrOTIl foiir Ui eighty inoht

in length, li- thfckncaa varwa froiii the -\/»- of tlie little

finder tn tlinl of flic thumb. Its ±>lir:illi i* composed •>!* am-
nion [ t! contalna am) oWrrlM oaxryinej l»h*>d /nun, and a wtfa
oanryitiB Mink! i», the Uetns which are imbedded in a mucoid

-ui -Liner [(Mown Jl* M'liail'ni'y jtfttf. TllCM VCWSCIfl Rift ill U
-|iir;il niiuiner, ll|c twinl- uxiuilU NlDg IrOtD right to left.

The rim n it mi ami chorion, With the shreddy remain)- of the

dwklua and tint plaoaotA, whan tbo3 :,r '' oxaniinod after da-
livrv, arc earn to (bun a «*c, winch hna been ruptured .if i na

•pot, ii-nally at (!« -lie of the interim) <i*, tO permit the raOBM

n( the tii-iu-

TIh 1 dflaidim on the meniluniie- t* mmewhal thicker tlimi

iii.it mi the maternal aepect of the placenta, rfiw it oooaiabof

the atrophied n ll.\a and (In -ii|ki li.-ml hiyer of the vcm. tl

i« reddiah in color and varv iVcihle.

I ':.. ehonou can !«■ naWtlv ■rj«inite<l iVom the iimninii, i.wh
of ihi- . (bHUine » di-limt tncmbr^ n a:- the e«lp of UM

TttBOrUM \T i>irn:ui .\r PSfUOC*S Or rr.i-i:\ i.\<*>. IS

plaOBDta. Tin- chorion will lie noted to l». Thicker, more
opaque, and less touch than the amnion.

Tin amnion, wfalcE fa tho mem bra ne next to the fu'liiH, w n

dear, tnnulueont membmoc whose chief chtn«crb*M ■ it-*

loin/fine-**. Tin's ioii^Ihh--*! permit.** tin- si'*, when diftfoudod

wild liqilui* n ii, ii wltbflt&fld CDO*»lriulil"' [injure, and

•OabtM tit** l«l^ •»!" HKinlM.-iiir- In art in ah ettiri" i i < > < '■

.1 livili«>-i:irii' amtof dm log the fir#i rlagt of lnl>or.

'i'li.: liquor mnnii, fffcich Ml the amniotic UK iod 111 wh oh
iii. imIu- i> loaprudodj i- :i light-cotorod turbid fluid of u
ipaohSe ofavftg ofaboul I0I0> tti quomUj rafta from one
to two plot* 111 the normtl Mate, h- amirce i* not •Itlnit" Iv
Lnowii. By mtaf ii b believed '■> exude from tht maternal

vr.- ( !- hi tin- tiUnne wall', lint i! i- probably "I t"t.tl oiiuin.
It* Jwn'fi'iH [fl lii BflVfQl 1 1h- lu'ttl- licim; |H"--ill lipOtl, :ilul

to iilliw M- I'n-r iii'vri<i[iuifiii. sinH'L-, diia i" liiiu 01 blovnoo

thrjuirf "'' '!" mother, nn.< |HYVi nted (Vi.hu ;itl! i'liOtt lh«- ft U
During Inlwr, u- liir Ix-eu ■ ii'l f it form- the nn.-i. Pfrfeot «li-
Iar.»r.it' lit- ivrvix uml |»r».t-iM- lh»..'liild from tlh gml prMB-

uro brought to bear on the uterine content* during tbi lir-t

BtUfT/.' of labor.

Tho Ovum at Different Period* of Prognaocy,
Ftnit month; Ar tbfi Kid of i Ik- fotlrtfl Vtafc tin- umiih

niivi-iim* about i inch iu diameter, and tho itraighteoataul
embryo about J inoh. The chorion u covim-d with villi, aod
the amnion doea not quite fill tho cavity of the chorion 1 , die

spun -.-(uniting them eiioininini; a elraf lluul.

Second month: At tfiOeodoTuh month thtnYnrn i- nearly
'J Inches in diameter, mat the embryo J ioeh long Tin

amnion (ill-* tho ohoriofL The chorion hove i* atfopbyttiej bol
tii. oonllsnol yet ti*ietod end oontaina n> loop of luteotii

ii* base.

Third month. By the twelfth week t In- ovum u 1 inche*

in liar lonj; liiami'l'T, ami tin* fi>iO0, U if '- DOW »ulli-<l. i-
nl Willi .'»J niche- 7-!' rni ) in Inngtll. Th* plaOBDUl U ffflil-
jilrirlv !'nrni..l ami lite n «i .if the olmrion W quito DM from
villi. Tht t run I i>- twUtiil ;inil tin* l*>o|i of inti-vtim In- bfJBO
uillnlrawn in!., tin- febdoBUOa] ouvity.

l'/,vy..vivT

Fourth month : At the <<inl of the MXttwntli wi*Ic the
measures about '< inohst (17 cm.) in length, Tin' head i- pro
pottionaJJy very large. Tbs rex can b<! tlwtin^uUlinL Lanugo
i- unwuit

Sixth month: TJh- nveni^r IfOffUl of the firtiw i- DOW HUOUt
IS inohw (*JS- :U cin.i. ,-hhI it weigh* about 23 J on now (G7G

gni,). Thi' testioks i» males in "(ill in the abdominal •-•>'• ii ■•

Seventh month; At the cud of this n ill the frctu* mcae-

utv- in Ifiiirth 18*78 t" 16 laches (86-38 cin,), and weigh* El]
oaooBB (11/0 gro,), The whole body is covered with i inuro
Exoopl sue pulm* mC the lifimlt uii«l 1 1><* sulr- ii(' the Feet xtn

pupillnry membrane disappear*.

Eighth month: The fatal now measures K> to Hi inches (3S>
to il em. )i» length and woighft3J pound§(1571 gm.) Id
h diw|ip<inriD| from tie- face, and ■ I * ■ - lell t--.ii.lr is in the

*er<»tiim. O^-ilic tviitre- mi- pmsviil in ihe l.iwei i-pipliysr- uf
the li-inur-. Tlif child it' Urni i* viable

Ninth month. Ai tin? end of this month, Clio thlrty-eixtll
wv k, 'lit- r«f(ii- average* HboaA ol noonda In weight At thin
period, if the total *hould ho born, Hire! oonsidere thai «nli

ordinary care it should certainly live.

Tin- ■'<-«!i!-idera!iun of the infant at full term, the fortioth
week, will be taken up under the heading Labor : but it I* oon-

vt'iiifut nt this point tit refer to the peculiarities of foetal nivu-

Iiihuii.

Fa'tal Oirculation (Fi^. lrt).
The fatal blood, having bean oxygenated in tin- terminal

villi in thfi plamihi. i* rrliit'iicd hv various- branches i,. tbfl
amhUical vein. Tin- \» carried along tin- curd (o tin fwtsl
body, which it enter*, ai ihe Ufoblllcus. It inn- thenee aluiij*

iln- anterior shoot il \n nil tt> the under surface of the liver.

when- it hrniu'lie-, lii'- larger hraneli emptying info the |w>rtal
vin, while ilit -nuiller, CStlM the ductus venosus, empties

directly into the asoandinc vona enva,

Tim- the In-, i quantity nf 1 1** H arteruil " hhmd from the
plmviitn uni-t pu*« thntiHsli l '"' f""'"' livtTi where it probably
undergo) some • hnnj*** before entering the general oironlnttooa

1 1» nee i* inured int-i tin nifht auricle of the heart, fmru tlic
ascending veno cava, n itreiim »\' bluud derived from (!) the

Ftl 1 N. • IHi I i \TtO.\

.77

l-'w. W.

:»

*»■

1M

m*

boputtc ■.■■in-: (2) lit.-

dtK'iiiK noom ; •041 (31

llir town «'\lri ftlllii Dl

tin I'.i'iu- along tin iliac

rin- mixed -'i- nil 'M

ii i -in mirii'lr |mh-
Ull i"rl«' i • _-in.li ,1 aiTO -
ll l>\ a Mil of tiiiiiihr.nn ,
lerrii'd ilic Eiw__xMji!i
ykIvii, through tin forn-

itirn ovidn, mi opening Efl
tin inUrr oiiriauUr -<|»
Cum, md tbae vatca tin-

Irj'i ntirii Ii

Tin.- Burtachimvmlvi .
I>v ilircvtiuir the blood-
ciimini ftoa (In- n^Jit
ventricle, thin " *hoif-

n:- nil " .-:i mi

ton tin- on<kvcdo|wid

lu-f:il lUDjP, wliii-li HI

:Ih Er unoxmniim con-
dition mold not contain

-iH-li :i lurjp' iiu:inlils tit

blood.

I :■']() Ml- left AUrfcll

lit- blond tntm «li«' left

venttlclt, imwuik InoDOt

r*iHi'r ii nlalnrv

i. u n I'-ioi .1
mjIlI inrl'U :

i i ii<n

•rmct*, f"» i i »«tv«:

.. .

n| ini i :>*#*tin» «. HHlO

• rcli: a*. »• 4ofMl p i

. litllllfUU

i if IOTU <•!*:

U ii.
muIiI iiurn U : i«Y, fulfill >f i-iti ■ vlatUii

tmU r»rtn II ■ " ' "■''■' ■ 'li' fi>ll' 'I"

■ :■■.!.

UK*!! '!■ I' I" <>t M" 'I 111 ■!« fl ■ ■ 1 d ■ III! ll thl ■Utlt lli>'

v ii.- ii lit- i . nil Jmrli* * Di •" III* •IlirllK WIM«I

l. •' i. , !• nmi>i ■ ■ u.*; ".*.i ii..- immU ..vii.ii

C'

/"V

'■■;

l

:m

rnw;\AyrY

u, tli.- aorta. Tin- greater port of the Mram w th«-n ilireet.nl
tbrourh the oarotku to the hond, a »nwll *^uantii v ouly con-
tinuing along th*- aorta.

ii- blood i*t iii hi 1114 from the head is collected ill the

d«*e*ndini rena cava, uml During thence into die right auricle

anteriorly, it finds it* way Into tne right ventricle. Ii In thou

Avml iiiin ilir pulmonary artery, whence it pa&HM by another

. i . i . i;ir," termed the ductus arteriosus, ftraptviofl into the

ir.fta jli^t beyond where tin.' r:irntuU hruneh Id the heuil ; only 1)

mftiWr-nt quantity for their uuiritiuii betag directed to the btittf*,

'I'll i - venoua IiIoikI thru ileBMMldi along liie aorta, the larger

ijiiamii . naming thence I" tho iliac nrleriott, from the internal

pair nf wliinh two arterial pa** directly to the umbilicus, and

then«* .ilmig tli* »..nl tn tin- pliirfiit:i. These arteries within

body nil tenaed the hypogastric arteries.

TOW the lower limbs of the net in PBOBtVe but n poor »iipplv

of wlmt- U practically vtnoui blood; bence their doca* develop"
nienl nt birth u compared with the bend, which rcocivea a rich
supply of fairlv freshly oxygenated blood. With the expan-

' n iif the lungs at birth the whole comae of tin* ofrciilafton

i-lmii^r- to thnt whieh pereists throughout liti\

CHANGES IN THE MATERNAL ORGANISM RESULTING
FROM PREGNANCY.

Uterus.
Tim increase in the size of the uterus tafcefl place ehi< Hy in

ihr body of that orgUi

The fiirihi of" the bo<ly increases in length from I J iuche*
(;!.7 .-nij in the unimprcgnated -Lite, tu 12 inches (.lo.'i mi,) .
thi width, from I J inobcB (8.2 cm) to Q foebca (23 em.) j f be
depth fanteropoatcrior), from nuthinp to l*iween * ami 9
iurhi- (30-23 em.). The capaeiry fe inor o a oo d from nothing
tonboot BOO eublo Inehat (8300 cemA

The tr.u/hi m| the organ. rocTeawae bom 1 oudob (30 gro*) to
about 9 1 ounces. (720 pro.),

These nii'M-iit.Tiirni* vary with the niw. 1 of the ranfafj the
qUAntlt) uf ilCjUOr amtiii, hihI in multiple pre^unnev.

"in* ineii-i-e in -t/.e in a growth, and not n men 1 'Intention,

i nut's.

i" i :n .. :..|.],- : .< -ill ion ih« us. in* i* i;>iiml b>gO OB growing, up

to and beyond the fourth month.

I'ln- changs* in slutpo ;uv *rh:i i~ i' i. rfajtfa In |li<- fffl

mint miMliliiui iln- nil ins i- pynlortii, I In- bugs **■ ■« I belu|
ii|>]m nun*! ; :in<l ll;ill< uril :ii|l< rOpONlOi lofty ,

In tha cailii'i inonltif of pnyiKinrv (In- lower |»:irl BMnM U)

incrvuiw En cnpocUy farter than the hjumt, »•> licit the uiaps of
ilir uterin Ui'mir. rougblt uplwriojkl ; while al Um BAh month,

BOOOftling lo \\eh»in*. l.lir orpin in unci' iimtr pynlomi in

inapt] hui tha witlr-t nut i* lowarmort.

A i i he tnd of prtvuauey tin uterua aatumei vers much t J i* •
oftu€ uou-prvguaol organ, lbs roonitaal pari being tgafa
uiuwroKWd

Thus up in the lift 1 1 mouth the Eoarai uu tha oapanSty of

ihf utCflll i- I'ltii'tlv in il« loWOT pflfl . mitl fmm lln'ii (ill l- nil
nuiulv ifl ir-. DppOf poitSoDa

Muscle-flbrw: The marked iiierniwin the hulk of tha m- ■

wall iluriiitr prc^iiiuioy it iimiiily due u> hypertrophy of tht

mu«ct--<<H>. Ilt'lliii' -l;ili- I lint llivlV i> DO lm*T|ihi*m, but

thai the a ling fibres htcreaae from wven to cloven timet in
length nod from lures to nea Untoa In breadth.

Tim ItftlUWMDCnl uf llii-M- miiM-lr-liliM ■ "ill be dJ cu od

later under tlir beading of anatomy '•! btAor.

i '!:<■ oouueLtlvc tissue «>i iln inertia luciOiHi n proportion
to ill.' uiiiM'iilnr. Thera alien a urns hyjarrplaatn en die eoo-
nootlvn tU-m , which hogim En tlw B*4gfiuorhoad of the I.UmxI-
bJa.

Mi. art«rl€« of (he litem- bOCOnM niail.ilh I mTtttffl ill

mlihr*' :iii-l length. Af tlis piaoyntal nils there t- :i ipiral
arnuignmenl of iln orterfa] tn i^?., :w il«-v penetrate the uttM'tiw

ilecitluu :ini! riiijilv itiltl llir lllOIUUO. Tin v*lim Uvuim- mr

rfftpooriliudy turrpSM«d in afar. In fast, the ntenu may l»'
rvfijirdfil :i> :i huge vi'iiiuin nlexu* il urine pregnaney, :ih tin-
1j1ckmI-hu|i[»1v i- ~. gnol 'I'll.' wnlNol' that* veioN m raduoed
to tho intimai uu uu nftei labor tbs man ootttractiau of lbs

ill. riiir miwli'-lihn- is -ulliri.'nl (u obllUVHtS ili.'ir Inniru,
Tin lymph^tiai of tli< ud rn- beounv iirnmiM^) hutli hv liv-

Itartmphy sod byporpleBUi Daneath tin deoidua eoonuooi
yniprt-apaoBi davelopi tha tubai or vaaaeli Ifadiim from thant
to tin' r/vnpbatio ptaua beoaath the perftooaJ hyv ••! U>

40 PREQNANCY.

uterus reaching the size of goose-quills. This condition of
tin: uterine lymphatic system explains the remarkably rapid
ttlviorptiiMl of the utenis after labor, as well as that of septic
material from the uterine cavity.

The nerve* of the uterus take part in the general develop-
ment, the increase being chiefly in the primitive sheath, and
not in the nerve-substance.

The ligament* of the uterus hypertrophy during pregnancy,
and their relationship become altered with the elevation of
the fundus in the abdominal cavity.

The connective tissue throughout the pelvis becomes succu-
lent and distensible.

Uterine contractions : Throughout pregnancy the uterus is in
a state of alternate contraction and relaxation. This condition
favors the circulation of the maternal blood in the uterine wall
ami placental sinuses. These contractions may be noted as soon
as the fundus becomes accessible to examination from the ab-
dominal surface.

Relation to Pelvis and Abdomen.

Up to the third month, while the uterus has increased in sice
and liecome quite globular iu form, its level in the jielvis has
undergoue no marked change. It has become somewhat more
anteflVxed, and from its weight has sunk down somewhat into
the pelvis, the cervix being carried backward, so that on mak-
ing a vaginal examination at this period, the anterior uterine
wall can l)e readily felt and seems to bulge forward.

By the end of the third month the fundus uteri has risen to
the brim of the pelvis, and may lx* felt on moderately deep
prnfeure just above the symphysis pubis.

By the end of the fourth month tlie fundus is in contact with
the anterior abdominal wall.

At the sixth month it reaches the level of the umbilicus.

At the seventh month it is half-way )>ctwecii the umbilicus
and the xiphoid cartilage.

At the ninth month it is up to the level of the lower ribs ;
but within about Urn icerktt of labor it falls forward somewhat,
and seems to be on a slightly lower level, on account of the
descent of the presenting part of the fu'tus into the brim of the

rn i yiiKH fV rur. tt/D ;•/■

Tin 1 inUiiUu«K :ut di-plaecd Upward hn tin? hii-mi* :i- il

hfuvihIh, bo that on peraiwon i dull not* >■ obtttead ow the
w hok ■ « i Dtraj pari of fhs abuoraoft.

Then* U .'i certain amount of dextrorotation of (hi DtSflM
retained throughout P'VRDinov. -» thafcUMonnui Mtwomo*

uli.i; tO i'" IWH WO "ill Tin- right i'lili'|iiitv of tin- uh ni*

may bo aooouutfd forty "" relation to Uio sigmoid flexurt and

ili-ivndiii^ colon, tin? left »dde <•!' flu oryjin DVlog |>u»hed for-
ward by thw tftruutura*.

Alterations in tha (Inrrix.

There ore two conditions of the OCCVBC during pregn I
which BM DOOttlktriy cbusabaritfiOi Hoth iin* dtR- loapnrtinl
obstflzetftOU in iln VSDOUi tttttffl which I cadi to Mtfteniiig nnd a
mnrkod bltM or violet di.-roluratiuii.

Tin- softening of the comx begin*, um a rule, about the MCood

mouth. Il in lirvt uppuniil SDOOl the Ii|». bill -plead.- upwind
us pregnancy advance*, 00 thai in Etta lotsf month* (bo

whole rn \ i\ bsoomos so onfl thai the nager, If amooitftomoil
to ragtnal examination, may have difficulty in finding the t»*

illni. The Otnrll in |invmm<'V ha* her 1 1 likened 111 Um'] to
thnt Of thi' DOBtod h|»»*-

Tlie violot diacoloratiou in due Mini ply tO the viinu- QCOnO"
inenl, and il limy !>«' pre*rnl even m the lir-l lew mug of
prtyiiJiury. Tin- canal of iln< roi vi\ remains ibroOgOOUl pftfl>
nancy ini;ilti red m WOgtb. Its mUCDOa gland- - ■ . i - 1 » ■

peculiarly tougb mucosi which - 1 - * i >- dp the canal like a wrk
ilironjfhoiit PfWRuanoy (mucous plujrji

Vagina, Vulva, and Breasts.
The Tafflna and tiiIth become Hirncnhat bypeKTOtibted

during pregnancy. The eulor of the mucous rnamnranc

bo bluish. There In u *li^litly incrotwe<l Mctrtfon of

mucin, nnd ilie |«ru Income lux nu<) soft,

Change* iu the Brcaata.

With the on-*'! of pracJOauOj then is tn incroaaed deter-
mination of blood In the htvnuf-: and n rialn itllerMioii* pre-
paratory to the function of lactation btgfo.

IS

tMt-

1W» (Wad* attain eaaplrt* tVv.L»r*i»ra« m tV fin*

IV b)kki tour** auJ lm«* ila-tinct fr*aa "Or anot

IV i fHl i l liB linia^ Uk viai U ri— m attire, Uarfii-
«rtam aaaat «filc>«|«taa«lna «f tV offer by***

TW*r f>41- cmclrrg" 6ilty vftrgrtmsliiui am! are «*t frw.
•citutby ecla-*r« ccejaacUa

V»ry early in pny wj t ■ Mall quantity «f imi ma/
U IP w ) from tV a»j<[

TV CM aad caaavctrrf tUra* Himamiiag the lobok* by|
tropiiv. aa>l tin breast* become enlarged aarl bmc* ffiawi

Cuoefrfcart milh d»eav efcaiign ibwrc is iorreaat* 1
MJOaR

TV ikla Imttn atitieM and ^irV .IcwI.^
radial doiribuiKpo ami iHflaal The veia* <«i iV
basoaat mn obraou*.

TV araola Uuxna darker from ik-j».*i( of pigmaat.
baiag n*<v nuri.nl la brunettes ilun in hi. oh- ( Kiy !~

Kin. IT

rrtBUttV of |*1mar? «W"'i . - •

.tarj 11^,1*

TV- • /•■"<< Ui of the orcein, ten nr twenty in iiniii-

'• r, become BOrl pK-iMiti.-nl. bCTDg "I* lighter odor. T!;< -■

.- a; tho margin nf rlw nrcolu being unonlorcd, Mud «wt
■. mi mill!, : ( - white ppuU, rormiog the -•• nil)e«l itetmaaty

J,]

nlppltj become more prominent as :i rule, ami an- -iii.T

Al.TEKATtnSS IS oTIWH 777.1 V <H A7 ■/;.! 771'/ Ofti I va i .;
than im tM n- >i i-| .t .'i;ii:int Btat6* In flit I:il«»r nnmtlm of ['•"eg-

nancy dried oekei o? wai lion may Ih< found vaorneted on tow

Alteration* in Other than the Generative Organs.

Nervous systnm : Thm' i- prownl during pnSHnn u comli-
li.iii of •suttol nm-i-/iu*ii»t. Hmmt lltt'if i- mm ituni-'il
1. ml-nry [>> nrrvou- iii-.titUilitv. Tin* woman ii more jininc- l«
hv-i- rial attackl. Then 1 are often present perversions of taste,
-■.mill, QtOt| tun DCUnugH| ••-[H-oiillv of the liioe nml teeth.

Monoid auVtioo* an ipl lo develop oaring this period
This oondiuua oi moietted nerve-tension iauhi nlNiut two-

thirdaofull fin^iimit women to suffer from DOMJBrR^Al some
time Of another of their pfena

Thi* eo-ciiNecl vomiting of pregnancy begiuB, in u large mn-
wriiy of enjci. > :iitv in DM K-eond mouth; it UMieU) penieta

during the ncond and third months but may lilt throughout

pn*j{liiiury. It limy lw KmiKi-iI lipOO :i- OM OT <ln- PytOptOOH 01

the pregnant condllloa,

It u-n:iilv oeaun en fir>i rifting in En* morning, end rnty be
mill) or MifficJenttv never* i" i ndaogvr the wonienni Info

The - - -<ni i;i i txeitino oaujw oi tha vomiting nrobebly oricjinr
id in iln |.Ihhm»I(i^h-:i1 utorhu otnitruatJoiwocourritiB through-
inn urejennncy (enc Pnrnfcsowi \'umiiiiiij).

Circulatory nyiUm : The total quantity of O&od i» [nCMfltd.

Tha quality i- :i!-.i chenffMi there hoing an EoofeeM in tihrin
;uh! white oorpuactee; whfle the red oorpUAclea end albumin

lire ilimiimlietl.

The li-'iri, probebly »* » raeoll «>i" ihe ehangea in l»1<»««l

!W\Y\\\ , mi I i • ome ilifafitlinn / but a* the QOOnUt] '»)" lilt-
loot] ie ioo r eeeed then ii i perfectly eonwenaeSory Ayj
which i* more n»urlo<l "ii il« I, n *iil<-, Hoth enfan Hid ffyfTOta
jpAin'/ nun u-' in -i/e.

Respiratory system ; At the rMpH of movi inrni of lh' liiii

nhrugm becomea intnriened with by the uterua the thorax
wMcm '-• » alight stent. Owing to inoreeee J oxbhUtoprproo*
c*sns the work of tii- loDgi b augmented
Tnere is but little ebougi in 3m *ttmonury system. The

I', Li v'i.' |n' --■• '"- MiiMowlmt re nriive, "i»i, B* n rule.

i In- appetite la Inorcoeedi l tj^ceti Ive durturbeacQ u ooenxnoeh

Urinary lyrtam : The urine t- inrroiml In quantity tod i*
niiffi' watery, the *|Mvific gltvty btfag B«00l IOJI. Tlio
»|ii:i:it ity Of urea BXCNbH U n< >ft ti:il.

CuUuuous *y»lom. The faiMtiom of il»' sHd nfi inemwY]

ihiriii-.' nn^imtiey.

I'lt/iimi/uliuii i* in. rea-ril. Tint-*- ix, :l> ii rule, ;i marked
dtpOnl of pigment over tin' linni ullia, *i iiiueli *) :t- to ©OB*
VtltUk' «>1K' of ill.' m^iim of |>ni5ii:ui.-y ; il flirty tV'.V'U iVrim 1 1 If
PObtS to the eiiMform enrtihiyv, Till' Hkiii ii roil ml llie c_v.v lfl

curia u. <l, nii<l fn'oMniilv irragawr *\*tt*. of |iigniMnt anpitv on
i in- -in I'l. . mi" ili.> ho.lv, I'liivfly in tin- ia««

Lines albic&ntes: Certain nkin^ntcka arc to Ik? noticed,
i Inetly u* a result of ovcr-st retching. They up? termed ttrvn .
ntMa o^ieonUtfUrua natonofm or hnea v"" "'*"'"". ido nppenr
usimlly on tin- skin ot the iiIm1ohi.ii ami hrvusl*. They run
usually in the lines of tension, ftinl :ire due In yielding Ox the

coriiiin in ttntohing, the qridonnli bwng continuous over them
without any change in structure. Tiny vary in length up to

two or mom uu-Ji»~-. ami when recent arc ml In color. loiter
011,11- :i mnll of si'di-lorumtinii, iliry Ihiimiii- white, nml form

hinmg |irvMiiii|iiiwi avkknoa mum present of immntM jin-y-

U!'llle\ .

DURATION; DIAGNOSIS; HYGIENE AND MANAGE-
MENT OF PREGNANCY.

Duration of Pregnancy.

An ft rule, it i> nti|«.--il»|.- i<> predict rxuetly the dale uli.n
l:ili"t will Hike pint v.

It thi date of fruitful coltun mo Im fixed, than tabor will
moti iik.-iy •n In two hundrad and savanty-owi day* latar,
atortfding Co Ahlicld,

Tin* common rule i* thai Labor "ill uocttr on um day of tftfl
leuih iiieiiHiniitl period — i >, iwo IimihIkJ mill eighty inut

siller llie lii-i d»v of llit* I:imI men»t nialion, Allowaiicv rniiMt
ill way h l» made lor the short month February.

\n | rule, one -elilom predict* flu .-\ae| ,f;xv of IftbOr, iiml llie
vari:itioti of a week or two Ik I'nr fro in common.

When prapDODoy oooim during n jm-HimI of raQDornxM) n *

nusr vntMKsri'M •/ i:jwti\'k svitrroM*

l.l

38

S3

M

30

•

10

an

ffl

D

fl.3

<H.

10

10.fi

19.6

a

s ■

M

:..»

IiHution; »r if' tlic ilntf of the Iiut iiuii-irii;iiiini wuiliol In?
■jeertajrwdy (hen the prolmble dntc of labor may be Jived by
noting tho height of tbo fundus :

'I'Im- t"-.ll<mi-i- i.ilil" ■ li i- l ■■ ■ en by Satugin and (lalubin:

\V«-U 10 10
[ncboi * 84

Cm. . 10

'I'Imk mtibod aw ouly Ik« employed in ob*h whore li"* heed

III- :il the brim «.t' tlic (x'lvi- I'll- n»"»'«(ii'iii i« tnnilr
v niacin*: ( lip <i|' :» jmii i.|' niliprr- OB tfit J niphy-i* jiiiUi-

ind the oiIht mi tbe Vaodai no i i

Tho date of qulckentnf — UA, the fir*l ou«*inn in uhii-h the

mother fceli the mow dm itU of the Rettu u of some mini Ea
GBtfmnilnff the duration of pregnancy. Quickening occurs iu
tho twentieth week m » rule iii primipuw. ; ud In toe fcw m>-

lin»l »P twrnly.-ntmul week in imill t |-:li ;i-.

Diagnosis of Pregnancy.

Tho nrcuriiition of pregnancy i« not :i!wsiv> an i-r-v 1 1 i:i1 1 • -■-,

i ■ |» oinlly in tbe earlier months of giatatfoo.

i in in!. -v-ti'in:it u\ ami, if ner»»Jiry ( n*|Kti(nl ■ KUiniiialkm

en n not fail to permit i oertarn dSaewMH being mad

/■.t'i'ur. in dl '- » nrly ttlwiiy* tin.' PNUIl of o:ip fo

ami un-v-N mitio i vniuiniilinii.

1'i.r convenience of study tlic nine nuODnor moothfl of J'"*B-

■ imiv bo divided Into BMuntsrsj end o clamifiontiflii of
tltC -y(n|i!..ii- ,tin I -iiM>- a* i" tin-*.- three perii-I- U made.

First Trimester — Subjective Symptoms,
Tho imppTMBion of rnooBtniation • nn-.iiiiiii- . e n rule, (Ik*

iIi-i evidence of pregnancr* This lunation to usually stw-

|Hinlttl ihroiiojioitt gestation j hut this i* not invariable. Bofflfl
women nMOatfUlte at fount once, and ooousinnully MVfllJ (nil- -
i eeiirrviMv of prvifnuiH'v. The value of this »ipi its
rviilctitt' i' !<■" in women who art- vi-ry irregular in nu-ri-tru-

- "m ■ .■ Suppression our/ reealt from cxpoAurc t<- ootd;

IV-.iii i!m- prcMiHT ■»!' (lrl>ilit:iiiu K di.:i-., :n lulirmil<
jiiui'iiini, i'lr. ; itviT-niiXH'ty or msirltitl li-iir of ptvjjnimry n.;\

prodaoa ilii* raeult, w may alnu Midden mental *horl< ; change

pf « liniiiti' nr BUrrouudinpi (waaionally mi in tin- >.imo v.
TJmu eacooptioni should Ik* held in mind *. but «uppre«aion of
menstruation in u hwiHIiy woman of regular haoil n-milly
BICUH prejrmmey.

Nauaea and vomiting, m. lining iu tin- nii.rnioi: r-|n<iu1U-,
form one ot' tin- mn*l eommnii KYinpimui! of prejjimney.

Tlir si-n-.iiiMi) usually fomo* mi when tirewoman firM n*-
aunies ihe erect pontSon in the morning, hence the term " mot n
ma ttetnun" commonly applied i<> it.

Thaao ■ymptoQUj Da b rule, appear in the fourth 01 fifth week \

lint may OCOUr CVW1 i-urTirr. Tin ) MUtfC, ri~ u rule, ill ■- Mil tlic
fan rill mmilh ; bill nuiy lamiM thnitijjliotil pregnancy. Tin
CiiujHiliim Imp already Urn reli'iied lo.

Thi' nummary change* la-gin :i> early as (he ftorond inmilli,
elir cOOgflltioD of the parts niuaiug; a scnwitinn of Piilmaa, wllo
tingling and lendcrm?*. InrrvUM. 1 of pigmentation nlariil ! li« ■
11 renin' ami ilic im'Ri'iH* of BPfUtu in tlie liidenl (Inula U'OUDM
appurent duriug the thinl monlli.

Vesical irritation ici often complained <»r wry early in pn g
nancy. V- n r*i»iih of the inon-aae in the normal untc-veraioji
of the uterm, the Mudder i- pre-st*] upon and it- fuuetiona in-
terfiTtil with; ilii^ ihhuIIv pcr-i>ls till the fmirth mmith.

Vv ■i|iit.-iitlv digestive disturbances uriw wirh in pn
having a reflex origin. The appetite liecouics enprieioiu*, ami
acidity is < ommon,

Nervoui disorders, « ln.fi are purely fiim-iionnl. arc not infre-
quent. PtjfuUtm i- not uncommon, and may persist throughout
rotation. JVVww/pioa, cardiac disturbances, mental pciturho-
D ind inilultiliiv frraucnUv manifest theiuaclvi-* vtT) car!)

and are often wtj nwaiatflot.

First Trimester — Objective Signs.

Th^"* 1 an ''miI'um.I .-liicfly to (lit* iilvruM and tin- In.-u.h.
Tin- »ofttnlng of the cervix uteri begjna in the ftrW nnuitli

ol picgnamnr. The »hot< ow-vix, bagfnnW first at th< axtaratl

i», gradually softens it* :i result of the phy»ioloj»ieal uterine

FJB8T TIUMBSTEB-OBJECTrvS BA9AS

OOtigttUOf). Thin Olingjl i» nm-l BMrlEM in the f(i'inii|K*m,

|)Ot h ;il-«» jmx'in in iln- itiullifKim. Tin- nrrvtx Ihvoiimw
plUflpd wilfl RlUGtM 84 B " -uli "I tli< hiitciihi' iii t\\v utiivily
01 fli< it'rvinil nmcoii- mrtnlininr.

X viohii dincoloration of tin- hiimihik iiii'inlinii (' lln

e erviu, ra&tu, and vulva muy be Dotal on inuwetionef then

imrlH, biguuiing M wri; a- tli« lit'ih wtflt iii ninny ro«v,

Thia rhjooloniion, bung diM to h <«Ttam <l<'iw of venous
Bbuiv, beooima man innrked u pwciminy .niv.-niix? ; it sliiulct

IYiiiii u ('ill' vi'il"! Iltiyi lit .1 tlu-.Ly lilui-^li iltlr

Tin- hofloning and «nlarconi«nt of the body of tb* ntonis

<"it-"|M'i>r ■ 1 1 pregnancy niny U« rwidily mndi» «<nt bj I n

Ail t»»ml»iii"i CMuninatloo. flwarfi iwn (ne Iwluw) of on U

DNffMOCV «I'|"M'I- ttpOlI flic pTVt'ii' i li i ■.■• • ■. m<l

111,1V In* utituilKil III <:it l» U tOC tlgll b »ccl<. \ ■ ,i !• ■nil "I
I ho PfOKDOE Of lit'' nViiin in tbo PpfGf MHRnoDI of tbti UtCrtH,

nil the dfarartaii of the tatlov booomt loeroModj wh!k tfao

BtnjttJ LUWftf MgffMfll .simply DMOUMH RuROMU *B*1 pprnAjW
ralhi-r lliimiitl out.

(In bimanual examination tlu< bulky, INUitv aoftoued <vrvix
<an In- li-Il • jiml iilwivf I his i- :i vi-ry -<.M ...nipi. -. ilili- :m;i ; ami

KW.lt

Oinut* in -1h |.r.,*iin»t iilvriM t.f ih< alitli vrak "n th# i> 1 *
rlfclit * ■. .....,- lid iiM-.ti i

>Hi'

*hov« tbfa :u,iii tlui I > round*;! Hindu' u(*ri may be&i

tinfjnfahod (Tig. l*). 'I'll* 1 MBMtilon ooovc^td to (he rtam-

is

ptusayA vn

iiu -r'* fii)|pr k lli:il llif r«-rvix i» join*] t<» tin- Imdy of lliv
BMm by Uvti liuiptudiiiiil buml* (Hntpirx *hjn\. ThU in
l»'-l (.!i(;ii!ir| b¥ UUSog ill'' tlllinib of lln ri^'ht li:uxl mi tin

interior vaginal lorn!* and iutitKliirinv iIhi furvfiugvr uf chi

Mime limul info (lie rectum, I Inn (In Ut) iiinul plinvd nvi'f

pab&i |»nw>» tlic ntertn downward ••> thai the ovvix

I'm. IV.

niranniial examination Aic«tin»r»-»*il>iHiY ol Ibi IsUtiuui hi IhealAltiw*
iDWllUMi i

lower port of tin- body may l»e gnwpod hctwwn the tbarab
and forefinger of tin* rifflu band ; or at* vbown in Fijf. 1".

In the ""'"'' month the body of tlic Menu* i* felt to be on*
tamm and rwnrtcd as wcil as raftaied; while tin- « link* orgnu,
wlii.'li pretty well Ml* the pelvic mviiy, is in .1 p^ition .»('
marked autcversion u a rulr.

Second Trimester.

In tli i-- im-HihI t Ik subjective symptoms are: (1) contlnoad

nbacnoe of manna* {'!) tho pausing away of tin- imuMi ■ c

nmnm ami varies] irritation: (3) the Bcnaation »t "quicken-
ing" — *-<•., firtnl movement.

\rm\h ri:i\/i<r/:i:

H

The objartvre signs tra: (I) enlargement of the abdomen;
pragmtva ehu&goi in the mamma*; (3) program v«

change* In ill-' 1IUIM-; I I) the Mim, ..( iihtttu ciitih*u'ttvn§

and of ill.- fatal a •■,.'.'. 1 • v i In- nominal ; (■■) a w uAoitoi

of fitful lif, i -•ohm/* ; ((>* hitl/iiftniicnt.

In iIh- fuanh iiMHitli ill.- flmdni beo ■■- nuft] aoctasdbJa

from il»' anterior abdominal wall ; hfDci* :u ilu* |n-nod for the

And lima nun In fell tin- irregular intermittent uterlno contrac-
tions whtdi contiuue LhroughotH prc^iumi'v. Tin--* 1 • -* »i it rr«**-
tiaru tokif plnoo :ii inlarvau »i Irotn Ian i" twnnty BiLuntoa, and
land in mm kit! liaranningof ton whole uterine luinor.

FccUl movonionu. or quickening, ;m> usually lii>l uoliivd

by ill*.* mother abooi the twentieth weak. A- iirwnaacraa-
vnocen iln--.- movement*: become, mono marked ana cottsfaotj
mid may b*j barf owouhn by Ibe pbjwciaoliy Buuuenh plucfug
Imm eolu hand on lha nii.tlu t V iinli.it. ii ..\. r tbi ntera*.

On ttuanilfalfai ;i loud bnsii maj behoird over someporlioii
i-t' tba dmtoj n early ■ 'It** fourth month. Idu sound has

been in me* I tin- " nt«in*5 souffle," Ir ih »ynohruimiM with tin.-
in uteri ml pulse, ami i* very uncertain in it* (lunitiuu ami p!u re-
It !•« li--:icl nut ..nil during pregnancy. hut it is occasionally

!i-Mintr.l witli tin' pn-M-ticc nl inii'i-tiiiiil tihrotdl . iiml witlinv.i-

rian i * 1 1 m • ra

I ha fatal heart Bound* may ba bald ii? e;irlv j? tlic t\\<n-

li-tii mch by ilriUed ennraeni Tiny are heard be*t while
the patient ii In tha -lurxi) p-iiiuii wuh the abdominal wall
relaxed, and irhh tha i«ll of rbi iitatlionoDpc lasting lightly in

contact with it. If pnaanra !«• mad toa Ml. or even if it

be bald In place by tha handj tin eonndi cannot ba board no
well.

The rtrtr of pulmJiun v. in."- iVoni I-'" I" 1»<> |>cr tniliUlC.
Mug >I»'\vit in mull - tliiin in I'rinul*"-. 'I'lir BDOOdl Bit

iTowhi, lha iir-i bains nomewbaJ olaafar ihan die Mcotm. Tin*
MOOaa of Ina fmtaJ heart liava been very npiK romnafm to

tlmw «f i wutt'h ticking UDtfaf ;i pillow, Tlif IW-liil JmmM-

Kwnda baar bo relation IOj and ari ouita diatlnd from, ihe
null tiiiiI uulaationa

ii-. iln- >i\ih mtiiiili. tin' iiiiiiliii having iraotiad tha lavel ol
iIm iimliilicti-. h Iti' ii Ii.ik boonma Ratianad onti tba abdomen baa
bfooraa quit* pioniiiiriit
(-Oka

\l thin limr -''l-'» :i browiiihh piKimiiiUUoa 111:1s Ik- nnlfd tX-
Uii'lmg from tlit- |iiil"- u|> to nitil Iwyond il» UlttMlk u-.

IUllotUmmit, DM of toO RIOBt valuably *i^m« of UfC|(Qftoey s

1 - - . - 1 . , . — . .iv.iiLihlr lute in tin- fourth month. It ic :i paaaivv

ramonl of the fatiu obtained by iln mhJuVh iliMilsowmint

iiMiu Mow liv ill-- >v am liter (Fig 80) While puofof (Ih-

V\u 20,

Itrtftni t.»i! <i, iu'mi. ml rri'intii. .I |HMiur*. tl »ii»iti uoiitti. iiileVlnmn.t

forafingvt of 'In- rijjhi bund in (lit- antarior vugiunl fornix,
inn iikiv l»y :■ brink impulw »li-|il:icr tin- fatua upward, which,

a- il iv-nun- it- original (Kiniliiin, tiiiivi'VK u gelillo tup to the

Roger-tip b«bl in the vagina. Ballottemattt can only In- timu

faM by u tfinull <'v-.iii- ovarian tlimor having a long jx-diele.

Tliinl Trltoestfr
Tin? nubJwUve symptoms in ttii- Mriod nnr. (H continued

■bnenea of neostruntion; [2) Pcouil naovttueato; (3)praaBUre-

-viiiploini,

stiMMMiY >>r i>n<;\asrs

r ''

The objective sign* are. (1} continued enliHV-'rniMit «■'' the
;il»l i> ; (-) miiiiiiiKHl nmniniiiry and Uterine ehangce-j (3

dwolopnionl of itvii on tbdomoo and breasta.

< )wiiijf BO 'In -i.-:ii ••ulurp-nii'iit «ii' i In- ni'*pua pretsuroGymp-
tomt become wry marked ra many cams. I'"< "■- ■ "i tin- lower
limU and mi1\:i, often accompanied by aafaklj booomo more
op l»* marked, Cbiutfpatfm from r.rcsHurc on the reaturo,
and netforn 1 ftrttaflfon from displacement «•! Ike bladder up
hit oomcAOtti

Vitturvantm ••/ r/ipwfMM ana of rwrnraluwi nro comnMMi, > ►- • ■ J «

resulting I'nmi lln ^rint nlHlominul ilixiriitioii.

Tlir movements of the foetus <-.m Ul plainly MWn through lliu
.ihtlimiuial wiilt.

Tin* -kin <m the abdomen frequently enowi I hi* :i r marking*!
wltii'li npfH-ur »* red radiating strif*. rliirllv on ibu lowwi T[ii8(l-
rantr.

Tli- umbilicus In'mim- |m incut, I tbtTO i- mm ioORHM ID

ilio depoaft "i' pjftinenl in lha middle line

••Settling": Within two «r.L- <>t' liil-.i tin- pro^ming poll
of the fa-tiis partially enters the brim ul the puvie, becoming
mora iccaatblo 1o the examfoiui: Anger. Thv -«tv \ :<l • !"•
limn?* Hiuifftli:it iliiiiiidl outina feeli Bbortewd, \t ii<i' time
i In- proroiuence of Ike abdomen becomee luw mmkril.

Tu then change! ooourring Inllnl^i twu «n-k- pi.-pimi-

[04 v io labor LOO term " MtttJtw/" ha- Imi:m applied.

Tin- mjunmftry chaiifio* conunue to become iiiuiv marfcedj and
I'oluftruvt can be eaeeeeecd from Uw nipple*

Summary of Dihriiomw.

Tin- presumptive evidences <»/ pregnancy ore : [1) menetfuaj
MibprcMlon; (2) morning defence*; (3) Irritable bladder; J)
mculal and unntMinni pnonomeiia«

Tin- probable ovitlanctta jiiv • (I) miiiiiuiaiv diangfttj (*J)

abdomfnaJ chaneea (*•?•■ at», ahape, marking*); (.'ti uterine
ahancna i-i/<\ chape, color, and ooneiafcuoy of cervix); (4i

ni< run' i*outr»<'tioii* ami Itrnil

I'in .inly aoafttra njiiu are/vro/f id fatal henrteoandej

('2) tii'tal uiiivt'liirnt* ; \?,) luilliiltrmt ul

rRW;\A.\CY

Differential Diagnosis of Pregnancy.

Tbi physician i* not. infrequently called npon to malta nn

examination where the jwtieiit either feigns, deflip •. <"'. unm-
commonlv, oonoenfe the condition of pregnancy. The difti-
enltlea or dUgnosiB arc much greater before the fourth month
of aeUtioo | but cnn-lnl -vKi.-iimiif examination will rcnrcclj
f:ii I lo <*tal))i«h it certainty in the in:i|<>ri(\ of case*. f*mv
iihihi )m< tikca nut to express an opinion until a reasonable «*-
i;iit)iy uf the condition present is obtained.

Fimt Trimester.

In this |x>riod ihe following conditions may resemble pn
uuncy ■ unenorrhnai ; subinvolution; metriti>* (it. rinc tilir.i.l ;
retained mensrs; malignant disease; tumors in the neighbor-
hood of the 'Kin U-, us ovarian growths; salpingitis; mid ectopic
gestation.

Simple amonorrluuA Heoottinanwd by symptoms of pistrir

irriiatioti may vary closely reaeinble pregnancy ; but :i cartful
btmannal examination will demonstrate the absence of utarfan

changes.

In ftibinTolntion the ntertiK doe* not increase in siw, and it
in not globular j while it* texture i- harder tlinn that of tbfl

organ ui pregnancy*.

In metritis 1 1 1 1 •" uterus, while enlarged, is sen fi rive to tin
toiirh. and is bard and danae. It- j-lmpc in thut of the unitn
preetiated organ simply inoraasd in size.

An interstitial fibroid of the uterus maybe ili-tin-jni-lifd l.y
ito danaaneai and by Ifca Irregular contour. Menstruation, in

Btead of belli); alwiil, is, n* :i rule, incrni-eil.

Retained manses rnay eniuv nn enlargement of the uterus;
bnl in ncJi <;i«'» tin' fact thai menstruation has never bem

<^t;»l.li-ln--l ainl :i hi-lorv of !ilnhmiiii;il jkhmm occurring at

monthly intervals, «ill ioaicate the nature 'it' (he case

In malignant disease of tin 1 uterus tin- menstruation is, M a

nil', increased, ind intermenstrual homotvhana occur.

I n OYarixo tumors the atorns in Rot affected um I menatrnt-

lioo persists u i role. The Inmor is usually situated to on«

M«ie of the otarui and causes some displacement of thut organ

ht.i'.wtars "F FMtiTY "i; \i /.uriiurr

Ectopic gftlUtktn limy xtnif tl:tt' DlarflM pKgiiftiiry - hill ■ •aiv-

ftil ixionluaiton will ravoi] the prawnec <■! .1 tomoi oul ft
thv iilom*

In the Later Month* of Pngntney

iln- following condition* mu lead to id error «f dintfiiwia ;

<.lH-ily, u-i'il*-., lytnpODitMj pmntoOl Uiiii'H', and l:itv «»\ nriuii

or AbfoTd tomora.

In oIxim womon u idi Irrofuloj nMiMtninttna ii i* not InlVs

(jiii'iillv iHfRvuJl 10 . -lahli.li :i dlutKlflfa of |m« _'ii;iiii v ; hul the
mtOOQ Of iiuiiinun C&flUgM ami lUflOUlttlul v glgOS will clear

op i:k ran

In aacitca ;t dia^im-i- iniiv Ik' made Ijv placing the (wiliin! in

tlir doraul dvunliiliw and uonaMiiug Mm uunotnoo. IJoih Hanki

Will giVd duu DOU whil* llm middle :m:i of > lie- alxlotiicti

w\\\ l«- I'h'iir- Fluctuation may Im nhtainud ; and 011 chan^in^*
tfai piwirian of the pat fool the inn of dulrw -- • ■!! liter.

In tympanit**. the* whok :il"luincii. while eulirewl, rival a
ounr note 011 perciMHDti, Tbe bimanual noualoatioa in botli

lie uVt"\ B ••"Miliii.m- ■** 1 1 1 1 won I il"- Miiiin|iivgiiulni fuinlitinn
of tin- atei U

Ftuntoni tumors, which in- << <> -. 1- !• >n:il lv met wiih in hysttfl

iiil womon, am bi noognixed c*n up|ilvin^ the 11-.mil i<-'- 1
.in iiiitiihMi, percuariotij ore.

PioudooyoBli, on ffOUfiOW pH&MRty, is | very mi-i ■

condition tiH'i with iMualli in iromon iboul th« flaw of the

lin'ni»|»;iil>r. The Woman imagine* liclxll |o lie Jinvmilil, lltul

!■ in iimnv of tin- ohancdrlntlc nrmntonu of bail oondU
iiou. Enlargement of too ibdoDMn. foloooi lad tendanun of

the hnu-K, may niUlciUI tlH CO rC WW • \:i:iLinrr; l>ul til hoth
llir:il).i\r ClftMOt of COM I In" :u liuiiii -I nil inn oj :m :in;i -f In 'he, (i>
(H-nnii of :i thorough examination, will rlmr n|> 1 1n- dia^nm!*.
Ovarian ind fibroid tumora, if hir^r, may imin di-t.-ntion of
(Im- ahdiiiucii ; hill in tin*-' HM llo' IUMO0V "I' Jill »;;.mi- of :i

t ii will wttoo i" dtriiuguieh tin- condition! from pregnancy.

Diaftnosis of Parity or Nulliparity.

Certain mechanical effects ire prodootra on the ibdomioal

wall ;iml hiilli-eanal of n woman Who luU previon-lv bOTOC it

rur:<.\ uvci

full-term child, which time Ruin quite u- ertulienio. On tb< -.
depcndi the "linL'iN'-i- of purity or iMilli|»iiri!v.

If the ovum nna boon discharged before it ww* vtifhYientfo
largo to produce theae changce, then it m practically impoivibfe
to bo certain m to parity.

rbw signs ivn-i-i of chungo* in too breasts, p>-i-iiK-mn,

vapina. ;i!id it r\i\. U w<-ll Sf luiTt) and StrUG ut tie- iiInIuMI-
ifDll Willi.

In iln- paroua woman tlw nrauoi ere apt i<> he ami I developed
ami wm#wli:ii |h ihIiiIoiis, the nipple- Icing targe and promi-
u< ill. Oeni.-mimlly slriir may Ik: noticed.

TL .t!,i!<wtntnl tnrff h U\- ami yielding, till' ttkil) U-iiij*
marked with white strife

The BfrtfMUffl may show mark- of laceration ami be MHlti
what la\ ; ilic fourvhetl* befog ali-cul.

The rfiffiii" i« OlpauiolH ami lax, t lit.* walls being -ohm what
■iiKK'tli. Tlw n mains of tin* liymoo may lie noticed as forming

uuracrotu "mall cMraooloB fatrauonlw mvitifbiTDoe}.
The fierou if diorl ami brand; very often it U liieerutcttj

L'.'Hi'iilIIv i«ii the left -ill.-

Diagnosis of Life or Death of Child.
Il Jm not alwa\- ea-v fo ilceiih' llial the child in dead, The

woman mar suspect this to l" tltc nu*u beenus* - of certain vague
wiiMHtimiN mj...i.Im< -■ about ih« pubes, ami because of a feeling
of weight or dragging. She mej uw i" feel ihc movcraenta

i.t* lie ft el II-

Tlie mallei nan only l»e rattled if after repeated examination
the physician f,iil- to bear tho fetal heart or feel fcctel move
meutti It" ;it the shim- rime the uterus cease* to grow, and the
bieaatl i« IDC Hubby, it may be inferred that the child ha-

perifdifdL

Hygiene and Management of Pregnancy.

While ili'- ooudiliou of the pregnant woman is it purely
phv-inh^ieal "ue, if mih! be borne in mind that the border*
line b e l wecu health ami duMttflO may be very easily passed.
Hence it i« the duty of the physician to give every woman
eiiffiitrin^ hi- •v\ i< ■■- f..r h-r eonlinem'-iit -ueh hygienic i n -I ru---
lion oa die may require. In fuel, u certain A-^k I' pro*

m i •' « . tjt U I 1 IGBMSNT OF PREGNANCY <w

ond

.1 |.rin

I '. - - 1 . . 1 1 : 1 1 :iluii!iMii RlkOOnl M giV*0 I* » :ill umui'H thhlUgOOUl

lli<' wlinlr Mriod of piv.;ii;iii<-\ .

Di«t: 'I'll' ili'l (Jllnng |iiTM-ii:in« v -IwuM l»< plain, Simple,

.-.t-ilv dlgMtiblVa iinil liiulilv nutritlOU8 (bod ttSoitM I" t:,l.in :i(

IxT inhi'\:il- Overeating, i"|«ii:ilU i:i ilu later WOUtlw,

-iiuuUi 1h- igu&rded again*!, M*;ii should I**' ratai but
diiilv, and Fruit, both cooked and t'n-ii, dtould form

rip;il part uf :tll hic;iIk,

Exdrnmi : \ll vi.ilrnt r\. tvi-i -Imiilil bt iivoidul. Willi;-.
in tiic niM<ii nir ,'iii<l -iuiplr gjmnMtlGft ITlthill doon ftfaoilkl 1h-

ioduleea io daily. All lii'iinv: and straining diould be avoided
r.i. v. itn.; i ! permitted u moderation, but not over rough
road- II- am* .ip|>ln- alio to carriagc~d riving.
Clothina niton Id ho worn in such o manner n? to avoid undue.

pn -in.- npi.ii <ii it. i »'ln-( i.r iii«iuiiH-ii. Tin- eoraetj ii worn
it nil, -liniihi !«• it linn umi -Imulil Ih' very loose. Women

With lax ii"l>'!nilMl W:ilK ihoald «<"if :ni :ilxlominftl HipjH.it

MtArrniiKotl thai tin- prmtnra i> oxerteri nyrward.

Bathing ihoukl bo Indulged in dally, MJiGClaUy ■mc id.-
I'iiiicIhui of tbfi iuViii i- Incrwiwd during itrajfiinncY. If die
woman i- in llw balm of inking coin hatnu dully, tiivy may bo

COM I muni, Iml I lie iuitiiil >Ii«h*L iiiiiv Im' avoided liy bflvfog tlW
I -ii) 1 1 wnnn al lir-l, it ml ihtMl adding fold HrAlOf Ui it. In lh<-

lain mhiiiiIi- ni laasl iwu w.'inu bath* [tor week should In taken,
\'.tv lii.i and ■,.ii ..lid baton ilionld In* avoided,

The cure ot the breasts : Attention HioUld beaJYeu tin bn ■'-'-
preparaton to Duraing A- these orwin* oolarge, tin- olnthiug

must !«• arranged 10 avoid UndU4 prpwuiro upon ill. in

Xbo nippli-. it' retracted, ibould be drawn mil and prutly

iMnnipuliHi-il l-.r a fc* ininnfr- daily. In rli<< I;i«l few W*elw
daily inUOCtiOQB of the aipuleJ With iri -h . -<k <>;i -Ihuht pT wbUo

aaaliue muy b" reeomtueoaed an » prophyuirtioHgaioil Rasuraa
duiiuj Dunuig, The utw trf DBtrinwol k'tnim, audi »- tea,
IhmihI.. etc., '''iiniimiilv i'iti|i].iv.»l, enould Ix 1 praaeribi I

Should »a«in»i di»ch*rge i» preaent, daily injectiooi of bono*
Mad wJuuon m tin- temperahiit of lh« body may Ik i eraploycdi

tlie fonntuin— win^'- only Ifimr u*«l.

Sexual inWroouTBe luusl l«' rratriotodi iod aboold not bi

mmIiiIl"'! in : « t lip' iii'-ii-tniul ilnli-s, - -(■> •• ■< 1 1 ! v I- w unicii \s Im

bavo pivuon-]\ aborted.

v;

OBSTEWIC ,IXi7'..i/r.

Digestive lrrcgiuariQeH mIhhiM Ih ronliollnl The regular
anion of ihu bowel miM bv maintained, Woman arama in In*
n iiiiliimllv ('on»ti|t:il<<il iirgMliiMii, and i- miwinllj «n dltrfflg

pregnancy All violent purgntivi - ihould be avoided ; the "■■
laxative* arc aloin and tn-t-aru si^rudn. Tlie mineral wattl
prove very Uflrful, mull aa -alino-, I le

Tho urinary excretion requires tare fill attention throughout
pregnancy, t'liemieul and iiiiernKi-npiiid examination of tin-
urine should lie made every mouth ui iir-i . and in ih. lab i
mouth- every week, I' lie total amount voided in tbt twenty
four hours should l>e noted.

The nervous condition of [lie pi riinanl wimiimii -1 l«i nlw

lie noted. All undna exoUoinciil should be avoided, nnd any
i|.-jii'-'--!iMi uf -pints iimiiUiN'iI. IMt-nlv of sleep — at h ■ ■■
right boun cadi night — >hould iN-ohtnlucd. Daily imps should
be eoooatBajBd.

Tht use of drugs thould l»e uvoidrd as nun-h i~ ]>«— iUe dur-
ing pregnancy, tage doom of quinine and calomel should
iiui be ad rain uttered, The all too ooniracm habit of inking
dnilEi "film c<iai-iar oniUH by women, to relieve headache, etc,,
ihould !»• especially diaoou raged during orcgnunnv, on arcounl

of their deleterious action on the heart. Mmv of tin e.is*'- nf

severe cardiac failure following labor may I* *et down to Lhtf
pernioioui habit.

The phy*i*'inu -hould make a careful general examination of
even pregnant woman under hiacaro about the eighth month
of the pregnaney. A eiin-ful external and. if thought ieoe«-
siry, an internul examination should be made. The pelvis
ihould be measured nnd the attitude of the fectua noted. The
iipph-4 should alb» be examined. Inquiry should
i 1 " be nude as ragndi the presence oi absence of vngimi]

discharge. If present, it* character should In* noted mid a
bacteriological examination made.

OBSTETRIC ANATOMY.

For nttaiM anatomy of th« tenia!** pelvic Mtrucinrw tho
pCodval i-> rcferrou io apvoial work-; or la ooatatnc "\>trm*<,
Mieli a* JewuttV " Prantitn uf Olntutrio*.

Tin chief anatomical olomcnU eonuernod in labor ant three

Tin: writ's

nnmta, namely: tn Ihi litem; (2) the peM-gmftal
canal ; (3) ili> foecua.

In ill-- net of parturition the mutual reaction of Jmm •-!*!—

menu i* concerned,

Tbff iilrnm liniv l»* BMluClvod of Bfl B rUUftdjlOTMO OfWDlflg

Into ;i ourvn) tula , the upper pan of which is buiiv, tliervfure
rigid; end tin' lunar pan yielding, befng formed of mnaele

:ihil Other m»H *liii'liii'-. "1 In- run— 1 In'u | H I Ik- |m Ivi-

genunl ■-ni.il, which includce tin* di*lcrotti>lG vnpiM, the upper
part bvSau lntrapvlvio> while tlie tower, in the pwvio floor, is

HiIjIItIvIC.

Tin yW(U Efl Hi*' lnuvmjgvr, :nnl CO0*1*n1 of !».■ uVOldBj tl |

trunk and thfl bead ; the former pleat!*?) ill*- Utter iin»n* or li

ripil, jiihI tliovlniv lite mum ini|Hirl:iiil :i- n ^:n«l- it- relation*
to I lie l>irih-r!iii:il.

The Otcrui.

Alt* nn llii ni. in- 1- an ovato yimiiim; it w ]ivm |uirl ut' (1m<

l)jrtlw-,in;il tluin it i- tin engine by which 1 1 * *_- uanuiger — tlic
fifbu — in expelled,

The canty of the oterue at term lm- been Mated 1

ing 12 inches in length, ft inchca in breadth, ind B inchca in
depthi

I'Im w.-vlln of III*- nteru* Viirv in iliirkm'^ IY.nn nm- fourth

t K'-iitil, of mi Inch; Ac ncatcriot being thicker loan toe

nn t trior.

The mueole-flbree of the ulerin m«y !>•■ i!.lml m

term n* forming 1 -tiU three layerai in onfar, u middle, end

mi iMiin lever:

In the outer layer there ore two ■ I • of Bbraj 1 1 1 longkudl-
iinl ami (2) trauavenw 1 Pie;, -1 1.

Till* Inu'jiUfVnml jiln-<M, pM-frm >f) v friilli Lflfl jlUH'l'loii of UM

lm«lv wiili the terrix, nw tn the form of :i birnn ImhhI vertt-
rath upward over the thnaoa end down the t*i i« 1^ 1 1« ■ line *nte*
imilv to (he cervix; the marginal fibres toward Ibe Cumin*
branching off in Interlace wficli thoec ■ >!' the round and broad
ligament*

riii- trnwtofrw fibre* arranged al rigid aiunee hi these paati

eeroai the nierua from ude to -■*!*• ; ;it the Cumin- naming from

n» tin' iither. Them Bbrea interlace in grcal 1

H

"}!.sTb:THtc ASAT")'Y.

tiic rid I* thauurm, bul boom of iheni arc urolound «l..iig

ilw bruwl und lb* round li^amints a*, well as Jong » !■• tub

i i* - -'i.

KxitTiial imiwiiIat layoff Of Ikl (hOfCffltf w*ll <>f ilu> Bl«fU

In thf middle Uycr ihc i» I ■> ■ ■-- lmv<- m> tl' limt<- ilim-iion on
ntvoimi «f tlm niiini'mii). blaodv<Mcln travcrning them. 1 )i*-\

llld-llt muHtiUi i«»»i »i tin- Atifltm • a, a, «np*rflcl»l Uy<-r <11hh«cIo<1 *>nrfc
cho» holoncuui t«t Ihi Intm inr^r . '. '. lubu

\nu* in •■\vrv direction t©B£>iuUiuul,trailHV3ree,iin(i uMIquA —

twl ii ■ iinl curving nboul ihe viwIm, Krt«|U«nt1y ihv M

•nii i rmi ■

W

■ •

arnin^'i! in tin- form of a ftgnft 'I' Iglllj i\> lining rfagfl aboill

ili.< wwU, thus ooiwtituitnjj living ligutnnv | Kuj, 22), Tin*

layer i- jwvIkiIiU flu- thlcfe -( , ami tf m-M mail:.*! '» W OppQf

■;l,M Ill III I IlC lltlTMM.

[n t In- imiHr Uyiir ROOM! film'- in trflUMgtd HI ;i MTMH of 000-

erottio lingi about the orifioM of iho tube* i Fi^ 23), Other
lii.n - ttoiw clirwlly arm-.- from
rornu r> the other trans-

ver-ely ; while other- pan

.],,,« Qfmrtl longitudinally Id

tlic* tvrvix, in I lie middle I in**

■ it" the Mrterior and poab rior
wall*

Uterine Mffmpnt*i: Theea
loj n ■ up- no! till ditfinetg bol

tliiwle Hii|»Te«'|ttil»li ililn nil"'

another. In tho "/./»/• put of

lln' (Hern- lln- an iirj'iiieul hi
i- I. nils diaUOCl ; "in
in the I/wet- piii't lln- DDKi MS
more loOMclv BTMllgOu, pn&lttg
c'IjuIK in :i longitudinal dip
lion,

H el ire the uleiil- may Iht
divided into two jMirlinti-, lln
inn-i nlar arrangement than lln- li>wtt!

Thorn portiona UN tertoen fwpwlivf(y tin- upper mnl tin.'

Tin' linn of Reparation between tlia aagutenni lies nearly at

id. level of tii- ut.-nwiim! fold of the peritoneum, and (•

i. riii'-l Hm >■'>■'>'"<■>-< "i</, "V f!'i>ni/'* ring*

Hie upper •t'Kiin.'iil piny* un H'tivr .,-,/, in lulnu". while the
l.iwi-r lin- luit i |Mi-.«.ivi- »'m/#\ The lower Kffmcnt nlon^ Willi
thcorrvix inn-l him It ■re" 1 • ■lil.'i»;*i »• 'ii MMp.ii; '"i v i ''It 1 '

of thefaru*.

The Upper lOgmont ineliale- roip_'lil* the U|>)»er twnthir.l
of the entire Ikmiv of the litem- ; while the lower Moment mid
the cervix, whieh art- n curly of numl length*, farm the reonln-
in|e one-third.

Tlnr round and die broad ligamcath. irWeh have boooflM

Tnd*«
iliuwn 'i

Mik i>( 'In mi" ri'-r n.t I

rtmrr Qf * Ii*- tivnj» u
lint In Hit- mnlUit

Pnrrin >

inner of whieh ha- i firmer

60 ORSTKTRW ANATOMY.

hypertrophic*! during pregnancy, serve as guys to steady the
uterus during its contractions, so tlnit its long axis corresponds
to that of tin* |H?lvio inlet.

The peritoneum covering the uterus is firmly attached to thin
organ as tar down as the retraction-ring ; 1k>1ow this its attach-
ment is loose and it may easily !«■ stripjKd otf. Thus the site
of tin- retraction-ring, or Handl's ring, is at the lower border
of firm peritoneal attachment.

The peritoneum at term has in front of and behind the uterus
the same relations as in the mm- pregnant condition ; but at the
jmc/ch it has Ik-mi so lifted up by the enlarged uterus that it does
not descend into the pelvis. Tile broad ligaments have become
so elevated that their bases are only at the pelvic brim, extend-
ing on either side from the iliopcctincnl eminence to the sacro-
iliac joint. Thus there exists on either side of the uterus at
term a large triangular area uncovered by jieritoueum. Owing
to the drawing up of the utcrosacral ligaments the pouch of
DouyhtH Ik-coiiics much dcc|K-r than in the non-pregnant con-
dition.

The Relation of the Full-term Uterus to Contiguous Structures.

The intestines do not descend In-hind the uterus at all, and
in front only as low as the umbilicus. A ]M»rlton of the rectum
lies iK-hiud the uterus, and otvnsionally a loop of the sigmoid
flexure of the colon.

The urinary bladder lies wholly within the pelvis before the
onset of labor, its highest point being Mow the symphysis
pubis, except when distended.

The cellular tissue about the uterus exists as a thin layer
Uliind ; but in front then? is a broad band between the cervix
and the bladder. At the sides of I be uterus it is enormously
increase* 1 as compared with the non-pregnant condition. At
the hones of the broad ligaments (defined above) there exists
only cellular tissue (no peritoneum) between the uterus and
the pel vie wall; this deposit extends upward and backward
between the layers of the broad ligament into the iliac fossa?.

The ureters enter the jwlvis just in front of each saero-iliac
joint ami |kiss downward, forward, and inward to the neck of
the bladder in such a way that they ore not in the least liable
to pressure between the uterus and the bony pelvis.

ntf.vv frr.vis

i.i

Tho ioh hi"! position of tii«' ub nw ■•!» \\<'il u il»' din ■

of tin' . i -.i- of ii* i-.ivify cltingf ;•• iln' *.»r>niii jki-"^ frum it-,
n l;i\'il itiii" i- .'iio of ariiv.' ■ nuM-urlioii. These will there-

fore be ili eoi -"i liter.

The Pelvi-genital Canal.
Bony PelviM.

Definition: The pelvis fa lltC boqy btttll, <>r CUM), which
form f I ■ - - MH).( EmporUnl pen of llu birth-omul i KSg H)

Pin. U

•

The tens i- derived from In* Uitin /«/»/*, a bowl! Htw pelvic

ennol M Irrcipiliirly Innrx-l «lui[»'.l, IIiu>mm<1 fmni l>.l.m I,;i, i : -
ward, the lur^cr end Ixokitig upward uim! forward, the rninlhr

downward and backward, when the woman is in the end
|>o«iti>)it. It contaiua in tin 1 non-prvgiunl Mate tho cwri-
■ [ttnn of generation, find in labor the child U «pelled
through it.

OBSTXTRIC WATOMY

\n intiiuitii.* kii"ul< ''L" 1 nf die pelvis a* related lo tin
DMNfaaanm •-■(' labor i- t*~entinl I" complete uudcrs lauding of
tin* problemj of the art *»f obstetric*.

GaneraJ description: Tlie pelvi* U .•.mij»™.>.l ..(' iln- mec-uni,

I '■>*, and the tun ..^-;i iimniiiiiiiitti. Knell of iIk*u

bones is made up "I -. lui-.ti.- p:ui.. wln-h hmmie united bj

the twentieth yew of fife. Tnc arllculaHoim of the potvb,
which km of considerable obstetrical Importance, :in- the mcki
Qiao joints, thfi wnruaoooygnil joint, una the syiuphynw pubtA

Tho sacroiliac joinU: Tl noosed nirfaem of snob bona

forming tlio-c joint* are (MfVtK'i with thin platen of uarttlOffQfa
These booorae icparated l»y spaced containing » -m:ill quantity
ofgtajry fluid, I*ii i no synovial niotnbranc cun be dvmon*traleu

Kiirh ill" (Im'-i 1 joint- htm anterior :unl iHWU<rior li^tiiiii'iilM jiikI
iii!fiv;irtd:ii;iimii- h:md- ; nf lUOMj (I"' posterior IIP- !>v l:n* I ho

10 ■ Important Bach of thaw poBtvnur licpmeuta i- formed

id" 1 1 1 it m* hWhuli ; (ho tWO MlpVrior mil Dearly hoti/»-iiI;iIly
from bone i" boiM ; Wltilo die inferior p:ii«'* i»hlii|ii<K ilowQi

word and (award (toco the posterior superior epi no of lire iliaiu
(-. the third and fourth sacra] vtutabm

I " sacrococcygeal joint Un- nn iiit>-i-"--< * tllirm-jniilu^c

wlii.h permits rcci*»inii of the coccyx, lis lipimentanre of
no iinportAiu*.

The symphysis pubis: The slightly convex surface of
pubii- bono i- covered with :i thin iilnic of cartilage suffic*
onK in till ■■Hi aojj irrevn Inn ties in tho bonos forming the joint,
Tin' onpoavl "uriiin-- am In-ld tup-ili-i by an intervening raaai
.if liliKMnrtllap', which oti.titntea the ftltoyuflfc dtefc A

•mall eavit] i- IVeauontly present in the centre of diis disk,
th( i *-nli if absorption of lha Hbrocartilage; h la non-ayi
oviu Hi etiaractor.

The it'jmnruix of ihi- j<»tnt aro four in iiiimlier — anterior,
posterior, Mtperior, and inferior; of umbo, ilia most powerful i»
thi inferior, often termed the tiffamxtttum arcuatum. It is a
■tnnic lihrou* htuidh' pii-^iiiLr :n-m« I'imiii one <!c*ct'iidiiip;

iiijr ramu to (hi other, bltodiog al Uhe median line with dm
Bb rpobie dial

IWide* the liynnii'iil- which ;m BAfloiatad with lh« pftlvlt
joints, we have tho sacroacUtlc ligaments, which play ;i vara

riant part in the meohaniaja of labor.

/■/j i r-
'lTie neater sacrosciatic ligament iri*M from tin- pOJttriof

infbriov ipinnaf [be ilium mm tron (Li videof tin morum

mi. I n>. h iiurrmvt iiihI tbiolteiH in ill middle put, bo-

owning brood nana ■) tie ulterior itUohaicnl to the iauer -nr-
noa ox Iha Eenliinl tuberosity/!

Tin- lewer sacrosciatlc Ligament taki* itl origin from the

side of tbo sacrum tnd coccyx, and, puring In front of In*
j I. it i . i- inserted into die spine of the i el

Mobility of the peine joints: Toward the bud "t gestation
there obtain* ii certain drgm- '»' w'-IIin^ «\ nd'-ma of nil tin*
mlereriiculiir aiiiieuirv ■ •( the pilvio iirti.ul.iiioii", which por-
nii:- of sonic Mijrht cxpaii»iunoi'th<- pel via during tibor, under
tbn vrodge-ltkc advance of the total hold. The norum per-
inltsof u -irjlit notation on ii> tmnmreno nxi& Thsro k also
a hlnge-Ilke motion of i ii<- ooocg \ on the nenrtu which permits
;m ..nhit^iiiiiii oC tin- antAropoatarlor dnnwtor nf tin- palvta
oatlet

The pelvis pn ■ auj tw diTiaiana, tin- f.itn- nnd rite Unt ]»i-
vi*. ttio iiividinir-liiie being jit the plnneof ibe brim — *. c, the
plum.- cutting the upper end of Ibe merum, ti" top ol Lbe -■ ■ •■-
physu pubis, imd toe iliopeotinea] line on ettba tide,

'riir fabio pelvis Um hut little obstetric internal; it ajmpl)
funofl with ill'- vertebra] column mid tlif nUIoinimd wulU a

iiiiiin l >iui|K-d Bnproael to the true pelvis, and is included in
ill. abdominal can rj .

Tin- true polvta ti'ii-in hi— ilmt iK>rti*;n uf the jielvij lying
DOlon I In* ninpOCl el limx It i*u •lt-»-j« in-.iu dinpt-d m\iK. iIm-

posterior u-nl/, formtd b) thaaacrurn md r«r) -., U-inr. -li.n | >; •
L-nrvnl Willi an niitn'mr-iiiirnvitv. !Ik- untt-ruf "«'/ i~ I'onnnl
l>\ (Ik miii|iIiv-i.- pQbffl and i- dioit mid -tian.dit. The fan '"'

mtiu, triifen are formed by the lower portions of the dm, the

i:imii ;md tiil»rr<».ilic, qf \\,i- i...|ii:i, lln -arm-M uir li^nnml-.

and i»ni- of ill* 1 di'-ii'Tidinj.' rami of (be pubfo, orv irregular in
outline, alopSng inward, -mi thai the tranavw»e diameh r of too
pel vis i- lew ui their tower than at their upper rxIrenritifUi

'I'Iih tni»' |ndvi- may l>" ilividrd inlo throu portion e : I, tin-

inli't, or -iij h i jor -tmii ; 'Z, i In* outlet, or Inferior ■trail ; 8j Ibe

'iiiion, or cavity
(I) Tln'inUt.oi miporior Ktrait,..!" ibe |<''lvi-. l -i)ini'linu- termed

tie jrtni] ib usually deneribed n b in liap..«l, ilmii^li in

Ill

".'.' Vl-Ttiir ASATuMY.

tin- frefln sttte it fa rv nearly circular, lis booitdarka Ufa

HrllfH't) Ity tin' in|i if the sacrum Iwhiml, tin- ■ I i- »| >• -« -I i m* ! lim-
on either *m1<- mimI iln' top of tin* syrnphyai* nubi* in front
(L' I'].. outlet, of inferior Hxait"(l'V*aA),i*boundftl by (fat

■nbpuUc ligament, the otaoandlne mini ol ili<- uube% the rami,

mln-fi-ilicM, mill IJljfMM ot'llie i-chiM, iho -:i<Tn.ri:iln' lltf-.lllli lit*,
mill the OOCVYX. llH outline i\ roughly triangular in MkftlHp,
Iiul when <li«lentlet| liy I In* Bilvuririiig lit':t< I in labor, ii Ixronn
ovate, Dwini: to ilio Hmtennihility of the wwnweiiitie ligament-
:ini! the yielding character of the \ \ ami wcw-iliuc joini

PM ■

■ '-'■> The oxoftVfttlon, or cavity of the pelvis, in (founded i.y
ttw superior and inferior -ti.tii-, and comprutv ;ill that |Ktrtian
of the (H-l\ i li'lnnii I hum.

Pbrierjo Wy , ill* cavity is bounded by the Nioruiii unci «-oeeyx
emttfiorltfi by the pubic bona and their mini : h/tntl/v, l>y lb

lower portioni of ih>- ilia, the bodies, tuberosities. bj»iim», nr

r.nm of fchi i-ehia, and l<y the weroM-iatie Ihvimwit-,

Tin 1 podtrior waU t* concave from ftbovc downward;
.1. |,iii. following the angra] curve, I- 1 1.5 to l-.S em. (4J to
tneni

The ojitrrior mill i- CCneaVO I rem Vale to side; ils ■]> \M\

tip rntnhj i i- l obi. ( 1 1 inehai |.
Tfc Inla-n! imll i- about !» Ml. (&] inches) in depth.

IE

/.'».Y> I'l ! Vl\

u

PM I' -<t I'hoii i:u-\i moil l» ilivi<lrd into linn DQfftloOtj
uliifii tuny In- OiapiMKl (Mil ill FijT, 20.

Thr /iY-/ ffi>rti"ii i- !ri:m'Mil:ii in - 1 1 : i| m ■ , if- Im- befog .1 line

ilniwn from kIm ili'»j»<iiin:ii eminenoe i * ► tfat lop of the ftaero-

iliiH joint, ;i- lateral Iwuntltirii Muvtinj; ;it tin iliac ptpiooa.

Tin- portion »- bony throughout, and to unootn and curved

Tin- Mooiui porwm lii- forward and aotuewlial below the
tirtt, tt 1 1 i 1 I *= i — but Hill-- boiKP in ii- oompoaitioUf being chiefly

niacte Dp "f 'ii' manhn m timm of ttw foramen ovale oov-

ered by the obturator mnaale.

Tliwc structures are at (arm WOWwhit loftened nml more
cltutic than in the uun-prtirnnut condition. When the pre-

Km 9fl

*\ttr Vlrw nf [*<tvl«

•cntinu port in labor, in advancing Eflipfagaaoo tbeee atrnororaa
their reeoauon convorta this portion of the lateral «»ll Into

i ■ "i !-■- "i i un-.M-, wiili tw.us (dtw and elastic floor :

,m ivoilaopMii a itdaaaaoda <l Its oaWtion fmU n>w:inl

owar boracr of tha eyniphyaie. Tba iaahiopoMe ramua
forming tbo lowei pan of Ihta portion, i- curved laterally out-
w:mi mill Icihu ii-rli* to the oonttnuatinn "(' tin- groove

Tha uuni portion i- niau* Dp matolj of the pyriforma
niiiH'le ami tin nliwtic sncrowitttio UgenientRj it* border* arc
boDf| befog (shh|mi-imI posteriorly >>t' ill.- Lateral bordara uf the*

•)l..1

QBSTKTRft \S.\TOMV

•i.'iMtn and <•< yx, mm anteriorly l» the poctcrioi cdn of die

Ilium. I'nt i UK neMciil "< i In- head thene ligament* mid dim-. I< ~
on I'm <mi ilit- Miridi, iiimI this portion i> thus eonvcrtod Into

11 lung, -|<rt:il _•(■■.. u\ uliicli iK' ,'■ .1- i- i .!<-.. -nil- mil in ■

forward.

The second :in<l third |Kirti»iw of the Intern! twill* ere termed
rr-(Kr(ivi-lv the anterior and (In- noAlormr taitrai tjroou* ttt i\n

Itplvi

The niiMtnifi of the rrfA Ihoy play, if any, in I he nnvli:nii-i.i
of tabor will be <ti«ouieed later,

Ob*totnc planes of the pelvix : \'U>< nvlvie carnal vnn» ■ in is
ud ibopc in diffisrenl purU of 'n* wmrnej (hew variation! «re

F<a 27.

■ >'. !■ :..■ I, . ■ , . ............ | | ,, i. dlu.(tivti<l T I IN in

dMM ri ' O. I'-'i bbll<|Ui : i". U»i rlsM "lill^m iMnmrtcr. ijrwvll

aodvntood l'v meaoa nf » «ith- of tnui-viTw planea
through tii< pelvio cavity at different li-vi-i-. i'lin* .-f tlieec
pucial importance nbeletrically: the phine of the fn'im,
iii<- |>s mi el mm .nil't. ii ■ m 1 nihil lli- | * 1 1 r •• ■ -I the cavity,

Plane of the brim Tin.' Bnotomicfll brim of the pelvis is nt
tin level of the true pcJvi*, while the obtitttrJeal plant nf
brim [a ritnnt^l ut the level <-t lm-r .\|..ih-i | the np|

OOSV ri 7.1 IS

67

• \( the |»-lvir <.wi.il. IflN lie- :il llie li'U'l <>(' tilt MIDI hill

;il |H"iiuiiihirv, i ii< IlitljM i iiin.il !iim ud thi DOrf
Itf/Oft ' 'I" "vin|iliy-f |»iii>i-.-'ii ;> |H'ini I fin, (| iif.ui iii.'lo

oafov a- upper runrgiu (Fig, -7j.

Plane of the outlnt : \ I i In- nutlet ;iUn tie UMtOIUIQn] Uxd

.i-Ni.i plane* diflcr. The obrietrkul plane ui tin ..ntlei

fa defl I by tli-' lip r.f f hi- m. mm, the lower border of the

wch'rol mlnta, und the lower border of the -\ m|.h\ -ii pubis at
a jwiint just above (Ik* lower Diorgiu \ I'V. 2s).

IV.. Ml

a,

) 1m W> |i. ' 4lmiM<-t» "t (Itu i«|vti >mM - i ■''■>.[ k il ipIit; Di. !.,••»

- ' ■ ■ Ml - bufal 1.1*11. -11 -M .i. ■

Plane of the cavity : Tin- inM'llV \<l f the pdvlcci

li<- ,u ill-- lave! of the upper rail »'f tin* ihiril pine of the
■cram, the middle of die rvmpbj fe pubie, and il»-' ceatraof
the acctatatai ■ i. itic | Pfg. 29t

Intornal polvio dUmotom : Tie- dhnen dons of wfl plum »\v

lira 111 fall 'lii«--ti.»i» : rlrmiif. i.>|... l.-not, ill-' lnm-veiW.

iiml the two obi Iq tie.
At the plane of the brim : The unUroponttrior tiiometerof

lli' Ur lu i- ill' !■■:( i ilixtUIKv iH'tWWll 1 1 1 » - -;mt;iI prODlOOtOn

l>tii>i-. hi- u»- :i - 1 1 :■• - i iVoin the nmldle of

68

OBSTETRIC ANATOMY.

the sacral promontory to the posterior surface of the symphi-
sis, at a point 1 cm. (j inch) below its upper margin. It is

Dlajrrum ■howlna axt* and planca of pelvis : A B C P, axfc »t entire parturient
canal; X, nu u 4fat«ll4«) at irme of expuNion; K F. plain' "t lirim : h L. mld-
plKic of cavity : Jf .V. plane of outlet : P. axUof lirini: tf. axl* of mid-place ;
5 T, axis of outlet ; // //. horizon j y S. dlajconal • • i: ij 1 1 ^ a i • • diameter.

termed the conjugate, or true conjugate, and measures 1 1 cm.
(4| inches) (Fig. 27).

most pelvis.

69

Plane* of the pelvis wilh horlum : A B. horizon: C D. vertical line: A B (.angle
of Inclination of pelvis to horizon, equal to 60°; BI C. angle of Inclination of pelvis
to spinal column, equal to 1J0° ; C 1 J. angle of Inclination of sacrum to spinal col-
umn, equal to l-V ; F. F. axis of pelvic Inlet ; 1. M. raid-plane in the middle line j
N, lowest point of mid-plane of Ischium. (Playfalr.)

The inlet, or superior strait.
A P, anteroposterior diameter, 4.S to */•> Inches, or i : -1 1 U centimetres.

TS, transverse. 5J " or 18U "

R O. right oblique, 4.7 to 4.9 " or 12-12H

tO, left oblique, 4.7 to 4.9 " or 12-I2X

The circumference of the Inlet Is 15.8 inches, or 40 centimetres.

70 OBSTETRIC AS ATOMY.

The fraimrcrse d lavieter (Fig. 81) is the greatest distance
betweeu the iliopectiucal lines, and measures 13.5 cm. (6J
inches).

The oblique diameter* (Fig. 81) arc measured one from the
right and the other from the left sacro-iliac joint where it inter-
sects the iliopectincfl] line, to the opposite iliopectineal emi-
nence. The right oblique springs from the right, and the left;
obli<|ue from the left, saero-iliuc joint. They each measure
altout 12.5 cm. (5 inches).

At the plane of the cavity : The tmteropattertor diameter is
the distance from the upper margin of the third piece of the
sacrum to a point midway on (lie ]>osterior surface of the sym-
physis (Fig. -30), and is 12.5 em. (5 inches).

The trumcerw diameter is the greatest diameter of the pelvis
at this plane, and measures 12 cm. (4 J inches).

The obtitjue diameter* of this plane are valueless from an
obstetrical point of view.

At the plane of the outlet : The anteroposterior diameter is a
line drawn from the tip ol the sacrum to a point just above the
lower liorder of the symphysis pubi>(Figs. 28 and 29). It
measures 11.5cm. (I.J inches).

The trunsrcr.se diameter at this plane may ta measured in
two places (Fig. 2K). The greatest transverse diameter is the
biflischinl line, which is measured from a point on the inner
surface of one ischial tuberosity ut the middle of its posterior
homer, to the same point on the opposite Side. This measures
11.5 cm. (4.J inches).

The least transverse diameter i> the distance between the
ischial spines, the bisischiatic diameter, which measures 10.5
cm. (4$ inches).

The otifii/iie diameter* at this plane are of no importance.

It will be noted by mmparing the dimensions at the differ-
ent planes, that the trnnsvcT>e diameter of the (telvic canal
grows progressively smaller from the brim to the nutlet ; the
difference lx'twcen these Ining 2.5 cm. (1 inch); and also
that the anteroinferior diameter »f the pel v if canal is 0.5
longer at the outlet than at the brim.

Measurements: The iuteriud diameter* of the bony (trivia
as stated in the following table are snfficicntlv accurate for all
practical purjKises, and should be ineinori/ed:

B tn, ; i

1 1 I B "i

Inclination of tho potvli : The inclination i\'"u. 80) of lie
plane oJ ill'- peh Ec bi fn i" the hurizu», «iili tli«- uum.ni in tin*
fic.-i |Hi.iiinii, iniiv I"- hih'il us till v -li\ '• il'-^ni-- Tin' iiirliiin-

Hon of iltc |hN i . ol qoui •. diffen with changcoof p

In tin* end pariaon Iho ■ymphyalii publn b Dearly 9 cm. (31
■ 1 : ■ -i "■- 1 Wow tin- !• vl of tbi promontory j ind r It-- coccyx i*
2 cm. {I (neb) above ill*.- level of itae lorn border or the
ayraphysw nubia, the pubococcygeal line melting en angle of
ten w grace with the horfnon.

The Soft Part* of tho Pelvic Gauxl

Tin- Iowa icgnoeni "i Ibe ii term ind tbcccrvfi Cbrra n [mrt
of tlie birth-canal ; vhtttthauppci -cgmtni la (bo chief aotiros
of tin 1 pTopelHog power. Thf* ptnTi.ni of the Bofi part* l>aa

all'-miv I HTM '1' - Tlbnl.

Tbeaq/I pari* which Un< Aa fcoiw patein and Ehoeo wbiob
eonttfbano i«> the formation ai (he pc/ewjlow ere <>i great oh*
utrlc Importance, Pha/brmoi itfmlnWi somewhat Ihodhune-

ii of the bom eevtt) ; tin- tattai f : -ri n tlie tower port rf

the I>iitIi-i-.iii:iI.

The plow and llUcu* muacion, which In- it tlie brfm, dlcatn-
[ah the tnuarvcrm diameter of ilii» portion of the PtlvSi :«
n iiaiiiT of nn ilKih "ii either Mtlr, lliu* hriitifinjc llii« ili:iirn(ci-
ilawn to ibotil the ftfai -it' the oblique dlamator.

The < - x t ■ 1 1 1 . 1 1 iliac \<-»>l- run ulnng Hit inner boruVn of
throe mosclce, and lha main trurjfa of Ihi lumbar pi •• u« ,: 'i
lows the oounw ■>< ili«' p-*wi-, the orural new running b« rvroeo
i In* mmotend iliaciM uia«olt9

obturator interna* wliii'li i* l>ui ■ iMii miicctc-ahenfc
tortionn of the anterior and lateral mtoIui ""I »< pan of
II iciatic notchi Thui it practically ooven the ulterior

in.

72 OBSTETRIC AX ATOMY.

v-izt'v: noteli, tli ji - "■oiUrihuting to the formation of the floor

'A* tl* %o-«all*d pomterior pelvic groove.

ft* anterior wall of (lie jtelvirt is uot covered by muscle,
t^»* 'Irjrifi^' pregnancy the bladder lies in relation with it.
tP-tnw/ h»\ftT the gr««tcr part of this viscus is drawn up above
fh* inlet ; but its Ixise nwy, in tedious labors, be subjected to
y*4laM**J pf wm w Uftween the head and the pubes, thus
'Umatfinir ii to such an extent that sloughing may occur and
y^W/vaginal fistula re»ull.

loerectam lie* in front of the left sacro-iliac joint. It runs
f/trvzfl and inward, descending in the median line down the
anterior »uria#*i «*f the kuthiii and coccyx. When distended
it ut*y eij'-roueh on the pelvic siHice to a very considerable
extent. It- brtfnwm in this jtortion of tlie pelvis is supposed
\i, w^jiint (of the greater fm|ucney with which the long
diarMrter of the f<etul head occupies the right oblique diameter
at the on-**t of labor.

Th* a*lric floor comprise-- tin* wilt structures which close the
outlet of the hony |n-|\'ih, lis function is to support the
pelvic vi-yj-ia. Ii- up|ier limit is tu« peritoneum, its lower,
the *kiij; it i* \f-rf*tntUt\ by the rcetutii, vagina, and urethra.

Uart let- divid'd the jielvie floor into two segment!, as
follows : the js inferior vaginal wall and the soft structures
Urliind it 'i/imlinite the ttivrul fir/mnit ; the anterior vaginal
wall and the soft slrUftlirun in front of it compose the pubic

In Ia!*or the pubie Hegim-nt indrawn upward and the sacral
segment i- pu-li'd downward and distended as the fcatua
de-eend-. The resiliency of the sacral segment holds the fetal
fiue*- in <■]<.-»■ relation with the ischiopuhic rami during the
hitler part of labor, and assists in its final expulsion.

The pelvic floor when stretched by the fO'tllfl measures,
from the tip of the Huoruin to the anterior bonier of the
puliie Moment, alsiut S inches (12.75 em.). It is mainly com-
posed of museles and fascia*.

The muscles forming the pelvic floor are the levator ani, the
sphincter ani, the transverse muscles of the perineum, and the
sphincter vagina:.

The levator ani muscle, which is the most iiu|Hirtant, takes
its origin from the posterior layer of the triangular ligament,

HH SOFT PART* OF TUB rRbYW ' i v i /.

important dement obttetricnUy than the muaolc layer. It

lug) Ih> daMfftbed in iwii portion*, a pnrictnl and I vfacaral

l.u'. r [K%. 33).

Tin' parietal layer, which ■ - llu- !*•*. iui|iti.l:inl, mvrr* the
itm-clo, jHulilm^ UlC -i']i-- "I LIm pel* i> ' hi li'ini n liinu- lli«*

|ioHk'no! i:iyiT .»(* iln triangular ligament, and it perforated bv
the urvlhn end vagina; ai the baric <i help* to ouvw the
■ariatio nvCchan

The vi»«r*l Uy»r ia oontfnuoua with the mtdi • evering Kite
*i<li"% of the pelvia, From ii- line of orfeln il tIk- *• white Fine"
the vuccrol layer |»;i--v* downward unil inward to the middle

lillC, « I Kir it* tilifi— I'll-w' Will | 1 1 !OtiVC UllHUI .It tllC lui>M

<>f iIm' Itliiililcr, the raffinaj nnd Ihc reetum, time -liti^m^ thaw
ttructura In the pelvuh On n- lowei Mtrfaca !■■ the levator

urn iniiM'Ir.

Tin- perineum m:i\ bedeftned M lhal portion of Lou body

Iving between the aouaand !i rificeoi llic vagina. Ii i*

torned by tin , nl '*•"'.» I Kg, 3 1 \ which ie Re aggraga-

It,. ■■xl<m«l «c"iiHi. " -!■.■<> in m»«l'i| -HI I '""i> <

nwfns: rf.uwiiiri ■•■■ I »• A*« """ " u "'- ■" " "

n i i. ■ mi a '■' nlr

lion of (he ii--or- tying between the rectum and vagina beta*

their p..itn -.( • id. On wctloti thi perineal burl/ 1 irl

angnlar in onillnv eml pyraraloal in fucnii I'- -!<■'» wirfive

I rrom (I..- niilcrior purl of the inn I i tin nueterfiM pari
.,i" ihc ragiiMl urlflcc raen-nri-- .ii.-.iit 2.0 cm, it inrlij.

76

OBSTETRIC AX ATOMY.

The parturient axis : The mathematical axis of the pel-
vic canal is a line which pierces each pelvic plane per-
pendicularly at its central
point. This axis is a curved
line with its concavity for-
ward, and represents very
closely the course the foetal
head follows in its descent
through the pelvis in normal
labor (Fig. 35).

The axis of the brim if pro-
longed would strike the tip
of the coccyx below, above
it would touch a point on
the aixlomen near the umbil-
icus.

The axis of the bony outlet,
if prolonged upward, would
pass immediately in front of
the sacral promontory. The
axis of the plane of the vulvo-
vaginal ring at the moment
when the head is excelled, is
a line directed upward almost
parallel with the lower part
of the abdominal wall of the
mother (Fig. 20).

Hirst points out that the
direction of the pelvic canal
deiKMids entirely on the curve

Ally wine litrtli-cunal : r.tnim; an, _ ' , • ■ , « ■

plain «f miiiet <»r (i.in[j,-U'<l i«riHi ; t, oi the sacrum, and that this
|.uE 1,cu,aP " pUnc or "'" rft * differs in every pelvis.

The Foetus.

The third anatomical element concerned in labor is the body
to be exj>elled. This consists of the whole ovum, viz., pla-
centa, membranes, and foetus. The anatomy of the placenta
and membranes has already been described, therefore this
section will be concerned with the foetus only.

mi- /VF7T-.S

The mature fotm At term tbc f «t ■ i umiuIIv

beAweoB in and 61 mi. (1&-20 Inohca) in length. [U nvtow
avernire* from 3160 t<< 3S0O erammM (7-7 1 , pound*), uaim

ROOMVlut heavier than female*. Not rureU the a
limy reach 11* high its V|tH» ynuniiic i 1 J |<mjii<l.|. llic tihe-
iM>iiiru:il Wright uf 1*000 grntnhie-< (20 pOVDd tkU DOM

recorded.

Tin- /urn/ l**M I nitirh larger proportion ftO 1 1 ■ ■ - trunk limit
in (In M'inlt. lb. duituet* I than thoftt ol :i-iv pert

Of thr trunk KM OR jiioiv iiit-niiipn-^iliU*. It lli.-r-'lmv On* r-

tln principal reuiatanov in tin- pnsaaure «•! tin- child through

the (M'lvih. In tin* nii'clunii-iii it!' IuImh it b Villi tin* In :i<(

tli;it abatatrfa problwm in audnlj oanoe f neq.

Tin ir/i.-/. hixhi of tiir rortu* before .mil daring labor forma
i roaghly ovoid moaa. ' s " long ee tta long dbuneter of tha
r.. i.ii ovoid ooiomdn hi DMn/ia powbl< with lh< exntof

the (Kirtiinriii Bttul thr tiierlumi«m i- ;i normal one. Tfadfl II
the ".II •■ whirhever extremity, boM Of brwli. the lulu.

prcaoni

Tht htacl II .:lly. tin- t'ut.il h«td |»tv:nii two 4M-

»ioil» : (1) M< ■' '"'// . ~Jl '/(< r/MiU'lt '.>"■■ "inlh;;.

The vault, which la eomprca*) de, I • oompoaad of thin, mem-
brano-cArtllaffinoui phtwa, -^\ I ■ ■* - J * an la ihciiwlvi* flexible
nut! ruv. with tli" exception. o| the front*] bona, united to the

DM ■ Mini DO MOh nt lit r li\ inrmlimnr nn!\

The buc i> termed of bonaa which are aolid and (Irmly
:mk« lnN-d. It i» therefore iniinii|ir("-ilik', tltu*. aflhedinie
peoiactJoa daring Urth Go the pwglia at tha ban of the

Tin- atUcfcinunt Iwlwmm tho ba« and tha vault. «»f ih,.

araninm i- along :i Hoc ilmwn ifcroogo tnojonodon of tha

.irl»jt;il nml "sanWDOtU *' |,i,i...| || M frontal DOnO, Continued

backward b* the aapamoa* eotura and downward by tha
hhwc-likajnnodon ol tha tabular pen "i tho ootfpital bone

to the hutikir nnJ condylar (Huti'mi.

The bonoa fonnint th« cranial vault on the two parietal

'''■■ ,:|1 - »«d the a aaaamon»" portion* of ti eipitni

and .i the two leraporoJ boo**. Them are united only by

the iin.>-,lM ( | evtvnml |.rn um .,„,! l, v ,|„. ,| (ir:i ,„ ,

rha pUrtkntj ot the vault i, due to the «irtila K ii M »ti

78

onsmriitc | A \TMIY

jh'Iit of the bone* »ntl I., ih.' i'«;-d".' of the monfarmnoiH
iolorepaoes.

Tin- aoturaa of the vault ar.- the mental 100

between Iwo adjutant bone*. The mo»i important m ttw
A't'iithif, running bctwren the tw«i parietal*; the f\ mtui
between die t«" portions of tin* irwiml bom . the
between tl><* frontal and parietal* . and the fa mbftoidal t bcti
the parietala tod the occipital bone I ig . ;•; ud :i7J.

i ,.. :<..

■

o»

Ml

a

A»tfll"f H"il |><<>l> rti.f RuiUllWllr*, MllllltAl, lulti I ■ I . ■ I, unit TimiiUI

HiRum
Xhl' fontaiieUes jut (in- l:iiy.n "pure* I'mim d by the wittei

log out of the suturea between the anirluM of three of fin
■fiuent bonce.

Tin limst i-* 1 1 * * ■ anterior Joutftiirftr, or brrgmn, Mtuateu ni

[hv jiiiit'tinii fif tin- Hiuiiwil, tli mniil, iiihI the frontal -m

in. I: I- kite-ehipoa, or quadrangular, with ii* mocri icuta
logic forward, It* average rfwmeter i- about one inch, bat
\i- '\y> varies in different head*. Four lines of auturee ran
into it.

Th'- ^n-./.-M.,, or imafl. fontaftdlt in formed »t the juuetit
of the Niyiiinl and Innibdoidal mturcs, mid la merely felt as
small triangular dopreeuon, There ore tlir»-i- line* •>( sunn
tunning into It

reaporalfordantllca; At the Junction of the temporal wi

• >nsri-;ri:h w nvMi

the pwrii'tiil iiml iKvipiiiil I" mi .. on either lid* 'if th?
then- (.'.lists n sum II ^uadrtlateml fonlanrllo.

fiuUt famtahtMta ore <«eonMonnll\ i.l.-.rv.l . ■ i r 1 1 r ■ r in tlir
body "t ihr hone or in ilic cour« of a nature. Tlw**-

duo ii- Mniir \\vtvo\ in o—ihciitMii. A <)iiajrilatcral Mm* Urn

Vn 40.

VWU \'-ft i -i-li '!'<"•"'••""• 1--LU1." iftllitinuiil ItviMlMBW »ml I *{*** |

l:iiulk' i- not 1 ti I i-iii liff illy tO be fill 111 Mir line (if ill*- WJFJU

lul liiiiir :i mIioi*( iIih|;iiht frurn l\iv u-iuil -nuill fun! 111 iclln.

Obstetric laudnmrkx' Certain liiniliimrk* siliitnt lint ftrttitl
ln<ul arc of t'ltiHidiTithlf iiii-ii irii-til ir»port*nfl&

The '■ rit t le thai portion «>i* Um? h>>;ui Uftwwn iiu- nun riot

rOS F'ETVS. fll

iimt posterior funtmiclU'., uml extending luti-nilly BO il".' (wrio-
bil eraineui ■

Tht CO ',-"' i- that [M.rii.iii !>(' ill.- licad U'liiml iIm> [H.Moriur

tullt.ilK'll" .

The wnvij/ut u (lull portion uf lln- Uvmi in front of tin.'

liregmn.

Ku.. II

Vcrt#x. (tU'iit ... . ,,„!.. mli b pottl i i ■' ■< ■ < in*«ign<*«nd Uf*c i
Thf ;h,h,!ln i. (fa OflR DVef llu- r.H.t of tin- mine nwl

between tli'- niprn orbital i klgi

/■ ,,« pwhtln ranee* ins | >r<-*ontc<1 Ity I lip crnniiil l>

1'ln- occipital i>,"'nhmi»" -.iuwtnl in tin- nii<Ml<* of <lio

tqnaxnotu portion of the •"•' ■ipitul boM tbout 3j5 <n. (1 inch)
behind ill-- |»>.i'-ri"L font&neile. The /"),,'•/')/ prohwmmto

v ( In- l"v ■ ■ <) itinni'li'-'- in tin- n'lilfi' <>f HU'll (MllM'til bO0C
ft-OUL

#/ir ITOMt

I ■ rata/ prrtttUr""-' i- tlw *»inrWT in tltr rrslrv uf

i

Diam«Un if the fetal be*d '■ v«W, rttrodiDg

fn»m U* gUMb to the tip *-f the occipital prntabcninre ;
I L6 cm. <4J tnch**l . |»*in>c • »•! K - . fl :.-. U^fc.

U

V.fui ».m i .:■■ poMinor i"*iik»u Oliltinum lf^ilmt™ •

c /,■ yrikrmcntnf, cxtcmliiiif from the tip til' I lie iwoiphnl pro-

t.. ilir ..nil. <*l lli.. rliin. M«-:iMirr* II Olll. (O.J,

Til- [xatcriui -ml, I''i_- .'!>*, in loo lligll.

Subotvih i !/?/»*". »\tciiiliii(5 from tin* junction of thf

■ i [put to the centra <>t' tin- lirrKMH. Mfimuit* fl-0

Luchi i

■ tocvijtito/rotitaf, extending from the junction of tli»n#o1e

v. i. < i R octipttfrpulMfor potiUM (Wbcmaat-M

r ■ t'iifhi-iffmnlir, i'\ tripling from the junction of tin.- nwk
Uld cliin to the wntn- ••( il>- lin-iriiiii. MriiMim ',».-.■ cm. ("J

Tho above divnottn (Pig* 38 nn*l 39) nro all of thora
more or K*x aoinprariBfe
Tin- rtmalnder nw facompreulbti,

tit,tllt*tmtl, liK'H-LUVtl llnulicjl tlf l)i:l:I"t.l |<|Yni-- .<■ .. 1 .'III.

(2f H.rhr-I.

H4

RSTF.TR1C l.\ 17'OW

ftinuifar, moaauml through tin- malar nuinmiv , 7 cm. (2|

Inches).

Bitemporal, nmsarvd through the lower extrcmitiea of lh*>

mnmiil miiIiiiv, M cm. Iltjj inclii'Hj,

Tlif following inhJa i- .umYii-riily N.'iMirutM for nil practical

purpotM .in*! iboald 1m> memorised ;

Fiu. 41.

I'uvo. lxt\ au-mo aiiuirlur (KDlllan. i rnniLwiif *u«1 Virntor.

Dfcwu&N "f thr Ifatal Brad <./<«'.//).

Sl|l»>.'ri|,jt..l.r,-Ml,l)ir'. !l . mi. j:l

Frunlonirntnl, 1> ora. (.'J

' h i Ipitoftontftl, 1 1 - f > cm, (-1

' '- i|iiiomcmal. M em, (6

an&TKTRW .i.vi"'"i

-milllot Jilalir.ilS Will '»* IKltfC*! ill till' ilium' llllilr, I* lll«V

ocdpitobre&matic, Thi imporUi* f tin- maun.

eompldo flexion of tins Jantal head until ulnae*! tlic tnunn-iii

„f ji . .I.lis'.rv will ilin- Ih Mfill' comjip lioinlrd.

i in, w;.

Vtn. Iltghx owntopottortor |M«titan iFnrnWur MTi>l Vnrnlor.l

MoulcUn* of the foetal head: During labor tlie head muiVr-
«i»rc nr I.-- r pnalon which results in ii* ulloniiinn

lini* rMtiltri From tlioovfrluppiii^ of 1 1m- umnuil Ikhik^
b ■ place in si definite way in all caw. The pnrit t4l

Hft i .1 rr J

bunoi override the oeoipfta] Mid frontal bono*; ami of tfcfl
[miR-luU llio one most [irt**«J iijinn, generally tlieoue in I'clu-

tluittotbfl 1 iit..ry. niu>iy-s slij.-. let (ho other.

OBSTKT&JC ASATOMT.

The fajUl trunk : 'Pit titirmrtm nf importune* in I

tffl nW, :>- ihr wlioli* IkmIv i- v» n ||KiUU|lfftHdbl<. "I

neromiot i« (he lonjgi«4 urn] meiiminw 1 3 phi I IJ im-hr- 1, m] b
rt>«lii«*il>ti- to tin' extent «>r '2 la '.\ cm.

Tnf fii/iorfitiiiln-ic mcn*Mrr* tboul I" no. ll i»

Tip' '/•/Morfrma/mco'iin'- l» cm. (3 J inalx ■

Fio- 48.

LaikMoru«nii>(i»i |x*i(lufi. i KhiuWiiI tnd V'infarJ

TVlmy4 <y" lAr f<rtui oroii/, that i*. from the vertex to the

mar lir given am 21 J l.ft i-ni < !* I l" 10 ini'li- ;.
M&Wrty *i U« f»ul b*U -ml trunk; Tie- movements of
W*xtcfi>ion. and mialiun ul (I hf*id arc of great

m» »n inn BMclHialnm of labor. Mcxion i* limited by
Mm ,.f ihi • liiii upon Ihr i*h»L

OaSTSTMC i \\J'"MV

parturition i" dm of ii. •. i..n, liir IicdiI being faced nn iIm

k| the thighs "ii ilu> obtlotncu, uikI the lege on Ibi thighx,

tin- unu being folded no the ■ Ik i

The relation of tb« uterine and fatal axe* During ihe
jmri of |iiri-n.i:i.\ .iri.l in |):iriiiriliu() iho l-n .. iii of the I'u-inl
nVnld in ^ "•rti-Hptind tn tin- Imiij/ itxin of f In* udTii* t l"ii^i-
[u'liimli : or inaji l"- at right angle* i<» i( ((rani verm),

lin.rb mpht t«rr»>pf«U'fior r*-»lit'« [FAntoMifeed ViiruiiT '

\,>rm'>'!</ ill.- long txM correspond . any den iation from thi
relfttiniinliip I.'iiiU to MTKiu- ootnplloktlom in luhor.

0>romnnN obstetrician* apply thi term presentation to

denote (be relutit l the long exit of il»- ftctal ovoid u> tlir

Uterine uxtn. In our opinion the »»-r uf this* U'rm 10 denote

(<•) brovr.
■ ■ foot
ii , | M -r i.mi. m) ihoulder, (6) •ft>ow J (cjhnnA

nlisrh'MIC -IN \Ti>\l\\

Tlin /'i//'r form nf |»P--'iil:ili'tti i- olt.-li Ihhk.I !r.m\<:

crosnd Wi to.

Position : Tin ptiVIO brim i- tliviilnl hy thfl Gonjontf nncl
InmfvmK ilianwUM - into jtmr madrwit* fnUum tOMy be

lii-tiiiril ii h tin- n'luli(m.-.lii|i oflltt pnwntiug jiirt of dM tottOH
(-. i ii«' anadfintg of ilir Iwvic brim. Tim* I.m- . a< Ii |»i-i--iita-

Fim, ai

Jh^nldor I., ft •**i.i.u.*nUfl< l rK-hltfi ,i'»»«:«u

: i

lion there no- fuiir j»oMtions. Thcv are. nnn> , - , 1 n.v-«.r«bng to
x\w particular quadrant oonfVonti '1 by tlw ['fronting part.

In T*rt«x. ta«, and breech presentations tin- long •iumcler
of llm i>r+»«*ntiti|* part niL.:i.-< - in imeof the oblique diameter*
of tin- |m-K u- inlet.

In nrfer prohibitum* utiCtl I tic ixviiMit confront* UlC left

nu raervB oa

latorloi qtudranl »»(' the pelvic brinij the podtfon la ItA

ooolpilo uut'Tiuf, and NO on.

J i prmatiathiu are named MmUtrly according t« the

dirci-limi of the chin, h-\\ mCDtO-CIIttf Ior p OtC,

/:..,■■}, preaenlatum* ere Denied noconung to the. poeHion of
the sacrum, left KU-nt-utiiermr, Ho.

i- in. as.

m

T

BhatUdfT pre*mtati(mr nm mimed according to the dbtetloa
of tin ROftpulfti left MQpulo-enfa friar, etc.

'Hi*' poHitioiiJi are -niiiriiun- Hpokvu < -r" u lir-i. Rroond, third,
or fenrthi til'* !• "it' ''"'" being tint '' r -' end von ouicn fol-
lowing in order from lefl U> nglil ernnnd tin- | •! • I \ i « • I trim.
Thin method '■ ; >| |( to mi-It «d, ;i^ varioui ftUUM>i> i :■-- liiv.-r .1 .

lo irbidi ie t ln> iir-i poritioa in ocrtaio 1 nteffcina, tad eon-

HmUdtr iMi->»« ■ <■" i '■!■> |iii.(,-iii.f [totiuiiti. (Ku .1 mil Yarntor.)

Vortex positions :

Ltfl oodpIto-Aiiioriof, I*. O. A.
[tight occlpleo-antorlnr, (;. < >. A.

Kijrlit oeci|iitM|Kt-i«-i'ntr. It. < ». I'.
l*l't ocdpitopoittcrior, L, O. ]'.

r«o positions ;

Irf'l'l iiii'iihi -jiMlrfini . I,. Nf. A.

Kij*lit mcolCHiotoriiir, It. M. A.
Kii»lit iiii'iiinpo-i.Ttin-. It. M. r.

Ia!": m<'m«)|M»Miriur. I,. M. I'.

JMi Till- MWIiiSlSM A\r> f>H,.sl f>l- \nnUAl t.ABOB.

That MHBi form of cephalic presentation ocoon in 07 Mfl
WiL of all casta is not uultc mtiafocturilj nc ounted tor.

Ttl«T<- ntv thive eoridltioii- <;ieh of which llflS WimC Hill mini-

in bringing nboul llib rasulL TIicm-jhv: 1,11k- pa irvn of

the renlrv of gravity of tin- loin* ; '2, lllc: lehilivv MMtnCM of

the uterus and of im tmtsw ; '•>, th*» movement* of the I" U
I. Matthew* Duncan long ami found Uml the centre of

gravity of tlie untmt lay wornrwlirn- about tliC Hhifflld* r-. and

nearer the rijrhi lI «:t i ■ iIh 1 luflt, nwinjc to lli* 1 nrwwnos o* tlw

liver mi I lir rijjlil WW, Thnx if n fii'tllN \* itnliMirHra i ri ti

'jiliiif fluid of ill-' same awcitio cruvitv aw ii* own,
info o p»i-iliori with tin* laiek nl" it* rijflil hhouhivr |i

downward, this, therefore, becoming the lowest pari of tin-
body.

ft The relative shape* of the nterus and of the fatna ; Th«
fiimliis i-^ nt trnn ilir must roomy [mrl of tin- uterus; hcnoc
nt ti'im the more bulkvbreeeh tint Is «rejiter iti'comniodation in
tin- uppei -i-j:m -nt. while the haul readily adapts ii-ell' to the
-MiiiUrr lower M'jrnieiit.

The fa-tal movements: The movement* of the legsof the
fietn- urc probably more powerful than those of tlie arm*.
Hi nee if tin.- ohild lie with tiro feet downward these will
when in n «t«!e of motion come into con tact with th* resist*
inu* pelvic brim, which will result in Intern! displacement of
the child's body. The shape of the ntcra* will thru tend to
convert this attitude ngnin into a longitudinal one. Tl><
■otina of the specific gravity nf the fietus will tend to bring

the eenliulie |»'l<' downward, und wbei -e this |K wit ion ha*

beon dbtoincd it^ alteration is not likely t" occur provided do
abnormal condition! in prnsant*

THE MECHANISM AND COURSE OF NORMAL
LABOR.

Definition: The trim nrfocMi, indicating normal labor,
Hpplied to labor- wliieli terminate witiioul artificial sin i>
without injury to ilie rnutJwr or child.

1"ml. r ihi- definition, in I hi* work, only utu'oiiiptiraittl
rrvirr tHWmtaHoiU will be oIsBBsd 00 norinnl.

At thin point it may be mentioned that :i woman pregnant

TttF CAUXBS Of THE QXSET OF LABOR.

N

for tlic fir»l tim* i* termed a a rfi fo r aWifa .- OM in labor Of fa
the iiin-rjioriuni fbl tin* frafl DIM, I prtfaifjM

It a woman ha* had several ohifdrvn or irdacsrHeaai |>r»-

vintixK si ir i? termed j multipara. \\ has it i- Mid t<> in-
dicate the i-iort iiiiriilMr.it l In- labor »lu i- IpofclB tf ** a

i |»im, ii |«ini, i |i;int, and »o on.

Stages of labor . While i.'n n i- nrratMoui I prttnonitnni
-int''- bajbffc labor actually iffj in ii i- CSartOCOtn h) divide
Iftbor ID to (lire* (li»tin<-l i-tjipw :

"I'lw tint rfrt'/», or -i;iir«' of dilatation, endl with the full
dilatation of ti»* d vfa ri, with which the raptui* of the
nseobowa i- Daoallj i dum ideal,

'|'h.> ammd '••/'. *>r ttagv of expulsion, ends with the

DomrJetc birtli of the < bild.

'I'h.- 'hi,-,i •■■■.;.. n placental -< v-- . •■"*'- with oompltte
oxpabioo of the pluccntn and membranes and retraction of
t Ik- Dtcrns-

Thr duration of normal labor: Thr iVVftH dortttOB of

IKiriiml labor in |'fimip:inf 111:1* 1"' -l:il.d :i - flghtUMl boUTI ;

while iii iini!ii|i;ir-,i' ii i- from right Ui fa Ihhid*.

Thi' :iv. ii';. duration nf lh«- /iV.rf liafft in |>nu.ip;iw i*
aboul lw.lv.- Bonn; in iTiiiltipane frOU -ix to i-iphl hour-.

Tin ■''•>,■ in nrlwiptrai lasts stool (bar lo tf>

hour-; ami in runltijmrn from one to two DOUHL

'I'iti bV«ra y*«/r, Wniob ii bul nnviv tennuantan npontstM

ihikIt, lR't< fmm a fefl ininnt.- to two hour*.

The Causes of the Onset of Labor.

N" entirely MtUfactnri theory ho* been advanced to nc-
eount for the onset nf labor, which usually occur* on th«- two
hundred and eightieth day after tin- beginning of the lust
inrii-iniiil period.

Ii i* known the] three motor ecntrv> exfcri which pn tdc
over uterine contrai-tinni . a centre in thti medulla , the ■*< r\i
eal ganglia; and 1 1 * ■ ganglia In the anterior vaginal wall and

tin- Dtenno vail
Labor i< art the reaoh of tlin>|HTutinii nf "in-. l>m rntber

of ii rniitihi-r of concurrent cnuiea. Hiece not bjf increasing

tin* [ >:■ i r ■ I - - — rhythmic enntnctlona of tin- uterus present

throughout the whole |«rfod "I pregnsncy.

7 — - -

UM Till Mfrinsfsv \\h rowsF OF vom/i/ > itSOtL

The following •'"' iiiiu'iiM lha moal probabloo

I. Looaonfng attachment of tlw ovum, tho* converting il
Into n foreign bodi .
'i. I'v... of oaruon dioxide In thobloodj
!$, DUlviitioii of ili»* ittorua l»v ili«- ovum ;
•I. Mental [mprwMilona.
I. Looiontng attachment of the ovum: It ban liccn nlincrviil

D

it. n

t icil lowaril I In' end l)f pregnancy til* IraUwubv ill tin- -p
\:\\ rr of lite doctdlU VOMl dffCfllW ill -i/.r. <:ill»i (l(j till" ];r.
:i- ii mrt, t<» nlirivi'I up, and I liu- cany reparation of llir orvtUH
18 permitted. A Inn slight lii'iiidrrlmgr*, which oooiur Ha
roBUH of violent uterine Contract lOflM, 1<*imI [o aid "tit detaching

tli< ovum from 1 1 1#* uterine whIIh. Tin* ovum tVni- hit

foreign body and exeitcw the iltentH in further artiou.

2. Excnsa of carbon dioxide in the blood: Ah tin- r
develop* it demandu more nourishment, and there iaal
same time :ni inemiN* in it* tipwe-wnatc. whieh inched**
carbon dioxide. Thin ga« hiw boon proved by Brown-Seqm
to txoit.' uterine action by stimulating tin: nrrvo-centrea nu-n-
tioned above.

tWtuiu rliaiiL-» arc simpo.rd U>tuk»' pltuio in the plaoi nta
loading to an inereu«e In the quantity of rarhon dloxido.

Whan tllO VOnou* blood has aceuniiihileil :i hiillicieiil ipinui
Or this (fin-, liter i no commotions nro *timulnlc«l to Mich no
- \ i' ni tail tabor U established.

.'t. Distention of the uterns: All hollow vinrora win n «li\-
tendtfd to h certain limit ronlracl and rx|H.'l their content*.
Wiinc-- the distention ol" tin- bladilrr, tin- rectum, anil tl
overloaded -loinacli of tin.' infant.

4. Mental Impressions: The emotion » play n largo oart t'i
rpienttv in ladnoing ntorino contraction* (Iron! grief, joy,
povon ftfghl axporicnood toward iho end of pregnancy fro-
1 1. i.ilv precipitate labor.

The Forces of Labor.
Tut wpoUenl fbrooa of labor are ;

I, ('onlniclion- of the uterus and of (lie vaginal and

\ ie unit 'Ie- ;

°.. I nntraotion? of the abdominal musolc* uud diaphragm .
:i. Gravity.

OONTBA* Of TBS fTKMVS, BTG »9

1 . Contraction* of the Utern» and of tho VaglnAl Mid Polvtc

MllACltft.

/ '/. riu- t bn/padanu,

TbeOC aft by fiir llif iikmI im|n>iiimt liiHnr in brhupoft

:ii«»:ii tli.' fxpuJrion of the t'Miin.

The oontnwtiocw are involuntary, ooourring indeiieiideuftly
of the WOOWtfl will ; thou*.'" they undoubtedly ;in »< ■ ii m i
or even inhiluted by variew Rgvnta Emotion, Mich u aha

Jr.. hI i.t |i;iin. nr n« -rv-.n-.n.— ruiifcd hy the witnuiee of flu'
j)hyfti(»iim or ft Btraflgcr, miiy inhibit tli.m \ loaded rectum
orn full bladder may raft uy niliil.it uterine contraction*.

They urc peristaltic, tire w.ivo of thfl COOtOU ii"ii doing from
tho fundus to the cervix, and tutting from mie-thirvl lu two-
tliif'li Uw length «i|' the ItbOl I'iiin.

They BHj intermittent. Tin- contraction begtaa gradually,
nipiillv rCBOnOI till ■OOlCi mill thru UUWll MHMj olf Tlu>
RM] DC OOllWDfltfaloa I'linirjill) !■% Keeping ll"' linnil oil llu*

wornair a MMOffluiM wall throughout a contraction j IheuiefM

uill be I'll i" lt:in!i'ii gradually ; (Ix-n, remain ins '»■ Cilia 000-
.lit inn i\>r a ^lii.rt FnCtrvalj to max and become wfl eoa

Their duraUoB averageii about one minute. In ifa earliest
■t;i.j. of labor < I • » ■ v occupy but ;i fire bgoojmIi : but in the in
pubivc Mnpr they tool mnen and mi' BUwuzcr. The oon
tractions nn» rhythmical in their fntrnnisefone. There i< ■
certain regularity in their appearand* end disappearance. The

greater their frequency ilie Ion-tor tlicir duration. At the
ii.yiniiiiiv; ..t' Iiiiii.r tlie interval i- !on£ aay a uunrtca or an

DOUrj tolVSfd the end the intervul hi-tween the DBIIU trmv DC

but it tv» H'oc.tid*, -«. t lint tin- contractlona aean '" he almoel
oootrnuona

The eontroettoM an> painful, hence tin- term "mtn
n-iiiillv applied to tlieni. Tin- pain i v due bo the forcible
tf retailing of tlic >'w\ iv nnd ii» attachment*, nml i>f the vagina
and vnlvii oamevntmriy ; alau in part to the i =»* -t Uml ili<
uteri-* i* contracting against reabdanue* \ 'umillel in ilii-
Inn. t occur*! in the int. -tin. tvhen an oltatruotHHi exiirta. The
pain Em usual!} n ferred lu tin wrral n^inn, reneeittUy in T li» i

.'lirlu'l ■■!:!-(■-; i. i i :,. i ,- .ire [.('(.--. ,1 i:|m.|1

by the ailvHwe unit i- felt down the lirnb*.

KM) nn: WKCEjUHSM AND COVJISK (>F SORHAL i.itt'tF;

Tho individual rmuefo-fifjm of tlic utenu during contraction
l» >••- ibortor nod thiekci tlinn lhc\ lire during reluj mi

Rotructlon ih u |>nii , f*.'s peculiar probubly to oil invohu
mlIM•lo-til>^"•' , bat in mrwt mnrkrd in llirwo of the morn..
I i< t ruction enable* a tniuelc-filire which hn« rhortcned dur-
ing commotion to relax without returning to its original
length. Tin* flbrca niter contraction do not quite return Ed
then original length, but remain pertinent I \ "imruhat nlioricr

uud ihteker.

U«-tf!Hii"ii i- duo in part also to n i mcnl of tJio

Rbroa, Them araoMUiucd ai the Iwfrfmiim* of labor la l>.

ii< ally end to end ; in the rollrtW of i' traction lln-v roiiie to
lie Almost Hfda to ftlda. Retraction i- pruclicalk liiniicdiliiruio*
labor iii (In- nitiM'li'-lilniH foriniii|* the hj#/hv itirriur rtfffttumt,
TIiih portion of tin' uterine wail a* tin* ovum in iiiikIih down
Ihtiiiiii. gradually thicker; tlm« iu propulsive Cure* dnrfnn
taction augment*, and it i-* enabled to remain ronatantlj
in ronhtw with the upper end of the ovum until it* expulsion

fpun thia segment

The /•>!" r uternu aqpaten^nol potKCfvuna* the power of reti tc
liuri, become* progrcwiivcly thinner ami dilntee a* the ovum
forced down through it. Het ruction thus enables the utanu
BO pMMtva the expulsive results of commotion.

Pohu-lty i- 1 navfttl term to cx|<tv« llie fact that throughout
labor the expelling |»nri of the uterus — tlic iiiijht segment— la
in ■ stale of nppuiite function to (he sphincter part — llio
lower Mvnu'nl nntl ocrvix.

During |it'.^ii:uirv (he IiHIh.-I. t'nntiilii: tin* IkhIv of lllM

utarus 18 practically at real, while the cervix, ewjieciaHy tho
interna] o-, fa Eo :» Btateof t<inic contnieiion, 11 i- aoIivh
During labor toil rrlaUon ii inverted, the ImhIv coutrnohj

while the OPT VII im relaxed, Thi* relation in taken adviiiiUUHl
of when ii i- MCasearj Ui induce labor for nny emine— thai >-
to dI kipaotivc oontraotiona in the mu*ole forming the body
of the titcrua. Thii i- osually acoomplUhed by dilating the
cervix either niuiituilly or by instrument*, which brings about
the desired result,

Effoct of uterine contra otion b : fn cAnno/wo/ tin *hnpi nnd
I o Won "i 'A- u/i t ai : Dnring i contraction the longitudinal
and aouropofftorfor diameter* of tin* ntarni arc Increased,

mUOWOS 01 "" \BDOitnfJL MVSahKS; ' /'• mi

wliitn ii- UWUWOrM duuoctCJ i dviTi'iiwil, the wli«il«- i.r^aii

a-"iiMiin» si i'»um|iI\ cylindrical lbnn(oioalan pu. 8fl and S&),
Tin fundus i- hum ajptlnsi the abdominal mil and bcomuoj
taon proruiuonl ; ihfx bring* die Eona ax! of * I • ■« - uAertM into

lilU Willi lluil of llic iiilrf of the prhi-.

Or tfu circulation in Uu utaii* and phwtnta s During oon>

lr;i.'li'Hi UiO UtOflM -inii-r- ;ir- dawK • »WI iu-r.tl* i J ;iii<l emptied,

refilling •- ii iuimmoITj l»ia the farta! portion of the placonte
n not iflrcted. Thus througtioul iii. «ii"i< wf pnguancj «li<-
circulation of blood in the utenui u emanated l»\ the regular

rlivlliiii"n-il Uterine OODtltU ii"i>«-

On the fatal htarii Tlw fecial huarl ia nlowtd beoauei Ihe
procure on the [ilaoeutaj afto nines' the genera] Rata] blood"
preMire.

On tha mob aai «■<■'•« .- The mafrriml pulee«rate IncraM
ii-ii i<i twenty bctU, thin • mutiny with thr fatal i >ul fi-
nite.

TIk'mo muwU'i pluy bui i wry imimportaut port in bring-
ing luotil tlw expukion "i the ovum Thty Ml only in ii"-

Inter stage)

2. Contraction of tho Abdominal Muscles and Diaphragm.

The anuauee entering into the format! *f the nlMlominal

Wills, along with tin- iliiiphr.ijfni. wlirn Mmiiliiin-.tii-.lv in n

utile of ..ntr.i. li.ti, inoreoae tho intnMibdoQilnaJ pra wire and
thus rentier very important ;*i<l i«» tin- im-rus. Tin' •■ uuaclf*

taken nil"/ ■'iln-r form, u> it hito, i second hivcr of mneenhu

ti ic ■■■.:-' oal to tho utcrnci
Ticir mode of action ia Be followa! A dean inanlratlon fl

taken, tint* ftntteninK onJ I ifapreai n| the UMubragni,

which i* than fixed bj tho closure of the glottis; than the
muieJti in the abdominal walk oontfael Hm di scorn <>i" tin*
diaphragm puahoe the fundufl forward; uSia i- rerirtod bj
id-- contraction "i the musclae of the abdominal wall, so lhal
ili-' racnllanl "f the combined prv**ureoI thvae mueclee n la
the direction of the loni .* i x i -% of the ntarui lhal i-, down-
ward iii the txU of the oolvio brim.

102 rill-: Mt.cn \si'M \ W 001 i;.-i: OF NORM Li I

rin lotion of iln'-c muscle* ' H »"' ■ storied until Hie eoonntl
or expulsive Majfe, and in :it firs! I'litiruly voluntary. In iho

I;ili r tftiuptf of llu' expulsive perim! I heir ni'liiifl i> enli: i l»

involuntary,

\t firftt they uol -inly daring thuaumc of u pain, wliaa tin
woman voluntarily bear* down; but later, when ill* pain
la-t- ii'ii^r, llu.- woman i« compelled to open tliv gluttia to
respire, tnni relaxing the pressure; but immediuiely another

brCttUJ i* takcu, they uel u^'iin, •-" (hut 1 1 1 1 ■ r* ■ ;ir«- nl'ii-n ^'v<-nU

ubdomiuiil < timotiom to our pain.

:;. Gravity.

Tlio weight of the* child und of tin* waters contained in
the membrane* exertfl but a small influence in aiding ex-
pulsion, except pcrhajtt during the first stupe of lobori w hon
the woman is more or It" in the erect or scrui recumbent

position.

LABOR— FIRST STAGE.
Premonitory 8ig*ns and Symptoms of Labor.

The events whieh indicate the nppnmeh tif labor nre vnriu-
I'li- tii their duration and may lie .»<» islighl ns quite In MOOM

observation,

The change of position of the uterus whirh tak** place*
during Hie lust weeks of pregnancy has been referred to

already.

Irregular pains, usually felt !■•« rlnwn in the ihdmucu in
front, lire freqilCTiilv complained of* by patient* for wane day*
before the owrt of true labor. They nre ■onetime* wvere,
and may cause miieh sulVering to sensitive women. Thaao
"false pains." us they nre termed, may lie distinguished
frtirn true puuis lo (heir irregularity and by their rite* true
labor- palm being fell ehiefly in the sue nil region. Them
false pain- haw abaotutely no eflTcot on the cervix, and no In

e in ihe vaifinal -irretimi iict-oiii|>uuic*> them.
Frequency of micturition and; leaf) often, of defecation, may
be Lronblemune during the lsis*t lew days, and are probably
noosed lis- increase i» the nervous excitability of the pelvic
Itfuolunw usually present ul this lime.

Vf.'V/.I.Y/vtf OF TIN FIIIST ffT.1i '

103

Characteristic Signs and Symptoms of the Onset of Labor.

Angular utnrine contraction** . Tli>< interval between th) r i-
bttj :»I lir-l, bill «tefldi]v ;i* tllC ItboT |irOgTWJC

The pain lit tlii- period all iilwuv referred to tlie moral

region.

Appearance of tho ••■bow"* Tlii- i* the iemi eojnroonrv

ii|>]<lie>l l«i the ntUOOi tinged with IiIhimI wliii-li >•■• ijm-. (mum
the cervix mid vnginu (it this lime. The nlttOOa Conji

chiefly from tin- cervix, nod ili<- blood from the tepann

>\\ih\>>- .[ (!«■ im«iii1'I.iim . iiinl the uterine wall* Juflt etiove

the internal o*.

Softening and ihortoDina of the cervix: TUeaaohaogp
onH be noticed by RiahEng :i vaniual examlnotuin, Th
tonenlne of tin cervix i- eTne to EnnltnMloi) vrlih -< n.n. txu>

date reeilltSflK ffOBI I he inlrrlrmn-c with llii irliini <*i ii-itl:i-

lion caused nj the ultrtae contractions, The shortening of
the corvb result! from the ;■ h kfipg of the internal o«j which
is undoubtedly u phyxioliHfifnl rfliivutioa ennkgona to thai
which tiiko.H plnci- in iphinotcr muscle*

Mechanism of the First Stage.

The uterine CODfttOttoiM during llii- itAffS :ir»- neiii|>iril m-
tirvlv with dilating thu cervix, tin v being lilfle or DO expulsion

of tin' ovum, thix tieine limited i<> the rifghl advance >>i the

Iihjt of nii'inhnimxi llinmyli (he in!, nial 0*.

Dilatation of the cervix result* from: ilr the yielding 01

the Enttrnal os, which is a physiological relaxation; i- • ti"
hyilro-tnlie prc--nn- .if the bag of waters i end S)tw srfion
ot the long israsoulsr tores i» the outer mueclt layer of tin
uterus,

1. The first of th* -■• hns already Wn discussed.

2. The hydrostatic pressurcof the bag of waters: The Rial
result of uterine contraction i» nn ■-■ <» the general
tii'riii' fttn<i !><••• i"'. When the waters are Kounoaat it ml
the DWREthfuni totnot the eflfecl of this pressure n nt/softr
ii- the (octal i- concerned, is the law "f fluid pressure i- 'hot
ti I- ••[iiiit uinl .i|.|K^ite in nil directions.

The rhriflloii nf tin- 1'nree nf tlie Uterine eiitil rtlctlOB \t

centripetal; tin- i»up|»uM'd "HMiififupilU l-\ I he bagofwaften

101 THE MErilKMSM \M> r.'OI fcvK 01 ■»■•/: w.t/. t.ABOR.

Tin' fenwoftbu contraction i* centripetal, wtiili* lln liir..-
exortod by the bag of water* in np|»otutioii in nwitrifuaal.

These two force* would then ttputlis* nnr mwtJutf if I >
the uterine wull wore of equal thickno*< throughout, .nil
therefore ofci|iuil Htrcnjrtl] throughout; and ii '[$) lire uterine
wull were in ii ilatc of equal contraction throughout at tha

MlliH' inoiiirlll of tiliii'.

ftvWf //»■*. mlitinnm fail in thai : />Y*>, the Uterine Wall i-

DOC of equal thick new throughout, tin- lower h^iucd!

thinner; and having a Kolutiou in it* continuity (the yield!
Internal on), il U weaker and therefore must expand .iccontUu,
the uterine wull in imt to :i »i«u* of e^unl unit ruction LurDOya*

not :it the same moment of him', ill thai the « Motion i«

vermicular, licgiimiug at the fundus and spread 1 1 1# downn.i
In tin- eervix, 'O that when the fundii* i> :ii ;l »:nl<- >•!' e*»n
Emotion the cervix in relaxed. This mav lw dcinonauaftcl
clinically by keeping the linker-tip on the lowest point of the
h»K of WaierRj when at l.ho oimet of a pain Lhis will Ik- fell to
become (COM BOme scnnmU before the woman eninplniiN) of

the |.iin which canne-i the moreiine of profiBUro.

For the*? reason* the force of the centrifugal pressure of
the waters is exerted mo«t markedly on the lower uterine?
Moment ami cervix ; hence difntntiim of thene \iart* takci plant
as a result of the iuorciuc in the general intm-uterine llmd

proBBore.

A* ditaUithm iiwrtuh tin- memlirniuw, having booOtnfl
loOfltfttd from their attachment to the uterine wall*, iti -niuai.
them— lw> into theopenite/. Since the fluid within tha mem-
bnVMl transmit* the loroeof tha uterine contraction equally m
all direction:-, the ling of water? is distended laterally :i- W< II
:i- downward, tllDa exerting an cxpunsivo action duvet U nil the
walls of the cervix, ami finally on the margin* of the externa]
(ta A- I he OerviX and external Oft dilate this lateral prfAMnl
Of the bag OX water* increases ]U'o|M»rlionately.

3. Thu action of the longitudinal inuacle-ilbroB of the uturua :
The emit* 11I-. of the ntern- heituf practically incompressible,
tin* pull of the longitudinal fibres will result in drawing the
lower uterine aegment and cervix, who* utruoture U thinner
thtn that of the upper legmeot, up over the contained body,
in thift action the oblique librcr a-.-irt ton considerable extent.

UWIIASISM oF Tilt: 1 1 list &TAQ&

10.,

'I'll* 1 wave DiooatnoUon probablj nesaoe through llie longi-
tudinal libra mow rapidly tliau tnrough thecinolar flhra,

being the lorunT ^ ill (t<ntl lo ilruw the mux "|i over llit<
prCMMltiXttJ p:ui wliilr tllH Imwr hi^llli'llL i irl;i\nl.

Win n tin r< i \ i\ .iihI i'\1itii:iI ii« liave Imhmhiii' w«I| dilated
tbo membranes tmually rupture. Tin-. :i- it nil. . m'nin ditriilK

u imin. iiml ie announced iiv u ^i-h of wnten from Uu vagina,
Tfio <|iuu>tity cMapiBff will depend on Low rapidly tin* pn

•.,-iiiiii'.' pari of tin- f.i-iii- dcflOODlll .hi.! DCCtUOl the loHTO]

nt. riiii- M-in-i.t.

The rapture of the BttmbnUMfl may occur at or before the
■mx-t of Ulibor; "r mny not take plii'«- till the iii'l of tli<-

Djcpohrivc MtagC . bat it i* v«-r_v nut that a full-term child i»

DOrn vvitli tin- iiirliibmtit"- Miiritpiuivil ; tboUgfl it hu Imp

pennd tlui! in prooruitiiir IhUhis rli-- uln.l.- <>^ hi- .-nmr

uwuy mm *

I )m tin- rupture ul" llie Ikijj nl" water-, tin- pr-seutjyg part of
thn ftctiiH takes its place as a dilator, The lluul -till retained
in titem then tmwmits Al effective intm-utcrim preeeUR «■>

thai portion of iii<- fbrtui in contact with (In margins of theo .
In dry labors — ir., in canee where die uNuibfunei rapture

SrriiiatiiM'ly, tbttfl permitting the e oapeof the waters before
iliitoli'.M DM progn Med tonny extent — tin- tir-t *t,vjv uf Inlmr
booomOJ tedloue, fur the reason tlral no part of the fu>tu* ■ <n

act a* a dilator n ■ciiUtortorily n« the hydrostatic pressure

i-Mlt.-.l Ie, til-' lull- ..I Ulll.l .. I < I I I." ■• - I ■- ill. ■ l»h L ' I'll 'I' '

of the ntenw nractfaelly dam the eervii np over the wedge*

BkjO pma»ntlng pur! of the I tie-, vvhutevei that [mil nun Ite

Th«M longitudinal fibre* when in a state of contraction

produce :» downward traction of the fundui upon the fiatUfl

Bending Co force ii downward ; thai force li tianaraittad i" the
preaenaog pan. in vortei m In br ee ch came, by the vertebral
oolumn ni the ehihl.

Thin downward traction of um fundus exerted by the longi-
tudinal fibn i « hen in ;i ittte of oootraotioni does not oauae e
diuwfag down. or J.-fni, of the fondue nteri, hecauee the
oirculaj tii r> - by their more powerful lotion tend, u ii wen ,

tit ftraigUtCU mil (In- -..iiii'wluit bowed I'.etu- j uiili (In- n -nh

iiml tht pootioo of the fundueia relation u> tin- abdominal

HW TBR UECUAHttM \Sl> COVKSE OF NORMAL LAB*
m;iII throughout labor doea it-it vary , but the whul* rami la i I

«f the Ibrotw rviTfi'il liy the contraction'' of ll ■ .,■ t\\u h-i.-

fibres Uj Lranemitted <ln\ui l he vertebral col oof the fu

ilit- prawnting parti which i* thus forced in advance, wh
it the una time the cervix in dilated ami drawn iiji ovet

Ob oteri during first rtago of Ubcr : On making a % n;- i !..• I
examination very curly in labor, in a priinijHira, thai port!
of i In* oervii not yet taken up may \*' felt a»a noP append

tD llic -jilnri'iil Nirfact uf ( Ik* llintriHliil lower pole <>f tin-
lltcni-.. POfldbh Hit- <\\lrtli:il OH IIUIV lie Mlllieietltly Mtfl md

dilated to pariml the insertion of the finger-tip, under

SUM cirriiin-tann*- in a mullipiini the or may lw quite pati'iH
Ions bnore tin.' cervix in taken up, ho that tin finger may
<:i-ilv be inserted into the uterus. I 'uder tbeeo eirctim«tanoaa
the only way to be certain of fheevtent nf cervix ■'till remain-
ing to '"' taken up i- to insert the finger till tin- in«-ii.l»nin."
enn Im.- felt, then, while withdrawing it making linn prcaaufQ
on the potteiior wall, note the length of cervix Before the mar-
gin of the cxternul oh ih reached.

Later, when the cervix i* completely taken up, during a

pJlm tin- -Inilp .'ili'«. ,,f tll«' rkti-riuil OS ran Ih- ili»iinguuthod,
ami tin- i »t I* Mir face of l hi- membrancM am In- felt *i retell-
ing across the aperture.

In primiparn tin- t-dga of the external OH i- :it first (hin ami
■luirp; later it become* more twlonmluiiK, In multipara it
tuny lie thick, ami a- a rexiiU of laceration in u previoim
lalMtr I lie external o*- may have a verv irregular anftpVi

The Degree of ililatalinn may he dfwribod by Mating lUAJ
tin* oh will anmlt one, two, or three fingers ; or it may In com*
piir.nl with tln> *i/.e of a fen-ecnt piece, quarter, etc.

Clinical Phenomena of the First Stage.

Tha initial labor-paina come OH, as a rule, in the earlier put
of tile lughl . and they differ but little from the falne pains,
■xespt that thev ooour more regularly and gradually increase

in *trength and frenueiey

The pain* are sharp and nu^in^r, many patient* finding
them moil' difficult to boar than those til* the expulsive *lugc
Many prefer to wnlk reMlt^-li about, bending over a ehnir

wciiAMsM './■ run S(.<->.\I> STAGS,

107

or th« fiboi »f ftbe l"-«l daring the nemo of tit- pain. [family
it plaintive cry or mou la ottered with each pain, and the

iwilii-fil 1 * filtv Im.mmi.'- cuiipM<*] itwinji to iiiV"llinlBff. lixulinli

of the nantratopy muscles.

Reflex vomiting i> <>! I'iv<|iii'iit iHi'iirrnuv a- dilatation pro-

eroBtos

The |«tiii ni tl compelled frv*|tMntly to evacuate the bladder
and rvctum <m areminl nftliv twira-nl ihm'voii- irr il:ilnlii \ nf
ill! 1 or>_':in-

Th«' pulmi tod respiration :* r«- not umrk>*<llv jimWImI, ;i* u

rule, in rliin *t.v^r, iliou^li in eases where ii la prolonged the
nte of l»"t'i ray be <<in-i'li nil). v leovlontfdj sod tat tem-

pnmtnni m:i\ rUS, to 100° P .. OTCVeC liij:li<'r.

Anatomy of the Soft Parts at the End of the First Stage,

Thi* external 08 1% as n rale* dilated ai u to admit three
(in^Tv. Tin' cervix i- < [ilru-lv t;iUm nji. The whole lower

tegment oi' tbi Dbtfta i* thinned oni somewhat foam -ini.li-
leej ; while 1 1 m' upper Mgiaeut i* ftUgbtry thinker than before
Iho nnasl of labor.

Tin bladder, :u n nil**, i» ilniwn upward Willi ihi CVrVlJC, the

iiimtr and Iwin^ ilin|ilncv<l forward over i lie pobse. Tin-
ii|>|Htr end of the vagina i* tomewheJ distended.

LABOR— SEOOKD STAGE

Mechanism of the Second Stage.

During thin rtage the ftetui* is expelled from the msi
naaaifWi

vertex nrccentajlinna being considered In this work m nor-
mal, nml tlm Ml rM>oij>i t« •-:» 1 1 l--*i- »r position hotnfl 01 far tlir

mopt common* tin aorres] Rita maehanfeni will Im- tolly

described al tin- poinl ; while rm meehaoien <>i the othei

p ii- u HI |>o desoribed only io n fhi :i- they differ from It

The mechanism of tlii- stage i-< concerned enfeiU with tin-

movement* wMofa the fffital head urnl trunk undergo in ilnir

).:i— :il'«- tliiMilL'll 1 Ik- Imlli iimal.

ins 77//. USCB i tf/AM .i.W fOVRSE OF S0R3UL S.AItoK.
'I'll.' mo- 1 iniportnul part »f the mcohaiihini E* licit n latins

hi I In- lu.nl. nil niiMllllll ill' iln -i/i' tlllil I In- it ni|itr-.-il>i|j: \

of EtaniMTWtnx ;i- oofnuorod wlili th« trunk.

The Bead Movements.

TIhw :nv ; rl.x-riii ; hV-xiun; internal rotation: ex
tod finally, aAor ex nulaioo, restitution or external rotation,

Descent : Descent »f the head begin*, n- already mentioned,
wiili i lir rupturoof tin' membrane*, or n> Minn iu ii ootnew En to
aotnplete nonfacl with th« lower uterine -pmih'iii. m •••. I-
rmiM-if In the uterine conirnoUonts reinforced ly the action of
tli*< abdominal munolra ami diaphragm, and per-wl* through-
oul this triage* resulting i» the other movement- alxmi t.. |k<

(I( -rrihctl

Flexion; The pomtioo of the head w naturnllv- one of jmr-
thil flexion, Off it lice in the lower uterine neguienl ;it th« do

of the n'< d tnign. As the head deaconuN thw flexion in-

aream !"• the m-ult of vaifow oaunmt

(fl) At the beginning of thlaatag* the Intm-titorliM fluid

prcH-ure net- on (lie whole base of the »kull, :iml flexion r<

nulte from the different angles nt which the anterior and poo-
lei iur eloped of Uhi vertex meet, the iWiHtance nf the lower
uterine MiilU. The friction ofTen <l bv the wall to the anterior

end of tin 1 bend h greater and thi- end i- more impeded In Eta
1 1, -.i-ni, benoe flexion i- i—mo-iI. Thin i- reinforced by tba
lotion of the eirculnr fibre* of the cervix wnnpremirig the
held. The force exerted bv the*: fibres not l>eiiig equal and
opjuKite, Boston of the linn I U ffivoi'eil.

\t») When the water* ilraiu away Mitlieiently to permit tbfj
fundui to come into direct contact with the fnptua, then n
more powerful foi'oc i* exerted to produce flexion of the
heud. The propuUivn force of the uterine notion trun*-

initloil doWD the vertebral column of the Uetio net- "ii the

bend along a line running nearer ih ipitnl than ibcain-

i ipitoj pole.

The head \t> mi attached |o the inuiL that if- sincipital la

longer than itaooclpital polo; it correaponiui to a lever with
unequal arm-, the ooofpno-atlantoid articulation bvitiK the

vmnxrsv >>r rur secohd STAfiK

109

iic* rcntftanca
receive* if

r«i. M.

^ifootal point lM ,| di,. rinciplta] the long umi
lenoe (he sincipital polo i* more noted on by

oflarnd i" deacon^ whflo the occipital pole
maximim pre nra Fran -« J »• ■ ^ - - iKig. 56.)
Tim" En Avaion pFoduoM

.111-1 tllHltlLllill <l.

Tim »dv»nt*gc oi Saxfe-n -

lli:i! it bnll0 t In- -miillr-t, or

Biibocoipito-onwinotiOj cirouni-
farvnoc of (ha naad Entu nslo-

t ion with lot (.'inlli- of nil
mire olli'ivt! t»y fh* |» i lvi- ;iml
-nf't |i:irl-L. It bIB0 n -ultK in

iIh Dotnpal reaching di« pelvia
Row in advance of mv othi r
jmri of the bend, i point »f
very ifdcmble Importance,

n -n lator.

Winn flexion U oorapleU the

po-tlTlor tV.litillli'Ilr i- lu'wlllfllt
within Winy rearh of the QX-

■nioioff 6navr< Ai wn time

if ilic -Jitridiil >-nt ii if In- fell, il
B0ORV) tfl lifl in'art i- f" tin' |"'

tenor ihu tu tha anterior

w.ill ..(' tin- jwlvin, mill the

head — <-m- to occupy i iocoo-

\vh;n nl.liijiic pomtlOIl ill thi'

l>.'l\ !■ i regard . thf place of

tie brim, On- uniiTiiir nr ri^lit

tal bone aaaming to lw at
.i lower level than S 'In- loft
parietal boflc ThtalfdNm
tu infi-r ■ lut t ill.- head nautili}
•nil -Mi] the peh i . %\ i t > ■ t Em- BhriUal attain Bearer to tha pron-
n than to tin* puhaa. Tlii- La not i real but anappar-
aal obliquity, and h dna to the polvle Inclination. Tha head
DormoUi rntn-. ill. palvii with lit horiaontal plane En com*
iilrii- col i umi i< tier wiih tin - plana of f ha brim, nun condition
liutrn :i- rynviititnH. The obwrnre of the proper relation "I

f V

9

...

lllU-l'>llliv Mm .1 !l. I. lit l*Cl-lh»of

fcollUI «tm. r I-. IIP ■'■■ i i :-H"'

Mrlli, l( ••. i.f I lu IPWI )■ i. •-■(.!. .1 !■> lllf

Imuticiui iJ» » '

110 /'///■• WSCBAJflSM AND COUHSK <" HOKHAU t \BOR.

LhdM plane* it known «* rwyrWuwm, ;i condition whirfc
usually ueeurs when any deformity of the wlvii i- pramnt.

Xnte'rual rotation: The long diameter of the foetal
OCOQpEu the i'ij;lit oulu|iie dinmcter of llw brim w Iwn ttie

Itoaluon la L. O. A., but it mual emergent (lie outlet vritli Iti
iHig tliimictrr ilii'rcU'*! mit4"htiMi^torinrl> ■■■>,- \ Hat

nl' tin- outlet i^ tlic greater. The movement by wbloh Uw

Fio. 67.

.

is

>;-

-"Jtmfau

.f t

//

Ucginttiiitf i'«ini-i'ni ni it-i.li {Dmbcnfaad Varolii

oblique position at the brim is converted into mi uutcropoo-
tcrior politico ut the outlet is termed ft<il'm,>.

Without g I flexi f the fa- to I head rotation ennnofl

ur. A«n result of llcvion the oerii.itnl pole of the fnr*toI

head occupies ft lower plane in the i>elvi» than does the *in-
ofcritol pole. When the iked put in directed forward the -in-
etput mu»t iiiuviT in :■ routrury direction — that is- Iwckward.

\\ Inn tin- head dc-eeiiiU in tin- I,. O. A. position, the oeeiput

mum of M.«'r--ii v inter die upper part of the nnterioi _■ •••

.11 ilu- lilt rfde of the pelvln. It will follow thi» trnxivo in
u- dtAoant, and will thru coca* Into contact with the pelvl

: I.-./.-0/ 'ii mi. ski -us h stm-K

(liKir well forwnnl of lln- (HUUrVVTM line t»f I In- Ml VIA. Afl t
!i -nil of llii* hliglllh liirwsml iluvrtitm OX t lie iMwE|llts] poll'

tin- -inc!|iii:il |m>Ii' will demond along i In 1 moto-Mm groove on

i In- rijrltl -itlr nl'iltr pelvis. \\ In n ttM puVSG ll'n>r H nwHinl
lln« lini' «il' I. :i-t rc-i-l.UKi' i- ilounwnnl :iml l'i>ru:inl, hflin
wliioln-vrr pint nf (In 1 Pi'tnl bow (io UlitJ OHM Ihfl OOuiput)
PomcM i it i i > petal ioiwnip with die polvio Boor 5rat| (olknvn thin
I i m < • nix! i- directed '<• the under border of the aympbytM
poMa In R.O. I 1 , and U "■ Pi poritktna the oooiput da-

i . 6V.

Ma* 1. huh, ili-iinli f (.'I'!' ■ ■ »'i|iutn# ><t luml nl I U p

■ fl<l \.irnl. f I

.»....! I)

an tul- ilong om "i" other, as tho crav may be, of Ore port< rioi
grooves of t h<- pelvia, boo impiora mi Mm pelvic Boor beftind

til** tiunaveraa tine of tfu pcivw not notation hiim u

longer being through tkrco-c!ghth« of b cTrolo inofead of •

eighth, m in interior pomtJoni

Thu» tlii- main joofor in cun-ini* rotation <>f the head i« tbo
rejiftAnce offered vy the pelvic tl« — • r . By the cItm the peri
neuna ii well distended rotutiun i-- 1 ipleted mid n portion of

II '2 TIIK Ml:' -iJAMs.it \M> i-'i j:*j-: >.i : :SfA I.AMOJt,

iln- Inin -nilp i»vrr t li<- ncriptit J» in \u-\s between Un *li*-
trndtd Inliiii,

Extension : Al tin- moment when the in \t mnvutnuitt

-i. mi, begin*, ihr mgittal mitnn* i* dim*t*d a ntertijxwtet'iorfj
tod the Finoipul In- in the hollow i»C the cicruni, IV-m^-hi
mm on in toil oowtioa until the occiput clwra tH
border of "l" 1 raopiihio tiffntuerit, and the 1< 1- pry-acd

liihilv .it-.tiiisl lit*- hm>k ni'llii' •vnijilivWA

Tin' base of (ho 00c i pul then pivot* on the lower edge ol
the »)*mphyHis, and at each puin the head extend*, itrmning

FM, 60.

Otvlpul niii . up hi fr^nt -»f tympll>< -

vn'pt*r

ivKlo ll< ■. ll«I«'"-tlf -l»l

lac perineum and vulvar rini; a* i' 'i'"- *>. (iramiaUv the
vertex, |>m\v, and i'ikt aueceaalvely dido from iiniK-r il» pert-
iiriiin. whirl) MtrUDI over the ehin and 'lie head i* bonfi

Restitution or external rotation: Directly nftrr the li*wl il
bona El reenoiei it- uncial relation to tho ^boulder*, namely,
with it* ooaapi (omental diameter :ii a right angle *>• tin bta-

nerooiial

I'lic vhoulden ••hut (he brim in tin. 1 nnj-.-ii.- .-Ml^ne to

CUSlvM i-msn\,,Si OF THE SECOND STAGE 113

thi bod; limn in [* 0. A. poeMou iIm-v onto la the lef)
olild|iiv diameter, end m tin v deecand ilio rlicht (boulder
eomei tn tin- inmi. clenoa toe heed when it oaoapvn rod)

tile vulva |:ini- i. (Ii:i( llir «hvi[H|I IHMIlI- ti> flic Icl I fide of
tlhC nmllirr, uliidi it (In- HDUI |hiiiIioo it OGCMpicd :il lli«»
brim. TIiik DlUVQlBMll Of Hir lii'ml i* Irrmril n 'ttUittun, nihl
i* of i ii I -• i* ■ - 1 . i- il indifah'* Usually il» |>riinarv noHltSoB

(Fig. 60).

DomLkiic* •ml I hb i

lliil-14 i

Delivery of tht Trunk.

The interior iboulder i>, a» n rule, arrvated ai the tower
li'.rJrf i if tbe *viiij»liv»i«, ao thai e li ■- posterior paasei ever tht
perineum iod appeal* it the vulva ftraL After the posterior
shoulder went* i iterfoi d* ceadi and ti delivered Tla

ln|. .■iih-p.m- with tin- In-iliac iliarnetui la the anteroposterior
poi felon.

Olinical Phenomena of the Second Stage.

\! (it.- i-oiirln-inlt of (he lir-t tfggQ ||„. pklnt nnl illfrc-

.|u«nilv oeaee for i time, end tin more or Iran exhausted

B— 01

TUB MKUWl.sM AND OOUBSR OF NORMAL LAROR.
womnn lin* a fi-w roonn-nt* of n-.i and pnonbly of ftlotp.

! llii* 111.- OtM If rlilonil DOS Ihvii inliuitiiPtrmt.

Tin- pain niv iiiiin- -rvi-rr ilnrtnir llu- -muni stap- mil]
In*-! lon^ri ; lint tin- |>:iiii>ii1 btOOUiefl FnOfS li'tju'ful ji.h ii nilr.

tot alio ii'ult/i - thai with often pain dafinite brofcittu i* being

nimlr. \\ lii'ii the palvtc lUn»r i* reaanw Km parfneuni

Iwtffna i" tlij«Urinl imin tin* ptVflBQTC "I* tlic* 0440, ;nul llu*
*|iliin<'U:r mil n-l».\r>, -o lli.il ii>il iiilVrijiiriilU' u <|ti;iutilY of
tau;al mattor or mucus monpeg Irntn llu- BOU8.

Ai rlu- lime llir rniilnii'liona of tlir HOTODUDaJ nuJOUW WK
involuntary, iiiul i In- patient i* Ebrovd In strain down wild

eaoh ptjfij ln)liliujf her braatb aa the dooa **>. A.- h nilv, tin*
wooutu graapa any aappori near by firmly with bar bnda
timl bnuwa nor fin, to naaial bar cxpuiaiva aftorta

lii tha intervals between the pains aha raata quietly itnd
miry GUI aalaeib

wllfill th* vulvar ring 1* being distended the mfltdDBIof

lit-- woman ninv boGOQM n intent* ih In nsult in n condition

bordering Minum. At tlii> [»criu«l the Im-wI mUhih-c-

nipitllv u it Ii riu'l) |i;iih, DODlllHJ pluioly into view BJ it dot*
•o. In the interval-* it mooiUOi tAUR p.-nuiitiny tin- <-iri-iil;t-

ti<«n ( ,f blood in till ]H*rinRum t" bo rosuratd.

If tblfl roeOMion docs 1 1* »t take phuv. o?dema of tlie part-
r:i|H(ll_v 0Om« 00, and ninv Im' very iniuKril in BOTDQ Cflfltt.

I -iliIIv llu n- i-:i pause wfcoa the he:nl Efl Wn.

Arniui|Htiiviiig tlio delivery of the hntlv tlieiv i* :i gUSU of
u.il.f- :ind liloml.

After the birth til* the child tln< woiicm BOOB QttWtl down,
no iimtttT how noiwy mIic ninv li:ivc Ixen ; itu- 1'ivedmn from

IflUJl nflnrd'mg her yreiil -cil i-liu-l'ioii mid n 1(060 MUM of rent.
lilt leiupenilure :ii lliU linir iti:iv !»' nli^lillv rli'Vnlc*! ;
t'.^]nM'i:i!ly it' llir hilmr li:i- 0660 Qlffloulti tht pUlSO-rtU
hijikIIv SUOHiaM :unl in » l'«'W DIOUODta rOSODlCB Vt DOflDal

fpo^utaoj .

Moulding of the Tcetal Head.

Tlii'Hiil.r-lu'jitl.i'vciiiniionniil laboriUndorgocsoonsidoribk]

liter ktion in ihtuc M it i- fori .'.I ilimiigh tlio mntvrnnl pas-wee*.
Tlio manner in wllldl the bone-* OVoriMp licif Iwen alr-'iclv

refcrrtd to,

Tin degree of moulding depenOw 00 tin relstivfl iltt • »(" tl
Imau ill"'! HM |»'lvi», mid :ii.-n QBOfl the i-xtint of o-.-i|ic:ilii
present

Tin moulding of ,nr hea*1 '* •mwbiuJ '» the meehaniatn of

llii' rx|nil-i\r IUr in lli.it il ttwlfe to :nl;i|'l:ii U "t ■ •! the Ihim!

lu the pelvis; and :ii-i. beeaoac its tlonffatioir favora rotatiot
i.\ increasing tb« dip of the Leading peat] lotBol ii ii dooi
ru*ily curveted fonranli

Elongation: In I. >i \ . ;in<l |,. ( l. |'. p letttOCU tin- Mange*
tiuii of tin In mi I U n\i.»na a line joining (Ik- «,- 1 ■ i n U» tin- |»' -<--ri- >i

upper angle of tha rfgnl parieta] bom.
I" B, O, A. and La P.po

liwnl MBlODgl line joining the oil in t-. tin- pG i-'ii-u UppoJ

A. ami It. i ». |\ poaitiofu tb« olonanti f lb*

angle of the left jmriftal bone.

Thii deformity u ■coentastod by tli<- tapui mcotdaruwn.

Caput Buccedantmm.

Definition; The onpat luoeeauneuni ii tin reueiuatoui -will
inn wliirli in ■ ] i \- . 1 . * | >. , I on tin pri scnting perl in Iho oom i n
birth, usually iftnr rupture of the membrane*. TIw vessels
of flu pn mating peri became angoreed during Iht peine, and
serous exudation lakes place into that portion of '!'<■ fcvtaJ
Hniiu-i wiiirli i :i|i the prnwiiw of t h< girdle "(' reaubinot

Ii-. 81ko wriee it iih '!»' degree of P>ro produi '"u it ; benee
it. it largo ii» difficull aid prolonged labon [tj rice Ii u
indication «*' the degree >•( obctruoti ^countered bj lb

l"t'i« in it* pn&mp.* through the |K'lvi*,

It' location iixlieute* the position in which tita bead hat

Mi .•.■nil.. i. in anterior positions ii ii ituetcdon Los posterior,
inul in tin- posterior positions oil the anterior Biped of the
aunmil of Ins head. In left poeitfonf it i* on the rigbl . rod
in rifcbt podtiom ii bon toe lofl of tha DMrlfan Una.

riw exact position •»!' tha caput may be modnled if the

linul lift* Imt|) Mihjcelnl to pmlnin.'etl |ir< -m- Ql the <>n|l.t Of

at the rolva.

Anatomy of the Second Stage.

I Hi TJIK MEf'll-WrsM I \7» COi'ItSK "I \'f>HM If /

The uterus hue retracted on thai purl of tli<* To Mu nataJa-
ing [odds it. The differentiation between iu upper and I"

vL'iin-iir- li;i- 1» ■- ■'•me nmrki-I ; mid it' lite labor i il difficult
one, the ivtraotion-ring nuv be felt n i n *. i m ^- ■»Ui.|M.i. .
tlir uterm ii -liui't distance uliovc the pill *<-• . The higha I In -
pin* i- till tin- more serious ia the obstruction which Bod been
anonuntered by the fataa,

The bladder i> now wholly .ilmw tin- puhe> and the m-
la graatlj elongated; hence catheU-riaatiun i> dlflicult and
urination impossible, the pressure of the head increaainaj tin
diAonltjr.

Tin- structures In the sacral noipuontnf iln- |» I\ !<• Hour have
l«'i ii paahad down wartl and Imckward; ilm mnicnu of the

iiiiiin :irc I'onvd mil by the |>iv—mv i»f I he bead ; and the
auit- ha* hemme widely diMemled, pcnuittini: Uie anterior
wull of the rectum to wnne into view . Thy vufput of il»' * idva

nr'i' |.n"'i 'I iiiiiirl and tin > iiiiiv 1»« "■!< tnatOUA

LABOR— THIRD STAGE.

Tlii» stage of labor i* occupied with the dotaohnv "'
expulsion of boa plaimitn and tin* membranca,

Mechanism of the Third Stage.

Separation of the Placenta.

Th« placenta ii npaiuted by retraction and contraction of
the uterus.

Many theories have htvn advanced in ■ \|.I:. in ihe method

or placental wpornrionj and the following tjWnptinn i- bal

marj of thoac moat gontrally accepted.

\ a result of rot root ion of the utarun aAcr

the t'lltlil tlir |il:i«'i-iil:i LA cniii|Hv--i d hi aliuiil OtlC-ludf

I'Xplll-inM ..f
I' ul:ii-ciila in eniii]ire--id In mIhimI

nil M/r berorii dataohoianl occurs*

Tho hhiImiI of its oelechi it depcndi on it- .*//*-.

It" the altn lie ODnfined to the wall and due* nol • ncrofw fa
on thr futidiiN, tin' eeparatiou prolmbly begins at tin* margina
mihI advances toward Ihe uentre, If Uie piuccntul uti n hracnt
in 10 any extant funds! 1 1 »- - plaj .ntn, u the re*ult of uterine

MB B IJVZSJf OF THE THUW STdOK

n-lnu'tiuii, IkjOOIW - Im-iiI nvtT al an uiiylr. ami lU-tncliiiicnl.
will hvpll nl. il>- lower margin ami tlrli'i)»ion will MtCUr. Tfial
■ |>I:hmiI:i w ill j-]\y QOWfl lIuOWKVl :i ■ UVMchfllMlt gOM
-m, ln'tiij; ill lacliiti |>v tin i\|iii1-im' fOTOQ Of tlW) UNnm <-•*■!-

tnuttioou

\ Kiipiiratinn •dVOAOtl nhiim- VftMHfi an- lorn arm-., ami
■.-mi. Ii.'iiiorrliau'.' lal-i* |i!.,.

In •>>ihi' .-a- - ilii» r« tropins nnt.\l U * mo rr liana pla\ - an mi-
I ...nan I rtffl \U i > la. Mir a I -li-l.i. l.iiK-ni ; ami in all GMfJB ll rvnilrr*
- a m- tin: (.hrilikagc of the |iI;htiiIiiI -iU' nuav &0B1 ttu
pltDQIltE.

Separation of the Membranes.

A- a ic-uli nl* t In- protrusion nl' ilic"li:ig of i m • i n brane* "
through i In- oh, in i lie lit -I ■'.! -i- nf labor, soma H*p«mti.)ii of
IrM niriiiluam'- from the wall* of "lit" bwtt iih-riui: KgfUtQl
lake- ItlOn

After rupture of tin- Ni«-iiil>r.i»r« ami <•*•;! |h.« of the «;i!.r.
the 11..11 i hiii,' nirinlii-iim- taoOUN thrown info fiiliU mul
wrinl.t. -. nnJ Bl ■ POSUll Imv.hiic n.irtiallv ilet;M ( hi.il in -.nine

dIoom. Tin- plttocntu, in ilio prooBc of ncpulaion strips tin*

me ml i rune* GDfDpIctolv off the uterine wall- a- ii ■! roil-

li i: iaipOftttOl thul tin- amnii'M ami Ihc chorion remain
flrmly united: failure of titttG itractuiva i<> tdbCK to one

aimiluT rOJOiU ill poitioni of H Imriwn Im-jmj |i-(i U-liiml

in tin- uicnu, ■ condition it la (fatirftbla i" * » *- ■ • i * I .

In oimi »b«r«i loo airly ruutara of the mnnbriBOfl ••crura,
than m do '• bag of w;uor>,'' ncnai tin- nwmbiBaca mIbon to
tin- utMHM' mil i"' oIomIy, ami no datachotnl of then i
occur Hiiiil tin- placenta In Eta ospulfJuo. utrfpi thorn ufl*.

Expulsion of the Placenta and M«mbrano.

Al thf moll "f utiTinr QODtT&rliMiih, tin- |ilacenta iv ex-
palled.

It nviitilK pjcftentft |1 llm vnlvii l*v ROHM -|«'( on il» Ratal

a -peri about two iiflio i'i'mii it- lowor niorjrm. Tha pron ntav

UOII 0* ttia I'n'lal •BpOOl i- iHMWdby the rr!n»[iheenlal MlinoN
totgt loading fo ilT1 iiivriviuti of I In placenta, wlneli h:i- to atrip
I't'im the nl fi am \\:tlt a portion of IftU im nilirain - IhIv.c Q |

|]fl nil-: UKCItA.StSM 1.\7> COVRSK "' S'MtMAt. I

lower margin iiii-t thoo* ; hence thUpart i« delayed to a certain
it 1 1 ig, >> 1 1. The higher in (he utcrue the pla< i

ntod the more raembnu e h

Ih- stripped «'fT tietwvcii it> lowor

margin ami the <>-. mid 1 1 » • -

r tlii deg - "i invention, «»r

folding ovei of the placenta,

IN-- plncvtitii never pre

ii ■ margin al the vnlvn unk -■ \U

lower rdej' %\:i ■ r i ltiikiUn i(n:iftH|

clow to Uie internal oo.

Thfi membrane* Are dragged <mt

1>\ tin J. -iriii of ilin placenta :
In in.- they art u-millv uiv.. rtcd
mid the arouion appear* "iiter-

IIHi-f,

Tin- whole Rinst <>f placenta
nnil nifioriniiK - i- accompAmed
by a variable 11 mount of elofj)
ami flnnl blood, theae coming
from the placental »uc.

After expulsion of the after-
birth the uti-riu in fmi lid rr-

Irai'ln) anil conli-Micil to nl>mit

tho *\xh of tin* f<ri;il head. !r..

randfl with llin afDOUUl nt retraction and with llir «j./.c
n! till- ObUdt

The position of the fundus iiniiidinteh after labor i- almut
Imlf-wiiv let wren ihe |»ii1m-. ami tiniliili.n- [jiler, wlii'li the
|MiniU/.<H| lower M-umi'iit hits retrained it? torn* by retraction,
tbc fiindlal ri«c* to o |»o8ition about the level of the HID

billouii

Labor in now completed, and the puerperal period begin*

Blood lort la labor: The average u nt of blood lout

in labor i- abool >-tv to tan < oat. The total quantity

..ii i« i conatdenhly. Wonien who meiihtrunii- |nu!u-l\

habitually low mure than thuw. whu-r meiisti nation is usually

leanty.

luvfimion "i i i un ■nitvimil

ta *• ah liiicii.J
no, i -, iu i -I'll ii u «r i

ttfiSTt-mur \.\rtM-:rsis

ll!»

THE MANAGEMENT OF NORMAL LABOR.

In the it. ... urn nt of n one of labor >' II the duty of thw

physician t<« und tin- urouu in the procenaci "i labor aim

rri|iiired, in onler that hIio muy he *|wnvil imneeevttry Buffer

iiijc mid JiriO'iiiiftji't ; und ttao to protc if from w$ info

iiuii which mi^lil In- mi|HMti-«l In. in iritllOttl.

Ii hftfl uln-mlv boon mentioned thai it iedoeimblc in i •

wiao in units.- a'prellminary examination of the Mtfall

IbOF UVckf hcfolV llli- r\|nvtr*l rulllllli'tilfUl. BcSKlo thtt Ofdi"

nary obstetric examination, the genvat condition of the patient
»houUl bo noted hi iln- iniir. A us imL'iilaiin.-- nhould Ih-
eoffoototL and everything fthould !«■ arranged n thai :ii '!»■
-Iiiir of Inn expected \u\mt ihr |>!in< m - -iinigih ami wialiiy

xhall In- the Im>! |nimiI>U>.

OBSTETRIC ANTISEPSIS.

LO 1847 LgOBtilM !?• SOJIllBelwefo, having Ihmiii •!■ ■• j >1 v i
praised by tin- heavy mortality in the Vienna Mat- nut- , u-i

applied tin* niiii-piir method to the mnnngnrnml of labor. Ry
simply compelling ititdonb) Attending -ill cmm erf labor to
clmntc the hand* thoroughly in chlorine-water, in' reduced
the mortality In the mntcrmt) clinic from IS baa oanl to
under 2 p in Iom than i year.

Hi nee thill diltr llie iiiiirliditv fr |iiiit|mt.iI ■• j.-:- in .ill

iniuri'tiiiv boapftab haj been raoiieed tn raiowderahly undo* I

pci .■.■n(.

That the application Of the iiiitiwplir tlnxl In the man-

•ni of jHi-ah labor aaao) oai do! been aa wi dq m r ead i
. lanced b) the Guri thai the mortalSty»returoH. both ui Brit-
ain and America, thou there ha* lieeo but little •!■ m in
the number ■.(' iii'iiiii- dm to puerperal tepeM In roocnt

• Mlt
The \tm\i mitiihen of WOOHD wbfl thfong tie ilflffM

nli nice in all partH of lb« oonntcjr, njffering from njaaaaa Dat-
ing from I nnrVtODfl i in'im-nt. tin- wit I., die furl

that the application of the intiecpttc method to the oooduet

labor i* still Car from bring an general a.i it ihoold bi

.

120 TBB MASAGKNEST OF SORMir LABOR

Antiseptic Agents.

Boftp ami but water are probably lilt- moi-l valuabi-
Many Who praeti-e ob-li-trie- neglect I Iicm-, while Diaklog
II-. of KMDl <r)>h'rrj/lir ,{m// ill Holutlun, which blind* litem Ni
IIm fact thai ftSOpeu i- moN important than aitti*ejWiK

Till" plentiful llpc i.»|* MMip ;um! lint water :ier<Mii|>:inicd by

iiiDicl. sod ootnxnon sew* would greatly nKltioa not oim
mortality, hut ill-** morbidity in nlmlclnr work, pV«0 If uuti-
npptici lm<l never been heard of,

fhc u*c of these agent** should alway- precede the employ-
inent of antiseptics.

Heat, either dry or moist, i« the most general and available
grrmieide.

VII utensils *-mph.y.-d nlx.ut i puerperal woman should be
at least molded thoroughly with not water, ami when |**si-
ble should bo boiled.

All dreasings or material which it is intended to wo ua
vulvar pad* should be boiled or steamed before labor, and
kepi carefully wrapjied tip until iimhI.

All UiHtninientB should bv fouled for nl leaal five mlmitot
in a 1 per cent, soda solution, after which Uley may bo placed

in Aeruued water.

All water u«ed in the hd tor-room dinnld In boiled, and
then kept covered until wanted.

lit fa.t, cleanliness in all that pertain n to the woman, not
only during Inimr, but for two week* Mjbnefpuuitly, ii> abso-
lutely nwiwiji if it U desired to have fever-free obrtetrfd

ra-i's,

Fii all details the method followed should be as simple. U

■Me.

Chemical Antiseptics.
The most UHcful chemical p-rinii ides are mrrcut'iv ehlorl'l? ;

oarbolic aotd ■. m&flmalin,

Creolin, lyanl, and jtenuan^aiiate of [tota^itim air al>o
von' commonly employed tu ob-tclric praciii ■<

1 1 Uituhl lie remembered that nostp decotuiHim" mercuric

chloride end permansaMta of potaMiiini, rendering tliem inert ;

that BrbollC Mid : ■■ i > < I pi'iiuane;an:ile of pOlUBttliU an incom-

nit: <>i;sn:rui<'!A.\

unee of jillniiiiiii, forming timvwiiii ni inert ejbuoiioouj of

ii,. : .i:rv.

Thn-J<>i> when lln> /"/'" i- ii*mI in u xuliHimi |«»r dniiehimr,

ii -imiiiti be onmbiiiod with tartaric, ratio, or hydrooblorw

u ul mi the jm ) rn-n of live pun* • •!* the uoid to one of
the mrri'iiriiil.

Omvcnii-iii'i' inn) ii«s>iini«'v are secured by tiling tablet*
oontAiningj Merenvii >t>l"<i-i> combined with the propel pro-
portion •>! the acid. Su J mote nludoiu m und in itrcogtru

of from I : OUOU tU 1 1 500

Formaliu BolntiotH IK DOT HipUffag ROblinUtc •olutfooi

fiip douching ptn pom --. m the) wn fret from the objection*
connected with lot net «'f the letler. Formolfn oolutloni

win in -uvn^lli IViiiii I : 'JtKHI fn I . ,'»*HI a> (.iMiiianl; n. ni.

I'll-- mm n^ili ->i tin* u>ti!il iruiniirt.i.ii fonntian Ii 10 pit cent,
of Uw gnaeou* compound formaldehyde En water.

In t In- application of i In ;mii-< ptii' method '•> um oondoot
of labor, nol only una the oothftrwian and uut ruth oon>

rented, bill WW I he ftlirnt.

Tho Obstetrician.

Tho nh-t«iri« i:m -litaihl alwayt Im- ea refill '<» Iti'i'p hli handi

not only clean, but tlw in good ooadttJon. He ibauld avoid
ii- ttir ii-i jm^ihU- unv wnrk whirl) will render lib hinds rough

uim! Imnl. Gkn ■bouN be taken to keep the aVin intact, for
oats. mntnbcB, and chapping all render tfai milrfugof the

li.ni'l- BOrgiOaUy clean an inipo»*ihilitv. Should there be
nnv of tbeut conditions present, it ia the duty of the obwtct-
rni.ni DO wear aseptic rubber glovw when eonduotilUJ u awe
of labor. Que -liuuM Im- taken i>< <t to AaneEft ananfi material .
If oonpclh-il t" •!•< ■. ■ ii< I iml ' i "ni. 1 1" • ■ tcrlliaed repeatedly

iil.-Mjiinith ■-

Put nalli tlwuld receive i.:irti« nlnr attention. Tin « -h-aiU
he OQt diurt ami well filed, vi that rugged edgi - I ■ not be
left lo -n-siti-h i-r iujnrr- in the »li^hu--t derive I lie maternal
oil pari .

I In i. :iit two methodi of tteiilirlng the handi. bat!) of
which am |irobnl>ly equally efficacious. Thcw may bedtolg*

122 THE MANAGEMENT OF NORMAL LABOR.

natetl respectively (1) the sublimate method ; (2) the perman-
ganate method.

The Sublimate Method.

((t) The hand- and forearms are scrubbed thoroughly for
five minutes with a nail-brush, using water as hot as can be
home and a good soap ; either an ethereal or alcoholic solu-
tion of green soap being the beat for this purpose. Special
attention must be paid to the nails and subungual space*.

(b) After thorough rinsing in plain sterilized water, the
nails should be cleansed with a nail-cleaner or sterilized mani-
cure-stick.

(<■) Then tint hands and forearms are laved with pan alcohol,
to dehydrate the skin, for at least one minute.

(</) The next step is to immerse the parts in a hot 1 :2000
solution of mercuric chloride for from three to live minutes.

The Permanganate Method.

The hands and forearms are scrubbed and cleaned as in
steps a and b of the preceding method.

(c) They are then immersed for five minutes in a hot satu-
rated solution of potassium permanganate, vigorous friction
being applied by means of a sterilized swab, till the skin in
stained a rieh nudiogany-brown.

((/) Then they are bathed in a hot saturated solution of
oxalic acid till the brown stain has been completely removed.
This may be followed by rinsing in plain sterilized warm
water or a I :HMKJ sublimate solution.

It is much to be desired that the obstetrician should follow
the operating surgeon's example not only in the preparation
of Ins hands, but in wearing a freshly laundried, or, better,
sterilized, long coat-gown of linen or duck, when attending a
ease of labor.

The Nurse.

The nurse should be no less particular in her attention to
detail, in the application of the antiseptic method to the con-
duet of labor.

rur VATIRST.

i -

Tin' nnr ■ ■.!■.. ul.l make (in entire ohanj» of clothing, afur
taking o bath. More uwiimtng charge ■ >!" .1 |»iitnnl in lntK.r.

Her clothing should bo Buaolnb ly tuvaa, ud riw ibouM war

»n*li-'ln --!•-

1 1' ihfl bu nocotfy ben exposed to septlit. it i- Iut ilm v in
EnJbnn tin- phyatcnui ■>!" tin- fiuri hefbn inking eharga of a
<f labor.

Btfoffl attending I<< the vulva ■■!' tin- |>:itii>ul the imi-r

ahould tterHute her naads ilnmmghlv, and m proow ahould
be repeated nob duM ibe, Imu occaeion 10 cfouiM Um purtti

The Patient,

Tin- HBptla pmuBtioa of the pndent nhouid win voejci

bofofe tin- OXUGOtOu tlrnV of hilmr. Sin* hIiiiuM In* mfunmil

i>i i!i. importance ofekrioj peraonui cfawlintm. Any aaaasoed

ifii'tififin* of lh" rt.vtmilj Ytilvn, or hhi.lil-r -IhuiM rts*c«ivy
ti. :ihnr||t

At the oiiHct 1 .1" labor tin' (Ki-ji Dl -li'inl.1 1.1I.. :i warm bath
Jlllil tlii'il |HI1 1 >■ j rli'jin linrtl. Tlir InWiT bnwrl -hnithl lit*
i'in|it:<>(! hv BO QOfffOO.

The niirHc .hnnM dim tboroUghh itcxub tli.- |..«.t (mil nt'
l!ir ibdOmtO :nnl thigh* Willi pWm ">mp ami lint uiiln',

making n-r or ■ ion band-bnuftj orajnte nvab, for uric pur-

UOHft

The pu/ftir ftflfr nIhiiiIiI be ollnwa if it be too long.

Then thene parti slwuld bt waahed with a warm lolution

j I BOO) "I" formalin Of <»t' {1 :-.»tHM»| mercuric chloride,

\K-r lln |»arN liiivi ln'i'ti ilnril wilii ;in a-i-plin towel 1
sterile vnlvar pail -hinihl 00 applied. The |»ul -ImiiM bl WOR!

during the Snri and t&oond Magi -"' labor.

The normal vaginal aacrotion nl a pregnant woman tin* been

|,i..\"i| n> hv gonniridul ; th«-rH<>r«< in ni>nn;tl i-.m-* m< untr
partnm vaginal injection-, -hmihi hi' permitted. \nt nnly U

\ 1 i 11 1 ■!■..■. tinri useless, I > ■ ■ t h mi i irtuaJ harm in in

fairing tin' accretive activity of the raginal wall-, Unu inlar*
bring with nature 1 ! protectwa aoaod antei*

THK WJICAVKMKfT OF \OBJiJL LJBO*.

PREPARATIONS FOR LABOK
Ob the Part of the Phyo«*n.

I u< | iii '•'.:.: 1 1 JtOukl /!' thfl jati.nl a li-,1 of tli'XC tlltli£«

III - to |.[..', nl«- illlt] have If3<l> fcf ll»r labor.
Tin patient) Si h |iritiii|i:tnt, tbuold be -warned of certain
litiotii uli "'I i mav nriiv al ihr un«* i ol labor { -mi li »» tirvtn-
nfnrv rinrtiav of MflhniM -. bemorriwgr, ete.. and irwtnJrtnl
Ni »ikI for rli.- |»hy-iri:ni i urly.

Tin: call to.' ■ r -In^ild alway* revive tin- jil.y-

•icianV immediate intention, such u *iimmon- taking prww-
■ I n**c over ever* thing.

He ihoaU $> provided with mcb instruments and drujj* an
nrv likiK t>i In- iicii'I«I !n the ■-• n i- 1 > m-i of ordinary labor xu<|
in tin- moTfl Important . oloCi'tl'ir i-mugcm-ies. 1 In -< cDfl all

Ik carried in a tiand-bqg,

'I'll*' obstetric bag frboold ■«»m ilim (Ik: following:

A |«lir -li" i»l»-li in. I'.. iv. p*

I'm. pajr of brmootatiQ Ibro i-.

One iiffilli-l'i»n N ■;•- Tot -muring,
\V..||.-. eurved iiini -trui^'ln, <>'. v.irimi. -i/*-.
\ imii i>(" h i-->.r*.
A rfinih ftiHHiulum.

A pair of lung uterine dresaing-foree]>*.
A double tanooiilum.

A pall iiin-ii r. ami :i inmsiiriiiK-tuiM-.
A liy jMKltTitiii- eiiM', well i'Hiii|t|M a (i.

A gravity pryrfna* IW doaaliinjg, etc

A long tili'ri Imirlii' iiidwIi', either .»!' "J;i-.> <m metal.

Two MoAVrubbtl ■ it! In -l. i ■-, .v.-. B I" 1-.

C-ttgut, -ilk, and rillcwonn-gul tor MUiriag,
Two nail-brashe*.

A hdbJI pnckagi of rtorik iodoform gauBe.
\ ha un bottle of chloroform,

A quarter- pound 1 in nf ethen

A iwn mince l"-nl<- 1,{ .vmi|. nf chloral.

\ nil optic tableti <»r lolutioaa.

Ah apparatus fbf llie »ubcut*n*ous injection of sterile Kilt
hIiduKI nlfta bo carried. Tins may consist of ii f'uir-

m .i

o.v TUB PATiT V! inr r:nr\r

afaad axploriiip-nocdle. ittaened to ■ piece of oefl rubber

lul'itt^ niie **onl ia length, and u fbUMWnoe glw 01 RUV

nmriiii AinooL

Mum phj • » « - i . i n - oath doo :» iVi'lilv leandriod li
and dunk lipron, u won u i jhiir ut' robber glove*. Thcuo

tattor may Im- -t.-rili/nl and wrapped up in u pin k age, act t"
In- opened nil rvtpiircU.

On the Part of the Patient.

Tbo labor-room • Whore practioable, a large, high, woll-
veatilated room should be selected far the lying-in ofiamber.
It should nol be expoecd to eoofauninatiofi from defective

pliinihtnp.

rii, room ■oleotad -liuuUJ be thoroiwlriy cleaned iv few day*
before tin- expected kbof it po LbtOt and all tiunec*
ImnpiiiL'- .mil tiiriiiuirc ivintivrd, i*|H-iiully thou J i U ■ • 1 v Ut

oolleol dint It i-* ««-ll to bavo ft ■ three omoll tabloa

avail, ildc fin* holding I>:imii», in-liuni'-iii-. <■!»■.

All linen and Other tliinp. provided fi>r tin- Inlmr should DO

k'.'pt I ■ imt in llitx nuiltl, H) U I" 1"' i uilii'' ! i::l- In :imu!-

able h roqtdrodL

* too -It. /.en towehj and :i belMoeon froahly laundrfod ihool •
*houM In- reedy.

Two rubber iheoti, or *l taof MOM tnpftrvSoQl man-rial, (o

rinu-li iirt<»- (In* Ihm], uImhu fuiir I'.-et wide, -lionld Im- provided.

The |i:inrnt -In-lit- 1 :il-ii make of obteft) :i labor pail, tbOUl

three not nunro ami about three inohoi thick, nudi "i

<■![■!■-.(■ eloili nml filled with AUretoeJ OOltOfl ">r Other ;i't-
-Mil.rii' material,

AlSO two OOMQ rnlvar pad* made of lit'- NMBC material

ibould l»- provided 'I 1 ! bould bo two Inchon th)dk t four

inches vide, end ton inobcfl longhand have ">i' piece atu hod
Be otther end (a ftuavn them i" 'if- binder, Two or three

lin r Qottotl bindom diould Ik* midy ; each should !"• |

yard and n half long and half a yard wide.

The Uboivpaili vulvar drcsninga, and J » i j i > I > ■ i ■ ■!! :t-

linll' a do/in tOWOla, nhould be wrapped in loin <•■ y:\r-

■ ••!-., Kta&mnil li.r half an hour, and llieli |>ijt iwuy and hut

opened till roanJrcd Ebr u >■

126 THE MANAGEMENT OF NORMAL LABOR.

The following should also be pre tided : a bed-pan, a Indian
of antiseptic tablets for solution, a fountain syringe, font
ounces 01 tincture of green soap, a half-pound package oa*
absorbent cotton, and a one-ounce bottle of vaseline, as wall
as a skein of bobbin.

On the Part of the None.

The nurse's first duty is to prepare the patient for labor,
as has already been described.

The labor-bed should then be made ready. This should
by preference be a single bed, with a stiff* spring and a fairly
hard hair-mattress. Over this a rubber sheet should be
spread and then covered by un ordinary sheet, which should
be securely pinned at each corner under the mattress. In
the middle third of the IkkI another rubber sheet is then laid,
covered over by a folded draw-sheet, both being securely
pinned under the mattress at each side of the bed. On this
the labor-pad is placed when it is required. The bed should
l>e accessible from both sides.

The nurse should see that everything likely to be needed in
the course of labor has been provided and is at hand for
immediate use.

The nurse should see that plenty of hot water is at hand,
and make ready two jugs of sterile water, covering the tops
and placing them where the water will rapidly cool.

A pair of scissors and the necessary ligatures for the cord
arc to be sterilized and placed within reach.

A small bowl containing a solution of boric acid, and a few
small cotton swabs, should be ready for washing out the child's
eyes and mouth.

Wrappings to receive the child should also be prepared, and
in winter kept warm till wanted for use.

Use of Anesthetics in Labor.

Obstetric anesthesia differs from surgical anaesthesia in that
in the former the object is to blunt and not wholly to abolish
the sensibilities.

/ 9K <■!■ i V.f.V/7//"/7(> /V l.ittfllt

i-17

Tin' prolnnjed .wid too free ow "f nn ■ during llboi

i.« capable of harm ; but at tin- mm limr- it i- the duty of t In-
phriiician t" rvlicvi: the patfanl of needle** «uflcring unil to

>|iurv ln.T ii ■tiv i.'xlmii-litih

Tin' rule should be to dbg ui mmtnetju when (lie ptiiH in

not ffdl DOTM without it. Th* il'vr.-f of HHH WfawB 0D1I

"I'lm-ii rio mhIiitv i* wonderful, while in othtf (DH the
limit of •'ixlurnnoc i« «wn reuohod.

Anaetbetiaa tro noMlIf mdicaUd toward tat mm) of ihc

-•rond »iiij£r uf labor. At tin- neme of i-\jml :■■••■■ -m

mitfcilifl *lioiild Im liP'.l, :iv n rillr.

Chloroform or othar iUj 1m- employed. Chlorofof« i*

Hiendlr preferred, u the n*cee*&r) qneoriy i- lea bulky,

ullll it ih plr:i-:mhr Ul tftlEVi ^ hOD DtftU :mie-llie>t:i i- :il!

that i- dnirod chloroform i- Eta Bore ■tfaftctary ; bal In

rrauiril)|thur)gi<li) iitiie-lh. -1:1 lor :m y length of rime el her

i« uinlniiliii'iflv ilw wfpr and the Iwt'or.

Chloroform ■ *-iiil i.i wciilico, untl ether rather to •liniu-

htaj nti-rii ntroettoni KiluT ihouM not !>•■ employed

when bronchi tis i- jut -« nt. or when the patient ll tM lab-
ject of atheroma.

Ill oelmnp-oii and iii'in nif (ion of I lie DittfNI ■•hloro-

form Ii i»- be preftmd.

Admintitratlnn ■ In r,i-e* ro#|uirin^ only /..i.'i'.-' •> a
the administration euti be entrusted to the nunc, noting under
the physician' .1 lection. \ mii*k or folded towd i- bold
over the imtieni'i nee, ft&d ii the npproecn of noli ptiin the

inn m i- In tnMttd i" tprinklc a foe Ii i ipoo it. It Ea

will 111 :iii ..:<- t.< lansf tin- i vn i- 1 . i '• t iob "iili .1 Itgbl coil-

[fig of ntM'liiK .i llit linn- tin-In mil II l« ■ ill '»ll

-k:n :mh! OMM ■"n-i»l.i:ililr irritation nbetqUCBtly -I Id

[III. |»prr:iilliotl he overlooked.

«'ur -lioiild :il-o Im* (liken t<i reino»e urn ImI-i 1 leelh bofofg

rotovu'ncnne Inn MininiNf ration of ihe en* Rtiienc.

Win ii wwgiral onovuifltfri In reonSred far enj lenigui <if

lime ll- )iiliiiiiii-ir;iii<»ii -lion Id m 9H l« !< m 1" 1 1 1 • * nUXW, but
n |»hy-i''i:ni xhotild In' Otlkd KIT tin- |>urpo-e.

128 THE MAXAGEMt'ST OF SOBMAL LABOR.

MANAGEMENT OF THE FIRST STAGE OF LABOR

Preliminary Conduct of the Physician.

The paviidao is usually (lie one person to whom the woman
in lalwr looks for help ami encouragement in her hour of trial.

His duty is to win (hi- absolute confidence of the patient,
and to inspire her with hoiwi'ulness and courage throughout
the labor.

His bearinf should be quiet and confident, nnd hi? mmnu-r,
while firm, should be sympathetic and gentle.

The effectiveness of a woman's labor depends very e«>ri--i«|, r-
ably on the preHervntion of her wlf-coiitml and the alisenon uf
strongly inhibiting emotions. The physician cannot afford to
lose the intelligent u distance, of his patient. Nor is he justi-
fied in adding fear or despair tit the sum-rings. Thus, what-
ever he may tell her relative*, he should, after hi* examination,
give his patient the impression that all is satisfactory.

The physician is sent for at this time because the patient
believes herself to l>c in labor. In this she may be mistaken.

On entering the lying-in-room the physician should not pro-
ceed at once to examine the patient ; but should try to set his
patient at ease and permit ncr to l>ccome accustomed to his
presence.

In a quiet, conversational manner, information aa to th«
time of onset, the frequency, and the duration of the pains
should be obtained.

The condition of the patient's general health since the last
visit of the physician should be learned, etc.

While thus engaged the physician may watch for himself any
symptoms of lal>or which may be manifest, and at the same
time he should observe Ins patient carefully for any obvious
sign of disease as shown in ncr face or bearing, and seek to
estimate for himself the character and type of woman with
whom he has to deal.

Should it be evident that labor has commenced the nurse
may then he instructed to prepare the patient, if this has not
been done already.

In any case the patient should have the bladder and
evacuated before any physical examination is made.

■ ■ I .'. 10/ Ith'X T OF THE F/JWT 8TAQM OF t~iKO£ I .">
Obstetric Examination

Kxtomal Examination.

i|;uti1

Preparation: Tin- patient ftboald Ih- pitted ID tin- dorotl

position clu-i' to I hi- edffl "I tbt b*d «:lli licr limit- r\\< ntlril
;ui<l licr licud OB 11 low |iilliivv. Tin* {"oUtEnt nlioulil Im 1

Iirnnnl 00 a- to expona tin tbdoncn from the enaifomi rur-
Ultge in iIm )imIh -, riir jiin-ii-ian. having washed hie bondi
in hot water, may t lii-n lake :t poahion aJoafnicIc Um patienti
either rittioD or rtftuding h nwy be don ooDveaienl

I Inspection : The nromincnoe Hod contour of Ihi uodonun
should itM Ik> obaervejd "1*1 1* - condition of the nmbitiou
whether deprean nd or prominent, the pretence ornbaenceof
-fri.r, ptsnttntntion, or icon, and *i nditlon of th<» flanki

^honkl nil i»* noted Ei tdenfli of utavin*- eontmction un<l of
feet nl movement* ihouU] la? looked tor.
Percuwion: The abdomen thonU than be pefenwod. In

niifinal (WU tin- iliilrir-- -huiihl DO liinil'il I" central rOglOtUI

nl' 1 In- abdomnn ettundinu from u umrt dfetanne above ihn
n:i\rl io tin- |inl"'-. wrniia the fltokfl noil epteaetne reaioiM

ihoulil (jive u rli-ir note.

Before proceeding to die BotuoJ palpation Use cJnuvon

tarpereture of the ikiu should receive eUcntion, Then the

degree of pnnuirnlii- idiDOtUf, ami tin* pn Mf* ■ Of anet&oe <■;

ii'ili.Fuii in llii- liypnffiir«trii n ■■.■ ■■ 1 ■. Iiniil'l )»: notedi The «lioi»o
of the Utorui Kid 'ii- height of the fnmUtu should than U<
miiili- miiI.

Tin* upper border* of the poivu should then be examined l«v

plftdng ihi- tJf* of tin- linv.tr- of nutfa ham] On iiIIki liijn-

■ 1 ' -T , with tin- tlinnili-jMiinl- mating un the atifrrinr Miiprrior

Elite -pnH-. Xhe relationship of tin- mine* h fitnuri' the
creel* -liituld Im' observed t end b rough astimate of the wiilth
»f ilii- pari of the pelvis made

Tin* upper border of the pnbet wionld then !«• located, fin
Ik (jinm 1- iw 1*1 n >\<i i" m intake (be pubce for the new when
1 ihi,;n .-i :i..' 1. 11 cplore the pdi ic cxnivitioo from eboee.

Tin: iriSAUEMKyr or XQBUAL mbojl

The next point i- i > explore the excavation of tin- prlvifl in
ordei to nccTtaln who! hpr it i* fiill or empty, and, If full, the
chnractorotic* of that |xirt of the lain- occnpyfnff it. In
order to-do this thct hand? diuuld be placed over tin- lateral
:i-]».i. ,ii the. lower abdomen with their palmar ■iirfuco

llltnii-l t:n'iii" fin-li nilii.M. llic hllgvr-tlpM lieiii); directed tnirarr]

iIm- patient' fool him! reeling abnul 1111 ineh nnt] :i half nU

r<'iij>:if I - li. -anient;..

The |»a!:< nl IN thru d I reel. -I ■ - • bn nil"' deeply, ami with Oftoh

i cpimtiun iln- 5 tiger-tint- urv prewod downward and bnokwi

into t lir- pelvi*, mri« U'lllg laki ti in avoid the |MiIm In i

•itivi' patient* tln> prpMtur** ext-rtrd nmv enntie pain; in *urli
owes Inif maiircnvre win be carried nnt I»v n series of bollotti

niciit-lilvc movements, and tin- iiif-.rmnii«m iloired ilnm oh-
! with tlw mini mum of discomfort to the patient.
If the cxcuvniii.Mi Ik- ocenpicd, tin- An^cr-tlfM are qnielJi
arrcatod in their decent. Tin* only purl of tin- ftetiu whi
ink* into tin* pelvis bcfuni nr wn early in labor la I
Ih':mI. ThiM nifty Ih 1 renu^iiiml by il- hanlne*. and I ■■.
globular outline, which rim bo readily defined. The: breech,
mm (In- other lunid, in soft nutl bulky, and il- otitliin VCTJ
difficnti tu define,

Should the. head of the Cntu- occupy the peWis in th« nor-
mal condition of flexion |" Fig, 62), il will be noted thnt *>w
liitn<l b arrested above the brim, while the other sink a to I
lower levi 1 before meeting with n-i-iaiiec

The part of tin- head which is thti* most neee— iM- i« the
brow. Thin condition i*> mo-t marked in ■ •> -« i j »i t ■ ■ j •> ■ ' « * i i - ■ i-
poaitkmii of the bend. Hence if tlii> fact bo noted the peti-
tion of the ftvtufl i> pretty noli indicnted.

If ili»- head be located at the brim mid tin- excavation
of the pelvii nol Ih- nceoiwililr. ji dtmild i» n rt.d vhethei il
i. ,-ni. i.M.d — that i". faat m tha brim— or whether ii Ik
movable. Il the head be found I" Ih* freely itmvahlo, an
attempl ihonld be mode to enjr.ipc it by pre«<injc " down*

wind and baokwtlrd in the ji\i- i>i (he ptdvte Inlet, and

i itinale ihr relaliM- pruportmnH of the-e pari-.

The uppwr poU of the litem* i- pa I pa led by K nmm *"R ■'
fuiidti* lirinly between ImiIIi hand", having' the linpr-ti ;> Ii

re ted toward tlie bead of the mother. By ihuu Kteivdying

Tlir M ISAGK.VKXT "I WtiN.iL 1 uu>r

nhoulder win generally bo located without difficult] i:
mniiinp firm premure downward on the Hindu with oao haiMi.
tho bnek. ifdirootod to the front, enii be more road
with tli«- nilivr. Tlii* |-n uk- u the U<ii« :ia ■•! il.
incnuM the convexity of thcdoranl plane aud renders it Bore
acooaaible.

\'\m' limba nro foil nil Mnftll n<nlnl<' . I. m-« -, Iwyl*, . IIkiw*.
eta. which gUp about fraarj under the louoli,

J I' (In: small part* :ir<< iiiiiih ron- ;iot| to II lit] III HI tin- mi<|.| I.

line of the abdomen, ;i posterior position of ilif iVetua la Indi-
cated, Finding nf the -moll unrt* in one scotinn ul icVi

metl rnnlirni- llir l< trillion nf I In- ilnnoiin in tin nji|wi*i|i rcgl' 'ii ,

ilm- small part*) I" the righl indicate n left, and mi mil pui I
'ii loft uMlieatea right position of the fintua

Aiiaoultation,

kaaoultation ii bent practised wit 1 1 the biuHiiral Htelhoaeopo,
It i5 n mistake to prcM tli" hell of tho instrument tinnlv on
the abdominal wall; it should be allowed t«* rest lightly upon
the skin, being steadied by ihe slightest toiicli <'t' one filler
on the er»w-lmr.

The tint abject i- to locate the. |ioint m which the fatal
hear I h hoard with raaxnuom tutonflty.

The fu>Ul lieftrtsounds an* ImiiHUiiftod limn Inndlv ihmug'h
the baek| generally about the lower angle i if the left fatal
>■ ipula,

fn anterior vertex pretcnUiiiaiiH the he»rf-« id* arc liecurd

beat ut n point midwuy between the n nihil ieon uml the iintgrfcvr

-ll|»'l Jnr !i|H*l)e of tllC Bide l« wliO'li tin Im'IjiI l.:i.-K ! iliivrh I .

while in port rfoi tn lea prea ntatimiH their point of muxinrain

intensity U in the Yeapoiidfng Hunk.

I Eg. o'.l illu-lnio- tile point« of mnxifuum intensity of tin-

Rata] haart-aound* in the vanon* position* nnd pre ttiona.

The sound* produced Uy the fuinl heart huve been com
pared (a the muffled ricking of n watch under n phV«. il><-
rate being alwul 120-180 per minute.

li -liooltl ba rcioriiiliiird thai In do r*>oi Mister loi iHwltiona, in
hydratnnlw, mid in curtain other cimdiiiiins the hoart-*oiiad

may not l»* audible*

MANAGEMENT OF TUK MIWT STAG K "> ' !/("/:. I;'.:'.

I'lx i I rh/Uunu iwfaMog lound occurring qyuebronouiuy

with Hi" iinh-rn.d hanil beat, ooautfoully beard Ion down on

OOO «>r otnflff -i«li- of llio uU»ni>, ii U'lmol tlic uterine bruit.

Tln> suiitul i- '•:iii>o«i \>\ tlic ru^hini* m1 l.(i •!■<) llirtin^li tl"'

*.* /•

ti ■■ /■'

or

r, ,

\

~T

*-,

liluKraiiua Hi- i-'iiit. ..( urnlnva Inttmuvof tottl tu rt kmjdOi id ran

U |,f. wuUIIiiim

enlargtd uterine vcnwli, umi i« tttotnJiy to be hiiml Iniulct
in the neighborhood of tin plaomt*.
Rutty ;i lin'l)-jiii<lic«l hMngoi blowing mtxnd, which i-

•>ii.-Im - uilli t In- pnlaftlloDK <*! llir f'rUil liriiM. m:i\ Ih

!i< vtr.l. 1 lii- i- irnuol f Ih- funic touffle. iiihI i> ran.nl Uy flic
IiIimmI i'u»lnii£ llirou^li tin vunvlh of llir coru. Il i-, U I

nilr, only hoard worn tbv cord in twlntd Rround clu- bodj of

ill.' fallM,

134 THE MAyA'iEXEST OF SORMAL LABOR.

Vaginal Ei animation.

The physician having ci»nipk'Ud the external examination
of the patient, should then ascertain ilie condition of
vulva, the vagina, the cervix, and che bog of waters.

While making the vaginal examination he should note the
position of the presenting part, and should make a rough esti-
mate of the capacity of the pelvis.

Preparations: The patient is placed on her left side, with
her hips brought well to the edge of the bed and her lower
limbs Hexed. The c-lothing should be so arranged as not to
interfere with the access of the examining hand, and a sheet
is then draped over the patient. While this is being attended
to, the physician should cleanse and sterilise his sands, ac-
cording to the directions already given.

The Examination.

Everything !>eing in readiness, the physician seats himself
facing the patient's genitalia. The nurse is then directed to
lift the sheet covering the patient, so as to expose the but-
tocks.

With his left hand the physician then gently cleanses the
vulva with a pledget of absorbent cotton wet with an anti-
septic solution.

Having moistened his right hand in the same solution, he
then separates the lips of the vulvu by means of the thumb
and mmdlc finger of this hand, holding the examining fore-
finger well flexed into the palm so that it will not come into
accidental contact with any part of the patient.

Having thus exposed the orifice of the vagina, he then ex-
tends Ins forefinger, |>assing it gently in in the direction of
the hollow nf the sacrum.

Having already noted the condition of the vulva and
vaginal discharge, he now examines the perineum and the
posterior vaginal wall. The finger is then passed upward
following the curve of the sacrum, which should be noted,
until it reaches the posterior vaginal fornix.

The posterior lip of the cervix will now 1m> felt, and is to
be traced down till the margin of the external os is reached.

ViVK/-umt Of THE FiRST STAOR Of ' IBQR 138

Tint tLngpt is llicii -ui-jii imuii'I lln i-virtiiiil Oft MO Dalng
I .I.V.-H Of il- OOndltlOC Hllil "t ill' <li*:-iir i.t ilil:il:itiu|i |.f< 'III.

Til.- ha* of wilcn h iln ii I'll \t pftftttl ; If not, the
Anger ■ - inavrtod within ttuxM miiil the hruawitliitt. pari a)
1 1 !«■ fWtUM hi reached. Tin- I- iIk-h i'\|.l(.i'i'il (in- landmark*
ami il- (Million !ii llio |h'I\ i- :iHi'.iijitni'l.

On withdrawing il»' font tiM Ulterior lip of the oervix
should Im- followed ; and tin- :ini< nor vaginal wall U W II M
the posterior eurfaot of ihc puboi -mould be explored.

i H N

Hhhh.i1 iii> tl»"l uf M-nr(H|> ll.r i1(a«iiliitl faifl

Tlic capacity of tbe pnlvis fthffllM llim he :isi-i rlnin.il li>
aweajnlng tlic finjpir aboal in rariima dirroUons. It hoa*Sl>ir,

t:i :ihcii»)i! m:i\ l»< ni.-iilc (o iv.-irli llii' jiroiuniilory frf lln-
■cicniin ; if l hit r;m n-.olily be 'onHnil | h. ri ;• -otm diym-

of iK-lvir- oontnwlion present

Tin- diagonal ronjucatr nhoulcl therefore I"' mi'inuivd

T'.ir tlii< purpose tin- fioEU AooW be tritbdrawn tAd thi
whole hand ignin imraerarci in an nntiventio solution. The
*ir*t and aoootid finc<r< niv than Inearted intn th** vagina, and
ill- tip of the neond finger placed in cmae! with tbfl »»»

i:i'i

rill-: MA.\.u;t:.\jt:.\r "/ yoj.w.i/. / i .

Iii'uinitu'iil |Kiin( of llin promontory; the radial ■ •', ■■»■ t ,{
unit! in lln'ii r;ii-<f 1 ntitit it rv-l- again*! tJi< - 1 1 1 >| .■. I .

ni. ni (FSjr 84). TbiM point of contact u then marked I
6ogvr-iui>n of Uiu other IiuihI. On withdrawing 1 1 ■ ■ - handi

ilu> di-cnirc between the two vb'mu of • I ii then mi

ured ami (In* tr lonjugale etf limited t ■■■ e Pel l imctl J

Succeeding the Examination.

Having DOW gathered all bin facta the physician u enabled
to make a diafnoala. It i« unwise to venture D diagooril till
all tin- lads art' in hum),

Predictions u lit tike probtiMi 1 duration of the labor fhoald
In avoid* '1 ; Inir ni the same linn the putieni should b< ••.
all the em ragemctit and BfBuranoe pottiblc.

If the prcncntutiiiu l»- fivornhlo and the purl well engaged
in the pelvic brim, the patient may he allowed the liberty of
her room, am I indeed should be encouraged t«» mow aljotit*

The attendance of the physician timing the first tinge aj

labor ia not required, in tlie uhwnce uf nnv complication

Tlie nuiM should be instructed to give the | mile til amaU
cjiumlilii'H of ti'/iti't nourUJanrni at nhort intrrvahi, It is
wi'll l*i leave a couple of 15-gruin done* of ehhiral I" In* n<]-
nlfaitrtffed to the patient, with an interval of twenty mini ;
between each, -limiM her MiiA'criug In-come acute. The nurse
■ImiiiM hIho he instructed to krrp the imtirnt in oeW, ami to
MCfnavoa t/n phyncittu when (he meiiinrnncn rupture "i* on

the ocoirrenoe of hearing-down paint

Alter an interval of two to four hours should the mem-
1 1 ran e* not have ruptured, a second vagi mi I examination may
be made to ascertain what progfcN hoc been attained.

Should it bfi fi>und (hat the ttfUBINaVof the bug of witters
remains the Mime during the pnins a- in the intervals, or
should the oh he dilated >-» a- ita^ily to admit three finger*,
then the membranes may bo ruptured.

'i 'hi is i- aooomnlichod by a scratching movement of the fore-
finger, arcnmpaninl by piv.-inv. Should thix lull, a rtcrilu&cd

probe or etraighteneu-out hairpin mny be employe*! for ihi»
purpows ili<' graiiaif oarc hotug cxprri*rd not in injure the
maternal tiwuee nor the ikio of die presenting part of the

lu'tilr.,

im vie;/ va:.v/' or ////•; skcomj .sr.it; a: r/F lm;>h;

MANAGEMENT OF THE SECOND STAGE OF LABOR.

During flu* irconDu stage of labor the uafioni tuHHild i»- kepi
in 1...I. Ilcr ordinary mght-elotbing ibould lie turned up

ami j»i id .it the should r, eo na to prevent i<" being •■■

Position: The patient met .I'-iini.- utv posture during ilii-"
-; i-jf .n v. lii-li -Im' i .in -I ■- hi- 1 i Ik l-i> .it'--! amount 01 I 010101%
provided there itfaa rcnauu uj liy «he »houM be cmwtnntly kept
in ooq position.

Bbc ibould !«• cnooanup-"! t<- Iring nil her ea|.ii1*i\i- ■-ffitrijv

inl-i OfMTatloU, uti'l i" ihw OOd li>«i ('.■•! rua\ In- In- <! agftifMt

aom« object, and aha Way be allowed i<i ;is.-i*i hrr-elf by i-itlnT

pulling *i|Mui ill.- hand* of • byatander <>r on a ahcet-aling

i:i-liinxl to tlir foot of the bad.

Iii rapid case* iIk-. incMiirc- -hotiM !»• at'oioVil, mul tin-

SUllil'lll illttnir'li'il linl to ln:ir iI»»imi, Inil In ftUAS her mUBOlfW
.V ilmri. panting breathing or bg r in* out ulood daring the

a<M d" the iitemi ntraotioaBi in mil wny Um moid die

tentfon end rapture of ili'* perineum inf !"• avoided The

[>hl ■n , i:i!l lIlOlllll DQ 111 ■■Ml-t.illl .lUrii'l.ilii'r ■ I'll! !i;* till- I v I,

I'lieiv hi luit little oeniiion to make a vaginal examination

when the acax>nd sown of lebov li a abltatied. Should Ei bo

foetid tliatailvoAca O009 not oocui In iptto orftppajrentl) rood

mi .-i IM Action, UlOfl :i \:n_'iii:il •■ \:ir a'mit -fi'MiM In- nt:u|i- In

eetnbltah If p eaiblc tha eona -id-lay ; hoi ftuoireel axamlna-

lion- .h. iM I).' n\ ii'uled.

During the second utoge an anKstlwUc may I*- ptnployixl
ooutrol and until tlie oaimtaiva ■norta of tea pattenl -liunM
thin lie deMired, an well u* in relieve her niflering Nol iufn

.|tiinilv il i- in <•( --.iiv t DvloV i' <" the fir-t m!iii»« f.n ll"

latter object I: ibould oolj be BilmintBtered during the
nniii". aooordinff bo the direetiona already rivm,

When the anna bagini to dUtend with era paint the be id
ba« reached the pelvic tloor and rotation i« under way,

Farlne&l rtago : Il i» now t f r ■ - dllt? of the physician to
etch ilir
the hend.

Wnleli tin- rffw'l rtf rlicln-.iltlfu.-l i.'H "I tll< UteRI

■ physic
I iii ii'U

aneiiig

A- the perineum !>< *ui- In h -r* n.J with r:ieli (tiiii. not iv

fraqnantty ;i irnall quantity of necnl matt tpellad from

lln- aim-. Tin- n.ii-l bt« wa-hcil away, from hftfotO baok , *t*»i\

189 rut: MASAQBM&NT Of VORMAl i.akok

(no u to I"' "'Hi Infection, wlih plcdjcalaof aboorlMiol 'utron
M(i:ikt*l in :in iniiiwplic ttlutfODi

Lac-oration ni tin perineum nornr* in oboul .;"• jh r era
nrimijiiii;. , mtil in iiIhmiI Imlf thai number til' multipart-.
Weventioii of thin accident dejiemU on lln dirtlomibilit^ .,
(In- pelvic floor and tin' smullnet* "1" \\w rnga
mo rf ili« fatal bead. Slow delivery of the fatal bead, bj

gradual »t retelling id' the perineui iniimVo* llic |mi

of rupture Hnlt' the injuria 'iirrinu to (he pell tC floor in

general obotetric practice are preventable by *kilfnl maBflugt-
ni. nt "t" the perineal «t*j*«» of lulmr.

rbc patient *hoiild at this time be placed on her left *\-U\
nrfth hor hip* close to the edge of the bed. Hei lcjr* should
Ik: flaxud iud u folded jiillmv phioud between Iht kneCfl

The pay»iclan should *il '■!..-<■ o> the edge • >! the bed, luring
ii ■ foot. KcflT mi hand on n choir or luu ruble »houM I
union containing an antiseptic Mdutinn, in w hic.li ho may • I ■ ■ •
liii- hand- from lime to time, a- well a- liptitirv* for tli» oorxt,
goiasora, -nab- do., whieJi he will require an the cant pro*

BO*,

The nit' of the dewenl of <".- head it modcrnwd by oon-
trolling Ac expulsive effort* of the patient mid by din.-.* pn —
ure upon tli'- |K'riiu'iini, Should there lie evidenee ol aaaVvnA
of ihi* region, hot fomcnnitinn* may bo applied. *>»ro being;
taken find to anoint the parts with curboliaod vaseline, ao aa
['■ prevent burning.

\ (In* moment of delivery of the In a<l upprouelwM 'In
pliv-u'uiN -Imidd »lip hi*» left hand over the patient'* abdo-
men ami balwfon hor thighs, so as to place his linger* on the
oooipal :i- ii amorge* boTow the pubic nrch (Fig. <>'•). My
exerting prenaurt with this hand too eorlv extension ■-! ifao
bead can b« pravrnlad, and any of the toll structurca "i the

fiiiii<- argnicnl of the pelvic floor, which nmy be caught in
runt of the oeripnl, CBjn be pushed back in thn inlervaly

bctwaao tin- pnina aiKl h«ld not »f the mud, wi »« to permit

u imiK- . -ei|M> under the aroh of tho pubaa,

The finger* of the right hand ore held on the lower Hah of
tie- vulva, and the thumb on the upper, while the palm oovenj

Um paifntuitt,

Av too occiput ewi»p«N uoder the pnbic aroh preetiir* l«

r. P./.in.vr Of THK HXVOSD STAVE Of ' \JtOM 139

tn.nlr wild ih< fingi i- :iu<l lliuiuli of Um light Ii;ui<1, 10 H to

Muh tlic baud forward>ind ul tl«' buui momcul the lefl band

lirmly gnuma ii io ordei i" i lente the rapidity of iti c cue

then ill-- nghl hand I« free la pravari tho pennctun ilipping
loo rapidly ovw the Re i

A* fli«he»dMcapci from the vulfft it i- well in liuw tin- unr c

rXt<lnl (lie liinlp*nf the patient m>iih-u lt:it. « huh UioMliHIil

reaulti in a certain degree of relaxation of the perineum,

Km, to

\

ri .!.-. i f , ■<!■ ftiM.i ..I -I. .iv •) drlnl Iixil Imru

Willi the hand* placed an directed above toeontfol iii<- <!•■-
livirv of i In* head, iln- alien -> ■• • ■ ■ «-t' iln- limbo taterferei in do
way wiili lh« physician's work.

During the moment of delivery the arMMthedo HhanM !»•
pnehed -<» .-i- i<» indnee Horefcal anawtfieelei En ordei to prei am

(nv nil. \|» . fad movt'iiH'lit ol' thr limtlirr :nnl ;il-i In -pure licr

■gonuriag pain.

II aving delivered the head, the ph\ -it-ian mnv lion quickly
clean u bn b indu in iln< ;intiM'|iiic hhhIwio wfor* itrocwdjng !•»

1?

" : r . ?•

ot
fil

at

as

- t£=£ff£ -T -li

l.v

i.;..

Mil
iJ-
til.
lilt

|MH

llli

In: :

■•

III.-'

iin 1 1

'I

ami
ami

.\

11 IV

.\
shin
eye:

V
in \

in i
tii.-

NAyAOBUKNT OF TBB rmi;!> wi-.r OF ' tBQB III

MANAGEMENT OF THE THIRD STAGE OF LABOR.
In order to immro Ann »nd continuous uterine QQPJfaCtloPi

either the moan or tin- phv<iciun should lake chance of the

I'immIiI' l"r <<iii t'lii- nmm.nl |||. iirni i- dcli\vrri| till ll|>- hinder

ii.i ■■ Iti-m :i|i|ilird. simuld tin- Dtonu beoonoe rotated ■ few
circular movomenti of the band ovm the fundua irffl tiimu-
lata contraction ami preveol beioorrbag

A ntorlllaod bed pan or fOUp plate MJ DOT bo pbfteod under

the bottooltM -" u (■■ notch enj MihhI thai mat osoam Iron the

Vagina iltld U» !<i tircnr the alter-ln'rlll.

Laceration* . While wniting for the placenta to I* fl\ Ilvered

many ]iliv-i«'ian- place tin 1 mir-.' in ohorp of ll"' 1'iitidiin while
liny Hlili/r ihi- tiiiii' (0 i'Xiiiiumc the vulva ;ui<l jHTiiuuia fi)t
the prOWIHNI of laeeratioti*.

Slt.HiM Ihc I:irenilit>n« not In i\tiii-h.. tlicv muv he im-

ninlinN ly wtand according to tin directum* given in the

'/'m <>tmm»t of A-'- • •■''■■»■ The aturra ihonld not bo lied

Mlltil tin- placenta hll-* I II CA|M-lliil ; I Mil I Ni'ii i-inls DM} I''

caught in a pair oi" nrteiv-lnrcep* meanwhile. The ndvan*

tun of poaeliig the mtura tf tin- done ■« thai the patient lg
—i *il pai'imliv under the hfloevoc of Ebo anflcrthetlc noil the
operation anneal no pain.

Should the. fi/'iriulit unl httVt OWWI mtflltd in ball 00 WHIf

after the birth of the cliild, preparation* *h<>uld !h« maud to
deliver it \\y Credo's mothod of oxproasion.

The patients I Irene ere drawn up till hoi Itei reel on the

hed Jihi-ln-c Q pomiblU to 1 lie buttocks, her knee- Ix'ili'/ \Mili I y

ienarateo> 'I'll'' shoot covering her w Iben arranged io ;.- Us
expoee "nly tin 1 vulva. The phyaituan should loon aterilito
hit hand-, for in aura where too placenta h round tirmlr
attached t" the uterine wall, in whole «>r in pan, it i-
ilc-inilih' that ilie hand be ready f.>r immediate entrance into
the ateru*
With hie left hand placed upon tin- fondneoo UlOl the

tin_''T- nre behind and I hi- thniiih ID front of it. ind Ow Ullinib

and forefinger of the right hand gnapbkj tUv oord jnel a ItSiln

the vulva, the phj -i-i.ni. iftei knoonfng the utenu toeecuro
good, linn cootracdon, nakoi ati i:. *wn>h prc—un- duw»-

WOnlintli .1 tin jh-lvii inlet, Ot the HDMS ttlDC BqUCtJ

ML'

nu; MtyjoHMKyr of - 1

lug tbe organ firmly. When the placenta 1> firh do detach III
gentle trnetioi ly be muilc upon i]i>- ■ I ■ la guide ii

OUl of the Vilgini).

Should the Aral attempt fail, m is repeated with each i
-ivr eontnctJoo until the after-birtfc i- i (pelled
Should the membranen be caught, they may lie craapt

the lin->f- nf die rt^rlil Ii:iimI :iik! gentle t ruction tnauV upwiirvl

toward Iho pubw and parallel with the vulva, In order to
Bopunta them.

Tha utirxu In now given charge of llic fiiinln- uliilc the
physician carefully examines the placenta and membrane* in a
pmd light in order to u*mre himself tlmt «•■ frnfftni
Imth left behind, Having ptuieficd hininelf on thia point) he

may now dike charge of the fundu- while the nurse |
reedr io w;i-li tlie vnlvu ami remove nil Milled linen from the

bed.

Retraction of the nteraa- Should the fundus not rcTrnrt
firmly nftcr delivery of the placenta, it drachm tlaae of the*
fluid extract of ergot should be administered to the patient,
In itll ctaaj the fundua »hoidd be gently kneaded for mil n
boumfter thfl delivery of the placenta. When i" >t notion i«
onfoplate the abdominal hinder inn\ he put on, :i trmh pad
applied to the vulva, and tlie patient made romfortabliL

The phymoian, before pmewd ng i<> wnnh up and colled bia
iiiKlnuut r.i-, etc., "honlil earefully examine tho infant for ihe
ponaibla fJEiatenou of developmental nuoumlicH, and to aaoi
lain ili.ii no injtiriea have been received in tliecoiirM m i!<
livery.

For farther dirtctitmii tu to the rare of the newborn the
router u r ef erre d to the oompend of thin tjerit - on ' /""Wmi'j

Final measures : Before leaving the patient ili<< pbvei

thould iBODra himeclf w to (hi udition of the fnnuna, the

I.H'hin, and the pulae. The nuraeahonld la* given full in-trur-
tiooi "ith reference to the care of the tn oilier and the 1 hild.
Ii i- veil to leave the nur=pe one or two hiiH'-dmchni doses of
ergot !'• be administered should the fuudiit t\u*\\ an\ tendem ■
to rfiloj . I"' tn II stao l»e left a prescription for relieving the
after- pain* »hohld they praVOOl DM patient i>-lhig.

nil rt r.r.rin I '. sTJkTk THE > Mill's

PUERPERAL STATE.

Tlm puorperiil p«nod, orpuorpenurn. li >gfnaal the termination
of labor; and aonoliNiea when Involution ami raganenuion »\'
the genital nr^nn- aiwoomfHatm.

Tlli« MflOfl VtJffoO in mtli v iitital r;i«-, l>ul ;i\ i-iiuj* ■ >boUt
six ffMKSi

The phyirioloffical plwnoraonn of tin- nicrpvnua aiOJI the
involution of the ntemo and vaginu; ■' U ration of the
dcoidui iifid the tv^'neruti'iii of tbc cndonurfriiuii . netoOBnilo

••Imiij^ir* III the uterine I ignnieiit*, helvie pcritonetUIl) OCllulaf
tuwao, lvin|.li!itio<, liloodvcmcU, and DCTVea ; Blttfatiocu in the

Mtn-1 iih'l <■ r. uLitory iy intra; ehaiijcc* hi bodj -weight, trm-

p nature, and -k li. u wtH u In tin.- urlnan ami tilimcni^ry

. irni-: and fjiinll v il .lulili-linirhi of laetarioo.

Tin- twooppoaod prooai r. ofdsoaji and Nyanaralfoo ooour.

>iiinilliini'int-ly ffllh fffftal nijmlily hi the piiei-peruim. ThfiN

nmomwi, woiiJi involve H'luih' nateum »»<! organsi take place

in the iiiilunil healthy woman without (fleeting bet ubjcol •
condition.

The puerperal state, though it ia physiological, burden mi
oloaely on ibe paUiotogical that ooodinona of diwasc may very

n-iulily nri -■.

Hence during Alio period Um ""tiinn is ao lie**! "itli iKfli-
cultic- ,in<l danger* thai iiecideiita and eompIEejiiloiu or*
lik-lv to OOQUf UlllcBi -lie is guarded and eared for frith

knowledge ami skill.

Anatomy of the Parts Immediately After Labor.

The Ut«ruB.
Position: "I'll i - organ lie* io aa ante vert ^ I and .1

utat** \v:lli 11- IuikIii- hi iiiiui wild the ann-rior nlxlorninul
w:ill. fa tfo« i- mindly nit irr.'trular OVOld

Tlii- unpaf uterine segment i- thiel.- walled (I \ inehe*. 3 to I
■ di 1 .mil i" pOJO pink in OUiOf 00 section,

The low«r utertnw segment i* rapurnled from the npper by

well-marked line. It* walk bdog nmoli thinner, an- tlimwi
into ful.J- U the w.icht of the Dpp DCnt

144 THE PVERPERAL STATE.

The cervix can roughly be made out, its wails being
rather thicker than the lower segment. The lips are usually
everted, resting on the posterior vaginal wall, and are flattened
by the weight of the uterus.

The lower segment and cervix are much congested, and
thus contrast with the bloodless body of the uterus.

The placental site, which measures roughly 4 by 3 inches,
has a ragged surface, and is somewhat elevated. It shows the
openings of the sinuses filled with clots. The area of the at-
tachment of the membranes is neJer in color and smoother than
the placental site. Shreds ofdecidua are scattered over the
surface.

The cavity of the uterus measures 6 to 6£ inches (15 to 16
cm.) in length.

The Vagina.

It retains its usual sha|>c, but is much distended. Its walls
arc thickened and their surface smooth and o'dematous; they
also present more or less evidence of contusion or abrasion.

The Vulva.

The vaginal orifice is stretched and torn toa variable degree.
All the external parts are frctjucnlly somewhat bruised and
lacerated, and may al-o present more or less u'dema.

The pelvic floor is greatly relaxed mill not infrequently torn,
the edges of the wound in this case gaping somewhat.

The Bladder.

This lies in its usual position, and is once more a pelvic
organ.

The Peritoneum and Broad Ligaments.

The peritoneum over the ftw/i/of the uterus is smooth ; but
at the W<* and at I >ouglas's pouch it is thrown into folds. The
broad tiffttmnif* lie folded and to a certain extent compressed
between the Imdy of the uterus ami the pelvic walls. This
compression of the broad ligaments must retard the circula-
tion in the vessels contained in them, and so lessen the en-
gorgement of the uterus.

ryvn i riuy.

II.)

Tlir abdominal walls itro relaxed uml tin- |kin iiMmlly
thrown Into loli)- :inil wrinkle*.

Physiology of the Puerperal Period

Involution.

Tho ut»ra»; [mntodiattly after llu> acpullioo of the placenta
the fundlH of the Merita may be felt abocl hull-way between
the mabnliciu and eIm pubaa . bat in u nhorl time, nan one i"
wis hour*, ii will be (bund to oonapy I position at or iHghll)
above the nmbtHoaa. Tin- dikftrtiaa of till lower atcrttM n
nifiit uml cervix necessary to permit the passagr of the child

rr»ulU in IDOn "i i' -» -Min|.]ri.- !■••« ..| tour, -«■ that the Weight

of iIm- uppoi acgmenl compreMcs than j bat as toai Ii re-
gained there become capable of EAinporttng the Miporimpoeed
wohrhi and the (undas uooormv elovaiod B Hjthtry<

I* n>m thiA lime tin- Nifiii- rliminUhti nnsalv h> riuoj ■« thai
the I'undu- gradually sJakau and ;it the tenth day may be found
;n the level of i in. pelvic brim.

Involution oftht uteroi proocetfe moat mpullv between tin

(bird ninl lit' 1 twelfth ilev oi thepucr|K'ntl penotl, The menu
never quite ratnrnn i<> ii virkfinnl <'<<n>iiii> <n. it- . ,i . .u in the

parotu mmm i>cing about hull' an inch longer than in the
virgin.

Chuncei In the muKleoells : Tbfl firm contraction and
nutation o) ihct uterua, often labor, out offlti blood-ouppli
to it very ceeuhlerable extent, nod thin being deprived of
nonrtohmonf the idowIimwIIh rapidly undergo lettj ilegvnern-

tiuti. \t I he -.'inn rime :i jHtfliun of I he eel I content* Ed 000
verted iiit«» ;i (wpUiiw, irhioh \t> alMorlin) into tin Moot] ;unl
ili»'h:ir^<{| throiieh t lio l.i.lie \ •.

It i- ooobtuy If my colli in destroyed hi tctoj fbr
Sanger 1 ! obotrvntioH prove thai reduction of (hi ub rtu oft r
labor i- effected bi i aimioalron in riw of tb ii"ii'- idual «x?IU
and not by their aeatruotiani

Chang** In to* nterine vewiclo and norrw ; The Uoodvcaoel*,

lviM|ili,itir-. ju)<I nerve* Iwive nil pnrtieipntnl in the crticral

iwth daring pre^nnney. HlfH all take on rrtrotfrnde

■ hangee, The bl (vcawp, which no eloeed by thrumhi, are

g obv

.

, Qmpraw "!. tlin- briDg '■.. nail- ir» sp|Mwiliori. I':i

bn .1 ;■■• lAtoMi i i- • !■•■- mhI unilv I

Of cootl i liaMK iii tin - ■■ . . -- l<

I it.i" iQodb

Uterine maco
ii oil ted) ihc uppc
attached la r Iii- chorion, iintl .■ hind on ihc utcrit* wall

[lie hmti* i-rtlnlat IftVM mi'l lli< •■ I i u-liiLi i pOftlOB.

Dimini-lii'il IiIoim|--u|i|»Is I1..111 in* pine rrtraeffoti .-.1
iv-ull- tn )d« ill' vilnhly 11 I In- loivel portion i-f
ilcciiliKi. fatty '!< _• mj ■ -nititi ami di*inU-|*Tatli>M of the tx-llr.
rapidly . ii-uc mill 1 ht v an < -- 1 - 1 <>(1" in iln tachuil tiwefia
XllW pi'-«v-- -01.11 I.iv- hare tlir ghimlnlnr Ihnit fnnu vi I,

* Th«- iiviim when it i* euM of enrrf-r* with
kt luvu ■■: the tlc-r-uluo, n tiiuR<-

tiiM new in ikhj u« in cm I) rani' original*** Tin- MiiithMiml i»4I
iln> glandular btyrr ru well n- the iuterglamliilar cm nccflvi
ii- - 1 »« • rapidly proliferate and form the new miinmi-j mi 1 ibru h
Tin's poieo-n takes uhotit eight weckn f 1 rompletci
Lochia: The terra /ooAw i< applied to the disclmi idi

OOfRftl from tin? Vftffiiin of (In- jitnrjM'nil woman.

Il 1- composed of Mood, oVe;' tuniti'l rpilhrli:il ivll*-, t|. hi .
of flut-, timeii-, :iinl ijiintitidr- tif I in null"* inirro-nrLiitHNin..
Il bOKln* lifter tlir phiwiiln tin- hern ili-livcnil, ;im! In-i 1 , , 1(

i'ii to (ourUwn cUvhi

It.** charnctnr <h:i ii_'_r«'- :i- tlir piii*r|H*riiiin :i«!v;iih« -. At t » r - - 1
il mainly voiiminU of pure MimmI mixed with i*i r\ icttl miieii
d Hinnl! clot -— Ihr mrhiti rnbrti. In *»

■ti*i -mi

\t\ or

three dm 1 j (

D6Com<Mi pnlnr nml eon-tuts of -••rum mid mnen? lit, (ockfa
tmM, Al-ont the -tixtli duv 't he ic* thinker iiikI fa ohoco-

laltoolorfd ; 'ml n* the hi*"*! «li*;ippt»:ir* mid leu tta ■■■•■■oni.

mnrc abundant, it is white, hnviiifr the iippeimuiee of thin pn
whiuli it practical ty i- — thttochh "'/«;.

Ii .|iii'iiiiy when the patient firvt u^snmts tin* erect [•outline
tie- loohifl an in becomes tinged more or lews with Mood.

h- qaantlty \v:i> fotinrrlv L'i'i:itl\ overt-Miniated Im ( Jammer,
uli 1 nvc it n* fthont lift) Dime**!*. Weocntlv (iile*. from Onr*
ful ruarcment in a fnrjye umuhrr of <-.i-.-. cM-matcd the

1'itnl i[imntit\ :t- iM'iiij- onl; ten :nnl :i Imlf OUROW.

I '"l-'i I peculiar. The loehin rnhni hm* the o*lor of frv«h
blOOd; hilt hiler the imii'its t'mni (In- vnlviir jjIiiiiiU ^tve- it n

pocoliar nnd aom«whtl m-oatnttlnc odor. I'iin*iie:ill\ the

i n i Kt.-l s" /.'. ////■■ I lil.S i/.T M v/'j i;

injn In- ilrfim.l :i- :ui .in. I mlnf win :i flu- dlwIlJlrg* U* tli>nri:il.

Ammoniac* 1 01 alkaline ouoralwaii - thai pulrvfaotive

gvrillh liuvc gaintti jk'.v-- |u llic vajpna.

Vulva and vagina . In priiuinirui tin- Imnui and fburobettc

ure iovarfabl) turn \ lha rwnainc of the forniHr j ■ ' > urauod
the vaginal orifice i" tin 1 form •»!' md&II irreguiarlv nbaped
elevations wltirli an- termed atruncuia myrtifwmtu

Mnrv r\(.-(i-iv« tc;ir- of tin vulva ;m<l perm, urn, if Dot

tutored, bail l»y gnnnlntioa tad okilriaiUon, DGCtudanaJJy

I. BVU1| . .!. ii-i.. -.-an*.

The vagina npidl^beoomoiaainiwr nod narrowei ; iti ■■
from being mootb, gradually bcooou rugated though tbo

i'iijji ,i r r- ntVSf *» marked iij* in the millijuiru. A> the nypon-

II- II | ill nl" ilu- pari- pll""'-. oil', ill'' Vlllv.l ill'l '. i ' > i : III.-'

more ( I in i previoua qqIof ton proportion*

rnvolntioo ttoo takes pin"- En c t ■ • - utortno Ujcumonu, ovation
ami tubes, abdominal walls. :in«l polvlc joints, all cnnluallv
returning more of lew i" Uieir ooiKiilion at before the ooouT"
natch of prceaamrj .

Changca in tha Circulatory System,

puW-raU shortly after labor ("iill* loaboul '•",
or even lowar Tbe qbum of 'lii- Km In Ihc reduction •>* the
general blood*prea»ure due to changci in the oonttitutfon of
the blood and alio to the decreased wtra-aWorainal pn

The blood, probnbljr u the nooll of hemaniiDgedariofl and

nftcr tlic tMnl rinse of labor) bcooniej dcfieJeoi in red w 1

coroiueJei ind Inemoglobin.

Tin- hwrt, which hat become "lightly hvpertropbled >\
pregnancy, quickly reanmei iu Ibrmef condition.

Changes in the Urinary Syswm.

Tbc nrlne i> in*! markedly rfaeed hi quantity, Peptone

and ioaronoftN add to be Normally praaanl Inlno nrina of

puerperal woman. Tin urrano od - ignr U not nnusual,

e*pcclallj when tbcro la dlotendoa of the urca*t& Albumin

iu:n l»- pir^lil fOT » !•"« 'las ■. lait il -. jm-i -i.-h-ii'-i- i- .il»\ :iv ..('

mva import

148 THE PUERPERAL STATE,

The bladder not infrequently becomes overd intended in
puerperal women and micturition impossible. The HMDBBI
of this condition are twofold : First, the Madder is now
subjected to leas pressure than U was, Ix-rmi-r the great I v
distended uterus b;i.s been emptied, in consequence of wliirh
the intra-abdominal pressure is greatly decreased and the
abdominal walls flaccid ; hence the bladder ha-* more room
to distend and less resistance is offered to it. Second, small
fissures about the vulva smart severely when the urine trickle
over them, hence Uie woman is led almost unconM'ii.uslv t<
retain her urine as long as possible.

The Skin.

During the nuerperiuin the sweat-glands become unusually
active. The skin is more moist and not infrequently during
sleep profuse perspiration takes place. This is probably one
of the factors by which the hydremia of pregnancy is cor-
rected.

The Digestive Apparatus.

The power of digestion of solid food is for a time enfeebled.

Thirst is usually present, and is easily accounted for by the
great drain of water from the body by perspiration, the lochia,
the milk, and the urinary secretion.

The bowels are apt to be sluggish, consti}Hition being usu-
ally present, probably caused by the decrease in intra-abdom-
inal pressure, the lax condition of the al>dominal wall, and
the great drain of water from the system referred to above.

Lou in weight takes place rapidly, as elimination exceeds
ingestion during the puerperium. This loss is very marked
in most cases, and has been estimated at from one-twelfth to
one-eighth the body-weight in the first seven days. This
diminution should cease by the tenth day.

Lactation.

By lactation is meant the suckling of the infant. It usu-
ally commences on the third day and lasts for about a year ;

/.UT.m<..v

I IV

■far tli" -v.-nili or eighth month there i« n fulling

nlf in ili>' >|iitiiiv ..I' milk ••'< iv i" I

The mammary glandi nro two lurjro raocmn-.- - 1 ' n- l;i fai

■ •I j .hi- siiiuit»'(l <>i\ die tipper portion of Int chant] ulterior
la th. Dinienln riraotnra "t the thoracic wnlU, They
oootnn t hf ■ ipnofi branded ibovc bj the third rib, and below
by tin- -ixili rlbj on the Inner dda b> tin* «<lgr »f tin*
uornum, knd on du outer by il»- anterior *xillar_>- lino.

Th«J UN <*|.il'l:i-ln- in-rii'in ami btlODf nfJBHltUlIlv to til*
-kin ; a-* iln the -m-al ami whaeeoii* ^laiitK.

Tllev are ijl-.lnilar. ami van in ftttt m ililVctvnl WO n.

At tin* -iiiiimii of ntoh broom m i unatl oonicnl oWvatioa
known ofl t In* uipjilu, wntun i* Burrunndfid bj in •ren of ply
nratotl rJc!ii| tsitnod tlsoa#w&i,in wbton tnori Em number of

lurp- Mihiirtnm* ^lawU — tin gland* •>/ Ifonigomery,

Internally .wli nminmary glawl i- emii|wmo«l of from

fifteen bo twenty-ii'iir lobe*, nmted by a oertnii imounl of

councc'tivc ti»iir Uld fit. Kiuli lobe \* difidod intofonv&v.
ami theso ire farther •nbdivided into it Inn"- (tnml)i'i or
acini or vetfelei in which iIm- null, i- iceKtod
Thti ttedeUt emptj their eonlanbi tote nnuUI dueto: the*

tOI Uff] -lii'T- lYoltl rmilij'llilll* Millie- unite In form a

single lai -* tilA '•'■ ■■■ ■ ■'/--(/.

Of thorn litter there an- fifteen or man la bboIi Itrnast,

r-ii'-li OOnVOyinU tin- milk fnim :i «|:inlc lulu- Id tin- nijipli".
Thi . jHilirliuui lining LOOM 0niiiil» i- euiitiiniuiix with 1 luil uf
tin 1 iiitegfimrrif.

OolMtrum: I'ntil (lie e-tahlinhmenl ..I la<iaiimi the htva^U
'vmt iin iuiIv " mln-lruin," which i- a yellnwi*li fluid reeemb*

liiiL' niilU, lint difluriOa i'lmu il ilinni'-allv. in tlial if I'nnt.iins
Ilium HUgir, fat, ami -alt-. I( liu-. a laxative rflivt mi I hi.*

oliild, tine to tl com of Gun end nib ji oontmim : <'

BoopioaJh/ it ran lw recognised by the laiv«-, -*i-ml1«l i
tniin-'i-ll-, whton in imply isir;.'-' npitbelial eelh rtudded
with &>globoJ«K
Milk i- (he accretion of the buu irj rand Ii i» u

V'll.iHi-li-wliitc fluid of mi ulknline ii-notion hiving D ipeolfto
gravity ff I0W Ko 1094.

OoikI human milk hil iipproxiinntcly the following ibomj

cnl eomnositioa :

Sugar,
ProUtd

Imw.'iii),

IVjrounl.

r.oo

87.30

Till* lilt-, Ml;;.ir, :tnu |iri>t«I<)- rttV |»rotlucv(l tlulil flic -vlU
lining flic acini nf the guUldft; tin- pla-inu ami .-nil- :iir -I"'
rived from l In- blood.

Tin' quality ill' l In* milk i» altered hv vi) tried condition* of

the mother; mental mid pliyMiud aiMtarhoiMwn may on onangn

i In- milk as to render >t uuwlioleaoow.

The quantity of milk secreted vatic- in different women :iml

at ilirt'crent ti s. At lirsl nUiiit lit Ml e.e. i- vied dnilv,

but ifter the tenth day the amount borcowB to froo -halt

tn two litre,

Tin- secretion of milk iihiuiHv bepin- about fortv-vitflit

lioin> after labor, Tin- biva-f- di-tend, '»•< oine . ii ; -.r-' L( i "ith

blood, and ore painful or louder whan touched.

Wlien tin- bread is full it fi hnnl und nodular to the feci,
mid milk imiv be r\|ir(iwd fmm tin* 1 1 1 1 > | ■ 1« - on the alighted

preatafa,

Tin- c»tabli»hinent of lactation rmiv \>c painful, find may
Itlvo tIm- to considerable emotional ulftarbnneo on the purt
of the padent) cawing a -lijrlti elevation of temperature; this
i-., however, rate except in primhpaeat. Then- i- no awh

thing :is the Mi-eulled "milk lever"; If fever occur nf tlii-

Ttmc. ii [■ :i traumatic law, and the retail of Infection only.

The Management of the Puerperium.
The lying-in-room duaild Ih* in the (|uinto-l |inrt nf the house

Ffpoarible, It should be well ventilated, ami Uielighl ihoatd
be *o arronjged MtnoauM no inconvenience to the |«itient.
Ii should !»■ kept thoroughly clean and well dmrtea. The
temperature nf the room olioiiIiJ be muintnincd si between W a
and 70* I' Soiled linen ihould be taken from the room u*
soon Jin powtble after being removed from the patient The

patient'* linen ami druw-sliect should be changed dairy.

f.inr. "i- 1:1:1 \srs si nsrsc 1 n

r :n M'l - uml n-ljitivr- -IidiiIiI imt in permitted to uk tin*

rcHiin ;if ;i geJHnoJ meeiiog-pul Ol

The cue of the genitalia; The vulvar tfoeMUB ibould l»-

ohSDgfd :it l<;t*t every llin- li..ur« ilurim* thv Hr»l t»n.t\

four; uiK'i HmV n- onto us wiled, or three oj four timoj
daily,
when tfwi pad i~ removod the external genital* »1iohM ha

nli';in-,ci i»l" liK'liiil l>\ Illl'llll:- itt' MV:ill> <li|t|M'<l ill M :i(uiiili-il

■olntion of boric acid end aqoeend diy, before 1 froth draav*
iqg u ipplied

After the bed-pas bag beau mod die Itnsai thovnlvi ibould
be gcotlj t en a n ted and n itreaa of vara boric aeld nlntlon
poured over them irom ■ uoucti bag uramall j<i>r. Tin* parti
hlxiiilri thru In* carefully drlixl a 1 1 1 ■ n rtorilu towel or bita of
nnao and :i fnu n re n ame applied.

All nunEpalaiiOM Hhoald be carried <>ut wiili th? «tru't»>»t
oaaptfa DfeoiDtlooa.

Care of Breaoti, Nuning. Eto.

The child ihould be put to th* i>rt*rt for a firw momenti

every *ix hour* until the wcrction of rnilk i«* established.

This niuy Ik? nipplonwtod by on DouaoiouoJ ounce of iwaet*
encd water ibould the infant prove rcrtl

When lactation n oitabluhed the dtikl ihould he auekled
every two hour* from <> \. m. ti» I ■ » r. u. UaaaUrit le
□aoosaurj to gfveona Bunrinff during the night for the tiV

-. The bnportsnoo of regularity in nureiog ibould be
impn-^rJ 11 1 win the niMilicT, far n ithoui regularity 11 UMarcvly

possible for ili't of child to da well. Ovcrfrcqucn< and

irrcgufi stag deranga the Irrfbnt'a dictation and tmratfa

inaltn of the milk.

The nipple* ihould be doomed with d Mturated baric-
acln -ilitiinn, Imtli before ana after luckllng.

In drying the nipplw 01113 atwirtiont cottou or ion goose
hIiouIi! be < , ii(|>Iu_v(><l, :iikI riiiv -IkiiiI.i be taken iwl *<» rub
theoi.

Should tuey become Cwitffl any aoliaaptio emollient may !»■
nppliedi Tho foil, win- natai 1 very astirfaetory oinli

for tlii- purpose :

|f/3

rut: ri l.i.l'KIUL STATE.

U \.-i.|. boric,

Iti-imilli. Milmil.,
Ol, ricini,

V\. wig.
8ig. To be applied after nursing, and covered with :i small

aqunreof whit* mixed |«i|ht.

It may 1>c noecwnrv to use n woll-fiUing (//«** nipjilf-Metd
for :i diarl dme, should the not of duckling give rise !<• Errfta

tinjl ill" tin- lii|i|il> "-.

Hot fofrtjouendy, usually in women with lurgt*, pauduloue
Of-OASte. ooiiiiiloi':itilp di-*onnfort, even iimouuting I" [win,
atlli-i'i'tl wlim tin- |_dnnd* become distended with milk. ! <
tliiijMj raw* a -Mindly fitting lircati^indn will afford Rival r.i..

:iikI comfort Either the Murphy or the Y binder may b«

employed.

Contraindications to suckling . While suckling benefit* the
mother by promoting involution through reflex tiervoui -■•

lion, tod \\\\\\'' then irt OTtitinlv im 1"< m h I <m Kliituhlc fi*P the
iiiiiini ;tw mother 1 !! inilli. there jire Mill evrlimi i-niiditioti*

■fhlon may lender it unwieofnr the patient to rnir«» her fluid.

A l'i>i>hic "Nile uf honlth, tnlnnnln-i-, and pfrHwtent -tlbu-

m'mitri.i nil OOfltnindicate suckling. The same applfei to

riuef in which pyphili* Im* been eon true ted late in jiii/u-uiry,

for ii ii possible die uhild may have escaped infection.

Inversion nf the nipple*, or nevcre nnd pninful fisHUresL

mMtitis, nrdeteetivi.' ^-.i.-t ioi. nil not n- eotitraiiiritentinne of

suckling.

Nourishment: A« the prooets of iliev^tiirn i* nsually im-
paired during ilif lii-i day* of the iiuemenmii. the diet .ii thia
period should oonBJal »-hiefly of fluid*. Milk, clear roup,
gruel, eoeon, week ten, l-i-i-t, stale bund, mid fofl-liuilod < : \
may be permitted. After the third day a gradual return t«>
the 11*011 1 diet tuny be mnde. Mull li<|ilor* And wine- may h*

permitted In -mall quantities If patient* atv nceiniomad t<>

tln-ir ii-.-.

Best* Everything About the pnlieiil Hhonld lie *n diVj I

that ihe nag obtain ibMlute mental nnd phyMml rmt. It U

not MeraMiry, /u-oviifrit utrrhu- n'lnirtiwi In- firm, for the
pntient t" remain constantly on her bnek ; *he rimy gently turn

i mn 01 i ax /:<!.\>!, i i ■ i

over i" one or other Bide *hould -I" o ilc ire kfter tin*

fir-t day -lh- may In ;ili.i\vi.l to riii- .iln-.-i it . lli. BXUlDC

posture Ebi n khorl time, should there In uaion, the ■>-< >■!'

(in- oathotor ilni- l» fag rendered nn --ht. All DIOVC-

ni.-nt - fhftuld !-■ ?l«.\v and •!• liberate, -nddi-n QOUgi od posl-

.111- ilvmji avoided

Aft«r pfttn* [n piimigMueo altai mud di to uterine con
traction an 'Mum wore enough in ilciiiuml relief In

multipene, on the other hand, tln-v vua In- •.. iroubli ■ n

in nraetaue nil poMibilitv «•( rert of deep. llorpMna flivee
relief, but ihoofd be uedwlthom. Doaae of jri &• l,l:,v
be repeated i » often u required. \\ hen n la undemrabla Bo
ii-*- (In. ilnt^, iiiiiiiVlirifi or pbonaootin in ajf. \ doeatj coo
Inncd will i rcilfriiH <-w., gr. ij, may be KiVMI,

Should thr nirniH remain Ux dim Bnft, Involllllon may Ih-
promoted l»j Motion iif tin' filming tea mlnuUv Iwa or ilmt-
lunee daily and a pSU eontaiiiuig i ergoi . p ii i quia, nilpfa .
gr. y; -ini'li tulpfav, gr, |L ; mni '- riven twice "i- thrice in
id.- tw.iirv-ii.iir Iiuum. After the fifth day u Imt vaginal
douclu. tii-lti and morning, may prove of rafue in tint coudi

tl.-ll.

Vults of the jtfiyelcUn : Tin- Bnri ^i>it alto Ubot ihottld \to.
mode within twelve houra, and eAerward one <'f two vbdta
daily, a- tip- m-. ma] require. W bile i Ik- paiunt may be

el lowed "out "i bad ' rKrn once tin- nteru ha bcci • a

pelvic organ, etfll ahe bonJd conalnuo let the phyidolan'e

i k'auon mini fully eonvaJeaoent

lit.' rinr>»- in cbarga uf tho eaaa flhonld Record, morning and
BVenhur. the tBm|M'rulurr, pnl»r, ami n-pirutioii, L- well :i-

evaonatlonfl of the bowcu and bladder, and the condition ol
the loobEe

At earii vi-ii the phyiuoiBn rinould note the record of toe

j :l- ti'in|K>nittin>, ri'Apirutiiiti, eto, 1 1 •- -Inuilil »!••• exam-
ine the condition of 1 1 ** - uteroe, the bladder (bearing ifl
mind lb< danger of distention of t h»* Inttcr:. the hna.i. ami

nipplea, il.. -I.ni, tln> i|igf.*»tivu it 1 1 nml the lochia*

The imwiii having been pretty well cleared al the Dt»
labor, it i i I'lmii that Hpargativc i- required till the third
doy. it ■ ' i i to s^ven doMof mator oUor other laaative

■o'aa to operate on the morning of the third day ; after tfab a

l.Vt

PATHOLOGY •■!■• /'/./■-.. \ WCY.

ilaily movement vhoiihl In- obtained, m.i \ mild laxativu

thouid be rcguliriy ■dnuoUtend if required.

The infturt'a temperature ulioiild be tnken twloi daily until
two day* after the separation of tbe cord, which Luuollj
plnoc in (roiu flvc i" ton dB¥&

ll ahoold be D doe practice to muke n bimanual examina-

tlon -it' tlic |»«-l\i gnns in the third nr (imrtli week of llii

ntiernerium. with the object of <\< termlnrng the prw#nne «<r
ujecDocox iijjtnif- Hi' ill..- vagina ami cervix, the degree of
uterine tovolutloD, and the existence of dtaplaoemenl of Um

ulenih QT oilier tiltiinriiiiil condition*.

PATHOLOGY OF PREGNANCY.

THE DEOIDOA.

Tlie decidual mucous membrane «if the prcKunut nd rn- tnnv
be the H-ut of dit*eu«e f owing to the eiior ua hyiK-rlmphy of

(ha muoou mombnun inoideul to pregnancy. Tlicsc disc m I
eonditiani often niatiifcBt IhcnnvlvcB in exaggerated form* n

ivnii|ini'f«l v% i e 1 > the non -pregnant state. In coiiscquci t

(he relation of the deoidua to the ovum, digenmd eorxllti oil
id' tin- ini'tiibiaiie m:ty have niuiv serious cou*equciicca then
in tin' noa-grav!d state. Most decidual diseases have theli
origin in either acute ur elmmic endometritis.

Acute Decidual Endometritis,

Etiology: Tlii> ii a very rare condition. Ii may retail
iVuin trauma, in MDaeanence of attempts t<« procure abortion ;
or from certain fofectJoua diseases, when oue to trauma the

iii!l:ini!ii:i!iuit [l fteqtH ml J of ■ aeptic Until i« . ami is • harae-
foritvd |»y lltr presence of mi offensive purulent duffihafjpa.
Deohfrdtia acoomjMUiying the development of infection* ill--

enei during pregnancy usually result* in abortion, ilii-
n-Hiilt i* probably due to the hypertrnphied m neons, heouiUM

of if- \ a-niliinlv. bacomfoft the •Ml of an intcn-e inflamma-
tion nod pertiuipating in the eruption which iihuuIIv uOtcta

111- \i\\u Off of •!»' IhmIv in exanlliemaia.

'I'lM- trutmimt in them* caw" coii-Im^ in emit rolline; hemor-

. UliOStr II Esr»jytsTmm !•'•&

rha#-. favoring abortion, and atuiitliiifc t«> conplieBtioM n*

they ari*\

Chronio Decidual Endometritis.

Occurrenca : Chronic inflammation of i In* docldun i> wij

OOimDOni Uld id tbl' <-ni-» <<\' a \a-l majonls >>!' ral'h :»l««r-
rinn-, USttllly 'It*' inilammatinii of tin 1 .luloinririniii aiiti;-
■ I it. - tin- |nvt,'n;iiny.

Two fornw arc commonlv obaervetl] ;i ofaronio <!i[h<!«- rutin
mdritii, di polypoid d generation andi mtarrW rmfoMtii tift,
or li/'irniTh rn /rivi.Iiinuii.

In dlirma «ndometriUii rlir-r<' i- moreOT less Af/perptatSa of

il xmaatfvfl thttiDj raauhing in peal Lfaionaing of ih*-

docldiut

Should tlic diMSMo advance wrth v"' rapWi^yan abortion
will usually mult, cither from hemorrhages into the d n

nu'iiilinuir. llin- WpHmtlOg il fniin tin* BterflM Willi; or from

rlii- death of the embryo owing to crowding of the ovuni by

ill*' nipidlv thiokviiiog dtwtdim, In the latin' cam 1 thr i'tn-

brvO inav bfl ah-'H'hcil. ami tilt* tlcciilna all<iu:ii'l <-a-l "II" US

an .'inpu oM with greatly thiokvned wall-, for <r wlmi i*

koOVU OJ a Jl''.i/iif in')'-

If the inflammation nf tlm OOOMUll lie of :» morn eATONM
cfutrwlrr, th»« pmgnanoy mav pro 'I '■> h-nn. In tin* hi*-"

ill.- parturition i-. likely 1 • • l>»- prolonged bi reoonu of the Un-
due idjUBHOU Of tM iTninl>raii''- . or _'nai dilliciiliy rita\ )>.■

aaoountored la tbe thinl 11(009 fruoi nobeMOo of tin plnocnlB

to t It** til. Tint' wai!

In tli" catarrhal form of Ohronlfl dccidaltui tlierv ii pn QOl
mil unlv 1 |in»lil«»niti»in nf tli- BfiUuloff elemeobl of tin- decMnu,
but nl»> increased secretion — •kydn/rrfottQ gravidarum* In
riiiv li.rni tiin-1- 1 .ik-- pi « , averj few day*, a dUchftfgi from
the uMrui of 1 groatei oi [oat quantit} of » rl<:ir vi-nd
liquid having 1 yollowiidi doge and oonualnlng albumin,
RvdforrhaH mouth mora frequently In andttnsne tlkam in

pi itni|iar.i . riic 1I1 ■■li.u'"t :- 1 t 1 ; 1 ■ U 'mi ■ iii-K ill liir (iri'^iiaiirv.

but u.«n:iiiv Qoenr toward tii" end.

Tin- treatment r.m-i-i- nf kipping tin policnl *« i)ni"I nn

po**il»li<. An Jliuxlyti" may b> atlmini-dr- <l oIb04|M QtVTIM

oontnotionj twoompaatr tbf owapn of fluid, Vaginal douolm

156 PATHOLOGY OF PREGNANCY.

arc likely to clu more liarm than good, and should not be em-
ployed.

Atrophy of the decidaa: Von' often the decidua may fail
to develop as it should during pregnancy, tending to prolapse
of the ovum, and ultimatelv in abortion.

THE FCETAL APPENDAGES.

The Amnion.

The amnion, like serous memliranes, is liable to be the site :
of change- iif j-eeretion ; and of the formation of plastic exu-
dates and Itand.- ui' adliesioii.

Oligohydramnios, or Deficiency of the Amniotic Fluid.

Tin- cause of tin- condition is unknown ; it ig usually
ns-oeiutcd Willi deformities of tue fietus.

Tin- quantity of Html mav Ik* so much In-low normal as
w>ri<ilt-ly to interfere with the growth of the fivtus and thus
%•> caii-e it- premature expulsion.

The condition rannot be recognized 1m- fore labor begins.
J-*il»»r i- ;ipt to !«■ tedious, owing to the absence of the fluid
wedge of the 'vhfltf of waters."

Hydramnios, or Dropsy of the Amnion.

Definition: The conventional limit of the ipinntity of liquor
atiinii i- -riven a* from two t« four pints. Should this be cx-
.-.-.-d.-d the condition of hydramnios exists.

Occurrence: In frequency it is a eom|mrativclv rare con-
dition, if the term be restricted bi eases in which the quantity
of fluid i- -iilrii-ii-iitlv in excels to cause symptoms. It has
U-en stated to occur in about 1 in every 150 to 200 eases; it
oc*'iir- more frequently in multigrnvidie and in twin preg-
nam-ies.

Etiology: T'ntil the origin nf the liquor amnii has been
isfactorily explained the etiology of this eoudilinn must
uain a purely hypothetical problem. It may be due to

//)/.'/: I. if was; or. DB0F81 OF TUB ivv/.-.v.

imeorettc r to deficient aboorotion of the Imuor amnii.

JC BUtboritKl h>>h\ tlml (lii- Bold |fl derived from the
blood-CUrant Of lilt mother 1 1 1 m n v I • 'In- r<|jnri< *n anil i In-

umnion l»y tTi 'ion. Other* consider it i. produced

*-\v\y I • y tlir I'.i'tu*. ciilirr a* an exervtimi from the UdlMj

ami -km "K l»y .i jir.-'t" |»<uli:ir t" the amnion.

Symptoms: Ae u role, brarnmnJoi tlo« not develop befon

l lie fifth ") -.i.\ih nimilli ill* _•( -i:ii mil. tlmuyli i( in:i\ nrcOf si-

aarh :i- the tenth week. Usual!) the tir>i ><i^ii toattracl the
|.i(it n'-- attention h (he undue •nlaryoroenl of thi abdnmeOj
which h UADflUt ->in of proportion t«» the pen led of nreenanoy,

Tbue ;" the -imIi mil the nforui ma* n :*« -I * the ilfophrafrm,

Thi* geea! distention E<*Cfl rfns toepdema "I' the lower limi.-.
|uitni(iiiii>ii hi' tin' heart, nod dyspnoea Locomotion bcoomei
difficult, the Amotion* of ill. liver or kidnej may !>•• inter-
fered uiili, and iotcrue oi albuminuria develop] leep may
»!*> Im» interfered with, ami tin nation! beconea awn inn

.rd.

* >n palpation the uterus is tense, and the fertile, If felt, irfll
be found pntornataraUy mobile; while •>" aneeultatfon the
lu-nrt-Hi.iiini-, may bo feeble or utindlbla

Diagnosis Tike condition la to be dhTorwntfntcd from ta/fn
i ii.-. taoitea, and ovarian ovate, ei follow i

In oWa )>)';;<>'tn,-i, die enlargement uf the abdomen begin*
earlier and nnl abruptly nt ahoul the tilth month ; thv preter-
natural mobility of the fetfua la not | at Twoftutal heart-

aotinda In iHffcreni part*, of the abdomen duq be beard. U

Ml\\ Ik- |ni..iMi< [n |i:il|.:ilr tw.i tii-tal IiraiU and l-uilir-.

In atcitn Che aymptonu of pregnane! are ebeentj bul il Ii
i|i:i!< possible thai both eondltiom ma] be pn *eni In thi nine
cast ( 'ii pi i'ii--I"ii a dull note i- nutaioed in iln flunk-,
while the neutral portion* of the abdomen are tympanitic In
hvdramnioH tin- rmtAapi i- In tln'«*utnil rrviiui of the ibdomen
while the Hank- arc tympanitic) In ■ ■■ change in the

Iiatfeoft pecitfon afton the location of the tympanitic areae.
ii i itceorgank diaeaai of the beari> liver, or kidnere will
Ik- foond *<■ txfart,

Urtirinn ryul j-> {•> In- di-l input* hrd hy th'- hi r ■ « i \ :m«l \>

ical #ifc'n-. . the growth hi more ^;rn»lnr»l and longei En develop-
ment. Menstruation i» generally preaent The flcrid wave h

1.W

r.-triroLOfir of nu:>;\'.\\< i

i <■ pro mood. X"' fatal parti can be palpated, A

bimanual examination will permit the uti-rn- to 1m- dififen ■>

(i:ii«-«l iVmiu tln< tiiiimi*. 'I'li«- mlnrgement "i" ili'- ibd si

net, in- :i rale, u >vinmotrionl a* in hydramnloa.

Prognosis : For ilie mother this ii usually favorable, but
probablv one-fourth »>f the children arc born dead or non-
vi:tl»li'. Tin- ri-k to the moihcr i- incivn*«l b) the tendency

In in:il|t4iHiti )|' lint I'liiM, liv nvtrilo-tcntioii of llie litem*

leading lo ehnngtw in ii- kiruoturc whieh render licnmrrhai

during tad subetrai t in labor more frequent, imd bj the

Increased liability to collapw following the sudden escape of
fluid.

Treatment: The ubdorocu nniy be Kiip|w irk*! liv h prttperly
Biting abdominal binder; the patient **K*mi t<! be kepi al i
w- iniH'li .i- p. -Up!.' When the distention beooraw exti m
nii-l serious symptoms develop then rl»> membranes should l»
ruptured. When tlii-* is done the liquor amnii should be
allowed to escape slowly mid precautions should be taken t<>
avoid syncope. Btryouninc far. ^)and fl. cat, of ergot (sj)
should be administered after the plnecnta hn» Urn delivered, u >
insure pHwl uterine contraction and to avoid (lie risks of poet
part am henorrhage.

Other Affections of the Amnion.

Amniotic bands : Early In embryonal life should them not
l« luffietent Honor nmnii present to M'|urnti< tin jutiuioii
Bom 'lie early formed *kin oi" thv embryo, adlieHionn may
lonn between the -kin and the amnion, A- the amniotic
cavity boontues duftendud the ndhenive rinileriiil bveomee
Ktreti'herli finally forming IhiimIh of greiiler or lew* len^lli
tmil thrakni'M. Xn *uli-iiiiol<iry theory lin- Iimui lulvnnosd lo

explain the pathology of this condition. Kruun repmb the
adliesions as resulting from fold.* nf amnion, inHummation of

tho amnion being impossible, as i« conr.-iin* n.. l<l Ivewele.

TIk* bund* thus formed result in producing prove deform*
ities in the flstaa, such tii*- eventration, nneneojihalus, nmputa-
tiiin of the limbo, eto. The fatal eord rony be iiitiftVmllv
shortened, oi even completely Revered l»_v such amniotic
UiiuU.

BYDATWiFORM i>t:<.KS*;KATi</\ OF OiQIUOX

Prnnuluro rupturo of ta« amnion: Several MUM have been
reported win re I:iti r on m |n. RUMMH the iirniii>ni hM under-

JOW ni|>lmv ami yi'l 1 1 w inlp/nh nl *ln> nviim IlIW Ixeit p|1*-
HTVcd liv tlivehorion, "I'Jn ' amnion in lite- i.M-*-% i- u»nallv

found roiled upon tteelf ud forming " earl "t ooff about im
placenta] end of iln 1 "Til.

Alteration* In the character of the liquor aim nil: The llotior
iiriinii i- ii <■ leu r limpid Hni>i lathe ■-. i r J i. - 1 month* of gMlA-
tiofl . later on it become* thicket and contaJni mel) whitish
flnkca derived from the vrrnl* n-ntKi. In ea«e. of tlmtli of

the fiatui with nmiHTitiion, the fluid bw un aiueh thickened,

of n dirty brownUlj or grea n tah oolar f eJid oooeriooallj emiti a
(fa ud utlor.

The Chorion

Hydxtidiform Dcgonn ration of tho Chorion, or VtnicuUir Moln.

Occurrence: Tin- i* the only di-ran- of tut* membrane
wliirli i- in any til '■■. common,

It 16 cbaraetorixwl hy liyiMTtn>|ihv Ox tin i-liorinnic villi,

.■ml by (heir conversion into py*ln varying in sun from lhal
of ii mi I lot •«'»-»l t.» .i lien** i«jyf. The** cryats are eonneoti d la

each other end t»* toe '»;' r the chorion by pedicle* of

varlnua length- end ire Riled with ■ flntd moch rwmhling

the liquor Limiii l''i'_*. 66).
Pathology: The degeneration of the chorion n-naily begin*

not lridi limn the U-litli "> « . I rUw the whole mrmlinmo

ht Involved and the fata periehcpi In hV I llii arloonitoho
found when the mole Ii expelled. Tl pithelian lining the

i hoi lonlfl villi i» tin- imrt lii ' ntV.-Wrtl, it undergoes n mucked

proHftretloo which abrtendi each vKtm ud inns libo -

iiki l»»lit - :ir«> |innlin'( ii. Orcn>lnnaJly when tlie dittvsc
eomei on bite it but be limited In the placenta, la excep-
tional ioftaneea the growth bmu enomaeh on una olivine wall
1 1 ■• i i-\ i'ii 1 1 rii. 1 1 iii' i In- nerttooonl noverwn
Etiology: Nothing definite w known a* to the oeum of the

ili-i -...- It n..'iir- iim-1 (V. .[iii'inN hetWi Q thoigWof twenty-

ftea end Rxrl • ycana
VeilcuUr mole— eymptonui • Three rymptonu tn available

I'm! ;lir Ji i ; ;-|.i-,- -.1' till- oull.Iitii.ill

VwleuUr uiolv, (Modified from RltMMUl IV—bIituc- Hid U ivngv.)

\i.) \ tudam ""'I rapid inerean in ifn tiu >4 tl« nbdi
m nhidl tin- nil riiic cnlurp"in« til Juts not corn'.- ]>■ -ml tu the
RUppowd period of BOBtAiioha

i-*i I'll'' tnni/«en qftjffiajram //>'• wtyina. Tin- i- the only

pCtllingDOnOIMG -yin|i(nin ,i:icl i* COmpDRllivcU l':irr. Tll<:

: VOMAUKH "/< TUR /7..HAA / i.

Itil

iit.ru- Ugually pri'-iul- a d<itij*liy f*>el and fatal movement.-
:iltil li;il|o!lrlin-lil !l[r:|!i»nil. The .-mudi ion may lie ronloiuidrd
Willi placenta nni'vin mid livilnurmiiiH,

Prognosis: "J'lii- is i;m lv gnva for the mother, Km U gen-
erally fatal for tin* i:hild. The tlmi^er* which threaten the

motun an- bcmorrhiun and septic ini'cciion,

Vesicular mole — treatrasnt: Tin- literal should be emptied
as 4onn H9 n diap[i<xi* it t'H(ubli->li'.-d. The patient mould be

iinie-tthcli/ed, the o* dilated, mid UlC KfOWtG -l"uK r.- v • ■■ f .

the hand onK being lined for this purpose. Should it l» Ira

tKntniblc completely to dear the literal in thi» wny, then the
ilunt curette may l>e emplovcd . hut it mu«t be borne in mind
that tlio uterine wall raay be *o thinnc<l out in area* o» to be

very cully penetrated. This* «huuld be followed by a hot

uterine douche and. IflltcrlnO olfaction full*, the Cftvltt of
tin- Utonih may bu packed with iiMloform or plain tfarfnaad
IMiire.

Anomalies of the Placenta.

I >l' position, size, shape, and weight: Normally tfw poaWoa
of the nlnocnta is near the fundus uteri, but it tuny occupy
idv poMtSon '""i the uterine walls {see Placenta Pram

lu tiV it may vury oonaidcnblyi In condition- of i I it

inflammation ot tin- Bodomatrinm the placenta nu he nb-
nonnaJly thick and BDlaraau in nil direction*, Alraphy of

the decidua or tatefstittal overgrowth followed by retraction
may ennat the placenta t-> !*> nlninrmallj small. In tin* ease
til"- fiatiu will l>c found ill developed.
The following vnrii-iic- n-. io ukatu niaj i»- encountered :

Placenta mem bran ace a : The villi may penrfal 0*at the

riiine wHhoa of the ohortoa and may nil develop oqiutlly.

Oresccntlc, or horseanoa placenta: Tin- i- ;i verv rare form.

Battledore placenta: In tin* form the OOltl i- in -erred at
the narBtn 0» KM pleOfntai 0*va«ionuMy ;tn !iee..'tttii:iiion ol"
iin form is MMfOj in which the verncls (rem thoonrd branch
..lit before reaching (be placenta — fchii ii termed i pefcuovmtou*
iiwrlimi of tin OOrd.

riacentar sticcentarlat* : There may occasionally be found
two or ni"t<- di-Mi-'t m:i--'v- nf plncr-nta! ti.«*uc prodmed h
the growth of raolnteil putchr- of ehorionie villi. The venal

m

PATIWUK. i "1 VliEUS < V« )

of i":n li pitch courac along the membranes to nnib w it» r I ■ . • — • ■

Ediig to lie- cord. In multiple pregnancice each child mav
bvg "n- own placenta,

Diseases of the Placenta.

GalcAi-eons dogonoration of the placenta: l)i<pu-ir>- of li

-.tli- in flu* placrnla are n»i( uncommon, The*e drpoajte onlj
Dcaur u fliM! saod-like particle*, or »■ ncal*« Tun* usually

ihtiiv lit I In *-.|».-, (lioti«rh \h>\ m;iy OC I ni.! ill iQi -ill- |

uf tin* i-iiiyli'.inii* ; inn! points of umnrttlioiii phnapba: i
[toil QBroomtts o) lime mm! iimj»in , «iu. TIh'v uinnot 1»- - i

t(i lllivi' 00) patht'ln^icjll -iL'nili.'Mii.'-

White InfwrctlonB : Yellowish or Krayi-li m.i--<- ..f.|. ■_.,-!,,.,
an '1 pluccntul tissue are to be found in wiirly every plncontA.
When small and few in number thev have no pathologic*]
significance; Inn if extensive, final death rimy reault.

Fatty degeneration of the pit ntn may hi aa (In- n -nit

"»l'-> I'x-.ii olmUnietion of IiIikkI Mimply to (lie jmriv alli-ciod.

Small areas are eomntnnh nh*wrv«l m»mi in Lhe mnrpn nftbo
plooents, If extensive degeneration oceiir* the function of
tLi plaOBnti may b* interfered with ami the foHiifl pariah

Placental Apoplexy.

Definition: This is tin cffunion of Wood either within or In
dm I tin- placenta. II ii lake* place heforc the third month
id. flflftiMti blood may force it* waj between the loose attach
iimni- of ilf drrnlna .'mil rln-n./ii ami tluiji h-Aiilt in abortfa
a very common occurrence.

Jououtiemiti (lamerilMNi throe well-manted fonna of placenta

Bpopll \\ :i- follow*:

(o) Tli'' .'ll'ii-'nui laki- plan- directly into "l" 1 <>r luofo

pi kintal notvleuoiu furiuinj! In n> and then' -mall w»l*i dot-.
(/.) The effusion tcad* to dctfrurtimi ni'pnrimiH nfplaeenta
forming irreffnTar eio itics which are mrnmnded hy infiltrati
iiiifl rwWeneu area*

(,•) Tli<' I'llii-ion may .livopv a i U i r of dourly drlin

irregular cuvicie? at varying aiaea, from millet - I Co

pigeon'a egg, which are not nurrouudcd by areas of infill

pi.AChxrirtx.

i.;::

lion. In tunc tlicw :i[m|>lit«tU' airA* low lli.-ir rnl.ir. btjONN
dniMT, and ram ywldwinli-wlnlr im:i>m».

Ciiuwa I'larcnlal apOpltXV i- ■ !« I> mnni'd l»v dtwawd
> l:il <■- •>! ciihrr tin- miili-rnnl nr llit- fatal hlruciiiri'- •■!*( criiiLr
into tin' formation 01 lM |»I:H'riilii. Mo-I OOOlMOOJV 1 1 ■•■
HUM i- mntrnurl ill origin, a- hrphriti- and ultiiiiiiiniiria,

which prodoM Inonnsed arterial b orion and vooooa oon-

^Mtion, TnniiuatibHi, a*a blow or kh'k npOB tfefl tbdoOMDi
may product l!

i.'n.iv iit. ..ni-< in-, in dimmed Qondittoni of the fatal
vim leading to rupture ] when tin* umbilical vroadi in dia-

MJfd, roptunofom or raoroof their linuieh*«i m:i\ iv-nlt
in fxsiiipu i notion of the fa-tun and its death.

The result* of placental apoplexy depend on the* »tnjro of
gestation at wbloh tlic hemorrhiipi' QOCtJRi, the DUDkbei ■ :

elots formed, ami tin* extant of mnocntn] daMM Involved.

After tin- third month pln^nlnl n|to|uY*v hut rarely remit,
in nborllon or pronuitora labor. If ihr amunon U lannand
the plioanui aitonttd low down, thfl I»1o<k1 may dwwwi it-

way dOWn tO til" 08 Ifld e*:i|M , OonstltOtiOjS arrulrninl himOt-

rhivje. LorgQ • RVistona may re*ull in <l« droving •<■ muoh of
the placenta thai the nourishment of uia fortun Eb iminJred

tii Hiirh an e\t.>nl that, it i» Iforn feeble end puny.

Placental apopUxy — nymptomi : Slight In ■morrnagfl C'vi*

r\*t> tit no BTniptomi ; large hemorrnagea give ri-.- to pain

and tene-Mini-. K the~ «ymptoitn arr prodnei-d, ilit'll tkwth
of the firtiin will pmhiihlv follow

Treacnent oonaiaU in abaolntc rest and reantivca, anon ■■

morphine (jrr. Ji, iidiiiinieterad BVCTJ -ix bourr.

Placentitis.

Thin term i* applied to an Inflammation of the KtbvtonOO

of tin- |>l i>viita. The onadilJnn li nirc.

Pathological changes: 9oiM authorities oODte&d that by
reason of the nnntnmienl ntnidtQN of the plneentii u true in*
Humiliation eanin>t «hviu\ Hut it i- certain that I tnnrked
huprr^nwi of (lie- ionneetive-h*-ilr erll- ehterine< into the

formation of the placenta dona rometlfnci oooni Hil R ■■ a
ohanga mej orfapaaBa En tin- decidua seiotiu:i. tin- placental

164 PATHOLOGY OF PBBGNABCT.

villi or the intervillous spaces. When the deodoa

is affected the result is firm attachment of the placenta to the

uterine wall, the so-called adherent placenta.

In the other two forms the placenta will be found to
tain a number of firm fibrous masses. Occasionally the
tral portions of these masses may undergo a cheesy degenera-
tion which appears very like pus.

Tumors of the Placenta.

Itarely cither cystic or solid tumors of the placenta are met
with.

Syphilis of the Placenta.

The syphilitic placenta is characterized by its thickness
and density, while its general color is paler than normal.
•Scattered over its surface and through its substance are
cherry-like nodules. There are present marked fibroid de-
generation ami great hyjtertrophy of the villi.

The seat and extent of the lesions vary with the manner
and time of the fietal infection. It is only by a miertmeopioai
rramhuUioii that a placenta can safely be pronounced syph-
ilitic.

(Edema of the Placenta.

A serous infiltration of the placenta is often observed with
a dead and macerated foetus. Interference with the foetal
or placental circulation may also produce this condition.

Anomalies of the Umbilical Oord.

Length : The cord may l>c found abnormally long, measuring
as much as seventy inches, or abnormally short, measuring
only two to four inches. Anomalies of iitwtinn of the cord
have already been mentioned.

Ooili : The eord, if it be of unusual length, may be found
encircling the limbs or neck of the child. Tt is most fre-
quently coiled about the neck; in extreme cases as many aa
six or eight coils may be present. In such cases asphyxia is
common.

Knott' When the liquor iintnii i* exoerwivc mid thfl OON

unusually fang it may >"• found to htroooc or two koottj

iMi'rihd \,\ tin* jiawige of the f.etu* through it* loOfM.

Rarefy tin* kbuIu in the uenthof ike faeui*.
Hernia into the cord: A ronjnintatl prttfnMJON of nme of

tlM :tl«lu(ninul \ i-<vr:i into ilic - 1 1< -:i T !• ol lhi> tiliil>tli'-:il OOTO I-
i'rr;i-inii:i)lv IIU'I With, ll i- tlllfl li< llli (rflli i'l « h'vrliijiii nut
of III.' :ilH|.iiniii:i| Willi »t the «<>;i| nf llir |u<riliu.

THE FtETUB.

Anomalies and Monstrosities.

TeratoloRr. whloh ia t * >• * science pertaining "» I'i'ial malfbr-
mationi md rooiwtroeitiee, forms a ^|m-.-i;i1 branch ofpathotug} .
reference to vrhieJ i-r ha bad rJsewherei

Surll liiilH'i||ii:i!Jo||~ .,|' id,- f.rtai :i- illliTli'lV Willi tile
linr'h:ihi»m of labof will lw <liseit>*ed under the heading of
dystocia of fatal causation.

DP3RA8B8 01 THE ions.

Ir i- pmhuMo t li ;< t total mortality rxeeedj* that of any
other period id' Li£ . It i- irapoaribls lo nay esuetly what i»
tin 1 fn-tnl dwtli-nii'-, jw lu'tual -I li li< in< wanting; hut that
it inii-t l»- vi-ry lu'irh the faqtuwH <>f abortion prow
Whitehead hafl stated that t l * * - ratio of uhortionf to prctfnao-
cia li I to 7 ; irhfte Priestly, from a study of the ml cat
ringe-mte in ui well-to-do elaamL considered the ratio of

■ tinil.H l*i |.(. jfi.imu - ;i- (lUitlt I in -I .'..

Bui n fo\i «<t' t in- more imnirm.ni |nitholin.'iml ei.mdiiioni
altwting 1 1 * ■_- IfotiM can Ih referrod hi in I limited work of
this kind.

Idiopathic Diseases.

Those orfgi rati Oft BO fkraeal present known, in the faltM
ItMlf;

0on£«niUl cystic elophaotiuiii : This dlSQmM \i 0A*tfUC*(rfa(

i r,.n 0%'erzrowth of the Bubeutaueoni sonneetive tlefue
.ill gvtr ti»- bonj \i interval! in tho hypertrophStd I

166 PATHOLOGY OF PREGNANCY.

cysts are present, which vary greatly in sue. As
tions of a grave character are usually associated with tins
disease, the subjects of it are usually born prenstorely sad
scarcely ever survive the birth.

Anasarca: General anasarca of the foetus is occestooallj
seen. The condition it usually associated with rinHimtinm of
fluid in the pleural and abdominal cavities. The ■objects of
this disease are usually born prematurely and seldom survive.

Ichthyosis: This disease is observed in two forms, the
grave and the mild.

The grave form is characterized by the existence over tfcsj
whole surface of the liody of hornv epidermic plates separated
from each other by fissures and furrows, and associated with
deformities of the face and extremities which lead to death
of the infant soon after birth.

The mild form is characterize* I hy the presence of a eol-
lodion-likc substance over the whole body of the foetus which
later, by a process of desquamation, forms into flakes. It is
usually associated with ectropion and eclabium. It does not,
as a rule, prove fatal, but may persist more or less throughout
life, or may terminate by complete cure.

With regard to (he etiology but little can be said beyond
asserting tliat heredity is probably the most powerful factor.

Treatment: Warm baths and inunctions with weak inti-
septic ointments promote separation of the scales. Perfect
cleanliness is necessary to prevent infection of the fissures
existing in the skin.

Rachitis: That this disease occasionally occurs during; in-
tra-utcrine life is believed by many. Children have been
horn whose hones were still soft and easily distortable; while
in others, in whom the disease had probably pursued a longer
'■nurse, the bones were thick and hard, and set in the de-
formed sha|M»s they had acquired in utero. The presence of
the disease in the foetus has been held to account for those
rare cases of spontaneous fracture in utero, in which there
has been no history of external violence.

Transmitted Diseases.
Those duo to fliirflfvi in the parental

Thh i> probably tin- roast important if not Ilia moat con
man (Hmom of Intm-aCotfiiM life. Etap linn reported that

h:i ix-r OMlt "t pi' mature mi') RtUlblrtli- have their catix ill

■ypnllfo of om boili parent*.

Iufecllon : The DVUU IMJ )•>■ -U <m ■«■<! 1 1. -lore itnpr» -^u:it J-m.

where the \v»iii:i!i I- i eyphllltie. [nfoetSon may oeeaf ftlonj

with impregnation where the male i- a -\ phililie. The

may hcciine inferled at any period ol ititra-ntrrmr lile,

should tin 1 mother contract uphill* whHe pregnant. When

ill** inieeliuii in diivelly /mlirwif in on^in, (he HVpliilftlC
pol-MHl nmv he <(iiivimmI I'min tilt fcctUI to (he mother ami
*]\p tuny UlUB develop -i-enmlnrv -vni'itoin- of the dn I
with. .iir n prinwirv legion. It i- undntilitrd that many « n

uive birth toeyphHitk offspring without thonwdva ■! any

time manifcttin^ wmptonifl of the dieeOiCi The likelihood

of development of dm Dtaeaao i'« ('»■ fo>ius i*. iindonl.u-dlv
affected l»v i hi- period of time nnoc the ootrubitlon of -\ plii li-
ny either parent, though us yet DO limftof ftfttj hoj boon

d covered. Tnaaataor ha met with a <»» where die <ii
enwe had remained Intent in the ntber for twdi ptftfa. The

mother at not gave evidence of yphitrtfo infed vol

the onli child ricvelopod well-marked ayinptnma a lea weolu

after birth. Untohmsoii hoi reported com to which « n

were Infected near term and gov birth taaypalHHe infant.

MavaiXciUtlons of fteUl syphilis : Tin diMa-e prodnec* a
ereal variety of mfintfo-ttallonx, the Indonn depending npnn

IhfJ tisotU • Ittackinl. Tim* tin -it :in- hidlmix irruptions of the

xkin ; irillamnnihon* Of uuieoii* ami -cniii- tiii'iiilirani -

■bnormol develnpmenl of oonncetto tierae la the liver
kidney h, longa, spleen, eta; end ■ characteristic osteitw and
osteochondritis! In wroe oneei ti"' infanta in bore appar-
ently healthy tad only roaoiftal lymptoins of th« iE eua

within a tVvv trecjQ 01 hirih.

DUgnoHii' should ii» beta be born dead the diftgnoai i a

1W PATBOLOGT OF

be made with certainty by a fr* perfcrtrr icUb awl
detected sign*.

The D«t certain sim »«f f rial ^yphni* ■ Co be
condition of the dividing line between the tfisu fci is i
ys- of the long t»oes — «hi* line instead of
and regular as it is in the healthy infant, will be
jagged. bn«d, and of a yellow col*, due to aa
tia. This is known as U'ogtxr* **/* and is
making an incision over the- trochanter as chough for
of the bead of tbe femur : the end *>f the bone is than
oat after cutting' its ligaments, and a median mtt— of the
epiphysis and diaphysis is made with a strong cartilage fcajjfc

The titer and rptten of a syphilitic infant are always
enlarged as a re»ult of connective-tissue overgrowth. Ft

"ie infant the

more detailed diagnosis of syphilis in the infant the
is referred to other mirks.

The treatment of ftetal syphilis consists in submitting the
mother to a thorough cuarav of antisyphilitic treatment
throughout pregnane v. If a history of syphilis in either
jtarent be obtained, whether oconrring before or subsequent to
conception, the woman should receive thronghont the preg-
nancy antisyphilitic treatment as a prophylactic measure.

Other Infectious Diseases.

A large number of cases have l>cen collected by various
observers which prove the possibility of contagions annates
l>cing transmitted from the mother to the Aetna in utero.
Itarc cases are recorded where children have been born with
tinmiritakahle evidences of variola, scarlatina, measles, ery-
sipelas malaria, and typhoid.

With regard to tabercalosis Hirst states that there is a
remote |>ossibility of the passage of the tubercle bacilli from
mother t(» Actus; but that it must be regarded as a very
exertional occurrence.

Fatal Death.

The dentil of the fictus in utero may be due to many causes.
Among these may l>c mentioned syphilis, acute infectious ilia—

TUR VULVA AMt VAtil.SA.

ic.n

':i«-, ickTu- eruvidnruiDi malnutrition, <■!<•. Ii i- also caused
l»v Iwuttinu nr knotting of tbe oorrt, diwmwH oofidMoni of

lln |ila<vn!.H, at by I iJitimu.

S«qu»l» ; [f Wtb •"■riir lii'lom tin- -*<<-<m<l month the

product of oonosption nay he autSrary ibaorbud. In i\w Inu-r
months of pregnancy (ha fbrtav may undergo nwiTmtiuii,

fMiintiiiitirulinti up fjilrilicatimi, Slunilil nut ri'l'ncf ion of llir

dead fcatui oowTj tin molliei m«v 1m> involved In wpaia. Thu
dead tortus in oaually auri out of lhe ntmM in fl snati UiBt,

though il may he rrl.iin. J l'..r ---tr-

PATHOLOOY OF THE PREONANT WOMAN.

hv lin-

The Vulva and Vagina.

Abnormal conditions- of the vulva or vuginn during Pitgr
itt&ay niv niiieniliy due either lo increased blood-duppty or

to iiiii-it'-n.
Vaiieet: OImIdh'Imhi i<> tin* runoui Saturn offend

Mllarrinff utrni. fomnciilly result* in Mirinwil iMiiiililuiM ■
nliuiil I In* VUlvS Of vagina; bhaM vnric- may Im nijdiiMHJ

by atr&lutng or by* blow or kirk; Mrvsr* hamorrhags may
ooonr and has proved fatal,

Trriitiiuul COOBSDI in prottCliOQ by DMOOJ of '•*■ BlUgtf

fitting T-bamlagPi uud real in In** I wiih the litw alovutcdi

(Edema n..i< QOOUf fa noniml PTtKUSUOy • tnply fmm pf. ■

-in f the uterus. Ii may result from renal iDuiAoJaooy or

Iron labial aba eat

Prurttu* of the vulvu in varying degrees it* not uncommon
during pregnancy. It may be caunrrl by irritating discharge*
"i* mm be i ncufosia

trmeni* ' Icanltneat and tepid Injections ofauoh solu-
tions :i- tha following . borax* 3J '" QS • 1 "'"'- oaAQHOy 1 :'J<ki ;

Inol aoSttti v- W ( >j ; on ointment eom|io«i*ii ill' .IiI.m.iI
liMlnitr, eampbor. ito >-. ung. :n|. i"-;r, ,-,i|, may [mvc relict.

In icvon oaacfl II maj be naoanaiy to sgrolj solutions ol

cocaina, i grains to the ounoa, la order to obtain ana relief!

Vujjiual loitcorrbou may m vary trooblosoma during prasp-

n:m« v In all 0USM whaft tllC ■ li-i:h:it'£i> i- profllM II inODld

be sxatutnen for gonoooooii Simple Ifuoonbass usually yields

•

rATHOVOQl 01 PBSaXAXl I

f.. mild HltuWJltcC :.-triiiL" nl ■ >w bi • iSouM I «c given

With great cure, t,ff, t GhmItV Hold, rj to < »j

Bboold gomconei i" found in flu ragim! i.-.-ltnrge tin*

treatment mould beencrgi \w -, bichloride I iSOOO)orpcfBMM-

SlliQt.- of |»-i i--Mi:n ' ".j t.i < >j) douche* should |> ( . given «»■
inly, and an occasional Bpidicat !•■ (be walls of the vagina

■JMiure&n of* solution ol silver nitrate (gr. x-xi u. will
profaoblj give good rcaultc.

Vegetatioasof too vulva -Jdiii'iiiiH'- reach e»ccssi -hir-

iug prwnauoy. The treatmmt va\i*\>\* in washing with lh|nor
grata * - i » J ( .1-1 1 1 : 1 1 1 « • . afterward ducting with calomel, and i-.' I II
Ilii-ni pi-rtivily dry.

The Uterus.

Tlii- onu dw in Pregnancy be displaced forward, Ixiok-
ivarcL to either wdc, or downward.

Retroversion of the Gravid Uterus.

Carnation : The ditnli men! i* of frequent occurrence and

may have existed before the oiifet »f pregnancy . 01 ii (
ofloMi ii ibo mult of a full of sudden jar.

Anatomical results : At long t- Mm* uterus i- \r-* rhan fi»nr
Inches in length it may !i«' across the axis of the pelvl*. A«
it* bulb aod length tnerca*'*, ii becomes nm In rye for the pel*
vi- If upward imivemi-iil lie |ii-i-\enlcd Ity llic projecting

iimriioittorv incnrcemtiiiii ihtui>, and pri*<»im< ci MiptofDa
M*gin to di-vi'Iop. Ifictrccftllintl ii-u:illv occur- -iliut-i (lie .icI

ill' the (bird "i- ilic l*cgmning nf the fourth mouth. Tin- dla
tended fundus will nn examination lw« found to occupy tho
hollow of the nerum onusuuc :i bulging downward of the pos
terior vagina] will, while the cervix i* prc**cd upward and
forward Kguiotl the pubcn, thin deiulncirtg; the anterior vag-
inal wall - * * t i urethra. The bladder !- thu« displaced upward
Tho DtOTUl msy i' j on ir- normal position bygrowiin- npwttrd

in the direct! 1 IcAat resistance; or it may remain incn

Otratod ind giw rise to serum* trouble.

Symptoms: The earliest nnd most distinctive symptom
dysurfaj ■eoompantcd by scnsni - nf weight and liearini

TNI I i •" s r <>}' RKTHUYk nsm\

171

down |KiinK. if the condition be) overlooked »»r neglected the
bladder lymptoan beoooM rapidly mors marked. Retention
of urine from pressure on tin* urctbrs brines: ;i' I overdis-
tension of tin blnddafj and ■ mora "r to i rent nyetitM
roaltb

Wliilf the urinary FjmptonM arc IIm mo I obaiacteruittc,
the condition ,»l- ■ give* riw t<i rn'uil Tonc.«mu» iind nbstinute
constipation. U^li'inii of tbo vulvi und of the uterine walls

mm) develop from interfcra wftb the | »* - 1 ^ i . - circulation.

Tho abdomen become distended end ranridnn may occur.

DUcnotU: Whore the retroversion In umi i"l i he bladder

moat Ami Im> r.iiin fin.-. it before making i eagtaatl etsmfna*
iidu. The condition Mill then \»- rraJllj aauerjalued.

The history of retention of urine end dribbling i" ;• woman
who has been prennani for three or four unniiii-, the rtmnJ
douchy-feeling mans ooounyrng the vngira. Mid die position
of tin- ecrvui make die ding I- com lusive.

Tin Lilian may be iwndafed \<\ ectopic gestation, *til»>

involution rathe uterus, intrn|M , iif"in , iil lin-inuO"'.'!.'. nirriin
llhrnid, and ovarian cvet i but careful examination, II neesi
»ry, nnilcr nn oneMtnedc, will den up tin dunjnoebi

Truatnisnt of Eetroversion.

In mild c«jm tin- hkddei having been catbt torta ' and die
patient placed in Hie knee-cbw<l position, [in- Dtertu can i»
replaced by pressure upward on ili<« fundus i» dn direction
of one or loe other woro-iliao Joinls, so u i«> avoid die

itromontorv. i«<> fingers being placed hi (he posterior vaginal
limit I'm- iliit purpose. If n e acie m ry 'In- cervix may n1 (Ik
lame daw be drawn down with i tenaculum) if the attempt

HUonecdHi ae ti usually dace, i large Kami should '"' phieed

in dm poet" rior vaginal Comix to n I lin • '" Dteran in position.
Tbie may be replaced later by a lurfl? nerd pcBBarv, If da

attempt nulf the naticnl uiould be \>\ Louder otoerend o.

tcoond « flbrl matte to mpl ice the uterus.

In severe Incarcerated cases there i« OOeasi'iiiiilly urtat dif-
ficulty in emptyinj? the bladder. If, aftor druwinir 3own the.
oorvix with u iciinoulum. tbo i-.itlietoi fn.l- t" paw, then 1)10
btuddvr immsi I..- u-|»irui.'ti U) niprapnbfc pvmotttrc. If eJR

i7a

n motor, i of i*/;/'. vi v< i

attempt* nt reduction fail, then nh..rtmn must lie induced. If
tlir oarvij cannot be rviiehed for this purpoec then the I
wnll inn-. i It.- puuetiuvd ihroiiirh the vn^trutl mull and kJm
liquor amiiii drained away. This nm* innkv it uo**ilde Co
draw down tin- otrvfc, which should thou lie dilated ami the
Dttrui emptied. Vaginal hysterectomy may be ooeeaaarj in

f.nv '-u.-r-. \t lute suppuration or p-tup-eiie of th<* uterioej \\n\\

\i\\* iKvuri'fil.

Prolapse of the Gravid Uterus.

Causation. This condition nun occur in the narlj months
. i |>ivriiiin v i- th« ■*«*« i ■ ] i of nn id* nl »i from i loloni itrfun
iu^ when llii' vaginal walla :uid outlet ;nv unyitly relaxed*

Treatment oonaiMla in the replacement of the prolapsed

organ and the adjustment of a jierfvcty fitting penary to

retail! it,

Endocorvicitis ; Tumors.

EmlocerviclUs: Thin condition in frequently found during
|M<'.'ii:iii('y. Il may be the origin of ji leucorrhiea and ih fre-
quently associated with hyperacBwEfli

li i- Ikmi iraiirfl with application* <>f fairly Mroru; snintioni
of silver nil nit*' (pr. xx lo 3j) I tiroui^li :i n\ liiiclritvl HpeoulutlL

TIi

tion ineu jm

I | five minute'*.

.. ...... HIHWH.^I.O .V .fJJ ...... ..p,» .. -_. — . "|" ....... ■(,

The ipnoulura i* pushed on ;i'_';on-t the cervix and the -In
lion then poured m nod allowed to remain in contact for nt

Uterine flbroirl» and cancer usually onmnlicute tabor more
than |'M fftHUb v , :md will therefore he dealt with under that

lit-ii'l.

Diseases of the Breasts.

Mamiuxry abacess ni;iy 'M-cnr during |ii*epn:ifii'v (see />i#
-if / 'u. rpWtil i'< ilii'l),

Excessive secretion : Occasionally duriiuz the latter pari of

Sregminey the breasts secrete « ».< -iv« | v , ean*iiu: n -erouu
ow which gives rise to considerable inconvenience, Appli-

eiltil.ll-, .if lirllieli'liltll Olll\ lltTnfil I'fiirl",

Eczema of the nipples may require treatment, though (he
Condition i* very obstinate.

VTYAU&M, OP, SALIVATION.

I>IJ*ttASRH HP niK aMMKNTARY OAXAL

IT3

OinKtvltli i* mi implcficont tbQQffh BOOltVOAl infrOQUOnl

■(faction of i In [•fiiMiitnt woman. Tli'^aii'l <ahor coadiuoui

almnt lii \tv iiirnlioricl niv dm-, not ■<• uili'-li in Ti-l.-inl in- - -.

:i- to an albaraliofl In iIh nortdoni >•! tho booed csvita

-r.iiH'iii upon |irt'{;ii:iiii'v. I mm lircomf *ponjQj ami *»tfl,

rud or vinlH. "i COlOf lit tin- iiriiL'in-, :iii<I <><• I ioO I Ij "I. ttfl
linn nci'iir-. Pain on MODfc I'tMil lin-alli, AIM blMning AN
■ \ iNfiloniK of thin rniidiiinn.

/'/. bCdm '"/.• Siiuffiiiii • nnglvlUlf ■ « very oU-tinair and fa
-jiirr of tmitment pcro-l* through pregnane} ""I BVOT beta-
lion. AHtrintfiMiit. locally, and alkaJiai tomo* give flu* tad

retalta S| utl Attention in the way nfolwmHm a regards

Una mouth ami t--'-t It abouM !>»-' owcrvod throughout .

iinnoy.
DenUl carles : Than i« ii oommoo <uymg among women.

•Mnr i rVH] <-liiM ;l (■"•ill," mi tVri|iir|]t i- -hk- oj (tn- tti'lli

during pri'ifiiiiiu'v. -VII di-mal ■*■»-. l t ■ « - - -lnmld Iki naeii tl
oul aim lillr-tl temporarily, an prolonged and |a\toful denial

oprrutiotiH atv in Im 1 avoided miring pKtfpmncy. Syrup of

I In- faolophoaphaui of lima in dowp* of ^j I. i. d. Iulm Imai

l» rniniili llilt'd.

Purotitu, either unilateral or bilateral] i- in [fifnqaent oonv

pllCallOn 01 |M'i'irn:iii«'v.

Ptyalism, or Salivation.

Occurroncc : Tin- lasoot fafrequenl complication of nrvg
imbov, Ii i- generally uaooiated vrirJi extreme iiaueca nnd
vomiting in highly neurotic women. Ii ma) perawl throngh-

niii pregnancy, hogirtning i- l'io'Iv ii<t lie -<• 1 month;

soma cnaas Ion as much w a quart of atlfoaaday. Ptyulin,
noil «ndinm aajti ire dimfni*ned or may bo etnenl from ton
■fiva. Frequently tbeee pAtlentu eotanmln of patn nn wraV
lowing; and ido lubmaiittary and mbltngual glandc become
iwoilen and tender.

Treatment i. meal nnaatlaftotorj In mnel caaaa l optoni
mi in- of tho mouth w i i.l i waafc nlutioai of poiawtiura ohlor-

au-, u-li I'.nk. ' ■hh-Ihmi.i. ere. inns in enrol I. Iii tin . \-

PATHOLOOr 01 /■/./■<. • i •. ■ )

pClieOGO "l" di'" anther. I-kmI incisures afford but little if any
relief The c litioo i» a wurotu and must l« tr ttod M

ueh, Therefore oh In ml nnri **linni bromide in large ii«
rum ba tried t atropine in <!»»*» of gr. ,,',,, 1. 1. "i. mm givi n
li.-f. Wli;i< u'rh (all* to give, tempo run relief i> nxirfiri

jr. M with atropine (jjr. yi*), ''"'**' administered logetlu

fi--- better rc*ult» iIkim uither alone. The latter mu-i do
m- pvill 114 routine Iiviilin-'iil bill «»iiK .mt:i-mmi:iI:v Iq p. rmi*.

real and aleon, while thu putieul ulmnltl aKuy* be kepi in
ignorance of what *hi» i* given in imlrr tJi gimnl njpunel ihr
lorm&tlon <>t* the morphine habit Aniipjrw gr. v f i. i. « I. >
and small doaea of cocaine hydrochlorab pr, ' , t, I, <l.i hatvc
proved natfbJ En ibc bands of ^une piiy-it inn-,

Indigestion ; Constipation ; Diarrhcea.

Indlgcotlon : Gastric iiHiigvttion i« very rommon in tin
• -:m ileal tiioniliN of iiivpmury. If cjircfiil fettling aud the

ordinary reined kw l;iil to give relief, (•Moral, l>r idea, ami

iiihiT nerve Hi>ilntivi« -IhiiiM I., r. nrinl (••. Intestinal in-
digCBtiou may give rise lo severe ii1m1*<mii util pnin> niitl wai
simulate appendicitir- or even pxtrn-iiteniie I 'riot ion. I'll.
aloea et aaafceticlre and careful dieting, ns a rule, jfiva good
n all

(V.imt ,|,.it i>.n i ■ -■ . ■ ■ ■■ |-|. i ' i : in |) I Women :i! :i!l lim. %

Gnrc ihonld be taken to r«-- 1 il:*i*- the ltoweU bv careful diet-
i»K nnil ordering plenty of lluiih.. Where iIiik (uimlHion ia
chronic the mbfot triturate of nloin, liellntlniiim, nimnra, find
strychnine will be found SAlintiu-ton ; active purgation it '«■

)•<■ n voided.

Dmrflid'u :i- :i c.iiipl i<-;it ion u\' prcgnuncy i- nnv ; if |h r-i-i

i-m in -Miii' of ordinary aMringeul ircnlincnt, nerve sedatives
will probably give relief

Vomiting
Vomiting i» one of the eomomneM tliM.nler- of the digestive

kind en Burring in pngMi^ -

II U in.! with in two fonus A •(/;(/»/- i-kimHh'j, whieh i«
pi ■ iologieol ; and peraiVlbm eamiting, which i- piitiiologlctX

n ■/;•./. roi •. VOMITISQ OF m>.\i\> )

170

Rimpl* mnlttaj of pregnancy bft« Ixcn :ihr.nl\ n-trnnl to.
It i" iiKiinllv itnvml during iIim wirliw tnutillt* anil i

l) n»l of llii' tilth month. W lull' <-:tii>ni> ■ ■ ■ :iml i)i>-

comfbrt ii dow do) •< non.h imjwir tin* nutrition of prejj-

IIUlU WOIIK II

Pernicious Vomiting of Pregnancy.

Tlii-. oo the other band, is ji in e i "omfition, vrbich

m ■■ . it i ii -i -i (ti 'iiiiiiciit, |>' (hi ■! i<"|".'vilv.

Symptoms: Tin-. unoontmUablc form of romhiiuj n elj
i" p u abruptly, 1 1»« ■ vomhing: wMdi IabI Rvm mlld.bccomlnj

Ui-.uhi:i:l\ mon MVOTI i « ■ I :» I m i. -i GOIMfaUlt. I'llili

golutel] DOthJlM COO bl retained, uml llw |KiiH'iM iri|in(l\ loMfl

-length. \i lit-! [In f'liitl"' ui'itt < i'iiih-I- tif llnrlv llllu'tt-.

nartleloi of fben, and I « « I • ; latw ami blow! rinim «l mnoiw »■

rjff'twl, QIMl 'If' t I'f fllUIJJ iiMiiiUi- llii Mi -. V4 I. . « | ijj.i-, ; m | :i I.
lopa, BO*] ihor b .--I--. if -I'M In food. \*X\ ...i-in ami

dtarrtia i im- an\ infn qui nl i il 'in- 'to^e. I !»• pnti< di rapidly

■i" '• -:' 1 ', !"■•■ pii iiiiili> <!• pi' --. ii. miii rafferi re

or I--** coMtuDl pain,

If lite condition ii not ivlii-vrtl tin* tuny n>im ■, ii .- uml
(he I'l'itin develop* - ' 1 1 » i ' t ■ « » , dI nuto ntoxieotion. The
temperature nut] range from 101' to 103 P. and c I •« - [rail

tV 1 20 to 140; the eitremii I and ill.

eoohI nod ehuninj : ib»* moatii booea orj and ^ I ■ « |

catnplaina o1 ihii'i i- ililrat j ordc appear on the teeth, tbo
tongue Iwooraa coaled wftb .■ lieavj brown Ihr, and tin*
lif»':iili i- !*\tiv!nrl' afTenalve. Tbo urine beeonu
i _i, colored and offem-iv. .i- .|».n:. -
it contains ■Imirain ind aapta.

I'!in:n -inli'iti ;i»l \ :un-t-- rapidlj :i ti< 1 llir piilttiil'). iitntlil i»«n
mmiii lin-omc- -rriouv ill 1 1n* i\h«inr (i T il;:il - \ ni|ttomt,
Ii;illutiii;ih :i Ifllrinm .m»l Iin-illv DOtQl dflVelfip elioillv

liefWrw death fl«>-«» Ibe scent

The duration of (In nial:nlv i. tWO nr III I** tin, nth-, '"it

I oouretj i- -nltj'ti to iilrriu it-atom i|m caw of whieb ii

bard tocffpbiiiii TTie winpioiii- n.i-. ili-ji|i|H«nr fur «■». nl

:nitl tin- p-L t ■• -ii f give evident'*' *■' in * i «i << \ ■■'#'«■*» i . wln.-ti

Buudvnlv llivj reeui nnlj b Ron with inerea rerity.

I7«

VATJfi.'x.i "/■ /■*;/■-,>. iv»*.

The etiology nt jK-nii<wti- vomiting i> win .•',.
many boton may contribute to the production of tl

llltlOtl tlial JH)*t wllllt in Mil' <:ni-i in :iii\ ijrjtiiilr «
nni-lv !»< stilled, (iilr* Ii:im point»<lmii ilmi pmli.-ili! -,
fjirtoi- VDtel 1 tola tin' nailMltlOII of tin* |ili\ -inlo^iivil Vomiting

of prt't'tmiMn*, namely (1) exalted nerve tension j (2) pcrlplt-
ernf nervous irritation urnting from the onlan^ini; m. m-. ■
.".i mi caay outlet for thin exulted tension, namely, the va

By the exaggeration of tiny one or two of these Qicton
pernicious vniititiny: nmv !»• prndiiefd. Hcuriny llicae llin
Factor* in mind, the prmiipoaiiig eau**a of pcrnioiou vomit*
\itll may Ik- grouped a-, follow- :

Ik) j'l'iitufu.hf. In r>rimi|iara- tin- distention of tie- w I.

is accompliflltcd with increased difficult) mi account of tlic

gmtor tonicity of the ntarfoo namctilav nbiwa.

ih) rrccJiitttiag di»caHC of the tiu*ni>, :i> nii'triti* or vmlo-
iiiririiis, nr diapfaoMnantfl of tlie organ.

(ei Diataae of other \»\\ lc -i nx-iurr*, either profa ■ -i \na or
oovxifttitiK ;iM BalianritiBi ovaritia, *«(<•.

(d) Pathological Btatca of the alimentary emiid, trie

ulcer, dy*pcp*iii, gu-uritiH, ele.

(f) Too frequent -viml intercourse.

(f) Mental or physio*] gbotika.

(y) Twdo oondlUonfl of the bloodj uraemia, wipm-min, oto.

Ii'i-ii-mly I have advanced the view ihnt probably the essen-
tial exciting cause of the iiuii-a mid vomiting of pregnancy
i* flu- li/u/xi'ifiM/i'-'it uterine Doutrnrtiorut. |i i- m id I known
licit i Im- uhTii- I. ■object to rhythmical contraction* through*,
out (In* wlioh* (KTiod of pregnancy. Tin- jHirjHiw of tin
Contractions i« probably tin' ae.-elevaiioii of the > Ji'iilntion ..|
Mood ihrotijjh I lit- uliTiiii' Hinuptr*. Uii' enormous dilatation
of the vein* of the utertn. which i»ccur»n» the n-ult *«T preg-
nancy brings about :• retardation of the Mood llow through

tin in. Ah the iv-iill of contraction of the uterine iiitmeular

fibres thoM RinuOM beooma am piled of Mood and rlum the
nt, in- m:iy I**- Mia to ■nppletncnt the net ion of the heart, lo
which if ni:iv l«' oomuarcJ,aji lu nervous supply i- cry irimU
lnr in arrangement. Tho norve KOpply of the uterus i*- chiefly
Jerived fir the ovarian and hypogastriu plexuses of the

PBRHIC100S VQMITIRQ OF PBEOMAJTCT.

Miiiitjillii'tii' M>l«'in, wliiili I'i u limited r-Atcni (niveau uulc-

pandunl action; while in the madulla than axlaM n oeout

I : 'liiijj nvrr uterine rotil niei ton. The ilevelopnienl 01 Hie

I'liihrvo mill it* onwIoraK, at mi 11 n- tbo hyperplasia id' the

ntertin ami 1!- lining, UW aeenmp:inied by I teniemlniiK ehemi-
eal rhanp". ll 1- reH.t:ni\ Iroin lln< V0DOUI 6UH1NH at the
plooeotd -in: thai the . nil.ryo derive- it- chief iimiri-l 1 Kill
and into whieh it- effatl materia] i* emptied, The ordinary
.Iriiiliiliiui of iln IiKhkI through |} h . .iini*e. t.>;i eertuitl extent

provides for oh&ngB in Lbe rapjpi v . tun nwinjr •«• tin- remm ■ ■
of the blood ourraai fir lilntatioii of toeae sinnpca then

iiiiidt In* u certain rcnidmuii, whieh, ii it heroines flureh
with effete material, probuhly act* n» an irritant and Itloitt-
lute* the litem- !<• OODUVCCRnij cunl tfata to I eertuiii decree
thoorglD may Im- -aid t<< * nipt ;. ilvlf.

It u lin-.' contraction*, hi brought about) which probably

preeipitale the DftTOX y RDM of DAUMfl mid Vomiting. Tho

nausea i- ntoorn oonalanC, Imt i- nanam rhythmical in fa
ooourreno& a- tuu already boon stated ii u uwUbrmoBt
Mven »" the moniiDg urban after a bog fa-t tin- patient ai*-
ninwtbctnsol powtwu. It is probable thai tin occurrence

of the retelling at ibis time h due to tbfl CUgOrgCfflfDl of the
pelvic einnlntii.ii roflfUipiciil on the ehiinye nf p»t-tnre. Thi-
engorgement lend* r«t nxeffrive Uterine eontmetinn, and tine
the peripheral irritation i* inei'ea-ed. It i* eommonlv DOtioad
that it' the patient partake* of food before riving niiuvca mid
vomiliiiK lire 1 1- «r «. likely t<< .-n-ue. Till* 1» dm- DO doubl to

tin- engoramMDl of the pelvic vein* bdng ml need by tlie
deti rmTnanon of \*h»*\ to the rtomanli from the preaooaa of
the bod In thai \ laomi

The r:iti:-e.- mentioned in the foregoing tallica- pndupotfng
to jhi'iim'umi- vomiting pmlmhly :iet l»y iiiere;i-iii'_' the t> riilenev
to cmtnietion <>n the pari of tb# ulentw (|Q0 (koDCUI infer

mnno; twrvnoa «booke and toxw oondibona) ; orbi reno*ei
iog Ulan nii.n* ilillienlt .mil thprvfore inomainc the irritation

th«y eaii-e (priniiparitv ; metritis, jiih! tli-.-a-e of nrig h boiilMj

itruoturN

'Pie prwrnwiK ihoold be gtnuxlcd ID all eiiw*. oji the niortnlity
'ue.' 1 1 'in :'■(» i" 'in per eent. in the |x-riiieiou» fonn.

IJ-Ot.L

Pernicious Vomiting — Treatment.

Dietetic and hygienic: The diet should be light and ostxily
di^vtUible ; before rising in the morning the patient ahould
inkr ii glut* of iced milk or some hot clear coffee <«i wt
i'-u. In mum enact i glass *'t sherry und n dry biscuit ron
i lii- purpose vt v well.

It is a good plan to order oniall qiuuitilic* of plain IihkI nt
tw'.-lioiir interval* during the day, inatead of allowing I be
patient three regular meal*. If the nausea Ik* inmldo-orne
I he i >: ■ r i ■_- i 1 1 -liutihl Ik- kept reclining us much n- pOURJblfe
when the westlier permit «, mil in the ojien air. * !■»>*■, ww
room.* and lighi clntliin.' fdioidd he avoided, mid attention
should be given to ih<» eondition of ihv bowela. When vom-
itin^ occur* only in the morning such menmirpH will en«l»L-
(In- patient to pus* the day in comparative comfort.

\\ hen vomiting takes place *evenil times a Jay. some Hiinjil.
sedative mixture -tlionM In. 1 ordered, Mich as the following .

fy. SimI. bran.,

Ai|. eiuuphone,

r% i.i.d.

gr. x< ;
J*. M.

KRervp-rcnt ln-nnmcatU-iiu 1 in drachm dotes three or four time*
daily often render* good eervice. Iodine or carbolic arid in
minim down, well diluted, may be tried.

Pationtd who do not yield to the above treatment Buonld l><*
Confined !<■ bod. A thorough examination should he made to
oaoarfntn if any of the pathological conditions above cntiBM r
atari :i- nrodlapoaing to hyperemesis gravidarum are present,
and if so appropriate treatmeiii should lie inaugurau-d.

Where nothing can Ik* discovered to accuimt (or I he eon-
dition beyond pregnancy, the stomach should Ik- given n
rest and rectal alimentation reported to. Prwllgcated millt
and eggs, nutrient broths, and beef ppptonnids may Im» ml-
mlnlatcred |mt rcotuni every *ix hours,

The rectum should be washed out at least twice daily, and
Immediately afterward n pint of norma! saline solution hImhiM
In- Introduced bjf means of a catheter attached 1o the nnxslc
fif the -ynnp', high up into the bowel, in order to relieve the

A

(■•,,••1.1

irri Ui'\

170

k"Mji!M« tl»ir-l which U n-ii:illy pre-eiif in lln-«- .•»- i -
Tlic niMii. nr •■rwMimr.i • limiM l« jjivcn wry -lowly, anil should
ii.-v.-r consist of QKHfJ than live »r *ix ounws. Twice doily
mi CM «<pu:iiiii ui» ahloml hyilnuc. [gr, xxluii'l tod. brum.

(jrr. xl) in U <Ht i milk should be jivco< * bid pooka to

ill'- [titic »ir tin- nnplkntioil of » *[>niy of tthef [n tfic region
of the fourth or ritth dorwl vertebra may pTOi a of benefit

Needy every druf in the pbarmawponi hoi boon recom-
mended a* a specific in tliii oooditloa. The following have
I n employed wiih uauoM by iiiunv : antipyrin, $r. v, t. i. d. ;

triiin:tl, tfr. \v. It. i. •!. ; ck-uiii, j;**. [ liutnlv till tivr tioODO linvi'

havii taken; to, byurooymiib}. nil., hvfl In carbonated water

:il'h r IDOa; Alld viii. ip.-ivu*. m liulf~liiniil:i ; • \ | rv lmur

for seven) « 1 « > »»« •»_ Tbe simuoatlon of i pet cent. mJuuou of
oocains <<> the corvix hei been rvoumniendeu very higbly, Tim
epplioatiou of eolutEoni of nitrate of suveTi *rr. xv-\l to the
Donoe, after tbe manner rooommauded io the tnalment of
enaoocrvuntSi . hoi many ndvoenb •
* lopenun fir«t recommended digital dilatation of the cervix

in tlic treatment ofthll eondition. i V-rvicol dilatation i* MOW
conveniently done by meane of instrument*, either llt-var'- Of
*;.m"|.||'., but cure* matt bo taken nol i-> rupture the mem-
brane*. Thi* treatment i* unerrtnin, ami hi therefore not to bo

r HIIHHInlr.l.

In rim- i'iH- if i i . ■■ ■ .i ■ !o Induce abortion r»ln t<»

iwvo ihr |miti mi'- life. It i» a difficult q n ea tf on to deride [nee
when one toJnotlAed In terminating the pregnancy, [fractal

:tlimrii(:illou I* ill- :ifVf :i tnir trill I llinl I lie pain ill i- .ili-.iliil.'ly

unable i" reUun anytuina; uo the rfiHoaoo; if tin- pales

in 120 and prwtratiou lawomw mafked, thru Umj noner the

ulanm i« emptied tin' better.

Tbmpiooedare should never b adopted trtthout theenp<
port of a competent oonvuUant

Icterus.

Jaundlco i- ••ei-ifiHimlly mm-1 vmiIi mi |KVirii:in<'V . It iu:i\

reaull from netrD-Inteattnal ratarrii, from pnoaphorni i

i:i" or from iili-triirlinil i>l tlM ImIimIih-! i)iii- In llir OfC i
M .in tivrnlUtrmh'il uti'i'iis. The di-vcl(i|mieiit of g&ll^tOM

LBO

I'ATIIo&X.Y "F /'!;/■■'. v.| v. )

in pregnancy i> <>f somewhat ftoquenl occurrence. A severe
form, uterus QfQvU gravidarum, is of vcr\ pare ooourronoQi It
i> nearly always fatal, and i- due to an aoulu decern ration of
the, whole hepetio structure. Acute defeneration nf iL. li
and icterus arc not infrequent in eclamptic wiw -.

Irlcnix cudauircrs in Ji hi^h 'Iffi'i.' tin' life of tin f«i In-, b«

bringing no abortion <>r hv the injurious action of the. Mui
aI(r< Nni infrequently Llw liquor uuiuiiund fivtusnn
l>v the coloring matter of tin- hil<.

Treatment; In mil. I nws, warm alkaline hath- and cole
■MOOiatcd With mild ptnyativ** wat.-r ,nv imli.'AtwI. It) \>i\
gevera cusc* the induction of abortion should be considered
especially if the fcotus is viable.

Hemorrhoids.

Tin' pelvic congestion of prepimnev and the pressure of the
gravid i mm* predispose t<> tin- iruiihle^imc iifTcetioBi

Treatment ceil only lie palliative. l,ux:itivr-, iv-t in L.|,
mid the frequent assumption of the kncc-ehesl posture will
afford relief I,.»ca1ly, ung. gnlhr cum npin, or hoi sugar of
[ttd lotion*, may 1m- serviceable. Suppositories containing
onlura (gr. £) and rxt. hamamolidis (gr.jj may In* omployca
il tin- pain h Mvert,

D1BBA8EH OF THE I imnaky systkm.

The Bladder.

Irritability of the bladder is a frequent funetinnal disorder
of pivgnmicy. Ii i- generally relieved by the rutminHtratioi
uf nlkaliiir Mtlniivi' mixtures.

Hematuria mav i»nii' during pregnancy, and is generally
MBOoioted with vesical hemorrhoid*. If severe, the bladder
should bfl washed out daily with n weak eullltinn of mIm
nil nile | jjr. &»-j to sj).

Scanty, high-colonid orine having a high specific gravity,
results from indiscretion in diet, and i* assoeiatod with mart iv-
itv of tin •'kin ami bowels ; th if condition of the urine should

always receive attention. A non-nitrogen on? diet, Isxadv

and copious draught* of water should be ordered,

rtti: Kifsi:\ •■■

181

AlbtimlnurU U found in frOBl S U) *> PW eeiil. ftf pre^iiftul
women, and i* iimihIIy »vmmJh!ihI with ktdne.s -<h:nige. tint' to

|.r. gnu* v, of Dephni

The Kidneys.

KldDty of fftgnanry There Blfetl undoubtedly a chrotno
fonn of ranal dletttBfl which i> depcndcnl 00 pregnancy, and
wbfah, M I ml*-. dOM Dot eiw rfat to RaTtou* diMui'ltuiii'i' "1' Hie

patient'* graeal health. It i> uraeJty aeon-dated who albu-
minuria ami BuheiuV* rapidly alter paiium-ou. It i> imj»or-

i:nii. h ii MedbpoMi i" the development of tlir condition of

eehiiunMii, in -• I'.r i il inirtti i.*- vmi Ii (In* proper fiiiict inii of
lliew iiii|Hiii:cnt exetelfity tHpuiK.

Fi-CQiioncy . A*alremlv Mated, al Imtuiuiiri-i In piv-rnt in I'roln
'i lo ti p0 eeiit. of all OQMtt "I" |MTttOUWJ i DOl il ifl proU-Me
that :i lar liu^r proportion Of O&Wfl MV0 ODDM degree Di renal

in-uiiiiien.y, thougn albumin may not bo pnoenl in the
urine

Pathology: Tb« hi'lney- are u .null-, au-emii-, Blld pTWCDl

evldcnci't of fatty inllltnition of ih<< epithelial ecJle without

iurhiiuiiutorv change*.

Symptoms: The ••.iiiditi.-n \~ in»t iiitVe.-u. ntlv mot with in

primipunr. The lymptoma DtuaUjr tnnnifeel theraetlv-ee iu

•lie Initer half of the pi' L'NiiiM -\ , and itiv generally milch
lleailaehe. pallor. wetikiK"**, and ^iyht -hortneM of bmifb
an- ii-nallv tin- mily mihjefitlVa manifestation.-. The Hrini Ii
lf..eii*d in quantity, i* char, and Its eneeiflc arnvitv i* re-

dneed ; it eontflim from ■ aaertti '" onafinn iu bulk of
oJbnmin, and a few granular coats; the ■Ibnnrifl iv mainly
paraaiobalEo. The area dath rxcntnl i- gem-rail) U-low

the a-.i i;i'.:« tlf health : eiiiriuil) the lower tin- index of II nil

tlie roon marked n- the p:i'ietii'- AjmptOIM. IMn. >

followed bj iiinre-i-., which i* Bnoef auwked from the lM™ to
tie liOh day,

Etiology : The cause of the condition it pfohebii aaimino-
tion of ibe btood-Miuply due in loefwaeed ioUa-abufsniiiaJ

T • 1 1 ■ "i.-ii ; mill |0 i mi.it i..n I *■ ■ ■ i * i I lie i m e-- uf ell elf -|lh*t:uiee-

oontoSned i" 'h< DBterneJ Mood.

Trnatmant i-» ;i» that fur true ni-pliririn.

182

PATHOLOGY OT

Ante and Chronic Nephritis.

These diseases are more prone to occur during pre^nanoy
on account of toe extra amount of work devolving ujkhj the
kidneys at this period.

The symptoms are the same as in cases not complicate*! by
pregnancy.

Differential diagnosis : Ii i- nut always easy to differential
between the kidney of pregnancy and chronic nephritis ;
the following differential signs may prove of aid:

huu*t

Quantity <»f urine.

HjK-pilii' gravity.
Cants.

Ketiniti*.

Qrave symptoms.

kl.iiwj of Prrpumcy.

Chronic

nancy.
Increased.

Kidney* normal before Exitted before
pregnaaoy.

About normal or slightly

lessened.

Few and only with severe

symptoms.

Absent.

Generally appear in later

month* of pregnancy.
Ceases with parturition.

Low,

Numerous and appnai
early id pregnancy.

Very often present.

May be pronounced
in early months.

Persists after partari-
tion.

Prognosis : The possibility of complications renders tho
prognosis for the mother doubtful, while us regards the child
it is decidedly grave on ncconnt of the tendency to the forma-
tion of placcntu! infarctions. Premature interruption of the
pregnancy is also of frequent occurrence.

Treatment : As it is important to know the condition of the
kidneys in pregnancy, frequent examinations of the urine
should lw made. Should evidences of renal insufficiency
present themselves, the patient should at once be pluced upon
n dietetic and hygienic regimen. Meat should be excluded,
ami the diet consist of milk and farinaceous foods; large
draughts of water, prefernblv Poland or lithia water, should
he systematically taken. The patient should be guarded
against fatigue and exposure to cold or dampness. A saline
laxative should be administered two or three times a week.

/>/.s>'|\7'.\ OF T11F RKsrrti iTO/iY sr.STh'N.

SbouM the quantity of the urine excreted net umumt, ami
crdema appear, tlic patient should then be placed on an ex-

alunvclv milk diet imd bo put to bed; » diurutic mixture
should do ordered, snob u ftithw'i mbt ftrri si anmoo.
■ottatia, V. S. I'., in gfledoaea after meaW

If under thi* treatment the aymptolM gmw gradually
Wi»r«c, then the tcnniitatiofl of pregnane} la MOOMBJ^ . u hen

albuminuric reliiiiliv develop*, abOFtloD BDOtM :il ODOS DO m-
dm-ed it tin- palnn)',-, lilV is lODO wived, hoOOQ the tiiiiHirr.Liiee
id' an ophtlmlimmmpir examination in all 088M in wliieli uli-
KcnriU of ViafOO i* h aymptmii.

DISEASES OF the UBFX&&TOB? system.

Cough, with Of without evidence of hrnnehiiil tutnrrh, U a

mtv niiiiniiiii mid ix'ea.M.iiallv tl'i«iMe-«>me urtretinn duriur.
pn^imnev- The n'llrx OOUgn of priynaney mas he \n\
|><i-i.u<iit, ami when the MrOXYtttU in - veiv and DODttODOUl
In it* tmilniruf anti-[ia-nnMlieH ami

ma

ny Had I" IDOrtJoOf

ivualivca are iudkated rmthv than vpeetonuita Bronriue

of ndium mill tr belladonna' in onmltinatiou givegood rOMlli ,

«« do ul«o draohra doera of the KiDOtoi oodeii

DyipncM DOCOjdooaJly occur* m o reflcY. and may OBUN Um

Eitiont eoninderahle <li»trciu. It i* more frequent in the
tcr month* of pret'iumcv, when it i- . ■ ■ i v due to over*

dl i' ntiiiii of the Bodomco ti»'i neohaincn] pressure of the

atonal DpOD the diuphm^in. In the firmer elnat of ea*e»
Milutivf* an- nidn-.iled . while in the latter relief um \- ob-
tained by avoid Ins; tight olothinp. ood having the pftdi -m
■loop with the head and shoulder* elevated.

Pneumonia i- n rtiflUPt miieh loin.- dreaded when complicated
I iv pnyn.iuey, The jR/atpOMM lire alwav- aggravated mid I lie

mortality f«u- both mother and fatoj Fa high.

Phthisis pulmonalis • l'lv^rianev hftl •< OBOel unfavorable In-
fluence on thi* disease. Rarely, patients "iill'eriiit- from pnthr
isi- -»viu to improve during pregnane* ; bw the (Ihajeav only

idvUOB the more rapidly after drluerv ha- OOOttROA

PATUOL'HiY ul VlttoiXASi

Women already affected anil pre* li-ponl (*■ tube]
-liotilil Im 1 ntningly advihrd again*! itmtiinily.

I>I*KA8Ji* OK THE CIRCULATORY SYSTEM.

Cardiac dtMaaoa in pregnancy urc no l rare ; tin- dangn r of
the henrl li'*iuiii« i< nu'i vowed by |irv|[ijiiiivv ; abortion i-. apt
baooonr from tit*- formation of nd'an-iion* in tin- pi.,
tint infrequently the chiUI i« horn badly ihun i.-L. d.

Tbo '•"/iifi/inttt'my to Ik: dreaded lire failure ol' enmpeii-ot ion
due in fatty degeneration ; and pulmonary ooufreatioBa If
OOfOpeDMtitill i« good, mi untoward symptnUH Jin' liL-rly to

develop, beyond milium ami nlbnminnrin, the latter bctfiH
<Iia< in riMial ooninwtiou. IIir~t stole* that will] proper trmt-

inent hi' ha* mi li>ar of h.-.iri dittwe in pregnant f

Treatment: All wutncti suffering From cardiac diseafi*
tliould I*' kept under constant observation tkrougj i til rant*
tkin, The urine ^ImuM !«■ l"i ■•-((null v examined. Slioukl
ryiDptonu of failure of comix-nan! ion arise, digitalis ami

BtrophtntblM mIhiIiIiI In- exhibited, combined with .-Irvcliniin ;
the bowel* -lii.tilil Im- l<r|il npeti, mid re>l. anil modofatA 8X-

cnii-i' ordiTiil,

HirBt atatw that ptTcnaucy hIiouIiI no! be allowed to con-
tinue longer than Um Ibirtv-nixili week in a woraau who i ■
hihiu nnv symptom* of imperfect com |m.-u*« lion. Cardura

di ni ' 'in iml. 1'i.intmiiiilii'ate the employment of nun**tlietl< ■

during labor. Thcac benefit by preventing the iiijurioue rffe
of draining and by quieting the action nf the bean during
parturition.

Functional heart-murmurs in pregnancy : Tn the Inter niontlis
of pregnancy *oft, blowing mnrmurv enn occasionally be lienrd.
IkiiIi over tin* mitral and aortic :u>:i>; these nil- usually sya-
tolfo in rhythm, bat may also be diantolic. They may he
rxj.laim-il In the hydremic, fttittt nf the blood in pregnancy,

ami may in pari be due to I certain amount of displacement
of the organ I'c^idting from overdUitmttoii of the abdomen*
They disappear completely Hhiirlly after lalMir.

The bloodvessels : Vaneo-i conditions of the vein- of the

.*■/./ II •»1;S.

M

p.'lvi-, alxlnniinal wall.-*, :tml lower luiiln- :irv fivc'iicnt iliiri!i|*

pregoancyi They Pwull in pari from change* In the veweu
1 1 1 1 ' 1 1 1 -t* ' 1 \- 1 ■ -* . mill iii |Kiri inmi tin* meahiuiioal nbetruotiuii In
iln i iivulittbiii niVi-nil by ilid inormtiiiUE \>n\U of the uturua,
iWn/Mi-iit ■••tn-.iVi- <-f vluetie rapport Whan Uiifl ia poaBlble,

mi*! in tin' iiv»»i.l;tn.'.' -.1' mnMipatioti.

Enlargement of the thyroid ffltuid ; The fuel ilmt there exiota

a ["-'.'iiliur rv1aii'*n--Iiii- ln'twecn the tliyroM gloml nn«I the
tiirni- :iu'l KtMicrtil I'inMilitlioa b well known. UsittUrj |
"vinp:iilir(!r growth <*f this gland occurs lit 1 1 •*• BUM time US

enlargomonl of the uttrw ; hence Clw fulnciM of the Mok «w

nil. II linhrrtl III |ilr,;u;Ul[ WdlllOl). TllUS ill «illl|l|t' llul 10

ncoplithaiinio gollrv pfMiuney astthi a very unfavorable
influence. Thogrowtn w (bo gland im:iv pmgroaa to web ■
degree as ■•> I'.in-c proMure upon Ihe (notion nmultlng En d) n
no '. wit! even threatening mnlernftl death from asphyxia. In
mra cnaa tnofaootoDij hat bono I moiled i-» in unier t»> <ivn

the pnticnt'* lit*.

NBEA0EB Of THE M5RV0UI BYSTBat

Nuuutljtia tit vuriotiM [uirlimix ul* tin* bouy i* ;i fremifiit af-
fection ul" tho pregnant woman- TImj moBl ooanon ntwtfoni

IN tlic hondj li:inil», boo, UMth, iim! brautft Pelvic DCUIulgbl

i- nmally din '» praoMira '«i' the Bowing ntorui upon tho
pelvic nerve* ; occasionally neuralgia oooon in the atorm

In tin- frnofaltHl of thi-i* ln>iil>l.-*<iin- in>uriil«.'i»?., Um'ws mo-

taining iron, quinine, and BflnnSe ore particularly valuable.
I Mention ibnetid »i« rya be paid i" tho matter of <Iirt, hInd,

ami tho «talc of tin* crmincti"irie* in the**> i-si-^-s Anv »>f the
CMl-tunloriviitivc*. combined with tin* oiiiatr ofoaOotiM t*i
prevent depronion, usually promntlj relieve tlio revere noan.
All source* of lucid irritation onowd U- sought ii>r ami n«-

OMVi'il.

Neuroses.

Ohurca : MiU ^r.ioV- nf rlmira ciiin-n !»■ -..Id to U- Ul

iikmi in pregnancy Chorea ii roor nunon In primipai

VATWH.oar "i- rt:t'<. WtxrY.

RfaeufDAtanij ohloraaiH, heredity, ami the previous occurrence
of ilf dineiwe in childhood arc rmiMilrred a* prcdi-jm-inu
QB1HCU It usually apposr* early in pregnancy Mid i* nj»t lo

persist throughout its course. Ai o rulei in tue milder miw

it d mil manifest it-.If during deep. 1" the grave form

it may result in the patient's death, after causing premature

expulsion of the ovum.

rhc inaiiii' ai i-. tho some na when not complicated by preg-
nancy.

Epilepsy is a rare complication of pregnancy. It dues not,
a* a rule, exert an unfavorable influence opon the cm we of
gestation, mid it can usual Iv be eontrollcd l)y the free admin-
istration of poUwura iodida.

Hysteria is fmpicnt during pregnancy.

Vomiting and coughing occur as neuroses during pregnancy ,
and have already been referred lo.

Pnyohical disturbances: Not uncommonly a complete enanaja
in the disposition Bnd menial character ul' the woman in:<\

occur during pregnancy!

Insomnia may be IroubleMome toward the elowc of pregnancy ■
A warm I with On retiring, a fglnisi of milk, or » cup <>t wnrni

infill, takea at the wins liour, may i><> tuifticicnl to induce

sleep; sulphonnl or trional in 10- to 15 grain doses may bo
resorifil to if roquiredi

much moiv likely to develop during the puerperal period
Melancholia and mania are ttic more ii<uml forme, the former

Insanity U of bul run 1 occurrence during pent a lion, being

<L
ia arc the more usual forme, the Form
lieing more frequent,

Iwsproynoiui in the maniacal form in more grave than in
the inelaneliolie. Insanity may reour in successive prcg-
nnncie*. It may be stated thai gravidity exerts usually an
unfavorable influence npoo insanity,

The. tnatmatl can only i» nxpeolanl and symptomatic ; in-
duction of litlwir. when marked symptoms have developed, only

tend* t«» i^nivati- the condition.

Temporary dsltrluu may occur during labor, and i* fur from
common. A woman rendered delirious from acute suffering
in labor mav do sertcoN injury to be? child, for which she
cannot Ik- held rtspODsIbtt

not* n/siash-s.

DISEASES 01 rilS CUTAKBOTJfl mm

Hnrpnn K«Kl»lumiK i- | DCOalim n./iirotlO -kin n fleet ion usu-
ally met willi in .ark prci'Mmcy. If p'H'.'mllv peraijrt*
uiruuffiioul gfwtutinn in spite of iivmment. Tin- eruption is

muUiiom ( exhibiting nrytae ■ ■■■ and bulls, Its trent-

mont eoneietl in the edmfoietnEtion of nerve eedntivo.*- nml (lie
regulation of the. diet and d o tv f life of the pnticnt.

Impetigo herpetiformis i* rare. It usually ocetii- toward the
dona of pregnancy. It generally locate* ti-.li [n the folds
of the budj around the groin*, the umbilicus and eatlhn, and
undo* tin- iiiniiiiiiir. Ii occur* n -mall pustules forming

.it li-inl- Ul enruul ni|>i<ll\ and ntav eiivrr tin- \vln.l««

body. Ii i* «.'i i . : i.;\ secompanied by marked symptome of
\ ttemw disturbance, hie?b fever, dull-, v*nfnitim& mu\ seven

IirOHlfBtioil. Ilir-I - f : ■ *. • - iliai (if 1 « el\ v i-a-r- [. n Irrmillllted
sially. Tin 1 (lihi'ii-i did nut lerninote g M t ati ofl prior Colba
maternal death.

The '■">t, l „„t I* symptomatic, with the application of - K

ii»K reinedic* lot-nlk.

Prurltoa I* usnally a local affection limited to the vulva :
hut it ma; ocoui ai a general affbotCon. It may cause- intense
Buffi ring to the patient, and oaani haws been reported En which
it w :■ *- neoaavri i" Induce lalmr iftoedei u> irlirvc tin- pMiu-ni.
/<■. "tmnii pnnHiet* En a I La I me bathe (8 ounce* of btennMnate
of sodium '<■ ill., bath), and MedotM with ledalrVe lodona, iw
amphor or ehlorofbrm liniment. I'.-nalU lubt treatment
iniist be combined with the Internal administration <<\ ohlonJ
ami bromide.

ExaRRi'rr.r.i'd piKinmiljittnn : l>arlt nt hiI.s of pigmentation tuny
ij ] *| •*-!» r i«(i thi- lirv»r.|-.. iliiyli-, ami aUlmncii. ami in-.-.i-mnallv

on the face The condition i« not amenable '<• treatment, and
LomaJlj dfaappean shortly utter laltor.

Infectious Diseases,

Certain of the infections dfeeaer* arc more prone toettacfe
the preprnanl woman than nrv <»tUr-r*.

Variolo i- probably the most viratarl of the infection* dh>
<i ittacJdna the nrepnnnt woman. It generally resnlu

ineedilj U3 boai fatal uml nmt.nml ilenth.

188

i'ATii"i,utn of ntEa>A& y.

Scarlatina is apt to be txeeediutfly virulent, but it U more

jM.Hu- io iitun'k ili« puerperal woman.

Measles in the pregnant woman usually assumed o
i\ pe :intl generally lead.- to abortion. The patient exhlbUna
marked tendency to develop pneumnnii as a complication

Typhoid fever due* not, ae * rule, tend to assume 80 ntni-nally
IftVAM iyi«- when it attacks the pregnant woman, 1m pro*
lODgeQ elevation <il' temperature lend* U) bring about aboMJOQa

TOXEMIA— EOLAMPS I A .

Eclampsia is u dimmlcr of pregnancy oharae
vuUion.-*, and tlt'|H , ii(Iiiig' DO

Definition
iwd liy epileptiform oonvulwonN, and de| tending; upon tfai
retention within the body of toxin* Tin- term i.« dcriv**]
from the Greek ixAarnf:^, a .-.hiniuj* forth. The ooovutslvo

sefsurea may oecur during pregrwnry, labor, or the iHierpftaJ

periodj though they art' most frrxpienllv :tH"ociaU'd with lit bur.

Frequency: ll oeruire about once in 30o m«rs of pr» ^imnoi
It is more frequently met with in primipiiru*, especially in
ill,,-, illegitimately pregnant and in tho*** over thirty yeara
of age. In niuItigravidiL- it i« more commonly associated with
multiple pregnancy, and with exposure to tlampnes.* and cold

in «Min,.-ii <it' (lit* |M»urer ehi>se- win* no: undi-rli-d ;uid over-

workc4l. Women who are defloieni in action of the skin, kid-

\u-\ -, and bowel* nru good Hubjtvt-* for ■-••lamp-M-i -hould they

beoonM pregpaot

Eclampsia -Symptoms.

Premonitory symptoms usually manifest tliemselvee aotoi
lime before the eclamptic nunvulakm. These are: !i noiKu-
tiuu of irritability ami heavines-; frontal headache; di--
ordered vision j tod diminished Beoreiion of urine. Oooa-
sionnlty oedema of the face and limbs is present ; and not
iiiiivoneuily ninn 1 or less lovere epiuestriu pain. The genera)
vuwular tenition is usually markedly increased, Rarely
cclampeia ooeara without any premonitorv symptoms,

The urine h diminUhcd in ocautity to from one-half to one>
thini the average in health. The spWjflo ffravUy ifl very hijrh #
from 1030 to {bit | in rure CMM 't may b« lower than nor-
mal. 1010; and the quantity of urine undimini«h"d

t.fl AMl-sj.l

Aihumui in, :ih a rule, prr-vnt in tin. 1 urine- in wry hirer
(jimntili' -, UlOUgh it may in rmv UWM bfl llUwilti Tllfl 'illm-
miDOUfl prceipiliiii- i- OompOSMl of wrmii-allmniin .-mil |oini-
^luhtilin. Tin 1 praUKM <n twee <(ti:uni!i«- "! -iTiiin-jIliitiiiiii
in tli. uriM indicate! wry ext.m-iw damage '" tin find •*.•! U.
in vrhiofa QtM tin? pn>»nn-i- i* rmd. nJ m. -r<- lerioU&i

To dit&inguieh tin- relative amount* of (in.' two kind* of

albumin, tit' urine nm-t !ir>*i 1* ruituniUil with nia^lieVjum

sulphate tonreoipitan the paraglobului. After filtering, tbc
(ilirrtU- may be toted far lerum albumin by the nitric m Id or

bent tcht. The precipitate obtained from tin- tilt rule may
then bo compared with that thrown down by ln.it or nitric
acid in a qwmmwi which ha* not been «aturutud with m
Minn Milpliuic, and the difference Doted.

Una U, iik ii rule, largely dlmnlf&ed, DOt only in quantity,
but alt-o in percentage

' ii ■■' nun <>r rnuy not bl fiMttd m the nnm-.

£cacfH »nd ryrwtn, II nognt for, will aannlly be found i'i

t!n» urine i>f I'cliiinptii *,

The eclamptic fit usually begin* with n filed expTcanon of

tin* evoffj the bead being turned In one aide; the eyelid* twitch
rapidly, the pupil** contract, nnd the cyehnlli roll. The tfm m

of the nuaniCfl Hri'M rpread* rapidly, the mouth la dnwn to
one side, the JaVI i I'-neh, often QMwlU Reran injury to the
tongue, which may be caught between the teeth ; tic- ln-.nl i-.

rolled rapidl) Iron ride to ride and then drawn back ; a* the

nuclei of ( In' trunk :iinl 1 1 1 til ■ > ■•mim' atT'retcd the wlmlr

ImhIv Ii thro* ii Into n e litinn «»f male epaem, A- rMplra-

ttnn 1 1 1 11 f 1-1 1. red witli tin- hoe become* Imd end bloody t*r ■ • * J »
ieg from the month;.

Thi* condition i* rapidly xnm'cdi'd hy :i aerlei ••! clonic
rjEHHvu in wtiten ell the muaclui ere thrown Into vioieni oon
traction** caunne; (pm-i* forcing movofocnm or the limit- and
bcadi In -i'mti' oum the woman nrnj he thrown into :i (• -i

t inn of OptPUhotOOOBi

QmenouiBeai i- lo»t during tha fttttek end the pattern
tumally remain* to i condition of ooroa, bn nthing itertorounrj ,

Offll firm- ifV f

Tin* (ftmnVon of the ii' i- iclc! longer than ' minute^

while the come la*t* n variable tune, from a tew minotei to

190 PATHOLOGY OF PREGSASCY.

several hour*. The paroxy-m* are repealed at varying inter-
vals, in which the patient may regain oonsctousnesA. In noene
ca.*-* the patif-nt remains in a condition of coma, with or with-
out rest leanness. Sometimes resth*s<-Des£ precedes another
paroxy-Qi. An many a* 160 fit? have been counted in one
caae.

Course and Terminations.

Kclampsia ends in r*:ror<vi/ or detith in from thirty-six to
forty-eight hour-.

Death may occur from ■edema of the brain, of the lungs or
of the larynx, asphyxia, exhau-tion, or heart-failure. An
overwhelming accumulation ftf the toxin* in the sy stem may
cau.se the coma to grow decj«er and deeiier, with or without
the cessation of fits. Not infrequently the temperature
steadily rise.-, and the patient dies with hyperpyrexia.

Recovery take- place in about two-thirds of all cases under
proper treatment. The fit:- eea-e, the secretion of the urine
increases, and the coma fades gradually, though mental con-
fusion often persists for some time. The lw»wels and skin
l>ccomc active. In some cages a condition of puerperal in-
sanity may complicate the recovery ; hut when it occurs it
is generally mild and passes off in a few days.

Etiology.

While we do not know the cause of eclampsia, the present
view most generally accepted is that it is the result of a
toxamia, originating in the bodies of the mother and of the
fo'tus. The urine of a healthy individual is highly charged
with toxic materials. I ion chard has isolated from the urine
two substances which produce convulsions, ami one which

1 midlines coma. The urine of the albuminuric jtntient has
M'cn proved to lie much less toxic than in the normal state;
while the urine of the eclamptic is smrcely toxic at all.

In the eclamptic then- is a diminution of the urinary
accretion ; eomhincd with this is an absence of toxicity of the
urine and an arrest of elimination of the toxins. Coinciding
with thcdisap|>c:irauccnf the toxicity of the urine there arc an

arrCHt of elimination of ami all accumulation of toxitlS in the

fATHOLOUtCM . I.V.I rn.M\ Of A. MJftfSM.

Mood. Tim! llm (iixiiim am rrljiinttl in (In- blood hit* Ihnui

Iirovrd Uy »m inanimation of KM blood-eeruin i>I* crlnmiittc*.
t liit'* been foaod ilisii in Iheoe wren iImi tautloU* of the I»i«hk1-
H(*riitii in in Invent proportion i" ti»' Uixfattj of (he uitne«

\- hi the fornutiou of tfuuw toxiiw hut littll i- known. It
in kii|)|h)««*I I iy -iiiiih that they uri^ioaU 1 chiefly trnoi the pres-
ence of the total in Abe iii*ru- ■ bai Uh most geoertJly
»<■» -opted view if that they originate (rum tin* deoooiueeiti on

of r<M>iI within llii' Ixiwcl. Tin- liver jimlmlily iiIhvk mi im-

poctaat |»rt in toe deatroctioa of the tonne, irnUa Cite kid*
nen and *kin ire oharged with their elimuMtiaiL

It is a well -known f.ict that the pregnant woman rarely ex-
erctcs a nonunl nuioiiDt of urvii. urea ii |1h mael powerful
diuretic known, .uul it is [im.IhiMc iluit it- function i* to
^limulnto the kidm-y* In the elimination of the tOXUU.

rii-tire wlvn l he mv.i U dimmi-hi-d tit.- Li.in.v .>••■ <!■•]. ri\ <-,)
of their 6tiraulue to the everetion of these powon*.

Tim effect of the effort* of the liver find the kidney* to

hrvuk uj» »iul •rlmuiiutti lit- toxinx ia in bring uhuut certain

i lm preeenen of

ulhumtti, a* well a* of Ictniu *nd tvrotfn, in tin- urine.

clmiiKt'M in thi'ir -trnrluni which ftlplilD

Pathological Anatomy of Eclampsia.

The kidney*: In Hunt onece mi wlneh iieeropi-ie-t hnve |>erniit-
tcd the etnimnatinn of the kMmv-. tOCM OTginj prvM-uted
maeroiioopic evidence* of either toate m chronic nenhritta.
In »me com* the kidncv* have appeared perfe c tly lu:ilthv.
Bui In all ceeee In which the kfdnej mvi bcvamlenMcopically

i ciiiLinril, rrrlnin obangOl in tin itiVeDm hav t Imth lot I lid

which tie ii'H Ummm of inflammation, l>ni rath t of uWanere-

tlon, and Htf llmilar to fh<M> ehanv;i a ted with IjIimkI-

[»•■!■ CUM';.

Till* >fryrnrr<tli'-», w<iti» In lw nl' a colloid nature, ami i-
n-tiallv niont iniirked ID tin.' rjiitln-liiil oelb of thfl KUDOUM of
llii' cortex. To thr naked eye, kidoeyi whiell DOVC utnliT-
■jDM tliw dMnaeretioo hsvc very nuofa the Rppeennw of
pateoohymatoui nephritir, and it Ei onlj hgf mam of the

uiinrvi^eope that the true character of theobvigi Dm Dl BU

by made out.

192

rtriirn.oi.-r <>f vup.hsasi y

Tim. ill »vl:ilii|i-in I III' I. -ion |>i- m'm) ill the *% ii I H« -

tn'|ihriii>, lint in acuta (Itineration due to loxina in ihe blood.

The liver : Efciuorrlunnv into the eubetam of the liver arv

tin- niD-i marked change to l»' noted ia Timv

(K.-ur h dark-red ittaiufl «»r blntehea, innl may (>•■ rerj c*-

give : or so dipjil .1- only t« Ik* revealed by the micru

Between the nitee of the hemorrhage* tl" liver- >..«

either fatty deevacrution or actual iiccroxi*. Theac clung
OHI only roii 1 1 from -j-vrT.' eoutnmioution of tin blood.

The spleen [in-jiil-, it- ;t rule, d-ry mm-li tin; ■ i-li ml- -

U thofio ftiim<l in the liven

The lungs mi' I brain usually show certain cliaugea, whiah
probably result chiefly from the tmivtiUioaft,

Diagnosis,

I'llamn-iiii hiis t<t U; JUtiiiyuislicl fruin eoovul&iona due kj
epQepVYi byoteria, nod organic brain disease. The distinction
may M nude by an examination of the urine.

Prognosis of Eclampsia.

Maternal mortality i.» admit. '.'At per cent., while the fatal
noortaliCV teaJbnul IK) \><r mil. Tin- earlier in |iii<^naney tho
eohunptio condition noctira (he worse ia (In 1 prognoaia.

Prognosis IB favorable when :

The ultiwL- nre iiifn'i|iienl iitnl mihl ;

Xbo patient rwgaina emwcionanps* between the atfaakfi ;
The nkini bowels, anil kidneys can Imi plimiilated to fulto-

tkmota freely,

PrOgnoail i- unfavorable when:

The ftttnoki become progressively more severe in spite of
treatment ;

The urine is completely lupprewd, ami purgation cannot
be Induoed.

Treatment.

The prophylactic treatment of eclampsia consist* in the

frequem ejuunlnatlon of the urine, wllb apeeial rcpied to the
quantity aeereted| tho percentage of urea and of albumin,

ami 1I1.' (in-.- ;im>I rlumietcr of sediment.

/•/.'': i VMKXT '"■ I cj.a V7VIX

The nowtb ud |£m -Ik.mIi! bfl kept lOtive by the internal
and external B ■ -i Wit r, md mild laxative* aliould bo
OIBploycd ivyiilurlv if mpiirt'd

Tin- pntieol i Id '» ordered n readily oxidized tod uon

GonatfpBttqg ili'-i. Ufl DQtaooi BJMTOUM in moderation, and
diroodra to avoid exposure tn cold and dampncM.

Medical treatment: Should the urcu present in the urine
full tn I." pa ocnt, then tKAtment should be inaugurated, as

I In- Imlinite rrliul ilitlilivjUIUM .

Til*' ntli*y»"" m ''''' *ho»ld It rvduced by jilaciii^ tlir
pAllent OB a dirt Of null.. (Mi. and uhiti* DMAtA. Klimin:ihM!i

of tin toxlnt bj stimulating tlu action oJ lha !><>«< I., skin,

jiml IttdnOYJ i- the object of treatment. Th't- 0bjMtCt3>D4

obUlllfd by the niftdur DSO of 8 pill of idon. and i-nlurMiih.
V. ill bwtlDIO, Worm Imlh- two or ilinT tifin> n utrlt, ami

Er

'Tin' neotftionnl employ i u nl

;unl -ihI.-i, (>r> | . .11 Ih

the frw ontof drinkiiig*wat*r

of ;i daw oonMstiiig on calomel

found to -tii.r.iUi.- iIm- lotion of the liver.

When toil treatment (ail- t<» improve matter-, the pntient
should lie put tt> bed, iuhI the diet United t*> milk i>« fur on
p.. -.. ill- Tlir I'liiniiiitfivi- lieulinrtit already WflSCBtcd DftJ DC
reinforced by Ihc doily Invitee of the colon with nt lenM two
i*:ill«'ii* "(' norma] *olt solution nt a temperature of 1 110° l'\
The pill of aloe* and eoloevnth mny be replaced by Kpvni
or Koehclle wit* in these more serious case*.

The kbfllOffl being already »\ l ruscd. the employment of
viimulnlinn uiurrties hlinuld he nvoided.

Duilng the eclamptic attack the following obkcCM of treat

ni.-uf offim the be* nlnncc of m jm in tin- author'.- Dpi i

DurtOJ ih.- BOnvliUioii mltiiimstrr vldorotbrflDL and ilea uliui-
rvi-r for any reason the patient Ifl («> Ik- disturbed, *h<uih) il In-

found ilnit mefa dioturbaoot tendi to prvcipitaUj ■ nonvnlaiun.

Thai itiji'«-i hvjNMlrrmiiTilly r\\. wralr. viriili- (11) xv' iiinl

give no <ii. him containing; nnlanj nvdrafr ("j in four ouooet
nf wnter)i ami nlnon two oTtojN of orotoji "il on the bank of llti
bonffnc Have the patient? efotuinar entirety removedj tnd
envelop berbodj iobfaukob wrong out of hot wttcr ooverimj

•h. . \,rii even] «lr\ ootsfi Tli'ii injct into tnc ooloo by

men ik of n lotgfl i«d I ltliei.*r nftnehi'd t" » fiuintaiii <ynnsi
wvernl i|iinrt-< of wnnn -nlin lution, Where powilih- ■

n-OM.

f'ATlltji I//.-K 01 . v iv< r

pint or more of sterile aallno solution «hould alao be iuj.
tinder lb« breiiaU-, iwiilj a lutu'i- vxpl -iii*

Sliniilil llu' emivnl-mn- P-riir and flu- putirnl In- :i full

blooded, HtnuiE wimmii, n pirn m more of l»Ii»>«l nay be

JfAWn Dt np#nni^ one or mure nf flm hirjn vein- of UM :ini>.
Tin* veralniiu, in lTJv iltMw, may In- injected :it -hurt mfrr-.
till tlic |xi 1 -«» i- redtioed '»■ 70 |»r niiiint«. The oblofft] enema
shoiild he repeated every I'niir hour*, provided the condition
ofthe nutee U m\t\*fwU>ry, \- *non a« the [mlienl twn rwallow,
dcwertitpooiiful diwee of a concent rated *nluti»u of l'|
nit tu.iv hi- administered every fifteen minud - till the bowel >
an? m:liiiL' freely. The hut pucka should bo renewed *uf-
li.-i. inly ni'tiMi to keep up free diupitorcjliM

The obMtetricRj treatment Wle-n -ln-tild pregnnnpy be t-r-
minuted in those ciise* in whe-li rrlninpMii i* threatened '
W'in'ii, in «pite of active treatment, the paticntfc condition
get-* steadily worse, or when* improvement i.- only tmnclonrf
And ivl:i|»«> occur, tliA only safe conrwt ia lo terminate !)><■

prtcntney.

When erl:uii|>«i:i (K-ciir* during parturition in!erfVr> ■n.--
with the urutfrvw <>f* lidior should he ii voided until I lie cm
in fnirlv well diluted. Accouchement loreft in td he r>u
t|< iiniml, eXCepI in very ran- iu-I.iuci-M. The ooilVlltnOfM rmiat

fir*i bi oomhated, and a- :i rulw lalwr comwon nnoirtancouiK
1 1 may be terminated by forcep* in order to pre v en I ii- und
prolongation, an MHin a* tin* m i« modenitclv diluted, the
patient always being deeply nmesthetizod for this purpose.

The altar-treatment oonaiata in keeping up free action of
the arannetoriea. Daily dose* »t' Kp-mn -alt -Iw.nl.l ho piven.
The patient ahould Ik? enooump-d t«» drink large i|unntiti<>> of
OTeUDB of tartar water, sj to the pint. The diet should he
limited to milk until the kidney condition hut improved.
Me.nrt tmiir* mny lie required, nml none is lietter tlmn Btryob-

iiin.' in full dn--

ABORTION AND PREMATURE LABOR.

Dflflnition : Abortion i- the term used to denote the "xptil-
aion of the ovum up to the end of the third month of prog-

SYMPTOM OF \B0RTTON Ui.'i

nancy, f'.mifitiin hil,<» UffOJffa ihi* birth of a rtobU (h

while flu' tern mitoarriaffi \* usually applied f>» Ihi expoJaton
tjj tbfl ovum bftWfUl I lie fourth mid lutil months of preg-

nniiey. •

Frequency: It iw ilDpOMbti '" BVtlOMtfl eotTOBtfy the fre-
quency of abortion ; but it i* probable that the proportion of
abortions- is about one in every three or four [pi.nimi.ics.

Symptoms.
The cardinal aymptoms of abortion aT*. pota, ft/WOrrJ

tinil the GSpaUoa of ill*- ovum. The pain Ea due Bo uterine

i-nsii ciclmti:- ; anil tlie lu-moi i linc.r PaMlll* from the M'|Htl al [|>n
Of 11)1 0-1 HIM tVnin i!:- DlonDO attarliuiriit-.

Iii «ome CMOS the MtwrrAo^i i- the /">' remnfomj the peJo
folluwiiiir after (In* ovum bai been converted into a foreign
body by the M»hmI uajviu obbpm i eepntvtiou of the uhju*-

hnini't I'm til I in* dcriduu.

In other cases tin- jutinr, /irw,h lh, h< iiw'-hagtl t,y *»'*
instance the abortion mmofe jnolonged, as a ranil of the
slow ^.-jHi ration of the BJflnlbrnni"*. It if- in tin- •"•In** of <*wm
that preventive treiitnieiit i- more lilo-l) to he Mu-conaful.

Lbortlon may take place suddenly; or it may hi»t over
- il 'lay-.

Aborti Marring at or before the eighth week partakce

of tmoninotai of* painful and rathei profuse mvnainwtlim.
Booh ii j- ofh-ti Kippoaed ra be by tin- patient In m

the BUT colic lna\ Ih- <*• ■ ei i- to caii-c vomiting Of m-r-

voiih i-lull- : the omiiii n-nallv paeana unnoticed with blood-
coota On biDuuunu examination the mem. will he found
anionndana tneue mora or lean neluloue. When the abor-

tiou i- not complete fragment* • >!' lite o\ nni may l-c lelt within

tip ofrrfab

At tbt third month, which ii i li»* moat pocobmhi ptriod for
abortion, Um piuveuu generally iwuw in two rtigei i tir*t. the
eatpulaioo of the fata* ; ana •ooom!, the expulsion of <l».

afwlj formed placenta and mombmnai The pr ■ u more

prolonged Bad more painful (Emu In the earlier nthm In

Mtnif r>rAi-A, i*-|io('itilly when tlie fa*lu.« lin> been dead for -ome
time, the |>hieentu and memhranei may *xm follow its vxpul*

ririroi.nr.y or piwovw r

•ion, Should the placenta remain tdberent, the ttrvb may
clow Igttlo, tboogfa the peine ami hemorrhage may cntiiim".
A» the placenta i* «ofW and more attached ED the UtCIUfl 1 1 ■ : 1 1 ■
it ir* later, it i* more apt to route aWU piecemeal ; hflDCt [KM -

tfotM muy be r « ■ l . i i I for da\> ; week#, oi DVfiH mould*, mid

give riw to n varied tntin of symptome.

Alxirtion after the fourth month gfvef rJsfl to ihc clinical
phenomena of a miniature labor.

Pathology of Abortion.

An the result of uterine contraction*, or from dcgencrfttiOD
of the vessels, blood Ik effused from the ruptured VCMelfl into
tin 1 deciduu vera, unci force* it* way between the deciduu and
i ItMiioii, -trippiiij; oil ill- mviiiii. w hi< li i- thru etp- lied ■ ■nii:c.
If the ovum bo flouted in water, it prcwSDH V&y mueh the
tippciir:iiM e nf :i ehi -tinit-btirr.

Occasionally the deefdua is cast off entire along wilb the
ovum, which it completely envelops.

I »< m*ionally also blood \> cxltimi-alod into llir inriiihmm ■■-,
■it inlii\ :i1h. Thie conciliates m ->lmtii, and lend* to tin- lor-
mutton of what is known ns a blood-mule.

In MMM mut'O the abortion may not be completed for horn*
time, .-mil tl»' rnWint'-mntter of I lie effUBW blood may he
absorbed, while the -tnt:i tindery partial oiynitization unci n
fleshy mole rOMlltti Xhw may imm :t ronniriiim with llie
uterine wnll, and be retained indelinitely,

In sbaso oafitt in which noTtfana oT placental are retained

thei*e nmAseft may form polypi, remaining io tin Dtarna for
weeks or months canning 11 fetid discharge and an elevation
of temperature.

Etiology.

The cause* of abortion may lw divided into (Iiok 1 f »f /»'''"' .<<)/,

of witftT'Htf, or oTJtnkU orurin.
Paternal: B^pbuis it probably the nrael ooininon paternal

influence in cau-ine abort ion, Other cnilAW which mav be
mentioned under this heading are alcoholism, debility, tuber-
culoid. leioVpoiwnin^, advanced age. ami excessive v< uerv.

Maternal: Genera) siiniltii onuses u> tboK mentioned in
the tiither net in the mother.

. \cuJU and chrvi icai ru • cnu c nbofCioo \>\ ■•.<-••■• ol lent'

IM'nilllii-. 01 llj I'l'Hril rliniirr-, mi Uy ;»f <hIii4-iii|>, allrr.llloil* ill

ilit* placenta. IVnifMtlimi mid ntvoni •motional dUtiirlHtncw
may iirodvua abortion * !ortain drug*, a* qui nine, kiviu, «

:iini ■ boftl oC.iih.f- in -;im! to ciin.. almitinti ; Imi it i-

doubtful if tlii- i- iIh' com wfc«fl Um uttrai it i" » oocma]
eondiltoo.

/■■//> Dttpll D0UO1 01 lit'' nt'-iti-, pflvfo inllainiualion-

or tdhcHom, otrvioii] U'-r.ition-, lodaraetritUj metritia, Bbro-
iiiyniiuta. in«l dmormal development of tin.- ubrrui may be

mentioned w condition* which |irvdj«|M>- to abortion.

riiffc iir«- ""iiion wlin iiliort -i.milv in whom BO ixmwoii*

■bio ommo qui bo found , to thi* condition the twin "hobiivol
abortion " \n applied.

FostU: Bj jilnli.v which lOtl by pfoduafauj DhtDgc* in the
ovum or in rlir pluwnt:!. hiding To ll»* dintl. of ihr

probably (be most ooremon fata] obqmoC tboitkin<

1' .. :icr:Ui<'i] ol' the rliiirioii, li\ ilnimnio-, atlil vict.ui- in ■*■[■-

(inn oT the plaoeota treq itl} result in abortion.

Diagnosis.

-1/

In i'ii--. «f |||fl|)00tttf] iiImu'T'ioii il i> iici' ar\ t>, d.tcrmim."

:iiii'\ . flu- iboftlofl ma.

or partiollv aaeomp i m n l.

[In- •jdatenee of pregnancy. THe abortion may t«> tfurwlmtdj

f rlti Jilt ; Of ulh)ll», or J Dili

Threatened abortion: If the patient hai been expoeed i"

tln> |ki— itiilifv of impregnation ami I hi- EBOIMI h:ive DO) '• RRH
pr I i! :i ItVUIOrrlia^i' fiMin tin uN rn- od-ur. .i

wtlli iimrc or KNfl |t»iii ". 10011 U i-> | » r* 1 1 »; 1 1 > I « < ihnl :in itlhirfion U

threatened

IK> iioitIiu'ji inny l>" mintaki'ii lor impending nlB.nion ;

i>nt in tlii- . ■!-.■ boa cervix if cdonsd ind Brm t.. the feel
QojnorrMra ubmsidm wiun tho prcocnooofi tojtpotvpoid

bunor in no iiTcmm, BaW simulate the condition of thrvnt-

.ii, .,1 kbordonvnj eloeeft : but a corvful local naodiMitloD

will ycnei !'• oatabltafa the imhirv of tin' "'MMiliiinM pmCBt.
Insrltable Abortion i When ibo mombmHM novo ruMOTid, oi

the t'i'fi: t 1 ad, "i wln-n sim fatal |>:irf i- ITU Iged ft lliO eer-
vi.T. tlit-* ibORion in. i' i" -.ii'l I-. i» ■■'"i/'(6& C'a>e* have
000U1 rod in ffhlob aUgfl pOlttoOl ol deoidua have i-Mcu|M<d from

11)8

t'Aivm.or, i .'/ rim. \ i

utvnitf) awa>riuted with roimiderublc heruorHian^ nnd yet

tavQ afterward gooi in t'ull li*rm< Vflttin Mw <.^ nun

open wrftictieuU) in admit the finger, yd eWe again, and the

nuncy continue. Ii i% therefore, Kiiuetima .. ! i.
matter to *iy that mi abortion i- " ineviiiilile."

Complete, or partial. abortion • It is important iilwny.* u> il» ■-
in mine whether ii part of, or the wliolc uterine I'tiiU'-n

been exptllcd. To inuke n d {agnosia, cvei'vtliirn; ,^.|

from the uterus must lie carefully examined , when any doubt
remalni a digital exploration of tlw uterine cavity nm-i In*
mode; when anything is retained, tin- cervix usually reoia

MttllulU mi tlml tllf lillp-l 'Mil \h- illM'l'N'il without lllllrli dtt'-

lioiilty.

In umwm of complete abortion in I In- lirNl two mouth* of
pn^nmiry there h functionally tin 1< M-lti:t 1 diMiliarye. Should

the lieuwrrhage continue ii if- prulinhle tli.it portions of the
deckliia liavfl been retained.

In incomplete ubortinn* ;>i ilie third month, or Inter, the
hx'liiul -Ii- I ■-:■_■" rcninins free and bloody, instead of gradual^
subsiding, iw it should when tin* uterus 1ms been emptied ana
i«. involuting properly.

Prognosis.

Tin- ptvLMinvU of abortion drjH>itdfl upon the treatment.

If the uterus haa been carefully emptied under aseptic pre
aanttrms, then tliv im*rt«lity from :ili'>rti->n should l»- fit/.

Eetalned maaaea of decidun or of placenta are followed bv
decomposition of tliew substances in utcro, iintl lellto nr

chronic septic infection is the result.

Hemorrhage very randy lends to u fatal result In cases of
titiortioi).

When neglected, abortion may he the starting-|K>lnt of vtktt-
'-(i- uterine diteases, an subinvolution, metritis, cii-., which
mav lend to invalidism.

Treatment of Abortion.

Prophylactic : When any of the conditions nrc present » loch
may tend to premature expulsion of the ovum, nil precaution*,

nucATMitxT or Attonrioy

i:im

muat I"? taken in mvwt man an aocMenl Appraprlata
- v -i. iMii' tn ntzncnf mould Im undertaken wnen ittdteaieuyand
at the •ami' time tin patient mould bo In&truotod toobnorvo

-. j .- -. ■ : 1 1 ].n>i riiitioii-, -m h - rhr iivniilaihr of n\. iv..iii"ii

by lifting or rauhing, portioalarly at fchomcnetruol period*.
Mho nee of atrooej purgative* taoutd be avoided. Ai mcI

nt'.-n-iniiil i.-jM»i.'li iIm- [Uticnt — 1 1 *_' 1 1 1 • I NflUUD in bod ftw MVtlftl

day** Abnormal uterine aondHlons, mieh :i- duudaoementa,
nir'iriiU. hi.- I liitvnitioiifl of cervix, should rocaive appropriate
treatment Beanol littereonrae should Ih- nvoi.lc.l, . -|»<vi ; iii\
at or about tlic moottrua) epoch*.

Thrcatcnod abortion : 'Mm- main prlndpUof inainimt i" i"

:"'urr fiir the nalinil :ili-i .1 ni<> n-i, m< ntal BIHI ohvVUMlI*
Tin- ih olttiniird by putting her In bed, ill ti colli, diirl.rii.-il
loom. * lici*' -lif nil Im 1.. |<i in a!)-tilinr (jiiiilii. ■ . and l>v
the In.' M-. of Oltflini, linnuiilc, ami clilnnil.

Opium i- l>r-»t :iiliiiini«t<-n-d hv til* rectum. A tiir»po*itory

couiainii)^ ojiiuui, gr. w, ■1k>hI<I Im gently faMrted even rfghl
hours, or ll lout Miftioiontly often to Keep the patient mil
under tin' influence of the drug. At the winu' iiiiu- a mixture

n.iitiiiiiiML' -odium hroinidr, k'|- ***. 1 cddoral hydrate i

kv, ma} Mglvn throotJmoi daily. ttain prefer the fluid
extract of viliiitiMini pruDifollam In dntcnm da**e, L f. d.,

lli-l«f:i(l ill' tin hrotnidr :mi'I - lilolal li

Inevitable abortion: TWO method.- of tnalimnl arc flV*Jl-
iitilr, ilir i x|«*«t;int mid tin- active:

Tlw nxpucUttt treatment. Should the bleeding Im were

btfoiT th" "* ■• diUtt'd, it nm-( b* Controlled |»V 01*0111 «i|" a

vutfitinl tani|."ii of aterile or iodoform |pvut*< To appb
rinol buopoOMf properly the patient ihould be placed in till
liit nmiproiM poiition t eritli the oipt resting on ;i rubber
shoot or Kdlv imd at mcdjnojf the bed, fte vulva ancl
vagina iboula then be ivevhea neHli vptriti of green •oepend
li"t rmter, and then *waW*-d with n 1 vm I'm-miilm -'liitiou,

It* tin' vulvar hair t* long, it should hi* t'lippfnl. Tin U

in>lntfiirii( Nqnlrtd fir' 1 a Sim« lUJMCUlom, n pair of uterine

nd ■ pair of aelaon, which naj tw tcrilfaeJ while
tlir- natteol fa being pjvpand.

Tin* anocnlam i* thin Inaci Bod And tin- parinosni retnolcd
-mi at to BXpoM tlic oorvli la elow. A -u\\> »i \puut Mtcrile

200

PATHotJHir of pit&;y.i

or iodoform), about two inrhra wide anil a van! lour. j-. then
seized above by mean- of the uterine fu;ce(is simi |«ck«*l
firmlv around the cervix. Aa (he gauze U being insert t-*i th*
speculum u gradually withdrawn. A .-ufficiem quantity of
gauze flhoula be iutnsluced in i1t-un<J tin' vagina. The
patient is then made comfortable, and .-ho old remain in bed.

To facilitate the emptying of the uterus, the fluid extract of
ergot may be admin i-t< r<<J iu Iialf-drachui dose* three times
daily. If the uterine contraction- an? painful, an opiate may
be combined with the ergot. The vaginal tampon *iiou!d he
removed in twenty-four hours, and replaced by a fresh ooe if
necessary. A cloa watch should l» kept over the patient i
temperature. Often when the find tampon w removed teal
ovum come* with it, or the cervix will be found softened and
the 00 sufficiently dilated to permit the introduction of the
finder, with which the ovum may be extracted. If the ovum
rupture anil a pan he retained in the uterus, the woman
must he kept in bed, the ergot continued, and the vagina
daily douched with a solution of formalin, 1 : 500. In many
case* this treatment will be sufficient; but in spite of every
precaution the discharges may l>ecome fotd and the tempera-,
turo rise, in which case the uterine cavity must be thoroughly
curetted.

Active treatment : This is the treatment to be recommended.
in preference to the expectant plan, in the large proportion of
cases. The vaginal tampon may l>e employed, as recommended
above. If at the end of twenty-four hours the oe ia not

Situlous, the patient should Im> anaesthetized, and the cervix
ilated with Hegar's or Barnes's dilators, and the uterus
emptied, as recommended below.

As soon as the os is sufficiently dilated to permit the intro-
duction of the forefinger the ovum should be wept out and
the deciduaor placenta removed by scraping. The forefinger
of the right hand is the best instniment for tl a purpose. It
can l>c made to reach all parts of the uterus, with the assist-
ance of the left hand pressing on the fundus through the
abdominal wall. When the secundines cannot all be removed
in this manner the interior of the uterus may be gently
soraped with a blunt curette. In all cases, after emptying the
uterus its cavity should be thoroughly douched with plain

Mtsxrn i.ititw

*t\

i ;;■ d water or fonnaJni lofntian, wed hot. For thin
|hhh> the Kriincli-BoBamu marine tvlheter tab) fki tin
intra meat The Eratnal ourettc t'i*rccp* will in- t»iind 1»»
n very vnlimblc adjuvant (a the cur. it. in removing »hi
from the m.-Hnc cavity.

After treatment of abortion; The w un ihoutd bfl kepi in

\*o<\ for At leniit a week of lea ■ J i ■ * .— . the teraMfnttan »li<mld U:
watched, tod, if nece»ary, a|i|ir»i|iriiirr iieniineiit In prevent
the onset of lactation should he applied.

Miucd Abortion.

h noi-.L-iuimiiv hanpena that the findn parlaher, qnBptonfl
of [mpondlng ibortmn di wlon only t<> <l':i|>|":ir, ana the
avwn i- renuned la tin- ntrfai laf tveek*.oi avan nontba. To

tin:- DmnliliMM I In f. mi " niiwd abortion " i* applied. V

Crvaoncni la ludlcatad, pravuiad tb# condition does not affeol
tlic genera] health "t* Uus patlenti for eDoneror Later oonl

liwui will occur uml the uteru- iiuptj iteelfof iu contents,

Prematura Labor and Miscarriage.

The phenomena of premature labor arc very much the
aame la of InUir ut term, wirh the wcwtion thai the plueenl
i. riinn* rrr.jii.-iiily n-lln-i. m i.> du otennc waft When *uei
i« t lie <')(•«• 1 he literal iihi-i be entered ami th<* placenta
•tripped oft" nml removed, nfivr which ;i lint nr.-rin.- rlnm-he
•hould be given.

Missed Labor.

In tliin condition, which 1- few rare, tin- woman may

exhJbil a feu Ineffectual aignfl of labor at tern ; thcen dSaen*
(M'Hf, .iimI th*i product ofeonaeptioB if retained hi oterofof
month-, or cvtn year*. The fortus in thmv oanan always
pi riabea. and either manermtff Of mummiiie-. 11m soft parti
ut" the RBtm n»iy ba ibaotbedi »ti*l lha bonef nav in 1 dis-
charged ut intervale for ■ long tima afterwirdi of Ifcey mv
find 'heir way through the ntcnw into <)»• Madder or reotttra.
It i* .1 gotwi -v """' »'•■ to induce labor in all * m - in which

the (Kit ient U known to have gone two weeks beyond the nor-
mal period of pregnancy.

•JM-

PATHOLOGY 01 PHK0SASCT,

ECTOPIC! GESTATION.

Definition: When th« impragnatad <ty bonomi ntloi ■

ftflu QvVwOgM uiil.-nlc tin; uterine ruvitv, I lie prt^niancv in

termed ectopic, ur extra-uterine.

Frequency: Kelopie gestation nec.-ur- proUiUv about DBCt
in $00 (t«Hi> uf pregnancy.

Varieties : There are tarn primary forms of ectopw ;jc*ta~
timt (I) tubal/ ft) ovarian t tad {&) abdtminal,

Many ;imlinn:;. - cl;i--ii\ th< \ .. i j. hi-* termination* of T 1 *- ■ |

Crirnury forms of eotojric gestation a* aecondarff JormMf each
eang draKuatod according to the location of the di*platnl
ovum. Tin- term "secondary" n* limn employed tunplj
tiniiii* ^nh^ifU'U\ t" i uptare or dieplaccmeut.

While primary ovarian ami abdominal pregnane.!** do
oeenr, they are undoubtedly iwtivmelv hire, und are dinVult
of absolute demonstration j a- n ^cticrol rule, ectopic floatations
:i en fnltnl.

Tubal preifnancioa are clarified Ji«eording to the -ite of the
lltllK'hineiil of the ovimi, R| :

(|J tntermUtini when (be ovum develop* in that portion of
the Lobe which DOWOa through the wall »»f the inVriiH, or in a
dlvaTtSi -ii linn of (hi? portion of the tube.

(J.) JVift tuoa/, or ampullar, when the ovum develop- in
lln- tree portion of the tube.

.ii Infundibular when the ovum develops in the infundib*
nluin of the ImU , and prevents the closure of the abdominal
ostium. Goae* of this varietv are also termed tubo-tnorimi.

Terminations of Ectopic Gestation.

Interstitial pregnancies usually terminate nhout the third
month In rupiitre into tlm peritonea] sac. The patient gen-
emllv Miirenrnli" lo hemorrhage uml shock. Kupture into the
uterine rarity, with exiinUiou of the fo_-tus through the cervix,
i- poSeJbUs il " '- tho rupture into the haw <»f the broad liga-
nierita.

True tubal nregnanclofc lermhmic h) ruptnr* either (a) Up-
ward into the abdominal cavity, or [ft) downward between
the huretl of the broad ligament. Winn the rupture occur*

1 1- i:mi\ i rroys of ectopic oesta tk > v 2* >:i

into tfi' u/'</' a ■■'■' .. tip- hi'fuurrluigo is usually •«■■
uihI urn be l:ti:i) in I'mtn Bitten 1 '" iiiiv. ..r tmir «Ia\*..

\v inn rupture ocoan onrh and the bomorrhajje i* not ntvtr^
ihi fotut may In- absorbed, u iIm unbryorde «nc tnmally

ruiilnri'- :U. I in? -unu' trim- ;ix the 111 lit*.

when the rupture ttoouft dawiueardf between tin- tnyen of

if hroatl li^rinn in, the ovcim may |>« ri-li and all (run pi ii
dioippi.Nir, while the bloOU Offliwd may lie iviaitied, (urinific :i

pelvte bioranUwcle. Tl run ma} develop for* time, and

then bom iiltn the [MM-itunciil mivitv, or OOOtlUUe fa loll U rU

by stripping the peritoneum Eton the pelvic wall ai it so*

largest. In cither ea«e ilic ovum develop* lor it time NhI

iIm -ii periahea,ind Ei cither absorbed <>r miocmtcdj when it

may ulcerate through Into the DOWolg bhwaOTj Of viiginii, and

e taapa.

Ill Mill nltlt'l r:i.c- ill*- |*ilitlltM)li-HW Mill) liinlrl-o patftfto-

tinii from eocene of bacteria rroxn the bowel, and be converted
Into a broad-ligament abscess whioh may rupture into tin*
iieritonenl cavity, nr into the Madder, rectum, or vagina. In

otlnr .a-.- (lit. 1 I'.ctti- after ih'.'itl v l». •/iiiivorieil into I

Lithopwdion or may be inuiiniiili<.<l, and thus remuin for

V. II-

Infundibular pregn*ocloB imiv either rupture into the (xsrita
nod envity or develop to lull term,

Ovarian pregnancies may terminate by rupture of the sne
and profuse bflDOfphnen ; or amat of development may
oaour el Jin natty period and the aeo ramata o eyatk) tumor*
Advance to Ml tarn Ea pocaibb, but not probable.

Abdominal prognanctet maj aavniMe A ft'll imn ; or the
fciii' niu» rupture. I'iirly, :intl llie I'm in. I, r either abwrlnyt or

mummify.

Tubal abortion: This term ii applied to a certain mn* tmn-
cntion in which Menu! b e ffu sed into the ovnm, bntroytna* ii
an<l He ftttaohmente to the tube-walla The ovum maj re*

main a- | luhirt mnlr, lor ruin.; a wild tlUDOf of the l' 1 '"' \ Of ii

may .-i'.. )..■ u ti, tin blood From the nWbrialed exbaouLj of

lit.- lube into the uhdniiiiiml ruvilv

Etiology of Kctopic Gestation.

A\ luw been stated, lite ovum UhUullv becomes imi-rry-
natod while -.till in we Fallopian tube. Ir' tlw tube i
u normal condition, the Impregnated ovum in moved alone
it until it tlnd» III rwtfng-plftca in the utctrim cavity. It i-
therefore probable tlial tliiMim.it uujKirfuiil factOI i" bfodudQg
ectopic v<- - 1 ;ii i . «i i i* Home abnormal condition of the tube*.

Bueh abnormal conditions may •rise either from injUim-
miil'mn of tin* tissues "f the lube* or from purnmetritic
exudation*, winch lead to their constriction or destruction,

j/afformathu of tba taboa are not infrequent) njoh u di-

vertinila, aeee-wtry tnhal <\in;iU, etc., und nave been noticed
in c.uiin'cti.in with eel. ipjc ^cstuti-in.

Any diseased condition of the mucous membrane of the
tul".--, or uny condition which interferes with their normnl
peristaltic ih'(i«»i, may bo tiaid to fnvor tin- development of
ectopic, station.

The uonditimi if j:cii<i'iiliv niixiuuUiivd In woman who

prociil )i liiHtory of u protracted period of sterility.

Patholog-y of Ectopic Oestation.

The ntenw : Willi the establishment of preptianoy the
dterai beffSni to enlarge ; the enlargement enntinnrs through-
out the prepiKinov, though at a lunch -lower rate t h.-iit i- the
case in (ntm-uterinc geattition, As ■ rule, this organ begins
to involute when thfl faitu perishes. A rfceidua forms in

all iw- of «r(o|ii.' -_'■ -laiinii, uhieh is quite similar to the

doctdna vera of normal pregnancy. It is cast off cither
ounplcte or in shred-, at the time of the primary tubal
rapture, whether the ovum perishes or not. The shredding
of ill'- ilr.'iilun it invariably nccompflnicd with rni-ti> •rr)in^io.
The dceJdufl varies hi thickness from one-eighth to one-fourth
of an inch : it is shaggy on its uterine side, while its inner
Mirfnctt is quite imooth ond shows no trace of cither the

dtofdoa etrotfni or reflajca.

Chftiigcii la the tube and ovum: A-. tin- tube i-ii!:ii'i*t> its

relation to ion iding puts ttoooroes greatly modified. Tin*

■ ! an "• m the tobe m a ttirgrticnuv, due to loonsifla in
jjae uf the v*>m*1s, the rftiiilt of the Mlmoltia of pTI -i-uaury.

The i lihn.«- "I* th. mix'- wiill* then [aonSM t" «* ,

bat l;»i. -r ;itr.ijil»> '01 - 1 1 j - - n-uli of DMUUl* niiilun'n ilur tOJHDft]
In MHtrritii^c- intii tlirir -iiti-l.iittt Tin n follOWfl (fOC » !• a • li «i »-
montof OODneOtivr li^nc, which rv|ilw.v- in lt-J(! piirt the
muwlc-tiliri- \- flip nvimi fiiljirp- r In- tuhr-vralli become

thinned "nr, the thfolo -t pari being nl the rite "i the plm riital

aHitolimi'iir. uii'J tlie tliimittl diraetiy i']tj)u»ite. I feature of

l lie .ilvli'liiui:il ii-liillii (i-vMulK lulu* |»hhr :it the >-i\tli or

■cventti ffcok ; ruptait of the tube takci place heibn the end
<»f the Mflond month in piooobh two*th!rai of the aiw
The tube u novam toe limited degree until fixwl ii\ prri-

toniti-. I'rofii il.- iiici«;i-."! vvi i^bl i! I . ml- Id f;ill li« low is
nornutl level. :in<l i! BUM Im t'oiiml hi Dnaslae'tl DOUObi A - ilir
ovum fOlfJBtQ 'In' nlern* i> |»ii-lir»l |o oDI lEdOi In -»>n»r

mum 'I"- tuw remains <'l«-«'lv BUtabttd (<> Lite uteru*. whih b

nthelK i! Jiu'lii- ii dittlne! PMBE

In tbepMnul tubearfraiotiiaii formed which iMiuiinarod

iif tin- n--(nil twii l.-iyi mperfk ml comgnot and it *i">ngy
lower layer. Hum portion <<t' tfie doddoi which is to funn

ihc maternal placenta, and which COTTo ep OOdi to the -■ - >r inn,

i;nn\- moic nijinlh tlmii thut in the r«et ol (!:<■ lulu.-. A ■!<•-

cadna rcflaxe la bud formed, bat ii tendi todcgvaerati rapidly,
and sEvea rise to hemoirbagei ecrj eerlj In the pregnancy.
Than bomorrhegM raeah in inflimmator^ change* which 1I101

tin- (pfwrnl h'XHHV "f the fml— .

Jin- piftccnta Ii formed in the nmc whj m m iiiini-iiieriae
goafiatloo. boi e I » ** \n<-l of Bpaca In the tunc ra aim In traaina-
ii-m- which altogether oJouumi ke character, eonvaiting ii into
a livrr-ltlvf iimM \\ ben tin tube rupture* die toniwalhi

of the tub* »|>rv:ul out, and -lioiihl ilu ovum -tit\i\r, f Im pla-
centa fbrme attachmenti to neighboring etructort and eoa>
limm ii> growth.

Tlii' aauiUia :iml churloii ;n. mih uttered (mm tin-it u-mmI

oonditione l»v ilu* raoujbi of framiuiand n-\

Symptomo of Ectopic OeBtation.
'Ilu- phenomene ffhSeh Indicate tin* cxlatence of ectopic Me-

1:ii inn ai . iiluf lirui'in fii'ify tniin lli< \:i_mii:i :irci»mji:iioill

with m<>i-> or km '■ '■' '• /»/'<'• pa fa \ ind um pi • aa* - a/ a mam
i-Amw /« Mini ojtm ruwciatoJ " ■■'/. CAri "/'•/«*.

200

r.iriroL'Hiy <■/' wi-ay-AScr

In .1 typical case the patient has been regular in mctotnia-
tiuii lor tofaQ lime, when she misses n period. Short!) after
this ills' has IitckqIai attacks of bleeding, accumpauiod -^ •■!■
Hlmrii, nulling iielvie fiaiii. 'l\«'-- • mntunu ma) load U> lliu
Mupiadon ofnoortlon, which U itreit^iii'-ii<->l (■_• i!c p.i- >■ -.■•
of portions of deoidua, Una of these attacks way beoxoaav
lively mvbm tnd giom oollapas. Sot infrequently tw -.
ut tucks an loaoaapfuiied by dyauria und metal teiiwmus.

The amouut of blood Iwt varies from n mere bhuM to .»
severe hemorrhage; with the blond may l»c H hi ml small »hn
"\ rnucoin, or even ft complete cum of the decidual lining of
the utcni*.

The pelvic pain is usually of u sharp, tearing cliurHcti.-r ;
when iMiMiK-iiitiiijr, nut] uecoiupnnicd with collapse, it indietitc*

U serious rupture.

A vngiimi examination in such ;i .a-c "ill revnil I In- pres-
ence of a mass in nloM? proximity to tin- utciu*, which May
be found somewhat ■nlarged. The oharaotwr of the iaomi de-
pend* iijH>n the situation of I hi! ovum ami whether it lini rupl
urod or not. In en«c» in which rupture has taken place euHv
into tlw EVDttraJ peritonea] cavity no iua«s may be felt.

[f i be Brat attack ba survived, nihnr similar uttnek* may
follow . im.I tli.« internal hemorrhage* Ik* Ininl, In other eases
the cfl'u^-d blood may be nh"»rl>ed after the prt'Miiir,- of the

ovum.

The ovum If it survive muygoon developing, m which cn«'
slgna of pregnancy will continue, an abdominal tumoi develop,
ami finally evidence-* of a living lotus will manifest ibem-
OclvCS. Such eases may pi on to full term und n spurious

labor occur.

1 11 other C11-M-J4 secondary rupture takes place at ;i later jiki-IimI
when the patient Usually die* of hemorrhage or pcnloniti* ; or

If tin: nation I survive, the fostUB become* raummifie<l or forma

a lithwMedtOO| being retained for some time, und finullv itfOUSt

out nfeoefoeo] through a fistulous opening*

Diagnosis.

To make a poaitWe dnumoafo of ectopic ratation previous
to nipturs of tJie sic, whuc poaaibla in a large majority of

n:i i / urST OP RCl'orf tlMTATltiS.

20:

«***«, \n jiIwji>- .1 mutter <»!' riiHieiilty. Tin- ln-mry of the
■i^m> of rally pregnancy, :i.-«m -illicit with ayyiuvntril ellcx
nOfYtMM plirii.mi. mi ; I he ruily appflaffUCfl 01 MMffpj rnimp-
liUc- (M-lvir puin increiu>iin£ iti H'Vi'ritv, multe :i < J i:i^n. i.-i- pu- •
-Nile

I -nalW tin OOOditlou i* iinl iiHMt^niMNl until ruptur* han
takan plact. At Ihi* time llu- hitfOfv of ileliiyeil metutrua*
timi, the (w.-i'iin-i'iu'i -n" ;i 11 of frightful puin. -inMen

oolkjMc. unil lymptama w internal hemorrhage molte the

<litigm»-i- very -.intjil.-.

A microscopical examination of (lie khtcdj DOntaDDod in t J «■ ■

\ . ■ : : ■ » •: ■ 1 IjIi'i_nI H ill re will thaii decidual dtti icter, and make ■

ililVrrniiiiil diu^iiuii- fruni aUirtnm jHoihlr, .1- im ehmmnic

villi vmII be fbund unless, the prtgiwncy li lutra-atorlna.

In GUM -tf advanced ectopic jreiUtlou the- <lui^in^i- i-, :i> ;i
rule, DOl ililtiehlt. OwiDB !<• 104 CfCttl tH*phirrinrtii "I 0OB-

tij;ii"tti- ■)i , pin^, :ilxl'iniiii:ii puin 1-, i.lli/n rvr.-.-ivr Tin Mail

i* line in purl. Ut pPWUJt, ;nul in \;\\{ m the development of
("•ritniiiti- of ;i OnTOfllQ type

Prognosis.
EGatopie geonttion I0OBM of 'I" 1 nnwt •crioiiH nhxteiriral condi-

tinn*. If laft to nature, the mortality i- over lio per CCJttq tin*

remainder recovering by death ->t' the ovnm and ibaorption
nf the contents of the rata tion no>

When treated by abdominal section, Hir-t .mi. ■■ tin mm--

tnlity -I1011M l»- hIhiiii ,"i per i'ciiI. »r Imvi-r, if tin- opea

— .■-. tin- jiiiii.-nt in time.

Treatment.
As fNin ai a diogiMKi* of ectopic mentation in nrtabli bod

the only rational treatment ...mi*.N in tl.- immediate removal
of tho gesUtlon-tac. whether it liiw ruptured «r ii>.t.

Abdominal «cction \» the mo«t satisfactory method of operat-
ing, th'iue.li -'im- "|H'rator* prefer the vuL'inul route I If

latter method boa ninny ilMdvantngu-. and ahould on\y !«-•
n ofted ut liv thoao operator! having epoch] oxfierieiiee In
opening by the -^ io1 rout*.

A- ii if :i 111:1' f ■ r nf i-iim.ulcr.ihle >i ilhrulty in ninii' 1 I

208 PATHOLOGY OF PREONASCT-

control tl»e hemorrhage awl to separate the
operation of abtlominai acdiou for the removal of am
gestation should not be undertaken by an unskilled oj .

Tka technique of the operation : Though the Q|i r r «l iu n
frequently to be performed id an emergency, plenty of ti
should be taken to secure an aseptic condition of the
of the jotient, of the operator, of the assistants, and of tbaj
instrument* and dressings.

Tlie operator, having opened the abdomen by a m— Kw^
incision, should at once insert his hand and seize the aff ec ted
tube at its uterine end, so as to control the hemorrhage. Taw
broad ligament should then be transfixed by a pedicle-needle
to the inner side of the round ligament, and the tube ligated
en intone. After the tube and ovary have been cut away, the
abdominal cavity should l>e cleared of clots, if necessary flush-
ing it with a lurgc quantity of warm sterile water. The
incision may then Itc closed without the insertion of a drain -
age-tulie, unless a considerable mini I «t of adhesions liave been
encountered. The subsequent treatment is the same as for an
uncomplicated ovariotomy.

When the hemorrhage has boon very considerable a quan-
tity of sterile salt solution should be injected under each
breast, during the operation, by an assistant. After the oper-
ation it is advisable in all cast's to inject at least a quart of
the same solution into the bowel, by means of a long rubber
tultc and gravity syringe.

In advanced ectopic pregnancy many advise that interference
be delayed until just short of term. In this case effort should
lw made to enucleate the fa-tal sac whole.

When this is found to be impossible, after the feet us has
been removal the cord should l>e cut as close as possible to
the placenta and the edges of the sac stitched to the edge of
the abdominal wall, and the sac drained by packing it lightly
with iodoform gauze.

The after-treatment in such cases consists in daily irrigation
of the sac with antiseptic solutions, dusting it well with an
antiseptic powder, and introducing fresh packing.

For further information on this subject reference should be
had to standard gynaecological works, as ectopic gestation has

Duoitom 09 oooiNTOposrgMon QAsm &09
pi i from ilic domain <>! obstetric* to that nf ^yn.-rmi.^y,

UAOI the iivaliiunji <•[' llie condition i* purely -ur^i.vil

PATHOLOGY OF LABOR.
The i. Tin outocu In applied to normal laboi n*hSobtennl-

r i : a 1 - ■ - • . i - I \ (VithoUl ■cnuii- (lainup tO iii«»i Jn-r Of ftnUlfl :>i"l

without Artificial aid.

Dy»loct» i- I h-- term apjdnd t-» nlnii.rmat hilmr 1 1' the
abnormality *»T (lir labor Uppvoda QJKIO WDM foftO of (tVtal

irnvulajrityi the annaition i- tot iljabd r/wefooM j while if it

be dependent upoo « abnormal condition in * 1 > - mother it

m known ;i- maternal Hwtiocia,

The caiiMii of tin dystocia may be id nny of the (faroc motor*

which oanatitute the mechanical problem of labor* The fatal

or ite upiK'n«luiff^ nmy be abnormal io •>■■•-. * b i pontioo 3

',,., /,,,,.- QUj be [fiaufflelrol of OEoemvc; or the

n i imv utlrmt l>y tin- iiuttmuU jXUatjg/M nM} \»- (00 K"' : "

■ >i too little.

When called ii|miii In i«!jiUt :i.--i-t:iiH" hi :i c;i-c ol' <J\ -I- n-'ux
flu- |iliy -ni:i'i should lir-! ;i-ccrlain wlltd] of the lactnr- I- ;il

EaalL i'!n- recognition <>l* Uie disturbing cause forme tin baaii
of rational treatment

DYSTOCIA DUE TO MALPOSITIONS OF THE FCETUS.
CXXUPlTOFOtfTK&IOH I ABBS.

Oocipkopoatarfoi |*cwition» of rite head are primary or
at luirtd.

Primary, if die bod eaten the brim ->i lite pelvb with the
oeetpoi poatei

Acquired, if Lite nootpal rotalM from ao Anterior potation ut
ilu- beginning of labor to a posterior •«» it- oloec tm latter it

wt' ran-

Dia*mo8iij of OccipitopoBterior Cases.
Abdominal rtxamlnatlon : The bnek of the fcetfli imiv he

fell In tiii- maternal Book! but En (VequeatU difficult bo oat-

l»n»' The fa?Inl m.mbcm may \»- frit i-v-t the w hi tic anterior

i peel of the abdomen. The bead can be felt atthepelyfa

ii >

210

PATBOLOGT Or LA

brim, whil* the anterior shoulder can easily be

at a point about midway between the Mawfc of

ligament an<l the ambiliro*. The fatal heart

beard in the flank at about the level of the nailiilii—

Va*tm*l exandaatkm : If the cervix L- dilated
the sagittal Hiture may tie felt in the line of the
diameter of lb*- pelvis while the posterior
directs! toward the right or it ft aacro-tliac joint.
o*ifipitopo-terior positions i- generally tedious, oW to
irregular and ifteffectna] |»ains which charaeteriae the
Htagc in tin--*: caK-, and also because of the long internal
lion which mu*i take place before the occiput is
under tlie pubic arch.

Mechanism of Occipitoposterior

In normal ciiet the mechanism L- much the
miUrior position* of the occiput. Flexion is more diflSonlt
on account of the maladaptation of the head to the pelvis in

tlu— c |Hj-i4-rior jMt-itiipn-, on the widest |»rt of the bend, the
biparictal, \h in relation with the narrowest part of the inlet,
the diameter lietwecn the iliopectineal prominence and the

Fia. (H.

Fio. 68.

Rlrhi ocfllpUnnnrtcrlur |i«>«ltl»n »f
hrM. Tlm*rr»iw«li"W-lhi'iIlnTl1<nii>f
tin* Ion* Irilprniil rotation tiiiulc by tin-
iM'rlput In ildlvrry. (.Irwrtl.)

l'-'l 'ii': IplloprtwlPrlnr position of hp*d
Tin- arrow "IrnHB tin* dln-ctlon of the Ion*
Intcriwl MlHtion mail): 1»>* the occiput in
iMIvcry. IJttWctl J

promontory. When flexion is complete and the head de-
HcemU to the |M?lvic floor, internal rotation is prolonged on
nttcnunl of the great dintniicc the occiput must traversex to
come under the pulwH; hence then* is greater pain, and t^e
hilhir im prolonged (Figs. 67 and 68). >

NfXMASrsX OF OQCXPirOPOSTB&tOB G4AB UJ

Abnormal Mochamnm

(I) Extended poiltlon of bead Tin- <ll j > n Im-chiimi

tin* OAnipitiil i-uil iif tin- la-Ail anil ilini p-irtlon of the brim En

rnUttoo to it inmd| frfrrrwJ to, miy i.-nh In Intorfaonoi
wttfa fits km i" raoo "> txttnl ilmi the how any votvr il» !

|h-Ivih in an rxlrnilnl |'«»iti.»n. ,.« i, t - i.irr ,,:.

(iuiM.

(i) F»cr to pulmM . Wlu'll tlir llt'wl .'iilriv I lie iwlvil i I ii i 'i i -

Hi'tlv Bsxod the MD-ninul nuu nioli (be polvio boor (ir-i, cod
i" lin'ii direotod knrerd tbc pubfo wli, whii*« the ix-<-i|>ut

•"•nil? i i. Iia [>ti 1 1- •lumii

t- .-hull*-:.!

■ ■■■■ into lln hollow of tl»" -*i"rum. Thin n
i • .. it, *Wh i < i !-■ pvba

In micIi p-ffpnlrtcnl ocdpltopocutrioi aua lla haul nou*
timu* u< dc*ecnd until tIio glabella (the root of the no»e)

ua

PATHOLOGY OF t.ASQK

1 <• Ol ill'" OOcfpttl DVtf tin* jH-fin
ili.'liv«Tr<l I lir l»t-.n! fxt.ii.!- :ni"l ihr

ptvod under the pulx*, wi ion take- tuaoeto permit I

lpttt over the ncHneaai, Wru Wrwn

WJClpT- In 'in ihhK

Dubai i f"' 1 !;. *••''■ Spontamwindi livrry in a nkvUi |iiilw> ram

i.nlv HOOQlDpMMMd wiili difficulty, and n*n ) mn<-i •Jnttij* pain*,
lax niateniul |>;in-. .md not ti><> l;iryv a hnnl irtli

ol tha be d toe nwahaniani i« the Mine -->* in other caaca\
(3) In other gwh tlic head mav enter the peh i- poorly

flexed, deieend Until il n;irl»- tin- |»lvir Ih-.r. jiiu! ill. i.

remain fixed with it~ Jong Juunfin i<> i in fA*

e|Wo azpfty, jirneniMy at the level of the Uehi)il *pino»,
'twrni whirl) u heoamfs impacted.

Moulding of head in face to pubee auae: The oocipllo-
iiiviital ami nrcipitnlYontal diameters of die fecta) bean are
ihortenad -.mil Dm suboccipitobrcgruutic lengthened, as a
reeull ol' tlic bead pivoting at the ghritclla (I'ig. TO).

I-:., ;«i

Management of Labor in Occipitoposterior Cases.

Prophylaxis: Attention ban been drawn to the deairabUibr

of making an alKlominnl examination t. - ilntci-mim- tht> |-<-i-
lion of llf fii'iiis *orae time before

the .'\|iri I, ,1 iMi-l of lilli-.l [f m

this examination the fo?tus bo found

i». iK'piijiy a |MHterinr ignition, i ;
possible lo rectify it by poatural We it*
nient in muny eases. The woman
ibould bo inatrueted to us-iime the
knec-ehest petition us frequently U

Iiitssilili-. niiil lo remain in this position
iir tome time before turning upon
the side to which it i> ili-.-iivd to

direct the occiput In this posture
the tendency i* for tin* i-hihl i«> paa
nwnv from 'In- brim undci ilr<- influ-
ence of gravity, an the fundu* and

.interior uterin< wall become thi
lowest portiuuj* of the uteru*. Tha
ofdld ihmi I monies free to rotate upon its mn u\i-. mul ic

Il - 1 ■ ■ r him i- heavier from the preea »\ the spinal column

■ i i ro< ''i' 1 'i t'i- !>'■'

• I.h'iil m i i|.n..|.i-ti'ii...

Mm • (wiMt <l

■ii il.

it i* brought Into 'ci" Ition wilh the interior wnll oi iht

UtOrUA. Honeo u tin- woman assumes the erect position
thfl child - hood tendfl to settle down nguiost the brim in
.in anterior |»oatlioii.

At the Pelvic Inlet
I Veoucol omnioatioiM dioaU bo mode U) •Boartoin ^ bother

lli-xinii i- dpinji iu:iinl:iiiiiil :i- Hie he:nl 0«(»nAi in In llie liriin.

Should e\hn-.i (f tin* head til kt* plnee without di'Mvnl,

ifitrrrerence i* <li<iu;in<l< (I, 01 then h but little IiIm llhood thll

the head will pMM <-"• brim by imiunil

77n.' tiht/io.1,- i.j fir/inn/ ;m jM.-.-ilih *

lrt. Version • Thi- i- proheoty ihi- BOOt PODIuU «•■ vn-II »•

ilic oufoel method of dealing inUi tin-, cm* . i mi*, an it

rule, the general practitioner mn perform thi- npe-niiioii with
greater eoec to himself ami lew danger to the patient than
Cither of the other method*.

2d. Normal restoration of flexion and rotation of the fatal
bend Mini body to an (interior ponlllon, with the subsequent ftp-
plication of the forceps : Thin i- n milter dillicull operation, unit

fthontd only be nndertelton by IftiOM ifho are thoroughly
•%. ^ M i '■ 1 1 in tiif iim' of roroepBi TV) perform 1 1» i»- operatfon

properly the jwfietit -lionld M |>l:u-<>< 1 under tlii \n&\3< '••'•' of
ehlonilbrm, H a* to relii* thoroughly the iitern*. The Open-
tor. afar the usual nnlueptic prreairtiooj have bean ubservou,
should then paoi bis whole hood into the ntorua so u firmly to

t;n»-]> Ufi lir.iw ,'inil \\„ ■• of the rrtild. The head DOVlOff l*er*n
r.ii-i-d -iiL-litlv. 10 ol to free it from the brim, i* then gently
rotated to an interior |*>*itn>rt. The external hand of the

operator ihoold be ueea to praraoti rotation of the trunk,

Wnicll -honld :e-i'nni|iiiiiy rotation of the head. The rotation
should bo liinied niil tlowl} ROd with the lltinofl yeulli'i-

Ann iin- has boon looomptlfhcd the head »huuld bo i

into the brim by NCtarnal prewure, and »honld he maintained
in position l)j -.in aeMstant «luli' torcegM ipplication i* made.
\- moll hfgu operation . onl) the axfaMreotfon foroep honld
Im- need.

3d. Application of the forceps without Alteration of poaltloa :
'I'M- operation should only bo nndei in U» n :i- :» l.,.i rr»ort, as

(

214 PATHOLOGY OP LABOR.

it is very dangerous both to mother and child. Aa a ]
liminary to tins operation the head should be flexed.

- rz
In the Fabric Oavttj.

As in all posterior positions the head tends to paw the brim
in n somewhat extended position, it is important toiajgfu a.
npecdy restoration of flexion, in order that the labor may be
accomplished ns easily and rapidly as possible, and to spare
the patient unnecessary suffering.

Flexion may lw restored by pressure upward upon U*e
sinciput with two Angers during the intervals between. the
pains. I hiring the jtains the descent of the sinciput may be
retarded by maintaining this pressure from below. OeoaauD-
nlly it is possible to hook the finger of the other hand over
the occiput and draw it down, while at the same time the
sinciput is being pressed up: but to do this the head most be
very low mid the parts lax.

When rotation fails ami signs of exhaustion occur, then the
forceps must be applied. During this o]>eration care should
he taken to prevent the blades slipping, as this accident is very
liable to occur, IJetwceu the tractions the blades should be
Heptirnted, because sometimes the occiput tends to rotate spon-
taneously. As the head emerges it should flex ami the root of
the nose pivot under the pelvic arch. It should be delivered
slowly and with extreme caution, so as to favor moulding and
to control the extent of iieriucnl laceration. In many cases
it iM necessary to perform episiotomy, in order to prevent the
laceration of the perineum extending into the rectum.

Prognosis.

The prognosis for both mother and child is not so favorable
as in anterior positions. Backward rotation of the occiput
takes place in about 1 J per cent, of ull cases of labor.

Laceration of the maternal soft parts is frequent and often
extensive. The mortality of the fo?tus is somewhat over
9 per cent., as compared with 5 per cent, in anterior posi-
tions.

tu.wxtisis "t r,r,,- t-HKSKxr moss

FACE I'KK-I.M ATHINH.
Occurrence : Face preacntatfona rarely exist prior to the

oDMtof labor; they w,:,\ i»- Donndorcd aaaherot] vertex pn

i-nlaii.iii;.. l i n-..-iii:iiiini ■ ■!' (In- I'w-e caUtMil be -m>\ i" !»' DOS-

innii, to* tt ooaui - one* la about avon 230 oases of labor,

Positions; Tlir eliin i- tin: »len>>iiiiii:il"i .1- il rfpIaetJ ihfl

»)Ccl|iiii hi llif iitnnhanfatil when compared !>> \<v\<\ pii'-cnla-

insim, lor die hand u extended instead of being Bexeoi
Tin- long duuneter of tin I ■>• . uY (rontouiental, usual!)

OOOUpiW lib.- right iilili. ( ii«' 1I1, 11 1, ■i.-r <>? the peh m- hrim : lielier
the BIOVl 1 H Pitiii'Hf. iirr ' If M P u d L M L«]

rarely, I! M. a and I*. M. I*, poahkuw mny In- met with.
Causes : Anv oowfitloii virion tend bo interfere wUbpropej

flexion of the head may bo »i-i down n» a gqu»c of fiioc pre*-

I'lltltioll. Til'' IH** - 1 I'MlllllKHl i-.HIVf— .in- !

1. Obliquity of tin- uterae, which toti by altering the line

of !-■■! i» ;i .1 pressure*

2. Twnofl 01 the lirl:il luck. I h\ runl, or lli\ iuii->.

3. Colli "i 1 thick oard around Cm doojl

4. Dead t'.rt.l-.
.». K\i'c--iM' lioaor amotf.
*i. Small •!/•• <►! i«ii n -.

7. Deloinii-il jH'IvtM.

H. TunkOfi of uterai of neighboring itruotnrest

!i. 1*11:1101- upon 'he heak, :i- mvniuguoslfb

10. Dolichocephalic beaa\

11. OcHiuntopovtafiof poaliouttj in « i»i*-li thttn in a tight lit

:il llir lirilll,

Diagnosis of Face Presentations.
Abdominal examination : It U BOinclii"''- :t matter <>!\IiMi-

-•niiy to miike ft dtwnoib of fhee prswonratUm when the
1 idomlnil wjII \t thiol «-i lane* I moll; the balky omnia]
vault can bi felt in one h '*• 1 .-i-f .n. and a deep groove

m.iy be made out between n sod th< i< EeJ tack. On the
njijMi.iie .i<li- uf tlir abdomen the Ratal members may bedfa-
1 ngaUhffd (Fig. 71X A* the fatal back li dtuplaoed from

lie- iileiinr WttU DJ I lie e.\|rinlei| 1m*:i»I llir httlH+mUuU UN

lie lir-.irtl niosl (lUlimllr mi tie MOM -"!• ••! llM alxli
tijK.n wltirli llit' t'M;ii .-xTi-wniti.-* ■'*• Mt

Vaginal examination: Eariv in labor before raptura o|
iln> iiH'iulininw, the rounded head to be felt in tiio vertex

Tnait vtw portilwn or flic« at *u|M<rt<>r »it»li

cam* i» waniinp, nml usually nothing cm Ik 1 reached but the

ImiIUv ivt^ ->f w-ii.'f-. i- ri,,- r ,- irroated hirii u]i Cm

ibotlid bo UuYoil not In rii|)lurr' tin* meabflUMS in ult<'tnpling
to rriirli (In- |.i.-"nt in,' purl oftHo f"tn- Should ttV hag of
mteri In rupturod, than u may !»• poslbk \» dfotinfritiidi the

<ni|M>ivilifiry ridgca, the eyes, the noan, and OBptcbUjv the month.

The littler is iJifiiiitfiiirthetl In feeling the toOglM and Mm-
alveoli! i maryliM li ttiocejioi fiuoocdanoun not formed over

the lili-i' t il nun DO iiii-1:immi foe :i lim-ih. nnlr-- nil. lit- Cikrii

to (li.tiM|Mn-li rlt-.irl\ llio relationship of thfl btrtt wiihin
rvarh of the lingvr.

Mechanism of Face Presentations.

The flrnt KUge of labor is delayed beOBUW Ibe head doCO
in.( ht ilu.' loan i in< line icgHient m wll ii-i iii vertex presen-
tation!

Tin- ineohnnU t* r I* ■ -■ ■ i^i--. differ* from tlmt of the

vertex in thai .

1 The eliin takes tl" I "l the m-eiput in being the
Iddhlfl purl of the li<::ul in dttCDSOt. Il iloe- nut ci "lontl

n &r "i advance oi the n-t of the li«:i<t :i« the occiput in
\i-iir\ oawa, -u iluii niternaJ rotatioo of the nhin forward to

UM jiiil.tf OrOn iM-rin- riilii. r luh ;iut! [n MOW.

'-!. Motlloilif !:ik< - | il; i . < with moiv ilitlieillh (hull ill Vnlcs

■
3, The lu.'Lil i- delayed lonpr :il ilir liiim, :i« • xtnixion

h;i- to bfl vwy marked bufbn <J* ueul « — ■ < » befrin; heuoeyifl »
ruloj labor i- delayed.

It. M P#j \- thi- is probably the oonuwoeal poeitloti, to
meehanian will In deaorihod <" detail

flu' long diameter ol tbi face. tb< frootofueotaJ deacendti
through the inlcl in the right obliaue diameter of the nelvio
brim Xbo ebbi deecendi along Inc i"- terror pel viopoovo
on the right - i*l< till it rtriki the pelvic Boor, then it rotates
forward through three-eighth* ■»! .t circle on the right fide of

the pelvi« till it r..riu' tinuVi the puhie ni'eh. The Itrow

. into tlu- billow «.f the sacrum, and the fronton*
diameter ihut corrcapooda to the autc^opoaterioi dintnofci "i
the outlet. Tin chin thru appear* ai loo vulva and cacaoce

1m mil i in- piiim- arch, The novemoot of Bearlan thanne-

the . I. in pivoting nndai tin- pubic oreh. and the iiuv,
forehead, writ \. and iioolpul racoeaalvelj clear the pei

T 1 .' , The Iteed now being free uamtni latlorwhlD

lu the »linn|i|ri-, ffhtcJl ■>('« npv thfl light Obliijur iliuinrter »«

21*

r rvotoer w uku

tb* privi* i (be revt of the iDccbaaMOi w the mm* m

off, a i

f, \f A.: Tb* »*eh*ni«n i« tltr mmtm* in i >-»«,

•serf* ilikt the <«riput m rrplftoctl by ike cfaia, wbidi pivou

Pfe.1l

!«(■#« in mil Uc 1 i. - dI luuilm in •ii, iii ncntoMBWttf i«f»M ( af ■ run*

pnMiaiMii abu nwiDi i" i"' 1 " ■■

nwler ilia pabmj then lh« head it dcliveml by Avxioa,

Siiiii»iiini> in a lurvi' pdvw ii"* h«.inl may bo puabeu throtttb
ii itoiMuon iv i thou I my Rpeofau nwalintLUHL
Id mentopoiUnor pwftfom tho head may <l< Mend into

M.W.VIKUEST t'F FACE /■/;/■'.- /■' \T,l 770M 219

jh-Ui- Millirii'iills fin l<' l»n vvnt .umplrti-h tho iHltcrinf i-«:.t-
llOII i»l" till- rlllll, \\lii.-li i> llll'll tnf.'i-.| iik.i (In- liollow of the

mcran. Tin- condition U pracdcallj fatal to the ■■lull. Ru

I lir aiilliur li:t- U'i-m :ilil<- tO And bill MM DAM KOOrded 111 uhirli

■ living Bnllu ww born aflvr i In - aceunnl Ixd ooenrrad.

Hawl-mouldiUi: . The \;mlf of the head ImcoTDM Rattened

ami |n)-|i<tl lnti'kuanl ; flu Jtanii'h'r- lengthened ar« the
occipitofrontal ami (lie - m -«-i pit* .11 i<-iit ;i 1 ; 1 1 1< • flhOlttiTB ibOrt"

rli.'d i. In -iiUnrri|ii(nln-i'j;iii;ili*' :mtl tlic OUVICnbfWIIiatSc.

The caput stjccedantjutn is luuml mi tin* lin-i , uhieily annual

the SVC « liiih li.- interior when (Ik Ijkv i- ;.l fhi' brim J

owing -."in.' Ituciij of the tZaaaenof <i"' boa the eweHiog it

i.lh-n vt-rv i:ivir .nni rln- di*0OloruttOn ii'ii-ni.-nililc Tli.

eye may i" wd for dnjre nitd the obihl may be unable to

suckle iroiu tlie swelling of the lip*.

Prognosis.

riu r.it.ni iiK-riJiliiy in mot a m laabottl 16 pet aentaj
the mutarnal mortality i* given u being over t> pet cent,,
for tbfM oneta are frequently RiiMuuna^ad. The labor i*
twiiou", ji- i rulf. Anterior position* of the ohifl an better
tlmn poaterior, u ti"' labor i- quicker. Than !■> oeoally
i>>. in ..i l. erioua laceration ofthe perineum,

Management of Face Presentations.

Tin' important point in the fir^t stage u to preserve the b*c
of walfim ini.n t t- long aa possible, ' ■« -■ *»*»■**.* the fuc*e U u poor

riilalurof the cervix. The patient should tbcrafbre beJoepl

in bed till through this stage.

Flexion by Senate's method- It the -Inn . p...i<-rh>r :m
Ittunpt -liniil«l In* mmh- i" ri'-ti.ri flexion and thtMOnnrerl

tin- posltl nton verted anterior Tfatama; bo accomplished

by

rvcMiilliH'liilcil IM v 'ii:ity. IT IJC- i.ll. I t|t> Woman ih III:

Oil*

gentle r.\h a iti:i1 niimiptilfttfon trcnnUng to the method

nillliiruitril In BchafS I ' ij'. 7.1 1. '! \v uoiimii i- phi.-. <1 in
l!i- I'n iiiI-I.iiI.i:i ; 00 Mi hi. wliirli I ti' ' >• :ii:enmpli-Ii< I ;

■rra&fgfojr an ordinary wooden chaii (Am sawing off « l ■*
eiONS t" the wooden -*■:**> on the •>■■-* I -<i thai it* hack forton

nil loOainad plain:, COVfing il Willi a fnl'ltvl lilanU. i

220

I'AT1!<-I."<-Y OF MRQR

drawing i Ik- patient up over it withal her buttocki r.

i lie bacft edp- of tht seat. The ojwn*tor then pnmti on tlw

•eiinil of tin* child Willi

Ml

Oil'

. .mnd, n> n* to I'nrvc il into flu-
Mlvm, wbll« In* prwwwi lli»" oIIht :ipiiii>i llif rliiUI'q nook OH
iJli' OlipOaiU) "ide, I hit* nVxili|* (hi' licml iiihI -li;Li_'lili'iiiii)/ tfu-
verlfltrid rotunO of ll"' lotn*. W hen hVxion h;i» tIium )iccii
iK'-niiinli-lii'il, prWHUm ■* tliOU maintained uiton tin fl I dlu
:l^ to loroa tin- bond i"i" the |>elvio brim in toe flexed pi

IT thii be round imrxwildi*, il»- cum' iihiv !*• h*ft until the
08 bu diltted| when, niter rupturing the Membrane*, mi rfWi

i ,,

!

m:iy \>r niiitlr to restore flexion liv Introducing the hand Into
tho uujrui.

If it he found impoMlMo to maintain the head in tlw
il. vtl position after thin maiuvuvrv, the forceps should foe ap-
plied unit the head drawn down into the cavtt*i in n tlexad
KwiUon, wlien the blades may !»• withdrawn nnd tin- doll von
rii io Douirui

II' lli- juilieiit i» ;i multipara with I:i\ |>:irt- :md the uterlll
roiitrnetioii- jire jtowerfnl, the COS* "i;iy be h ft In n:i(iin ; b

- an ibould be excreifad "> eeoura pood extension ••>• (he h
«l< , i ndi in onlcr that the chin may reach tlic pelvic floor i
advoin '• »>f tin- ivm of tin* lieml,

In i pnmipara in whom the presentation in posterior BH

uuvwn -nt - v/'i77'VVA

SSI

in found impossible to restore flexion, mknal NNNM may

U- employed.

Forceps: If nt-iun !*• imp.— iM<* in :un«*rii<r position?

ulirn- ili-Im sn at the brim, then fbfODgM mny be applied ;

bin ilui oinTtttlon U dtttteuli and diingcruii.s »> the Modus
i.mmI to -lip off tho head when taction i.« m:id<-.

If aJI i!i. ■-.■ .Il'i-l. !:ul and tin- dbifd ha.« perished, thi:u
craniotomy niu-l hi- performed to i-viin.- deliver;

When l lie head ha* |kiw<m1 t In t lniiti and fails to adv*nco fur-
ther, then u uaniBOt '" the ohfld from tanaion on (!>< > vi ■ ■-• I nf
the Doulc a&oaing ODwrgiMMml of Iba esrebraJ oircol&iion. In

Mirli i..-.- till 1 loKWp -lioiild I" 1 employed tO hWtfn delr.nv

nymphyiuotomy tui own recommended in • ;t i [« raigUrnt

nK'iii<ip<in\«'rior pouUoiu If the ofailil it living

Brow Pruwutatioiia.

Many

nut liiHitit-. dOJO?!bfl ft halfway atago in the drvrlup-

llirnt ol fan; prrtriitalion*. It can mmu'cI;, W rla-.-il'ml :i- :i

HMoial prmmlMEoOj bol uoold Im oonnUjirM u -imply aoU-

pl:t<'-|iiriif Of the veilr\.

Should hucIi ;l per. -dilation be im<t with, it ran only U* diaB-
iiltxcd by vaginal «'*:iNiin:ilnm. Tin r\ It 'ii-i- »it «>! il>< In ad in
n* top lifted by llir liirl thai, imlead of lbs V»rtl \. the BojEW

oomat in onotaot with tb# brow; pOMSbly iln- anterior footn-

iii'll* may be diatingoiahad, a« well ;i- (lie -upni-orhilnl ridge**

Trf.xtmunt oonsiata in th# manual restoration of 1 1 • ■ v ;

ami if tin* ba uapOBBible, << i--i.,ii mu-l Ih n—.rlrd tn in ord< i

to effect delivery wiili a minimum of risk to the mother m«l
.•liihl, In rare inataooeB in widen the brow radJroetad ante-
riorly tile bend m ■ .-mi tw rln- ptdvie rl ■ in ihi- pnrtiiillv

extended condition; in <ueh cases the sinciput, being ii
airsnoi of the re*t of the head. i» directed '" the puU".
the root of the OOM pivot* under the pubic arch, and the hei
i- delivered in flciinn, pn-ei.-h the -yinie >- li:i* Uvii de-
scribed In ipedking of "Bum ba pole- " ca&cs.

KKKKCII PRI 9K> i '. HUN&

Definition : The ph-.rnt.iii..!, ..!' -.my jNtrt of llo- pah la pola
of the I ■■' lul ovoid at the inlet \» li-rnnd J Imihm-Ii pioi n(:i-

lii.it. *n«' ftftHA, tln'tvl'mv, inrluilr- :t |>rvft»ntAtSon nftlM ■

Unfai, kru&t or fat, Xbo denomination 11 taken nun tin*

po*i(ion .1!' iln <nrnni,

Frequency Brettflt hiv&vnljitioii- orenriii lliv proportion of
1 in ao labors; if premature birthn bo cxduded, tlwn tbc

I'"' 1 ' ,■'■'■■ P....1.-... . 1 loirj In t. lull. .11 •«■(•» l"i>- f

nam < mvi % h »imin

proportion i* alniiit 1 ill 110. The pavilion* ill iinli-r <■!' 1V1

?uencf ire L. & A. ; It. S. P. . \\
4 and 75).

Causes: Certain condition* favor pnaenntJon of the breech.
J li. - M' . hi.v uterine or abdominal wnH», axccmIvc liquor
amnii. uterine obliquity, multiple pregnancy, death or proma"

DJAt;.\o.sr\ ->i liliEEvil MESBBTATJOXS

333

turitv of the fatas, plaovata pnu\ Et, (-■mtnieted polvit. tumor*

uf tfie tit em* or DtfebboftnK BtfUOtQfi ■-. numrtrcwiity, (ind

>. \ • 1 f. .. rl .1 ■ I. in -.

c«

riTMWt) pm#nl«lon. !*ft ww *nicrV>r r**IUon iAftorA.lt himi—.n i

I>iagTios]3 of Breech Presentations,

Abdominal examination: On exploring Ifae UCBVBtfoo of tb«

it will l>o fitiinr) • ni[»iv. V lull- uf tin- liriin B liiiV- 1'iilLv.
IrrcyuUr, movaldi' tnii- nun I* li Ungnulwd. ivlm-h U Ml
enjcMfw! nnlcM IntW lim well Mh mora, it UM ftinditt On-
lianl. wrll-.lcliin.i r.iiiii«nr ••( tin- )n-<i«l irlll b« . :i-ilv roecg-

lll/nl. Till' fui:i] tldirl MHItllK will lie lirnl'il nil llic -:iir (n

wlnrli On book i> dfnotad. at or almw I In- l*V«I Of tin 1 UUh
l.ilici

i:irunu>i;r nt i.utuu

Vaginal examination : Qatl mini bo taken '"•* to rupture

the DttnbruMsif they bo found tofaot« En mnafns the vaginal
enunimtioQi Generalfo the bravefa i* uiUiated eo high up

tlml it onnnol In* mohfld Without rUk of rapturing the h:ig

of water* if l\ xiiminatioii i- madr rally in labor. After

labor has udvnnccd nml tin- membrane* have ruptured the
brooch may l>c recognizo'l by fevlinj* lie -itoniin, OOOCyij ami
ischial tiibcro»itie* of the faatttf. Tho inui limy Ik 1 rom^ni/oil
by i he ^msp of the *|iliinokT uni. and b\ too prceenoe of me-
oonium on the examining linger. If the ohira in a male, the
MTutiMi :tutl peni* umv In 1 toil. Owa*ionnHy the former may
!«• trdrimitoiiH mill may then !«• ruiMukon tor tin lm^ of waters.
One or both fori in:i_\ be felt; the font inny ho oSi-iini-uMieo!

from ilio hand by the projotf Ions of tho bed ami ihe malleoli.
The knee nmy be dfaungofehod from Ebo elbow by tho pm

moo of tho patella And liy tho larger A/a: Ciiiv lnli-1 be

t;ikon Bo difiiuguMi tho breech from the lime, for which it is

otlon r 11 1 -i :i I-; ■■ii-

Mechanism of Breech Presentations.

Tho first stage of tabor is very |»ro]uiiov«l, lor tho breeOU
f.irnwa poor dilator of the cerviv. aii'l OU eOQOUnl of Etfl ->f1-
nots io't- imporferlly 11^ mi irriuitor of reflex Uterine ouiiinto-
tiofffl,

Tin* breech ilraeomk generally with tho anterior kip alight!}

in idvauoc of thi other. Tha ulterior hip in ^trikin-.- the
pelvic floor b rotated forward to the pubic arch, where it be>
oiniii'- iivo-1, while the trunk i* driven down ami the posterior
hip moves forward over the perineum iity. Ttij. ( i-jk

both hi|»- . ■m.'i'i'v through the- \ ulvu at th« • same time, then
follow the rhi'/h- and trunk. If th«' l<v- mi- flexwl properly,

tliev generally escape with the thlghi and breech.

The shoulders puss the brim with their long diameter trans-
eerae : they Ihen turn into the oblique, and liually.at the "in-
let, Into the nnterapoatcrloi diameter. The anterior ihouldex
ia generally delivered Hurt, followed by the |ioaler1or.

T! io head by tin- time, if flexion htm l>oon maintained by

aedve external contnotlooa, lm> entered ilw brim with it>

loii|_' (liiirn.-toi in the o|i|io>ito i>l.li(|uo diameter of the pelvii

''t:< ii.wtwi m r>i:t:i.<n ruhst.si ■ j-j

lo tint iii wliirli rim -lumldi-t - pngacctli Tin' OOOHHtl UMully

Btriki -■ 'in* pelvic floor ii r-*i tan rotated u> toe fmnt, while tlits

f;iri> t* ilinvlcil tu the hoUoWOf ill" IBOHIOli The EttOfl -«■»»*!

forehead in then born-, fallowed by the rati of ii"' beadi

Abnormalities in the mechanism: 1. The ortiBoA iiinv Ih> nr-
rcatod ut tin- brim <»r tuny nut onpitfo. Thi» nmv be dot
cither to |" It i in hi i. ,ii or to exctmjvt* sine of ilio fu*tu«.

::. The !■,.,<>!, in, n dcacvud into the cavity 1 of the pvlvi*

mid lliri'r I"' ;iii« -I<-d, Tin-. Inn\ !.«-* <ln<- fn «■.. l/r n|

the I ■ in , to ImrpMAcd «liliiliiln'li of the external Oft, lo pelvic
(l.l.'imii .. <>t tu the extended position of the limbs along the
bodj ul' the child preventing k?> Enteral flexion.

Pwi» of bum«k» oviT f rlnoiim in u buxvU com. (After naraml

3 Tin owi may become eortended »"<l enune attest of th<>
in >j .ii the neivk i>riin. Tiii- Boctddal rag he doe t<> in
hopcffeetjv dilated oe or to pelvic i Dntmetion 1* In *i ry ftp!
to occur if traction i* made Upon the body of the fatal > ■•
ncoclorato delivery,

I. Tin- /*"»•/ RU£ be urv-tcd nt the btflO ,,T ID tbfl

Im n rv-.iilt of cxternaon or (ViHii pelvic deformity i
I • ■■■ 'K- «ii, -ii die bee i* directed uterlorlj the chin mny

catch <>ii the uppef border of t lit* pahce and cants delnv.

Moulding of the fcetus : The brtvoli le generally ivouen hi. I
often dboolorod from eccibj row ca . thedlecolostlon i*gencraUv
bV-Obtf.

m

I'VIWH.'h.Y of l.Minli.

iimiv m:irlM<I over ilic jinirriur hi|). 1 1' lh<i ehild Eft a mall tbl

scrotum it Evoorulrj fwensatoun.

Prognosis of Breech Presentations.

The foetal mortality vuru- (Yum !<> tn '■'>" \m- mi!.. <lr|towl
log upon ill'-* skill of ti»«- physician. Tin- risks to lira ehIM

:nv (jii-at, due hi tin- |iruI:i|M0 of tbc OOfd :iml I lie pTOS nir ..!'

tbo afar-coming bead upon it. FVaotniw and mUocatlonn
iiiuv bo caunad byaflurtaat rapid dallvery.

The risks to the mother are mcreaaed only b) the tondoncft
to I;m'**i-:ic umi and i<» bruising of the aofl parte on account of
tin- ni , "' , --iiy for rapid and sometimes violent extraction ol
tin.- ■Aer-ooniiue bead.

Management of Labor in Breech Presentations.

General: Very .urly in I:il..ir. before the membrane* have
ruptured nr the bnn.'li luis become engaged in the brirn, it
mi:iv bo poosibla i" perform an external version, The opens*
lion i- n"i always practicable, and thencfiuv duirild not be
attriii|it(il null— ■ there i^ xrinintj ilmi ii can he saftCcsafttUy
Odaomplbihod.

The position of Umi phyricion En alierge of a brooch com
-.liniiiii bo 000 of armed expectancy. Ac long an iho natural

troocogoB are proflresoiofr strafaotorily hoaiwuin be watchful
at inactive, and sImhuo be pre|Mired i" bitcrfefti promptly od
the tmpenniDix of uaojwr to the, child.

Wneri pasaiblca skilled assistant should be obtained, when
ilnty it i- (•• ajSvc tbo anaesthetic and attend to tlte maintenance
of pressure opoa tho fonduftj so a* to ptweat extension of thi
bead dtirinp: the delivery.

Preparations -huiiM !»• minle i'<-r treating ttPphvxln of tbc

newborn Enfant. At huml should be piaocd, tferiliied und
i. :i-l\ fur us.*, iltr llgntares for kho cord, scissor*, two jmirsof

:i.rtrrv-fi»rrr|iMlo he un-il Instead of lignum* iiirjix 1 * in wMoll

spew is demanded), a haaln containing warm sterile (rater hi

which are I oouplo of sterile towels for wrapping around

(lie cluM's IhmIt (hiring delivery, :in<I llic ordinary obstOwC

foro 11

UAjrd9BVBNr or labor &&agxm*sauarrArxm 223

Throuichout labor llir ptdflUl dimiM !»• K* |-t m Im-1. :mi<I

ill. mi I in- cautioned again>l h training during the flew* tinge, ■<■■

it i* ilc-inihle I" n'l;nn (lie Mii'iiilit:ii» - w illi-mt mptine ft* limy

na powibtaj i<» favor ootuplotfl outtmiion of il»- oe ixtori. Tim

t'.ftjil ln':irt-iuiunl- ihullld I"' liv<|miitlv ;iiwiil!;itcil during ill"'

aooond ttMgc of iiii»«>r, unoe there u always auicvr of oou>

Erenvion of il ord irregularity of the heart-noais il sttf
i ii'iit (.in-.- fur inliM'tti'i'ihc.
Win 11 delivery is imminent the patient fthonjd lie in the
dorsal potftioDi with the thighs flexed. In canes in which it in
ncecuary to effect a *pccdy datively the patient should be
placed ncro** the bed in the lithotomy position. \- -< i

the bnttDcta amargtt thej ihanld be n. rapped in d muni tattle

tOWtlj Bo pf6Y0nJ dM ebltd making ctiort» nt r. ptl

From tin- Ruml the tmttoaln :i|i|icornt tin- vulva till the

pnUNtntA U d<>livi'rr-d the fumlim Atari nhonld I OMtanfy

under tlm control OX :i" IfWItlllTllii Tin- Irunk, :i- it iMiuf^<-,

-iioiiM hi.' - ii i >j .1 n-r i <1. ... ;u» (0 i.nvctil limine -(r:i:n ii[»oil (he

perfovuia ninl (motion upon 'I"' ■farooming lieau\ \- won
:i i the feet appear the lege rony be gently drawn down in uion
x way ni to nutki- bo traction upon the bod* of the child,

X i <■ thr umltiliru- mi within roodi of the fnv-i,

n loop of cord may bi gently drawn down and examined. If
il i pulaating well, the com muv he allowed to deliver «lowlj ;

hut would then* l» i-.i'li' ■ nt" ••nin|iri'-M..ii DpOD •'. tboo the

delivered portion of tin- .'IhM'* body should !*• piv <■<! b tcli
ward md upward, and an attempt made t<< loosen thcoord

Rod to pliOt it in i other iliac fo*. i out of h.i m' »:n :

if thin effort fiiiU. then delivery ihoold be accomplished a*

lily n» puwible.

\ the elbows ippear nt the Vtthni the aWM -I Id Ih'

drawn down, Uld then the ohild - body »hnuld l>.- well rl. -

• :n<ii. .1 i iii prevent the escape of the headi

In tlif i|fli\i'iv of the h«Ad Ihen' 1-. tut need for rapidity in

nornud eooMj when onoe the raouth -thI nostril" hnvt • N in i
rhe ptrtnnttUi These must be wiped off to preeetrt ifpin-
tioti of muoui -honi.l tru child iMi onpH lo bn rtne Then ih*
hetd should ix deJivered ito wly and cucTulIy, *o ■ tonrotd
rapturing ti" pcrineunii

•12*

r intoLoti v '>/■ i. a m

Trefttmont of Arrest of Brooch at tho Brln.

»t of the brooch at tho brim may be due t" 1 1 ** » exi r
of the child or fan polvic deformity. Tho precaution
flhould always be taken (if Biouunng the mother''* pelvis,
nnle*,* this lift* been done, before any njier.itive men-nrc are
»d-t|itfd.

To Moun dcnoenl five niothode an available: (h by
bringing down (be anterior lea ; i-) traction nidi n finger fn

the groin . i;i) I lie bllinl hook ; (4) (lie llllrt ; :uul ij nppll-

r.ition of roreepa.

Traction iifUr bringing down a leg. The IuiimI, the jmliu of
wlneh GOrrc»|H»tida to tlit* flbdoDiinul asjieet of the ohftd, la

l .... ",

Brweh r**— nuiioii-luB* «i b 6

slowly introduced in the uterus can being taken to u i cretin
the nofkloD of the ftetnl oord n u to = i >. • . i . 1 dragging i< < !<■«■».
h well ni m iii pren gently baek the breech, m u to die-
engage u from (be brim before seizing n t ; »'t. The interim
fool -iiouhl olwaye be selected, end when firmly grwped may

.VI \ UiKUKXrorLAROR r- kith n vi;FM--\r\iUiSX 22f»

be gently drawn through the o» and vagina. Occasionally flu
log* may U- found extended along the chert of the child (Fig.

77|. In ntofa ii cux* the foot uaj bo l*r* ■ ■ i>- 1 1 < within rem-h \>\

pti~-in^ inn tin-! i- nl-inif tin- l.'n-l, hi' i lit- thigh, nt tin- suae
lime ■Edaediu ii -" u to prcei die knot t ■ • • <i ■< - ade; ihua tin*

lnul U-ii.|~ tn (Imp «KiWn Hi lh« median Inn of (lie rhr-t, uliil

m:iv Ik> i>rnfij*'-\ U -li|»|iinj» tlu- tlngem down along the l<^

l'iu\ idcil llirfi: lire DO Indication* ncceealtottllg >|M*cily dclivei y,
llic QBfB Duty I" - It'll 1" iniinri :i- MOO 0* tilt iQOt BM DOM

drawn down to ile- vulva.

Should llm |i;ilirnt In- c.\li!iii-|i(l, *li'livtn iimv be h:i>1nic{|
l»y rwiul>iiird Ir.U'lKin tin tin I xi| \* hicili lull been (iRIUghl dOWfl,
and |HT--iirc mi ilii' fundus iVnin ibovi The l:iitir -Imiild U*

managed bj the etariHtant, m tlutf 'l" 1 operator nny give hi*
whole :iii«'iiiion in ilu' nbilu, Win ii ii iKuwirvd loefteol .1
aneedj delivery the patient -Imiild he placed in the Welolicr
poritioD»and when poanbJ ;i table. Tin' fool ahoald l>e

gnUpod between th< lir-.f ninl '•■i- I fingers, and the lint-

of traction »hould l»- .lu«n":ii'l mul bark ward in the nxi*

i.f tin- pelvic brim. When tin leg i- beyond the vulva it
ahouid l»- wrapped in n warm aterflc level, and then .i> mu-.-li
of the limb u i" 1 - Able ihoutd he gnuned in the whole hand.
The operator nioiihI hnlfodoea the focefingei of bin freehand
InUi ilu- v:iimii:i and bona ii Into the noafenoi groin ai oon ■
it oonei within reach, hi order i<» dtatrlbnu the tractive fore*
a» wnirU :i- |K.— ii.jc. and ilni.- reduoa the mka of mjurv t<>

llir rliili). A- the l>i-«<li diMl ■ml- I lie |.i-iincmn it .Ixnild Im-

drawn fbrwanl BgainM ilu* |hiIh-, bo ai to avoid laceration.
A- -null ;i- noeaibTethe poeterior limb ilmiild In- ltuiIv drawn
out, in doing ilii-. preaaore on lb* thigh ahoald be evomedi
oare being token to kbEm the fool anoVdrav down Uu lag in
-m ii .1 wav thai the knee a ■ down in lb* median line of

tl liildV Ih.iIv.

\\ I., q ii ■ irapoaoble to bring down n r««»t it may be |«»-'-

Bibli] to hook the forefinger In tho groin, which nay he done in

nny nidniii-r ni- ni i.i ilu- «■(-•> ..!■ o*. I'm. -inn rnn> then

I- in ide don Dward and Imekwow, cure bcinp uiki-n t«» avnid
prrMiiri' on ilu* ahaft of the femur, on aeoounl <•( the danger

of ii- mapping.

Tin- blunt hook of Allot may bv uvd nvu tractor. The hitter

230

i'\nim.r«;y 09 LABOR.

ohould U' n-..'<I l»y preference II mwh tern Kablfl to do damage
to mother or child.

Tin- fillet i> usually e*nnp«>-i <l of a Bl rip of -i>-rili^.-« ! oottofl
or Mii*v bsndu^c Tin- U-I in-lruincill for piecing UMS til let

i* a gum elastic catheter. The catheter «hould be Ihn I
wild a loop nt -hinj and then, with it* stilot. should be bent
*o a» to form u large hook. After it hat been sterilized tbi

hook -huulil Im guided nut (lie anterior hip und rotated >o

ihm Its polnl pomes between the child's thigh and abdomen,
Tim finger riiould thee Im passed between the thigh*, an<l tliu

loop i)f titling drugged down until llie lilli't run Im- threaded

through It when bv withdrawing tin catheter and erring th*

Hlli-t QtO Im drawn into place. The linr of traction should
i!;i :i l>. i - . w : 1 1-* J the child'* HjKTum, •<> :ih to avoid In-caking (In*
liiniir,

A* B Iteri reeerti shonld .ill other menu* fail, the forcaps

should be applied to the breech.

Impaction In the Pelvic Cavity.

When the brooch becomes impacted in tbo pelvic cevity (Fig.
78) it i* gffDCBdlv importable to draw ilnwn :i h-g.

Trnotion nun be exerted by hooking all index-finger into

the groin , nr the fillet may ho u*od. When these means full
■ ■ .i nun be employed. If ilw child i* alive and moderate
traotfon with the forceps tail**, then ■ymphyxintomy maybe
resorted tOi When the child ha* psrlshed embryotomy i?>
neoMHiy,

Rapid Extraction of tha Trunk.

A* -non sj ibfl lags and tho pelvis of the ehild Imve escaped
(cam tin- vulva they should he wr.ip|H<d m n warm towel and
grasped with both hands in neb a way that the thumbs of the
operator lie along tin' mcram, while die Angers wise \ht
thijrh*. Thh given the mom 1 secure grasp. Traction is then
neat downward and backward with both band* while the
assistant prcssr* flrmlj on tin fundua, As won m the card

enn Ik- iviu-lird ft loop should l»e drawn down, as i- done in
normal delivery of the hrceeh.

When the angle* of the acapul* corny into view the delivery

v IXAQKM1 \i <t t \i;nn t\ t;t:t /.• u i r:i r\ r.\ n<>\ ■ I

cd* (lit* anii- hIhiiiIiI l><< atbMDptan To <!<» tlit"> IWO lingi-r- of
tl»' OMratorV band wliloli corn qwnda i<> the win ii in utaired

to rrarh, -li-mM Ih' i*;i — - -I Up OVW tl"« ftbouldtf hkI iIi.w D the

arm |n lln> cllinw, wliirli inav (lion l><> «w»-|i( HOTON Uh • i

o i to bring down lot forearm ami bond, Uw ohilfft body

bring In-M in Midi a ou-itimi si- In give I lie greatest freodoni

to,

l*IU»ry of ohiUI lit * Vnxvb <■•** 1-v (mcUoo tu««)< t»tih ftnu n. (toll.

i \n,» v i: ...

Of inovi'fiifiii poasJblu t" ili«' operator. Having rtlia-.-tl ono
:.nn. i}m operator iboald thco rfangi handi aod daltvoi tbi

ntlici arm l>\ ;t -iiiiilar inati'i uvtv,

Upward displacement of the irmi: \'"t bsfraquanUV Ih*
nrmt nre found to be AUpiaoed upward aloqgtkla tin boad.
'I'lii- i-. generally iiHlieii.nl by greater hniaranoe i" Iraotwm

232

r.iTliOLOGY OF I.ABOK

:i!'h if the M-nimluT have until- into view. Whan thii oompHo*
lion i* found tin- body of the nVtu* nhocld be pUBfled up in

the a.\i- of ilir hum, K) Of to dfeolofflh ilir juc--uic QD tint
trOUti that level. The bodv whould then DO rotated tinhl Etfl
hack i>i directed Ul one or Other Pndo of I In 1 mother. I'-ualty
Ilir pOOtirkV Oltll 111 BlOttl accr>*ihlr, and Efl llicrclorr brought

down fine* Molding (he ehlld'i body up againftl the nooee
i!h' operator pn ■ w I ifo Sogers op ovet ton posterior shoulder
to the elbow, and iweepe the ana down leroaj the (aeoand
chest it- 1 directed above* Saving released the posterior arm,
tii< onild'e body i" preaaed over against the perineum, and tbo
Ulterior arm U brought down by b Biiuiur duumbuvtOi

The anterior arm moy l>c 00 (irmly caught between the head
.ni'l the | in he* thut it may he impossible to dislodge it. In
this caw it should be rotated r»> as to conic into i posterior
I « '-it ■ • > ■ i Tin* notation i* uccoiii|fli»hcd l>\ gmspine. the 1 1 tin tv
»f the child's ImhIv firmly with both hmnU. lowering it u :» to
bring ii- I'uii: : i x i « to correspond to dmt of tho pelvic brioi (
mill then shoving it. up m m io roloiM the anterior arm from
pn ntiPO. Ac toon a* the arm i» I < m »m « alnng-idc of i!ic head,
tin ehild ib rotated abont it" looe exit) bo thai the arm which

ha* heen ;ml«:rior p:i-*'- along the -am. -id. of Mm pelvil

backward and resti h> frool of tha wuvtMliao aynohonnfoaia
By thi- manipulation the baoli i- moved from one iidc to tin*
fraoti and then Io the opposite side. The arm i* then drliv<

-•r.'.l a* wiift the posterior nrm in the first instance, OooaBSoD*
ally tbaaoterior arm may be folded behind the oeeinut. In
this ease the revolution of tin- body must Ik- muae in the
opposite direction. FirM turn the nhdumen of the child fol
ward and then to the <ij»|» i.-.ii«- -*idc, ihllfi musing the shoulder
DO rotate through three -quartan of n circle.

Constriction of the head by the cervix: Occasionally the
earvfal may Iweorne tightly constricted ahour the child'. neck .

ii condition which generally ftUklWeN the life of the ehdd.

I'll, patient ibould b* deeply Bnaeainstirod, and traction medc

on the ihoaldci-v with our hand, while tin- lingt*« of tho
other, placed in ihe chihlV mouth, give: what. eafilstaiMfl tl

|H>h*ih|»'.

KABABKMMSTO* ' VtOB ffl r.iu.i en r/;/ ••/•. TA now, 839

D«lt7«r7 of the Afl«r-cominff Btad.
DoTcnler'i* m«lhod . Probtbh thl • :i-h-i motttod of * ■ n • * - 1 ~

ir»fj u '|"« ilv •!. In . rv in ;i r:i-i- in whirl) tin! pQlYlfl |n nmt* ill*
(Ir-rcnl t)|' tin Ih.wiI wi'li Hit iiniu rxti'tiilcd ulnn^.-nlr i'
I), i ; nli-r'n. Tlir IhmIv (|f the (lllltd i> dfOpMO QOWflU :inl,

the (••<< mi graijpod with om bsntL wbUi tin- othoi p ro wl
upon tin* uppor ttur&M of tbv shou'dan, tbt neck iwiiiji i**-
twwn ihefinl tmd tooood ftogvT9i XVtctton b Dudi dowowtnj
toward the 0oor, the Mttffat Iwiug in tl»u liilmiomv |»o»ilioii.

■

• in riot it>mtir>n ft oral put

Thu« the ocefoul appvon M lb* vulva, tin- vottta nli|i. unlet

the pdvifi ftl'cli. mid llii- haul i> drlivrml in r\ Im-inti, pCing
fullnWi'il liV llit- iiniiK. Tin.- method i- jipplii.iUi' only in i\w«
III which t)n> JM'lvir -|:t. i i- -nOir-ii-Tit lt> permit (lie dCMCRl
<it llii- lie:ul :in*l : l i* i r i - IngVthcr When the lii'lu- U -mull, :i-
tii pmmilttrr tun .. tlii«, in (In r\|«-ni u.'c nf the writer, is
in ( :unl fiin-l rapid method of delivery ("niilmrv to

OXpftetfttifffl, 1*4 M.tli.'ii of the perineum ■ « rniv in i-Ji-^s in
uliich tin- ineihod of -I-'liv i-i \ i- |M.--ili|.'.

234

PATIIf>/-'»;Y "h LABOR,

Armi Delivered— Head Still Retimed.

Having delivered the arm*, the head being *iill retained,
the operator lias live method.* of delivery at hi* dinpowd.

1. The Smeilio method : The body of the child having DM
wnpped in u nnn tOWd, lfl placed <»u the flexor fUirliice •>(
(he iipcrntor'a left arm, tin- leg> hunting on eltho! side. The
lingvis ol [In- IiimiiI urfl |M-'-'l imIu ilie vagina, so that the

h» HO.

Tl»- Hi IM -lltf Vvil mvlbftd or «xlnwtlHK Ui« ullvr comliiit ti(-i<J I'Mcrlclu >

ti|i n -i on llii' fin*** on either tide of (lie alula'* in we. "I'lu-
6nger-fip» nf ilie riyht lituxl Jin- then pllOfd on the child'-.

occiput Before making effort* .-it extraction the head w

well flexed by pushing upward with the finder? on the occiput.
mid ;d the «iiiiii' time palling down with the fingers on the
face. Having MOHrod good Hexioc, tfac operator pulls down-
ward until tin- oecjpat U well under the pubin arcn (Fig. 7Hi,

ami then, but not till then. tllC tnmk ifl rained* i* f tin- nine
ft that traction is made mi a* to pivot the oceiput under

ma\ I'.imj \i >>i i. Mini. j.\ y./;r/:> u /'/.7>/:.v7 :\riu\.y. 235

I lie pubio nirli. iiml ibtll r i. Rum *wco|w over the perineum
and tin- hi mI i- ili-!i\<>i'i >i * 'it-- i.i n-t be CXCTtcd DOt C" lAlkt

'tioii ujth wn degree of force ooob Um bead dbtcndatlM
rinouni| other wi** thr In-ml will ♦!•■! i v »r with a mail rod

tllf Trunk will prol>lll»U Ih- .in '■ ' i. i< i- hin-iulioii.

2. The SmeUlc Velt or Maurtceau method: The ohfld'l bocty
i(< nlaeon "ii the opemtori ■no :i- dmcribed above, Imi dm or
two Angers ore inserted into the nooth in-i< ;i*l of on rtiher
hum <>i tin- iiuhi'. Too other limn! i-. pamd along fhv ehihlV
hack until Km minalci finger rest* an the oeejtritel protulier-
toot, \ilnti' il:i index ami ring finger* ore find 0T*f ll»*

I'm. HI.

'<>

:.

m-'.

Thfl Wigind-Mtnin meUu-Suf dollo-iiti* Ulc '",■ •!•« '■'■<' ilMOvrlvla}

nhouldrrs on cither <iclo of the neoR ( Kijr. 80). Raving

Iimii'iuiI lli.' Ih-ii'l and M-.nr. ,1 ^ I flexion, tnirtiuii i* then

made with both hand* M once, u mm uifl of Ino pelvic onl
lit. until ile neeJpnl plvoti under the pahei ; then the ohikfa
Uh1\ i- rairifil upward inward the ninther'* abdomen, thi*
niovi-iiii'iit I'fino; made Taw ilowlv nnd deliberately, in avoid

hu'craiiim of the parioemn. I tare must be ukeii not to nw I
ore or dislocate tin- ln\wi j:i« .

£16

r.\Tlii'i.oi;v /)/■■ j.Mto/i.

Vm. --'.

rrnuuf «nn>.

3. Wigand-Mnrtin msthod: Xfa« obild'd body ifl held on the
left jinn, tin- hidex-fiii^r ©f Uk Icfl band being ineertcd into

the mouth iii order '" ill » I In- li.;nl. The nj^ht liniul in then

pjaoed i<n the mother* nhduiMi'ii mvi-v tin- puboti ••• n to

■ ■ un *» (inn graap or the
iKitf. sl). Firm prcaaure i* ihcu
in nir with Hie rigM luind in the
nxU uf i he parturient DUIll . ut
tin- nine linn- traction i* nude

Willi I In- hit llrlh'l, :' iii i .!<• (lie
hr;itl ilrsivinl.' tin- < .nl'/ ■ IhmIv is
rlevnted toward tin- iiiuthi-r'- :il>-

llotlMII.

4. Prague method : Hiivint: wrap-
ped the body to ji warn) lowol, the
operator *r'\/A<» iUv child'- foel with
tne right band) the middle Auger
being pb - 'i between *l»o Internal

malleoli, the index and ring Rl

being above the external malleoli.

Th«' left kind i-.tln.-u j»] ii iii m)i the

chihl'* Bhouiden in wch a \\ n v an

to M0DT6 n firm ovaep (Fig. 82).

Flexion h than made down warn
i>uth t,<>t/i hand* until the oocipni
appeal* under the pubea. Tnen

tlir riijlii band -wiiii.'- tin- body
nji\v:inl, :ii the "iiiiM 1 tiinr making

traction, while tin left Imnd in In 1. 1
lil'llllv in pOMtSoDj bfifig n-«*d :i- ;i

fnleruni around which th* Iw ad
move*, until it i« finally forced
nut of the parturient canal by
iUU lever-lin owemen) of the
txxb

The fount exerted by 1 1 . i- methirfl

i* very considerable, end therefore it ihould be used only after

the f"»regoiiiL' in- tlind* have been attempted.

5. Forceps: Manna] effort* at extractiun hnvinp failed, the

(bfvepe may !»• need. To pannYl bVaanptie.-ttioii ut' the Wade.,

n: r.-r/./.s,' /•/,•/>/ V7 ITVOJVS

2X

icHiiM'- head miial Ik- held up townnl tho motlu'rV nlulo-
i mm bj in lasbturt. Properli dirctcl ^upr uj.uJ.i.- .
I»\ mi :i"i>iiun iiK'i'i-.i-i-- id.- emoacj of :ili methodi or ddlv>
run..- (Im- : i i t i - 1 aomfng head. Six nlmiUa In Bit* maxlmom
iiiur at tlir operate] - 'ii-| »-"l nnoa tho plaonotal elroalatlon
li:i- Imiti i'uiii|jl«'ii-h cut iiif Thorofore ii I- :i-K Emble to have
tin antstani <-:ilI on tlw uinatoi m- the time pasnaa, bo iIuk
the la*t two limy In- iifili/.cil for tho ftppRcAtlon of llir foiWpS
xlutiiM rNOUMS l'> tlir-t' inMninirni- D4 fMUifod.

TIUN: > . . . F'Kl i.'-i M'iuNr

Defluition. Anv preaeiitadon of the trunk of il'<* chikTa

ImmIv El trnnt'<l ii tr.iii-vrr-c pmwiiMtioil. A* ihr n'-itll of
lltrriiir ii'Iioii ;ill.r 1 1 ■• oiim I of UUHtt Ir.iii-vnvr |nv-.nl:i

liimx revolve Into nhauliUr vramfafion*, Tlw Bern arose*
/mV//i id frequently applied )>• > tratwverae prewntatJon*

Frequency: Las tluui 0,5 per OBDt of all nw« of labor
present transverse praeottUkmB.

Causes' TIm ruho (Mil---- that result in brccoli premutations

:il-<. :n-l iti |tr>M|iiciinj thnifrVCI •- | •« ■■ -■ i > f ttl0D&

Varieties: Tin' long nxlaof (lit- tninx Ii vers rarely truss-
v.r-r. hut i- ii-imll_v olili.|tiilv placed Bfl ropndi tho long axfa

Of th. in. in- ; tWfl :mv part Of tin- ftrllM may pTOttM g| tbfl

I* rim,

Positions: Home writer* rl:i--if\ lum-vnx pnWBlAtlons

lux'iniiitip to tin* iiomtlon of IImi k»w«ml NlKHildar, making iwa
of tin.* poipoLi aa the denominator ; t,ff.,a. I* A.-, s, K. r
He. tt i* generallv boBohoI to claaaffy (I«j |Kwiti<>n* a-

folIn« -

I") I lend on the right ride of mother
h n.,,.1 on I, -n tide FSa 83),

J)

-"<

2. /' ":

i.ri Road on right side.

l/i 11. i'l 'Ii Irt'l ld&

.Ihr ftorjutitf pedtio* ii dono-uitCTior! bead to Ehi

right h<1c i»f the mother.

Trmnmriff pwwmutloii. Dono-iintorior. html <.n tuft pM*. •rai prolnpwd.
[Fmbtui i

<>r t von iniiiKVir-f Tin- ln«;ul will pmnilly ln< dm ml in out-
er oiIut iljiir I'.-M. wliil- ii i- impomubtfl lo exploit lln |" I* to
\c:ivjnioii frtwi nbove, for I lie trunk, u u nil'-. OOmpleKflv
Bill ihc Ui\- pel v in, If tbc back i» t" the front, iU m ii>

MBOBAmSN Of TRAlfSVgBJMi /'/;/-w.v/\rr/'».v\ 8

surface «;in lw fUt aero** the lower rone of the mother's aUlo-
mon. If the hack i* directed poMerlorlr, the fatal limb* eon
ho (VI ( in front. The fatal licnrt-*uuu<U mv beard baton 1 the

uiiiImIkii., [)!:iii>K nln-ii (In- btoll El to tlM liMiit ; family, if at

all. whan tii«' limb* II'- anterior.

ViL|iniil uxualnatiou . If tin- mruihmne* Ifa umuvtand, DO

purl Of (lit' fatll« ran I»i n>:lrhi'il liV the iXiirolntng liiitfi-r
without great tliflicnliv. tt«i:i.:..ii;illv a limit ur the prolttptwd
cunl initv bfl fell within (IM big 0* wal'-t*.. When the mt'iii-

i>mi»''» have raptured the finger may oorno >» ooutact with aa

iirm i»r the ihooltfer The l.iinlniurU- to I" 1 Ml ere 1 1 ■ * ■ rhiv-
iok| the hmni'm-.tiiHl thcapiOOof tliC -•.ipnln, The RogBT may
Ik? force*! into the axUlu anil the ril>- I" It, iIium ui-tinguiehiijg
it from the groin. Very frequent!/ in KfaWYem pn-.ii
lactone i bud ic found prola|Mled| which ham! it is being
distinguished by shaking luunU with it.

Prognoata.

V- »pimlnnmu« delivery i- vcrv nin- in tnin-vcr-r prr-wn-

tationa, iht pragnoai hi oaaee leal to [future i- rcrv groWf

th lor toe mothti and the oniM it artiRoiaJ delivery i*

rale lo thaw otees. the proffooaia dependi on 'lie length

hniM tin- am ban i ii allowed to jro on without treat-

tnr'oi ninl the Ditun of 'In operative interference.

The dxngoTs to th« motboT Are exhaustion, rupture of (lie

uterus from thinning out "f the lower uterine legrnanL rlaks
of operative interference and of eubaequcnl aapeta

Mechanism of Transverse Presentations.

rule, natural delivery \* impo-.-il.Ir> in timi-vri ■-. pi<-

i-, hni in altremelT rtra imtancre Nature may offed
i.v dm of E&rei method i

1. Spontaneous version i't. ii 1 1 * ■ I ontffaetloOfl Daj n -tilt in

displacement of the Ebtna and iistrnulutil \>t- , an thai h-

long axil Snail) corrtaponda i" t }■«• hm^ axb of Iheolerua.
Thua the tranaTenei preaantnifon become* altered to lhal of
the breech or the hind, the delivery then Baking plaofl aaeorn%

ing tit the new praaeillatlon. Bponhitn'oii- vrr-ioti inn

240

r.tTiioioor of i..\n

Clue MVhV Kit «ftlT rupllin Of llir lMi-||llif!llir>, fllhl i:. IHiHV
Ikely to oooni in multipara tad whan the olilld hi llvfaf.

2. SponUncoun evolution: ThU mechanism i- favored by

i v i -•!'.'< ly RtronU iitciiiit c<»nli L :»r|inii-, | KXHttj pil\'i», ;»lnl :i
XIIKlll fii'tllh.

By ill* 1 strong* iitvriiw contractions MM sou nor *lnnililrr U
iinrii down Into the |H'lviv, end rotate! to theiroaty while the
boon lleeabovi tin- liriin mill over tlic pubes; ilia brvech W&
trunk an thai mpreasod, and grailuallj forotd past the

hiiiI .mt.ri.M- *hoii|<h>r. which pivot- mi t ho pubic iirch.

BfOM rolaHOB Kim ii*tfc

UrOJ the chert ami brooch slip port the shouhler, over the
perineum, iiml arc delivered, 1' imilly the head I litem <h. pi-l-

vis nn<l rotateSj n ilmt lbs liptrl pivot* under the pubic wvli

and the (hoc iweep> ' »\ • -t 'In- pi-niii-nni, flm* ••ompWinff (he

delivery i Figs. $!-««).

3. Delivery with th« body doubltd op (JCr;futi» *>» dupBcatQ

< t>>h rim condition! favoring flu- roeehanku ire strong

244 PATHOL",, i- „>■ /..i^Oft

Management-

Transverse pn entationi should never be left la Nature to
deliver. Ff seen early and the firtu* is olive, Temlou -li-.tiiil

lio porlVirmod,

If »en Into, when impaction ha% taken piano and the Ratus
Ims perished, then, if version mnnot l« «:i. : h p. t formed,

decapitation and eviseorattoa fthould be dona, to ft* bo rodtsM

the rirfli to the mothci bo the unnllcsl possible limit

PBOLAFGE OF Till; POSTAL LIMBH.

In Head Presentations.

Any or oil of Ihi fata] extremities may prolapio elongstdi
tlm head.

I'Im- most Qomotofl lorni of ilii- avoidant i" a prolapse of a
hiimi, wliirli, when «i oecuns m found aloes to the temporal
region • Tbe worst (bra it) when an aim lieaaorues thooaali
of the neoki

Treatment.
It" ilw ( ..Tiilition i$ diaOOVared bamrfl Uio ruptun of UU

membra oca, an sttempl should be made to overcome the dim*
•-«il in by pfHt/unit (rtutm/mt Tin* woman ohouM lie >•» the

■i.lr opjHm/i I lie |»iii1ii| I (Mr.inilv, with the hip.* slightly

devated.

Atti-v the mombrsnos havo ruptured an attempt should be
rnudo to ilitloiltfe and pin-h up the prolapsed extremity. To
do thio the woman ihould be placed at recommended shove*
Should tin- attempt (all i In- /bragM mo) be applied, care being
taken to avoid Including the hand in the grasp of il»- blades,
and the bead drawn down to the nollet. Thin wry often
onuses the arm t < » slip up out of 1 1 ■*• way. should it !»■ found
iinjMi-tihli' to dislodge the arm tuffloivntiy to apply tlieforeopo
rersfon may !»■ win-i. «I mi:

When the oondition i* 001 disoovorrd lilt ihr h«*inl in low

down in ili.- aovity. the Ebroepi ihould be applied and the oast

terminntod u rapidly an is povuluV,

rn IS L.UiOJts.

! i

In Breech Presentations.
Tho prolapsa '»t* ti>- bud ii of no [uimruuiQa iu

pp, . in. •(!• mi-. nnl ii" mi itiinn iii-cil Ik' p:iii! i.i ||

liri'i cli

In Transverse Presentations.
Tl»c uroJipse of * foot u, <if oouiwi favorable.

SliniiM ii hand nr un bo found prolapsed, if ii OWUMM be

pitthid up oul of ill*- wny, it baj bo drawn down guffioiently

to I'r-icii .1 broad iiu-rc <>i tupo jbuiit tin.- wri«t. Umu* v< reiou
Iu i' ■ i ;■ i I'nrfih'il the tape nuiy bo bud B ■ 10 UfGYttnl lM
:triii It.MH i. ii- . ■ ii.-i-U ihv licurl nn*l ixiiupluviting it*

do otnl

l'UIUI. BOtTHd.

Twin Labors.

'Hi. :uv ii ici.i- m j and uacomplioataol.

Twin projgnancv occur* sboui once hi ISO unci of gra in -

li»»:i ; \\\i\U- Inplil- '.rem ftboul ODOd m BOfifl CM

The U&douuy i a twill |iH' L »iiiuit'v i> mi\ fraqj* nilv favnl!-

I'll-;/, Tii- 'i.:i'. -i numlx i of reported pomm have occurred En
ft I ortffnaneit t,
According to tlii origin of the ot» will trta tin- vnrioui

|«'r'iili:ii'ilii'- in the ilrvrli>|>iiirtil Of tl»' plm^'iiNr ;im) nii'iii-
Iinui. .

If the tWO OVI bftVl 'H'i'M ill -rived |'r ■ Itraiifimi

lollirlf", «wh will h*vi ltd ..mi |.'..i. .-m.i. COW > ln.ri.ni. .in.)

. . . ooi mob i» ing bide] lent of fit. otbnr,

si Ill the two vi fmvi been derived from n tingle

firuiiiiuii follicle, the amniotic no will bo <ti-iin«'t, bat too

•n and placcnti will ba i mum, the two curd

Brao the ■ im* placenta*
i n.illv twin* arUing fVoai ova from b single Graafian

follicle, nt Of tbn nunc au : while ivlun the <-ri^tuiil ovi

in.' dl tinol onon i* t«f un opjw ite vi. MaU twin ore

slightly marc common than female twins.
Diagnosis. Van fannantlj the ritatuoaui of twine j* not

Brack mill after ili<- birth of the in -i ootid. Tho Ofilj t&ia&n

2U>

PATHOLOGY OF > N- ■>■>■

Kii/itK of twin pfMMBOJ :m the pTMUMM ol two t\vin\ heart-
eoanda, heard at differed point- over the abdominal surface,
ud having a different rhj thra . and the paUpadon of two dh>
tincj heads.

Of Are */</«* ;in c\rr--ivr -i/< of (In- uImIuiih-m, with '■»-

. ii:i-mI uterine diatontiuii| iriwiilarllj * >i" the uterine outline)
niul tliu prestuoe of a number of ustaJ extfenwleei

Prognosis: 'I'ltr ITUBtflTlo/prOffBOail t- *c>inewhat graver than
in ^inffle birth*. The •I'nujn-g are; K&Hfltf inrrtin dlM to
ovcrdifttontioii of the uterine walla J a6nonnai prvafaiOBtmj

(tlbiimimtrut \\\\<\ eO&Jjnp*U*« more frequent in plural plfS
rmneie- ; hnum.'hmi, iii the third ibtgjD of* labor DOin inuil.l.-
in the doli von* of the placenta,

Tin- /.-'.'/ prcpnotrui i> aJwm mora aarioua than in single
birth,*. The damjcr* are: deficient development from DVOf>
trowdtog in the uluru» ; maijto*ition ami mo/j/i ttt uttithii ;
and hifhnmui"*.

Muchtuiiflin : Tin- (oTlowijtf lahie from SlMWUlborie, h:i-cd

on linn labnnji jives lira oonbSned preeentadonfi in iln*ir
oroQi of frequency

Bo(|) hoadi i«re*onlitii: .

I i ■; iiinl hnvi'h . . .

Boto pelvU pfatoaaulau
Ettod iod moBTfliai
Rntech and iranavofM

Il'tth irun»vi , r»r , . ,

. iu.oo pet cent.

. 8.G"

. «.1K

I.H
. ".37

The order qf dettven varies, When Imih h«-uil» present,

tiMiall* I In* larger im di'liw-ii-d liivl. If nnc t«in prewnfi hv
the breech nnd the other by tin- head, ii»iinlly the lull, r i-

doUvered lint; If one pi *--* m - tran-ver>clv and tin 1 otbtff

longitudinally, the hitter i- iijtually nx palled fifSt

Hanoceinaut of labor: Whin the presentation of the fir-t

child if, normal do special treatmanl i- indicated. When (he
lir-t child baa bean delivered and it*- reaxriratonr function wall

< -laWi-hrd, before culling (he cord rhe phy-iciiin should |Hil-

pata the niiniirr'- abdomen to laoertain the petition of the

MOOnd ehild, If any abnormality exi-l-, it should be o( OOOl

corrected hv externa] mudpuhition^ nnd the fundus uteri
gently kneaded to ■timatate reiruetion. The fundus muy then
lie placed in charge of the nurse or assistant while the jdiysi-

otao eifandi hi tin- cold of tbt Brat ottki Tin* ahould be
tied in two pliuv* and then divided between the ligature*, in
nm there should in- conjuunjkatJoa bttwean the placental
circulations and iii« wound child bleed to death.

i'rirljitH on ()ii' In mill* xhuilld Ih- IO*Jalnod linlil (lir nt-i im-

eootrnotiuoe are firmly MtabliMira. Ii i>- not advisable i"
w*Jl mote than ban an hoot for iIm btrth of the aanond dilla.

Tlio nWOOd uniiiiiiih- -:w. -liuiil'l iIm'H In 1 nijitiirrd :iml tin*
uterine OOOtnotSom rtioforocd hy linn preiwiiv on the liimlii-

. i i.. iv|«diic tin ift li> ■ r- of | b ■ ■•■«. n.i • hildi

From thai tune until ivirnetion Inn been firmly wtiihli->hed,

after Kh< plot* emptying of th»' utcriMi 'In- (undue iltould

l>c kept eonatnntfy under control in order to prevent it-, relax-
ation and the oeenrreiiee uf hemorrhage.

Should bemarrhagc follow tin <h-liwrv .»f the flr*t child,
tin: mtuikI Mn'iiUl Im- delivered n rapidly u poeaiblc. citbi i

by liiivcn- or n-rvlnii, mid the uU'l'ii- i-m plied urlilleitilly, It

i- not lavittble to Inform the mother during labor, ihoold a

dlUnUMUtt of tWlOl I*' eMnblixlied, n* the BUOOK m:iv inhibit

uterine aetion.

Com plies lion* of Twin Birth*.

Compound prwnUttoiiK < v. ■ ionsilU Inith net u me i. ml t»
enjpiBi- sitnnlt ITH ■■■n-ly in the brim When tmth Ih-iuIh lend

to preeeul at the aunc time, the bighc*) should it" ponriblt be
pu i>< I aPfftod the foreen* then applied to Che lower head

and Im tiMii ••xcrted until it i* firmly enpjrcd. l>urinc the

rmecfoa an a*»i*mit may Ih ible to hold Em bead of the other
child out <'l" the way ( \-s |>rc**urc on the abdominal n ill of
the mother.

When the head of one child ami tin- l.ive.ii «.| iiu-Mther
ti'inl i.» engage el the mom mne. the breech ihoold In- pm mod

lip :m.l ill* |j.-:lil ill-.iH ii •lown.

When Ratal fMirniiiir. ;uc luiim) in present along "llll I
head, the) mould be r«|il:i(c«l md the bead drawn down by

Meant of the (brovpa.

Interlocking twin*. Oonutionallv Imlh hem I- enter the

pel vip, one being generally well in advance of the other; Tim
u|>|mt bead then beoomi ■ jammed against the booh and thoraj
of die 6r*t child.

21*

p I VHOLOOY Of I [Ron

ftvoaaati: The mort advanced bead should be delivered

bj fcroepa. ai unlocking n eenenll) mil of the question.

rin- Mcond head Bhould then !><• dclfrorcd, and when this Is

dona the bad* af tin- Aral child ma) bo extracted, die bead

of i!u' second being bald dui of tin* «a« bj an assistant

Sometimes h i- neeeowg to perfor.ur hoc of ihc heads in

order to |»crmil the delivery 01 the oilier. \\ lien flu- of tc- ra-
tion r- ni|uiri'il if -hotdd In- |K-rlonind on I lie head of ihc lii^t
child, because (lie -icennd i- more likely In lie alive, there befog
lex- rink of etnii|ire-.-.iiiii of 1(4 » onl.

hi c.-L-e- in which (lie hn-ceh ■ »!' one child and tin- bead of ihc
otln-r heroine ini|Kieted in the pet Via ail endenvor -hoiild be

made to puafa up the bead and deliver the breech) Hie bodj
of 'l Inld preaonting by the breech should onl} be delivered

n* far |g the neck, ii- the Iff" head-, n-tiuilly I.e. .nor look) d OJ

ihc brim by the overlapping <«f the chin*, or »f ilie occiputs, or

by the mca of 000 child being ]nv— .d !tt(ainsT the book of the
other child's neck.

Should it be ImpoesTbU do paeh back tin- head of the ■acond
child or to apply forceps and deliver it, the bead of the breeoh

child ihonld 1m- perforated and eXlrnctftl In-I'mc at Irrupting IV

deliver the other.

Triplets.

As a role no difficulty fa encountered in thcdclnciv of trip*
Etta. u* the greater the number of lo-ru..-. the cheater the
tendency Uj prviunturitv iif delivery.

The labor is generally prolonged on aecouni of rielej h)
the tint etage from imiierfasl atartne contraction*,

The third HtftgO mUlt l»- w-ry carefully RMOaffltl, and il is
advisable ro empty the menu arlilirialfv in order to ingori

that no pordoni of placenta an retained.

DYSTOCIA DUE TO ANOMALIES OF FCETAL
DEVELOPMENT.

Overgrowth of the Fcstus.
Definition: A child may he said to lie overgrown when il

weighs eleven pounds, or over, al the lime of birth, li i« bat

very seldom thai ;i child \» Imrn neighing twelve pouuda ; hot

MiH \n i:i •'■■■•iiKM-ins nr TBM tXULL 848

ea*« ni\' r »nir.| in which ihr liirlh-wcif fit WW nvi«r tw.-nly

pounda

CauHc : S'otbuie. ifefiotco in known i- i" the oouh of
thi ove r g r owth. Miihipnriiy, advanced Age of one or both

i ►. ■ t « -mi-, and [»r'il«tii.-.iii'ii) . I n nicy .in.' yciut'jll; '■

u* the probable eau>< .

Mcchauism Winn tin- bond prcaentH it" tli'-" .I-.- it
ipnenlly oaten tin polvl in eitreme ilr\imi. Moulding i«
BfDttrall) w> nmrlvid n* tin: rc*iilt of h prolonged *ecoud

KtA0

Treatment.

The beat treatment i* prophylactic. \\ ban the eondftton Ei
.n-|M'c!. ii, whlcu :- ran :> oarefnl palpation should i«- made

jiinl lli<- -i/» <il ilu In -cited. The lietid xliunld tlii'ii

he Iiirrnl inlu tin- brim l»v ilu* privxnv in mi idtme.to give

one en apprnaiinate idea "I lite rweriva nixeof tl»' pelvia, If

ii be found thai i' u ;• » ■ >r I * « lit. then labor -l id !«■ at onee

induced, i- »<■ tulvunnitrc outi bi gained ty waiting on nature*

When the condition 1* not (Uncovered until labor, then the

Draper coufm to paim \* Co nupport the patient'* strength

ana eoncrol the peine hj mean* Drnynodenntai of morphine u

M required, until ihe head hoe had tiroc t<> mould ihor-

mighty, when ma) he applied and an attempt nude to

deliver tin- eliil.l. CaT* duiiild Im< tnUm toaVOM eXOASdw

force in traction.

[f no edvnari tamooN and theohfld la4Ujtoa,ejfinnAyjn0(onv
i ■ then taavmry.

Wnen lue condition i v recognised early and tlie disproportion
Di n the head and the pelvis ii not marked) Mtonafear*
id, in:i'. offer tin' ehilil .1 greater ahanoe of lift- than a high
form |i- ";>. ration. The choir*- nf .ipf-nnnm de|H'tidn in great
ni, ruure oa the ikill of the oparator in performing the one or
the other

1 1' tli*- rli i Id liii- perianea a 1 WOf yowinjf should he theuprrntiuii

Premature Ossification of the Skull

I'm hi 1 > i hi • m iiM'ntii f tde I ••- uf tin* iku 11, cnualnfl

more 01 Ion* obliteration of the uitnrw and (bntanones^givatlj

2«i

PATNOMHi\ 01 LAMM

BlodSto <!"' nmuldahility of t ho head, Hid hi:iv tfalll had En
delay in labor.

Position: The bend may DC BHOatod at tin brim OF in tllB
• uvity.

Treatments Foroepa or *ymnh\ wiotottjl nmy Ik- nmnfflrjf to

Nonrc delivery of n living child.

Hydrocephalus.
This i^ nrolwbly the commonest oau«e of e\e.- i\< ,'izc of

ill.- fu-Tlll I|«-:m I

Etiology: The condition indue to the accumulation »>f ttu
Mi-um in the ventricle* of the brum. The accumulation of
fluid may he so ir rent u* l.« i*ini«c obliteration ,.| lh. eenbrwl

convolutions and Bxeoaslv* thinning of the er&nla] bone*.

which become widely wparated. From llie e\ec-si\e mw of
the VOUll lli» MM appears >mall. SpinO bilida or -oiiir oilier
mill forma! inn in pMierally pre-en' in I lie-ie cawe-,

Di agnosia - In abOQl '•* braid rf all BBMBof hvdrncpphahi-

lhe breech |>n'-eiit-. The condition .|mnld : .|uav- l» -11--

peotcd whoa in vertex preocntationti the head fails to engage

in the brim, nltlmugli tin- pelvia i- normal in BUBO am) DO

good reason ou be found for the delay.

Hy abdonUntU tttOMlkniaii<>i< tin* gaping funtanellei* ami
mturec may bo made out and fluctuation may be obtained in
iln>, regions. The cranial bones may be felt to be exec -i • ■ K
thin, and preaniN ^*n them may Line the ren&ntiun uf crcpita-
t Mm. The brail i- fell to In- i-nlniKt-d mid ->oft.

TboBfl Condition/) may lie licltci till by a t/imommt isumllUU

tlim whan tin- i- ]">--ilile.

Prognoais . Tin- life uf the child i* to be considered as of
lilt!.- moment, far -honld i( survive liirlh death generally

lakes place shortly afier.

Death of ih<- mother may rc.-ull from exhaustion or from

rupture of tha uteroe Toe ruptura gontmlly occiini in tw
lower segment, which btoanica greatly atretohed and thinned.

Treatment: When the htid pream/j [FSg 00), it -.honld he

El rfbmted nrul the fluid penniltcd to drain away, When the
cod collapse* deliver? nmy be effected either by vcraion or

l«\ meant of a • Tnniocloat.

livnnocKMALVS. Ml

be Spblii'il In a liV'li i>1 ml io Inuul

ii' i In- . "'"iit . i ' i ii"i«« i ill- iii moan

a nod gmpon locounl of it- comprMrfbtlliy.

Whrii Ull hrrcvh /./.-..,(/«. tin- Hunk ;unl tfTDI m;iv It. dOt-
tfUQUMl :inil lit) ntlrmjil iii:nlc 10 D^lfOTiU |Im n'aliijil vnull bjf

'Pilnninr *»f I'.wrr wpn ■ • ■» It ..i-i n,- m r,.,,, hrdTQCfPbftllM

■ ii ■ i'..,.H

the :..iii|.t»r:il luiiinnrllr II' ill! ■ umot 04 " K (bed . tlMB ''"'
kjmumI iNiniil •;limili| We n|»'iu'ii iii ilw tiiin-nl r-yinii hy i
oi n |»nir of *oi*»or«, n.Hl n ontbttCf ftH Uiraagfl it into
the cr.iiiurl • .ivitraml the flui.l thai niWIMlfl (V«I Untveft

rout'tim i-r .['iiiHi c*n«| in « m«* ut iiyiiriHTfiiialui nlwirutiluF Uhrtr.

I.VdiT ]|< I I

Encephalocele ; Meningocele ; Hydrencephsluu.

TIh-ti* rnmliiHHi'- when nrraaai <l<i nol often htIohsIv com-
plicate labor, ai lh« tiK&ora ire either small or aw BoaitQ

1iUt\ that tlx'V foil kO nlVr.i ni;itrri:tllv lln prO BrCBl Olf tfw

<:i-. [f obstruction bo tabor oooar ( the growth *hould be
perforated, when ibt oontcnta will drain away and mnke «lc-

livi t . | ililo.

Tumors of the Fatal Trunk.

Ceitaiu tiunom arfalng in OunneOtSou With the fatal tniuU
in, iv b) llicir bulk nr situation imliitT dyMOOia.

M-V/-V7I hX-V TO UtynnMAUTUlX. II'
Varieties :Spiim liiliiln . l<>riil<>m:il . iln:il><t -hi tIm- >|niir,

taw, or i>riiit . Iiv(in>(l«)i i> . i ■■■•!' ■■ q lie degeneration '•('
the kidney*; nmlivriiinii conditio] ol the lira 1 . Rplaea, or
paaercaj ; dwi ntion of the arinarv bladd&r, and Semis «»i
vunan tbrotuh cleftr En tha abdominal or thoracic whIIm, mny
Ik- mentioned undo tin. heading

Treatment. SlnntM deliver) w delayed, foravpt or version
in:iv m retorted to, or some lormof ambrvotoniv Tamon
with f lu t< I content* «l)(»nl(l l»' avanuafed,

Monstrosities

Anonecphalun off hemiceplmliM i- (lie Com moH DODttOnl)
Wail, IMuv MjrfnorailV caueed id toe oral tfage by tin*

■net' ut' tin- nOftd M :i dflator, Wlirn llir duuniOSitl i-
Iii;uli\ M'l-ioii, |f |>.i--il)ir, -InmM !>.« |MMlonili'tl,

Double mODilin ; ThfiH RUVV vi-rv -■ thmi-Iv OOfflpUcale
labor; but - , nl, , ■]„■ RBtUMi are nnmll und datively
n.i'iinillv. In difficult CBSes craniotomy or sonic olhcr
form of chi'iiynTMHiy is ncocwry u> eflVet delft a |

DYSTOCIA DUE TO ABNORMALITIES OF THE FCETAL
APPENDAGES

Short cord: Cukm have been rccnrdi<d in which llw OUfd

ha nm bum i more than two [octal in length. Relative

■hortm-- of tin- -.i'..| m u y occur fnun it- • liiugorouod lb«
iit-k ami Itinlrt of the fu-tu*.

The condition mo) 1 « *= « - 1 t.. premature tlctachmenl of tin*

placenta, rupture of tbi rd, 01 oompri ion ol i(

From itratcning. which muilta In dtan of the fbrtUBi

The diagnomt i- dlthVoIt. Sometime* tli«' ivnii'iil r.»nm-
|>I:iin- of luarkiii pain :il the pLnmtitl silv during - »n li

i.-.i. Hon, Occasionally :i porrlonof too ntcrinc nil m
(lii bo bf drawn downward and toward during each contrao-

limi l-'MNjunilly flu> pTPMq»til , rctiiulnl r.ipidly i-

Iba otorine contraction «ub«kn -

Trriiluinif oaaaKStl m rapid deliver) with the foi«rp> w hy
version.

'.'.-. J

PATHOLOGY OF LABOR.

Prolapse of the Cord.

\ loopoftlu umbilical nord may prolapse iilimifsidi.' or in
QfODtoflha prOBOnliag pari A< labor iimis"****" Ihv c>r«l

i-* exposed to preenure between the preflcntirnr imn and ilio
u 'ill. wnfoh raraltfl io interruption of the foriopkeental

«itriil,ili"!i, ui'l |i'i->ili|v in tiio deiuli of the KetOR

ProllUMO of (he OOTQ amy occur either before or after rupt-
ure uf i he menibraoofl.

Frequency . This aeddcnl DGOttrSOnOG in abool 250 cart

labor. It i- mi'i with moet lYequeotljr in praaftntetfane of

til? pel Vie poll' of the f.i III-.

Etiology: The es-mulial eau.-c of prolapse of (he cord i»

dlure of tin- prMtndog put of the fatal t>> mi. completely

ind eonlinuoii-ly, 1 1 ■ •_- lower avgnicfll of tl"' utern-.

Jlie J'wluf riiiiilitt'tiiH wliieh nn'di-|KiM- |0 Mil* neeidelll :ltt' :

melpontloneond nnalnfeaentalinoa j mall *i*«< and inem-med

iiMliility of the fatUBj anoiunlie- of other fatal :ip|MMnIap'»,

ai matyinul insertion or exoewiive length of Ibe eord, hydram*

nioaj puneutn pneviu; and -nidilcn i --Jipo of the liquor amnii

with the patient in the orocl poaidon.

The 1'ivdi- posing rrvttm -mi oondiHona an i pelvic deformity :
relaxed abdocniDl] wnll, iim in «imc mulliparrc; atOrllM BM

other tumoral uterine obliquity.

The accident is alto more liuble to occur in cn*c* of multi-
ple |ircK»iilie\

IHagwuli.

Before the rupture of the mcmhrmie» it U a mmewhnt diffi-
cult matter, u B rule. to recognize ii prolapse of the eord on

lOOOUDl 01 fta BOflW Btfting nninre u»d the case with ulneli

it rcci'iU'i* lielore lie- rturniniDg RflgcTi

After rupture of UN membnnt'* it may be tN-nenilU f

Bused without diilii'iihy. on account of Its twletfl and the pube

ROM of it* vessel*.

It lin- been nod infrequently mistaken for n prolapwd loop
Of iilte-lim- ; -old neeui'iinilK m portion of Eotcatlfle It"- neen

mistaken for i he oord. Gere m examination should make
enoJi ftn error m dlftglHMtg Impowlbti

The position the eord usually ooOUgriM Ifl nl uw or other

ritoi \rst-: >>b rttr ftjni>.

IAA

i.l- of :ln ■•••Ivi- M>tin-uli:it [mi-Ici m.H- : r:n-l\ it m:tv lir

tit-bar mi ii"Mi "I' t Ik* pronnaitorj <>t bohind uhj wuiphHit
pabii

\\ h.'ii the f»Ul tutlrt-totindi gtOV pro-.'-. •■■•.. N «
..ml BO OBQM i- .1 1 'l >:i r i - n t , prohfMM i>t* 'li< DON SODOM h«»
MipeoMd ;iimI appropriate trvutim-nt iinuijjnnii-,il.

PrognoaM.
Tln>- oompUaatioo rarely iiiHiicwc- iln- ■.■''■■.'no>.i> for tho

mother, MVI hi *i> Cur U UM OpOtVtSvC tfUaUOItfll CXpOM! OCT

to rbJu of -Ihk'K tad wpaIa.

I'W the child tlu- piugtx I omawhai £**-% ihi mortality
rUlrw t*> nomawhat ov»r DO par oeat Tin- etUH of fatal

tlfUtll i* ckvIiihHHI '>1 ill'* i(ih'pl:i'*:iUll niriiliili'Hi itOtO pro***
dii till OOfO. Tin- jii"--iifi' rv»lill* in ;i-|iliv ligtlofl uf

chilli, Slum hi ilir [>rolaDwa portion of tin- oord hIiuw an
moi of potation lor t. n i.r fifti « 11 ininiir. -, iin.i abdominal
ilbttkm tiiil to pocmil tin- datcettaa of hcart-iound^ the
death of tin* fatal i- nurad

Treatment.
If {In child htf i«'i'i-lii-il, QO trviitnu'iil i- inii'h-. it«>i!, uml

ibaoaai bum in I'll l" Viiim-.

Brforu nipturH of th« membr»no» : Tlic indkatSoM fbl

tn iiiiin'iii in** to proven! raptnn ofthi membiinni »- lonrai

I- 1 libli . nod !•> favor '•>« raplaoenv □( of ti»' oord bv appro-

poaturiDg of toe patient Tho woman should bemado

bo kdopl boa ffeaupectoral poatun (Rg 92). WbUa the

•t i< in tlii- poaltioa tho Influanet of p kvltj ■ uini dm
oord to Battle dowly toward the fundus, und thu* the pro-

i looji i- irnniiuiIU widiilrnvvn. 1 hiring tin inti/i'*iti 1m

lUi'i-ll tin- |>,IUI- llil I-i'iV In- JOntly Jill-ll'-il K;iiK With tin-

I, mil. . in- K.-tni; f-aKi'i) nut tn niptinv tin- mumbratMll. Wln-u

the rottdition hi feted, iha pAfJcoi mm he parntlttijd

In ivdine on the li'lc opiiOmte !•• thai ■>«-i*ii|»n-<l !■> tin- ronl.

The vhan|(c of pohiiion anould bemado ilowh inu eeretnlly,

nVafiOftVoU forcing the C.ir»l .!<»u ii upiiii. Tin- im-iulir-uir-

inm then hi raptumlj care being taken lo fbrwi tin head
down b) pro on from above vrnOa ilii^ h bdng dona.

206

l'ATttQLQQ\ OF LAhOR

Aft*r rupture of the membrane* : IVfon- IfttOpClog to r«-

il:in lha |ir«il:i|.-( <1 l< m i| i of run I nl'l-T mjilun «>l tll« nnut-
nii -. . hi should I"' taken In find nut whctfn p Uii child i«
ivt\ |C j.iil-.iiiuii ii.i I in ilk.- ii.nl, tin in nt m:i' -ti .

be beating; if thii i- the •■•*-■* the pracnline part -1 1«i bi

jui-hod uji. and the cord replaced ttftrr pulsition rvturi

The ffomn tbould bi planed in ibeSura pomHooon the

-iil> onpodtc to lif |»i\>IujRwd OOfQ. TIk- liip> >huuld bv elc*

rated by iii'-jiii' of a fbldnd pillow. Hms op* i ' " booM tben

-li lark tin* nrrM'iitint; l» ii> td rclcaM ilu- OAfd. This

KM Pi

i'otniml Itralmrnt of |>T"lipw t.f H>.

in:i'. ilirii lie loiwlv [ui-i.i!, rnn< Itiing inki-n DOl !«• int> rlriv
with il- |>iil..ih'..n<, and the tui^leil 111:1 — g.-nlly |Ul*hcd Up
I" 'oinl the |in--i'n1injr fmrt-

If it In- found iin|io-.-il»]r to replace id*' «'tinl Midi tin- wommi

in llic Sun- |Mi-:iii.ti, eh< -hould U> pltfOvd (W llW kntH Mid

kmI ;imifln r ut l<Tii|»t ninth if m . .-r-;irv £mri£ :ifi anM-

tlii'tir - '• :t- 'o relax thr Ml. ni- •■■ >in| >i«<l<>l \- . Till objection

i" iln kn * '" -i position Is the lendcm y for ;»ir t.» mtrr the

HI. run- r:ivilv ; it (lit- :nvn|in! '.our-, tin -ill ... . |iic:it IftbQf

ihnuld nul l» undid) prolonged.

Should man uil pffort* fail, o »uitnbl« imttmmrnl for rvnlto-

/•/;«'/ i/sT- '/j n/A --/:,'.

--V*7

lOg i!ih OOVd WW I"' i»i|trm t-<.l with :i No. ID or Xn, I2gum

elantio ("iiiii -ii-f and lomt tjij«-. A l-»«»|i nf tajn« i* m&utto

. iniivlt.' llh.i i-onl lixt-rly, :iii'l its l'i" PIKW ;m :itl.irlir«l to tin-

Up of Hi. ii k b r Tm OBtbotor, with if- «tvli«t Lojfrtwl, in
iiii-ii poflwil w. ll up into tin' utenuh canying toe cord «iili it
(Vi'j :»."'., :M, mid n.'.i, I'lf t>i. i id then mthdimwa tod tat

hi... wt

i- ..,. :>;.

■

nffn

Bmuo'i r- i" ■nil.... i.f *.,(.1
i\\tr..,«.n .

.'.iiiciiiT l«-0 in ili. ii'. in- (ooomcaw jy with the child. Cur©

should i»- Itfctn ii» remove 1 1*.- bona SnHoa from the and of

(lie mil rti r

IT : 1 1 1 aUvmptl ll rc| i of Um OOrd fail, then rithrr

rrr/itm or farerpHy witti rapid delivery, mu*t be ro*nrted to
in order to ■ I" the lift of (he child. Bofon tidier nl then
opmtioni tbff loop cf the « < I ihoald ho pieced uppoelf i the
Mcrojliw j"i"t. when- it will bo leant prowed upon.

i; 01 ■

2tf

V.iTltou»;y i>i l.Mion.

»'I0, W-V

Coiling of the Cord about the Fatal Neck.

Quite frequently the I'ft.il <'<>nl u fbliud tO be OOlled tOOUl

the neok of the child, It any racirele the ncali i veral tlmee,

and Mm- nrodllOCI relative shortening
id the QOTOi

The condition i* difficult io diagnose
before delivery co* the head, It nmy
Ik- inspected if (in- lirml dcMoood wall

Willi nwJl |i:iin. I)lil mpiilU m-flc* in

(In 1 Interval between a !■■- contraction*.

E«*Ult»: Uc-r;L-i..ii;illv till' Il'IUllOll I.

BowtMflfl '» Inttrfon with Ina fceto-

thit-i ntiil circulation; end Km been
nown to '"in"' premature detachment
i»i* tl«« plnoooak

Tluwmlv treatment that enii he ■<
ogMtod la the Application "t" the f^rceim
itml the rsipiii delivery of the ben ,
wln'ii tlir i-..i'il limy he out nml uti-

nulcil from the dock before tbe birth

ill' the trunk tnVv- place.

Placenta Praevia.

The placenta if* normally implanted
entirety within the Dppcr uterine »e(f-
nii-nt.

\\ hni il Ifl uiiphinled. in whole OT in
pail. IUMHI till- lowrt'llti'l'tlir .-I'liiriH the

condition i- known tl placenta pr*vla.

Varietlea: Three varfotlea arc d#>
gorlbed i

ill riiirnila prjivi.i rriilnili" : TIih
plncenbi i< no -itunicd tliAl ii- contra
uorrCTMonde with the internal im (Fig

(2) Placenta nnevia marginalia ; Tlie
placenta i* rituated ao thut bol i portion of \U murgin ovcrj
up the Interna) dj i Kijr,. 97).
(3) Placenta pnevla lateraliai Tin- plajocnui i* -.Hunted on

^ In'i ii..l...»l ■< (■ ■

i .... .( ron

rucryiA rn.xi'iA.

2fitt

itcrul wall uf tlic uterwi, cxtcndfag well down Into tfa

lower Ngmcut, but not nachlofl u Ear as ibc bDtvmd <>*

In tin- .-muni mxl iMiirgimil vnrieiif« UM btmorrbArai nuw
Mao t.:i:l\ in prtguoQ ; »i ii repeated frpquently, ind in

laiM.u- i> mmlt more ttnOttt limn in the lal.Tal virirtv.

Kin. 97.

riM«Btn»rwv1«*«!

I'lucculA prtvm mirvluilU,

Kw. 9*.

n«, .... I i kNMlli <*rt.-rl>fckln.)

Frequency: Placenta p| I Ifl CCfUtltlu U v. r\ nirr . lai. ml

ninl limryiiial pueratfl MWvk in ll" 1 tDOflCOl rflrii

riaf.nt.i J n . « * \ i:i (MSCUI >bot)1 OHQt hi MMKi riUC*. I' Etf miw

ii oj ;'ini(lji mci wltb in multipara thu in primipnnr.

Etiology: A -aii- fa ■ '■•!' OtpknttiOD of the occurrence of

iMHi

i-\runf.u.) „i i tnon

placenta pmvUl lin> never been advanced. Chronic InflUBSU"

u>ry ehingaa in the mucouj membrane certainly pfedlenaee to
its occurrence. Other probable coham ire: subinvolution.

Atn»hy »)f ■ ll<_- 'Irrnlnn. i:.'V BjTOWl li-, uii'l limltorilintioilM of
I lie? HtePWL

Symptoms mid Physical Signs.
The symptoms of placenta ptwfa do not usually praaenl

themeclves ufllQ after the wxw mouth of pregnancy

The first indication of the condition m » sudden giiah of
blood from the* jp-uilulff, UMially without BapBTCUl BBflBG ami

without l'ftin. Thn i»l ling wen raraia al interval! u prog"

jiiiim v auvnnce*. The amount of blood lo*t la proportionate

to the extant of the placental separation. When hmiorrbngc
lakti place (liirinif pre^inmcy it i- probabl) dnetos partial
eparation of i lit- MAoenta in the lower uterine -'iritnHi. whore
itM etteohmeoi [a imperifcoL Thie separation hennaed l>y the
normal uterine oootrnotionfi which oonainntty oonur lltroiiglH

•ml pregnant 'y.

Tin* first h<>in..nh.i</<> wIumi it ocniire dOflOff labor imiy be BO

severe ;i* to threaten the patient's Ufa, Ana rale, the bleeding
i- moat profuaa in the interval* between ihe parna; but tin*

I'niMiut l»e slid to be diaffnoetM of tm nditiun.

Itv abdominal examination Lbo location of (In- placenta may

be recognised, when thefmplnntatton ban the anterior uterine
will!, by roollng fee edge, which piv-«nN :i- a . ,-n i mur.
Below tbU point tfaa atorna fitelaaoft and boggy, and tin- fortS
parti can only bo felt imli.-t iiM't 1 v, while el-cwln.iv they may
be readny nuuleout Overthie boggy area the placenta] brufi
\h to 1m- heard with great distinctness. If Uie larger portion
of Inn placenta ooaupiea the lower uterine Bvgnitmt, inaJprve-

riil.ilinnH of Ihe ft lUB iniiv OOCUT, a.s the present: tit; part i-

thnH prevented entering the pelvic brim;

I'.\ vaginal examination tM OCFtb Bud lower uterine seg-
ment an round bo be toiler tlnui usual, If the insertion • ■)
tin placenta u narsjinaJionc hoc of the cervix and lower aesj"

ment may bo softer ami mora boggy than tl tbor. I'ul-

aating vessel* may be felt around the cervix.

Tlie external os ia usually pntolona, and through it tin'
Bnpcr may be pushed til! the internal os is reached, where the

r;.i' i .\ n in.xri.i

[61

nwUTiuil Nlfacc i»r tin- |ii:ifiMiin may he fell, I gritty feci dis-
tinguishing it from n btOOOHllol <-r tin- rncmbno"

whoa hcfDorrhvgv tabot place in the later months of pree>

iiaiirv ■ r-nvfiil examination -hoilM In- iniido In a-i-i-rt..i:i \\-.

eauae. Tii,. rapture of a vaifooacd vain ■» the vagina and

CI i M;r, del " tlineill of Hit: normally situated placenta may
■d I ,.(.■. i ..;• 11 ii iiimii: \\-. ..)" prvj/naney.

A careful and .t* cxanuDntion will generally permit a

dingii" ■< ■ la DC DMCMi

Tr*j»tra-jnt of PUcnnU Prj-ri*

'l 'in' conttoi of uaioorriuic« i- the principal bkUeatSoa of
treatment

In the run* aaaea in which tli« condition of placenta pnevia
i* mognind before the fatua i* viable it mny be po»»iblc lo

enrry out m eapectant plan of treatment until the Miciith
month <>f the prtynuiirv ii reach rd. The patient ihu-i be

leap) In had, not being pormlClcd to rUa fbran) pnTpoaa It

may he well t- .hIummoi, r i-liloral (gr, xv) or lii|. opii tad.
(Ill XV) tWO or three rime* dad*. I" eunir.il the QOrVOQI •« lt«a.

When the levanth i th hai bean reached Ubor ihonld be

iudueed, a* nftrr lhi> pfnod I lie woman ma\ tuOtd to UCaCfa

before medical aid oan reaeh bar.

Being mtfefied thai tin* condition of plareut:-. | me via ii

nl, i( i- till' iluty of tho pliy-idaii at onoi lO empty tho
ntcnia if the child is viable.

The paiieni *!n>uM be aiMntbeticeu and pUn-d in the
lithotomy pueicion, with her lii j»h at (ae edge of the bed, A
Kelly pad ihootd l»' plaoed unoW bet The vulva and tragic i
ihould tit*" be earubbed and dounhed with formalin or bi-
chloride natation, The operator bavin? sterilir*-d hi- UmvU

and nrnir, aboold then dilute the cervix by in-erlinp one

finger, tlicn n iconul, and then the chonb of the rlghi baud.
ii ihonld then be made for the edge of the placenta. If

the phu-'-nta ia lateral or marginal, it maj I"' Bnfieient to

roptnn the membrane*. t<aiiiiy thrin I reply, and to sweep the

Rjrvotoar n» e iwut

finj^rK muml under the maryin n f tli«- plan, nil wuio

rafc it from I be utcru» for ;i ohorfl di*tmne. The timjrr* my

:i«n !"• mtbdnvfl if the Imul of the fotue in pnaentipe,

Finn pi.- hi i tin fwiiliif, noo Co crowd the brad into um

l-'lvi-, inn. then ba iuffioal li Dtrol Um hemorrhage: if

*.-, ihr >Mw may now be left to Nature. If the o* hn« been nit-
ficirntly dilated, the (bretM may ite applied and the head
drawn down, alter which tin- nw may li left to Katun to

deliver.

If the pUetatA u control, or if :i conatderobla portion of the

plaeenfa is found ov.-t lit*- Internal At, I he projMT I nut mint it
in (Mi I'm in internal VoraSoo. A fool i- atlaod and drawn
down until IQ4 toOBOrVOttyV U cheeked. I'Voin lime to tunc
the prDtrudlliB leg "»:i\ he drawn iijh >n to h:i>t*-n dilatation of
UM oerv», I'll niv or time inn-t ba allowed for iln> oerru to

ililiil. roinplHilv, olhorWiai llirrr v. ill U dillirnily in c\

log ilic :iii« r-eotning i I

ll' (ben bn bean n <ji' nt |,.« nf Mood anil the eerrix w
found to b» rigid, it i* bettor to pick the cervix and vag Dfl
with sterile iodoform panze, which may be left in (dace until
ih«' [uitient lin> hud time to rnlU under appropriate treutmctit
(•co Port- part um Hemorrhage), The gauze tampon nol only
oheolu the hotnofrhoge, Kilt iuo o**i&U in softening and di-
ii Nit'- the cervix and oe.

Many author! recommend tilt employment of hydrostatic
dilator* InntOsd of the gaiixe tampon. Tlie Chaiiinelier d«
Ki!m> Imj: i- the hex! for tin- piiriM-*-. Tl i* cmimcrlthot the

line; control! tl"' hemorrltaga and dilates dn- oervlx mora eili d -

uallv limn doe- I ln< vaginal paehiu*^, while il n> n mla £011001

law diooonifori to > I > * a patient. r"oi tha introduction of the bag
Um nation) U placed la the lithotomy partition, the anterior lip

of tin Oervil i- -ei/.'d with a leiiaeiilnm and drawn well
liiiward, being then held by an nmixlnnt. The dilating hay i»
folded into n eyliuder. gneped with a jwiir of ftimepB, am!

ful tied carefully into theocrvii ud through tha Internal oft
Eefbrc withdrawing the (breept the di-teniion of the hajj
ibould ba oouunenoed bv injecting htto it boilad water by

mean* of a r/ringt attached to the tube of the bay Then an
tic bog dhrtend the forocpo may be unlocked nm\ earefuUy

withdrawn. \< a precaution against rupture of the bogi the

Plit 1/ I77.7M ShTAf, I""- 01 n Wf VI i

sea

operator ahoiiM uwrllhl beforehand li-iw nuuv luilbfuls of
■ ■ r ara nM|iiiml to dilate <t completely.
Tin' ino-t riy.i-1 prei -: 1 1 1 ■ I- ■ ■ i i rcfflirdl a-scpali ihooU be

i . i rved '» 'I" 1 lieatmenl of nteoeiite pran la, u the 1 1
infection fegreetei Hum In oralnarj oaaee,an Recount of tbi

low position sf llx' placental -n. .

After the child haa been delivered tlir operator -li»uld IntfQ-

du< i lii- bind 111!" tlu> Literal *•> remove the ulaeenta ind any

olotl llint muv Iw foilfK] Him Tin- -tumid In* followed I iv a

traloagcd hoi intra uteriad rfotichi of *terile tali notation or
iAOO formolin. A lull done of il»«' Boid extxaoi of ergol

should he administered ,i« - n *- the litem i- emptied, or

clso a hypodermic of ergot in.

Prognosis: Placenta pne\ i i conatitttto 'i moel lerioai oom

Clirui ton of pregnane); '<r lubor U>r both mother of ohild.
fader prompt and aamfo treatment the maternal tallta

should be prHi'tic.'illy na. A> prematura deliver} b franuant,

tin nil:!!)! iii<.rt.-.litv-::ili i- high.

Premature Separation of a Normally Situated Placenta :
Accidental Hemorrhage.

Tin nemorrnige associated with premature detaebmeoi of

■a normalW altnuled placenta U termed ••accidental," to dl

Itsfohh ti fnmi ilie "unavoidable' 1 bemorrban of ptaonntft

!':■". i.I.

Varieties . AaotoVnCaJ hanofrhan may be oynorenloreoii"
r alttt*

hi apparent accidental hemorrhage rlir Mood diwt* it<

was- between the membnoei and decidiin, and rsc.i|H-> iln'»iL'h
tin oervii

I i noniwalari accidental honjoirhago tlio Mood fail* t- lin-l

a in/of eKBpe, mill mai edled within the nterua in »ulli-
cicut quantity to i-i i • i \ nptome, or oven death of the

patient.

In thi« form any oft be following condition* may obtain end

l. Tlt«- placantj Bit in* detached only u the eentraj the
margin remaining ndherenl ;

%, Tho ij|-|mt margin nmy U- detached. ■>• iltul blood acou-
itiulalo U'lwwii the iiiuiijU ii- Kid tlu UUfilM WW J

. A portion of the edge
Fu*. »- of the phiecutA and of the

adjaiH'iu membranca min
dctftOhcd ; tin- lattet "nmy

rupture :ni'l (H-iinii fcbfl blood

d> mingle wuli llit- lienor

annul m tin- -:u\

4. TlW COf :v iii:iv lw <>Ii-

itruofeu by :i olut, ilir do-
uirliul OHtmbwHV) or iba
pnmitSne part of lha mn

[Fig, !>Mi.

Etioionr ; The prcdiapoa*

iliy run*'* "Ui» !-'• viv«Q M t
UlbCTOOlv uiul syphilitic Jc-

generation "t the doosdua,
plaomtal degvncrntiui . no

jiliiih", iiiHi'tum, :nnl (In*
iiciiic inR 'i ioun tli»i!i«*'«». In
the 1'ivriii'c of rlit'-r hut :t

trivial exciting eauw Efl re-
quired t.> produce wperatiwi
i l tin* iiljifrnlit. A -mlili-u
jur, u Itlmv on tltf :ilwli>nn-n,

or violent inunvular exertion

may be :ill lh;it i- requiiee]

l,i hrinir uhout -ii< Ii :» ••■paru-

■n whft dlxl of •oi'iilonul humor th»n.
ri»ftf» <ii ft"* Mn(Tnll>' Or IV*"J'>ii.
Ill i »ni1 Vftniii-f i

Symptom* and Diagnosis of Accidental Hemorrhaga.
Tin- «vmptoma r< . riiM-- tliowr <>f rupture of the utcrua,

but an not ■-■■ at 1 ! era

In tin- apparent variety tin- fuel nf homoi ilinyc U obvlou*
It DflnaJU t.iKi> piano «-:ii'ly in hilmr or during the I:iU«r
ni'Titii* of prvjjnanc\ Severe looaJIxod pain :ii th«< placenta)]
*'lc i- do! infrequent. Tim iihru- may buljp« at tin* point.

PBl:.\UTfHE SKPARATIOy OF PLACENTA.

I'laeenm |*iiivi:i i ivndiljT 'li:-tin^>ii-lnti In :' ear*fu] vaginal

examination.

Concealed hemorrhage El lUMfllll revealed liy tin- ■ntomio
. 'fleet*. Itapiil |mt«t\ pallor, cold •■xtreiiiitirf, *-*- — 1 1* — i .» --,
ftljghing r» •]'ir:ili"ii, gnu OOlIapHO Dlftj I"' |>n -■ m, It' tobot

in- begun* the uterine contraction* owm of become m ik.

iln.n^li tb« pttioDl may .'ontplinii pf mure Of LCBB continual

pain at the plaoentnl -it-. On abdominal a n < lie

uterine wall may be Found bulging ul t !•• - -«it ••!' t|„ in-mor
rhage ami the CbMaJ heaft-«oana* on- fable end Irregular,

Rupture of the utcru* tnav lie dnuinpuiflheri from concealed
accnleninl hemorrhage by the fuel tliut the former occur* late
in lultor, ii h illy nfn.r rupture uf the membrane?, tuul iliut the
preMiitiu^ jMirt uf the (n«tn> KQfldeS

PrornoHs.

In Apparent hemorrha^o vbe pfognoetl fa ROod Tor the*
mother, l»nl ncit favorable fur the rliihl. If liiliiir doM mil

■ "i n mi once, there fa ihnijjer of mnerJoft of ln« blood-

between die edfc 4 '"* l,M ' placenta ami ihf ■*, moulting

in wil ■

In th<< concwlcd hemorrhage I In |>< nrniage of Dlort&Ktj for

ImiiIi mother end child i- liurh, Death retnritH fniui hemor-
dmok t\ii'iii. iru mi:i , »-r lerane. 'I'lir fatal mortality
i- ohm bo interference with the uteroplacental mrouiaUon.

TrtaUnfnt.

External variety : If the external hemorrhage ia moderate
in amount, a full doee of opium (liq, opii mm., Rlxxv) and
n -• in Im'«I for • (en deyi arifl be the only treatment required*

The patient**) Uno| J M be tenon twice daily for a

wed: or (on unrvn, ami if mtdanoe* o( infection of the hhxxJ-
trai i oooun the Menu v ! ■- -■ ■ I • 1 be emptlM. W ben the btood*
i Mining it limy Im- aooe fl aaiy to induon tabor. The oj
d be dilated rligitalh to permit rupture ol the tnem-
Jirane*. A Baroce or ChanifM*tter do Ribeabng nsnj then m
introduced into Ihfl eervia end lefl tliere 'ill ■ ' i* eapoliadj
"li.-n i |i nifiv Im :>|i|iliiM I. -In hi hi the reran of Katun fau

in uvoraptlj cffci ling deuverj When ii la required to empty

260

l'ATIf<!')i.Y OF LABOR.

tin- utenu ImCDftdlfttelv. tilt etr\ ix diould k- dilated mindly ;
if in--' — :n \ . if •hoiild Ik* lltefstd and POndon performed.

Concealod vojioty : If ihr patient ■ condition i- nidi a t"
I ■ i rl » i 1 1 urlivo nlw-lclrir iiili-i li-mm , I lie I real maul t-lmuld lw»
directed to rimilpHtiiijr tJ )(l nfftota of ihn flhocK and hcniot-

rbugo (sm TrwdnvDl of Koet-partum rluroorrhngt>)<

The 1'ntnlit- -ii.Miid i><- i-..ni|in-«.i |>v meant of ■ snugly

ntting Under end pud. The fool of lie bed should in- de-
nted.
When the patient 1 * condition penaito, the uterui ►bould ba

cmplir-d 1»\ iiinins nf ninminl dilntnihoi of * 1 * ■ - eervil ond \vr-
j»ion. rhfl placenta Lit tfaflM cn»e* ?hould be removed manu-
ally, and a hoi intru-utarlnfl injection should l»c given after

the Dttnil hiw been rinpiM-d.

IV nf'1'T-tK'alllirill sIliMlKI lie directed In ■ ' >tll 1 'ol |ii| k < lllf
effect* nf nevcre hemorrhage, ami to -'■•■unn^ l'»«1 nterim*

contraction*

Retained Placenta.

Tlii-t Ooodltian i* of (n-qnont occurrence. The placenta t-

IWrially rn||||il.;lclv <Ii|;i*' Iki 1, and H«B in tin- dilated loWflT

uterine Beg nl or in the upper pan of tin- vagina.

Cause*- Feeble uterine contraction-, or, more frequently,
impfO|H'r method* of placental eipn — - i ■ ■ i ■ , generally jrive Hue.
ti. the condition, A full bladder or rectum may load to reten-
tion <>f the placenta.

Treatment: The proper application of Orotic'* mcthoil ol

"lv u\ that i* nMuii

flic Uteriln inav Ik- Meadu-d and held in iKMltHin by

expreaoion u uanallj

irvd iii the wa\ yf trwrt-

laving one hand iicrow* (hi* ituprUp tibia nvion nf I In- uhduman,
trnlla tin- other firtnlv inuoeace the ftindu* and at iho tame

tunc exert* plY-.uiv in lit" a.\i« of the jM'U'it- inlet oHfrftty o

uterine contraction. This method will rarely tail foaoonre iJC-
pulakin of the placenuk Very oocowonaUy o may Ik* neeee*

wiry to iiilrndinv :i mimic of linger- into the VHgifM, *> ' tO

reeoh the lower '■d^i* «•! tln« uIboghui end hook it forward,

■

Adherent Placenta.

In tlii* eonditloo, wfaieh i* rnn\ tlm placenta i* not only
i< -t tined, but i»- also adherent \<> tin- uterine wall. The adlta-

2«8

t'ATUOlMQY "l I. \HOH

.lil<l pUOHltaJ tlt'^'in'ivnimt-, dUC to ottfOftK) tu'|ilin!i- in -n.

notlH i\ nii.v givt ri-t tO ;nllnTi'nI pl:uvtit:i,

Treatment: If < iv.i."-. method .1 Kprewjon ,;i ''* "'"I &•

hemorrhage in profuse, the cavity of the uterus muel be entered
and the putGcntfl gently separated and removed.

In perforin this opemtion one IiiumI grappa tin* luodni
aceurefv, while I ho other i* inserted Into the Vflgtao anil fob
low* u|> the cord as a ^iiule till the placenta if reached. A
ihed ed ice i* then tVlt lor. the Soger Opt tnaerted between
the i'l: nta and the uterine wnll.and by gentle lateral move-
mi nt • of Hi*- band the Knaratfon '<■ completed end the
placenta geoth grasped. Too outer hand then make* Mo-
tion over the tumlux until a eoiiinieiiim li:» been simulated,

« lii'ii UNI Internal li;iu<l :iih! plsn'ruta :in' >lmvlv wtiliiliawn
(1'V I'M I).

Thv Internal band and the placenta iibould never be with-
drawn uotil uterine uoutravtion hut occurred] on Hooonnl of
the danger of producing inversion of the utertu TTie band
fthouM than !"■ re-introdaced tnd the whole uterine mvity
explored to make rare that no frngim-ntfr nf placental tiane
have been retained* A hot intrauterine douche should then

In- pven 1 1 i" ;t<lvi-nU«: in n.lininistcr u full do* of I rgUt u*

won a* the utnnu bai been Emptied*

MATERNAL DYSTOCIA.

The mhjeel of matornai dy*tocU may be divided Into three
headioea :
l. Aoomeiiee in ti"' fbreei of labor;

'2. Aimm;ili< g id tin palvil ;

!i. A iiinniili)'- iti ll»' niiitrnml wil'l <tlriirtiin*H.

I, AN0MAI.I1> IN T11K KOWK.S OK LABOR

Precipitate Labor.

Excvkmitm pownr in the capote! v* forcw of labor may nwilt
in the very speedy ooronlefion of the act*

EUolojry ■ Tin Ooadition i- umkiIIv »hie to uiutur frritohitittf

..»' tfu ivmpathdk ncrcoM ^am, mther than i" caoewove

rhi '//■!/ 177 /. (/■'■/:

260

niu-eular il.-velnpnU'iif. II may lln-ivtm.- hi met with in
ymnt^ | • r ■ tn ■ |>:a rjr- a- well u> in \\<utirii •>!" tm>reail\
UKJ ,!' .'K.'iiri- t : 1 1 1 - h i : I : i r ilrveinpniem. The Rllfl ll llial the
m ijui.n \ OOOUfl in ilw WOPMf "'".'/' of bbofj tbl ftl*l hloyv

being quite normal.

Cbnotttnu cwHtrin^ rcbntfoii of the polvk floor, -*- debili-
tating rli-oa.-o*. previous Ianerati"ii, dr., lavnr the OUUUftOOa
of precipitate Jtibor.

/•W lon'ona, wot ■■ (Vrir Of nim'cty, nmj ucl by

iucpcn^iiij^ the force of die UttrilM contraction!

Suddtn and potoafal uta*m< oanflraofffan iriKA (fa patunl in
'/«« ■'"' poafi « mult En thi mpid oxpolaoo of tbo

fuetii*, whnli may fall to the floor jihI receive «oriou» injury.
Tim* it not i(ifr*'.|iioutly happen* that women .m uiMenly
deliveivd while Mttiiij- in n [»ri v V or wnler-cloiet. ami Ufl
••lull may fnll into 1 1 1- • -.--pit or bowl of the oloiDt and
pariah botore ai-l la «eenrvd.

PnitiiuHiH Ijic-itjiIioii- ill' llii' ?OtftlM) :i in I [H'nnelim, hittMl -
rli'i '-■ from |ai-|i:il i»r eomplete •.|nt,i||.»ii ©f 1 1 1 ■ • phi-nl.i,
iuv. r-tun of ilir ur< mi-, ami oei'a.ioii:iIlv retention of the

*i;i'i -.1 '.vitli hi*n r-tr):t-- eoiifruetioii of "he UttrOO,

(ME mr nti.Hinl :t« -.etpieh pf pneipif ate l.'llh.r.

Tin- MliKliii .v niMtii.il of ibe nli'lilir 0000 fll m.'V ha. I I..

•even* nr .".i'ii fatal ijrooop «m tin- put -.1' tl.. BDOthtfi The

ftpr.il m.irfaiitv i< wmewliat mtn Ana normal

Treatment* When tin- UtWIM lOtimi B powcrlUI md the

■ iIos-viuU rnpiiilv; ir m;n \»- 1>,l.l l..u I- l.v in»iTtin- till
Sogers "i il)i- .[i_-iuti uml ivi-.liiii; 'In' (iilvanee nf tbc pro

mating | hi rt. while m tha mum time chloroform m administered

to the mothai Tin- piiiirnt -(lonl.i In- in*t n i.-i«- I i" keep the

mouth OpMk Hid I" pant or OfJ out during eaeh pain.

If ii previtni* labor ha* l»-eti pK.-ipti.it> . tin- woman -houM
Ik- K.'pt ••oii-tiuitly |Q | M .| utter the ohm I "I lulmr. If the

painM lend to I ia too ponerfiil, chloral iliould In- freely

;|i|iiuni-terei|. liltiili Of IWOMA '_*i:i!U- m:i\ he gtvOfl :il I
&0t6, :in-l rep-iilrt! m interval- 0? luentv iniimt. • until a

i n or tin sotlon of to-e drui bu

obtained It i- anvmhlr (•► adoifnIfth>r eihlaroform vrhila
waiting for lln chloral ' ( > bo abwriwd inlo Iho ■yslvm.

Die iii.inu^eni' lit <ii" iiif thirti ttagt of Labor demand* tpocial

r ,,; '■ '■ \ROR.

is

* tnrrv |» often .1 complete :iI>h-ii.*- nf
^dgilBAfrWiwn-i-fllli'i'hilil; In tier thr UteHl* b«WOm»
H ;i!- li.lUrrli llir |»:illl». I li<

jk«iW h* t<|rt ••''" undei rout ml, Arm Prlctloc audi.
a<w .-» tain le stimulate oonlrnulioii, una plenty of tint"

jy . l>4 t**f.*v attempting lo 1* x |M-I I In- phieeflt.'l.
Jkpr taw KUMlWon Of tin' |tl;ii'niil:i the iiltiu- dOW not
■ jtfMllW'T'i n *'"' (ISO I . ) inlru-iihTilH douche -liotild

««-i (w a h) podennic injection «■! ergot (agspUe}

TW !nniliit hIioiiIi! he (vtnlniltitl until 1 lit' nlfru-.

fL -„ llTr tirmK contracted.

DeUyed Labor; Uterine Inertia.

vim the expulsive action of (lie ateru i< unable to over-
aormal roRistanco of (lie uiati-rnal jpa>*igcs, lnl>or U
I and the peine nrc said '<■ I"- " weak.
• The ooraraoncsl cause of nterfae inertia m pre-

r rapture cif flic membrane*, rigid o», a distended blander
jriweom, and general debrlit; nf the put lent Ohliquity of the
*!£■*• overdUientionj a* in multiple prqinBncyorbydnusDlotj

L^acnit'"'! <>f tl terhio rausclo-fibriw from uinWiiution

gf no frequent childhenrtng ; tnalnrraentation ; ntcrSae UimoN
0f iiiiiinr- of neighboring Htruetureh ; and lovr attachments of
,y placenta, may all be mentioned Ha oauw • of uterine liMriSli

gtlaf nosus : Before malting :i dui^mi-is of uterine it"
0ff should lit' inki-u tn ilfx'Prtiiill if the bladder and r.vliim

jg,vc been emptied, lly external examination the oootn

|f the uteniM uiiiy be felt to be weak, for the orynn will not
j#*ume the intent linrdnee* associated with good uterine
action. Ky vaginal examination in the first Ptnpv the bap of
n iter* doc* inn Iwonic tense dnrinp a pain, or if the mem-
bra" 1 - have ruptured the presenting pun docs not >1< —md.
Examination should thru be Dim h) ftEQBrtftln tlmt the

lalwir U not delayed by somo obstruction^

Tlir propnoiH depends on the Btnge of labor and the rauae
of the inertia. In the lit^l stag* then U littlfl dePgW I"

giber mother or child iinleai the membranes have been long
ruptured. In the trrond stage of labor then is dangef lo
mother and ehild from prolongation of die labor.

hi. I 1 17V i i/it'U rrtuixr ix rim i

No hard- i -l "1-1 rule ns to how long delay mi^lit Im with

OOt danger can be laid down. When the h'eud is low in the
pelvi* prolonged delay may cause Btrioos injury to the mater-
nal part* (t"iu pressure of the head. The condition of the

mother mid rhild should In- mri-fully watelml. l>am*<T to
the cliM i- itiruittV-T.-il \ t \ ;i slowing of tin- fielal h«!iit\

a, whHo danger bo tba mother i* Indicated by loot]
.edema in'! :i n-niL- pulae and temperature. It may hi naM
iimt u delay nf over rix hour* in the second ategi warraott

I he urtilieiiil (•-rinnialioii of the hibor.

Treatment Thi- il> pendh on the BtftM 0* I :» 1 ■* ■ i- :md the

e;m»e of the inertia. '1 In i'n-t duty i- to a-eerfain ihe (ADM

of the delay, and, if poeafbte, remove il The bladder
and reatom should l«* emptied The prolongation nf the
fir»t ttflga of labor nay hiiv" 1 exhaojtad the patient, and when
tfaii uj the cue no effort abtmld be modi* to rtimulatc uterine

contraction* until the puticnt In* been reeuDren l»v n good

reati and, if poneiblo, deep. Thin may be accomplished by
giving Iier o bypodmnli: Injection ol morphine H |?.), and
repeating i) In hah an hour if n t oaaw r y. a\fl the name time

HM may be given aniiu- hot htolli or millc.oi .nine *hcrr\ and
:i blaooil, to maintain her -m in/th.

• 'hioral [ate be preferred <•» Morphine, a- it «eldnm arre»t«

tin |nv»ri • nf l;il>or. Two ilciehm- of the -vrnp i-l < hli.rnl

may Ik given in ■ cupful nf warm milk, ami repeated ■"
but an hour if required. On vrakiniTi the patient may Im*
pv< n tome bol broth or < er b *k>K< ' ' the contraction* do nol

then -.■( in with iinn.i-.-l |^•.^w r. rflurta Day Im made (a

-.timnline iIm ntena to action.

Slni.'hnu,. I ■• ■ idnu'ni^ered hv podermieidly, i- pmlin-

lilv tiie mo*t Suable uterine stimulant Qnhune in large
doaet far. xvi. repeated En half nn hour, aeti ircD In «nmc
i i ■ . hut theituhof I in-- failed i<> hud it completely «ii»-
Ibotory.

Erp>t ieonJj mentioned to be rondcinm-d. for it tend* to
induee tetania nterlne action, and dm Interfere* with the

!>l.i'tiii il circulation, ft nhauld rmrt be tuted until //<<■ uUtna
tot eeai ttnptUd. Hoi rojrlnaj douche* (120* K.), given at

interval- of half an hour, often prOVI of '_''cat Valttt

.l/<v,/ /(1 / baj proved a verj •twactoiy uterine pttimahuH En

wa

V.lTW>1.:<>:\ "t I.AIW.

n- !iinlior'»<:.\|KM-icOO*; il t- bcatgivtD in the lurtq of »1ktt\ ,

rteomaaeoikd b) miat.and <imuM bo aiowlv atpped, too

ptlitflH bring informed UMl il «ill -urrly bring bach the
|»nin* mill lia- lt:i id.' ilrlivrrv.

Ill Vt'l-y oilMinah .1 1 .'• .//>;../ titnh/ir in;t\ Ik 1 i(--":!n|

into dm ntonw. aod tin* vagina packed lightly with iodoform

gauze, »* I'll' t lit- imlm-ii'ii) of pivmatui- Inline. Tin iottV-

il'i'-iiim into thcoervii of a Ohuopeticr da Babes hag or of a
Bi oae bag ia a very ueeful t »>«t troublceooie method of treat*
iiH-nt. Tbcee not only stimulate the uterat) to action bill
dilate r 1 > • • cervix, and tin- i-^-l-r in »v<>rcoming tlm i- -i"tanoi
ortoretl by tho o*.

The On*/ of teak?* should not be raptured until the o* is

dilated, unteu it is evident that there lean oxoaesof fiqjiai

tiimiii pi'e-i-tit.aud tlml lh(S b the pFObtblo CHIUO Ol n« llj.-imt

utcrlnn action.

Win it inertia !■* present in the «<»•«»»■/ ttOQtaf labof thr

patient mn be allowed to walk eboQt»ta the hope thai the
aceoeot of the head under the Influence of gravity will *'t up
nterina action liv pHm\ •liniii.tiN.n uf iln.< |x<lvia Boon

Pleasure on the fundua with the patient in the dorsal poai-
tion may prove of valui when employed during uterine cos-
IraotlODJ. When other mcnsiirc* fuif rv*>uroc inn-t !»• had
to the foroape to terminate labor.

2. ANOMALIES OF TIIK I'KI.VH

The graft* niij.n'ity of BttORttJiM of tilt prlvl- am of Afl
uuturt- •>!' contraction. ("<Hiii;u(ii)u- hi the diameter* of tin
pelvic brim five nee lothe monl lerione conMcquencM both
to mother and to child, in urojtorlion tn the degree of ob
itruotton offered in v I ••* jm— age of tin- nvrne<

Frequency ; Until rconntlv it wa* oommonK believed tJbaJ

ulninnn.il pelve- wen' much more (Srol) met «ifh in \in.ri. i
than In Europe; bin the more general nraetice of pelvimetry
wbieb ban prevailad inofa tetrit alinini during tin pn«t deende
Uiim revealed the faol thai in Lmeriea deformity or the pelvi*
mel with in aboul e I • • * ainu proportion ><t women u in

En rnpp,

Tho records of European clinics show a wide variation in

'v

AVOUlf.n-s Oh TffF PELVIS,

lln- |Klv.iif.i'jH- l.|...iU-.|, I In- ilitVrtrlir.' rxfciiflirig tnuil 1 .'J

writ, in Ku>titi. i" "Ji.' pi-r iritt. in Saxony. \'-<n.
Vinckd considers nil faun tuto (ft mi oenr, of German

Wiiiini |i:im> ili-i'oi'iiic-i pftlVM; btlt llial 111 otilv B |MT cent

tat obstruction tenons enough Co Ik> noticed.

Among Aiii.iicaii amnrvnr ,' piint, in New xork* (ttuml
1 .42 pot t-i'iii. of pelvis oootnotwfi ; U»yii"M-, in Rmton,

1.13 jK-r i-i'iit. ; ( 'ni—.m, in Si. I.tmix, " |m r t<'iil, ; Dobbin,

in Baltimore, 11,45 i" i '''Hi.; :nnl SV'illisinnj in Baltimore
1:1,1 mi oanl I 'a ■■ i - , iv, .in log recoitts of 122-4 notiento,

ronrludi'- lli;it '.'.'• |nr rent of th* woiiii-M in thl Unit*

Nun- h.iY. pelves mallei iiinn the avenge, while 7 percent,
tare pelves larger than the average.

Hirst states thai deformed peYvfJ IN bv no means mi
uruonp native-born women in the EuatUn Slates.

GQnatteation : Vtiriinjt olufwiticutiojis uf nclvii anomalies
hare been employer] in tlilTcmit n inn tries, liui the fbUowini
taken than Jewett'i JVodfo <■/ 0/.^, ,',/»-., «ill be found »ui-
ftoSendy comproheDolvs i" moot all requirements:

l Pelves normally proportioned buJ ibnotmal in in
i Uniformly enlarged fjiiHtotnajnr),
2. EJnifbrmly oontrectcd JostoaiiDoi

II. Pelvoi "iili anomaliei <»t' <i w . t shape, inolinaiiOBi of
ponbinaiioni of these i

1. Those With rniimr iU>vein|>im'iitnl |nTiilianliei

fa' Maaculino ;
<M Shallow ;

M I p;

(cy P i- lolloped.

H Anteroposterior!) oontmotod]

(■ V la] i i i-l !•■ .

■ '.) I'lni Mohftlo.

;*.. < tbliquely contracted

(>ti By Inpcrfccl J«-\. Ir.|.iin-iit of one wcrul nlti

i fcfrejrela polvl

[>•) \\\ toiporflM'l "i ■ :ili»li-lir.| ii t' Mm' limit .

(r\ V,\ UNnaJ ••nr\ StUM.

l Dnvli i i baa Jooftii»i of Ofcswsrios, .)•».. 1909.

PATBQLQCY OF LABOR.

L Irmnftvcrarlr nmtnoted t

(<ij Br Imperfect <fevelo|>fi» m of boili Mcnl abe

■ •-i- ol tic- -jiinc.
■*». I '»niij)H-.-.«*ii ptlvb :

(#j Paeodcmialaeaataan nddife.

• •. S|miiii|_v1«)|i-[1h-(i<'.

7 reive* distorted bj Injury ttimof*i >ncb}

■

{ l I. I i: tn:t ■ ilur |i> -|U!i:lI mrv.'il tin- :

fa) K jrphotSc :
./,, Sootiotio]
Kyp h oaooliotk ;

DUfiioits: Ww-fiicntlif ii i- tli.- duty of the physician to
take oartftil mwunrvmeni of the polvj* of rrarj woman Im U

Cttiled Upon tojlUnd in labor; |>ni<li<:i! Jn . tliifl i- riivlv JotM

until delay in tin* pragrcn of lai><>i colli attention to Ac fta
thai ponalbfy »mc oibMCraotlon exfa&i la tin* pelvU

Deformity of the pel via hvuuifrtmmUltf met with in thorn

ffOAMO »ho in Oolhlhood liaw HUflferM] from ncilnttliitioii,

ri. I., t-, or tnuoroulonifi of I In ■• i rh bni or joint* of the lower
limbs, or wbo early in lift have luflereri from accident to a
limit u'liii'li fun remitted in HhorteuiiiBj dMuertfion, pic

Malnutrition mnl Imrif ir*tA rnv\\ in lift not ml'ri'iin- 1: U

iv ult in fattening of the pelvic brim. IHAru may wad to
varioiM ■eric id pelvic defbrmitiee, A hidory of late denti-
tii.n. (iv-.! "ii:-- <l iii'livr-t i'-n. of not nuking ;ifuT the leeond
j . m ■. would mggGRt this * 1 i —* •**—<■ . An examination of nidi n

Itnii'hi might reveal tbo iquorc head, pigeon brcaati bead
im of tbo ril<>. or bending or tw5*ting of ilio long boni

mimm im tin- tli^-n-.v l'-nnllv Mi.-.- ]>it)r>nf»areof abort
etfltlU*.

/>/■<•" oi m \d\ ' rcaulting in deformity of the apSiM at

lower liml.. when tbej have iirred enrth in tii I in

abnormal development <«t* the peli I

I ••Unit nfth$> itrit'l i- fffmvrui ni'» </» jtetifit it oi before tl
..ii- i of labor, n luted with nndne prominent* of fine nl>di

t'Hi vwrrin-

inni, tbould always suggest obrtnictioD nt the pel via onm
whm iii'-^' oondiuonsaN found pNsenri in i i>rimij»aru withu

v*rt»!X pivx-n union.

Pelvimetry.

DoJbnnitittof tin* pelvis tmiv bo dou-Wiil l>y •j-in-imi ami
into not palpation/ sod b) BMonununCij * ►< ■ = J * exteratJ and
internal, of (hoise diamct'i> ■ •!' the palvh wbiofl in JOOOMilUfa

For t-ikii>:/ potato HMOjHirmMnti tht examiner* 1 linp-TH, m
t.ij>.' iiii-ii-.hu . tod i ptir of iiuxlifiel calipers, known u n pw
nnclcf, uv nsnaUi anployed. The pplvJmctci devived Iw

BuutttJooquo in 1 7 * -"• ( I-'ifcr. "lOl > is m-oiinM) ihl best) though
many other* haw mihv l»i>n invented,

1 M 101

Im bed, while die phymcian standi betide bar looking toward

.T ln«H<l. He then liikvi the pelvimeter ;u«l I * • ■ 1 « i - i n*l in

• .11 1 1 li.itiri, tin- up iii 'in i ml i •. finger being' Ii knooj m»I

tlie roniling surFiro of i i» -'i ; - held •>■• n* u* Im RML

Tin- knobs of the prlvinu't-T IK lofiD phased >>n tho-?iitrrior
lUfHrlor epinei >;j Uti UU\ or on the dl I.itn jn-t 1m-|((M-

tIi-iii, a« tuffjuy*ie<l I'V \\ in-li'-l. in the normal pelvni tliU
t ■ i ifftnem ihould Dt 10001 lOj im lie !'j i in . llic knob*

of the pelviinctfif one then moved il tJ

/:»• /•(•-.,/» i j 1 1 F i 1 the gfSfttCBl dlltMkOO 1* ("■ •ill**!, I lie nn-i-Mn--

rmml up which nhould be about II inehe* <:W cm.), The

length of tfaoM niiii-nniiirii'-. :i- u. II ;i- any important differ*
imec lit'tween them, etmhlr* ii- to draw OOt GODclBnODI U BO
the (lrVrlojuiM ill 01 th*J iiinominaN' Im.hh'-. tfld l Im ■ uu'ih qJ
titt InitiMrrryr dtOHUUr "I Hir liilfl.

The patient m then mede t<» bum on her »»!«■, with Un
I u slightly Bcxed, The taob of one rod n then placed in

tilt flCpTPtfMOri ,'"■■/ hrliit, ill- np'ui, i>f tht lad Inmhu, tt,!tl,->

.in-l lirmly held in thl« poeitfon, while the other knoh Ii placed

on the sympliy-i*. ptiln. 01 :i |M.iiit ahoul one-eSghtll of on tneJl
IwliiH it- ii|i|mt IhimIit, and prcHMnl lirmly into |"«ilem. I lir

mooNiTcmcni thug obtained should U- !il><>m 7' m.ln^ < i!i
i-iii. i. ui'l i- known u the externa/ eenjugalr, or tin* uVojne-
r. /■ /»/' aawMocqur. To ulit»iii im idea of the trot* pnnju
gate .'•'. Inohen (9 cm,] nbould Im' deducted from the moae-
oremeol of 1 1 »<■ ezti mol conjugate] to allow for (he thfokiM ■-
nf bone and »fl n— ni- ; t hi- would give the oormol true
mimipiii*, I inches (ID am i.

Theo&MfNe aVamefers ■•>'■''" &rwi may be mi nuuircd by planing
mm knob "l" the pelvimeter in the depression marking the

|mi«ti<rii>r -iipcrior -ph f nm- nido, and ll th.-r I b Ofl

the interior superior ipim of the uppmitc »idc. In tym*
metrical pelvea tbeec im iinmiiitv m-c usimlly o«|U!iI t and

should l»' ;>i » 9 inched (22.6 em.),

Tin- i'i,;'\n,iii rma of the pclvfa mnv be mcontircd I »_\ pirn i
n tape-line around the body, no thai it will pa** Juai ov« iIh*
pymphvMs. under the ilioo nnatn. :iu«l nvei the middle of the

■crura behind. In n wi.rn.iii «.(' ;iv<t:i.m (hvclopraeM and

wiili ii Dorraa] pclvii Chin meesareraonl ahould be about Uo^

iiii'Iu- • im i .-ill./.

vi ivnn tuv

The other external mcafturrmcnU of importance nrc tfaQM

of tlM -.iff/-/ o/tfi fttMa, Thv b"Ofifi mnruta of ili<* oot-
id i • inaaavred b\ plncfng the Itnofae of the peh Emetej on the

i i ■ i*ii' - <■! llic i-rliml (itlit)i»i(ii'.. Tin* UuttTOptH

Witmtit t i « - : J ^ !»• llH'Jimilvil I « % planing »M ROOD iiflhr |M*I\ ilil-

ette on the under border of the syittpltywfl puttie ind the
other fttnob "ii t Ji<- -kin over the lowtf border of the tip of the

•.HTiini. 1 1 dim (In- I 1 •-in. um-! be ilciliii'U'd to allow for
ilni'Lur— of il"' bom. eU 1 Tub mcvMirvmenl out be better
obtained bj plemigthe ii|> of Mm oiiddU; finger of t lie left

IkiikI, tDMrtW into the v;ii:iii;i, Ugajnal the end of tin* aWUBI

- « -■ i |.n*«iii|_' tin I'd.;.- ..r the bad igninal tfcolowti border
of the aympnyau, the point i.f contact U'ing markoil U the

null \ >fiugi ■■• of rta right hniid UIhI the duttlMB liieH.-urcd

Eld ■ i ■< '" IiiiimI hoi beai » lUuIfsweh

Internal meaaorementa : A giiod pi urn I iilrn of llic rapacity

of tin- pelvic can*! buj bo obtained from :t nuvful v.-i^innl
■semination. Tho point* of HnrpoTtanco in ilim examination
are lii- Uiiokneea, height, and Inclination of the pubis; tin'
condition of the lateral walla »>■ regard* projections, etc; the
• (um lit i< hi of tin Bacrococcygeol |oinl ; the curve of the mctudi ;
and the ouuuitiofl nf im promontory if thin nan l>r rescued.

Xhi tivifftmal oon/aoew — i *., the Bieajnffo&aanl from the
promontory to Hu mbpabic ligament— oan uraolW l» ob-
tajned without much difficulty provided the examination ii
made careftdlj end methodically.

The patient fa put in the lithotomy poaition with the biri>

I.H-1, . |il..|r.'[,hU' I.H.T I 1 "' dip.' Ill till' l»"l 111 l.'ll.jl PliC

cxjiinimT then introduce! Uic Am two Hngofi or the left huwl
Into the vagina and estenda them Inward and upward until

-■■ i finger reata upon the promontory •-(' the

MORHD I i- |nj,. i .„;■ must l>c taken not to mistake tlie
Ia»t hunbai pertebrufof the first mem I. ai no Mrel The
radtal ddc of the bond »■• (ben rahvd until the imprcwof

iln ubpOblc li":tr:niit i> fill U|miii ir. With :i lini'i'i iiiiM «if

the nth*] hand the point of contact U marked, and both hand*
iln a withdrawn, With a pelvimeter the. di*t:iiu-e between the
milk and the tip of the weond finger i* then mcaanred. Thin
u Um length "'' the diagonal conjugate, rriim Mn- moafturo*
uiriii I jni'h 1 1.70 ein.i wionkl In' di'diii'ii <l to obtaJo the lino

OTA

pATUOt.OOY or l.MHtll

i-Miijn^iir #! inrii.-rir Thi-< average difference between tin ■
hM oLRtneten depends •»[•■•■■ :!"■ ft iajht <>i the ■yiophyeiB { l J

LnchcBj i i, •> oonnal meU between tbeoxisof the puma

i ti- 1 tlio true conjugate! 105 degrees)] ;' Dormd tAiekneaaof the

in;>li* f M!*, and a normal height of iho promontory.

Winn toe height of the *vmphvsi» isgreutcr titan I j inches

'I <'m.i. about ,' invh (- cm.) Hioiii-I i"' deducted Eroni the
otogonal conjugate
TIic trut oaiyugait mm In- measured with almost peried

lOOttroflp liy nous of a special pelvimeter Invented by Hint,

fa. 102.

liiUmtl p- lvknUTy. Mumirlitf OV rikgoiu] conjugal- »ltl> ItolUUldi »Jow«U.)

of Philadelphia. Hirst'* measurement i" (Vom the promontory
t<t n point otie-elghth ft' an inch below the upper, outer bonier
of I he symplr. *i- pubhl Hirit's pelvimeter coroti»t* o|'n long,
Btra ghl rod, to which i?- nttuchcd a movable Imr having ■

flight cut > ' .

The pliv.-iriiin having jiluecil the miilille linger tif the left

hand upon the promontory, the Up of the Ktrni^hi mil of the

rih i iu< -u*! i- poshed into ptaoe alongaiitei when- he holds it
I'mly. wlulc :in aaaistanl adjuata the tip of the movable bar
over o point one-sigbth of an inch below the miter upper
border or the symphysis Thia bar u blien screwed iiu'1". the
pelvimeter removed, lod the distance between the tip- mcan-

nrttl Uv iii.iii- -.I' ii uijie. The tbiaknOBS Of the -vmph\-i-

Siin- i. i ii- i nired by guiding mm Up of 1 1 1»- pelvimeter,
traduced bu the vagina, to b point • •in----i^ln h of an bieli
from id'- top ; bbc ootti bar i- then adjusted to tin- urns potm
m- before and lerevred right, and the Cutanea between the tip*
intaMiini jlI'ici i lie [H-Ui Mr he* been withdrawn,

Pelves Normally Proportioned but Abnormal m fine.

Uniformly Enlarged Polvls iJuttonuyor
Definition: Tllla Hirrii of |»h i- pn p r\ ■. ) nil rlir Hinnt"ter<

of tba normal bul -ill i'- tnenauroraenfc m inoraucd. It i^
gtnerallY to be (bund in women of greai rtntnre, though u h

m. i witii ocuaionaJljr in women below the medium height.

W»eiiosis ,\U the incuauxements are found to bo in exceea
nf tin- norma] while pn er» ng their relative proportion.

Influence on pregnancy and labor' During pregnancy the
ni. -in- tandi to remain mruntf in the peiv!*. than in Ilia normal

Condition, til 111 >-i\ in •[ ri(W In »li-!iiH>:iiHV» OT the hlmhhr :hkI

nf ihi- reotum, For tba earne reamn tin praam re ymptoma
in the latter part "i" pregnanov an often mvertj and mat
rend 1 comotktii difficult,

lii ndttion predfapuece t<» preoipib Wrvor/. TTm

imprrirtM reauftaoov offered t.» tin hood in it- doaoenl bmj

I, id t(i |i.k* r>f Buiorii ind thtU reiurd rotation.

Uniformly Contracted Palria (Junlaminori.

Definition i Tu thw tj \»- <>( palvu the Tumi m pn ierw & t bol
it* *\f En liiiiiini licil.
Three vortotic* nf tin- JtaUotntnor pelvis ore naually do

VOrinadl "I' iIm-m". tin- nn»*t common i* the .in which

ih«' l>nii« - are «m:ill and deader; the nawunni. in which the
Ihhh-- ira beavj and tMeh . and the qVmf/, ->r pelvfai nunn, in
vhfeh the bonoa ire thin and Fragile, and the oartnoglnona

jimrlion. between llu- aONtltUenl • of tin 1 <•• I I D In :

retained.

OccuTwuci: The uniform!* 1 contracted palvh U nanal
be found in noder-eSsed womeDj though it mag l«- mol with
in women of average height, or even hi tall women. Tt i*

2*1

i:\nt-tt. • i.taon.

!!;<■ I ••niiiumniy iiH-L Willi in Ani'Tica ill -Imp- ami f:ir|ury-
jjirl*.

EtioloKy : I Ik «:m>:ihnn n| ! In- jti-i. -mumr p< ki« ha» not
bdufl -;ti i-l'jic'i.ii'ilv i \|iitiiiinl. 1 1. \* prtifrnlly lhi< rCSoll <»!'
;irrr>ti-i| <IcVt>lo|iint<nf <hlr !o mila. maUi- hvgieQK I iirroiiml -

ton tad bad nutrition in earlj lif*.

ChururtrrliittcB - The SCDI mllv i "iitraotcd pclvw B|iprnnelH-*
(In Inffcuttle iu type yl'iL*. 108/t The ulic of the nioruoi urc

103.

f

UmcNllr ■ r»rt*4 flwtrt pdtti « Af>.-» winrM >

narrow, wlii). iln- Kirriim it-ili' i* xlmrt nnd ha» louenod for-
IfUt] inrltnalinti U OOmpefed with tile nui'imil. Tin- PVDD20H

t«irv \n liiirli Imi imt promloeoL The pnbtc bone* and §ym
pi.v En have n lenvoen Enolfaatfon outward. Thou win

|):tli'iil -1:hkI> rm-l DM Micliiiiilinn nf flic pcl\ ir i'lil liiliiO t(l
tin- ftbdonifiel :i\i> tnnki'i ;i more obtUM' witch' limn H'olllfl l>e

lit*' c:i-c in :i nnrmal pelvi.- (Kir I"' 1

I -nally llir mill nicl i<in i- n«.( \ cry treat. Tin- mnjiipilr

diameter i- widow betow it nn i.^j indu-i.

DtuRnoKiK Onrefal pelvimetry will -how thai all the mow*
Uremont- nn- U'lmv nnrmal, with I he rxivpiinn powibrv of the

i-tti-rnrtl ■ -■•)■.' .it.- iliiiiiiottT which i- loOffV tluni would la?

I'l.l t fils AIlSaliM \l, IS sl/.F

r*tn*ft»], mi Hcminit Of tli«' pO»t«fior |Hwtlioii ami li'**»'IU>d
int'liiiutiuii forward of I In- MOnilU. In tlii> form of OODtfftCtod
pdvifl ihl iii<':i-iiniiii'iii of tbfl pilvic cirriimfrrvmT i- (tencr-
ully I'jir lh.'1-tw tin' normal, 90 pin '••' int'!ir»|.

Influence of labor : Tin- LnonMUwd ir-i-murr nflrrnl Id llm

.]<•- mbdI "i" die hud mould in fWxiun Mug wore marked tun
IK ii In (ha normal pelvS* Tin head gancmlly entcri the brim
in tii- oblique dianata

In /., . . I eatm the rhiM'* heml IDUftt !*• well ffoietlj hv tlm

<'jK-i:ii"f putting i> ■ -* linger in iu mouth and drawing down

Fi«. 104.

IUrt,?..m »hf<Hiiif I li tw.i- ml uii.1 Ju- inn' [#HU lill .i-.to.l

m«Ml Mrtion. nuci. n»nit»i Rid, jiumnlnor.

the .'liin before bo attempt i» muuY lo secure engagement in
the lirim.

I '...»■ £b utnalfy prolangtd, and tlie bead nmetioei nueh
mouldiug, the caput aDoaadaneuni befog Dnuaaalli Imp*.

rhe ■IllMXi-ipitolH.^jnalic <li:unr|. i ( .f (lir hriul i- c.iii-

prcMt'il and il"- occipitomental elongated (Fig. 105V

Treatment If tin- \u-:i<[ i- advancing under the influence

Of QteniN 00UO1 iiifcrlVnni'-' i- <-;i!l'«l Tot. Tin* |i:itn'iit'«

rtrength mart In* miNtafned by nppropriale nourbbmeol, end

o|mi;iii m;iv lie nfttd li_V|Krtlrnini';illy lo rvhVvi* li.T -nflrriiiir*.

Plenty of time tiiu-t be allowed to aware good BMOldinffof

tin- Imrnl,

3*2

PJTBOlOOr OF LABOR

Ytu. ttt.

Wbeo labor i* ddQf^S and advaorv of tl»r lw*d ntw.
fcrc*f» Uicald I* trfrd. Th* axU-trartbn fcrrep* 4»ouM be

rai|4uyni. .l> a rule. HRafl die
cuntr. IMM ttl BBOll-

mrtrv il»- bead >-jii I- .Mil. I i
ii b* ratrK rati and hii batn nl-

lowad en h 'II ttOQkUd

If unxlvral* rfl't Klractiotl

«:ili tin Ibtvepe fail U> bring alioul
odniiinr of tin- limd ami tin* rhuj
14 *till uWogi Bfmphymolomy sooauj
be performed

VrT-ii.ii i- not •.. !«■ r inniiMHliiI

on account «>f tin? difficulty in mob**
log the proper amount of flexion
i . . . ■ . .if. '" permit the engag* mail
of ilipiiftn '.lining licn.J in the |M-I-
\i«- liriiu.

Munm •huwinc li«>d un

.MUl.i-.l «tlll III HI ill >1 I ;■ Uli •

In u lualiimtnar cim

■aA. uumoulilcij.
: BflutdM

Pelves with Anomalies of Size, Shape, Inclination; or
Combinations of These.

Minor Developmental Peculiarities.

Maeouline pelvis: In this jk-Ivis the hone* are lieuvy and
ntronff, and tin* whole pdvifl tfl nAfcullM In character.

Lilnti limy Ik- prolonged and difficult on account of delay
riilur iii tin' lirifu or tin- millet. Korecp* are frequently iv-
quirad to accomplish delivery.

Shallow polvia: The distance between tin- brim and the
outlet fi relative!} \em in lliia fnrm of jH-lvia than In the
not tn:il. fa ii nili\ labor is easy, though oooswonnln loroofai
arc reeufnta,

Deep pelvis : Tin !■' i- in Abnormal Increase >n ilic dUlanco
between the inlet ind tin* outlet in tlii* form of pelvK Pro-
vided the iliarneteo un- normal, tabor i« not Interfered with,

Funnel HhJipcd pelvis: In this form of pelvin tin 1 -jutimii in
nrmw and ha> little p'riH-ndicuuir curve, urn! iIiiim (lie dentil
(li. conn I I- iiM-r-'ii— •! (Fig 106). In thin form of pel via
ntrnetion i- im-si marked at tlie outlet, and may Ih hi

rrj.vi- wnu .ivifi/,ifs <>f sizf, etc.

ntero] i >>< • linim-ui, »t in (he lateral, or in Uiili.

I In- pel Vli llin LippIiMurlio: lit" ni:i fiiliiM- in tTMk

frfouna on Labor: Pho mwhanlum of kbar m Intorl
with ud tin -in-.nl tcadi Lo become txtanded lototcavlti -i
the pelvfa; lini- btdtward i - >t = ■ ■ j * *> <,i tin occfpui li likely to

orcur. IjiImit i- ii-uall_v prolonged, tin- delay ocourriOM «1» "

I lie Itiinl i- :it tin' nutli l. Tlti-ir i- great*? n«k of MtflD*lV«

riipinn ..i in- |<u;n!nii. tl li parts at the pelvie nutlet

ar<: Uk- iv hJ bi mjurad bj Badue prenurc of the head.

ll.i 100.

■| .(..(-.I l-!vl. 'AK/fWUn

Trmtmmt : In ill. lea I i-l- • of <■ ::iiiinii the woman

Biai be delivered 9poutan lely or by Corcepa. I» (!»• Ih^Iut

-ri.i. - i . i i no operation nay bo required. Bjoipny-
MOtoor/ may i» antplovvd when tin contraction in ilw outlet

i- not nmr(<<il ami cfhrU ti • rtnotioil b) DOStlfl of At for-

oapi fail

Plat TalrtK.

ShortnniDC of the conjiic.itr diameter of tin- Itrim i* tin-
main i«liiinn ■l.-ri-lii- ■ <(" flat \xA-

Sim^U t'l'lt I'tlrrr ; S^n-W^f'U'ii-,
S-hiinlt'i- -s.ii«- ihfll liii- \ :in* !v nf .li'l'uniit'ii |m-1\ U in more

Ibeqacntjj am i" Barop* than .ill (ho otlieff Ibrzw put

-'HI

! \llf>l<l,,\ Oh f iB'tfi

tOg*Ul«r lu Amirii.'i llm *ini|il( fat, :imJ tin- «rrne'rullv cnn-
t: u h.l, :ii.' tlir two ',;ui<>Il<> ul" pfllvlc diTormily liioet lr(«-

queotly "Hi wiili.

Hirst, in a jtono* of .'till \w\vm in woinvo of luMrtau
birth, found flatteniug Uittxial iu 6.8 peroral Dftvu, in ,\
aerii ol 1224 peLva^ (baud the »ifnpla ihit in 5,7 pi r 01 <•*.

Characteristic* : Tho BLOTUOl i* MlMtj ttod pTOBN doWD-
wanliunl Fbmrd bet wmi tin* ili;>«' i.wn.- . i- ii i- not rotated

Vu. Iffl

J

I

Kill MMMfcUfe |-'i»li. After KMrmarM

forwunl on it.-* trantwrM dtamotir, tlw nntompnAtarior diam-
eter of tho ptslvii w lh*refor* contracted throughout it* whole

i-vtont. The h-iii wr..< ilmiiirtiT rornnin- :ih (TWO* U in ilw

normal pelvU (Pig. 107 1

FvMiMntTy in thit polrcm tliero i* n <i<i>i/>ti- promontory, mj

lh:i! :i 1 1 in ■ drCW botWMB 'h< BOO ' - ;|1 i.l . ••rti.-hl'll tllld the

ftvmphjrola i- often m short its or ihorter than, tho true ©on*
Junto

FEt.\'E3 WITH ASOMAUES OF SIZE. ETC.

l's:,

I lie ttnjrrr ,,f , — nhurttim \> ll*U:illv Hut gtvul, :i- il i- t:ii. Iv

beloa B on. (.'ij Inohee), and anally not under i>.'» am

iixtlio).

Etiolofyr The condition M ti«n:illv coii^i'iiiIji), llmii^li hard
work in youtbj 100 curly unliving, :iml B3tQWiiv< *liindin^ mi
itn ir.l msiy !*■ mentioned lg rjniHjilivf lueinr-

DiaffnoM*: Toll pvlvEl niuv he found in -niiill or in UUTO

women Than " usually nothing hi the patient 1 ! Norton or

appearance to luggeel the deformity, unli •- -In- hn* had -iirti-

ouKj in previoua labor* By pelvimetry the tranveim

nieu-iircinenr* will Ik found to be itormul, while the Bfltero
pwlvrior diameter will he diiiiininhrd,

n< Flat Rachitic Writ.

Ki.. i<»

ObarectenstlOfi : EUouKfl lend* to Inonaaed BOBdemation in
tlio bones; bonce hi the Hat nofaltio pelvis they aro ha

thicker, and w-mr«h:iT mhuIIit than in the normal. Tho
Moriim \* wider tlmii m the normal pclviv

I in- iii.w (v. ■-/.'. :< i «■ mora of law iveJted at their a&tsrlo*

eiitl-, mi that the :n!rr-|>m:il diameter i- equal (ft OT gTtetSY

than the inPreri-inl. The ilia ;\v llmii-iied, >«> th:it (lie !<»-»»■

jirr nol m cliMtinofly hollowed ool nor are t !*<■ Hiss vrinin w
expanded si in tin normal pelvSa Toe pcfefo eVAn \s kidney-
ihapad| ool he:in ih&ped, »- in the normal pelvis. The oon-

jui/ti'r i- fliiiiiiii'hed ; :i imI the trtltW-

WW ifi'imtl.r ivlafivcly Or lili-utiilely

increased) /U theovwl the transverse
diameter um* be widened and f i»'
«M*ropo«tcriQi be either normal or
iucreuacd (Fig. 108}.

The puatc area is wider than nor-
mal, ind the ■rmpnvsui b dcepe

■ml i- '"' itcd on ir ■ trnn»vpr*e

<li. A - ' ilcif it- njijM>r border

' "h'.ei _• - Inward the |H olNolllor\ .

rhoa Um relation of the true rnnjupftte

to Uke dlUk-mial «-yn|iiBnte l» not the RUDfi u- in ihe normal

petvii (Fig. KW).

t)lMKr*iii •IifimMi- >ullht>
Of lifllii ..r iiwiu.) 4>liO i.f
llm rai'|ilM< t>

in-.- i n« m«»i it. t n.i

r.iTW>L'>tir or t..<

In the rachitic pclvi* the vxyugata rmt may I- -bed

I:.. 1<"..

[•Itii

to any extent, dep ih i tl»e

degree of di-fnnniiv |

luolocy EUobiui in it- coi-Iv
stiiffc« cMaaa a weening of tl»e
bone* aod l^aracnti The wrigbt
nf the bod) tends to pu*h tbe
praaontNy of the aacrtna down*

ward And forward ; this eauaes a
rotaii' i. od the Mcwm on
ttnavemi diameter, mid trod*
to clovatc Ibc Iowa |ort of

Im>h<- :im.1 i In - iiMvyx upward ami
backward. Tin itronf 2|nxMBl|

attached i» tbe lora pm of th«

■OiiTiitn prevent it- turn • im-nt
upward mid iKirkwnrd, and bat

remit ia a oban hemline, of tna
iMdii' produced in th*» nrighbor-

Ii.m-I of (In finirlli -arnil eert*-

bim.

i: idea lb* w.i^itt of i in- body, tba actio* -;/ tA$ tutrntm

Attached fcO ilif |" 'M- i.- i1n.uI tin- deformity, Tbi

Inenaacd HftHir-n of the ischial luberoiiria b dm- i-

aotion of the abductor ami rotator inutclca of tin Ibigba. The

■•-. of Jofbnnity fo dc ead by mcbitia depends on ii"' dot

■■I it* ii|-|- r .:- amity, An duration, and the habit* of

Am <lniii.
Dioaaofts : Tin* faiaton of tin woman, Ih-t nppcnrmre, and

ili«' m atiJofl and DMaaamaantf of be* pelVM will permit

- > - . i liditucnt of a dia^noaU.

Tlw mchltfc woman i> MHialK uoder-oiaEd. She ma) have

a BqimiT-^miicd head nr defuriiinl tlmi m-bltBBtb bend-

ing of the rUM, and curved long; bnnaa, ah ten mnji bcenlai_

nt the end.*. When »hc In :i flat »orl:i<r with the linil

well extended lordosis is MMfallj proMDt

Pata mi rill MKrw that tbo relation of the -jm

aud emit* of the tlm U alined, Tbc external owjna-ate and
tlie diagonal conjugate iJijniKi.r- will !*■ found diiuiuMied. On
account of the iner«..M-. I depth ol the -vniphy>i- ami the dlv«r-

m Oumtaj A\Wm
all i i n .' Raa,rarallfei

PBLV&S WITH \ SOX AUEB OF &1ZF. ETO 381

■••■ loo of ito lower margin, I Inch i .' era.) niiut !*• deducted
from the t.lujjjiioul conjugate, instead of t lie average j Inch

Can ma-t Ik- taken lo :i-<*Tt:iin if n doubt* j/roiaontoi J [|

■it ; tod If *>. the conjugate ihould bo iwoanrad from the
projection of ihi ncran \vlii<-li i.- nearer the ivmpbyi I ..

\f,-futin'Hin it/' itubOT in l-f"l /'• '".v.

Tin DtraCtod ■ "million of tin lijupih- prevent*

entrance lola the pelvic ralat of the prctcriting part ; hence, tli
abdomen i* n-uiliv mora or lean pendulous.

The |iiv.-iiihnir |, ;i tl, d* if i- lltx head, t.-. Usually luuml :il l!i<

oooct of labor to w rooting En one ur other iliac fbaan; <»r it
nay be lirmly pmwwl thiwn upon tlw brim to :t tnnitvera

CltJon, h ilun ii- lungeol diameter is BjOooDimodtttfd i" the
dlarauUT of the |« liria Inkt.

M»lpr«Mntatlonn »n- COD3 i, ad pfolop I 'I t'l Mid

of the i stn mil* i- not Infrequent.

The flrrt lUfe ••! IflW i> u«unlly |>r»il< ■> ■_ [** .!■< • •!' the

nt of the hcml. The iiirinbrune- |.i- »t i u- i<- Iihm lin-
os in ■ iTiiihin. ii pouch. Unfnrtiuiiiu-ly the bag of amten
n u;illv ruptara bofu : and hi thtacnac diuuatfoa ara only bo
effected hi > retraction of thr cervix ovor the hood.

In the eecond itigo ■»! lobar I be dement of the bend

by ihe projection of the mend promontory Thai 'I

acctpul :- punned toanaafd* nil it caoaoi toto contact vrrlh Ihe

lateral brim of tho pelvis ''"• IllopcotlnonJ Ifne, whoro it :•

nntotM. The naeiiitii iwl being roHiHtetl, titan deaornaa. and

llin* rvliiisinn of Ilia head uooumj ■ I * ■ — briiip* the ►twill hi-
ii mpornl, Inotaad of ih» larBR 1 biparietal, dfaraouti of the liend
loto relation with llrt cautnietal ivnju^ile.

Tin- imivi iiieiit " roiuidUf thi» promontory" then Uikv*

lii- posterior parietal ifiw i»v ■ <! <>n the

proroontory, ao thai thohend becomen oblwurfy diwphmd by

i I ■<_' m 'I-. initeni|h.-i> riiii- tiiiirii'-t'T rilUB the 000

-iitur- . mi >.( of ran ilninaj ii» Aa middle of the pnlvli inl<-t,

tpprcni ba the pro nonl ay, n^ the anterior lwrieul burn- -li|>-

he apper border of the ^rraphyola ana cntsra the eaviry

of the pel ' Then the pootcnor parietal u>w ■■-Hi-. |.. i il-

FAT/WI.". V OF LABOR,

Ite na

1-— *.- ih--u»i. HI rwUll.-

prontoMorv, sad the head mm the pelvic cavltr in u> »trt»Jnl
-.>an(Ag. 1!0)l
Oho- the obstroetten At the inoertor strait li patted,

lies*! i loo tids wiili tiu*' awl rapalilv, the p

iii-ni giiiiii; un aormallv. OcwhkbIIv rotation of

heed fail*, ami OVfag !•> the width 'if tin- imovrrv dial

of rln (- K i- il i- »-x[- lit- 1 from Hi-- « ill... in i

V+r*t> .»r in An (ihliqm* pQOltioB

He*d-moiUdinn : Hie oput -iwcedaneimi U generally not
cxagpTnlMt GsUeJ I li ld\

head *h<m» vhat i* knmvn w* tin
" promontory mark." Thi* maybe
tinlva rod mark on the parietal re-
gion, batmen the entei nolle
tad the parietal eminence whidi was
in contact with tin- promontory. Ov
.-.i-i.ifiii |% tin ■;.- um> U' :ih aottttl

prw*i ! tin' jiahctiil Uiiii' in iIh'm

i' " Komi tim - ii cutter

mote way '"■ """"I in a Una running outward bm rorwaH

on the pnUd'b bIeuN. Usually tin- poRtarior > I-"'" i-

.|.|.n«#nl bfloa il" 1 tmi(TH>r, wliirh m-iT)np« It at the sagittal

mi tore.

T-'nfnu,il <>{ hihnr in Flat Petal

( 'are -liniild Im- taken n keep the merabmnw tnUct as
x* iKv-ilil'-, l<v keeping tin* nattvni m bod during the first
of IiiIhh. and I • % n-nrniim Imi -ipiiiiHl " Waring down " flurill

lb pains.

If the conjnastn i- sol pwtly diminished, the head will
usually onoge, provided it be given plenty of tin).- 1.. moakl
}), litf rnd the uterine contiwtinns -dtniild bo controlled

nnmi-* nt'li^ |"i«l< Mile- iiijrrti..n- <■! |

lion. The patient's strength «l id be nmi -1 \>y il

administration of nourishing broths, <%(g-nnggs, cot. If tl
eliild'- head U- not unduly «>"iiiHl, tlii* matim-nt iii the largo
pru|Kir[n>ti id' n wo will prove sarui.

Should the hand not dnnrnnd, !nt« a rl<'i •■! ■• •• should not
delavad loo long, for than* i* dimmer that tin- [nv»ureofth
lieaii inav ro-nll in |uwro»i» of tte eerVICal lUSUe OVU

."f/j.i'A.v with .i.w.v.u. //■-.■ './■ sr/j: t trie.

■

promontori lo 4 tin interior voffEntl mil btihiod tho fyrm-

|»llV-l".

j ». h v*i v by iln emplovBHBl of ftXfe-tacltoii foroepi mm

lln'ii l» ml. 'in|ihi| ; for DlU opcnitmn tln< |mti"iit -h.nilil l>c

Etnovl mi Wtlehcn povitioo. Should Ifau fbtQuw opcratiua
ill, deliver] of living •_»! • ■ 1* 1 oui oolv I** effected bv reoourw
bo qrmpb/nutouiy or to f'ncsoronn mouoil

Obliquely ContraoUd 7*1tm.

(>M»|in.lv oiii(rn«'tc«l |hIvo. result (Yum :

i" liu|»'Mi'<-i .1. vclupiiLciii (if ma- wcrui aln;

Pro, in

4

**

i* 1 -

,. . ■.!■ . ,, h H I .. r .. ■ Alfa . VlMkaL]

\K) [mpcrfori or aboil*))'- 1 n-..-..r •■no limb; or

(r| Ln. rol CO] v:i!lirr of lln- juln .
IV HW.

rni

r.lTltor.'M) nr i.a.

Iii th«-M' [dive* ili.- jK'Ivio inM Hm on oy: vrhJl '!«■

•mnll pobl diluted i" ibc atrophied tide uf lb* wh-
im

Tti'- dl*f no»l» i» lr.i>ril ii|mhi llie !n-(..tv .it ijm w«eiuut t ami

a ear itii examination and nuaenn bet i* h

Iaftoeno* on labor: Tlw mettnanh f the head in |<i*->m£

iiiniKj'li an obliquety enotraeted ndvb i» the nmc a» in tin

Ola* of * jtiRtuiiiiinir |h Ui». Tin- hrwl usually cuter* tire

Km. IIS

<U*

*

TrkMivrw-I) . ..(.iru-tt'l j«1vli. tAftcrr. Martin.)

Urame flexion, «ii!i ii- long diameter in relation to the

l. .it-, obi In no diameter >>\ the pelvis. Tic l"iȣ, oblique
diameter in usually that of tho diseased side. A- llie bead

A « ii . .11 rimy luil and the oocipal cure turn toward

Ihi aurora.
Treatment: Tin- lung diameter nf tbr bond should ulwav*

I" ' :'Kl it»'" M-I'iiinir liip wild iIm- long uliliqilC 'liiiiiMl'-:

Hi- pelvd liv mAimnl rotation, should Nniurc have relied la

ace I'li-ii rlu- Ix'tnfr i lit- 4tn-ci iif labor.

Should deeoenl ni' lha bund Ikj delayed, the ax U-t notion
fi rt op hould bo tried. Should t In--- i-iil, ( ';i--.nv:tii section k

lit* <>nlv opentllOD .'ivjiilulile.

Shonld the condition ho ilingiHwd mrlv in pfngnanoy-j pre-

ri i \/\ WVFSt \NOMAURS OP r/XJEj ' "

Ml

mitort Itftot nwy '- tarfucvd, pnvIM tin d«foctaIly <>(' On-
pdvu ii "°i oxtrtnct

Transversely Contracted Pclvca I V\%. 112),

Trans vvrw oontnictioii of tin pi Ivb renult* from ;

(«i) [mptrfect tictx&qimrnt ufbolh mtrntl nhr (Rubvrl |«'lvi«J;

(/') KvpnOtn of the *imn
Toll i- I '■"[}' r»w deformity.

As delivery "per via* Mturalce'' ii itupowible. Owuresn
■octlon miutt be einployol

OompriMtd P«lvtj».

Twu varletlftt «<f comprow<i |«elvi* hove been «Kwriborl, tat
tfftnTftftfflftfl ;iml tli-' /'" ui/i/HUittuonf/on.

Muhmmtnm,

Charictortotici : The whole pdvil is Rirntly oJt< nnl in -.Ii;i|.,-.
ThoN i» ft ninrke*) buiilin^ of the iliue wiiiirs thr miM-mr

gupgrior iplitci turning imnud Tin- poind brim b trindiite)

r««, ii.v

Flu. ll«.

Mwrun t*t"winit (Jilltreacw *«•

rUonmi'ilicclnU.' ,,
Hl««k. normal.

I.. 'puitcntWOO.

M*«Tiim •h<-iTlHtf ouIIIik of brim *f normal

■ I I ■ ■ I ' I ■ l"l-

. I .mini
K4 I. IMJMOIIWM)

owing to tbi promontory ma lh« iwUjihijh bring approx-
imated. The pubic bonca an clOM ini'Whcr and project :.-
beak. The curve of the Mcnitu in greatly <-\:i ©p rated wwj
ill.- coccyx pointa upward into the pwlvic canal (Fig* I 15, IN
imil IIS

Etiology: Tin condition u bvonghl about by gn*t iofti oin •
Of i lit' Ihiiicm rwnliinj,' from OBtwnnn lucid (rimllitk* ->--:n

Tin* (litwM* i« met with chiefly uj ESnropo, wd i* obaraateriaa

Flo. Mi.

MsU..-1-i.t, |..U'i*, ■«-»» ftuiit »Iiotp, (Afl*r Wlneln-1.)

by ii removal of the lime tcilte from the bone*. It usually
.l< v(]o|» during the piierperium, but nlso occurs in pregiuinoy.
Tin.- ildoniiitv railltJ from tr*namiafiion of the weight of rot

body Lbrougb the polvfi to the loner limb-..

Diagnosis; Thin i« ban-d upon the history of the wnmmt
and an examination of the |h<1vU.

Treatment : When tin* Urnc* arc soft delivery may l* . j V
by DMttt Of fOr08Bi ; when lh* bono arc hard and the d< TofTO*
ity permanent, Cn-iin-iin vcdtuii iiiiikI Imj juTluniinl »}i..iiM the

pelvic oontncuon bt i-un-mc.

I t #v>iom»''i>u->*tf?,n ( Rachitic).

Toll deformity of the pelvU, produced by never* rachltu,
DUjf cloaely approximate that produced by oMftomalfteie.

rr/\'i:s WITH .WWAtm OF SIZK ETC

ttfi

Willi".* tilt- itt'furinily of (Ik- tflM DflvU ■ VWJ i Ii a* III

tin- ii. in, tin iliac wintr-. arc wiili ly M'|wnitiil a* in the

typical ndbJtk condition,

Bi)uiidyUilii.U)uUe Felve*.

Definition: The uunii' Applied to llu- vaiiiiy of |»-lvir •!•■-
Ibnnltg :ii«li' ■*> 'l*'' < •lulni'in — " •.|j.MnlyU'lit«llii»i.v,"uiili(i|niii:
down ofthi rertobm, bang dtrfvnd from •ffffeooioc, -m-i-
i« i>n," :mmI <•■ ■■■■■■.■. - ■■ i» -lipping down. 11

Pm no.

^

-l-ii<IM..liifJi«tlPp*lvl>. lAftM tSUnin.i

Tin- • Ifl-.-i in ily i» due to a dfoloattiofl of tbfl Iji*i lumhai
vertcbn in tV<«ni <-!' llu- -acniiii. Tin- ImhIv of (hi (bntttJ i-
iimijIIv f.miul to have )-Ii[i|Mil down in fmnl ■•!' llu 1 fip*t «.n-r-.il
■.'•I tpbm, '" Which ii hu WOOfDfl tttlohod hy \«,\\y union \:i

***jOf , ' r:,|, ''I loreonSi i- pruunotut) wi thai two or mort of i!»'

lilmKir vrrfciini- dawwiKl IDtO llu- pf Ivic inN-l ami nli-liurl it>

tpOit*rior ■lianii'liM- Tin- riorum i« |m-!i(il <lou iiwhkI

rtml lur'.vvanj. aiu! 1n COmpnMlUB till" llu alienor I t:t 1 1* -1 llu

/'{TiltiLOGY OF I IBOB,

ttt\\ i t.it fin- !..-;■.■ Ill of the •vnijtii' r ui'tTCIIMtl

mi

The puvic inlet it ihui diminished both lat>-i ilh ami auim»-
pewtennrh.

Etiology: Injur)', di~:i--. und ili*vi a I«i|»rin'ti!iil .Mid* ;t rt_-
li-nnllv nivatiDUud :i- |iroaih|iuiiiig eatnm*.

Tlii- dlaicnotia id aomawnat diltiriili mil'- it ItLtOII M

srcll marked. Tin- Atiitiini til' iln- u<»Mi;iii in diminiaUod, tod

tin- rilw rri.iv OHM IfltD Htoal 00nta« I with the ilut
Lordoiil is •Strc.iie and tin- -Imnld.r- ;n. .;im<d well Imok

h inn tin- pationl i* erect. The posterior nupwior 3uu *piu«
arc wnli-ly MpRratcd, Tin- pclvk iDoJination "littered, » llial
t lu VUlW rrjjinii i> (-11 1 i«. I -«.iu<uliit i'.h \\;ird.

Interned namlfttitioii i* w.ti- tin- ]ir..ji.-tii-»n of the lumUn-
vcrtebne li may |i • •'■Mr -<> feel the lower end of tin-
iOlti pufaftlnf.

Troatnant: Tb« urtbriuity i« nf the nature of =i flattening
,,i i!, ( ipolrfa ■ (bit 'l"- Mecjinnium af labor raembltf that
which oaean m the flat rachitic polvU, Tin otaruottaa to

lilU.I' •!• /"Il'l* I Mtir'-lv UpMl lltr plojirliim nf tllf liliill,,! Vi|-

t,.|.i:<- li"' tri'inrii.'iit if conducted on Tin* M»me Yum n* ID 9oi

I>lvn Dhlorted by Injurtoi, Tumon, or DIhcaab.

Luaatlon of the femur; Thin condition, which U n-millv
congenital) rarely proaucM itioh dnfarmity of the pole i

tfCTHHU'lv to itlwtru<-t labor.

Tumon Tho nrrninmnml tumore wliich occur In connection
with the nnlvb mm rrorfo*** of tho joints. Fibroma, tareomn,
mivniuiini. mui enrhomlroma of the pelvic honn may «li«tor1
tin- pell i- :itid -o lend to olKtriirtiini (Fig, 117).

Treatment j \\\wn the growth i« not cxo»t\<- di-livery by
the natural |>:i- ■:<'_'.•• iiniv I-- po^ible. When Bitch i* nol tin-

Cmm ' ;» -.in ;iii KctiOD rauat In- performed. SyniphyMtotonav
nay 1h cinplovi'd iii unliable on*.'-, whi-n tin :tin»-iliitc joinu
an- not Involved in tfafl tnCIOT

Prmctnr« of tho ptlvU ; Deformity tho rmuli of fractun of
tin | H-Ivio bones it rare.

Separation of tho aymphyRl* pubis Thin acridvnl may

■■-. WITH ASO.V )/" v "F Sl/.l I I,

at a n*u It of great force being exerted in the extraction .if ihc
lieftd by iiKAin of l'"i" |-. ■ i jftfi v.r-iMii |i;i-. !.•-* n |Mii»nu«<l.
Ikfconiuln'-iii, meniti rphili*. nmi lubt-rviilohi , m um \hi*-

fbtllld 'lU-lH-vi.t. m:i\ prnli |....r (.. the ■■■'■nrnji'v ©f ill:- :nvi-
-Itiil.

Ih'ttjutwi*: Tin |kiIh nl ;;< inr.ilU QOnlplafo* of NHAJU mf *l

tin- moaikdI of Mpemttoii of tin* jom!. T h<> condition rati '"
rvcofcnixori l>y httrodiidiiu the iod< c-fineer into I he vnjfimi
i- in n« 1 1; jinn itnd grogung ii bttira n Un Aug r ud tbuiobi

I i. 1 IT

i\

,ti|. .1

lOBOft" ') IT ' •lin !<■■

Tmifmr,,/ : Tin i»i*ts in 0m application of n firm pelfk

gfnfU n raemniBMidtd fbv iw after tlie operation of »ym*

pli_v»i<>t<>niv.

AnchyloftU of pelvic JolnU: TliU nuiililuM i n uflWi iiny
nf (In- in 1 v ii- joint* WIh'm llit Rjjmiuln i i!l"i"l ii hn*
Imii Httw irifliniu-c mi labor Anchylow* nf ih* Kino-Hinc

ru:iv i.-iitl in HflOUK | ' llvio ili'fiiriuily N'ol uncom-
monly f Ii* NMrocoooygral joint ii eflfectod, in which cm

IfrVCtiOll nj:iy fiCCUf :i! tin ■ ■■ : I !• I l'Y:i<fuiv of flu COCCyX >*

the imnnl n-nll.

/ 17/!"V.-H.l • >!■ r.Mi'W.

Split polrii; Went of oompfaU do volupraenl of &e interior
wull iif tin- pelvis romta i» tnh ooodhlou. !i done not cnoM
utiy onsirnotlon to labor, but is liUvlv i<» be aftsoualod bvuIi

|jri_-4i|iit;ilc delivery.

PeWc Deformities Duo to Spinal Curvature.

Kyphosis: Tin- dogMfl "i' pelvic drloniniy resulting from
k; pnoeia dopenda on ve aftuafton «i tue bump; liu ooutruib

in tO tlic simim lliv greater i* 'In- <l<l"i mit-, of \\u- )»1m-
I t«-m-r:dly tin* ttypJioua OWUI"* about the juiu-liun of till' iln: -;il
ami lumbar virU'linu,

I'l'niinnii ; [f the degree of contraction ia Blight; labor to

usually riiMy. Tiiere oxisla uii old saving limt " liuiirlibuckd

Via. »a

Lonlmlp \m\r\% (Afirr Klein- ... 1.1 |

have easy labors." When delav bake* plAM Ibrespj may be
required to effect delivery, in extreme tootraotioo ib"

OiHWum operation is demanded.

Lordosll i-n rare >viMilitinii. nud i» nxiuilly -wwiidan toeptinJ
discafie or pelvic deformity. To n certain degree ii onbldl

I

l.KoU.u.iKs nt r ji:i:t\r: ni:yh;i.<u:\it.xT

297

<itiu[M !i.-;iImiii ; titn, CM :i rule, if i' n<>! -ullifK til, :nul :i rolll-
lion ill' UM xienim oeenr-, ->■ tlmi the upper uxl ik thrown
hackwfttd : n i . i .lnw n\\;ml (Fie;. 1 1 H ) . The jh-K if OUMll f« tmU

la imanc tiiiuu I— ii:ij».i on nooounl ■»)' the projeotion Rwiranj
of ihc tower ptn "i' in. im nun Bod 1 1 ■»- poratt! oblfti ration of

thi pfOfflOOtWTi

Ai the fcUet the co»jii£ate is iiicrwwcd while the UtftfO-

| i nor diameter i- <li ishcd. The diameter* at the vulM

are UiuiniU DOOR >'r lea diminished.

Scoiioni ; Thcefleot of MoUottoon 1 1 ■* - nolvui depeodi on the

-iui:iii"u n .«f the £puinl fiirviiiiifv. Tin! lower tl l>

ami tlir t-.*riier it occur*, the mere mti«u» are the • fleet* pi<>

dnetd in the pelvis. There i> iikuidly Km* dome of obucjiM

COnt mtt BrcwM in the JK-Ivi.s uf ii p:iiieiil the Mlihjeol of

MXlliwU. Tho Condition i- ti.tpii-ht I) tOHSVMtvd «ifli nieliili-,,

I'lir initmititiatr DOfUtj toward whiell the lllinhar vertehni' are

rurvwl, wur« tin £tvii!vr f >:ift Of the bodr-WelgM. ;in<l ii

therefore punned upward, inwnrd, ind h.-..kw.»nl l.y il».- •\ic>

Irannre exerted on H bj ih< bond of the femur, laooed
Km on tin* Nfh H ili^placed upward and inward toward the

viemm. The "/"t/Jiifi* i* thu» pushed inward the "-pp-i-ite

nide. Tim* the grcato) degree of pelvi mUvotioo in on Ai

EoTi "f Of •yi)u\l coon "'''.'.
In AtW tin? Urged |<«rt uf the head general!) dooooadson

UH) i .it <id<- itl tin . .-, through ffblOfl '' IDs} DOM

when hi a HUtlr ■>!' px«t llexitill.

In COJM in « ln'-li (he prlvie ileliirniilv i extreme thfl Ormo-

re« ii operation niiuti !*■ raoorlra to.
Kypboncoaoiiui . RaehhU rim preduei Ih>iIi k vphofna nod

•i- in til* -anie uoiikiii. ll'liit kyphoHf :- -iiuali'd hijjh
BD] hill lil'.le elVi't HIIIV Ih prodtlod •>!■ the pelvi".

8, ANOM ALU* OF THE MATERNAL SOFT STflUCTUHER.

Anomalies of Uterine Development.
Vortettoi: Labor nn be raropu*oatad in own nrnje in n

patient Who hll" ,\ >!• .ill .h ur -ept.ite llteniv M

the Hem. :ne common. The nnraipragnatod hull mar enn«e
obatraetfon u it' balk, u it n-mally undergoes consi'doraWe

■.-".,

PATHOLOQY OF LABOR.

fofWM in bE« i" M'ni|Ki(ti_v willi the Impregnated holt" If
tin- plaiWtitt i- :itlartl«! to (hr ■• p!nm, . ■ n hw.L.irmige mny
BUM |.l:i'i- Ottfag to lni|»erl«vi ciiilnicii'tn, Kttptun of the

MTptum >>r <ii iIm uterui nu oerar

Tin* iliv-iilmil iiiriiitimiir winch hn» fbraKd in the imprep-
ihiimI naif of tin- mi in- nugr i» rebutted, ind. uudery-'iii^ pn>-
liirriiii.il ■Aer ili'livrry, miiy jjtvc rUe toacfioc Infection.

In all oaan of anofti:il'>*' lirv.-lnjinR'ni »»f ili»- m--
tains HI umiuIIv ihort mid iiirnWiil.

I'--.- MM9 Id a rudimentary torn |i :i imvi nu Nttdft-

Dos, And when dm u > ■>. ii -LonUl U inyi«i mm a can- of

i-cliijiir ^rinhnii

Treatment: Koreans or version nm-i Im- mudn lo in rkmI
of IboBKAimi in artwr tocin.-r delivery. Tl» former soon Id

I'M* I'lllftOII it) pl.'Idl'WV tu the I.HI'T wllf'II pOtHllilCl Cmiwi
Mdioli 1 1 mv Ik- iik' --:\vy

Abnormal Conditions of the, Cervix.

Varieties: AtrarifL cjotfrioial cotxLitionp, oontimiioO] md
rigidity <«i (In- rarvix, may nil jrive ri»c lo raoffl or !«• ob-
Mraofloo in tin- nr*i >.tftot*of labor.

Atresia Ii ;. ran ran condition, and ii is very wMom com-

plot*, 'I'hr >iiu;ui t l)i'' external <r. nnty !»■ rn'i^nirod n*

■ dimple. I'n-— QJV UpOO t liir- w itli n liluni iii-huiim hi. -in )>
:ih llu* lip of ii uterine -imml. If u imllv ftll llio! i» required to

prrlurylr ft, liner which iltl:if:K (OH DMbIIv proceed.- rapidly.

Cicatricial contraction of tin- « « r v j \ i- usually due !o old
Imi'rntion.or il rimy ftriM frniu :i ivp:nr Opcrfttion, from OHltO>
izstioii, .»r from xypliili* <ir eiuierr.

Bttfdtty of the Cervix,

Etiology: Wlu-n noi rim- bo oraonso ehanoeir, it ifl mid to bo
funrfinnnl. Functional rigidity m OOromon ID highly MDtltni
young women ond in elderly priraiporo. It ■* twunlly dm i<>
lOtTM imperfection in tta DOUe-aupply of tin m. ni.. mid bj
frequently WJoeioted with inefficient uterine ponlrftrtioog.

Treatment When the rigidity "t" tin- cervix is functional in
origin it may iHimliy bo overcome by the cmplmnit'iii of nerve

IWLMCBMKm OF THE rin:r.s. 29!)

iiv.'- ind bol do mIm . Hjjrr. oMokL bjdntiL, ~i--. thonld

be iulniim*fi;n?il hi wan ilk. TVn niuiulo later n hot v:i|f-

ioal douctrt ( ! IV K.) -Iiould tx givon, at ItUC two ^iwtiof

:i i.-ol. Kvitn MICO '•■line Icn minute- ;i t|«we ol

.1 and i hoi douche Aoold l><- rfvon In allsrattlon, Ufl
tin' joticut li.i- rucwivail thmi atm* of enlonu UM IMM hot
iloiirli.-, ehould tho onrvis not yield bofbro. In tno autnori

nVDOfl 'hi- |il;ui ttl' irealmeiit liu- ::i:< l\ tailed.
In -{.!»».■ i a- ■ i hypmlrrniK' injection of morphine, i/r. J, :*

ill i but. m required ftintuuj On cervix with :> 3 per cent

wiliiiinii of cuaunc pju Iwcu highly rocomiimmhil. UOOUioo*

»l)y a fvw whiiis of gfaJiirolbriD with nob i"i" boi Kite ii obvm

in reticvingtliU ciiiHliiion wbt<ii ii .•.in- in u hijjhly ucrvo-im

potiont

Wh.n than BKtfcodi tail, artificial dilatation \n nicvio* of
the linger* or by the mtrodaotioa uf n Burn** or Ommpoticr

do Ktbc* bug OMV bo i"-"*-.--nry.

In cxi mil" cans Ii ma) be w nt— iry to i u- 1- - ■ win I -mall

UaOUoiM, oiic-(|ii:iiiri l. «■ half inch dotp, in lln- Qtrvfa U>

foro proooodiBg Ui artihVbil delivery.

Impaction of the Anterior Lip of the Omx.
Occurrence. Lnia oondltlvo may oocvaiouallj oh-tnirt the

idnnca Of the hciu! :i( tho OtttlOL ThO lOtOnOC lip in then?

qobm Ei oancbl between tbo heed ud pobcfj ud^ Twrming

ntollon ami ii'tli-mahiii., uiav ;irtu:illy prnlnnh' at ihi' vulvii
A It. i htlmr it may aloilgh.

I'lic prop r treatment i- to Btttmpl t<- DOM it ")• IB the

interval- K'ini'.n tin point, U" it be v. rv cedomotoua, linn
bonoooamrv Sm Bo nkb i oonibor »t' muU uKnioai into it
i.i permit uweeoajw of wrum, when ii^ reduction mny Ik- ■>

OOCDpUabtvl without ililli.iilty.

XHapl&r.omenta of tho Ctonm,

Anterior dtaplaoemont of ihc lltBrVI BJ tho KlflM of labor
not iofrOOBMl. Il I* ifouendly iluc to ii lax condition of t
abdominal wall*.

r.-1-nuxnt coootsti in ibo Bpplfestta) oft ti^lit icxfeafafld

PATHOLOGY or LABOR.

binder, rod in keeping the patient oa her back m a baaf-reetitt-

in-.' |- -Mr- linf in- Iit..r.

Latent displacement v> one or other ride mar take place.
The pregnant uteru> ■ ii-nallv tilted •lightly to tie right «id*.
When the lateral inclination i? exec-»ivr part of the propuNive
force of the uteru- if lor, on aaamal 1 fa prcwure of tbe
prcaeniing part again*! the literal nail of the ".rlviav

:.tl 'iis|ilinvmeiil iif the ntCflM 'id hronc-

('•••|"l l-\ iiiiiLifii: lie put .■mi 1 1 - - • i. 'I It OppoarnB Dt :■'.' bo

H liuli the fun-lu- i*J.

EetndispUcement of thej-ravnl ueeru* ho* already been re-
ftrroJ t<». Should the tax gu «>u to mil term the detention of
tli<- tUeruj to Accommodate ibc firtua i» Bceonipllalicd by ih<*
BtraCeninff of i In- anterior wall, while Um fnndufi and Um p

tartof wall remain vhiilnn ■ I ■*- |H:lvix The a nidili m

a* " |MMtenot suvnlaiiun Pl ->l tin- uterojt

In ihcao ca om llw cervix i- alwaya displaced antenom and
fa prwed ofoM to tna anorxnioaj wall.

'IW.itm -»/.■ Quaiuui Motion i- nldora rircc-Mirv in the**
. . ■ ■ delivers can ucntllv be eflceted by artiflcia djlatafjoti
of Uu CaWMal iwnnl and atuacnucni intermil ■.<

ProlapM of the pregnant otarn* U p---*ible. l-nl the?* caaa*
never ro to full term. The prolapse of Um utoru* .it term u
iwimlly part in), and only the elongated cervix cse&pa from tin
vulval, ilii- fondus being in iu nana] poaitUra (Fifc lift). In
ItiUir ihr ivrvix may be retracted within die vagina* or if it
be ritfid ir may liecuuie ledeumttiii*, and hy it* bulk pfal
delivery of Um child.

n ■'")<'(.'.■ Whan poMtlblt the carvix ahonld l«- poahad httc
(be vajrjna, and retained there iill dilatation occun icbofl

forcnal ma) ha applied and tin- child delivered, Winn tin-

carvix i» ri^id ind DttdantaCotn 11 should ha fmdv iiMMad ami

dilated, to permit th«- :i|>|>liratt< f foreapf t.» Um ■liild".

hand. An aaantanl may ' tared the traction of tha tbroapa.

hv pii>lun|' up tin- carmen) ttaanej during the extniceuM of
IbeahM

Ventrofixation 01 luapanalo uteri mnv had in n1»4rtiotfon In
labor If lot landm ha- baan attached loo low down on the an-
terior wall. If the luiidii- i- w» linnlv ;i(ia-lm! (.* the u1kI(hii-

ituil mil th:il it h p*a\Tiile*l fni m rminj;, the inn plOf wall of

r.irttoiooT or uxor.

Twtnsnt ; If the obstruction oAVitd by the folded and
thickened oMeeior aUrii* null bveognvl »»" o>fu| can

off the pelvic inlet, < *>nrr*n aNtion mart be ]»-rformcd. In
aome cams it may be ponaible to deliver the thixl by mmm of
ver*ioD, the danger of thU operation Wnjf rapture of tin:
UiinnoJ-out posterior will of die uterus The ariter id ooo
cmc ww «M»- to jhiJi the interior wall tmt of the vray
nVicntly di permit lli< appHoaaiaa of the bftCtai to llic lutul,

■rtllllll WM * lull 'In 'Alt lill'.MI.

Abnormal Condition* of the Viginu and Vulrav

Lonoitndloal and tT*nrrer*e i*pt» may be preeent in tin*
vagina and •A-atrtict die advance of ibc pro* DUng uirt of the
fortus. They are acldom very ilcnx in MnKtura ami are ca»ily
ruptured. If ihcy do not yield, uV-y mo) Ix- divided bctvocai
ligatures.

Unruptured hymen: Tlu« rcinditmn may I*' loimd i*nv>-iil in
lalmr ; il QMBEB but slight uhstruetiun ; OCXSMOOlllf 'I niaT he
nerowiry to inn— it.

AtravU of the vagina : Narrowing M" the vagina mnv 1^
due to msMcvel"pmciit or to cicatricial eontruetioM after pre-
vious injury.

Tre*\t mi- at • II"t douche* followed by injection of 'i'lixod
•wcet "il may !*• employed i.. MitVn the iMirt. IMlaaUMO may
be effected by tbfl IBB or Chimpatlef da nil**'* b

Rigidity of perineum: The perineum mav bo ►<■ ■ <-u\ a- n,
pntvni advance id the lu-ius. Tliia condition la common fa
muscular WOOan lad iti elderly priunparic.

Trr'i'm'tit: In theae caaca the foroepn may bo required t.i
draw down the nvtne. During did i von tho perineum msj be
>«iii« mad by IM ftv* ueifof lioi fomentation*, enrv beiiig fakea

iii-nu.ir tin- pad-- with vaseline, to prevent burning. When

Itcanttloo in certain, • nituototny may m performed!

Haunalema: Tin- condition i>. whon pro«nt, foond 11 tlM
Vaginal or16oi

JVmbtumit If lorn enough to obHtrort labor, tin tonor
nliontd I»- Mti'i«Mil and the content* cleared out . after delivery.
it barnorrhage from theaivity tnkc« plnee, it ihould be paokttd
with i'«Ioforra pause,

rr\fi)RS OF THE GEStTAL CANAL, ETC

:so:j

Varicose veins wln-n present seldom obstruct lubor.
Mim rupture or t«* >•• liruued n? (•» lloogh ufWward.

CEdtma of the vulva duo to heart •<■ I MWM RUtJ ob-

■trod labor. Multiple jmucture* should only be reported to in
extreme ease*, a* there i* pttt risk of *e|*i* or (r.iiijrn-iM- fol-
lowing delivery.

Abnormal Conditions of the Bladder
DlAtonded bladder: Tin- Is i nut BOOOSDtnon gmeM of deity

m latar Mm) should ilwayi l» boruo In mind. Th* nrlna

>liuuM lie removed with a sterile, long, *A\ csiihrier, ihr pre

«uiin^ j«irt being poshed up w» a» bo pormli soota to [hi

bladder. In i-im> in which it i^ impossible to pax. i In- QSthe-
t.r pvforalAHJ llinmgli the iiUlimnii:il wall may In- rsauired,

Cyitucele . in llii» condition (In- bladder may protrude
U»murii the vulva.

TVodsmdJi Th* urine mutt bi dmwn by means of n noil
eat Inter, and the prolapsed nnrt afterward pushed tpntU up
above the prOHOtUlg part of the foetus, if reduction prove
imp.iv.11,1.., i||.- part hum 1m- Ik Id up while the chBd fa eX-

traetcd l-s iiK'ttltt of tin' furoepa.

Vcaicn.1 oafculu* ; ll -mull, ( In- calcuIlM IsaV not olsjtrUOf
l.ihoi. IC pOjAlO, il lintilil be pioihd nji almv.* flu- -yni-
jihy

Winn lofgV, H may !*■ extruded alter ddalinp; ih<- ure-
thra; or it may Ik.' im.'- mi [o im« i^- the bladder through lot
.■■• i nor vapaoej wall. After lal>or the incisioa may he
saturttL

Tumors of the Genital Canal and Neighboring Organs.

Carcinoma of the cervix • It DH 1-' siid thrrt, a* a rule,

when thi- ivindiii'Ui i* present .it lull term *erious ohstnid

to labor multa. Spontaneous delivery mny occur if the di—

MR fa limited I" tin- uiitcriur li|» and ii uot »ui i-muded liy a

iron of cicatricial Inftltntlon.

IliiMMi ■rlui',''- unil ■•(> i arc likely to nri-c diiiiiiy: tin' i

nil,
<-iw«reaii section is the proper ttvatnunt, if the dUcose U
fairly exfti ulvft

w

• \:n->!.OQY Of tJBOR.

FibruuiyuiLAl*.
TlivoUcrihium* f<> Iftboi rvMiliihL' from tin- |.i>-.n"v riflH.ro

my :ii:i 'l»|K'ini on Am *itu»tion of the new growth. If it

.11— fattO lln. tom* iitiTiin- M-^iiH-n iii'-mh, ii inn
b»-*i»iiu.' iiH-.u.-. r.il.-tJ iii rhc [vlvia and ultfolntcly prOVOQl i In

docem "( fiba child I Fig, ISO).

Fi«. ISO.

■'•"'•taw

*> "'"■ " ■ "-"ilof i-wttmicT. (Allor ' | i. ,. !Ui*.»

Effect*: Thrv lead '«» malpraKntatiom and malpoNliont of
ilir rartiM, to promiM ■»! ti,> corcl, to vlhcrrnt placenta, nod to

iH'miiM'liHp'. Tin- labor-point ore likely (•• !><■ inefficient A
i.l;inu' oondUfibn of tin- iirnnm i« not infrequently met with in
than CMK,

Tin- prntturt of Uw tumor nun- produce »cvcrc contn

»>p (Vaotarvaof the fatal ilcull. Tin in iii' I-- a injured

during lnlmr thai iloughing and gangrene way follow ud
ri.e tu « ptio inf. etJon.

TUMQ& H 'in / \ ; 1/ | i.\ \r., VIC 306
When il»' UtfVOf ■ aituntcd on the BDfacrloi wall it may be

tliiplaoed upward bj uterine oontractioa, and thai eanaa fa

Met the edvatHv uf the rliHd.

Di* guoi u When &i muted low down hi il"- oteroe ;i fibroid
tamor may be nietaken Fbr the nVul hftul. A careful oxami.

UrtloO nhullltl UfttWOl llii- lili.-Likr.

Pro«nt»i»: Tin* dopeodfl upon the earb Noogntiloa of tin
condition and the (t':iini<ni adopted, The experience of the

wrihr lAQuI In in In OOHMldW lln- DCfAMIM of tiivniii:i ji gfOYe
ivjtii|iltt':i(ioii of l:il*ir. In ;i wrUw nl MM) of lie ■•■■ isww ml-
lneled by Letfleur the mortality ror 1 1 ■• ; mothers, of delivery by

the n:ihir:il |>:<- -i n >v .■ !i In ... j-r (Tilt, ;ili<l 77 |mt c*llL

liir tlic children

Trnatrnmit ! WImii llti' (iim-ir >>r tumor* RV BftMfW'rtf '"*'/'* "/'

labor may termintfai naturally, l" *mw« <««wj labor i- pro
loogotl on i . Miini .»t' in. rin. innrtm, and mart !»• ttrminatcd

r-i.»|i DC lltl*. I '|>*.

When the tumor u ««(// find Kituntol low (itwit, it may be

| M( .ji,).- (u otivli it UP OOt of lirii'in'. huv by placing till- petit-lit

m tha kocoCchon poahlon. ir Udi fniu. it moj be poi nbli to
extrad the child bj mean of the foeaeu «!ili the woman In
Watcher' poeftlon. II il«i>- !«• hupoauble. Qa ea roan motion
mn»t ho per/brtnodj or tin Porro'i operation.

If UH Lamoc i> nut ind attached to um cervut. it

may be poadblc to remove ii by enucleation even eftar labor
[um begun. Ai'irr moot UW tumor cavity hbouW be peeked

«iili Iodoform :;:ni/».

Iti oHctutt in which "itii'.iv takes place [brooch lhi oeto>
ral paacagai then :- ureal tUmfftrcf nmnorrhaot troto Imper-
DDtraotioa of the plaoeatal ate. Should l ■ ■ ►< iotru-uterjiM
duuobei bjmI hypodcrrniro of crept toil Id ountrol il" 1 ketnor-
rhage, the cavity of * > »*- oterui mud l»" peaked with iteriliecd
iodoform genac Tin- gause may be lofi in the cavity for three
ot Gnu d tya, end if neoaaeuv ii may th™ !>■ rwwMl

Polypi.

tfueoOl polype araally -priii-/ iV tin rvii.il <:m:il or

: he aj the «' nix. ami when pivwnt may ubstroct
labor.

3fj* PJTHOLOGT OF lUMOM.

KfMn If tr.j^'if th** p'^TP* w/oii be
'/ ialvir. hw tratt-ux:n*r ami tjinz die f*.ii*cV_ aad cHUg

Ch*m 3»»V.

Onrtaa Cy*t«.

TV.*** raxtry 4HKbK*a?4 iaW. It* dl-coracd dnriar ¥**%
MiMV, tb«y -h<»ild b*r r*-nv>v~J. Small o«ma tumors bit
pro!a [/-*- awl -an-*- oi**nv*wn in rb*> pelvfe.

Treatment; I f the tumor tm found below the brim m ifce
time of laoor, '-.fT-xT- -h- -i t'J be made to posh it op into ifce
ahdormrial cavi*y. To '!<• this it may f*r necessary to anrs-
thetize the patient and to place her io it**: knee-chest poertioau
If it i* ir..po»-ihIe to reduce the tumor, it mar be tapped from
lli<: vagina, flu or*ration <amii< be nivfumeodei, as ■
expo*-- the patient to th'r danger of peritonitis, from ex-ape of
tli" content-, into tli«: j- ritoneal cavity. It i- better to p erf o rm
Cit.-nv.kU vx-tioti, and at the -ame time remove the tumor. If
tin* <-y-t only partially orchid** the pelvic inlet, it may be pos-
mIjI'i to effect delivery by ver-ioii or forceps.

Vaginal cy»t-, dermoid '-vsts, *wtrllin« of tbe tubes and
broad li?amentH f prolttf*^ "I" a floating kidney to the pelvic
inlet, hylatiil ty-t* of the pf-lt-i*, and tumors of tbe liver or

Hpleen may lie found to can* obstruction in labor.

Bnptnre of the Uterus.

Occurrence: Kupturc of tltr* Uterus may take place during
pregnancy, labor, or the pucr|teral period. In the vast major-
ity of the-c. W*n thf: rupture takes place during the second
Mug* of l.-iUir, and con-i-is of a laceration of some portion of
lli'- ufirjtie wall.

Frequency: TIiih accident U said to minir about once in
l<H»0 ca-e**, I nit tlii- writer is of the opinion that it occurs
inmlj mure frequently than is generally thought, as prac-
titioners are mil prone to rejiort these case* 1 when they occur in
private practice.

Etiology: The most frequent cause of rupture of the uterus
i" oveiilistcntinn of tin' lower uterine segment, the result of
mimr uliHlntrliiiii which prevents the descent of the presenting
purl nf the child.

i;rrri /;/• m nn vtkrvs

Tim* |>elvio deformity. "vr^rowth of rhc child, hydro-
* - phalli*, a tumor Mojliiuji the ptlvfa, rfgii Itj of the *>i\

part>, or iimlpii-.rnlaimir:., rwillt in nrntmetioiia of (In nirni-

lurang tin' child 1 '- both imio 1 1 1 ■ - lower Qtafiaa segment, which

Im-omhi-- enormously ili^ttmhd, while tm uptm- MUfnont, with
It* wall* 'H.Mily (Im-Li'iKil, i* drawn lip unit! "it form* 11 dis-
tinct tnoior, which ran be t'tli through the aUlorniiinl Wtll
iboVC (bt child,

There ik ii-imllv | uyH-iI./uuiI li,„ DOtWMfl (!»' thicke-ied
upper -^'griKMit mid tM .li-r. nd< d !"*»« r wrnMBl ThU line ■
p'lH-nilly vi-.il>li-, ,-i* well n- }ki||-ki1»I«> ( running ..Minn, ly nerow

the ■boooMD lomtwbal bewvp the nmWIiewt Thw i« the

rvinw'tion-rirn. 1 HHaUcd "OdOtfMtloD-ring of Unndl."
M hen the limit of tlie Opacity of the lower uterine wall in
tn ■ bog ind lauiuinjz is reached nipt tin.- (.do* place.

When tho uterine v*xil i* loeafowd Iran any ohbf, raeb o*n
Itluw or WI during progntneyj fatty or oilier degeneration, or

1 1 "Hi iimli^ii:uil nr i>lln'i diwiiw. rii|ihir"' may take plnrc early,

1 <t\ 11 without niinh dltfentton of the lower wgmrai.

r'inally, rnpluri' may OOOIir during mtA-itful uttnn/t'.- at ver-
•ion, tbf liijrh application 01 fcro i>-, Of *• partition <»| go ndher-
1 lit pttOBD&k

RuptUFB of the iifcni- pM 0600 rOOOnW ■ foUoWUJD Ihc
orfmtfWfratibfl • >/ rrrjnt tn lia-(. li (DO c\ pulsion of the child.
JolW hu OOllOOM li'inv three -neh cn*c».

Sit* of tbt rupture; The tar notify begins in the wall of
the lower uterine segment and run* transversely. When the
rupture U ipontancoui it mi hilly occur* in tin- Int. -ml Willi
W ben due to trniiinjiii-tu the anterior wall is usually th" Etc
uf the liver it ion.

The '.'tin/ -j 'If tap vatic* from a small rent limit-) t" the
fniwciiUr 0011 to complete penetration into the abdominal
cavity. I'-milly tin I' ihc niMimi !iivjaeu"d :nnl in-v-

uhir, and mtiltr.itiil with IiIihmI.

\\ hi'ii unfit tl"' muyrutiu- i'tnit iV turn, tin- |wi ihimnl OOVOring
OC tin- litem, may Im -lnpp<d off for a ■ II di ;:mee

beyond the bur, tin- mi- Aim brood becoming idled with
btond-ciot<

The l<«tii> and placenta may 1 t-;i|»c into tin- [n ritoueal cavity

vrmtM.miy of r.Anoi;

when the ml i$ ejeUntirr. and the inlcfttinc* may proline* into
the vagina.

Symptom;. Kiipttnc of tlit* uU-ru* »1k-ii iwU-iisiia. U UMIftUj

iKXYjiiiiKintrit with iiliiriiiiu^ '_vni|iloii)". The lltct I

iiun- nave pruliiiMv Ihtii '. ij ii- lor wmir lime, and tin-

wniniiiiV suffering Imiihiicn I'Mrcme. Complaint » unuullv
ma-1. of niiiimiiou" ami stvt-iv <i im p-Ii ko pain in the lower
pari of ii"* nbdomeOi

On oWonunoi aapamwatffW ilka uterus will !*• found in a

-t.itr ,,l' ;ilni.,-| ii'iiiiiii 1 i- -ii in i 'I ion Willi the lOV fftnctit

greatly dwtQrwkcd. The retraotiun-rinis msv In- palpable

wen vi«ilile, Sinldciily then* U a |hH*»li:ir -burp, hun-m.

Iain, the woman gives a loud cry, and uwerti thai wniothlaj*
101 lorn. The sound of the tear may be audible i bei
follow* absolute ovation of uterine action, Blood Bow
the vaginai and symptoms of profound dioi b rapidl) nWi lop.
On making 11 vft'/iini/ examination, ih>- preventing pari "ill I"?

f.Minil i<> I tn % ■ - p.-h-.l : ii l(M>|)iif intivtinc ma) be c mt< n I

or tin- hiind may \mm diruagh the reni Into tlic abdominal
cavil v.

when ill'* rupture b only partial, there may bo noayaiptomi
until after lho birth of the child. There may lw a inodernti l*
eavere hemorrhage before the placenta ewmeu away, Ltftrino
action Ik ii-n.illv poor, and lUvtv may In* *jine difficulty :|
pulling the placental The ulttnis tenda to remain Rnroul, and
than ni:iv bi some poat-partum hemorrhage. Now of the c
eymptonu any auggeot the condition actually nrceem 1 ii ■
nil lid development of icptic peritonitis may loud to an intra*
uterine examination being made within twenty-four or :
right liiitir-, when n pui'iinl laceration will lie discovered il
tit.' ii torn i rnvity Ik- careful I v • \ploivd.

Tin' auilhtr ban had experience of one case In which then
wen no ayatptoau to indicate that rupture had taken fJaoa.
beyond n somewhat severe Ikmimi i hage with the cxpoLdan i if

the pfoootrtn. On the second ilaj of the puerperal period the

pniient developed a slight temperature, and on the third a
•ever* hemorrhage look place. On mukin^ :m itit.r&~Ut trine
examination a rent, sufficiently large to admit two tingerc mu
found in [In- posterolateral wall jn-i ulnive the external oft.
The prognosis depeodt on the lite aud exti :ii of tlw loo Rl

"

i npl to rupture is mueli more tila-Iy tu prove dual iliiiii is

put in I rVptttl^OD lOOOttfil "t l lio ilivulv.-m. ir ol tilt UUritOfll \\

' &i ih . More thus one lull "' 'I" can pcriali u u lii 1 1 Lvrcntv-
fniir hours of i lie- aookleaL Tko cause* ol death arc icpaa,
boroorrhaeja, and abode.
Treatment; When vigorotw uterine crartrooiloai foil loauiaa

&dl UMB "!' tin* prGNDtlug part, tin. 1 i-omlihoii <'l iln- Ut\\-t

UltTiiif th IIH'UI -lionlil VC :i- ■• llaiiinl. Winn lli<- nt cifh- »:i-
ntUJ OB K:itnll i- tO I"' t«-]i ii:il(-«:i\ Ih(\v<v n ill*' pUOV* :itl(l llir
iimUliuil* I:i1kii -iMiuhl Im terminated (0 ni|ndl\ ;i- puwitllv, ill
i.r.li l !■• "ininl :i :.un-[ the iHVlllTi'Iirc of niptim*. The pfO-

■-■ in Im- :uliipt(tl will depend <►" the conditions iirmivnl.

I'.. ! ii' MNttttlUJC 'I' 4 ' |Wtl«!ll -ImtiM '<»• :i :i:i '•: In I i/«'<I U) till
HUil if l!n- fill- lit iv|;i\ tin' til'Tii* (••iinpli (rlv

;i hypodermic injection of morphine may be given,

117,. <■ rupfur* /'»<" /'it-' n ptac* i lio pb\ M-inn' i II rot dutv it to
empty di«' iih*nift uihI to control lieniorniagc It' tin- » lnl-1 Ium

not aacaned Into the p pj( iwty, it tftould bo delivered

rapidly by tho application of (creep* of hj crauloloiny. The
ata ahould taan Im removed manually, and the alia one]
■- vii-iii of the laceration examined.

In inamphti tacmttl < i I euflffcfoil |o Irrigate the cavity
of tin' ivni antn a hoi antuwriitie mUition, -m-ii a- lunnnlui
1 1 ;fiOO), and to nook ii gently with iodoform gauge. Tfafa

Weill -liotiltl Ik' repeated al iulfi v:iU of from luchly-liKir

to forty-* \g\t\ limit-, until the real ban heelcdi

Winn llir rnpturr i« found lo In COOTpMc th« 'r. :iliiniil
I p ikIm <-ii ItH MlH Mini I'MrnI Wlii'ii it i- -mull ami •ilnatiil

low dow a. ind laii little if any foreign niattci hai escaped ioto

peritoneal envityi Uui read may I* irrigated and packed

iodofo ■ In auufa n oaa ■ a it.'ii afaould I*

i. 1 1 for rmpto I poritonitia; and If nub develop the abdo

n.iii.i K. promptly onencd« the perttoocal oavitr Hena cdj
iiiul thorongli vaginal anil abdomionl drainago provided
When ill'- nipt u re <* i-^imnitu the hMuidcd should l«'

promptly o|«'iu'il ami tin* pi-iitoncuiii t-ln i .< all rloi- ami

vtJicr furcigu matter. It" rlio «.!-.- ,.i \U,- w.nml an.- raggwl

PATBOLQCr OF LABOM.

mnJtratoa 1 with Usui, mo «lim will UM ; in ih«- r»*
autlwn MiWiiWimi ita* the uf«ne br mamnl. wttiW
**Ihtm rbin rurttml m-tllt* fawn Mvftrly pftrriilnif ft* gml
wfitul awl alaloxmal draina**.

<t«*lit»ga of *fcor*\ if jfr-ot. »V*iId U irwlfld
tairrfiun, -im-tima*. ifeyttalU, «■! brandy, aad lb*
of beat tolfc* Mrfaaa ,,! tba bjjy.

In the mtliiT- - Ep ri root, limixl lo ftwx *■■«»" in «hrh
tr««tnMw< win »wil»l«-, ow»-i ■•xtvMmt n^uli* fdlluwtd <wr*f«I
irri^ati<» and p»ujr |»r killer. Is two c€ ta*we caaa* tfcr per-
fmtioo*, tltou^n »mall, extended c<upWicly tbroagn iWr
ulcra*. TIh- Im nifirrlia^t *n» eercre in all four case*, taat
fairiy well controlled by prating Ike utcrw* irmly
in "« * lac nerval from bIkivc.

Aftet ''•' I*"! don-he |he M"--l '*ti-e* in fl«m for a 4-irt
j-fi-l; thii lime mu«l be utilixod by onWtlv |"cki»r I
<artt* of to* i- nt with fipiinr, which may w gmd«l laau plar*
along ill** lam ■»< Ln4 I* fl hand placed ;■ ilwrwix.

'ir it mn iim-i U- * urri- I in removing I hi pin rr jurkiop.
«h : peraaajry ; it mii*< !*• draws ou( nit by nit, xhiwly

:iiul gently, in Mnl« - 1" r. • . i. I -utriiiuj n hviiiorrbajas Tlw* qhm
rigid vepiM i- rmuiri'd in tin' prrfanaanc* i»f'i;i«li drnwdnc of
tIm : on. Tii< nus pnnkine enoald net l»e too firm.

th*rii((li •urti'-M »• -l.'.nl.l (« inserted to pn-vcnt bluing, but
not no tightly naked n« 1v prevent fa*c ilmitia^v.

Inversion of the Uterus.

Occurrtnca; Tlii- iccfdcat b fortunately extremely rare. It

ii met with more freqwmtly lo private tiiiui in hospital prac-

Ifo Ii.'m [on of tin- «teni» mpv be noil to «» chronica Ii h

(villi the acute form the obstetrician Inn to deal. TIip invert

Ion mm', bt partial or ■ osu&fa

In partial Invoralon the I undue may I-- ilio *ilc of a con-

h.iji..! .li|.i.-.*iM| ( , or it may :i'ti]:illv |nol.i|»-- "utticit-ntlx r .*

profrwli ftom the o».

In complete Inversion the ntitn- in lumfd ni-i<lr out, am!

imiv protrada i'iotii tba rnlvaj appenriuuj »» a rouDdad mttai

Im-iw"'* u tin patlantV tliijcli*.

EUolocy . * 'niiipluic Inertia nU-ri, or utninc p;inily i-. ;n ill-

rwY.'.-wv pi/- /■///:• r//:i;rs

rliw ill" tll< MHIilld -i\i— of UboT, U ill*: lin*>l illllMU'lillll |i[«"-
dtHIOtftag -an-e. II may iKYlir »|Hint:i!irou*!y l ami iniundiah lv

follow em birth of *!••■ eliild.

!l ha- h—n produci'd by un -Itilflll :iM<'lilpl* :il pliiivnUll ra-
pid-ion. WraeHan on ih.- nonf, to idd ihi< txpulmon >>\ the pl;»-
ivnii, ii;c» brought tboul imwaioOi Wii-n turn w ■'»» uoiuul
or relative ihOTUnlug of Ibl <*<>nl it i* UOBttMl tout tlit-tnic-

linn i.:i l hi placental Ulft may dng down tin fundil* -n un ult'l-

iiint-ly )■> prodm i.' iiivrr-inii

Symptom*: Tin* inversion u-iiulh -udileiily. mi

i utfcd with Borera shock, ptSn,anO hemorrhage V

and rcct«l tcneimu* may be present. The pain i« usually KVO
vhilo the- hemorrhnjre i« rarely profane. Hy abdominal exam-
ination the absence of the uterine tumor will be noticed. Oil
milking mi intcraal ••vnmiiiiition ih- hiv-rled hi rid us will he
found either protruding from the ooor pi«»ihly -ompl-teU Itll-
in; (lie vafcimi.

DUgnosu: [nvtnrfofl of tin utoroj eon uftUftlly Ih- dtaeaawl
by a urutu oxtaraad and Internal KKatnfnntioii. Im only oou-

iIiImui Prom which ii iiiu-I \h- dilliniiiiiit'fl i« |n>»l;tp-i of a

iiiciiM'- |hiIv|mi- Tiii' iniiMt Eioporteut point to dwtingutifaiiig

between ilirir roaililiuiw i* I bo prewncr or :i!mh<" <a a marine
i-.nity. Thifl '"in li-trillv (h- • Ji-mu >ii-i imI-^I ..t excluded «nti-i-

&otoriIy by tfai uUroductioa of ■ ntwiM sound

Prornosls: In thOMDtl R>m |Ik m<.rf;ilily-vate i- extremely
In/lt, Deiith mny tnke place in u i'vw hour* from ihock, h< D>

orrnigCi or cxhiiu'tii'ii, of Inter from --ptietcmitt.

Bfrnvi'i-\ , lolloweil -piiniuu ■ u- i -pcr-ilion, nnd nftei BO

,ii ninii ,.i" Hi.- iiivi-rtfl -H-gon by if ughing
Spvnta '■ rmtaUkn U mora likely to occur when the

invention i« partial than when it \* oompttto.
Treatment' R opoaii fa o In to h \x the only treatment umihIIv

availaluV. [f ill- pt:in-|it:i U -tilt Jllla-ln-d |Q the Ht-i'i

■■ir. -i.l-l Im- npanted boforo napodcton EaaUAtnjpttd Tin- olmn

olliitlld I" <l Ii- I VMlh :i In it .ilih-cptie Millltmii. Tlir pftdtOl

NlOUM thou !h' ;ui;i-!lii'ti/jd and jiI:m».| in ihc litltol .inv [Mo-
tion. The IhkIv ul' tin- iii< ru- inooM bo goully piuhra ewek

Within lln- ■• nlva, :ind llic uprnifui'- lian.l m-M'hd mt'i t In-
vnj*in.t mill well LnmiIc luwnnl tin- vjienim, liaviu- I In jialiu
ilirretwl upward. Tbf fiogVT-lipi linn i/ta-p I Im- lOWOT iiiriinr

312 PATBOLOOY Of r/ir PUSBPBB1L vrw

augment and exert premure upon it, in i direction ad

forward, toward the anterior abdominal w.-ill, and in the ax t*
of the pelvie iulct.
After tk< rmodtfon has bean oomplolaa* the band ibooH bo

ktjpl within th<-<?tvin until a cfuitrwlton uerurs when it i
Ik- gt'iitlv H ilii.lciwu. A hoi ni!i-.iv:igitml doUoht fboflU th«
\tc gtvtn, and strychnin* 1 i J | emu hi nod with orgOttlM :•'-

adniini.-:-.Mil iiypndriimr.i. \

'efforts ai uaanMuiatfl reponltiou laM f it should hratmupt^d

within a Inv hour-.

1 1" ii In- impoBBiUc i" reduce the inversion. uwusunM *hnuM
be taken bo pnreat the occurrence of *cpiic infection, and tbt
COM Iflfl Ibf operative treatment al a later dole. If infootiOO

occur, tin* I>«-»1 mrtlnKl is vaginal hyn» tx-<-i..in\.

PATHOLOOY OF THE PUERPERAL PERIOD.
HEMORRHAGES DURING THE PUERPERIUM.

Postpartum Hemorrhage.

Definition: Excessive low of Mnod from the gnnltal oamU
immMliniuly following th« birth of tin- placenta, or taking

Mime within ! wonty-Ionr hours of labor, is usually u-imed |»>-t-
piirlnrn licfm n*rli:ij^<_-.

Etiology : The ouninioiieal cause of this ^rave uovklnnl bilttav
miuiigenwnl of tl"' third Htngv of labor. Sptirolbarg
• i.e. J ih;it nvtra post-partum lioniorrhnge i- almad without

. KOBption tb* bull of thti nu-lical attendant It i- (vrtain that

tlii- accident w mot »tili much mon frequently in private prao-

tin than "I wrll-nrjpini/.ril uiutcrtiitir'", the lVii-.iii being licit, in

tJbn i in titotiona the aJt*iHlunt'» arc individual* of special -kill.

I'Uriur inrrlin |fl a lin|Ui<n( CBUK' "I* p.i-(-pnrlum btmor

rhafrc. Tl terns taili to rwrnet properly after the expnbft

of the placenta; hence the pliKcnt.il sinuses remain patent UK
blood of poumi out into the uterine cavity, where clots twin
which acting us u foreign bodv may stimulutc contmctiovnfc
Thr*** enn tract inns niv UMiulry weak iiimI inefficient, while llMB
intra uterine .-I")- ore i r leas firmly attached to the walls,

PGS1 r w/i \l lit Mm; I, il I'.t

313

nod honco dlficull to dbdodgc. In iln- iottrvafa botwctn the

niOtTMtiOIU nON blood t* |H)tmtl mil, until finally by tluB DTO>

• -- 1 1 ; • lit* Ttt- may DOCOMO di-lrtidvd tO il- filll i:iji;n-i(y The

external booaorrbjuv tony \»- iowguifioial iu amount* though ft
i- usually greatbr in nnuc of the normal,

'h/>,. . , ,'.>!., u* wliirli predupoM la I" moffbue arc pre-

i i| I: il.' liiitoi . tivi'i'ili-.ti'iiiiitii ill tli«- morns, na In Tiydnimiiio-.
r.vin (< " "•'. •'!>'. ; n ili-n n.j.-tl Mulder ftf rectum ; the reten-
tion of Knoll portions of the placenta or uciulmiw - ; tumors
and other new growth* in the atom*; and tx)i;iu»iiun lullowiiut
a prolonged ana diftieiilt Id

Ccrtiun ctmrtltutkmal ormdliioni prcdUpOAt to (Ma accident

I Dfpbrldl < \ll.HH- :iii:i-ijii;i. and h: it im i J t) 1 1 J 131.

S'vi-iv jKi-t ■ |*:i t t iii i» h-MnorrraM in:iv n>uli Iron Eneerafltowi

La DOoloWN part of llic liirlli-«-.iii:il. LocWltloOl of ih. oa

vi\ InvolviM thi drcular :iri--ry, or of Um ralvt Involving
got of iim' huilw of tin v.-iiiiiiic amy wmmqb nven hwnat-
rfaaa

Symptom*: The hi-iuorrlio^. VOCOUf «'iih Of alUT the ex-

pubrlou of i In- nliMi'iihi. Ii nun i«' an abrupt, ■harp hemot

rliagr, or *inijpg itAadl drifalullUj whWl bf it* i

: in nn e\i.-n-ive Iom of Mood. The Llmling may ha

rial, int. dial, or both.

Tin- ptt/of i- I lie iiimt iTCliiin iniliertlor of (lie -iv< ntv «>f llic

In -iiinn 'hag*, If after delivery ih.' pnlto-raM abowa ii Doodoncy

1d tarjDUH more mpid, lln- pu«-d>i)i'y nt hi'iiionhap' mt ih! hit

boriM in mind. It i- :i boot] raid not lo loavi i patient vhoM

pttbt-ntl IB 100 Ot nion- to tin* uiitiutit till all |x»»il>iljf v of
ih.' rv-nirn im •>!' h> innrrlia -i ha- pn.i<d.

In D K0Cr« COM -yiii|.l.un» indii-at m of rxun-ivi- I>1ihh)-Iin-m

rapidly nVvtlon. "I'll* 1 pu&m bec ot nni rapid nnd th r eady ; n-—

iMrAiion i*» kIuiHiiw, hi pid. aw) ■jsninfl*; the patient InwonuM

ratio* in bet nam I . towing ncrwlf about nod railing (•>■

air. She nn;. 1 1'inphiin nf tliir-i Il.i-I.inl on Id ind

covered with » ehwninv -«iut. If the hriiwiThnpe eoiiliniic-,
ryneopc, eo)ivuUiiiiir*,Hfiil death hrini: tii*.- pninfuWeene l'»i\elo>c.

The dlaanoala i- ndd linlcuRj thongb In condition "i

■ Iim-i, occurring Inuncdlntcly nftor utboi! nil the lyrap
Iorm of wvare bnmorrhagi may Ih- prottot, moopl evident lona
of bliKid and a nltixed ntarm

:i\ I IWTUOLOQTt OF THB FUKKPKRAL FBRl

The branched fa<i\ • lanttm -kin. rapid, thready pol* . nd
Ighinz respiration, all indicate liuuorrWe ; though tin ex-
ii rail l ■ ■ "i blood iiinv hare bosn out <-! ill proportion :<> tin
xympuiMi. [n--.ni. On palpation •»! toe abdomen the bard

SJolmliir hIitih will In- mMBftd from ttfl IMUaI lotOtlofl Imlt-v
n i wi.ii I lie umbilicus arid *yni[ihysis,uml tin? -«itl, l»ni;iyr I'timlu-
nt:iv lw found mic.hiiig uluio.-t up to thf eiisiform •.-.irtiliiffi*.

In otttt in which the bwnorrnage Brian from laoarauofii of
i fit- lower i'i"*t of the birto-ouoJ the fundus will be (bund id

!ls n-inil pOOltlODi lirniU rnnlnirliHl, in spite of lln? fsirl l!i:i(
Mood is ewnpiug from the volvn, An internal examination
menn* of ii -jK^'iilum, it' iiot'ewary, will revtol the bleeding

>int.

Prognosis: These coses rarely termimile fatal jv when -killed
B-MiBtanoc i* at Imud. The greater tin.* low of I>Uh1 the gravur
13 lln? prognosis. Thi? iinst iinfitvonihlc ewer* ore lOOM in
which tin' blood lo-.t if* ill tit find watcrv, and mill l<> clot
propftrly, :i- iin.- i- iiulii-ahvc of ft It load dy.vi':i-iii.

Treatment of Postpartum Hemorrhage

Tin- airitlt-ni nm iHimlly lie prevented bv tho prOpM MIDD
■mbmoI Of In* Infra plogc o* labor. The directions given i"t
iin manaeeinoDl of uw third silage of In I hip onnHtttnte tn out*
linn of the preventive treatment of pnat-nartnm hemorrhage.

Tin.- prompt, energetic treatment of :i r:i«r of pim! -part uni
bMDOfrhuo * -rf» II-* for -wlf-cnntrol, readiness' in rraooroe, ami

pmenoa or mind on tin- pari of the uliyuieiHn Hi-* object ie
i<> -.rijiv pood. Hi' m riiiiiuuiion of the iiIthm. Ii i- well In
Imvr "-li-urh minimi a rouitni treatment l« wpciin Mkiaobjeol
Tho fiwt tiling to !«• doin> in to atimulat* the ntenia to action

In- making rigorous friction over the fundus through the
abdomioal wall. Ae the organ becomes outlined nn contract-
ing. pr-fe-Aiins rimy In- .'Xfrfrd in the manner nv.ti ndfd l\><

Kpolaton of the placenta Booh ooutprwiou may load to
iln- eXDuWoa of olote from tlw genital aaiinl, ana fbrthcr
haraon'li-iu"' niwyi'wi«e. If thi- forrnnatereaultdocB not follow.

bi frei Ii.mkI ihould be averted into the viiffina a»<l pOMcd
into tlic Dteru-*, nnd udlicn ni • l»it-. mnv !»' Looacncd iiitd broken
ii|< Kv mnping the mitli with tho tlni^r-tips The ntem^

lOUld ilu'ii l« i rnlilicii mid kiuiKKil bi'twoen the •■*« ternnl mid

I7»v/. /■!/;// 1/ IIFUonnnAGh

Internal IiuihIv, io n^ i" 4timuliiu» miurowiini>. A* hoon n*

n-liuii )i:i- I" " «■ --Mi'-'l lli« hi|i-(m:i1 lmti<t *ImmiM lie witli-

drt vn and ao Inm nterfaod Jib of hoi i-nli/.t-d water bIhuiUI

be (jiv i i in- effectual, iii<- watar ihoold Im bctwooo lift*
■od 126 (''.. utd at land a gallon ahoiiM Ik- employed. A
alu-donehc ihould Im- nied, and the noulv. either of glaai
oi natal, hniiiil bo carried (o tbo faodo*. While (Jie douche
I I- mi ■ voi il»<- lundiu ihould Ik' kneaded through !h«
obdotaiooJ wall.

ir ilir hemorrhage i- not ohaotcwJ by tin- nuaDo. tbc [njee-

tion -lionlil Im' rvpoatfcl, after adding to the aWrilized water

enough iic'iic acid i<> make u •* parueal Bolotion — *'. **., font

lotbostllon. If thai fni In in -[i.|i the bleeding, ihoa

tht uterine cnviiv iiiu-t bfl tamponed with strips of iodoform

gtQBB,

Th- technique of (bin procedure it very simple. The [inte-
rior lip of the eervi\ hi asi&ed with B u-uaeuhnti-forcep and
drown down i" tin vulva. The cod "i a atrip of gaaxe i^ then

deed bj un:m> «»l :i |Hiir itf uU'lilie tlnWnijf-l'ot.i p. :nnl
"tiiilnl Id the I'iiixIiik; tlietl llic whole UBvity in liltnlv MRKttl

viitli ineaenjive layer*. Ii is ool oeoanorv hi park the vh [Sim
u woJI| imt ifter raooving tba tODaouhun from t- 1 * * ■ oarvu ■'>

atrip Of ROttM BUT I*- DUMBd IB iln- upper juirt «f tin v;i'/in;i

to Keep the cervix in pluov. The game may !»• leH IB pjao
(to v-nrv (oar to forty • ighl boaraud then gently removed

I( i- -'Mora nccemrv to n \- ll the EnllW-tlttrilM packing.

A* enon bi the ateraa tun boon emptied of clots a bypoder*
rn'if of oj n antic, I*ark<. Davia & <-'o.J, 3». should be

Si , Bad repeated in half an hour if required. If after
e first hot douche no acetic acid is available, a pica of
nttnliBed gnuac,or evonaoknn pocket hundkerohief, »my be

saturated «i)li vinegar, carried t» ill- finidti*, ;nnl iIk-i. ., -. ■.!

out Tin- vinegar should ba itarfnad through ooUoimvooI

Mini- Ix-ni- uhiI t'..i ihi* purpone.

Bavlng rlirekiid tin' lii'iiimrliup:, lll« pliv-i-iini'. duty i*

than io <-"!ni):ii iIh- evil rfi'iei- of nvoN loaf of blood.

lWatnmit '>; Actih Anaemia,

The pilli.u- -li.iiil-i l>e removed lV'»m Iwneaili \\\r pnti«Dtfr
livud :in.l the foot of tbo bed r*i«d on aotnc booka or brickw,

316 PJTBOLOQT <>F Till VI > rrhl;M t'EMOIt.

H0t-W*t0r bOttlUM BhOtlld I"' lIpplM-lJ |0 till <-\livilll(l< i.( ll.r

jKilinil. MM MM hIioiiKI Ih- entered '.vit li w;irm lil;inlt<ti If
tlnn' l* I U'litlrnrv In -viirdlH-, ;i liV|HHliTliiir injOOtiofl of

-iiv.initiH iiiiimi i-'i- ',) and uitroglycrrin I i should

i» ravffiL

\ -imiii nh jxauble a quart oTKiIvral 110 ET., containing
two ii-;i.-|tiHiiii'iiU of oonunoo salt should be inj«*t«d late the
rectum. Pot ihir purpow n bob rubber catheter ihoald !*•

attar])"! to tlii- nojHUf of n fouutniu-pyriiige, no tint the injec-
tion limy be cam i'J n» fur up as ]Jo*>iblc.

Ii (lie In-in'- BOtkffl Dab to improve, hypodermic injections

"1 iiiiti , n M-liiiin, iintl DhroglyOCriti mnv i» em ploy fl.

NmftOA km vomiting arc Eroqueul la these castst, end there b
but little absorption (Vom Lhe stomach nntll these am*. Am

■DOB M "In- Mutinied will irtnin nnytliuur. Mini II minlilitir> ••!'
DO) OOfluI, li"l l<I-.imlv Mra Water, or W;iltli milk ni:iv In- -ivrn
BIN tli fluently repeated. \\ ln'ii mot'lON llOM Imvm . •|:iltli-h< i!

■ hvpodttmic of morphine (gr. J) should be given to quiet the

1 1; ji miiI.

In dnxp*r*tn cuuwr tin- -Jilinr -olutioO nniv he -j.-rlli/.*!, wvl

injected beneath tin- Im ;i-;i- MrurK iitiu die median bullifl

vein .

I • Insert the salt solution beneath tlio breasts n lniy<
ploifag-neodll mnv Ik- iw-.l. A j^lns* funnel and a piece of

rl (OCT Iiilnni' C pktC the :i|i|i:iI':iIiin. TbOBG -lie itl<l be

iIi/mI after being fitted together IV use. Hie breasts ere then

wji>IhiI with MAD :uul Imt w:iln, end ruMml with olcohol.

I iRving filled t It*- funnel. iIh- physician pTHSpff the bran*! firmly
wifli out' band, lifts \t from In* cbrst-wall, end with the other
hand i lii* neudU) (wiili tli** solution flowing from ii) w pluinjetl
ImMlv into i!n loo*c theme burnetii the brvwit. Qftrc should
be i:ikni iii prevent the entrance of eh*.

IntrxvmioUK iiu>ctioli i- seldom iinwI on invmiul <it' the Iiiiio

rt'ouiretl to perfbrm 1 1 1#* operation, end Ik^.-iut ili<< metlMOB
t> ore given eonn r 'i"' purt«ee]usl ;ih well. For the nv thod
of optnlioii th" rvuiler ip rvernHi to irorki on mrgerji

Convalmscenco in those CttiOl is slow mid tetlioiis. 'Hie
podoil should not be allowed tn sii upright for two or three
week*. The diet should conaisl lergclj of Ruidevand iron in
v.mir form . hould be ad mm ten ■!.

ii im i ;■</!/ i

:tiv

Puerperal or Secondary Hemorrhage.

Definition liit- i. mi i- iimhI In clrnnh Itotlionluntl from
tin 1 nillBil (titial i.l" 11 woiiiiiu OWUrrilW Hi iiiiv time :iI'ut [In-

111 -i l\\< l It y- I't HI r I lull: • tO Ihe «'inl of till' |»lMT|>"niini.

Etiology: The moat Eroquenl ouiieaofereoiiuary tiemorrliuge
daring iliv poorpvriua i* the retention of portion! of plaoenw
Had mcmbimnei CIoU lb lb* Bteriuet iv&ty ortbediato

meutofdotl in ill .1 -in*, (!i-|il;i(. in, in I of the UlCIt) ,

rolaxutHni of the otorae, lii.r. -i-i- . pulypi partial rupture, tba

-rpnrni i< >i> >>f « itwtigli. ninl ovtrdntcution of the bioddol 01
fCOtUBB MR bfl nn'iilionnl us giving riw i*< |>ut. i-jierul ltctnor-

rbagc. Sudden emotion or coaatiluuoaal causea may romlt in

i h !-.■. itui mi- ii,.- |ni. 1 1» rimii.

Dl»cn«is: Having the oon iii mind, it i- tbt duty of the

Ithyaiofan lo inako u careful actaroal .i»«l Internal axiiMi'mniinn
ti .ill oanoi of aaoondflry bejnorrhugr. Tin; diajjip-r ^nmld
ran lv prove difficult.

Tin treatment ilciH'inf- on lli<< r:in-<i til" lite Ii'-iikiitIiii^-.

\ I'd r emptying tin- iilniiirr tiir f.-ivtiy at' (he ntertM iboold be
espIoreoL Ernucnivoui <>i plaovntd »nd tnembraiMN or qjou
ifanuM Ih- removed and ; > Iwi inlra-ulpHne ilnudto givuui If
tin' ..in-, t- I'linuii i» be other than iboao juBl n tioned^ap-

proprint* trr'iitrn.'iil ihould Im- inaugurated,

Hwiuatoma.

Definition: in this form of bafnorriuun tin' effb>ion of blood

i- mil r.i:ii:il. 'I'lii- n-iili of tin- loeiaent U tht Ibrrnetkmof

i tumor varying in iue with the degree of the bamorrhaRe.

mort rreuuenl situation of hwnatomi i* in one or otoer

labium, rarely >" both* It may ocooj En any portion of the

ide of ihe atom

Etiology \ vari and oongcetod eonditkm of the prflvit

prediepareto ili»- ooea oftMn accident T£o do-

tcnstning cauic is u*unllr direct injury of the ti<auc* from

iirv*<tirv of the nctol hood or from fbrecw Forcing 01 -imin-

II llio |orl iii' tin* woniuii insty lenil to the PUptUni of ;iii

•"I win. ii> I o ■ ■■ i : o to ill" condition, [troey ict i
before or atffare the completion of labor.

::is PATBOLOQJ of- rut. tiEUPF.RM MOM

Treatment: K pofflbte, the ftfannidoa of the iflbftfld blood

■liouM Im' vuawnntd, Ouv- aIiouM !*• taken i-» n<ml it.
ni:niJ|Mil:iiioti in nenoruiSnff tho toilet of ilu- valve. FVniui -ii

Ifctilli" itri^;itinn wild iv.'inn, until :inh-*'ptir miIiiIi'oiik Rlfl
employed. If ;it»orplioii i- ilel.-mil, the tumor abouM bt 10-
01*00, ihf COtltODfal tbrDOd "Hi, :iti<! ill* 1 c.ivilv jKirk^l ffftl

ionVnotni hhuml If on incniog tin- lamor ;i bJetutog
found, it uioald bt tied before psckiag too cavity Fre qu e ol
mi. my nixl rigid i-<i>i- in neaeeary to prevent the oerarv
ronec ot EnhfltioOi

SUBINVOLUTION.

Definition. When tlir jn'iiro- i.f involution of fhf pUBTMlBtl
* in- j- Brratcd OT nttrded the <<rgiiii ieruid to be iii u can*
lltinn of Mihinvnlmi.in.

Etiology.
Any condition which prevent* a mpnl dnnuntl>.'n in the hlouiU

Hillnihj of the |MHT|K-nil litems Imii \ I"- -lih! In I*' u i* 1 1 we of
tiiliinvnUitiou. Any condition wliiel) intrrfetM •>uth eon£rdtt-

tt n of tin- rnotoalir thmeeof the paerperel ntortM Uodn to

|'l\r l'1/.i' t(i HuhlllVollllion.

Tlir |V>l|f»\vintr OonflltSoo* which t'ii'1 to intwrfer* with tb»
diminution of tho blood -imp ply of the pWfporml litem* WW bfl
mi nlKiiiivi n« (fivintr rim' tn mm I tin volution : In |n rpl:i-i;i nf the
i n<l..niitriuin, ilie rOHlll of IoObI Congestion DT nf milt!

inftH-liuti ; liirenition of li ervix ; 800*11 lii.rni.l- ; metritis,

ememtly wptie in origin; retention >A' xenitnlirHi or glafel

nttrlnoaupucemcotB] ohroaio oomtipotioD | and tho rammj*

lion of the onliuury duties of life too HOOO after nboition V
labor.

Condition* giving rim- to subinvolution by intorfonng with
■Urine contractions are: the retention of InrRr cloti 01
mnnt* of the placenta, or plnoentce luoccnturiotte ; dfapuMe>
IDettl of the Mem* from overt] intention of the bladder j l:irg»>

Intramural fibroid-; and peritoneal adhesfom from old or

preriii iuihiiiiumtury nltncU*.

BublOYOltltlOa 1- pniriiciilly iiKvnv- the result '.I' .utile l»;>i
iliAurtlrr. CotuUtuttmttl </t'xhn-htinm v<tv exeeptintiiilly give
ri-e in tin 1 condition, though in women with yfiierul lack of

TJtKATAIKXT "/' SVHINVOt.VTIftN

?.\W

toncv frith Babfey 'liu-.I*- ami i1iii.iiii-h«-l < !irinn;iim pOWea,

-nhiiivoliiii.jii niiiy wvur without uriy evidence of u dintinct
local (iii«.

Diagnosis of Subinvolution.

The uitpl -I- I- 1 1 - t i ; i . 1 \ . :|.y.

By tin- tnntii day of iii< puarpenj period the fundus uteri
-honl.l boon ii i«'vt l with or n lii.t 1-' belon tl" brim of the

l*lvk |j»ti ( r, if the ituiilitiiiii i- Mi-poctcd, ifacdeptfa of tho
- mar be iftfuiuted by means *»t" tl.*> intn<«tcniM sound.

I i ' lochia, in-lt-.id of becoming imIc mul puriform, ii'inaiiB

bloody ind it- ttnabnrge h prolonged. The condition u

iifuallr lusoeiulcd with • •we-tipiiti'.n •■*■>■ 1 :■ '-ooted tongOQ*

AhftcM hMaVnwnattcnrlontoLhc fhd thai free nufgriratlon
daring the [iopi |tcrimii is tiHiinllv MRMfitlod villi firm uterine

<>•> uti.niN.il- ; nlii-n perspiration falls in appear heal way.-. IooL-
fur uterine relaxation.

Treatment of Subinvolution.

In tin- oarllor period of the piu-rpri-ium )!«• literal may D*
Stimulated l<i contraction by pPotle IVielion of I hi' I'unduK

through ili" abdominal wall rat ten mtauta or bo, three or
(bar UnM daily. A pill oontaioing ergotiu, e-r. j; nauiine,

gr j: and •irv.iiniue, BTi jn »mv In BJVOI UlfW Mini - daily.

Bbould 'ii tmenl jiiii to improve neftfari and there is

no ilirninuti'iii in the lost of Mix*], the cavity of the uterus
should bt explored with the Bn-« r. II' »cm— iiry. tin- i untie
•md plno-ntul forcer* mav Ik- i ■ -<*t I , bcinp followed l»y | doachfl

of hot formalin dilution d :&(*>), n ixl the introduction of ■
Mfjoh "i iodoform amine to tin.- Eundun. The titter Kite by

stimulating the ntWUS t<i eoiitrnrlinn ami hv fftVnring drain. ,■/■■

inn ihooM lie removal ;it the end a\ forty-eighl noun

i.iul .1 li<»! VfUtinftl <l<»iiclir oner ..i I \\ !■'■ ■ l:n h mav i» ■ M' I ■ ■ r « -« I .

i >.: i free ■ wicuation of the bowel* should i»- secured.

II* tin- in. -ru- l.c displaced, it shouJdbeMil In proper porittoB
end retained dure bv mcnnaoia posstnry.

OceawiaoRlii ilie condition i»t'-iilMim«hiiuui i* mil <i inwii-d
laU m the puerperal period, alter the woman has been

rraJkioc about for boum lime, In soon rasei the eaviiy of the

ISO pathology of wie pvksiperal PEai>>t>.

uttriM ihould Ix- paioad wifh « ."'linivliiir. eolntti F lodla^

and :i v:iirii»:il liiinjwm nf wool Bttttmifld with DOIOclygtffD

ihmiltl be iflflftfled two or throe liiiiuj n work.

ANOMALIES AND DISEASES OF THE NIPPLES AND
BREASTS.

Anomalies of the Nipples.

Supernumerary nipples are of frmuenl OOOUIT0DM

Defects of the Dipplei IM chiefly UOpOrtftOj Bfl fhrr rnaT

Interfere witli nursing.

■version of the nipple is u very COD1D30U eoml5tioD, which
be congenital or «••< Miin^l . Thi mny conirtituto U

lute unpedlmcni in lictntioD.

taring ill*- Ia»t month of pregunnoy itbnpfa fihould lx*
BUdfl to draw oiii ili« iij|.|)|.* l.y moans of u breast-pump.

Whin the nipple* in -mull or Imperfectly developed deilv
gentle tttictioo upon tin-in by tlw nun« or pbj u<:ian nn r»>ufi

hi iitiprovx'iiiriit, it ih

ployed la enable the cU

If ihis finis :i nipple-sli
> Itl (m liiir-H?.

■M liut-l Ih- ■

Anomalies of the Breasts.
Absence of mamme : While imperfect devoIetMnenl of the

lii:iiiiiu:v i' "ii.'iM'j. 1 li-ir miupli/te ;Jwinr i- a vorv r.ir*' i <mi-
ditto ii. It is QmAuj ftSBOcSHtea with deformitta nf the \» Ivic
sexual organs)

Hypertrophy of the mamma : Thi« condition 18 11 RUN
n teu preeenl ii don not of nmsnfy onntramdiost* oureMOE.

Supernumerary mamma : 8upvniUtnefiry breasts ; i"' to M

mot with oompanrtWely frequently. Tner ocmr with do

ragulurny i.i" *iui;itioM ; tin* most frequent position is below the

true mammas; the/have been found over the pubavou the
buttocks, shoulders, and in the udilm In most com* no
litorv influence can '••• truc«l.

Anomalies in Milk Secretion.

lie

Deficient Secretion.
OomptHe nliHfH<e of miIli-^"T"(inn is n run ...milium; hut

d/fm'rnt mi/k-«>fi;tl„u m only too frequently encountered

4S0XAUF* tS VrtJT SECRPTiOy.

S*j

Etlolocr: /.-if* o/ aV*rfo/m*i ndttfaf tlffnanf (!»»■

Lmt»u i» the niu* common «u*- of deficient n w tlcin of milk,

lack "! ■!<■•' I' icn l»r ilur to hemlitJin rsiui

to codUoooom prcMura bom tijriii ofothloa;; or n may u>

I Idi ■».-|.i[n?ir ni ,.t iln- uiIht M-xrml anw ><\
'!i. body.

Tli. >/:. ,-t /■',. '• ■•'• i- iii. tBcUcitlon of llwir ability t<>
fur nix 1 1 milk. Tin- luiiclmii dftwuclis uiiiivly u|mhi (lie
Dili of gtamltiliir 1 1--11 |>rr-»-uf in tin Invji-l- Sune

MrnoMii with «'ll-<i' \i loped brvaeti bav bul little prlondulai
^ -in. ami tliernfon make poor oiintni while otttvnf with
■|i|ni>>niU' Inn | • id m !..|.in.nf of tbes oipuu ban I i u h

,imI -il hi ii- l.i nt -iijiplv of mill; for Lh< tr oftpriog.

Tii. -.. i. tfoo "! milk may bt ■ i t m: ;>i • h.-H by the ocewrp'mv
of few, In nion-lmp -, rlir-uiic (li.irrli.cji, urnl iDBUffloitfll nolir-
i-.lutii'iii , BorioUfl OTganic iii-. .-. • ,il-,» p -nit in •liiiiiu! Im >l

Dtilk niioti. Knmtinii- prufnuiMlly nflCfll tin- RcretSoti of

. jifulongoi grief in a mil known i-iiiim- nt il.fnii -m

Ion.

'I'll.- iWni h ../ RWIUfi t<nt,c,n, \\\\\\y il m:iv amvl ll<< i]ii;inl ilv
ami Ql |]| tt (hfl milk rtrvretnl, mnmil I"' MNJ inv;in:ilil\ 1"

prouura ihiM ■■ miIi h may be stated t i « ■ ■ t . h ;i ruk Ihi p ■

turn of lln- fuiHttioil blH bu| littli- influence nil Rli)k-fl*On ,l " tl
Traatuitml : l?»l liltlc can Ih' mijg^Mi*! in thr wiiy of tmif-

rofnl ; good, plain food and plenty of i' ; moderate < ( " raw in
p i tt l-'iir glaanni of milk daily hdwa an

m-il-. fcfld | u-in« RHUaflll of CXllVOl of malt tli'i* *.' <litil' . ■■ I

Hlitatfl about all Ine treatment powible There in no meai

• niv valin iii tli" . \|-ri.n<v <<( tin.- »nVr

Iw iai t i it SocroUon — Polygalactia.

Jn n, wliinli i- not Infrequently mtf with, tin

i» la exeeu of tin- drrnande of ifao obi '
TrMtmtut. lit. • should Ik kepi nlnx«l urn) llu

>|ii:i[:'ii% .-! IIuhI- imbibed rulmii! 'Im 1 limM* may l«-
cqmun Mil bi nt rn n • of . tijjhily lilting in Tin-

m .inn i -iiuulil tiil.i plriiti nf tmnl *%trri>m ilaiti In lln in
:iir. It' tlii- m. in. i' in l":n - tin- *xnm nf milk nm
|iumi i rqjpbn* int.-rvaU.

322 PATtti)r,On\ "/ TJir rei i.ri i: 1/ rHUtoh

OaUctorrliirii

Thii i'-i mi i- applied to an mbiIm wowttoof mil* which
p- I aftci weaning. Tl«- Son of milk i- noi ncocMorilv
1 b ncklliig flic child. Tin- milk b thlu and watery,
tire 'jiKiu'i/t/ being nxccaifva. Oim a mow brtaatt roaj i»
::!i»- i"l, iukI i hr condition icrfoaal) Impair tho itMicral henltli.
Tuo condition moj tart rorvcafc.

Etiology : Kotbing (li'linili* 1* known til (»» I In CUUHRttOD 04*
thi .itntliiiun. It li:i- boon attributed (0 8 i ration (W p ■

y-i- of iiir circular nuaoular Rbni Borrounding the milk-

ouci ■

TnmtmMit: Tin * cOJMi 1 r. < t n. ntl \ offer VCTT itobbottl TC-

Jim.. 1.. nil iifiiinti'iir Firm owmiri toned Ac 1
meant of » iw .•■■ binder and th< admiobtj ition of potaaritim
iodide (gr k I i »l.i and of tl. cxl wgol 1 111 1 1. fbi 1 a
cmble ptriod ooiumtute lire ii*iial trcatmcnl Ganaral tonlat

I iron should I*- adt immiiI.

En|or|«meut of tire BrauU.

loloo . Krti'M'lin' fi:i- :i.n;ulv Urn inihli lit till- l:i''I lli:it
-iuii.'illy mill tire MtftblMilirenl iif Int'dltii'li lln In
ni.iv OfCODW POngWt«l And Migur^d- I I": - Condition of cii-

Sn'iri'ini'iii ni:iv occur at anv linic tliroiiuhmil ttre period of
.lui-in K%|»i-nrv of ill' 1 lnr:i-l- '<> iiild mr :mil hv|» i
linn of milk DW tin nin-t I'liiiuiinii (1him> 11J tlii- i-uinlilmn.
Jiymptmnn : Tln« brm*t* i|nil<- MinMi'lih Imv.h t]

with mill audi on eatcni a* hMK-nu-ion vrrv cYiii*idvrabn
diatnm lo 1 1>> patient. 'I 'In- pain and tcudcroein nnv bt thi-
ll OT lll'lll- 0t MM ' '• -V.-lllMM (it l« ' III|H-I"ll mi-,

Ti-'a/iii-'it.

T n-hrvi flir pitfall I it in nr<-*--:<v\ |o ivninvr tlic 1 • •
iminiiiil 01 milk iinJ !■> |>nvi ill fuillnr n ■; cii ■_•■ UKIll of thi
in .'I- 'I'll 1 ■ l.n:i-|-. ni;iv U' • in pi it tl l)V permitting tlir inl'inl

bj the brtnrt pump 1 iml by mnmage,
[f ■ •> nbltd ntii- to ptr the bjYftMts the milk rrnifl
I* drawn uff* by mean* of the bmMt-pump l'c I

.4.VU/.I/.//.V J\ ui;.k st.rur.TI :

323

the moft injiaacton bncnat pomp fa tbal known u the
i ', -li.li" pump Riot part of lb* pomp arnica a applied

:. the bran U ibould In- free Inmi jn ■_■•_■ ■•!. rmijrli edges, othoi

vim tlwM may produce K>m<j nbranonn
2CMMg0 of the brewit* : When proper perforated (fail is
are tfflcMOt niJ in rdievtug congestion ud engorgement

Jt -lioiiM never be employed if than is evidence of mtei tin)

iull:iiiiiu:ili>Hi nf liirbrcOBtFL

Tin- (liiii'-iil. Im-im" In iIk- li'.r-jil |HiMthiii. i- dire.-*"! i<» *uj>
l"i iii bfttHl by placing her forearm under it und dra*-u

u|>. The bn-Jiot i» ilu'ii anointed, with irnrai oil, aita which
the nj. rotor bfgta the manipnutiom In- placing bin fl

■ p |.n;ii'il |8 Widely 01 pOSublc, Ol LUC prnpliny "I" ill"'

1 A rapid though gentle rtruking nabveraeiil Ea then
mode toward ii"' nipple, iho flnger-ttpj being brought grad

ualh tngvllwr mi ;i- (11 'I ill Hi*' lormtimlion of lli<* Btroko,

Kaon twcnnenl of the gland in thus rapidly stroked Id buck*-

noOfCBoii movemem terminating ;it th< nipple. TIm po Bun

exerted by the Bngcr-tipachoula be gradually increuaed, tborl

■i I'l'-lufiug aevcrc poiu. Tola rtroking venMUt in ubout

fivu niiiiiiii- iiKimiK . -.-,,-.•- t'MinH' jcuii, rii"'n theopentoi

Mpporting the breast in tin* ]kiIui nf one hand, with the loop*

li(»* nf tllC Other Ililll'l -»'lrcl- ;i t"»'>t'r • if imhlttltlnll, wliii'll III'

- toward the nipple, gradually ocnplovine deeper and
Armef preaanrc Etch Dodtuc of uwnratJoo Kb Lntn treated la
uoa ion.
Ni"lulc> wlii'-li (In- manipulation ('ml- to eorom moj than

!"■ i-i.inpK- 'I In plii.iin: f l»' baud lint upon ihcin and eareri

Maiuj gentle pronura downward agaiuel the ebart-wall« Toe
I :.. ilni- 1 iet*tn] dmuld Ih* zirwu ••. at tin- periphery 01 the
gland. Aiu r a few momenta »i vtcaoy prtvutrcj gentle r atai j

i /omenta of ilinhiuxl may bo mode over tin* lump If \a\\»

1- t plained of, tlie Rtroking movenwnta ibould !*• resumed

llir braawl -liuuiil then '»<• crapped with « M »th hands "«> oa to
trcJi it completely . and the vnola gland gently raiacd and
aojttpreaova 1 , while toe two tudt i iii i- an quick]) itrofced
timnnl the nipple to favor the canape of mill., Than variotu
uiuni(Hiliiii»m- Bbould ha repented 'ii -liori intcxvab ninil the
glanafl h i\> u u ..t cned and emptied of their corrtantSj when

a prrwurc-bonduge »hould be npphed.

:: i JJ r.u'it"! f, I ../■ via. fl ri:rrL \< I'KMOto

The DlOfll -iii- :i ■! >iv brcflj»t-bftnd»dc, in the opinion of tin'
writer, in the Y-lnintliu.1', which wu lir-t employed in the

I Winn Lying-in Hospital ThU miy l» nunK of |wo pieo
Of -oil, imlil'iK'lird CU( lOfl or \'T'V- rye ImW. II III;.-, :il»mi iliirtv-
■ix Inches tODg :mil ti'ii or twlvi inches widi , I .

ordinary bond towels (bf ihta purpose, end And r i *

iiiliuinihly Tln-.r lit folded mm *lrrp-» iihiini rliiv. ,r i ■ ■ 1 1 r
i i ii he- WHIS ; oik | of I In -. || folded .-ml PO ''til, lint) tin doubled

end taroed over bo -.** to ooaveel tin strip into nn Lehspc,
when tin' ftv« <'iii!- ire wpintcdi The nprx of tin- - ? i- 1 j • i«.
tinea Dinned with lima or four «afciy-pins to oik> •■ikJ »f c 1 10

OthtT «lri|», *» iik tO foftD the V-bttlKlUgtV

I'll.- brcasta ■"«• then dusted with pondered starch oi
dur4in^-powder, nod the longer arm of the bandage dipped

under tM patient'' Iwiek tit th»- l-«\v«-r |mri ill' tin- - ■ ■■
region until the upex of the Cork i* just external la tin

edge of the left breast, The patient then lifts her hri
upward und t'jwurU etch other, while the lower inn of lire
fork t- drawn tightly neroee ih* chest beneath die breasts; the
Inferior liordar of tins arm should extend al leasl nn toon lielnw
tln« lower raannitu of the breasts,

Thoappcr arm of the fork i- then ilrawu aero** iliei
above the breasts i» mch i way that it* upper lmnl*T ■ w.nd-

;i;i tih-li li'vnii'l tin upper mnivin- "t th. I>re:i»t- The frw

ends of the two iron or the fork should Ihus meel a] the outer
margin ol the rjgbl breast, where thej should them b» drawn
Light and -rriin-lv pinned with mfetY-pin* to the rtrin whioh
bos boon passed neneoth the hnek. Tin- Irce end of i'*- I n b
strip iiiuv then lie ovnr the apices of both li -' I li ■ *trip
passing underneath the breasts i- then pinned t" the binder lo

keep i( from bllpping up; shoulder-straps moj then be pi si

to the uppei nt'iii ol ihc farfc and fastened behind to the ooi
stri|» ( tliu- keeping the upper arm of the fork from -hppiiii:
down. The IimIImw U-twei-ii the hrenstf may ili"n be fillwl with

eott end ihU held hi plsoa Irj two »afeiy-{>iii« joined togetha

end pinned lo the upper und lower ermi of die lark.

In piece of tlii- the Murphy binder nut} I inployed. I

nrndi- of :i etrlw of thick gray cotton, forty Inehe* long And Ben

wide. Iu tin' upper border of thfs rtrip » nsrrow notch

til.- ni'ck, :ui<l two deep ootchfls foi the arms, The

■■'./.'/■ KiiTLBi

323

binder i- applied tijdillv over (In l»i.:i-l- and pi tit n 1 1 in front*

Wlwn it i- deairvd tiv rnake application* la Hn nip_lo>y two

fit.uhir twit* ilif -i/r uf :i >il\cr Icill* dollar (ID In- nil in flic

Murphi btnaei ; th*j riaiviim of InoM bouM 1001110 !»■ button*

hole »'it' tnxl.

In rtw • in which the •iiBonE*>n»*iit 1- inlctmr and (lie hmmtn
-.( « 11 :u\ v 1 bat iiuutipulalioa u iupONiibk much relief qui ba

K1V0B t'V tin ipplkwlion ul' hot cnniprHMMix. l-'Ianiid »<utUcd

in bot MahT mill aarbonati of ainioonioDi i~j to the pint).
wrung drj and then applied i" ibfl braMta, and repeated al

imrr\al- .,(" livi' niinni--. -,»<n ffjVCi relivl oml pi-runt* l In.'
application <-i tin <inw*t-l>iud(-r.

In ' ■ m« -.; (A< I t« -li. <d<l he obtniiinl

l>\ the adniinistniiiuii uf t«-n^j •■ m >n J 1 1 1 .!..«-. ■ -1 l;.«')nili- -n!t in

mrn water, il intervali or fifteen rninnta till pur*pti

induced.

Sore Nipploi.

Etiology and ayniptoma: Tbi child in nuoiog may manr-

iii. -n|.tiiii;tl < piilitlium oftha nipple* Small Mipvrftdnl

uJoan maj thua b< (brood • • t the anion or at the l>a-c. ol llw

tiippli -. which am difficult to had becnuM tba bbiki in naming

rvnarata their <-i-. Tin- pain cauecd by 1 lii- condition

between ilmpk toudeniojai m the n> vl tbi aMId

Bftw : " nJ| i I- . 1 -I hi 1 hi ■ hi rim? tin wli»l< .1. 1

of nuckliriK. Krwion of the nipples occurs rUQM Impic-mly

in priaJpam

TiHatmnnt.
iphylacUc tioatmont -hould !*• btttin toward the end of

*nnno) aaha* baaa mmitfonad. Cfaw attention to clean**

Hi'.* "I (l.«- inpjili - Jim! of lh. child'- innuili I. of >iipi*:me ltn-

pOrtaAOB iftff i'iir-m;_', thfl iiippl<* .liotild Ih WfiMMC With

"•I' arid lotHNI and •-trrlullv drml. \i l\\-\ . >i:n- u das 1 1 if

child* t iili iImhiuJ Ik- Mtftbbnl with plcdgeo) t.f nit ton waned

in ejljcarinum ImrarU, The bhioauth nute recomnwodad in tha
atctton on Manop'mcnl During the Puerperal flpriod may

U i<in ployed fo| low in/ tin- pro Ultiofiary ■■!■ -m--i m-' after nilrv-
llllf. To till- oinliiM n( it in;iv be WoU 10 Hlld Ull-Wlltl Ol I'm'i

(Smi) hIhhiM ilut" hi- i-vi.lu.. of ibraaioa,

the

16 iwruoinr.v of nu: riit:tn:\t. itr.tuu
Painting the nipple*, hy menu of ;> eamtlVhsir l-ni.lt> irith

i In? |Hiiiuil tfootnii •'< beo/,"ni. •-; i lOgnuutothi ounce

«oluti<< m mtnii<, will be found wry mti wfi mNwy trait-

mvnl in iii.mv ■A-vvu- .m-.. - If.. .. ■ i tn tttd l>y

dnlll I liiii:- tin-in Mircl'lllly with thn -nli.l tidi of nitrate

»>f nJvff.

In Mime ej\«c* extreme tenderne-a of ilie nipples may be

oornplifncd of, and vet the mo«t eiii'i.'iiil 1 1 1 mi nation fiul to

pdvi nu :t i * v trues "i either iTiwiun or flasur** Iii there cases

i n wii'li-h:i/i-l (est, bamamelidie) will be found

UM-tiil; il m:tv bfl •tujiUiN *-<! pUN w dililt«d wltll tlTOOFtfafM
j.n!.- -.I" lunlcd wntrr.

Tbo wrii.T htf bad rfcry satlaTaotory ronh* from punting
tin- tantfar nipples wiih d utn rated alcoholic eolation <ii ortho-
form. :i( Ir.i-I :i- l:ir :i- glVIIIg Pclfftf OWfl [i:un while hUnflUJ ■»
riHKVUH'tl. Till* NlunTd lie applied Willi I tiinn'1 V-li;n:
jU8i In lore r;ii*li :ipp|i«-iliini Ol ill" <lnlil tO UM nippl'- ' •)-

tun writea oUitu to hate had Mtrere inflammatory reaction

tMlow it* •.'iiiploymi'nt, no tliiit n -IhhiIiI ulw:i\ - I.* untd Willi

(Wltinii.

hi ill cases iii wbinb the nipnlcg in tender ;i gfcna : ""l rob-
ber nipple- shield should be employed while nursing, Thdhield
ihould 1 10 kept Riirgicnlly olenn.

En some oases it may* be 11 miliary far the mother not even

to attempt to nur^o the child U<> tw ntv fniir hour*, or ■ ■ - D
Imij-er. In til--- 'i-' th'- bfCBlll inuy be I'lnptii-d In :nr:iii»

nf maeisKo, the brcast-jMiup not being used unless it prove

ulwoltiti'ly f in :e*iu'y.

In vrrv an -piiiniiil cjiM-i* untiling bill weaning will remit in
|nTtii:iii<ntlv r*.lii'viii|j the oondifion.

Inflammation of the Breasts Mastitis.

Varieties: Three firm* of mastitis are uwmlly described:
the ni'^t frenuent vnriety i-* the i»nYiic!itfmftttm4,orgtoMhdaF,
in wbicb the ueini of the u'ltiml nrv primarily the nte "f lha

ittl iiiimution. In tlii' Mubeu/nwoM variety the i neotive

tiuue imiiM'li.'ii' Is Un.uh tin- vKin !•• n Hacked. Fntbeeuo
glandular or p ort*mammar j t form the connective thane between

' o gland and the chest-wall la the 'it<- of tbe Inflammation,

vi //my -./ ,/n i:u, \sn 1/ lAT/Ttt a*j"

The inflammation i* but rarely oonfload COOM of [ban 'o-
ckluia, -••> tbal dinii >IK Iwo or <»H [breomnj bt oombinw,
n ruse* which tin n<>t t*»-iM- prompl tn Amen!
■ Ih-im- in id.- uoiti i of the glniid, whanoo "

prand i" the conacdivfl timio and approaches tlie slcio ur*
foe

Frequency: Mntttttt OCCUa in nboul 8peJ "Hi Of oil mil-

lag woni'ii, tlnmjjii tl i- itiihl Iri'.j.irnlK tmi Willi 111 plirn-
ijiurw. J[ Mi:iv tcniiinnlir hy h:m>IiiIiuu "i In Miji|.ui;i>lon.

Etioloity: All forme oJ rnaatltifl ■ : "i nferabfc origin. The

iillirli-.:: i.. hmi;i1Iv due I" thi I'lilr.Ui'V tli MttptlJ loOOOCl, ■ ItlW

tbi Quraufl or iilln^. thougli streptococci 01 other pu*-pi*odndng
iip^iiii-in- iiuiv givo ran i«' ill*- ooiKiitiou.

Tfc* in/Vi-i i> mi nsaaly arJMi la :i finura of auraatonaf tin-
ni|i|i!< and iprradi eltnar bj manna of i In* tytaph-ehaniwiti bMo

lii CDDftVCtK't I J — T t . ; i.r Ul:.r|lv s)OOU ill'' • f,'tll'fium o) (I

•luri \., in, ,i, inn-, posefbly lo stvwaL Tiw [nflaouuntiofl maj

Ut fir*t U li I (•> ili<: '■pillu'lintii, but 1000 vpivudp lo tin-

»nrn»4iru)iii^ connective tissue. Impaired jrenernl health aua
koad mri-liiiiiinil Injuria are important pralmposta-j ctu -

M<tl (taw woo )ii one llmo |hoqg*bl i«> be flu causa of rim-
li l I'm noUioloffi iavfi proved tlial -i:i-»- aluna will ool
proaneo ■ * i« ■ condition. If In |KMiiMA thai -t.-i-t- of milk multa

in nn | >:iirtui-nt oflfa* i-pii lirlium of the dUCtS ;iinl llm- n'iu|rr»

Infection more liable Ui occur.

A |n ■- - 1 ill'' AOlirCO ul i:tU.l:mi i- lln< Unntl. |*>«liiTl-*li

ilmt Monliyloononi which have (mined aroma Id i In- blood
llinni^li iiili-v't ion of llm Htnirol CAOflj are ineratod lu the milk.

8ymptoms of Mastitis.
All form* of martin* n- inpaniccl by the *igns of

The oncvt of the inflammation i-t t-cucrally cfaartotcrind by

:i distinct ■•hill OF by :i prii-«' of rhillhii*". Tin* tiMi*|»-r?«t ui>>
to i - rtrul fin- pntlcnl complain* of polo and tendon* ■
in the affected hrenrt.

In tbf parenchymatous form one or more tender nodule* will

and In ih« affected brooot. ThosWn overt; lag the e nort-

■Jaarno) di maj twi bo rerl-l«nei1. Pi aani i< on ili<-«* nodule*

888 PATBOlOQf Of VBM fUB&XSM \

ii-.n.iliy DtodoCCi a ^liiir]., milling pain. Tin UUBpCmtOFC may

ri-i' to i"i I*'., "i i v. a higher

[nlhv low intmtitUl form the pain i* tint li ndh lor»1-
i»ti and no nodule can Ijc t»-li in titc breast. Tin temperature

• DON gradually ■ml chilly sensations nre more frequent

than » dirtinQt rigor. The ikin ovro ibe h fleeted i ■

|.f...nii- ii'tliii'Miil, iiihl it will Ik' fiMjii-nih noticed tliut ll»-
site of the inflammation corresponds to a riwuie in the nipple.
Thin form of inflammation fa wry dithVnlt i«- abort Rod
■ lly rc*ultt in alwee** formation, tliough if the breast 1* opened
early but very little pn- may be found.

Treatment of HAntitis.

Abortive : The iadiaitiom are to wcurc complete rest fui tin-

ill'id-d gland I iy (rt) RSOOiUtcij I "ii'lii biting nur-itnj t'i"iit either
bmut ; (/») removing by meant •»! maspago end tin* hrea»t-
iHiiun the content* of the gbudtj and (e) rodtKlDg the loCfl]
Iih»Hl-«upply.

It ih mijiorliuil tO decide if ponible whether the inllnmnia-
|IOD i- Ol WW pJinnclivMijiloiH or of tlM ml .1 -iiiinl form. I'hr
nodi of (iiN'i, condition of (In 1 nipple, :ip|»eanmee and feel ..('
ihr hrniHl, nnd ihr tiirl thai tiie |i:ii-rnrliymnlouH form occur*
tuoMl frequently, will ail'onl a-MrtaiH-c in making a HiagnoftSv.

If the Ivj* of ioAaaiRMCioa preBQQl Ea parenehymatouj, tln«
routine of treatment may In.' given a- p.llow- : tin I in 1-1- are
1'nipliid I iy innininf iwiiutitgr and the brtBrt-pUmp, ill inniirpn-
I.41 i . . « » -* U'ing on gently carried out li pomble Tin' nippies
lire then dcBOBfla mid an Rlltiarptil dn inj applied, 1- piv*-

vinnnly recoauDeodeo 1 \ tightly fitting fiurptvy binder i*

flu 11 ippUed »o as to secure a« firm comprWmn of both bna*l<f

1 1- en rible, without more— ing the pain in the nflbetod parol

Then an HT-lwg may In- placed nu'«»le ihr binder OVCf tM
jiffit'tMl jHM'iion nf tin- gfnml. Tin' in' Imv thotiKd be kepi
ronctantly applied for from rvdvc t.» iwenn^four hour-, tna

1 of time being determined hy the relief of pain nnd 011 b*

ildefl 1 Uunpentorc

Tin* lewniiig of the local blood Rlppli of tfcc irlnuil nany

urincd by the derivative action of niIhm . uiuin 1 , wWu h
■hould befYeelj edmlol bntd h prvvkMuly recommcoded.

M77.li/.v i /V'-v Of nir RMCAST& i/is/v/v
If »ft*r tw*nty-fo«r hour* iln- i< mpftBtUM ha- dropped UM

die jKthi disappcoxod, tbc pnamm oa ill* 1 breoata majy b«
duos by loottniog tbc mitfar ronewbali The ke-oaffnioj

ihen be removed Tor mi hour or tWO. Imt Hhuukl 1m 1 iimiI iiilrr-

■'i < i i--iiil_v till oil toodcrnafl of t 1 "' brawl diaejipaaira and the

l!uw til" milk hi* Ikvii iv-i-iabli-hi-d. ill nin« inttUKM UM lo»-
lwg it not wdl borne by the putJent, in which ai-< a rumpir-
wriing ont of 11 solution mI* lead and opium (1 ; 10) -lion M 04
Applied over the aHceted j-rliuii of the u'h" ii ami ■ ov«uw3 wiih

otJerl wlb or :i layer ol oon-oliaorbroi cotton, vw which the
Bffurphy Model tnej be Ifchtlj applied.

Too treatment ol" tint interstitial fonn ui' muntiiU differ*
■"inniliii from (In- iHvmling. In this tiirni uiawafEv should
be avoided, n only lauding i" u^ruvate tin* erudition. The
Murphy model vaoald bo applied sou merely toaapporttha
i<i>:i-i-, Imi not in ottopreaa umio ; otherwiaa the inmiueni of
UM i«ti (brim i-? ilic NiiiM'. In Bom of nil Inolmenl d hum

|)!o|"iitnili ul' ihtiMC i-.imos Irniiinah* ill :ilt-ro- formation.

Mammary Abscess.

The fii- "HIV be located in the Bjtod*emfartaiicu or in the

-nUnianiinitrv connective ti**ue.

Symptom*: It i> not always poaublc to be certain that mip-

puraiioo boa taJraa plici ft tic aynoptoma giveo. Pluctoav*

iii. ii. iln' hci-( ivrtiiin sign of uliiiv*,*- formation, U raivlv In lie
ti.iinil until lain.

Seven tiirobbina or stabbing ptiin anggwu ftbocan Ibrmo-
imii. ■■upeciullv when iOBOiDpBOKa wiih chilly annaotlono. a
higher groda uf temperature, and greater rapidity <•!" pulan
Ufimllv ii hlui-.li diarolonttlon and aome otikma of iba "kin

marl; the lo-ulity wht-h! tin- nhacaej will " |minl," WpeeUUy i"

ill' innri' ' I1H»H |t:lHii*'liviti:il') I- (i trill.

In the hUentUuufarm the poa taxkh r<« burrow axtaouvely,

iiimI ii" actual ■ mnv Im- ili-o rmiiir tboogfa t' M ' whow

v:l:iM'l i- found to I-- riddled with pua-Cnctei If tuoh a < i
■41 BOO I "i i". the put will I-- Ion ml ■■ pointing " in *'vi.'nil plan*.

Surgical Ttoacjm

Preliminary : The patient ihould nlwayi U-
btjfero attempcing to Open or trad » ninnimnry ubaoana, unlaaa

tMIMATW: !WJ UUE4-SZS HABVtTt& ftfe

If *JUc t»»nly-four hour* lli<- UtfupOMtOn ha- dropped anil
the |uin ili-4iji|« :"< <l, llip |in*Min t n i tna broatf) rot) ba N>

-foaan • Is coidb •!»' binder aorntwhat, Tnt lca>nM£ nug

iben l"- removed foi on hoar pi two, i>nt -houM i»* wed Inter-

ally iili all low! : ]»car.- iind the

How of milk Im- bwn rx*-* ■-■ tn t »! i - Ji* > I . In nii> inattDOaa DM

. ircll borne by lb< putiwrt, >" whloh cast a Comoro*
il of :i aofutiofi of bod rod opium (1 101 ihould ba

i;.pli..l ov. r il.- nil'.-. i..i |...rti-.ii of the £Uind .mil oOVOnd wilfa
Oifed »ilk or ti layer "l U"ii .il-<rl-in OOttOOj Ottt winch I lie
Murphy Undo iniiv be lightly applied.

The !c miKiii of i tic toterrtlUftl fonn of luatitaa differ*

•omovlial from (in 1 |>i> In thi*. Ibnn ma-wigf should

!►■ :H<t]..|,«,], il> milv lOOdlllfl I" :if'JI i« :•(■' rh mhHiimii. 'I'Ik*

Uurpbj tiimli'i nhonld Ik- npptkn m tamoreJy to aapport ihc
bffjtu*, boi no 1 ('■ ooinpreja toon . oihorwfao Un troKmaitof

ikl two 1 • ■■ i ii - UthoaUDO. in -pile of all irtitliiKiit a luri(v
proportion "I lln -i -:i-(-. trr:nin:ilr It) :il>"T-.. lonnjllioli.

MAinmitry Abscess
[to |)n- may be located in the. rzIoiid-xiiUiAiuit or in the

MibnaniBBBry conn otlvt flame

Hymptonw: Il i-. not ,,\\\i\\ (.m-mI-K- to !■<■ •t-rcain thai Np-

' Iti' i.ilcn y\t\<>- from lln- ~ymptoin- irivea FlodOa-

"vrlmn »ign of iih-*oe-» tonnation, Ea rarely to In'
found Mttril I
s.-me ilirobbffng or »LiblmiK pain mi|*-£v<im aliMi** Rrnu-

1100, •-■|K.i:(IU Mwll BOC |>:tiiu-il mill dully ■ m.-.ii iou-, a

lii^lni grade '»i f<iMj«:niiit«-. and greater rapidity of pul«e.
I muIIs :i biuUh dlarnloration and noma o*d«mn of the akin

hull k ihc liH-ality ulicfv tin will " |x>Jnc

■ iromou mrtnchynatoQi fonn.

In 'i filial farm tot pofl teodi to hurmw txtentivclv,

and !!■• n:i nl i" ■ ■ may !»■ diaofrnibla i hough the vrhon
eland i- found to he riddled with pUB"tnd 1 1 < h a oone he
i. ■ : ha puj nil] !»• loiin.i " pointing" in atrvtnJ p

8urghal TnahntnL
rrflimiDArT The paclatil ibonM alwayi !-■ ajtaaalhctixod

licfcire utteniptilltf 1" ■ ■ix-n u In ,u :i nianiinary .il>- > ■-, BalllM

llie binder may lie removed (HHf ur twine daily lu jx-rtnit i»f
mCUtOffC Of (IN UM Of tilt brttld piaup, Tim ltna-,1* may llit*n

Ik covered with gly<writ4 of belbulonnN nnd the binder or

b&od&g* reapplied 1 -iinllv under flu- in ;iiti|i ill tin- breasts
tieeoine iuaehve in In** fluiri a WW >.

To vml lactation when the woman Ana 6*mi narvutg Ebi
point' t inif -, firm comprwwon of the Up .-;- I>\ meoiuj of tin
Y-l>iinl«'i- oombiocd with toe u*e> of aaKnee will be rofficienl

The milk usually 0OWI BWiJ 1 ratify under cln ii»iupn**Mt»n

bj ptcd bj the y-biodcr, km there in do dispc rtioD of the
bronata to U'kiiih' I'D^urger] boo ccucoOi

Mn— -i-_'*' iiml the me of the pump thou Id ho omitted an

Ion.; " the mill; H..u- iiwuv freely In ;\ tew - !■■>-- thr broiuU
will cease flowing, when a Murphy binder nioy fcc applied and

worn till tin braurta become *oft,

After prolonged tadaiion then' u but little difficulty in

tlmwiun iiwiiv ill*- milk when the ehihl U weaned gradually.
Should POCreUou noraist it innjr be ncccwary to employ com*
praMioa and to nive Atropine internally.

DJTERCUBRENT DISEASES IN THE FUEBPEEIUM.

MisceUaueous Diseases.

Scarlet fever : This Uu ran- eomplieniion of the puerpt-rium,
It nliM'.'-l always npjieart within three dnva of wbori 1I1 1 '
root oomplleauons are slight, die rush appear* quickly, Efl

pitllv ditt'iated, aru I i" u-ually of an intense dark-red QOlOTi
'oiivalewenee 1- u-nallv trdinu*. ( )» r.i-imiallv tlir perrtc

ormwi an- profoundly nffeuttd by ibis duernKvuN when tail

in tlu< tiwe tlic pfOgUOBUi i* very jjrave

When ilif attack iemfraoKOM awl tin nuioiui in

much involved the pTOffnom i- not unfavorable, LhoUgfl llie

comlitian i* a grave one

Mt-HxloM : The pucrperium i« rarely complicated by thjadia-
CHB nnleaj the Btteoll has occurred during progrronev aixl DM
led to pr>."iieihii. DEpobioo of the ovum, flit condition pre-
di-.piw' in he rrhagc and nlso to pneumonin.

variola: Toil i* a very grave complication of the puer-
peruun.

\n\r,:i,i.A.\f:ors />/*//.tSB&

Rotheln : ThU iW:i*c doc* not Uorkedrv gflbfil il

■i. 1m tWO or llic-c CMH which htVfl COfne umler my
imfiiv flir >li - vclN null) in «-h:u:iriiT. lUOQgh in 006

U,.- r.i-li u.i- n n m:trk<M.

Erytlpelm: Thi* <li.-r:i-<- u-unlly :ifli.-i. tht< : rnif:il. whtt

:r- during llif pu<T|x'r»l [KTiocl, It i- PCldoO) !IHIU-

tt>tnl I iv ;j ciiciiirou- i-ni|»i :nti. Wlirn I he nuiitan "iilv

»n> nlfci-tnl tin* prwnorffl '■■ very VTSVl , :mtl it i- iinp<M»il)h<

l.i Ji-liii^iu'h IM DIM (rotti CSM of tmlinary •Irvptixvuiii*
(ion
Eryth«m*ton» rashes : IV-rjienil erythema H DOl U infre-

.jii. in loixlition.

In mpte r.itu* tben is ipl lobe » iiiod«*rai»- elcvettoa «»f
BHDpemtare, rod the lorhin may Ikhviik* ofltaero Then

nmyU KMM nterim* nr prlvi.' N'M.lrrn- - The KKlditioD il
therefore looked upon uh u mild BBpCia HlftctioP,

Iodoform when freely uhO nboul the gCD&aJN niiiv -.! up
KB WU'iintVf vryttiviuu ni-li . ill iht OR the temperature

nn<l pubs remain imeflbetcd mlCM the dtb (rrtteltoo caam
flu- pnlienl much • 1 * — i h

Ki v[!kiii:i ii iiiy Ih' nii-(: ( krli (f>f -riii'l- ' i- \ ■ i ;nnl il i- mil

1 1 1 1 1 • 4|n« -ii 1 1 \ amoi'istnl with pr*v« Mptknraitt.

Diphtheria : Thtfl diMBM may affivl the throaf or (hi (nmitaie,
in I hi.* hitter <:ih :i variety of jjenenil « |>-i« i*iihiu -

PriBtimoiiia: Thix duwoM? poovtitutfn ii very gruvi eomplioa*
linn ..i' :li. tmerperiuoi. It noJ rnfreaueotlj owuri wremlnrv
to septic infection. Itc kentmerri will 1»« iKbdubuI i*> t !«*■

section on puerperal inllvtion.

Rheumatism; arthritis: The diagnosis between Septic ■rthri-
i e ueute rhctimntism i* u matter of u'"" 11 ' "liMirulty
(lin.ii._- iii<> pocrpofiont Simple rheamutr>ni ii-ml- '<•
serem! Joint*, while the rtrthriit* ti «optie in origin nn<l lunmJIy

only l. M 'o joint in aflbefad. In the latter ease there may

be liltie evidence of general icptfc Enfectioni Simple rbeuruiv

It) mils it- ui.liliiin i ■' :ili.| <l"»' I"'' filYivt. the

P U eiperiuril, nor i- it :ihVelr.] iiivatlv liy if.

Tin- treatment al nealc rheunuiinn U the mnten* erben i'
Docunei sin cxhei rime. In »/;'»■■ arthrHU rcoovexyli tli<-
rule, bal vrtch -.\ peaty damaged joint. Loool tratneol ""ly

xtvhv, ".'M<r.i! im-ilif-.itiuii lxin\: >»S \\V\\v

/ 177/.//..*, j f„ 1,1 firEI1.iL PEI

Malaria.

Tli«' |miit|h<ri1 i-!: generally utlmiilril, prvdmjKnM to

m»lari:il rUiu I.- Wnmni who an -uhjci in mnlaria njonlli

iiianiii'-i iin' diBMN after deliver/, probably u a n mi of ih*
trauzottlam of lebor a

'I'll-' malarial attack il iwnally of 3 mild ty|»e, bill 0001
nlly il "my U< ovtivrimlv K!V«i Th li . i< ulii.lt inually
manHeeoj itself about the third dley nftei delivery, pr >lepo»«
to iiuci'imtuI hemorrhage; it nl*" niodifie* milk accretion, c*pe-

i'mIIv rlii ring: th" ev/hfrlmti.-in >.t" frVAT. Ir \% nol generally

admitted that the genu of di^;i»ooan lie tmumittta in lb*
milk to id. nnniDg infant.

Diagnosis: Mulium ooaurrlog darine, the paerperium rnnat
bedfnVenUntcd from septic mtectlon or typhoid fever, The

rliiigii<"-i- i- >i<':i-utii:illy :\ nciii'-i of' .'ini'idcmblo aimcultf

Tin frver ill imihin.'i Ifl tniim-iilly QORl iliuoto ill lii-l. I.iif lOfltl

beooDx - r.'iniii'iii in type.

In douhtftil eoeei die Woo*/ aftou/b! 6* AAimfoeo! fVn* m.ilirinl
orgnnuma, anil Wiilul'- t< -■ ii-i- iv|ili-.M r.:i.'ti.<n should be
applied. A bnctermtogieoj examination of the uterine lochia
should alx» be nunV', fi.r it ie quite possible thnl maleriaj poi
onlug 1 1 in v be nswciutnl wirh septic in foot ion in Brum- im*<->
Willi ili«">- h-j-t- hi "ii''- disposal are should not remain In

iluulil n* to tlu; origin of the ftVtr in nny given i

Treatment: U.-iiiilJy ii it ncceeeory to give lar^c dose*
of c|uiiiiiu- to '(Hitrol the fv\i-i 'luring the puorperiam.
Wli.'ii (In- almlv iliiw nf ijiiininr \~ jti uitiiiib «»r nmli-i i i.
Hi'Mnm neoaaaery to remove tlio child from the brawl but
wli.'ii ilit- »!<."• i iwivolnl i ho infiwit if likely to soft] from

ih.- efleott.

Puerperal Anosmia,

After delivery the M I liegin i f" undergo » change in i on

atltarioti by which ir i« converted from the bydncmie of ptea>

iiiiii.v to tin: noniifi! ]irn]i<irii'<ii ..f Ii- coiiftitucnl porta in the
lK)ii-^i'uvi.l .'.-iii.JJlii.n.

Thh change i* usually completed by the end of the second
weak of i In- puerperal period
Many causes umy Interfere with thin process of involution

ni I'H ' I . |A] OTIC, LVS

:;:■:;»

of tin- hiatal, -iicli :i- «|i-i- r\n> !iIuinI-Ic»* h1 lii*' bUH Of
lab0T| Of :m> WOWtlng '•!* dftpnivinjC if EmUM'- hi -ni'li nine*
llie Kici-iiii.t i- nd- (d :iK-iifii(< ;i |» ruinonfl farm if ti..iitm'iit ih
n e g lecte d

Cureful blood exAtninuUotm «h.,nlil I"' mwk from i'ii. to

En the*cc««e« iii order bo jadgi --r tin i flw'l of tmttoeat

The treatment -i-t- ID tli< .uliiiiiii-ir.iiion of '"■>'•■ -Inig*

rod -Me i'ii fading. Iran sad aiaanioj la the fbnn of t i »• -

pound Blnid pill, u-inllv give eati-nVt.Tv n^uli-, In wine
cox* in which, iron i* not well borne urv.uk' ;ilone will •ucccul.

Htimorrliold*.

Qrcnl ili-.''.inlin-i i- t' I'i'iini lv ■•anwd by mi iiilnoli t»f hrm-
nfrluiiil- during thfl Berlin day <•(' :ln- pm-ruorul ucriul.

Treatment: i'lin bowoUtbould be freely opened, mid unreal
rvli<T may bfl obtained by tlM ApplkatiOU 0* 1 1* *t oumpwsa*:*
wrung niil of Iml Ie:i(l-;in(|-o|iiiini ■ohitinn I 1 : I"). fa 0OCM

tin i|>pl i i mi ..f iob is mom oomfortiuK ,o we patient
.\u ointment oompond of equal |«Art* of nag. pubs euro opu>]
ung. rtnunoa and nng, liellud. will further relieve ptio.

Diseases of the Uriuary Organs.

R«t*nlion of nnne I'aii.nt- not mfmpi' mlv ">mplatn of

rnabilifj ?•» urlueto after ddivcrj Tin- ooodiuoa taty be tlie
nmH of injury to thi urethra or As anterior vaginal will
during labor. .M.ntv women are unable rapty im Madder

wliil.- lying in bed. In Ototfl l !»*• How of tbi UITM 0V*f

• nmH uMiriom of Mie vulva nti up Irritation, which fliey

to avoid by holding the urine u long ■ uoorible. The

relaxed 1'iinlitiitii .it tin- alxhmmiul wall- untl iln< miwyirnt

diminution ol [ntra^e^bdomtnal preMare to stent rotor*

fere with tin 1 Amotion of micturition during thai periadi

Treatment: Thr iiurw -Imntd !*■ in-tnii't'-d r.. •e*- 1 lint the
[■iimmi I'ltiptu ■ in bladder ;ii lout twice d.-iilv. For All ptir-
pow% il'iiiialil.- i-i |.a- v.-ii. r iithri-M i-i-. the patient RMT .mnmc
ft kiMvliu^ |><i-(uf< ,or nmv Ih' nueed i-.iivflillv v , m (n be :tl l<
I" -it mi the bed-niD, Hot nppli'iit inn ■ riuiv pruvr of n>

■n<- . :il-» tii«- -timnliw aauaed ha me lonndofrun

PATBOL0Q1 <<r mi n rur* >■ i; \i. PERIOD.

watvr. if tenMiM Ml, the nana ibooM bi hMrncJnd (<

dot tbf '"iiiiiii-r into die bladder, and toobesrvatfei
antiseptic precautions In no nofofc

Incontinence of urine; This condition miiy ruuill IVoiii m • r~

distention ')'' tin' Mniliter from retention of mine Thi.« i* iho

ciiiiiiiioikM tinihf Ollur eim-os ufllii' rouilitioti an |>ii'
tin* ppliimiiT mii^lt* ii nH vesicovaginal or v. HCCMtt«riu« li-iul:i,
A ninfuf f.nimifilion will r. v il ili< .-.in Til million.

Thcnrowani mini vwy with the onuw of llie iiicunthiHK*.
Cystitis; This is unroitouirtely a common IVHipliuBtiOH of

ti\c puerperal Btoie. It la uauilfy due idtlur n» injury from

ovcivlUu-iilir.ii nf iIip Madder or lo aarelcaa i tth«t< rii ttioii

s>/„tf>'->n)i; l'r"|iHiu micturition, a»ooiatcd with burning

and tenesmus is the mt»i (Him I ivniMoni ; ihc ninpcrutara

mnv riaeto Ui2"-iii:; B*., nud the pniw3 become mpid. Tha
hi tin- i- ti^nully found to eoninin niuous inul put in varying
qnaatftiea.

Twitm- nt ; Prompt Mini .'ii.iMflic ln>:i!meiil i- n-mlly <li-

rnanded to prevent ih** infection pprvadlna; '<> the meter* and

kulneys, 'I'll*- tdadder should lw irrigated daily with :i w.iim

solution of boric awl fjrr av— .\ji. The dwl ufcoold vonei I ■•:

milU only, iitnl the following mixture -Imulil In* ortk'nil ;

ty. Sod. bibor.j

Ac. benaoic.,
Inf. buchu,
Sip. A nibknpooitfti]

timm daily.

in n

ftfi $m :
Jvj.-M.
wineglaecful of water three

If the condition p'T-i-if nlW imputing With borio -mUition,
tlif bladder should !»' distended with n solution uf «ilvcr nitrate
(gr. n*-.\jt. nil ttf whifli -JimiM be allowed to dmin nwnv with
the exception of about nn ounce, which mnv be left in the

Madder

Pyelonephritis: This condition mnv follow an infection of
the bladder by extension t.f the disease along the nn ■'- 1 ■■, wr it
mnv reanli from a grnenil tcptio in&ctfon.

hiiti/Hi**!* can usiinlly I"- nmdr. hv nn OXnmhudoB fif the

urine

Vrtvttitf-iit : .Stimulation, *up|M»rl. 1 1>« - :»lniiin-l|-.i! tnn of

AfSl U8S OF PHS KfiAl 01 S 81 ■'/- II &'*7

bland *1 i m ■ • i ■ . :i i ■■ ! da! in on of ihr bladder oonfltUuta

ihu irvuimrtii «>f ilit- tondlttoD.

Hematuria. Bloody urm. i- jornetfrnai ■■'" .i!i>i labor, and

m:iv follow awera unntoaion of the tilmldrr either by the rjiUd'o

if the larcena. Nni fafrequently tlir condition w due t"

tin peraiiitenee i*r vesical hemorrhoid* which di w loped during

ancy, I -u:ill\ Ihe blood dleanpeBia fn.in (lie nrfui in i
|. w day* willi'Hil in uti !

Diseases of tho Nervous System.
Noarltla And Myelltbt.
Win Mowing labor i» <!«• vHuCr (0 I") MTVt injury

thi r. -uli of pnaaairc by i In- rhild's head or by fntoep*] or to

{l>\ iktw ili-i:i- Ihi' I- -nil .it' *'[»!:. ■ iiil'.«-lin|i.

Nvuriti* dim U> injury: "I'Jk- injury to lli*« lutllboMGJlI

plcrnj may bi -•- »Hgni im i- produce nothing Iwl ;» partial

lo*» of powet BaaoctBtod wild hot «ligbt pnin Of t"ml« rii-v-- on
BJOVermnl, wbidi «ulwrii* without «jnviiil n> mumi i . vw

In more revere onao Ihi pnin may l»' iutiiw mid « -

tlanl, while panlyals and tlfophy of the affected ruuaclosmBy

Pol low, being aaaooieted vviili iiiiu-i!i<.-.-iii. I 'ream re on the

moral ptaciu by naana of the fin^*r introduced into the rootna

i ■!-!■ to LntcRM pata.

Ncuritw due to septic infection may i^-umc nIut<M imy

ivp. being multiple, diffused, or tainted, while eftnci d

tMor) nerves tuay bo affected. OocasJonallj la tb!« form

tbl ii:r.li:in |»r Ulnar in-rvf |ii:iv l»- :i01'I''(I.

Mynlitii i poo rally the ramll of aeptfc Infection, though
Bim mention* having owl with R raaewlitVh |>nivn1 f:itul, iiml

in wliirli DO HfptN PoOlM Off RpOpiVJEy COQ*U lw diwivrrrd el tlie

poat-morti n
Treatment: in the eoati etage fixation tod extension "f tli**

part affected will ghre the relief. Alternate bol mid

cold application*, and the ndminiatrntion of pbevaoatio
nccevory, opium, will ■COUTC turtle r n-ll.-f fi.tin pin, M'hi n

tli ■■ i:r.'> Im' iii.j.|i.| ih'i-.'i-."-. electricity, end |>i--k.- iimvi ■-

combined with the uannniatratl n |»"t. lod. iut t-xv

i. i. i), will boatful the ra torallon of the port to Danfaw
:s— oi»t.

338 VATWtiswr ■«/'• mi: ri rt:ri-:n.\i rmioif

Cerebral Hemorrhage iuut EmbuUxin.

\ n mi (In- eouditiou nC whoae Arierit* |>i «■■ I j -[«»--•- bar to

cerebral heinorrh&ire i- uiUttb niorv Itlu'lv by I" Iriukea with
tbo accident during labor than ;»i uny iiUht limy. Hemiplegia
is no) infrequently round to follon an iiUaok of aahunuafia
Cerebral embolism wln-n il fa Dol wtthiu the potrperium

generally follow) on endocarditis or plilebUu of wpcio orfgbx

Puerperal luaanity.

Occurrence: Mental uenuigoracnl tuoniHwhi Itself 10 ■ <n in- «■ -
lion witn nhildbonring moat freqiHtntly during Uim uunrprnil
porSodj rawly daring latrtataon, ami bin axcopiioBally during
preKnoiMrj

LW 1 rin puvrpCnil in-anilv \n li< -iv ti*. -I u . ill |j ■.•u:,:< rhe.i>o-

otirrtooaof mantel deruug ratnl il nny |Sna between lh« btitb
of tho child iiml tin- termination of lactation. Tiic condition

is iiiixt likely to ocelli h nneotioa "ii'i tfic 6

tlimi^h in :i -rniill number of caaea mental dcnuigcnKnl nurj
tir*t morrffofl i'M-lf wiih the aooond or third porhnritton.
Etlolocy: fairiitpdting eammt In manv qmm iIhtt t*

(ilV-i'lif :i li--iv.lil.il;- • ii-po-i lull [n ri-:M:il 1 1 r :t : . - - :i,"iil. A

woman with an unstablo nervou* iyflt«m l« manifatly nnaojted
to bon thanarvoutJ btntfoi Enoidanl u> pregnancy, pirturiliooj
hi lactadon. Charon pnilensy, ami liv-ii'iia previoovlv ei
im/ pwllapoao io the aaveinitment i.r in-.Miiiv in oopoo rt ioo
with tin' puerperal period, (leoholiani and tor Darcot* Imhit

-lioillil !><• nivnlioti-'d ;i- |»vdi«|«"dii;.' ..in-.-.

I '■ ■ 'i/hiif .'.(!/■. Bdiirl;»l ;iiifeni'ii. -"p- mninuria.

unpain, great pbyMcal or mental cxlinution, and profound
emotion novo been cited m wiling cause* of 1 1ris condition,

1/ ,'<'! i;».r»*'i/ in I1CC< Inn W itli domCAtie \\«<n I- nun,

unii illegitimate pregnane) 1 map be mentioned as tin ejecting

i in ■.

Forme: Two forms <»f inaaiiU) Itnarllv met uiili, tbo

imtninrtii nini ihu nwtaiichatie : the former occurs mnoh mora
frequently during lh< pucrpcrit] period; while il»' laffsf I

■ ■ • i j ■ ■ i . » 1 1 ■- ii? iii'utrrd with lactation i
Puerperal insanity— iymptom*: In l»>ili forma arooV

i.\/:.s "I till-. Shiiitns Msrn/

.:.;;)

tffmv i oma anally awmlfaM rham i Tto m h labUltr

.. d'-ir--. <»ii:pIalnH "! ptlt) :iiiii- -s i:i« - . .:l:<l ;«!:oil> . ji"

dtptt-sion, alicrntflDg with couditloni of Dervom taoffan. A

COInIUmMI OJ MIKYoJ ill-ln-.illli I- iMUAlll ii!:iiiili •(.<! Iiv [o ■ Of
iijijHlitr, iiKlip--linii, I'nti-lijBiliiKi, :inil lliilultin-r. Tlii' jmlnni
i- ti-ii;illy jm1< lh> puta i- irril;ili|»* and "jiii* 1. , ;iimI *!tfi m

in inn -I in .mill. -ii outbreaks of iwirfutiHMi.

Till COUfliUca ttlM\ il. .|»n nijinllv, Hl)(l liver tli'Vi lit|t, :in.|
•I. In -i-.il- ;ui.l li:iilii. -minion- bwiW m:inili-1 lit. huigUagl
ImKOUHX nli-.-»'iir. ami lhi|iH'ti|ly imtir iN:iti;li'*tJil inn- ln.-..rin

i\i.i. nf. Tlii- |.ni> ,i betomoi unoontrolhililfv and lb viulaoi

in bar MtioOl ; MM iiimv Bt1«mpl i" «!' -!"■' h*I inf'Uit in* jiII.m'U

bet ■MamUnti
in die mWnnaAoK . tl .■'■Hi beccanaj noroaCi do-

prva*<1, iii*l Iisilr<*; cwllHrioni pel CCUti rf frcqaaot

Site itivii'-i-. Iti-i liirhiMi'l '"t' inlhli'liii . ••! mI i\ni

■•-ii .• c inx ■ s; lic bean robot toUIna bar to kill ba -ii.
which -In- ma) attempt in Uct niiltw- cuicavly watched.
In t-.ini .:i-. - tin prodronutl vmploifMi oiay !«• *<• */»//*' hk

. .i|*> i-li<u<rv.itiuii ; ur tin 1 r >u<i||ion m.iv DC nyjinlni U

nnp t»f onlinnrv rwuraatbtnio, whan nddanly the patient mat
attack am! deatroy her infonl a attendant, oc m.-ty acomiplwli

tic.

Wljcn •> woman during tba puerperal period maniftal
ctaaivc Irritability ot iinnaunl loqu icily of ' "ininiiiv. aanrintcd
with >lr« |.i.- -ii' ih>i ccinatipation. n cloat watch Rhoitld Em
kapton ill bar. udooa, and whe -dwnldea lione^-nnt baleA
niih bar Infant.

XHacnaaiii: T'-umIIv thin can In- made without difficulty.

rin- iliIiriiiTii <>)' Mismiii moat DC iti:-imi;ui'li"l It that OX

t vor mill thai nt iMflrlnm tnmaiv

Prornoaia: Aboin iwiH htnU of all eaaai recover theft ivaton
in trott fwo in -ix montlax Of In* other Intra, mi pal cant

■ I. .1 - i ion .ml tin- bafanca rtmafn penm-

nciitlj In i

Mania in 1'^- likrly tonauh i'i permanam iu^miiv iJran id
malancholiB . but it may l"' and tnat ifa nailfntSi lift ik in

i 1'r.tin initnin than from uivJanciliolia. Tlw
tn |i:uniii. tho mow rapid tlu unlw, nud the mow |-tor»i ■•
iiou of tciii|» rmnra. (ftn mor gravi aUifimjgi

3K> r.tTfiorsx.r ny rnr. prKRPKP.il P£&?>

'hen eelampaia bean a caiual relation to the cuarittioti ibr
it dWtiudlr more CironUt, for thaw f*iirat» r. -
i much quicker lhaii in any other variety.

Bnuftwwd e/ V'ifrymxt /n*a*iV».

• i |c-«>iltlr. patSaOtl -iilTirin^' fniiii lh*> aflfirlion ah'AiM
I •• rCfDOVed to «pncUl initUtulionji (or In > ittc CBU I

tiii- i- done tli-- lietter When Ibw '• ii

ihouM In* Unlated with two or three attendants r.

i tagen u- her Bhe ihoaU never be lefi for one mini
linii . the iriodov/i ahoald b*- vccurely Irak-di*), and all un-
ary furniture removed from the t'xxa.
When in aunlA it b niWMLty to k«vp the paU-nl in beat
tliU nmy l«c done fan covering her with :i »trori(c tlnn
at the nidc* ami fool of chc bed; other* »
nMmini ahould never I -<• i uiploj ■ <!. bul n Hufficienl numb* r o
ittandantl -lictulil alwaya lw mi liMiitl i<> control ihv nai

l' ihj- Im- nrimaang

Tii.- tro xi othorwiM ■' 1*1 '»•' large!) »ymptao»*tic.

\"uii'iii"ii liould lii- promoted by every menus pcaaiblcj but
"IhiImh ihouM Ih- ivtiiilfd.

Ii i alwovi mil to begin byaecuring a fre«- ■' Uio

bowtli. Tin* nmy Im ;ir. m|,i|)Ij*.|im] hi ih< ad mini* ration of
:i mercurial ffftll ft «lb»n|m:iit MililK-. I'll-- iv^-nlrn
tratlOl) ill" ill|.*-lin:il :tlill-'pl!>- ; ■ 1 1 - ■_■ l.il ■- <T --! Hl.'ll ur

ravphthaliu (gr. v i. i. aX i- eni mine.

AU«p mnv Im: nmmolMl by i;nim: iiiirnhlfthydc.
nigbl Instead of this, lalfoiial or Irional In 20 grata
mat l« . mployed

Hydrotherapy in of advantage both ■** controlling the

peretuR and in wearing Bleep,

The di«t ahoald consul of milh in generous ijuantitiea m

in i Inter, ■■ arid meal may be added n- digi*ti«u impr.-v.-.

siiiMiiliiiit# «houlil bo employed when ii^craem Unit ex-
tmol am valuable adjuvant* to the 'lift.

Forced fecdlnf by mean* of the rrwopluigcal ml* may
required In rare Initancw, and ii mny U- ivjihwvd :ii n,u-

by litllrirjil QlHUnatfl.

Iron and anionic f>lmuld Ixi'.m'ii ir^uliirh in lull

si I't't . /•/ 1/7/ M nil ri KIU'EHll V,

U\

10011 OB tin mikIiIidii ol" llir iii_"-h\'- lrjii-1 |HTlnil> ol tlnir

I • . ■ j . I - - v ;„. Ill

\ <n .i |H»-^.iliIr tin p:ni< ill -lionlil In- krpl puUHteutlv in

ilio open »ir during il»' dpytinwi ;i"*l oxoruiw uori of JhIii^iki
ihoitld I-' looour igcd.

I'll- (ii. r tint pelvic condition* liavi* DIM l> fa) llo "iili tin-
ili ,.| »|.filCDl of tllll COmKdl D rvndiTW it IHIIMOWIV t olul I

cartful examination of tin rtato of tin •• organs in oil mw*.

All abnormal n>ihli(i<.ji& «lionI<l Im.> . in- nvu.il ;i- i*ir u- |k>ma!I.>]o.

In in - i m npenulee tra mi bai bean fallowed by bril*

liiini rnunta; but toacoumjilUli iliis, mkIi pivwluiv nhuuld Ik*
itad early In the liistoi v «»i tin- m--.

Sudden Death in the Pucrpehum.
I hi ma»l common causoi of sudden ilmtli in the puerperal

•iaueat. ami httirt-fwlnrc.

Pulmonary Embolism and ThrombosU.

Etmiojty : Some authorities I'liiim thai primary tod fpoota-
Beoai coagnlatmn of blood may toko plana la il»c palmonoCT

iTtej v.
The mail ■ |U---1 view U tlmt pultnnnm-v cm-

K3llMH Ull ffnlil thv M|»ui:Uii»li til :i p.il'lioii ul :i ilitiillllillN

which hoa formal in ■ peripheral eoin. rhrottbeafa) moat

commonly take* place either iii ao [Mae, femoral, or uterine

Villi.

Symptomi and diaonoida: Thi« aividmi may OOQQT Ol anv

lime durlog the earlier waakc of tlia puerperal purled The
r^mptomi n-iiiilly iU'vclo|i with gr<oi »wfW'ii«'M, and tlicTr

• On 'I' |" nil- nn lira sum of iIm- < miIh>Iii«. Wln-n ilic "It

Amotion of the pulmonary artery b txMiipIetOj death maybe
practically mstanttneoaaj or ii nay be preceded by precordial
Djppi rfon real dynpnrea, end eyanoaia [ftunlly too pa ■ i

nii'i- :i "liiirp -TV ; tin.' iv«pir:ittOOI beOOlOO ihauOWj aoaptQgi

mill irrauulor, ma in ■ few aeeoudo eeaai altogether; In com

hi which iho cml>olua i mall 1 1 * id oi lymptQffia \* nut

-m» Qddcn bm Uicj ire aimilur, though not so severe. Death

-I PATHOLOGY OF TUh fft:i;!'FS:M. MM

nm) • mil inki* |»l:ni' fur xuvftral <l»v>. ami \>-\) r:n»|.
Bail rallOW. lln' *\ ■iiipl'iiii- 1 1 - 1 1 :t 1 1 v follow -'Mi'' -
ilimtiiiriil, )-n<'li ;t- -HliiiL* up. Uuglliliu;, -ti.tintn^ :i! atOOl

Tin- following niav In .;i..i :.. an Uluatrative cue: tin
lit, :i niulii|iiir.i, Ici'l iiuuli ;i perfect •■om\-:i|« - 00 '

uneventful tabor, when on the morning of tin- thirteenth <lny,
ail being "iniv moved <•• ;> eofa placed ntoiwnbN of Mf
bed, -i., luduontv gnve a -■>■]■. B lib ■• nthoplllowi end fin
n moment I"-' son* imienenv. I '■..IX -i- rapidly developed)

: in i r |iir:ui-iii, became Itiboml IIMJ I DMfld ElUMN " : In mil*

Xhi |>mIm.' ik flrri wii rni»iil and ptrooa bul ijuieMj

U'l-iiriK- lliixn«lv. mi' i .■■! -.-I horih iiftei the luilm DOf n .
tion.

\i (h. atuiopn than wan found la certain oi the Inrprr
veina in DoaDecnou with the uterovaginal plexua large, well*
formed thrombi; ■ tbraaboa wai baud i" extend into the
rlgbi Internal lilac vein, irhena h ended abruptly «i<li ■ una
i-itiit! :iml apparently broken-o(T wnd. Ituili t-iylii and Ufl

jHilnniiuirv iiili-tir- wrrr liiuiul jilinolnli'lv m-clmlul IVlUl litni

redotol at their van origin, NTething abnormal wai Rmnd
eleewherc in the bony.

Treatment: I'nmllv death tnkw place before iinv rn-atmwil
can bo iimntfiiniietl. In nil • i- In which there ie evidence of
venous thrombonla pro/urn/i-' wmI ••'•mfihtr fwe* nhoukl '■ en>

joined From in cxaniinati rt? the n rdi of four of tbeac

caeca which came undei the r tllon of the writer. En n •

of which there exlatedanj evidence of ibixrnibnrifl beJbre tlio
on*c( of the fmal aymptome, the only abnormal condition i

i i tO all wii- a -otniwliitt iiirrwiM.il |hiIk-hiI"-. Ill nil Ibof

e 1 1 r - pol as -r:ii<' ti never recorded as bcim; i..|..h .mi. ti,
death took plant In each between thotentfa ind the Rftcenth
dai of the ptterpenl period. In view of ilii- fad die mum

i- in the habit "' keeping all --i.-'* Iiavnijr an untbualh

1iul-< -ntt ,-t- quiet :ik poattlble for el leoal (bur week* ani i
firth of the child, or until the puLr-nitr Ultimo normal
In muWoeuMV in winch imiimirii in iHwibie the Indication*
are to keep op ( 1>< bodiMeMinerBinre by tin appli.-.ihnn or

heal externally, to -ti late il'" cardiac and wplratorj n

bribe Ddmlmntratton of appropriate rrrnrdlen, and to «cciw
the nii'-i .J' ill-' |>livii;il mill nii'iiinl iv. i for the patient.

nrrjs m use ran pukrpkrwx, ttq

Eotranoo of Air into iho Utvruio 8lnunc».

I'Im i a vor) rare accident. Air ma} Bud

AStl til" 'In* lll« ■ :i flic OMlfM "I Itillti-ill'l-iiu-

manipulation*, mdi m: t In- Introduction uf tba liiiiul, 1 In: giving
of an jii!i.i-wi< 1 me «linn-ln\ "i bjf naniMtlon following I ebanga
In noattMV ( >i the patient

Symptoms : TltOM) :n« |»i-:u-tic:ill\ \Ur <hui ;i- in pulmonary

i'IiiIhiI 1.1

Troatmaut . Tnttoouttfaui in i lie hypodenuic (ulniinuftr 1
Mini. mi- iikI the ' ni|iUi\ ■mi-ill of artificial respiration.
Inhalation of oxygvn eai inonhr (■» inHnCt- flic lung? awl 10

• \\- I M ftfl BID tll| laa Urn BOggCBted.

Fever during the Puerperium due to Other than Septic

Causes.

Elevation of t*mpemture mnv occur in the course of the
|.ii. i|* r.il pciim] ignite [odepCMCnlll Of ■ }'f» it'/i'-ti",,, fi..m

-M'li cause* 1 1 \|"-iiit in cold, eoMnpotlaiij emotion, or reft 1

Irrirtl of :iny kiliil.

motional favor: Profound p»ychicAl Impn mi m , men if
l*, inovr, fmr, or *v*n raunrnVf |oy, may bsv* nan to * mi

■tiotl Of !■ iii|k v;i!im\ «-|>.riivlK' tthwi i \ j>< it- r.<«! (Ilil'illR

the curly |>nu|>ermm, Tb« lUfchanuou of Mils • n-vntiuii "f
bempenian i* noi wttcvutibni of explanation ui flu- nnMUl

.. i.ni' kit«»w N'l^i
III RMIt«rDitV hospital- pnintimiiil t'p\. r i' l'iM|inntU rim wiili

in awes of ittfffitimafs peegntmay ■boat the (with day of the
DUtrperiam, an .1 rennli of anxiety on the pari of men 1 it* till
unsnl tothah ability to provide for acnnetvoi and their
-iiiKImm m the immodMte mtnre. In eootional firvai (hi
hvnpmfnra nurj riaa to m» 1 " lOfl°F.i htrt tha came bail •
uaualrj 1 ni«iii tho temperature quScith fa\U ho noroiftl.

Expo«uro to eold: Eleval 1 Icmporntnre may follon

expomin of ihi broaitioi abdomen to cold; loo Iowa ttnv

ni:n in llx kiin/.-m POom 0? ;n DulcfoM 04 <l cJoI him* BOB)
rxpow tin- psitifiil !•■ :i Hull, wlih-h i- n.milK followed b] aNDC
lion of ifmj-itiliii.

I'll, idmin'wtnitimi ofaimie warm drink nml theappHea

: roal heal UMiallY i-.ui-e the li-MT to <li*:i|i|H:u prompt!?.

ill VATItnUUiY "i nn- I i Km: it

Constipation: TWa K u ii»i infmpatfnl rauv ol i "»••'

temfnmuro during the earlier pari ..r rJ»#- poerperium. Th-

fever w prolwiUy dua i" the irritati

Tin* ml in i nisi rut lull ttf U '!<■■.■ of OMtOf oU Will profcoMy

i cull in b drop of the tfiii|M-ininit' to normal h won n»

ilir Ikjw«I- Iii • <- l> ■ •-■ t <■■ iioimtcd.

Fever from reflex irriUtlon : Thaeftol 4 POftilWtion whtn

it i*v\tr* in I he |Hiei(K'iiuin i iu example of reflex irritali I

sii-' utirvo©8«yBt«m producing fevci winch at other limn n

tlliVD :i U IUOU i«:--ull.

Imtulinu from i-tiijiii-i/rmmt p/ //«' hnu*t* In.,' I -»illt*

in elevation of temperature, m m been mentioned • Ucwhcre-.

Several tiinei we bevc ni-'t wlib ctttM «>r fevcf in hU I

.•;iu«' oould be found i«) us plain the condition until ttgtncnu
of :i tapeworm orn round worrn appeared lu die utoola ! al-
lowing 'In' administration of appropriate rommlivi Inn wartm
worn expelled and the temperature promptly returned in
uorninl,

Tympanites : Tvrnp;inin-», 01 overt) i«ionti on of ilir iiux
wiih \*x%, i* not infrvi|Ut:ntly m.-t with in thr earlier pari oflrM
1'iir rpcra! jwriod. Tnboon<litii>n 11.1; i hum not tie attended

Willi l.-vi-r. Winn till" CHiililiuii 1- :i>-'K-i:m-f| with rh-v;ilioti
of tin: i< iii|H-nitiiif '.nv nm-t lie tuken to iluttiogU*U it frcim

perftonltia.

/' ituuiit ; Turpentine anftinata iii diorl intcrvali^
liinril with tlir Internal edtniuUtration <■!' muall doea ofeal

nn I, ilMlully relieve (In MtMOL

I ' -mill \ it 1- DfOVHU? lo -t:iii tli«> trentim-lil with all •■nnna

of h. ■[ unep-wolor and turpentine ( ( >ij to oj|. Then caloi ici

,'„ ) should I" 1 '-'iv.-ii every Iiuur. \i the end t.f <i\ boun

1 dons of Bpaom m\ *",--. in twoouuoeaof hot water) nay be

Kivcn ; and it' tin- ti no! eftVtu;il ii; in hour an enema
tainlng fjywin \r,j), turjientiuc i.-m. E| i •oil
water (Siij'i ihnuld lie u'v- a

The niloiiiel should I*- kepi up foi two imya, fend then
1 ■ duced to two or three daws diilv V* 1 liene com* ere dua b 1

paralrnis of the muscular if- "t the intevtlne, a hypodi rrafa

f ttrychnine (gr. ^ a ) ehould Ik- given ever) four or eta boun
until die condition improve*

HPBHAI. SF.PTlf 1SFF.CT10S

m

Puerperal Septic Infection,
Tin- ^cii' i puerperal septic infection U Iwf oapJoYOu

to dta'tKiMK 'In* Kumv ind i irkd Jumatd coudii ■ ultinjr.

DfoctlOO of till fou*h> g«llitsl bMl duriug IiWjikI tli-

,,ih||~ num. I.V TliirH.H^.m: ni

rrwuency : PraviOUl i" iIm- mtfoJttc£on flf tire annWptio
iIi.h| ,,f .■..ndiioting tabor t ho mortality-rate from wptic
lection varied Ut"i<x>ii 10 ud 1"> percent, in ike targe
at) iii-niutn.ni. Ai tUc malt of the application of
rigid auti-- .i- )-i- i." baophal |>rn- 1 mortality

li Bfptfc lut> Im-n minced tc i a low fraction of I p*r

•

In private practice ■ 1 >* ■ bonrfictal nwilbi *»( the antiseptic
ntthod tra miikIi It-, marked than In bowpltsl prnctic*, Kpi-

il'iui<-- of UW i [h nil in!', .-linn or* now I nit r»n-ly I ward ■>(, \>ul

it,. Qortolrty-rttpnu -till thorn j tatgl ptoponta of dmifaa
following parturition.
Tlml wptio oonditiofM frwiuentlv tianpluat* the fwi-r|^-t nim
idenced bj iIm- ovcfcvomka condition • >(' 1 1 ■ .

I'nri'-td ilnti'-. hi nil parti ■ • itilrv. A vity lafgl I-"-

io o) >it. r "_Mi:rculn[: • praaant conditiotM avian

li'-lli I" lilmlr nllivimn* xr;-mtC during (Im- inicr-

p4-ial period,

Bacteriology.

I'll, stroptooocoui i- tin matt li

■Mofodcd with 'I n : ml avpaini It i- to bo

found in nearly nil fnt.il ■ .!-■■

Di< rUphylococcui aorvni i* lb* Mil moat <" It* Ol MM*
wrperal Mpttc Infection. N>-t inf. - ■•! infra-

mill -ih-jit' mod mid 'p!:.. ■ i <>■ >• iimIi'imI.

Tin 1 jieuococcufc, liftcUlua *oli cotflmnnl*. bactllua diphtheria,
bacillus acrobatic* capmilatu*. pneumococcal mid baallu*
typaoHu if:i« In mentioned ;«- rare caneei nf pucrprral
mi', .-(ion. 'IIm-. mny l«- found para or mixed wiiti -<
n <-i ; rben lh« attar i- the raee Hi- Infertfon b gpMalIj
Piarptiimnlly -. irnlcnl

Tfc mm important pari in rh< production
of puerperal -*■(>■!-. KroniK liu* i ; u ll lo '« pn anl io W

3-HJ PATHOLOGY OF TIM riJ!;tl.i;M PJUUOD

out of 178 cawi uiesantfag febrile naarperla. It appaun oav-

:tllv t<> causa a mild in&ution, nnli» nwudolvd with a ptlivpto-
eocons, in which raw (lie inlneiinn is u-uallv » en \ Irulont.
Sapriemia: Then b :i considerable d*M of CeJOl 111 which

ilk- Bvmptonu ere due tu the absorption of toxic prwnxtf pro-

<Iiici.| I iv organism- within I lie. genital lf*d which do not
make their \v:iv into the hloml-i'iirmil. TIhmt an- hio-tly of
an BbtSfouki nature, belong! ug In the mtfr*f(wtitH OUl
liiicroor£ani«iii*, of which little is known. Tlii v u-unlv prc-
iluee (ju*, uml hence give n*e tu frothy, *"• ml- -id* 1 1 i t »^r die-
ehaivm,
Uxvutiy agn :it deal of boot" riologScnl wort hat ecni imed

out in the -iiniv ill' the vaginal secretion, li llOF DOFfl pnic-

liiallv pTOVfld fliat ill.' 'mill vagMH HI pivyiwiia v i

Irtuti iNithi^rMiii! nniTo6iv*;aii«niF, at least in it* tinner third.

Tin 1 vaginal secretions ore commonly strongly acid in their
reaction, due in i he proviiiv •>( n -<-<ulI.il vaginal btcilhiS)
which in itn Iil«-|trn«fl6cs |irtitliHv* lactic m'itl. It i* prohabljr
thi* (T'iil oanditiofl of tlM ngfnft] ^wrr-lintis Bssodntea with ;i
4-erlnin leukocytosis due tu chernota>;ie :i« tioii, which results In

the rnpM destruction of Ibc pathogenic bacteria should they
tiuil entrance i" the vagina.
It has been pfovi'il I titii I'liili'i^i-iiM' I •!!«■! *-i iii introduced into

n liiirnial Vagina pfTtftll in l'n<iii eleven tu twenty faotlW through

the ecruiicidal action of tho normal secretion*. I'nliinui.iiN

antiseptic vaginal douches have bocn proved to iohibil the
p.'1'iiiiriilal action of normal vaginal Hi-rctimm. Piilhiigciriv
bacteria have been I' mud to Ihrnrudi from eight tit lixtecu

hours longer in the healthy vagina nftai antiseptic douching

than when no doiirhiii'/ \va- employed.

Thi' cervix ha- been n-imlly I • 1 1 ■ n* I t<> contain in il» lower

fart I fi'W pethogCOlC liartrria of jjirairv dimiiiudied vtmleiav.
I- ii|i|mt pari is In variably Hiomi< in iln* iKirnial condition.

Thi' uterine riivity normally i« entirely free from micnionMJi-
inw, 1ml h in tha |H'i^natil ami in (he iK»i-|HTpianl itMKWH U.

Tlic nlcfoOrganlsms to in' fotiiKl in lb* low#r pari of tin*

vaxinii nre n-nally D01WOMBPtiotW| luit ^liunhl palliopiii- liac-
teria In- prvwnt) their virnlciuv i^ invariably greatly diiiiin-

i-lieil a- n rmnll oJ" thp genmeklal action of thfl HMkl RM1 -

ti-in«,

t\W7tn\

Pathology of Puorpcrml Scptk Infection.

The consequence* of :nln--.iti n£ th* i;inii:i| Inid <»f the
i>iHT|N<nil Wgnan iiimh. a:

The iiilrrlliiti iu:iv In' liniihil |Q I 1 ■'■ << < >l" tin- \iilvn nr ..i^ilial

in! , .1 may rapidly WW ,il hum tin- lomlitv
riiviiv. In lii.' in. -i .irii.ni (u-.- DO : mark tli»-

. _■. nil- |;:.» .:"!*. :..| . u entrancv. and >*•:
:li* |viiii nr iii.iv RMSuml) I i«i. iipiiliiy.

I .,.<'.-,.,. i« jlT.-. ti»| i. . of

of poorpend septic infection ffa flvdovuMn i I
i • is H u the ranlt of fofotfan u
pyogenic or putprfiioiive microuraanifm*.

Tbe mi i m of piirrpcral trpric infection u the puer-

peral ulcer. TIict puvrjA-ral ulcer* ape «uiplv Inftrffrl bo ra-
filial uullrt ami vuK'ii. Tin-* UVatHy pn- m I
dirty, ijrv'iiMi-;. flj'iw MlpMfUIOt ami U1 lwllml 111 u I mi rul-iit

Pornwrl) tin i mnl diphtheritic nl«»i--. bill

i i- i«rj rvmU frun infection with r In Klciw

I.--I11 r lai iJI

l'-i:ill.- ih.\ C-MI-- '.hi littli flivtnifcuOBi ad

IiipIi'. (heir |iiv-riir. mi; * v pMI Mil
Tn» puorpuTjJ T»ciniU» ni.u i-oir.lmt ii ic. it '-.* char-
u I In in inflammation of 'In- \itginnl muixM, which
wwvlU .ni.l --.I:. ; -. becoming hotbed in ■ poreTcnl
LMinstiotu in Uw vagina ariien inrVi-tinn ocenni uulli booonit
■ tvcrorl with i p*rado<]JphthcritM membrane. Hardy, in it*
diphtheritic vngioUii mn occur.

£nflom«trHi« \ n lul«>r tin? morv or Ifaalocontod condi-
tion of fd.- udoaneti run, mil (In- uneven placental -if'- villi

it* tllP>nib<*-xl altUUt*, mirier the ill lal U

• ■ |.'i .1- to th* ptl mind pmpai'ftthni ■ .)' inlirlis. ■ .1 :i;ii-ni-

nenoc the moat ooamun tctloa aaapoitf od with puerperal teptic

itk

The inl'-i-lKiii i:i:i\ lx- linitml In tin- phuvnlal -ih- * Of m:i',

extend over th* dhole of th. endometrium.

Wlini thi Infection U folded* to tk* pfa&ntul •<'• 1!.' organ-

tlevelop in iln ihrombi in the pwaeniSl MtiUMO, -ctiini; tip
:i phlcbitU whirl 1 in:i> Ik- limited to the uterine wall, 111 mai

:;is i \)iioLoaY of wr. rvERPi on

end u\ the iui round no, .■ In*, and (hi
secondary nitcdion el t

\\'li'"i 1 1n- icAo/j ftic/anirffttini i> involved lite n «v»-

\ it I'-i imim ;i Ranking, necrotic favor, which i> hathad h
blood; iHachirga Tfi© Quantity of uoerotlc material Kumn!
i- oftun ooMtdcnbloj and n recur* with i ai>i :
removal by th« pursue. Ii eonaiftt* of necrotic dcci< i

H

S f

... pttlenl 'i • tn r '■« ih< iciiih dny fnn» « ]
:ili<l lilirin-vxihliilc loaded "iili nuCTOO'rgUl 11*111* I Fi£>. 1-1

and i 12)

When tin infection i- due to lb* gtrrphemttut or Bo tlia
tphyiocotvut the odor of tlw Iwhia nun nol '«■ aflbcCrO,

ii:- In t|jp it. ..-I '.-'viil. HI i :i« • thl< locllill Mi;.\ ivm:iin :-v

limit . but wIk-ij til' "'/(tji tmvUto* or any of tin- /»ifr^-

7":.-- *.' *■••:• •••• t:: ■ is p.n^t; ::**>» --nHiaiiuc •>*"
i»tt -. - \*~.: l. u:.-: i, .-■:— .c*--u« -t-i_-u^ic tu nitTr-
••-y.: •• .- - t ;..- - i &■*■* •? HIL:.!— — :! n&caiTi.a. *i*
• » «ir- ■* *s»*K' ':. * - ri:^.^:^,; v-v 7 ui * lan-a-ra. txI»- miier

— ■■*. • : - - •:■ :~ >i '■ 'in*, vi-n ti»* nrW-r.i n - :tk :•>
)•■:--■'..■■ - .. -••-*..::.—:.- ;.- :: <•*."*•<■ mv-»h» * t.«. •»— ilj*i
'.«■ A*. . ~*"*>^»-*!i •• ■ :-tL : »"r ■ ••- ««:nu: :ucvrii.

'Ik— ..-• •-.——. r* nr '*- .- ■\-i.~o-_

J* ■*.> ;..--: tepzc waiiinufSJaa r«uiuii 1.11; r.»'«:»*r;*tii'.

T-.t-n v.- ;-;*.-.-- ••;:.:.- ia* «*- ".i-»-ar **t--cc ,«r.«^.-i «:-r

•fa::'; ■ ■ \> : a* e -u^_'. — :' :i£Lmr.«.« nay zt wa

r :v>"""*** * "•-::■-:. •■ --?: *ar;--i- 1; ■— «ir . tij: ::•* si:*r-
i'.M ••«?•* * ■■ si 1 "* :ui" > !»■* :ir ** * 5r**<ettr. 'm '---rv :&:n.
-'."- ■- - " ". ■ ••z'-'.r'-v f ' :»- :;"•— *""- ;r«*^r-f ■••^ir? bT
■•.••n > * r " " - ■'"■ '•-;•- - i-'- - ■ ■" <**•&!* — ~ «ir^ ":>- -:-rinie
vi - ;#■•■■ »;•--; ..;-••• - . > -*«— ij ir 1 ::»rC~rV. iym-

w*V'* ***■ ■ -■ ' - —•;•■ •■'"" i".-. T 1- '/Htt/'-Srttfirfif
.■ .;» " •-- ■- :•- :* ■•• -."• •: ~" 1 :i>:p ■> *i^iil &&Ke&ef
-.-.•.•./ «-.* •-.-•'-:.-. cr: **»- " — • i-s rATkeri ju*
-*-. n- * - - -■ •■-.-.

?*n=*Tr."5J . • .".•'.* ■:" v.-r * L2rt«Hi*4 ti-«ie

'=.".* .'. .- " * - "-•:• ■•-.>-.• - • . «-- .im- -;>ria»- int'ec-
" .*. . . • „•■-••-■•"•-*'. "... 7..- - ;■-*> *■- : :h-t aii-.-rt^pjan-
'.'•:.• .- .i ■■»**-»-„„■ ^ --^ ]- l.;-iX«»*-*6 ;jnc *fr* ernl'-roel-
f".". '. • - .••-."-•",* • .:.— t:vr ":— :-e. • *«ROoaIty ibe

7 :.••:..••— '-•• -. J ;..'.:*!• r. •: t..- 5#-r:-':>rxat n*orMctivc
t'« . • :.• *: • -*"-■.•*■•* •«•'■ *. T:.i- tisv r»MiIt in rvsolu-
ri',i», -..- r, -.;•:•■ ~i":v. .'»:.; ;; "-—>*—:* .rr.^: : n. When ox-
t':fi'l •.-! •.: "(i • >.:'-'*?: -n ■•-•■•lr- lil-cj :h- lyni|>haiio« in the
ant'rr.r |».ri.N •-: *-.«- [•<-; vi-. :h- ittrianiniarev •edema >ur-
f#iiii'l- i>i* ■• Ti'-r V---I- »it" th- lUi-jh in tic- iiri^hlir>rhooil iif
tint iri^unitil r*-.'f'* ; '. y-'-i^'if ri-*: t>» «»ii>- i**rit) •A [-l-l'^iuitia alba

8*lplniflti« : 'l'li«* !-":ill'»j»i:iti tii(K-i in a c-^rtain number of
r;i«K Ih^mh'' ititi-r-inl l»y «iirr«;l «*xiMi-i«iii <it' ilic inflammation
li'Hii ili'- iili-liifi- 'iiviiy. Ofi'n-ionally lliv inlW-tion mav be
••nni'-'l lo lli'- lliln* ;it ttt'll as ovari<>, by means of the Ivm-
|i'itili'- .

rvExrERAf, 3&R7C nrraenoK

FtriteolU* : I 4ldl1 UhliulU :ili '■- :i • lli ■■ i till nf'llin

iid Mtciwiun of lnf«cdon Irum rln nniine cavity liv mtww

<if til' D pi UllOt U* ulltMli* li»*4*I'lli."«l.

r ■.;!. in: ma] in- 1, occur En fionMtqnmrc <>t* Hh> rupiur*

nl" a DUO-CuIm , of "I an "\ n in" '>r pnhiiiu tnlic aliiomft. S ptir

tiitix i- uMiall) the niro I ceoat of death In the vwl our
joriij ol lata) ohm

Pyjnmia : A- already im-iil i«mi^ I . (lie ioivOtivO mioroOfniH

i-.ni- iii;i. j«iwli.i!i llir thiamin' .it llu- jihirvnlii! ■ .u I ,

i- -nl'- in ft condition of eaptk nhlebiliK, which meg bi :

■.-.in- in !m ni.viiK trail or maj extend to the veuu in
tli.' ii.i^| t i..rli..-(. Mi.- iliprKnUi-ii 111:1; ■■■■ id a- llir n* the
injiTiur vt'iiii ntvii Tin ■ iiiftvfMl thrombi Mil- break down,
hiu] Koall portion inn\ be •'uiit m In ulood conent to d
uini parti of m'i. body, thus amiug up b condition of pyju ,

TbtM '••{'<("( r.nLJi i,i;,> 1- dtpOMtCfl ill the ill-l huil vi*-

cera, lliu hing*, the brain, anion] OOfd, thejoblbr, or in the *ib-

rnUDftHM liwuc iii any portion »>t die body eurfatr, ulu-ii' th.M

pjtVi M ■•■ DO :il- ■•- III lli' ■ ■ 1 I '■ <h<n 1- v< ry llttfO

invitKriiirti! of llir ulrni-, infection thru bviug li|nil»'l
n-ii:illy In I he fil:iivnl;il «iif DOolll 10 llir*-' OBMft 10 iiHUIllly

.1.1. 1 . \luni-ihiii following a long wppontfive prOQ
PhlifUAAU x\hn dol«n»: Tin- munition U known to llw

Uity m " milk kg " ■'• " Wftl popalftriv - 11 j*| »< — . I I mie (

• Iiir to ;i 11. of mflli it dccub a» the remit

ruin r .ii" iiir . \r. ii-n.ii -it 11 ibrombotu from the marine v. fa i

to tnew of 'if low eatremi or of a wpti | tritn

spreading lo Lha connective tiaue of the thigh,

In wombotfo phlrgmaMa the nralira of the ftffactod limb
otuall, 1 l> .' n- nliont the fo it, nnd rapidly extendi to the thigh.

In tvlliilit,, p/i/rymaw'i the rwcUing begin* in the thigh and
iprcade down the limb.

Inbothfbnm 'he afTec-tcl Emb bed a noranooalj swol-
len. In the fiii 1 i then i* ii-imlK mora m low tcnaarnnw

along id- eotrraa of tha fimoraJ vafai, vrhlolt h ueonlry narked
b) .1 line of Inflammatory i. -in. ...

M'xioa of infection: Tin- DOM oatnni node ol' loifCtlon 1

die halroductton of wptic malarial intn lha vvoltal caoa] l oa
the tuiiuU in 1 in, rumrnlm nl" iln- pliy^inmi or niiitwifitj doav
tnrf iQHfl HcrwfjiM i'i "in mMinafi of ant kino, pnoh :>* iniVdad

252 i'jTUOLoar or ran pvatn \i

al«niM<«n* on the buds of a our-* or phyairi D I -in/trdom

dm rccdoaI l"* i wsj ifl i" iportMBof oaar*

The inrirr uned tooW-lt*- the pal mi ■ •yarn'

patfcorenie gem faro tb< genital canaL On i - wUa

-i-Iotr*-* or personal linen, or with infected vulvar
jcul*, may ae> ,i«*.

Inooi eta mi tbcantborii i EprricDeE infection ua*iir«habiy
dawtotba<Jtrfy land of tk porawf, ajttoeoukJBu! U i< ir.ii- •;
fnim wrttcbEng ihc nuv&

\. ha* I*- ii h! tow n, ill.' nor himI vagina i« prui-timlU -i.
to that win n int'ertiun oCt-ure :i i- ;:• mr.il;. tl; I* tb«

intnyh'.-h ■ pathogenic material j "»<< irt't'iont K|»»

in Nj'-i i' -ii Inn r barn klarnpeu mil in roaNvnitii by
avoiding nil inlvni»] < lamination- Tin I* -t niorti
mortality rtviinl- have been obtained in ititfitiilioi
vnjpn.il exaari nation* havi been eliminated a- dbl*

Anio-infection may be livid !<• aooouol for .1 wry MQ&1I pn -
portion "I 'tl** of piHTjrnil H|»-i- lii til' • ■ -i • • 1 ii« i
panic nrma arc bad iu Ik- resident in the bod
li:nr been Etltfodoocd from without, ilnrinu IW InUir.

Tho raternSryxniaina nn ba lodged In 'I"' ■ •.

orathrn. ■« m ctaa of rhojo. Badoaietnria antedating

r(jn<v|ii!) av account for tin- lodganeni "i im in tbi

ut- rim 1 mtlCOfll inrml«niii*-, ulncli 111 tin- bvonbtc • -•

exiatlng :ift'r tWSvery way becoma riruknfl and > 1 up wpife
infaotjou. In tha kiiih' May mi oM Mia-aae in 00a of tho

lot* :m»v ruplurv doritig! labor eii«l<:iii ' a *i|ihc j

Symptomatology.

The ->viiipriun- of wntJu infontloii may devalop withm tlir>
fiM tuvuti -four hnnn nfli 1 • dfliverv ; Iml, AM a nil*, n« it In iilt

nut ni* 1 In 1 ordinary i* in l«* noted until Mi* third 01 foiiflli d&g .

Th* OMrt or inl'vtinn mav !«' ;.i:>inli,| uitli :i ■- ii-«- of

nmlaiM? m»l possibly a -liu'lit In i< iches A- lli« laranei
ucajn lo riw Iht* patient develop* a more 01 l< nti dull

1 may nmounl lo 111 irtoal rigor, Th* lamp 1
i|iii.'l;lv ri— In 103° K. or higher, mnl ( 1 ■ • - pill* bacon**

1 ipidi * '-unllv titer.- i- amy oni cltill, but the h * ip n •
nin? nniaina p ily < li'vntrd.

r.\>,w > <

Tl* fccAi'i may foMnu* ««^nt. hut a* a role iln- dlKhliyv In-
(TtWnt in I: m:iv nKBato blood) Off DMQ Bpldt} I—-

jHiriil.nl. In llif tinM Vifill.'lil r-.i-i-. nlfl jn ihiiH- ilu>-
-i»t-u< nlcolHHi, vrn lilllr, it' ain , OOOf i* hi I*-

I

/'.»i/-n)i.iV.'n./ I<x*ii:il «li-li;ii ■_••■ inticnro ;i |>tl!riiJ

:...rriii- or a mined inf-xtloo din to pyogenic aa wtli ai

l-Dir-rj.M.. .. . uunoak

Willi |fa »l I'liil.nnrlnli- < i I ln-i- of lln -.pin- OT ifcfl

[iiirri'l foca inrolnlion ..! ill.. UttVtM " OIMD QBWI| |1mM fav«>r-

Uli iiiftviinn, iii rli.it ili« hra)pb-di«OQofe,

• .(i, rcniaiii |«itcni :nnl ilri- .-IT. r I. --

twiotonrc to the parage of niicnH>tvnm*tU3.

If the ptUU BW extends beyond the at^nm, tfw

«y nipt ma* which than develop depend ana fli*' tiaM< il
valve*!. S» ni|ii.iin- indicative of peritonitis pnntmi'triti-i vr

ihlH ORflUC

Peritonitli: Tin ooactof thai c pluvtion is imliuilnl ■ - -.

the OOoflRI iic<- of litinw p:tin. whldl M ;>t 6lM IllttEUd !•■ tin-

lOWVf BQtli' of ll»- ;iUIhiii. ii, Imt i;nnlii:illv c*trtt<U :n llir

rtliolr |HTil'Hirtiin U conn- .iflivlnl. A- |Kit-ilvi- of tin 1 ID*

ir nil. brJuB |il:i«-r RinHceil tyni|i:iiii!t . iH-ciir-- III RlBft] OBMfl

f| i : - u : 1 1 1 < btjfcal jil:n»' within rim lir>t t»-n day- of (hi

inn rperiunii

P*riLni«thtU : 'I'lii- .•..mr.li.7iti.iii. ;i« n role, develop* when

il idoni. iriii- i ipparcntly anbeading fa oomM it fp*>

qn ni!v Rttentlcd with si chill; the DempemtURt which hn*

probably fallen . >-. ■ . ti"! I pomes an e

lew irregnl ii • onnc. The extension of the utflanMnatofj proo*

Hii'-ii nun ni.it usually ho detected by a vaginal

examination. The intlltr.tlrd tuques tuirmmidini*, ihi- uleni-

i hard nrnl tense x-> the feel, Thai EnflimmBtSoo
pod in Raolntion m Ed a&an w foi manVft — me lai _■■ irernl
■mull niftv ("nil. Tin* pns limy Inirdv nbooi and

ni.il.f ItH S*JM Rita Inn hliuMrr. ivchini, vagina, ul MritOOWl
* io-i.i«>n:iil\ -ui'li :iti : 1 1 »— -» i— in:i\' jmmiiI :il ]'«»

ligament, of even above the crest of the ilium.
Pyemia . In raaea of pyaftnlii the Initial -unpfum- oi n-

firlinn an- nol ... innrl.i-l M in tl"' QtllW (OtDlfi Tin 1 l« iiijmt-

Jj-i.1„i.

::..1 PATBOJjOO} Of TBK PCFHPKR.U. PFItl».»

doc* not rviiiaiii conaianily alavatrd, bul (hi

nvlir lypft. < 'lull* 11 n- li-li:iiK OJ faqiiani 00 I in.«

The nuL)MMfU*'ii( NViii|>l«>iu* * f <■ [ m-ih I u|»>n ll r<j.«>- in\

l>v thfl InlVrlccI itii'Minlii. Mi. -i loiiinimily Willi pys*nn:i
have gymutOOlM o|" :m illfWrliuUH liniiH'liiipii-'iiMioiiNi -li'V< 'li'jiinu*.
Tliix p'limilly proves rapidly Glial

I ii trut a«ptic*mU, which [a Ibc uoatTtrulcal fbrmof aeptii
iafadfoo, tli« orgouimu make theii way so nnidly into tin

gtOvnil hlo<w|-<uiTrin tUit llie.Y (iul tO bCOOHM walrttd in any

umtorgaui Thtt in the nioai rapidly batel form of infection .
(loath may o< ■ ur ou the third or fourth day of the pucrperium,
iIim poison being ao viruleal m to iodaoeo iditumol pro

lolltIO phook.

DUguo»i« of Puerperal Septic Iufucliou.

If on tlie iliinl or fbnrtll day of lli'- puerperal period B

Vomaa develop! ft tomporaturo of I'M ' I'., ur i -, which

penpal* lor Iwrnly-fimr liotio, I lie condition piv*<nl i- afanOVl
eert;nnl\ f)Dfl "1" -eplie inleet inn pmviilnl I here LB »«> other Up-
piiniii oaQBI to Meount '.ili-tiiclorilv Cor rl>< lympl

rii' moal eoanmoo cauaea of an elevation ottempen

early in the !"" I'l^num. not oaaoefafod vtth icptic lofatloat,
•ii« ttipotiou, irritation from the breast^ and t tlooal

'■"■iii-hM-iit. tVii.-lii, or grief Malaria nod typhoid nai

■ Mj.li(ii(n [|m- j.iii-i |ii-riuni, and inn) I IKMindod w illi IOBIm

infection.

A lihgnoali of malaria i> only poaalble when thft pnwinv
oJ too blaamodluni lie* been uVnion>!i-.ii'\l m die bl<v-l.

A dlajrnowb of typhoid fever i- not | M-rnti - -1 1 ■!* tfl flu
ah tn'i 01 Widafa hlood-«onun lest,

lU'lorr making a tlm^iiimin nf wplift infection, en refill, -
ni;iii<- physical examination of Hie patient should be DMo

\ i.mf'nl 1 \:imiHtil:..n of the elm meter* of the lochia! di»-

charno mav render unmihle diagmnw of which variety of
1 udnnx triii- I- |h. -.-Hi in !i given awe <<i [Miwporal aeptle in

■ ion
In at] oajoi iho phyateiin should make an ocular raaraiuati m

of the ru/r,!. fomna, niwi «tpi> in a good light, employin
iln- purpose 1 urge ipecutara.

PC KB FERAL SEPTIC iSFECTIOS. 355

As it is desirable to know ■ hat crg-uinu are concerned in
the production of the infection, a culture may be taken from
the interior of the uterus. Tut* may be accompli-bed with
but little difficulty by tbe method recommended l#v Professor
Williams, of Baltimore.

Tbe apparatus necessary const* ~ of a glass tube, 20 to 25
cm. in length and 3 to 4 mm. in diameter, with a flight bend
at one end so as to facilitate its introduction into the uterus.
This may be sterilized after placing it in a long test-tube of
thick glass, which contain? in it? lover extremity a pledget of
cotton-wool, while hs opper end mar be dosed bv a cotton
plug (Figs. 123-125).

W illiatns thus describes tbe method to \# followed in ob-
taining a culture from the uterine cavity : ** When we wish to
make cultures from the uterus, oar hands and tbe external
genitalia should be thoroughly dUinf«led, tlie patient placed
in the Sims position, and a sterilized .Sim- or Simons speculum
introdnced soas to retract the posterior vaginal wall ; then the
cervix is caught with a volsellura forceps and brought down to
the vulva ; the vaginal portion of tbe cervix is then carefully
cleansed with a bit of sterilized cotton, and the Herile lx-hial
tuhe is removed from it- tube and introduced into the uterus as
high up as h will go. care being taken to avoid touching tl»e
external genitals in tbe operation. To the end of the lochia I
tube which protrudes from tbe vulva a syringe, which draws
well, is attached by means of a rubber tube. Suction i- made
whereby a eertain amount of tbe uterine contents i* drawn up
in the tulie. The tnbe is then withdrawn and its ends scaled
with sealing-wax, when it can be carried to the laboratory*
without fear of contamination. On reaching the laboratory it
is broken in its middle portion and cultures are taken from it*
content-, which we know represent the uncontaruinated lochia
from the upper part of tlte uterus."

When there is un-h»JA"l trvlntcf of endometritis the mterior
of the uteru« 4>ould be explored by means of the sterile tlnxer.
This procedure '-an be carried out vthen the culture has been
obtained. By thi- means important information may l>e uo-
tained which will indicate the line of treatment to be pursued.
When the ira/£» of tbe uterine cavity are rough, the prolabiliry
is that we have to deal with a pvttrftKtirt nulometriti* ; or

tine due to a pvogenie organism of a I-u <!. > : i. « of * iruloncv
Whtn thecavitv r- perfectly trmimth ili<- inlrntiuri in probably

iltui to virulent «ln i ,l,> l ->H'n „v ni<i},hyh,<fHxi,

i U It -/ CT/r iSFh'i-TIOX.

857

Treatment of Puerperal Septic Infection.

Prophylaxis i The occurrence "I" pmTiKTtil neubc inraotiofl i-

lo u praveneod by tl baervnnofi w the moot Benapulow

rufptu m the method of oondocdofl l.ibor. Thin *iilij<-fi ii.i-
Ik-om fully dcult wild in tbe MCtioa • ■ « ■ 'ho rouiiiur^nK'iit of

liii«.i. [<> *iii.'li ill-- rentier i* aifiiiii rot'env-i.

Pfoph) In 1 ic dbueftci nhunld not be employed except when

the vngih'i pReenM marked evidences of abnormality*

no-! 1 1 ambiaiknu should be ni.nl'* :i- nii'iii|U>htly l- («»« i J ■ 1»-
.■■_; labor: in normal com* more than one Ot two arc *cldom
ii»"- -siry.

i iginel uml vulval lacavtioni -anion extend deeper than

the mnceaa ihonld bo "<'"• ad ImmedlntaJj nftei il onolodon

iii' labor.
E)arlng iii" 1 Hnrt hao "■■/.fur tin- puerperal period !li<' meal

rigid asepsifi »l lull 1*1 Ik* nl.*Tvi'tl iii tin i;iiv i.f ili< . \ii riial

genital Dm utbjw haj been discussed hi this work on the
:.in in ilir manesemeol of the puerpcrioni.

/,-,'■»(/ Tii'Otinr/.f.

If nn examination nf the viilvii Bioughimj rarfooj are die*
covered, ll ihnnH bo painted daily with tinctan if Iodine

\Vh«n sutured wounds nf tin- v;i*.-iniil miili't pNaanl BVld
of infection, the ntfo hen should be removed in order to et-curc
free drainiK?*-.

Endometritis i» the condition moat frequently prceont in

paerpera] optic infection.

A» prevloaalv mentioned', the cavity of the ntena honld be
;-»! Rod i portion of tho lochia ramoved for DXamFnadon.

The method of Irvatmam to !«■ followed will depend in a
l:irv« measure on in* coiMntions pmaent In the uterine ru* \ty .
I hi indication* ate to remove »ll debris and ihrodi of broken-
down liana , and toi'lvunar thoroughly (he inlorfor of die nti run.

Tin.* niu'iiit u-f ivl" I In- rtm !!• in all «-:i*i- of |HH'r|K'i-»l i-ndo-

in.iriti- i- mentioned only i"> \* condemned, M In oarlaln ooo>
■ iim>'iit may rcanlt iii tin prod notion of nu? mote

n thin u' r,,- l

When th<: w»11m of tin llt»'riin< tin ily utv fmiiti) to be perfectly

PATHOI.Oi ' >•! THE ri i mi n U

HUiuuth llirrt' i- uImoIiiIiU' DO imlicalioti fur the Vlllulw IM

ilic ciin 1 1, m UiMi Ik nothing pranMit lhat cm h n i - ■ 1 l > -.

it. 'llir «-ivn\ -liuuld U- ifoiuJii'i thorough (1 uiih a gallon

two "!' hoi Cvrut formalin loIatioH 1 1 i iOU)i ifttt which i ilHp
of -ii'iiii/ivl iodoform nun, ml 1m I -n *. to form i di ill k wick
riali* to ifii incln'» long) ninv Ih introduced If b%jfa I I
inihiu-, Thii iriok ■■ favors drainage, hm En

lOfl in th« r»\ ir. -iin;iil.ii.- t h. iit. in- (o CDDtTBCl
nh-'rlriri;!!!- |.r. fi r (0 |«uvk lightly ill- ut-ni- "i(li 'trips of

■mum :ii1it doui hinir, I -it i tlii-, rather tcndi to i with

in. .ii.nn:i-r. .iihI iIm-i. l',.|. (fac OHM »ick is to be ptvfenv!.

If ihi-tocUnoloajcal examination oi the lochia nvtfllfl thai the

mi'. ■ lion k '!<>' to tanenax further lorol t r e atm e u l i» to be

avoided nod the gaiuc removed in (brtr-cigbl li'-urs.

I f the interior of flit ntffDJ he found rough and jagged, and
i<..\,|,.l vmiIi more or Ion falec rod \ the «ull> <A i\%v

envitv -Im-iiIiI bt BJ -I'-iiuiliriilly MTBJtcd «ilh it bhllri CRFCBUI

(M I'-'.], Lhoogn iii:m» prwci the fingers for thb jiur|KM>.

. W/c/ runtttiiif tlir W»J» AlimiM 1 H l \ |>|ofi J hy llic tinge-

(" mokoauro thai .*iil il.'bn- luu Ihi'h removed b) Uw cure) i
A douche of hot formalin solution (l :600) mat iben !*•• em-
ployed tOClCUDM tfaf <*.ivify (Imroii^lilv gftl r u Inch :i DOOgtt Off.
(v..> enakPOwd of iodoform (.>■>■* unci vtillirinit nl llunlirnni to

timl . ii Imn^fif tun in< \u" long of llir thick m** of an ornnaaiT
lead pjenoil, may u iotrodaceu ■■*• high bb Ihi fandoa. These
bougie* nre bald in position by the gause wicking, which ibocJd
be introduced iih reeoinm ended above.

This trrnlment usually result* in » marked Imuiovemenl
of the n/nptoma, the temperature ralli within ;i f < v. i.<

iiiul ili«- I'H-liiii l»t K". more normnl in typo. Should tin-

tampancai nol \»-U\ ta fbo firat injection, the tmrtoxnt nay
In- n (icMiril dftUj, nrovitled ihere i» no 1 1 idenoc thai llic in-
foetloo rm nrtandad bayond the atcraa, In which con local
traatffltai ihoold ba abandoDad.

Itidilornh ,i' inci'iii'v >o1hiimii -hoiiM not be employed In

intrH-ottvinv dooohcf 1 a> wlii-n ilii- «:iU route* in eontaot With
blood it formfl an inooounofi nlhnminaie. Itnuiin hna ►)i<«ti
that bichloride injeetioiw iMMU'iraif t h« i i->m- to only ■

. \u :ii Thr ntii
«iilt (In infected

i untie doe* not remain long enoup^i in contad
1 tinue to eaert mu< l> cermk'idal actvon.

• Mti'lUHt. si'tYtC r,i t:cTIOS

. i'J

tliit l.ifl.T (tHMi MnI Imtiiw tlW umiii uhjiii of llio ildiH'hi-

i- to ut-li awn*' wbrw wliitili ha* Item ttotaiJiad by the eurattft
or floger, inaag prefei toempUg (or liia purjMm aunple aterik
'v ii-r or unit aoluii

Infonwocoal oatfeuMtritii i' i btUer to wnplo* do local
treatment, u Um majority of ikm naaaj recover witbool ii :
oral ihi- wood an- !<-ii Willi <> ohTonii endomctrita whiob ran
bo trvnr-.l (•■ beUftl B<K mtaao I a

Loci! IrntfmetH -linuM DOl Lm I - i -»-i '-"I ill when ii if ovi-

■ i<iii thai If bill to Imp ova (ha eoMitioii of the patient In

fl»cwai-T» all lliul «-.iii Ih* doM i« I* diro'i our effort* to flic
tyurral iMipMvcinrni of iin- oondhioa of ili" patient.

(fauraJ ftoaJetenA

I'll -«• |.;,liin:*- -I1..11M (1 i.iv- ;il! 1 1 1 * I'ikkI ll; \ • :.n ;i ■ -1 unhid

The liet ihooJd oooaari .-iii. iiv of milk, oggfli and roeat-JaioB,

These aliould be given m luff"! qoantttte*, iif ahurl interval]

and if ucoc*«nry <houbl '"■ prodigested

I .)'• ilrpn?>Miiit nrrion of iln- fci\in* thonld '" ifaotod "

orae stimulation, and fin thai poi pow 1 ibom potent rnncdrai

are .iKiiliul .mil >tiv» liniiir.

An muvii ■■/■■.■■ .' liould bo ejvon m can be onaatimad with-
out producing tti phraiological effoow. It i> mrpnalog wbal .1
quaratil) ol alcohol thoot paticnta cwi take without npjaircHUjr

I loofnaj in. autowaid roaoU.

cfeyamnbu ihouM al b Avon In l:nyv i h wo a, from A in
i>,j grain U1M-. t-- admlnJatarm tverj three hou • in
awe*. Itigilali* 111:1; be oombined Willi ili<- -in-rlmm" when
I hr pllU'-r:iti' Eh hijph.

i,, control tha lainparatora, ojM w.-r paaloj -IhhiM be 00
plOyOUp an Wdll :i* llir lOIMttp, Aft it rule, iuili|iyn'tir U Of

ebould bi avoided on acmuni • •!" |baj dopfi «*ni iction ii»<\v
aaart

Boom bat recommended Ihi rooJiu employ aMat of etfol
in caw of poorper al endometrita*, in order 10 mure bettor

OOQtncttou, ui<] liin- ."ilnilr in -"in. divm 1 !n IvmphutioD m
lliP uterine Will Fl.OXl • ill \i mux I-' uivin'vriv -.\

honr», or it m.v ba ■ Moan widiojmnini • id (pvan

in a wii;ui»lr mixture.

360 PATHOLoar of Tin: pvi:uu;m. •

Tltr bowels >h.>u!<i Im- kept active by n in of a dailj
which acta favorably 1»\ draining Uw polvio lyrni

Tim mbenUMOOfl injection of large qoaotiUM of normal
iillnt lolotion Jia- Iwvti .-iiiplovl in tin tnttftMftl of MMff-
paral ten ff| . irlo i benvticial rwulta- h ;- — * i j * [
act by dilating the blood, thin favoring » l »* ■ xpuhuon of l"

matter. Tin 1 mliiM -t'luiiuii m:.' I>. inject"! untliT lli< l»n i-.

n* reoomtnradnd in tin* treatment «■! hemorrhage! off in
orjaveaieotly into the bowel) io itbiob cue rrf - quart*

ibould be even nt anon injection

Baociitly ii luia I" i i that nucleln bl employed In

the tmitni' tn nt' three cueee with u view of producing an artl-
ii< iiil leucoiTtoiiK Hirni couiiiU-n» that thU plan of treatment
v i v . • |nunii-*' 4 if" practical n*»]t*, nml thai more U to bo

expected of ii than of ••■nun tli.Mupy.

Senna-therapy; When Mariuorck in 1883 pabrMmd tin*
ro#ulot he liAtl obtained by the employment of antbttrefCo-

00000 xtuim DO UM tt i-:it tiifiil of Kpaia, In n Jiunl n>nll» w- n

expootad to follow ii- um in puerperal ■ ••»*. Kecent -uii-tie*
Beam In prove thai the results thru far obi in <l by the empt ■

in. ill of the -wriini lire not more foTOrobll limn [Im— ■ bl Dtotf
mi'lh'-l- '.I it'i'iitiii'-ni.

\- many coee* of puerperal infection nre due to other agtutfl
than streptoeooci, its routine emploi ment in all COMi 0*1 Iy

!"■ ll-Hijin n'i[|, ,| uim.-i. \\ !..■!!«. t|l ,|]. ■:,(,> .if .I, ;|.;|M.-i- .ti:il.i.»

u& to prove in a given caw that the infection M 0*00 to UM
BtrfSptOOOOOODM itoUB, Hun tlie x-riim >\ M Ih' • nip tr >\« <t, (nit

not i" 1 1 j« - axcJualon of other methoda of troatnient.

1 1' ran- i- taken In iiiiiLirnn :iiviu:itrdi:n; i- thai lliriiile. -turn

1* dllO to tin' ulrrpfinwsau O/OfW, -'i uril-l hOfapj ma; Ih- hii-
plovi-d with lair n-rlainly <>!' «uc<v--. especially if it i* QMn
early mid in large doM.

P-UaiaoLrltift: Tliix condition may In- treated r ■ v . ilur In.i
Or mid nppliral'nui-, w lii.-lu'vi-r jimvi mm. im.h.I |fl i]h-

patient. The foe-bag will Im« (bond to control the oztenaion
of the inflammation in mam' 'ii-c. while it iifuaJIy n I •
the l<«"»l pain to a marked degree. When it if not well bom
hot lla\-.i'(| |M.ultin- nniy Ue npplieil to thr lower abdomen
anil hot vngiaoJ douohct given a( regtdar iutervnlii

I'nibiiblv mOBt ofthOK C0608 beitl l>y rcaolaitoDj bin u oluac

/Tl.s/oVwln'

361

i. miwt I* kept for evidence* of euppuration. When
fluotUAtUU i» olitnimd ihc idwecu may Ik' opened throin/li the
■I '..uiii *\ h'-n |»"- il'li.' . In ionic one* ii inny be noci

XI TV tO MBImI tli<- ill* ■i'.]M|| (llldllj-ll ll|>' :il"|ii|ilillUl Willi.

PcrttoDiui: WImd peritonkk dovolop. i h«- Iraitinoal iIm dM
s be expectant, In iba Itape thai tin- inflammation will

bttCODM looUlnd. CtfiinU'rirruutiiHi ami bol fomentation* fo

ill. abdomen, oomblncd with the frw oat of akllnt ctlhartSea,

. vr good rSBUItl. If tlir -viiiplotn* projjrex* or do not

i(v wiiIiim ihir(\--iv lining, iln'ii tOAobdomm may be opened
■nd ill* .-..-< treated ■aoordfng Bo the ooneUtinni found* Ali-
tttm, h' loimd, should in ..| i ., .1 and drained. Distended

tube* -'I'll mv.iu, - •houid In r M.i. ; uii! under otrtaiD ooo-

ditj ii may i * oeoeaaary to perform b y / ttowBC ODiy;

The indication* for />.yw/ivoVomy nre tin- praamee of multiple

in tK< hi. riin- Wlilln ; mid putrid cimImIH. In'ii" ninth

i, til- I.. \ j. id I., r.-jxiiiiil intra- uterine iiriflntiotu and curetting*

Pbl«tfmatla ilba dolcnn • The PAllcol Id he kept in DAd

wnli 1 1 ■ •■ jiiIWimI iimi) t-ii-vsiittl ><> iiv to finoi the nCnrn eircu-
l;iiion. The timbtbould 1h- vnpped in ruti.ui And hnndaged
luoselVi Th&QtMrol trtatsnmi *-lionld In* ..iip|i<>ri inland -tunu-
litiop,

In (In- oeUtilitie vnrii'iy Mvwtration Is very liken In lake

C' n»- in tin eonneetive tame of the thi^h. A hwei-M» »Jii»uhl
mtefaed (brand promptly opened, to ai lo avoid banovroe

OBSTETRIC OPERATIONS.
Episiotomy.

Definition' Episiotomy In tin- tarn nppli*d t*» any inoiioon
of the maternal genitals to prevent extensive laceration taking

pJAnj daring the pa&apn of the ohltd .it the time of Urth.

'I'll, operation unmioi Ik* .-aid to be in levncral use in this

country, bui Eiornnmoo In Germany ind Anatrta,

Indications : Hat* inv :

1. Tin . ■ nlnil niptlilV ■•!' llw ;> mi:< urn.

2. ( i real narrow new of I lie external p uitala.

'X Kij*idity of llic perineum, i>|»rially when diie to eiefl-
trioii ti i

362

■ rwttlC OPBRATI-w

I. Faulty ]• — <i i. >:■ >>i ih< iidvudB ili r.riMM

IMllll-t.

«i. UihIiii- ftlXfl ||f Ulf I'l'Inl hr:ul.

Opm-ation . Tarnier In- ranamuiiuinl mi oliliunr inci

1 Mining to onf or other wd* of tin anuN. TIh (Wrinam [»cv-
k*r lateral oblique inovioM diraoted towanliJH noriorior com

miMun It i- -tit.il thai Huh an iatnatoa I an [1 inch) in

length incmm the eirvumtoreuoe of the vulvar unflco 2 era.

(J inch).

Tin- toil wed b h blunt pointed tciMun. Dminu* u

pain odc blacta "f the open nclaaora ■ dipped udew •••*&

ili-- bead and 1 1 ■ * - vulva, and than tnmed mid the n <ut.

Tht advantage BfaphiotaBiy i- ili*- iih-muti >n i enl

Hi" dafinln -i/". hi :i plnol tfhari h can <lo no ham, Rn id n-
ngulai taarafJea ol rodHiimr .iw«liicii mi. -it

in-ill Injury Bo iln 1 palfent AU> a dean lada i- nacn mow

welly Miturou iliuu a jn»p*l laceration.

IMMEDIATE REPAIR OF VAGINAL AMD PERISTAL
LACERATIONS

whether the pelvic fasria (»r (he fibres of" th<9 levator ui

imwlr* 010 tli*'.i|]-iiii|n»i-t.iiit. -iru. lur.- KHXanwd ■ :» I !»*■ -tlpjmrt

of the infrrn.il pelvic rtruotures is -till a matter of d<

li Evj bofrtvar, certain that the wedge nf ti**ue between the
vagina and rectum ooeopostog the perineal body b u | ra tirully

fiolliinvr to il> whii (li' >up|Miri ■■; ili»- |H-K'ti ivuiU'iii*.

Artrorriiiig' t" Ki'ilv. tii<- *'rml supporting mccliani
ii (1 ootid i- the • nfi iot portion of too forafoi aai h lie

more generally held opinion, however, i» thni the ■ "«^a

h the nppottina Bwcaan'ma nl the oatfct, and tliat the aheeti

loriniitj BBC be hi' 'perineal layer of ilie rectovesical fjooia are
nic«t imp<»nnni in ilii- CDBOeOCkBL

Whoa if i« uaaailaiaJ th >i tha vicinal orifice, normally 2 to
3 em. in •MivmiitVreitce, la dilated to ■'>'■'■ cm. 04 the BWWMfll af
delivery tu [lerniii the pa^nge of an ordinary *itfd child, it m

■ I) IB I I

\- i matter ol routine, after Ok- eoncla lea of lalmr, the
- Y .*.iri:i.i w|„„il.l earafully taamlna the %n1va mid \agianl on-
In : n>. 1 'In- examination may ordinarily lie made

with lb prtl n I ii tit- dcnsJ ootidon, having Ae tbjglu
everted. A. good ligfat w ■! iv wbanants*

tcrnul aopvrnctal tear i- found il a epnirednl ono#|M

dir cted bei <vi

If, howCTO it ii extensive laceration ~-Iihii|< I !.<• im- n(, farther

• oVJei e , until pti i'H tdoo Dave, boa

I | p QUI QgNAOOU.
Injuries | ■ ft igmul >>ucK-i ill-- n-.uli ■ ■! • ■hiMliirth may be
classified un tullii '

1 Kxto mil .n|.'i iiiiul imp.

2. Internal ■■ »i omitMiut] uii<im:iI hip I •ttcrnn) tear.

"■. ' bropleta ienr of ill-- rectovaginal aantuar.

1. External Superficial Tear.

Ii i- fbrn of injiiiy t'r..iii parturition w tlie niwt fr«du»nt
and also die leaet Important, Bfl it in DO wuv »hVt- ilir -up

porting ttructtirej of Ibe pelvic outlet.

The fear Involve* wiiipK tin- MPOrftoitl P*> ' H

portion 'i iii' 1 wedjp of Tax tlnoo between
ilir vaginii ami rratom Ii becinaaj ifca
Intrmtaa vaginas and extenda bankwan!
through lb? skin in 1 1 . - median Km . oooa-

aionally i' max i*xt«»nH inw ml u &T II till
posterior cwloura of the * igina | l'i- I
Tlii" lii.vr.itiiui ..in i- inspected Ebroagh-

<»,i ii- wliuli* i-vl.-ul l»\ iin-r. Iv -.| ..ui.lii.-.'

th> labia.

W lion the lair dimply rxtoutU //*«"<-;/<
tntfonrchttU rtrid • lc(inline» until it hm
cd i» nil that i< required.

when the (aeration \m* a bote 2 3 em.
(I to \\ ih<li.-i in length it iboaU be
attinred bnmoliatelv.

When peaoibie, It i- ilir « r it- 1 '- li:il<it
i<> utiiM- ill.—- fttra while waitlna for the
Attachment of the placenta, n> tin- pntii'iii

at thai iirac i- -nil •■ or loan Dmkr

Ibe 'iiiltirtMv of ditnrofornt. limim- ilie slight opcrotiou the
nurae i» placed In charn of the Cumin*.

|A«M1 tOTT CI

I Irt niijfr« f*rlliiK
l«M» ml it > in

nn i

I

:;»;i

in i |, it .1' ."... ■ ; :||. n in/ ...i..j.|. led iftei th .1, |

..f r| (i |i[. t . . n: i

Nece«»ry for the operation \ nip!. irnnll curved nee*

.il.-. i Dccdlo-holder, tbi ! -uutor*ilk •iitarr*.

iiikI i pair of eciuuori should i»- rteriliied M

employ hi / ' ■

lion . i! ■ onoien "i i dc die « ill) d i ro, monitMd e i

handle; the needle m pa-eed, threaded, and then witli

Tin- 'ii' U to place the patient ut-r<e* the bod With the lnii-

toekaovoi die edge, the lea using flexed over tin bachaof
trtu chain pi k trrauguJ. In mam bbmkIi I m*«nSu>io

RHnn t I a rr*-*- lUnplf In wltltoa! .ii-iutliiii^ l!i. |. ; iihiil

btyObd -'| tm .ii i Hi' ami OVWTlillg In r llir^'li-

Blittirlnv : I'll*' piilicut l>.-ui£ pitted u- nm-f tonVPIlirnl
lip- uf ilir (cir pre In -1*1 Bprrl by ihu finmrx <"i n>r |< i band,

tlic llimdod iH'-illr r> ihrii iulr.Hliirnl m:ir I In UptMV Ult

winnl abonl .]. oiii. i \ inch i fnmi iu margin, limujpil i ul
nt the floor, end i ■• i i (ooraerKeon tin skniwirfaooop
poaitt the point of entrance A rimQar *uture i- than p

war tli'- InwiT Linpl'', ;ii«l Ih.iIi -nii;t>- tii.i ;ii'n-r tin- wound
lm> <■• -n -.1 (ii •!.

If (lie :i]ij»r"*iiMHlinil U DO) quite Niti-f-ii tOTJ .

■uporficial eutnre* nui In- required. The end of tin
siimiM | M > I. ii fairly joiif?, an that they imiv be en-.
Mini prevented tVom rousing the put lent inoonven

pricking. Tin- j-utiif- • 'M. iv i- i. ..[.."./ mi tbcdgfttli duv.

2. Internal Tear, or Combined Internal and External

Tear.

Conditions: .\ti nuWnaJ bur "Inn prrso.nl ifl f'Hiiid to ex-
tend t'lt'in tin' fburobette toward from om to two Inohea, in-
votvmgoneor l^th lateral ->it< i (Fig, 127). This tern alwaya
dtatmra tli" integrity of the pelvic wpportlog rtraeton ■, tad

if n. ■■rlr.-f.d l.-.itl-i tn •- rinilH n-«iilt».

Sack nn internal hoerataon may I «■ prawnl mitfumi •<
ternal travsotj bu1 niuaUy the external injury (ulnnd* d- -

MVfbcd) ie to !*> found tnaorittfrrt- with the intrrnal t- it- u h-n

it U prewnt. On inapeotion n ragged bleuding wound vlfl be

MKP.iM 0* vi-,/.vw. AMD P8XJ H ttATTOXi

(bond ii Kbc (<"-' r vaginal wall, oaooiitcd probably wUJi

:,:,.,. ,| r null |:icrr;ili«»n.

Method of Rflpjur.

Tii«- patta)! should bi plaood Mtoa tb« ' M, *l "'idi ili«' but-
tocks over the •■'■-■■. u prtvfoiudj faorfhed

PM. Iff.

-

miH«rtfi«li»mIiitK'l internal »n<lcilom«I u-itr. »hoi*lii,- paftSaa of l- »r m v»/m«

UmU u

Hi.- uiumijuition or the field of operation ehoald b tin >« I

ohtiiin:ibl.t.

I :il<-- flu- pntimt ■- pivjiur"! i» Mifl'<T ;i lift k |.iin, mi
MMaatlo, pirfemblT ether, would be admnriatered, Through*

uiii i1h< i>|Ni.i(!iiii i -. i-.i. Mi) ihi.iilil •_• 1 -it- ('in. in uteri i"

prevent reUi ution.

I " l ■ ■- m*tr»mpDU r .-. ,m" i .-. 1 -in- ili" 'mno u beforo mentioned,

wuli tin- kI-IiIch |m. il.U .if :. couple of vaginal rotraetore.

>;ff ONUU

I'll.' flnt sup it. ili.- ppmthjB in to ruwcrtnin the nature and
extent of the. lou-ration. '!• obtUB n p>.«l view, it may be
oocciwiry to pock the upper part ol tl"- victual canal with
-in ile pan "r cotton to prcvrai ins So* at blood amn iboi .
All nijrgitt iiikI badly brntecd Iumuc iliuiiltl u- tl».-i. ■ mc
nml ilit- ii|»|k-i- angle of the wound tT|«iatri bv inran* of tfic
fingr-n of ili- Igfl ntndof l>v ■ rotnetof hold W an aanatanc.

Tlir SUturinit tlltmlil ennillK'ii. • :il lli' ''pOtt JUtflt' vt l!n*

loir, mill ihv -ut lire* ebould Im- about a centimetre sput ; ae

hMDY shouM be employed a*
an required to bring iheadgog
of tln< wound, or wound*, w*l]

Iht.
Tin mrthort o( Inxurttng the
Hutunw in of vrry • •nu-iili r.iM..-

EuiportaooQ) u tin' i>i»j'H'i i- to

nn llie union i>f tfafl iim-

Sorting ■tructurtt of the pel via
Mffc. L28). The nmllc

■Koala be Introduced on the

inuiiMi?. -urlVv O.'i an. ( '
inrh) from i In- margin a

Pi . 13*.

/

*-■"■ " i iv. v.' -,\u mi. ..... - «

tmamri. rwly l«tl.'

»1 •nii-ln* iwi . II* I til

i.. i-. ,i. .,

iln wound und directed ihmiif*h the tiwne* to im- direction
of tin- until'!, brought mil ut the lm*\ llien rcintrod
ilin-t'ti'il in Wind ;iml njnvnnl m as lo emerge on r 1 1* - DlttGOa
(toe ;i t ;, pomt opposite [ft Insertion. Thai the loop of

jr>J TAQWAL i>/' POLOtLU UCBUnOMt 967

wh mtnr* wfcrn in iil*» t- dk*rtnl !o*»r.l ibfl ourntor (Pme.

Ka.-h -uturr dimilJ I* In I l» inn l!..- n. xl i- introduced.
Tin- lux) xilurv 0>li» ililn*Uir»d -IhhiIiI lifjn^ lOHtllCf ill-*

lorn ulg** 1.1" r- n. i ( \u..ii .1! •!,. 1 igrnal oril

rii«' external round nay than 1- ivpriRd bg <i fen Riper*

ficial -ii in- - introduced 11 -it. tl.. -kin fjirTac*.

1

to

v< ■■. c

• r. lMf>l*lMf Uir f.. t..*-yln-l •r|4Nm.

DriAtlQv II. !• :i. |. •!■:.: :.,iiji f.itn|iuii m:i\ (lull bo ronii'i '<■ I.
n:il 'liiuli. _'i v< l*. BUU tht wmiinl *!•■ — !■ • I Willi :ill inili-

W jit ir powoVr uffbn I In vulvar jmd i- applied.

Aft*rtr»*tro«nt: Ttot wound would '" let p< w«fl ilorted
>\iili iodoform nnd boric n^'l pawdei (1 "'. coOBtii
E&ould be avoided, ■nd (be patienl Forbidden t<> strain whUv

m<«icHi of ike bowel*. !f there (« macfc femoo iii
, iMtlitt^riratfcm moy be ttgr t a W T in ont.r |0 r«'i
Udder, i .it* may I* removal oa the eighth or

tenth day, but the |*xci<.«c fhuuld be kcf4 iu bed for at ban
fourteen day*.

3. Complete Tear.
i: A tonpbu tan "i tin- nilnwn t* dm taaend-

inav ffutn rh. ftmrebMti backward through lb* -.• ai,

aiS Ib*oMd£ the nvloYaginul —p:< I jrrcntcr or ks*

ru

■ UM t>w«1

Mrtutl (Ffg. 130). Such tear* involve I Unction of th»
ftiocttaa of the iphinotcr uni muaole, nod rcaull in inenntl*
iieiire <•? in-11-.. iiml llntu.%. The i-i.mihiou f»f the pfttkol ibtu

bttoocnM nasi dfatiwifrng.

Operation.

AnaUhosu in this instance ii Iroporative for thcproiwr por-
m iiner of the operation.

m/; o$ I \Q& U im MOUWMJ i iCKRATIOM 309

I be position of tiu- (uii.i.i ibould be J* t'-»r the mvvioiuly

ilr-MiU'*! operation, riii' nature uml osteal "t too wuuml

ftboult] In- DM MOCRoIflod MI'i 1 1 ** - li'-W of o|K*mci'Ui ilmr-
lv 4-Iimiim-iI.

The Mctom i* f!r»t repaired l»y mron* of Interrupted mtgut
-ii'iip - Introduced from tlie nuooue nirftoe. ThcemH>>: iii.

-| .1 1 - n« -l - r iiiu^t lw mrHnllv :i|»|<io\iituilnl l«\ mniur. i<l I. mini

<-JII^1ll .ijlllM

Tin* t&kuui zeat -ImuM tlum be repelred on before Tcooft-
rm nded i end, (iiialh. ilm «/('/i nurfaeu of tha perinea] irouad
iihimc Ik> (iMiti^lii cof^vtber.

I ft 131

Dwp Interrupt**! UHtafl •inurw In poaino*.

h ir- will to nloforc* tin- mtiuit yuturc* uniting the torn

.•ii'1-..f thtepliiiicti-r. Ii\ im-mt- «.t ;t liirge MltlinrMif Nilltworiii-

gul Introduced on » l j ■ - utln curfew o En Include In ii- )<»>ji
■ eaneSdernble portion »>i tlto noeelo u well an «>!' i In- Hcjiiiiru
above n Kp 131-134).

Aft* r- treatment . QoMtI{MlJOn -huiilil be nvnul.il, tlir
31 oi-i

lilt Hi ..trlltdl Mtt*t>

xlionlil In- Kepi Well ftlannwd urn) diluted « it li mi jiiih- pli-

powder. The niluw tots be removed "it the tenth i" tbe
twelfth day. The potfoDl ihould remain in bed for tliirc
weoke,

IMMEDIATE REPAIR OF CEBVIOAL LACERATIONS
L V enttSom of llie rorvlj nrc rarely repaired unit—- il.. < it-

euln artery i* Involved and *ovcrc homorrlmr' remit*
Cervical lafwntlona, even when eeverc, frc<|inml\ (mil U

lirNt Intention without operation.
Operation : The operation run usually lie performed without

difficulty. The patient i>- placed ns recommended In the

/ utonnoy

371

_ trniiiiii-. the earvU Ei -<i/--ti with n tenaculum, drawn
lowD, ami lii'ld in padtion tor suturing,

I'll. -util)\ ■ should be |»l:u-< -I .it I ulU- IlK'li :i|i:il'l. :in<I the

- Iii i «il- J bo placed at the upper angle. Silkworm-gut
ibould bo employed, and tlw rtftoEee Dm} Ik- removed an the

iwi iii_v-iii-i day.

INDUCTION OF ABORTION.

Doflnitlon . I(v the EwluorioO of ibortIdD i inriiut [In- arti-
ficial smpfrfng <•! ili" ataroi before the period of viability
of tl blld i- r*ii«ln*«l — that 1*. before (In I otf lha twenty-

• tL'liili ffwk "! proKiiancy. Sunt- authoni limn t\\>~ term

" imlurlinn i)I' -illinium " tl) ill' 1 emptying Ot 'he Ultttll before
llic ■ ii-l Ot KIM -i.xlrrnlli WVCK, I ««-nn?-*- llif uirlln»l - ttt <i|M-ni-

iii in iIiIVit lirlini' and after thin iMirioa.

Indication*: The uoonnenoe of patbnlogtaal oonaitSoaa oou-

r/aaeat upon prvgnaao/i «nd the iggnvitmn of eoruin d!m-

«ncc< by geatation. give riec oooneionally to tin* Dwomtvef

• inMvin^ thi' uterus by urtiticml rucun* lit tin- i\\|k?h >: I i

. liilii'- Eft in order to mve the womaiL A mono; the coo
ditaons which may render awry the imlm-tioii •■( nlt-ortiou

tin' fallowing may In- im>itti<>ncd

I. /////" " '/'■ "■ pro* nii'i ii'ii.

J. Ittnnl iiiii </, with threatened fefllainp m.

«-/ (In fttiut,

utv. M'-tilliiit; from mi- ml'l-i-iv -tied by |irn;ti!iiioy.
5k Itirnivi'iutioii of :t r<-imll<\r.| iii.ru>.

ii. Prawnce i>r benign ur maiijpiAni lumora vbEoh wnuhl
pnteliMli tl"' dellveri of a vtaMa child or render Q*nx«*n

section ;it lei n \o$a\ [entile.

7. Acute liydnunniofl and cystic degeneration of thv
chorion.

8, Certain hi I discs w Eeuooeytbjenun and perniokHM

;uui'iiii;i.

'.». fcUrelv hemorrhage fc hlu<vnm fir-win ma) rendu

ii •*« ■< m irv the Lennhurion of pregnancy before, the period od
th.- viability of the child i« mn Imi.

Tin* intending physician »houM eonttilt with u ooMcague
befrrv deciding I he ijiieMion of inb-rfervmv, uml u full ex-

OBSTgTRIC 0PRBAT10y&
I iltiitiit !••!■ of i lie eireum i id. i ■ of tin- i!d be made to

b member* of the family moat dircctl) rued

Methods of Inducing Abortion

Tin- ndnunistration of drugs mtrriialU lor ilir |Mirpon
Inducing abortion i* only mentioned t<- be condemned. I In i

union III -low :>nd iMir.iduii, und their u*r || not niln .,iiciit K

attended v\iili danger.

I Ip in the end of the sixteenth week iln- onlclteel and mo I

BNttlD inrlliod M hi niiimlinj* the |«n •>Mi:iur% i -. lie following

Dilating tbe Cervix »nd Curetting the Uterine Cavity.

Ad¥JinUges; The operation <•»» Ik- done in from ten to

twi'itiv BUOUtGU ; i' ia Certain 10 eflbotj and wlw-it |imjH.<r1\ ' :n

pied '»m it i* praatLoalrv unattended with danger In tbe
patient

The instrummitM required liir tlii* Opemtfoil :nv VolwHum

faroepa, a Smon perineal retractor, a <i of Hegu'edilatoa
i pair of branched dilator*, such ae Goodolft in I'mmet
eurotte-fnrcapa, i ibarp owettsj and ;i pair or" long uterine
drcaalng-fureep* Some atripo of iodowrra gauze (10 i*-r
cent.) tar packing , ^>- uterine cavity and vagina should nl*o

lie )ifr|i:ir<-d.

Preliminary to operation • The patient, oAer being ana)
ri/.i'd, in placed in the. lithotomy pmriilon ona table vhlch Fn
in :i good light, the limb* bafofr held In poeirion by rimm of
:i rolled nhool oi bv :i crutch. Wie vagina end vulva are tben
aorubbed with Kpfrlbi of green soap and hoi water, rofton**ool

-wiili- being employ**!. Tlw pnt-i - urw llinn iJUinfeeted l»v
means of a douche nf 1 : oiH) mrnutfn -olmion. The handa
of ilic operator ere tben sti rStixi d.

Tbe operation : The perineal retractor i« placed in il"
gine, ino the anterior ii|> of the <• rviz seised with a voleellura

and drawn will down. Tlieae iii»tnimcn(i may dun !..

i»v mi aawtanL Tl ptt« i- then eWftti I by i I

i prV mid Goodelft dilator* (ill ii paril) admit* thi
Anger. The Emmel corette-forecru i- tben inserted into tbe
utarixMoavh) and the ovum icized and crushed before tbe

t\l>t rrm\ <.,■ PRJSXATUBB LABOR. 373

Inatrnmcnl i withdrawn with whatever may have beta

•i|. The i '''i intl a* much of At part -'i iln- OTIUBU

i* puMiblc •hould be removed bj tnoK farcejMj after which

uterine wall* tlmuM In- rnnt'ulk uml «y*t«raaticaUv

''<•/. bill uitllnllC lilllrl) fitYi'v.

After operation: Tin- DtttfM cavln i* than douched wiA

hd l"tni:ilin ■■■!mi"ii, Uftd :tth-rivnrd paoJbki willi i<i<loliinii
8*4120. I'lii' Volaeltum OIhI J" rim-ill mtrtOtOr nrv lln n rniiovt-fl

uml ihr operation li oompiatcd,

Snmfl OpenMor* pn i'< t not to empty the uterus At one sitting,

inn ;iii. r MiiiiVim.- tin f-i-iu- ii> pack Qn ocrvb with gauge
■od to tampon the raginti with antmepric wool, which an lefl
m plana for Lwentj four l r-. On tbcii removal, If At

nilev "i il viiiii u iimi liJM'liBnteil from tilt 00, t lio cer-
vix Ih iti'_' :>.u- ii. .1 I.- il.. i ihi|Hiii, it fnrllitr tliliilcil ami At
uterine euvit\ i' t h< »r*>i ii^li t\ i-urriiril ; and li then douched
md naeltad with annaa i reccmrrjemtal Thai pauxe

tacking should bt ramovtd In from twooty-foar lo tMrtj Ix
lovn.

Tin [kiIh ni -Imiild be kept Ln Led Inn n OMWtall l«> It'll

■ l:i\ . :i|'i. r lln- Dpi niimn.

Abortion, when induced xiW the sixteenth we*k i- :ic<*»>in-
iilisbpd liv mcano of il»' netbodc to 1h« recommended I'<t tin.'

■ fatfOTi

INDUCTION OF PREMATTJRE LABOR.
Tin indication* fnr the Induction of prcmntiin* InW ere

li the amaaaAoM given for il»- ladocdon of abortion.

In addition, however, may l» mendontd '•ontfactni pelct in
which ri • laired to avoid the now | of daarean opera-

ii »r -vni|>)iv ■-iiitniiiv. Placenta pnevla. while n nm- mdi-

cation fin abortion, ruit infroouenilj neoewntatea the Induction
of premaiora labor.

li maj I •• ' ■ induce laboi prematurely In ad-

:■ i-<| li. :iri ih-* .im and in tub* iriiWmiH.

.7 1

onsmw "i i ■

Methods of Inducing Premature Labor.
Kranse's method : This IB tin- Minplr.it ana the aw i

factory iii tlf va-i majority of caeca. El eonriaei En ine iruVv*
tfuohon of a bona* into the uterine cavity between tin »"
bmfw .mil the vv;ill of the ntem*-

One or two bougia f No. lOor IS English) are Btvriluo
making fat m iiouf in tiooW Eolation of fonnilia i iWw

The patient is prepared by Inning tin- vulva ami vagina
waehod end douched as juvviunsly described, She >- 'l»i>
pliioisl in the <lnr*il poVitiun across the bed with her feel on
two chnirs. The operator, after stcrilmmr hi* bands, intrc*
tUifv* i wo Angora of hie u u hand into toe vagina as fir n»
the external oa. A bougie anointed with oarboTind nuctfae
rfded along the Satan fnte t > ■- - cervix and poshed

up until ■ 1 1 1 1 y an iunh or v " remafiii la the ex-

taroal otj care being lafc tot in rupture tin- m.-iiiUram -.

Sterile otuae i> then p:iekeil about the bntt of the bongfc ,

keep il in plm'e and t-> (invent injury ufthe p .-!. ri >r v

wrili. Mm t he end or twenty-four hour* tabor-paini have
inti manifested themselves, the nose and boogie d I'l be

t-iMUi t Vi'< I. (hi* V.lL'ilM i l>ilK'1|Ci|, ii|<l niMillirr Imlltfie IflMTtod

Taraier'a method; Tin- consists in the dilatation of the cervix
and the introduction •>( dilatable rubber haps. Tanner'. \>
is an ov&l affair, to which i.« attached a l>m* rnblwr tula- will
11 -i«t|ieoek. Tin- ItLi^ i> lutTLxluocvi by meaii->"l' :i special for-

cops, and then dilated by pumping in Bteriliend water.
B ■-'- bags way also be Hand for thli purpose, though the

bail l*g ill ahapa ami material i> j • 1 ■ * ! . r ■ : > ' hainiteliei de

Rib« .

Many other methods have been recommended fbi the fndoo*
tioo of prematura labor, but the methnde described arepractl-

••ally the niosl commonly employed.

FOKCKI'S

Hlatory : Il i» probable that the nli-ielne forcejsi in ermle
form were employed before tin* (hri-liaii nra. 'I'll'' in-tns

iiniii- Benin In have fallen into ili-n-f and wen practically

menta mwih

unknown in the initlilk 1 Sltfe*,

t'oHfi

;.:.

'I'lu invention of ifa modern laatramcni \* k*rnmilly i*J. ti-
lted toon* IV t<r • 'liiiinln-rlitu, I lir miii of a K true 1 1 HllffOeUOt

|,liv -:■ i:in WI»y had -i'(|!n| ill Kll^lilinl. ThO nlt-UIlM- forcojM
i. iiimmu <l H family BWrtWl Willi Mm' < 'liumlH'i'lan- lor tlim p II

nation* I' was nol till I73S itial lite wrcrt of the ( 'IiiiiiiIht-
1;iu Gun ili leaked ool in England and the obetetrtc roroeiN
in . .Hiii* public property

[in-, foroapa bail ontv the oephalio curve, which permitted

11 tn'in groan of tin- hcml. Later HnuJIti in England and

Lei n : in l'i in..- improved

the forocpj l»\ adding n KalA

■ md carve, whica idnpled

the inttniincnt* to tin oarva
imv M thi i 'Ivicuviiy. The
oVra forcep iply im-

proved modoli of iboao In-
vented l«\ Sraollleand L-mvi.

Dtixcriptioii : Tlic iihnirtrii

foroepi - "ii-i-i- of two into>
looking bum '"'* '"" Wade*
«ioh of whii h i- provided
M'ith j handle to tadluate
bvotioOi
Tin- btada in ueuall? fai
tied, and have .1 double
curve, a '•- fthti/ir, adapting

tluiu in tin- klia|tc «'t (he
i" lal head, and ■ polefe, ac-
commodating loom t" the

».!iji|h' uf tlir iH-l\ ii' i-:tnnl.

I lie (ufiru/.iii if the

nude* i- in the fbi 1 U

OjH'Il llK-k Itl till' Kllfll-ll

IllOlIt I-. h loir (In- I 'onti-

nnii.-il mouela general U have

(lie I'n-nrli loOJC, uliii'li oon-

•1-1- of 1 oiorliHc and tenon
tightened hy mean* ol" a
Blew. I'Im' Biujlinli look, having tli*- advantage

■ ■

1. 1 :i->

:i7(t

"nsrrrnif ortcRATlOXA

.IjU-fni.-iit. i,- 1q Ih pr< t-'irr<l (0 till- l!H>rr OOmpHCOflad «l»d

i^id Freocfa lock,

Tin- hituilliH .if tlif ftmi'|i» arc iiniuIIj

ir.-n.-vi-r-i.h , togivt i better hoMi In the Iwti r modal
Imndlfi an- provided with pnjecting should) ilUoie

tr.iriiiiii. a .-/ ' obtUirk ftmsep* uould l»' made oi

torn pared -■'"■!. polished nnd heavily nickel-plated ttiroagfcont.
The edges of the bladu and the rcneatra ahould be rooofW
und Aroooth. I" England nnd America il»- favorite fan n
U the Btrnparm-lUrne*. It baa the Ifcraw blade- nw\ tlir

»iiii|iM.n liiimli'-- i Kiir. 1-15I.

Mrftei Iim found that lor general uac the i»«
trv obstetric (arcana In Di OiHnafoii'j modal "t the Simp"
ton-Bamoi [Mtrananc. Dr.Ounoron lin» nwdified th*» neJvffl

Km. I8U.

J^

■ niiic i ' .

enrvaof the blades in nii'h u manner :i« i<i pvrmil ■ nodi
ibojy ataorn gragp of (he fatal mwl bring nbtaund than u
lha eon* in other raodele (Fig, KW).

For low operation* | -implp, liplit inntnimrnt, nueh M
Sawj fr'-. i-. i err wefiili

In hijh npuniliniiH 1 1n line of inu'timi mini correspond u

1 ii ■ i"! '• MontnaL

FORf-Fl-*-

::;:

much ii- i-.->ti.l.- i-. theuii of flic pelvic intef Eneuoh

i'|)'-i.:i "in i _ '-Hi :ui iii »\ emotion force ii loal beeann it ii

hnpondbk to gtf the haodlei of the ordinary force}* bti>

MMlBgVl "ii ICCOUQl of rcfltUnce nfli-rcd l»y (bo r*'ri"«.'tmi

tin- dMHculti iiu- ben overcoat by the invention of the

rorapl by Turiiitr. in 1877 (Kig. 137). By

Ttn.lfF- m* trnfilnii forwj*

ii" in- Of i 'in, ii n. I. :ill.i.li. <l In tin- \>:i-r of tiofa bttoV
fi(tiu£ ut llmr lower <-ml- ililo :i M|H<ri:illv rurvrtl (htjihmI
l>:it, U3 «ln- Ii i- ,ill:i. In! :i ii'ii- -bar :t- :i liuixllr, (In- line Of
the (fiction torw i* Immylit into mlalionwirp with tin ;i\i-

brim. Tin' Tiirnirr (iiraem I* on cwttHtraatml thai

lower <>rnl- of tin* fnirii.ni nnl- if* held 1 DtO, from

ii.-irik- the line of ihe pull will be In tlw ftfu of tl»' birth-
no matter what the position of the bfcui - may be in tin*
pelvic,
M»ny otter mootefir of uie-traotion fbroepe have been lo>

vrnti'l. l-iit iioih I. i |.rnv.-il -t. ./I'lienillv Mfi-liu'lorv a thr
Tmfer,

n

: ■ nrt'jr nfKR I770.VX

Indications for the Use of Forceps

In general terms it nuiv bt -f.u.d thai the Mima of ft
woman to deliver uaraelf. when delay in delivery will en-
danger the life of the mother or Iheehud, or both, i- mi indi-
carjoa K.r the employ I of Foroe-pj t" tcrminao labor

Anomalies of the mootunisra of labor resulting i O nitnrc
of lb* pffWDting port i" mlvnn<y have been foil) dinn—id
id detail.

Other Indication! : [naufflcUHtt MTpuIsive |»o\.t\ :i* uti-riiir
inci-ii :i from whatever e:m-e J hi"-' Uod rCBUtO&CC III ilf |mI-
vie e:m:il from lumlcmle pcWlfl I UU*I i"M 01 '<••<■> UB

■ of t' ift etruornfoa; over^fan or undo* oodBc

ill" the liet:d lend ; :ilihunn:il prvxentatloM til |»> ItlofM of tilO

fatal head,ai face proMoiatlon and ocdpltononterloi ponfttcma;

ur,-ii/fnl'i/ •'•/iirtHi'ms, Mieh Bfl r(*l:uii|»-i:i. plaOMIU pr.rwu. ptO-

lapf of tin' fond or of ;» ratal monitor.

Exhaustion of Din muUmr i* evidenced hy n itcadv incmiso

in the rapidity of the pul ■ i ib , ruing tanpornUfroi nd .1
progrearivc fbthm in 1 h*- force of (he nlcrine contraction*.

Dangftr to tho child I- Indicated by (In* f ■ 1 d boari brat*
haonmSng rapid mid weak or Uhm and fooblp.

If in the euiir-e ill' 1I1.' .. i„,it 'Uuf of hl.ni ilif head tail*

to advance, and, - itln r became of feeble contractioiip < ( r from
inomiwd reaistanofsll arreted for half an hour, ths labor
ghonlu be trrmioated by iotwdh

When t"i .1-. . p - ;n- rnnintvd the fbllowfOK condition* must
be present to render the Application of the blades permissible:

1. The os mind be plctely dilated <»r rosily dilatable ;

Si The membrani - muat be ruptured;
3. The child mii-t U living nod viable]
1. The head muii be engaged in Ihc brim; i,r ■* mint
ho jKis-iUle 1.1 i'imwi! the bend ilown to the pelvic inlet by
■ il preai
'. I'ln- head must l»e crl average size and ri.n-i*ten.v. --i

the hlndc* will not retain their hold :
8 I he relative proportion between the head ind the pelvis'

be meh onto make extraction possible with ant;
thcf Mini t'» child ;
7. The position of the boad must l»e favorable ; for instance,

/'//.'< v./".

379

ii i- practically impossible to ileliveramcntouoeteriorpnaftiNi
hi' iii>- fan

Preparation for the Forceps Operation.

In«irum»nU, etc. \ Tl <■ ofaatttrie foreqi-. «~ well n* sneli in
-iriini. nf. mil -mni-' .1- may U« n-(|uired DDT tin- Mpafl of

i.i, , i:niuiis mbacquenl t<> delivery, shoald be wrapped in a

rlun lnwcl unci ImhIi-iI |'..r ten BuUtltCf) uiu-i' wliii-h tln_> muv

\" placed in b bun containing « -• »1 * 1 stei lie water, to cool "ii.

Preparation of the patient. The U,-l,l,, end poofUM dtonld

In eoiptied] eftoi which tie- abdomen, tfi Ighn. ind external

genital* ehould he rendered as MPplfc :i> pomrible. IT there

Be rte iuapcci contain nation ■•! the vagina, the infernal

j»nr-*tgcM should '"■ thorouffhl] scrubbed and ditticlwd »- lor »

Deration, Tlw l'ilitin(_\ of the pcrli iiv.i\ then !»*■

■il h\ l lie i|<|.lir:iiion •»(' ntariHxod glycerin or vaeelinA

W Inn ilic OptftUOO h:i» I" bftClOBG with flu- juitirnt i" /»•<',

A Kelh pud or robber phret nbculd !'•• arranged nnoVr th*-
H - hip* n ii '«» conduct ilJ dieeharEca into ■ imhyV
bath-tub or othei eearel on the Boor, The patimft limb*
ahoald then be wmrated nbou.1 with fre-My laundried w

The operator* hands nnd foteann* -ImtiM IjcMoriliwd, and
be ihould weir cither n ati'riiiaed apron on sheet, to protect

i.- elt tl

Preliminary to operation The (mentor -IhhiM then sit
down bcliiu tin* n«nirnl- nf lii.-. (anient. < !"-<■ i» hi* hand

ahonld Im' jriaood hi- Instrument* find a burfn mntniiM i
weak formalin solution (I : hhhu. u »<■)! »- ^ pfecM of

- ii/- <i t.ui/ • :i iiiriiiiiul - 1 1 1 -| >l > •<( clean towefa.

|:< I'.t. j.r - .. ceding; to applj toe forceps the quality Mid
fretjneney of ihi ,/vfa/ Amii-oraoi ihonld be ;■ eerteJnco and
i in knowledge of the potfuVen and rhataettrot tin- _/"/<*/
A..r./ nbcainedt For ihi- Inttcr it may be occrantrj to paea
tin entire bond into the uterus j hence the nathrnl should be
;uin'-thc ti/<«l before niskine? thin ixamtnatioi). Any nai-
pofiition of tlie head should then lie altered if poewble bewm
tin- ikppliearion of the blade in stu mpted

An.T«t.hi»h i a It i 1- |>-« — «1>J«- to <>nipluy lh» nh-ti'lric

fnriT|w «ui»fat4orily ijbW tftit patent iW

id' xn aiuathatic. Kor prolonged or difficult nm* ttawe
ibooU bt-Uaed in ■ -i omtVirni, ami it* adm

t ntni-lvd (u J innliod x^-i-Unt,

PoBtor* of the Patient
Tlw appIEc likm of tl I, .1-! cii- i". pa Able *ilii il*e

S!l :ii i-M H'-l M: lis-' dOTOll 01 ill ill.' kit UUtlAl P-MtUOU.
i i tluit the application of the firecp* U I
lit in the left lateral than in the doral pavilion; but

tin- difficulty i- i ■ h thao rml.

Generally ■paekioftj tin? lateral position uilVr- nuns adi i

.•-iirriully If lllf OpftfatOr lack* a hlullud I - ■; l:mt. Itl

i- pofllttoii i ii ■ Rraht do not raenrini to t»

I. Tim application of both blauan » eccompJUhod n

i ii/!it bond, while the finger* ••! the i<-ti band phtt-nl
within the vagina psrve to guide both th*i btadw
Daring traoHon the perineum is under ouetani abeorfiiioDj

ami extraction i« wwrr ami sefir.

Walcbere ponition : On account of the Inoic lilHl

of the aaonwliafl joints in the latter mantba -<i pregnane] i

••ert.iin limited amount of rntntKm »f the aternno h ponftwla
ID rtnlaBftXi* pa-Vm* through iu noood vertebra.

ATut experimenta with the live inbjnct end "itli ihr

OMAVrr, Wnl.-hi-i' ili-nwii-t r<it<-«| t lint l»\ |il:irin^ tin' «iwn :ii

full term on a table in tin- il-ir^i! | motion with the botloela

m 'ii -life, nnd the lower limb* hanging ma ■■
i jaunt'- iliaim-u-i i- lengthen**! by iroro one hall* to

one centimetre. Thii iMn-mn- iif tli<- patient U known an

\\ tlohar'i poaitlon. Tbi puoUira out* I Lilizvd

toge in high roroeM operation* or in uifliniili vvrnIoM,

The Forceps Operation.

Than eM two methods of application of the foreepe That
known aj the QngU*h mtthnn i« » »> tpplr the i«l idee no M to
anrrwpond {•> tin- tide* of the |»cIvih. .,uii.< regardbanv of lhn
: ion «»f the hcncL

The OanHnnnUU metfod i- to apply llio liloalnc to the *■ iil»--

of ihi ahUcft head rngndliei oTUm pelvuv

WKCfit'S

3M

in

rii. pelvic application ■>(' the bluoAN — f, .,, the Kne^Ii-di

rilio<l — i. Ofl ihr whole --ill ■■• ;in.l IhIIit, h- le« damage i*
|K**.|l»h< in ill' 1 tiiSlti-nisil -oil |>:iH-

Tln c. |>h:i!ie Upptll .iti.ni of thr MjkIi-. — i, t . the t ..iilni.nl.il

method — should only l«' employed bi axperienaed ind opal

..|H'r;il»r-, u- it i- ihi> ni-nv ei.ni|ili- at.. I 1 difficult*

The vperation ii divided Into the nipA, the prwrffwn, ud tin
/«ir, loooraioa i" ili" potutioc of tiic bead in till 1 pclvit

In tic bin operation tin- head laarrenfed ntorjiuri enga g ed
in i In' pelvic lirini. In the mafias) operation the hand i->

;irrr-t..l well within 'If ptlvii cavitv. In Hi. I,,* Operation
ili-' head rwt- iijm)|] die pel vie flitor.

In btjh oporatfon* tin- iiNU-truction forcop* ahould be cra-
■ I.iimI tin patient flhoOM be phottJ inWnleherV |h wit u,n

until the hfiitl Im?- been drawn down brio the pelvlo cavity.

I ' iiiic.it is non convenient lot il pemtoi and bettor

for the patient it' *hr be placed on a tabic lor the high Porcepfl
Operation.

hi medium MM low operations (lie patient RMT bf plscvd

eitlier in Hi. I. ft biorel or in fhe danuJ pu-iiiim, whichever
Is ninn- convenient forth operator

Foronpn Operation in tho Denial Position.

The patient having been prepared for the opentioii| ii

plared in tb* domal position, ncm- ■ flic l"'<! with the hmtorhx
I , . jooting ilighlh 01 01 the cage

Support of th© Hint** When asfeouite in not obtainable tn
hold tin- limbs, they may !«■ upported n in the lithotomy

I ■ [tion by motUM of a rolled *hcet pii-wed im-b r th'- DOOR
and OVM one shoulder, having the rtnK tVe-ti'ii-d nt the

patient** knots,

A brUti 1 method m to plnce i"" ordinary wuoden chain a

•hurt tln-Ci • aparl with llicir h:i<-L- bo tin- tdg* of * In- bed,

The |mlient'> ktire :ile (Inn fliwed <>Vtp |be lueU «if the
r|i:iii-, [bldou tOWeht heme; m> |>l:nv.| a» tO DYOMOl \h% (>"|»-

hi.-il rtjrjoni from Injury, Tin operator - Il 1 tefng tie
patient.

Introduction of thu liladn* . Having m:nle :m inf i-rtinl ft*>

ami nation and having mttanad blmavlfafl *<> the exnoi poaltlon

fiftSTKTRfr OPH/l I770.VS

oJ iiit> fatal bead, the operator solei ta the feft 01 ton* . Made

Of tin* t'nrcep*, which he gr:i-p- « lose to the "halt with tin*

flngero of the '-/' Aemoj. bowing the taatrtimejrt u In nrould ;>
pen. Tun or mow Queen of the rtpftJ Acme! are ion ted
within the vagina, uml if possible) within iho cervix* their
pnlmnr anrfluM being iii oontael with the ehild'a head. The
linger-* art- currici ,i> high a*, it i- possible ta Introduce them,
Hi- 1 the imiiernal soft porta held outward away from the head.

Tilt '<// ''/"'/■ S| HOI /((/</ y«. /» U'Hrl'/ilJi, |<. ||n- V\i.|!Uh'-

bndy, uml tin- tip in guided ulmig the linger- <»i the right
Ifiinl within thi- vulva. No force i* required tu intrt«hiee
ihe blade, which is guide! along tin- fingenof the lot
hund, by slowly sweeping tho handle downward along the
Internal mrioec of the mother^ left thigh. This blade when
in [Mt-iiimi 11-1-. ImIwitn the head and i In- Icfl lateral wall of
the pelvis.

The tijtfitr btndt in then held in thorryAl hand in ifmflar
fashion, and is guided along the linger- of toe left ham!

within the vagina, the handle being depressed along tin*
mother* right thigh.
The forceps are than

toward the perincon and

ti«»n. Chre should ba taken nol ••> include liairora portion
of the vulva in the bite of the lock. In guiding thx blaoN -
into poaitioh it is important in Imve the linger-, of the ioteruaJ

hninl introduced as fur a* \*-- il.l. nod In pn ■ ■ I hi matenud
t ir — Ml'*- Well Id DIM BSdO-

After locking the forceps a careful internal examination

should he made If uncertain ii' a good grasp of the bead DM
been obtained, ami that nothing but the hend has been ID>

nluded in the bite of the f"lcep». The fa miff en ■<*• (ASM

tjMMjml linn' the l'«"l. with one hand. the finger! being booked
.i\.r i lie prnjiTiing shoulder* while- the back of tho hand i*
directed upward.

Extraction is effected by steady pulling, «'i\ l-eiler, i>; excit-
ing:! flight |H<ti(hilliiu movement al ihe *;\uw liinC.

1 lie lino of traction ahould enmwnond in the iixiv "f ih<<
pliine of UlO pelvia in which (he head ifl engaged ; tlltM in MjgtR

vptratim* the line of traction i- directly backward i ■

respond fee fin- ;i*i N of the brim; in mtdium openrtkOMJ MM

locked by ili'iiH't-inij the handle-

Eeutly rotulinu the blades into pwd-

WWt-rx

m

iradioo t* dlraath Borixaatalj vthOe in ta now

!'!>■> r>l m» that tfir li»r»ll<** »r» n< ... |DV rd iftv

mother* abdomen.

Tlw ir.irit..ii- - '•• >t,|. I In inUnnm#ot. like thn mttiau 1 \ u
A nod rnl«* i« to pull for one niBUtS un«l then B9 I
two, taurine ill*' itiUT*ol* M i* bettor r<> un/ixNt /.'..« ; .,
...i. i.. r. ii, \. ih« head from pneuurv and ul«u to favor it*
mint inn n* it llfTlltft

Tnwtinn, whoa MM thi perineum beelnj todlsumt hum

mwie vory ouvfally in wder to avoid the nddoa aejaotal ■ •

Tin- •'•<" >•;' ' ' - bould I" 1 |n>:i\ miH'li bnrisnolal until
tin* ... fHoofr under 1 1 »«» pubis an<ii. liter ihu

nOOUrntl "" f'ttfh'i li<tif ii.ii \^ n«-v.irv, hut 1 1 ii- iit'.ul i--l«iulv

iiimI r* refill lv extended by panning the handwi upn*M in the
iliti'<*ir>u i»f the mother'* ubdimieu.

Wii4'ii ill-- '»"■"' eon At ,:'.-t,;.-i ,„ 'h. pffiin \>\ pi« hi
applied from behind in (be roeo) %ca\ rojrion, the forceo*

lie BUltlv r.'iinivrt] iinil I lie hc:i>) ih*li vnnl WtthoUl llicm. Tin-

h i I ' >> Id ni potulitm hv graaping it through the periBeaca
in tfi the l**l"t hunil. On "•> aoootinl ihonkl the fingen be
inaBrted i»i" UV nun foe 'hi- parpune, u ii ii 'mm^i— tj
; ii.i dangerou! to «1" *».
Whoa the bend km & Wd m ponfifo the M&dei may b*

removed in tin- reVBfBB order of their iip|ilii':il(-m. Tin' ultim-t
^I'litlriii'-. Ii'tiihl In- i>iii|ili.*yi*il in theft iciii"\:il ( :u l( | qq fafOC

anonU be exerted if uny abeawhi l»- eneoantered When

l-i'iilli' iii.kiii|iiil.ilii>n rail- i<> hl.'u-* .1 tiltiik i' should be left in

place natfl the be nl 1- 1 liv«n-.l.

After tlic (breeja bttVO hen ivnmv.M tin- ht-iv1 mn !*•
delivered b) prearar© over the perineum.

Am :i ^rim-nil nil.-, ftmwpa uporutiom arc performed with

<ivr intra, henra the frequency of laceration* of tin*

a ttte r na J son parti following their cmploymaal

Axl» Traotiuu.

'" high 'I't.ii.m axle-traction forcep* *l 1,1 i„. ,,.,. ( | (

tfaoogh a certain degree of bxu traction mat l btaloed with

foMepi ; u will be deeeribed lat«r.

Ui idini iohkI «tni fun-t'iM blade; m*)i ni'i'"'*''""
in ;l miiiiciiI i- u-.d, llir l(K'l(-|>itl \n icrvwnl UMinVrjiU'h ti^'lil.

I'lic bar oonncoUng ihe bandfoa ih iln-n thrown norov IoodmI,
ami i!i«' s row tight" nod until tint blwlra have poooretfl ■ firm

bOl tint !«». lifilit HI\T*T> uf tllC fn-t.il lli-wl.

(hi tniriiun-lmry unacr tlic iAhuiIm ire then loosaood iad
tin' |m riii. J hiifKlli- niljiMtol (<> them nnd looked

FORCtifS.

m

V ii> t 1001 it.iMini;' that a |ih>|wr urijMif lln licud ha* Ihimi
■ >Ihi::h»I :iml tlinl tin- \an<nM BCfVWfl urr proiwrJY wJhttJtod
without llii- ini'lii-i'»ii ol iMtriiDti- < » I" vulvar ii.-n< ilw pjitiuit
ran \w pAMOd in llir Wiilcliur puxition J i >■ removing tin.' Mili-

porta I'nuii her liiul>*. IW plume Inrgr block* or I Kt

under the [oblt-lcgi douw fi pontoi tin- table ou be

i .... ::,u.

fc.vv^

Trmotl"ti with a«UinwiI..o f.-rcn*-

l«»o far ovvr Omm^Iip? wli«u Irnirtioii i- cmtiihI.

b* pollol

ic line "t

nirliiiiM in mii h :i man hit I kit (liu bnttocka "ill J ■» «t )h* pulled

vit fin nhng u It. i
■iii.-tion -limilil In- UOWOWanl :tinl lmi'lv\v:tnl :i • htr :r po tbl*,

th. iniiii.m hhU bcioc kept nbonl A qimrtwr of mi iMn from

ill. -iiiini.- throughout the pull I l-V- i 19

2*tW0«n tho traction*, the OOOSfOtinff-bftr DetWOff) llic

3»

n.rnst artcR.w ■•

ii.iinllc* abould be Bucmred and Un pin lock loosened in

order '-■ relievo tin- fhztad hold fhw utinued prewurc.

Wln-u tbt head baa been drawn down to the peine floor
ihoft t- no forthei urnd fifth - the W*Ic Itien or

1'i.r llif :ivi-!i.i.'!i««!i roil*. I In- p iliciil niuy thru I- pluen! i»

tin- ordinary poaii , lbs periuenl hukDo m ■■ «!,

tnd chr hu'-iKin-rtKl. fastened En tbeir place* beneath the

hl:|i)i -, tin' FwOUpe llli'ii Im-iiij; (i--I :i- (lie < Hrl inurs IM

nii-iii. Sumo operatora proffer Enrernovn tnoTarnlei m-

tiii'iil :i- MAD II thi ImKI mohM tli< pelvic ROOF, OOnpIttlM

tin delivery l»y meaiM of Bawyorti mjuhi forrom.

In blgb OpfinlkNU :' '•' , rl:iin inii'Miiii i i i (ion can Ik

PXOTb I With tin 1 ordiimry loan forcups. I- Pa 01

GfllabinV manepuvn the line m traction r*n l»' hnmglit to
oorrovDOod fairly well with th« mil of the pelvio Intel

Thue by piv--niu' or pulling downward with och band

placed u- near fit" -lunik- M poaaible, and by prewing or

pulling upward with il»<> other band on <li" handle* imh

■ brought io t" LK'iinii, with tin- til'.', t tiiii ■ K. -

rcaultanl acta En the linoof daaoeatof the head. The (broo

by thlfi ni:iini-iivr«' t- n-cil i- >f\; tin- li.'ind prut ping UN

I.- being the fulcrum.
In employing thi* mun-invre tlw p-rctite«t can mu»t Ik*

arcrofeod to pi'scni tho bbtdoe -lipping.

Forceps Operation in the Left LsUnU Position.
The patient is placed Aomowhal obi lonely loroM liw bod,
h iiiir on her left aide with her thtgha well flexed, •!.« blpfi
being brought well over the ri^hi edga of < t ■* - bod. A foMr»l
pillow inn* be placed botuwMi Iht kmr. to keep the tbfaha
aenoratad. Tho operator -ii- Hiring the pntfentV bultnak*.

Tin- preparation! lor ilia i.pn-.vdnii :in- udii-rui** tin •iimr

a* montlontd in dealing w Ith iha application of porcepa hi the
dofaal poaitlon.

Inaortiou uf tho blades: Two finger* of the nperatorV Irft
wind ore inwrtwu along Un« pn-i.i'i.ir mill nf il«* vagina,
!linmj.'li tin- cervix win n [Hwinlc mul well new tin* pn -- ni -
injr p:nt, pivotfas ill.' lii iiptMi i lit- brad B^nbo, tfhfn

ilir orrviXf the |K«(erior nd lhc pertavntn an

n! book u far n possible "»t <•(' ili«- w»«-

r

Fonrrrx

The farm Mad* being bald In tin* rfahl hand with the
i" ■!■■ !•• oura directed backward, o thai the tin • >! the Inatro-
mctri i-. in QonfiBd «ii!i the l<ii hand] i- thui Introduced
within tha regfna. i •• Dusitllana the Introduction of the tip of
the blade in tin- (M^ition, (In- handle miuri !>•■ held Ion down,
f»rn.-.| iri.- i.i itn< direction Of iln- ^hitc;il Intel of ill.-

eiliem left bottoch [Ffo. i EU). At won u the flyof the
lade ha* been euidod In the finger* of (In- left bend ovic the

14ft

l\

lv*lilon of iwtlnu ft>r forwr* -h-h*"t • <»•! »"-i*' 01 lAtdMhi MM*

c(»n\<\iiv nl* tin- brad tin* ti'Hiiifr is reined being uve|4 np-

wjinl over bSe raothert rfejfll thigh, iiml Iiiuill> kiokward am)
downward, until the (thank IMfa behind the operntorti hit
wrist The handle » I ■ ♦ pe Uironnrh near]) wrce-quArtera

of i circle mi iln blade i- being Introduced and puehed up.
Tlii* in. , Mm. ni of the handle oenaer the tip of the blade to
•weep around end uiuler the head

Toe finp/rv of il» trfi futnd remain En oontnd with the head
throngnoul the inacrtion of both bladt •. <l"' Stal blade befog

0M8TXTXK 0PKSATI0S8,

held toporitimi nftor it- introfhictiun In roting npin ■■! tin
1mo| of the \,-\\ wrist while the eeeond u bevng onnipnleted

inlo p0Blli00<

'I'ln- upper MmA fa then grouped in the right bund :< t !
tip introduced Into the vulva ibove (he molt ol
butfe with the pelvic eurvo dtraouid forward. Tin tiu ie
raided Into portion <>\<t tin- e»nvexiiy <>t the head by Ah
fingers of the left hund |I'V 111). XbeAantf& hi then wrenl

!(,Ii...UuIi.ii ..I I In i.|-|- r Mm!

downward unil fowls wnrri nNmp tin- mother'* left thigh, thus
OBOeing tli" lil.-ule to m..v<- iimnm! tlm upprr -urtjicr 0* the
heed t" tiilt •• if- |».-iiimi opiKtsite flu* rn-lit ilium,
The second bloxte, having been placed in position, ie naed

M " Enido in looking the handles. If is held BtCOOf while

the fin-i hhule. which may become displaced during tin- Intro
■luctton of the fceond, is manamvren into position M U to
look (Fig* 149 .

Extraction: After e semination to w that nil if* secure, the

oneratoi'i grasping the hnndlee over the projecting shoulders

r,.M':..'.v.

399

with ha right huml, q.wtu traction ■■ Tar bsokwird hi (">■■
sjblc, »t tii" rum linn.' *tci»lviiiu the [mtienl'i Kipt wiih bit
Ivft IiimkI. 1 >< i » i i - iwinii iii ill.- l,u. J |»wition tbo

liitmUc* Jcseribe ■• noriiontftl kit from I. i'i m right.

i ... u..

vs

rofwfa it. |.«iii..ii Ti«.'im. ^ •■(■ of tin i>rlm,4Awi)*»rd ind iw***ni

M.i-

Wliri ill. it. 'ul (bd t>C retainod In the distended ponnnum

lluj (bnsopa nmv I..- gentfy rcntovrd mnl the delivery Don

pltttod truflOllt tliem.

Forceps In Persistent Ocelpltopostcrior Oases.

Ordinarily, \v\wn El i- DDOMMn t<> NtiiiiiuiIi' l:ilx»r In iih'ftn*
nf ill.- imri-jv- tu |MM(«riiir poAitionD of tht nonipiil, ti (lit head
,. ir<V jl.-rnt licllin- flu- in-.i nimontt) Rrv uutamni, uitd El ill' 1
ill. t If an itiwnu»tfw] nomplpttfty In unlocking ilicm utir
Mah !i:niivi- ttlfiiri, ill*' occiput will !><• bronchi li uum

•.villi ill.' jH-lvic 11* M»r lir-t, .unl will tluiH rOUEtf |m tlH) I'mnl

v. id. nit "(ht'i.tI iliflinilty

Whm ioUUob forward of i. an fafli to cafco tiling

Of linn bouM i far pop- I m-wI'I%ihj '■!' ibr

i<:cl to iM-rUf.

jTui noffmal inaduutUni nl d< p fatv i.- |>m

mi:-( U Ih.mi'- mi ini:i<I, Mid the (■•:«■ |»- - - ■ i

inii un . rbi Una of traction should i.- in ill.- j\i- <.i tl.
vie cavity— -tlmi i*. hurltootallt — iiniil iin forehead VI

Hiiflirii'iitlv t<>r lln glabella |o jir.nl imiirr ihc publC MVJ1 J

I lie ]i;i:nlii'- an* tlii'ti mi- i! 10 ;i.- n. . >i IDC I i»- Dl : :>••■

perinemn, after which the Dw n. doli en i • If by

. v t, n-1,. ti of tlii bi id

• tin... tdi gfaMia loi pivoted Bhuit operator* prefer to
remove the bladoi unci deliver tin* Ik-.h1 duumUt,

Foreopa In Face Presentation*.
In posterior positions • •( Hi. < din in Ami pr—nhUtofll ttSa

fbroapa itc contrtlodkatad.

In mentoanterior position*, when natureV effort! are iomuF
hcienl to complete delivery,, the Ebroepe maj be emplorerii

Tin' lilmlr- -Intuit! Im> iipjilii'il lo tin- hide- (if ihc Hiilif- need
in hiicIi :i uuv Bl In -c ■rinv a firm RBap of tin OOWpUt '''" »

torn "lionld I wde turritontaUy until ill" ohin in brought

under the pubio arch ; then by retains tin- liandtee end a ii h
•mi (Hilling, the head i- flesnd, bJuu sweeping the fiicc. v
inn! occiput hm< <■• - -.i V4-I i over the [M'titii'Min. "l~lti-« mm wewt

i>l ih i ma should I"' rnntii' (nth greet ili-lilh-niiuin, mni WDCfll

a ■ itian of Lhe perineum tokei plant and tbreaiena to extend
into the rectum u lateral morion should !»<■ made i« Ofda t"
nvuitl this troublesome complication,

Forceps in Breech Oases.

Indications: When in breech ease* it ie impossible to rcneh
I foot Of to employ n fillet or the flncer t ui ffl «lowu the

I'l.-.i iiIiml' part, the forr»'|i» nmv '■ i I Winn |**»ublc,

tin' axle-traction fbrocp ih

Pin- Kiasp Of tho bicci'h

Up of I be blade* over each trochanter and below the ibao

WU.ii il.i- Ik.I.I .-ium-u ■« I, tin- Made*

sold i»- employed for t- 1 ■ i - puipo

Ire obtained by placing ibe

h, \s

:;m

i*< Introduced bo thai ■ " ooatael wftfa the aacrum

tod DIM itnnri of thr ri.il-l, whih- the OthoV El ill con toot

\Mii. iIk> |mi.(i i-i,»r surface of ill' 1 opposite thigh, u« rooom-

i.i. nil. .! by Oiii. :. .

The aiUrcoming head bafl oocatfooally to be delivered by
i<i the failure of other method*. Tbe application

I ti.-i ililtiriilt, prmi.iVil the chlhfJ body i»

held n|» over the abdomen of the mother by on a»«i*tant.

Tho Danger* of Forecp* Operation*.

The forccpi judiciously and skilfully iiK-d should oeldom
■ toll in the production of scriou* injury to either mother or

When furerp- ip|wniii.nis sire imd.-riiik.-n In un -killed
operator* and in ratsuhable cases the most dlanntroui eonan*
opener* may follow . the UtCffUl hu beta perforated by the

• it ihe blades; tin* cervix nnd lower otei DC legnical

have been lorn ftWOJ ; the prlvie joint- ha vi 1 liecii hprung
:tp:iM ; while nio- 1 r\i'ii-i\t' Vajtliwl hierrai ttm> :in- not in-
(irijiiiiii. :i llic nuiilt of Improperly perforiniil foTWp*
«i|i)'tritioi]-. Tin iim-1 <'<>tn limit injiu ir . . t . : I:i< ■ i :i ( n . r i v . in. n

m I* ■ - ■ ■.:* n-'n i', of i lie perineum and carina, ton certain m-
jurii - of tin child'* IimiI ihe n-nlt of comprertion ui the;
M.ul< ■. i '.iiiiti-inii- ond abnuumu i»t" tliu fnoeor ■until nre not iu«

ln.|iiiu( :nnl OOUHHionally liicinl p:tr:tl\-i- iiuiy liillmv pfl

li pi in fiiriul niTV.'-lfiiuk- Inlr.nr.iiiuil hcitiol -t'luij*** arc tint

ini'i. q -u :ii in. i i..ii.j»- opera tinn*. Such hemorrhaga any
i. -nil [n ra ltd death ol tin newborn child, or, If nurvived
to idiocy | heminli gin, • pilepwy, etc, < leva ■

tilly the mnl ni:i\ Im ground the I'liiM'- tiri'U, |m) Im «ii i'X-
.l(i |in"-.inv from tin- lip of the hlmli- lli.it (jit.-il

..-pli- ■ . . i , aeur

VERSIONS.

Definition : Tin- grnrrol t<-nii i « , *fon in applied |A HUn ob-

Metrie operation! u are dn igned to hrinp ul i am altera

tinn in tod relation nftbe long axu of the ohiloft head to f'»<

Imic .ivi« of the menu,

VarietieB- Then are three vnrietie< of veniiona:

ODSTFTIi/C OPERATIONS.

t'-f/nihr, (taking in prvmittfofi •>( ilm heml;

, flf llir liteeeh ; :iii.|
/W<r/ce, Of "tie "I* \n<\\\ I'rrl.

Mctiodi: There !iiv three iiu-iIukI. of ptHofOmiL' \ei -imm :
frlrtrrnnl rcr/n»i, whieli i« mviuii|ili*lieil I > v manipulation
llimn^h ilit- altclnmen ;

ttipolar portion, Moompllshod hy external AIM lotefnil

umipvlfttioiu combined ;

liii.-i-wil i..--i"..ii, jivi»Hi|iIi-ln.'(l l>> (lie inlrfKliiftioii of the
hnml within the uterus.

External Vcreion.
By BMM of oxtornftl vcrilon either the heml m 1 tin- lirw-h

.-:iu in- mad* tn pr o aant »i tin- ptlvle brim, li k probably
tin- -niipir-i :ni»i nfeai DUthod ox ttrnifigftt than bj pnao-

liejillv tm (ljUI£l<r f'lill. '<•!«■«! with it.

Tin nnnv |ir.ii'(i-c<I fltr .»|m nilMf i- ill :il»lniiiin:il ptilp:iti<m

Ml" ihfl prognanl ulortu tin mow skilful will In* prove in ihe

|Hl loi nuilirr .if eternal version.

Indications: The nm-t QOfnmOD imlie.-itimi lor < <.)ern:il

verelon i-* breach premutation, when diagnosed daring Ihe
Ltttu week* of pcegaano; while the irtdieattooa tor thai

form of version hiv in l." nend tfce WDic 11* tin I*.* that. Apply

|Q il dm forms, the diet that ir emi U- employed only '>•

(,„•• >•{■• u '" fif in labor limits it* avaltabilitYi

Conditions for' external version: The momblMMM bould b*
IntnotOV but recently ruptured. The uterine sin) abdominal

mil* nhoold Ih- lux mel the child freely movable. TheM
conditions aw only pre .. -Hi before the onset of labor or ton
early in it> oratTea, In-nee to those periods Iho oueratiod n
I in triad.
Preparations: The bladder and roctum ahonld be emptied,

Th«< p;ifient should h* in the ilor-:il deCUbltUft, with her rliijrh-
-li^hllv Hexed ;ind the lienu ami Hliulllileni inpi-irletl hy pil-
tonrSi 'I'll' IxInTiien kIioiiIi) Ih- e\|K\He<l nr enveml only l>v ;i

sheet) under which tin* ImncU of tha npenitnrare oboes! \u
■iMBthotifl i- not required unWw the patient i- extremely

nervous.

l/A-SM.V.v

Method of Operation.

Tin" flnri duty hi* il peraioi \t Qateftilly bo mop out the

bn OCOOlrir'i l«v il ttilil. Thin is ilmie by palpation,

>iijii)lrm«ino<l iiv auKultotion "i' the fatal bi

II. .!|..ni.| iIm-ii plot out (In- in.iinriKiv lie tliftnftl tO 0'V"iu-
|.li-l] ft. .hi bodDnfnU In .-ml. ImIiiiv uttciiiptifu; lit dlftphoo iii

mi i ij t in- t ■*■( u>.

In |.-i iM,:uiii(- axiom*] WTflfon llir moat important point i*

to kivp tli.- \\v\a\ ovoi'l int.K'i throng) tout the operation,

The uianormvTe* : Tho operator place* ;i li:m<! on each iiul
*•( llir RVtlJ oVniil, Willi llir pAlRlM (ju'iinr :unl the KngeiV 01

one hand ilirv.-i.'i toward ill'- uti-s of tin' other. By ihtij
alternate fluxnin or ilu* Rrunm of either Imml 1 1 ■«* version n

eaooninllfthed. One fund give* :i move 11 of iaomii and

rlii< oiIht n iiioviniriii of dmrent, aaoh aottau alternately.

I'h.. exfrenlt) of tin fatal ovoid N is desired f-» brfos
down i- made i" follow the ahortari route which will bring il
int. i proper relauon»hip «itii the pelvic brim, Should ntcnn«
contraction occur during the manipulation*, the ppet ■
be content i" liol'i tin- (''-in- in ilu- n<w!t!on gaSnod until n>
laxaiion oomirt, whnn the oiwrnlion may be nrooMQwd fftth.

\\ lien the fiiiii- h;i- been placed In the dwircd potttion a

\:i'-i:i:il f \.niiin;it ion should !»«■ m:t«!i' to :i-ci'i !;n n wln-lln-r till'

presenting pari is properly ovw the inlet.

To nafcun IhtJatuBtn position until die preventing part hnt*
. ngcuEtdi longitudinal p;nl- eompoeed of (oldi d towebi may be

ij mm cither dido •»(' the tortus unit a Brno nbd uud

lea* applied

ly, when external version h;i* liven ourrir<l mil
nt"t or the onjd of (ubor. it in udvisablfl to rupturo the mom
bnncs, no tw to favor the retention of the fatal in it> m-w

DO) Hi" il.

Bipolar Version.

Tltr chief advantage of the hipolnr method U that complete

diiAtAtion of tl ervix i- unii"-' 1 - u * . i* by this method vi-i-

n -hi be Bocoraplnhed u non n I mi;.,.-, can & nuotal

Bipolar vonlon liiu tin- disadvantage thai it i'ml. u K ive

tiiisvFTiiV •tw \rmss

the opemtor —■■■-!• "Uitrolof the Pi-tii ^ <r<ii u.ii <

inti ma) method.

ThM form of roMloB U aluo known a* the Brwrton-Hick*
method.

Indications: Ptaeaita prtnvia with l>ui partial diktat*

thaoeh riven it. most bcst-l kaa* the chid Indication f»r

etlootlc fiMi method of performlna, Iranian.

In du . ixpfii ii-in-r ..(' (In- writes 1 , the verj tad theft the pi
cento biUutlodin thekrwei uterine Hyment amfmfnoVain^
the employment of tbi* method, »s, wiili only two liiipri
tlinnigli lite oh, tin* prvecuiUnn purl cannol bo Mfttiniacturilv
reached , for Ine mh Ic Intel in ooonpicd more or m* be Iho

lilllkv plui'l'tltU. Kor llil- IV;imhi in placenta pi:*\ m, wluii

voralon i>- nealnune, the Internal method ■lioufil b

mid llie 01 dllfltod "lilil tin* wliolr Ikiiii) ran hi in! n«liu« /! inin
the Dtaflia,

Other htHenlitmt for Info method UO; abnormal prorata-
tiofii or porftfoni of the bead, lucfa eu Rue w brc* pre

*'■-•■- and profa] f the oord, vrlioo dtagn srrr in lalnir.

It is also vet) u-< -iiii in tnuavene caeca, whether it ii deaii

tit Urine tlnvvii tin- hnri-h or tin- head.

Conditions Tor bipolar venlon Tne Diembl ><>••* shuiiM 1«-
initii'i "i --■ recently ruptured tlmi r In- ohlU is still frtyW'

in. .v il»|r. Tin* cervix should admit i«<« flngert, in. I the

i be capable of containing did operator^ tmn-I if i
sary. The nterfne and abdominal «.i!i- should bo lax.

Preparation: The pattern ahoold be prepared nfon fa
caps operation, Sin- ohooM be placed In tin (l»»rvjil |M».ition,

the bed, with her hip* ni the vder, the leg* h i
ported be chain. The operator rite between tie pollenr 1
thfgha, :i lit ii having well uterlllied iii- benda and forei a
The >\'< null bend ban Em kepi from contamination by wrjit-
|iinj: it in a -u rilixi <l towel

\ii;iMthr-i;L Ih dwirable Imi not ni'r*"-Kirv, provided tin-
vogioi and vulva arc lax mill the patient not nervona.

Method of operation: IMirrt proomfiao to BBrrmV, the
dSaanoau "I the position of uh (ortiM ihnnid he confirmed by
careful external and internal examination. The detail* of
enofa movement of the operation should then bi planned n

I KKSttlKX

that the ••iwmtor bin di-iirly in mind oxaetK- ■feati Bfl vn«hea
in .1 ■ ■ pi b by hii muiKcuvrca.
in '. , in which ii » ■'■ [own

ilx i fhouU be movod in the dirvctHui in

ipiii |».

Mi-- l.nv the liiinti, the piln of ■Udl pdiflbl in tin'

ilinvti,»n [n vhlon Ii r <lr*irod M mirtv tin: prcx-nting pari,

idooad through ihn «-r« ix. i prtaantatlon

j- I.. i >. A. mild ii i- oeatfed to brint; down the !»:<■< i-h, two
gain muf i!i. Irfl hand ore inCroducM within I m • -tvi*. «l-
mi right hand pn*MM iluwn llw Urvwih, through the alMjoininaJ

wall Tlir viT-iim I i|>li-ln.I Ii v ft Mtin of aid mate

jmi-Im^ Willi either hand, t 'arc -IhhiM at ; ' '•> nipl I

the n. 'iiil.nu. -, -li.»iil<i llu-y Im> ini i. r 1 1 > r * 1 1 » f....i or li*^ ii
within r Mvh of the mtanwl ringvreit the pelw* brim.

III eurr. |1 -iiil pn.-M.'ntutioa "1 ' I hv

. anbmod manipulation the linger* of the Internal hund pu-h
■ ii- mrl "i the Ratal bono upward and backward while

tin < \li-in:il hand, Imviii". loOOlfll UN QQOipUt through the jiIi-
clnminnl wall, emliuViir* I>> t'onv the virlrx downward Mid

forward within the peJvIe brink

In mod cm w, if th«' membrane! hnre not raptored, din
lAeu&f l<>- bnhn tit wm in the pojUi'.ui ..[ th« heml i itlu-rt-'l.
I'r MR -ImhiIi! iIicii Ik i maintained upon the fnndn « until the
vertex ha* beoonu' (irmly iri-,^,1 in ill. I>

Internal Version.

ThU method "i reunion \$ moat onmmoatj employed, ta •'
i. probably tin- most rapid and effeetaa] mtj of wearing
deliver) when the bead <• not engaged to the pelvie brinii It
i- the moat dangtrovu method <>< in rwinn, an the liand muni bo

(Jaeed inin the ntvrine eevity in order In wine oof of l«>tli
ii :.
Indication*: Krhmip-ia, plmvnta nnevia. threatened Aid*

den maternal death, prolapac of the ■). ind aorfdenta]

hemorrhage ma*, be mentioned aa industkma fbr thk method

of vi- .Mil, « proudly when rapid deliver*' i* de«ireo\

(jih, i iinli>*i(i>.iw are trnnavone preacntatioQa, ino*Joratc
|K'hir oontrnotiun, pruliip-*!' of fn*iiil niembai
ol the H'i'i-,

' nit ru'i :

sna

bra

Condition* for inUnul »«nuon The oetvia imi-t i» .lil.-iti.i.

nr <liliil;iltlf ; tin 1 Uelvitf imi-l I" IffllVtClltll iinir-i! in jxTmit
■ i - -_ i-*» i'[' tin' sil'ii r-<«iuiJM^ lii'.ul, and tin- in. in- inn i mm

in- teunicalt; OLurtntcted about Lheehild. Th lition *f

th.- I..U.T uterine - ■jin.nf -iiHiii<j btaercrtaini <i I i ioo

u ittomptc-i, .mil tin.- poiiiioti of tii- i' in. non-ring uolei, if

it be prvrttiit. Tliir fain* imut not be impuetcd in tin (telvi*.
but should be vufTivteiitly itc^ • 1 ■ I ■_- r<i permit tin- pn icllting

jmrt t»> bo puabed bud.. "II MM Mould be triable.

Prcparatlonfl : When jn»vubh» the path: 1 bouM In placed
-n | labia Am opttfltion. I'rcjiunitiuiii nluniM bi made i

:i fiiri'(-|i« npi-ruthiii. Tin i ihotllil i.|...|::io

rOXldtftU niiii-rj.ii'-. Ix.iiil; jIuivmimI .im;iic<l Willi -!.rili/.'l

flv.-rnii or oil. The mom ■■ ---!■■! muiUFptio for *ach •-.<■
vw»l ororoolmykfl tin- batanoc* have lubricating nualtticH
ninl ronaor too employment of glywriu ur «>i! nnntii

I ;- u'i'll t<i Iijvm :il kind -otii i/.-l b:iml:i^r-m:i

01 lm>;i<l I.i|m in i-ii-i' it limy Im' n.'iv--.nv In Ufl .1

about the fetal limbs tu fiicilitutc extnn'tiun, I'hc i
■hoald bo anmUutitett, and fbi - purpose Ghloroninn It
Dsaalh re intended u bringing al I better uterine re

■ mil tflflD rllnT. ll is ilr-.intlilr llmt tin- UUBfttlCtH! -Imnl-I BC

admin! toned by a medical iMtstant.

Tlir patient -l M be olaoed In tin- lithotomy position with

her Mps at tho edge of 1 1 »-■ bad or labia. Tin- operator, « rtfi

hi- li:in<U :tml arm- .-u-iib/'il anil hid ClOthlflg protected DJ ■"'

apron, sits or itandi facing tin* pntlonL

MuUiod of operating: TI10 JuA cJSeu 111 llic Operation 1
rniifirm llir dtBgt* . - i --. uf I III 1 fii'fcll (xmil'mil liv :i • -< inihinnl

internal sod external examination, Tin various ■'» nj of the
n|H r.iti.ui ..t" turning the feotui are then planned, and d detn-
Mun moda it- 1'> virion hand -hall !»• Introuud d into tni uti Mi-
ami which fbol of thfl inl'imt <■ i/.'«i

W I K-n the lung axil of tlie feetua is in the I""'.' &xh of th"
the operator ahouid httroduct th* hand whh
in ili- »i>h of th* ui'itln-t toward which the /<"< aUino pari U

ttfert, TImii- mi LhO. A. ur K. it. V. poaliiooa the left hand
i- Intfndnoad Into ibr ntorua. In such eu*e* the interior foot
should always ba nlsod. In CMC of duubt both feet may be
brought aowOi

VERSIONS. 397

When the long axis of the fcetus is transverse to the axis
of the uterus the hand to be introduced is the one which corre-
sponds to the side of the mother to trhtch the breech is directed.
When the breech is directed to the mother's right side the
operator should introduce his right hand.

In dorso-anterior positions the near foot should be seized
and brought down, and in dorsoposterior |>ositions the remote
foot. Thus when the child's back is directed to the front,
seize the front (near) foot; when the back is directed to the
back, seize the back (remote) foot

Before introduction the hand and arm should be dipped in
ereolin solution or smeared with sterilized oil.

The hand, with the tips of the fingers and thumb placed
together to as to form a cone, is then introduced through the
vagina and cervix with a rotary motion. The uterus should
always be entered with the palm of the hand directed toward
the abdomen of the fcetus. The hand should be pushed
steadily though gently upward to the fundus, where the feet
are usually to be found. A common mistake of inexperienced
operators is to feel about for the feet before the hand has been
introduced tar enough. The foot can l»e easily recognized by
the prominence of the heel and malleoli.

The external hand, protected with a sterilize*] towel, should
co-operate by making counter-pressure on the fundus, in order
to steady the fetus as well as to press the breech down, so tliat
the feet may more easily lie reached.

If the membrane* be found intact, they should b* rvjAuml
and the band pushed quickly up, in onler that tlie forearm
may plug the vagina and so prevent mw* of the liquor
amnii. i S fcwiftl nirrinc contraction ownr, the hand with the
fingers extended -boo Id lie held quiet until relaxation da-
ta ken place.

If the thrstfdrr be f*MH*l imyrttd in the pe]vi- ar.d %U '/»?«

prolapsed, a noo*e of gauze fond*?* ht ta|*- -h'-old he »'i|.|««l
over the child"* wri-t. and ffcn the ift,;*'-;Mi may l*- renw*H
by gentle upward pre-rore f ;po». \\a \*A** >>i *b* P*fB-.

Id rvforin? an iBUAetioa of 'he ra?a« *}.'-. -»f:.«- r.U- ap-
plies as in :fc* r*#ivery u of 4.'; ;rr;[«w*i ?>-rr.J». "Tm f*rt
that haaeocEK «V/»"i U*t &*t»A '*■*- w.:TZ.*A £.*--/* '!>.■-• tfc*
□pward pt* J wnr* *ty.d>J £r-f. \jh app.aed 'j, *tJC Y<r'vx* of u*

QBftTBTHl'- 'OSS,

fatal niuiv.t ilir pelvlo Kuril. unrl than tuooemMlf nlwig

btnlv until tin* ji|»'x of the r] Idol U ran -Iii-ii.

\\ iii'ii 'i m run- t/nifiji <>i <ht d boen obtained

El i- draws ifaadlly down iuw.it. I the i I. boboh]

liniiil in ill* -.iMir iiiiir being ontplqyed In directing 1 1 * • ■ Ik-.-.!
toward the fondua. Tin* turning movement ihoan only In-

ni;iili' win ii the Ml* rii - i- •mink rrliixrd.

Tin 1 n|irnilioii m;iy \w >-<>n*i<lr,.<l tUKH/OpUi* wlim I In- ehlUft
liive.li i- efUMged in lln» petvlfl inlcl. \\ In-ri (>.<•. ihl< tin- (***>
■fcoultl thwi DQ Wl U) n:itn:i tOCOBkpteta the ilrlmM.

.{ll'-r th> ' >u,n >•/ vrrtttnit tlir i<rl:il In -art -liuulil I*'

iiii-'MilfHt.ti itn>l I hi' cviK'nil condition ul Inv nioUHU i
BUBodi Bboold < itlicr lie ul I'-nilt Uir «im' mIiuiiM Im' tcrnii-

mtod bg taptd uttraotion of the Rptoa

Knr detail- ■ '• (■'• the vnrmii- inctluMlH of #j*/WjW*'o« '</* fAr

brweA, tin reader ii referred to ti>< awtion on thi tfanagotteBl

of Itrccoh Cases,

d*Dgf-rH of [sterna] veaaoci an Im r*twm or rapture

of tlir DGBfttf tr-iin tin* I'liiplnvmi'iil of DOatn RkVBj taDUR>

rliji-,'1'. -Ii.m'Ii. mill ftibflcqncal MpeJ from nnoleanh ■ al um

lime at H|>< ■rutinii. In ordftT tu proVWll tlir- litter tbe wtn

me oavtt) should bi dawned with n hot antiseptic noladoa

lloriiiuliii, I . BOO) U lOOD U ifat pUcCXltO DM NMD ■Mivurvd.

SYMPHYSIOTOMY.

Definition ■ Derived from <» . -. <>-•■■. i foJnt, :im! rort/j, a
rutting, symphysiotomy ifl the term applied t<> the operation
of notion <»t the symphysis pahle iii .1 woman En labor. The
.1/1/. w ut the --pr.rti.Mi is to Increase the diameter of 1 ■ in
trnotcd pelvis, and thus to permit the deliver) erf a living
child through the natnrn] pm

History: The operation was fim pvrfoniii'd mirncveTully t»T
fifgSJlIt, in Pari*, 111 1777. Il w:i>«riimjiiimliv(*r« popular dn*>
ing tho rorly (foeadef of tlm present urntarv, hoi ml into dia-

itii by 18&8.
In IHUtJ Ilir o|M-ni(inii w:i* «ti«i wfully rrviv.'d hr Mori'
if N:ipli'- 1*1 wlivitu 1- iliu- Uw «!iii'l' < T<i Ii t of the improved
hnirpii i.l flu- iihhI.tii npi'mliiHi. Ii WMS nintnulin, ,1 mil,

si ;/.•■// j. >/i//oj/r.

399

by I'iiuinl in 1802, nod ww finri penbrroed in Anwrioo
by Jcwett, on SrjM 80, 1*102

Rational* of ftymphyeiolomy ; Tin -• iparation of tin- ■vm-
u-.. i l.-ri./rli. inner ..f tlw r!i:mi< t.-ri of the pelVU, tin 1

being the a> ranted mat) in ewacquenoi o**oa

ctiai ■•)' the pubic bono moving downward n wall n on

iiln-n -4-|*inttitl I'll.- - 1, i .hi ,■ iikI i nil- i- tltif In
the Bust il»it i-m-Ii iif iiif •oiTo-ilim* jamb rotata upon an
..] .1 i.|ii«- tin running from above downward and f nritboufl

iiiOTni. A »»|»rationof ;icm.(JJ inches) cnuM»a dnoi-nt nl

2 in. | . Inch) : —a ill farther -!■■ i I bdnj < tiuacd by the don o
mnrd nvnmmra of tbo fitul lu-aJ. The ■aparntion or uic
pubic bonce alao pcmlm ibe interim parietal cminenci oftine
Ratal bond u< pnyed Enta lift inatrgMrtae apace.

ThoB&ympnymottivay n mhi in enlargement of the p
canal by 1 1 ■<- npaniioa and descent of ilic* end* of the puWc
Ixmh ■-. and iiv |).riinniiiL' :i pmitimi'iui.' "i* ilir foctoJ bead to

•H'riiitv llir iiiU'i -milne muuv.

Indications: N\ in|ili\ -i<ii(iiny hold- :i ntaoo hetwOt'tl ( :i i

in -..'linn anil the minor operationi or forcena and veminn,
It i. an operation deaianed to wore the birth of n living ;"i<l

i ;..u. . bild, and ha i bief rival*, in i krati degreca of \ «

narrowing, nre the mduetion of praraatun labor and version
or for. ■ i ■* term. Tbc following oonatituta the eWn/mdioa-
tiont fbi ■ » rapbvi iol )

1. Simple lint pelvca with p ennjugntn vera between 7 and
9 em- flfi and 3.1 Inch.

2. Generally contracted pelvc*. with a eonjiijrnta vera

i U tad 10 am. '■'.- and 3.U inch. .

:t. Impacted or taadnoibni rmnf«i|M>.t<nor poaltiom of Ilia
Mao,

4. [mnented oceipitD|Mwiorl(ir ponHEonj nl tin- perl ■•..

Anki I"-j- or any dtwemed conmrJan of the nwro-iluu Joinio,
and ili«' | »f Infection conlrAindicxt* tin- cniention.

TIlC time !'<ir M|>iT?llttHl i- ;it tin' r»iin]ilrtrnli ">i ill*' lu i ' ■

».i bubofi

Preparation*: The rfufrttfWUVl required fnr llic operation

an i a common fenlpel»a ■lightly curved, Wunt-poinfed Ma-

murj , i ' hdbi iti or i Paal f koifi , q metal female oath

-. ocedli .i fi h ba anon tt tfr

>■

TV Matwiaa a ^ eWafc aboaM afa» be prgaartd . iodufcnn
«rit». aardtrt* of ihwrtwnl a<D«. suture* of rat*ut,
nlkwono-fat. sad Ulk. pwkiConn and boric powder 1 1 :
*«X*cal drrsMajr. ottliivl ul ■-l<itbfW rxu«- rbtftl

«Oon faaU, all of ikU *ht«iU be omitted.

'a«4rf ti i aid be pfov»k>l | tar dr» i^uv,

and 1U1 hi aii r of rtniagt eullofi, «*e, belt of ratita*,

ti**mi*t aiih tv<> ..r threr betod -trip* */ ilu *aaw tmi.t'a]
afovaitd with «ul.lr b*cfclf».

TW poavatf cJaaoU be p W UTwl aa fee an ahdorninol ojUBr-
lii*, iW paliir i**"* 1 4»veJ, aad U»r vagina Mrriliard A
»uilU4r table- i hwald br rr*Ki«-.
daring* la* cfsrrainHi. Thrre n«*i*-tant* at*- reaain

lM a aJ t i< hHk, aad two I | ; • pal

and pvc what other htlp the operator may rtqtaire.

' rfioo »iH>ald be prec ared in rave of aiv rv
bcaaorriiagv oc jauvk, and other saita' tativoj should

I' !i!«l al»i ho aaaV fur ibr>i«aiMi%liii]<'iii i>t'

maJiailmi ■boold tl* child ha htn a* phyxutta

The operation : There- an- two

iotoniy, It* Icalinn ami tin I n rtrm.

Italian method: I 'h. npn nf thi- method BfO ilni

i In Hound i- tnorv nwdily ItpiH from in (< • liuii uftpi own arj
nod tlml tin Kindlier ami uretbrn nrr h*- lialili to Injnrj
during tin- omnrtlorji

The patient] bovine been anamthettaed, in placed In Um

>Ii- with l.> r il i_!i- ---mii what
Sojced nnd iiipported by two n— ^tiuib*. Tbi iperafov then
oof kite depth, direction, and Lhieknei of tin pubis and

loortai il otral oppression <ni it* upper d nh»h

indicate* the position >>f tlio rymphysU,

Sf.ui-li i In- rju'lit-linnd adc oi th< patient, the openrh r

mnlccfl a vertical inoUiun an inch lonf* in The abdominal witll
torintimling a1 u point 1 cut. (? Inch) bclon tin Upper
margin "t" the -\inpliy.iv. The IncMon ihonld extend

h. tin- BUpOrllclal UMClt. An :i--iv| :1 iiI tlini itr-Jl

cpjthotof in the woman'" nrethrn, In»l#3i nj^ It down and to one

Mvi'i/y.N/MRi/r

mi

sM* mi •* to U? etenr nf the • . mphs sis The attachment* »f

tto redl to the pobai an khan out innloiaat!) t>> naruft tin
EauodiKftJoo of tin EwdhifBA The focaaami of tin- left
buni i- ilii-n la Mtud Into the wound ami nmh down behind
iIm- -.ympliv)-!.--. Oeoojtlonalrj the fatal head on prom

■ ■• !.i the nobea tli:it ilf opcfitoi mtjr (iml iftffieulty in
Inm-Mnt,: hi Mhlnd the itympbvitt*. In inch cam the

tfHii If .i«! -Iiniild 1m- pUffa*] Up OUt of llif mi l>v :lii :l-i-[-
lUll "i:li In- RlW«r* in llic VU£?Dtt.

Tin rvtrnpnbio m--u< • are a pouulo*! bj the indi i-fingi

It i* |ii|.)ii'<l OOWD Im'ImipI tin' -_viii|>liv-i- :ui<) boolnd UIhIit

i in* mbpubin liesmpol The ourvw Uhu\v of the <;.iHii:iii

Lntn :• (Inn guided along tim lndex-&0ger nf lllfl Iflfl band

uito a poeatfon behind tho joint, aa Ihal h- tup pa»«M ih><i<-i

the ■ooptiliii' li In place of the tialbiali knife ;m

ui.l:n;ir\ lilum-|>-'iinoil, ili^htly curved bi-toury mny lx*

'1 iir- faint stnirhti [Im'U dividi'd with :MI li [i vi :ir il. fur*

wan I i miring movemonl of too Icnffa. While tfac Jofnl i

bohii: ''<ii thmogh) tha Idt <•( too polvli drauld l» uipportad

by tKa iarinfanU, in oftlcr (»• inrvnl the iMnU of I he knii*

anting t"-' much. FVagnSntlv one (afli t<> oal tha unb-
pnblo Itaamoiri in '-iiiiiiiL.' uirouM tin* joint. In which cane it
xlionM Nnunvdiaton !>'• wvored by meant of :< hlnnt-jMiiiiUHi

lii-luilfV.

r.u:ili» picitv ..... n Kmorrhofft followfl the lection of tha
Joint, but firm packlne; of tha wound with iodoform

inv:iri:tl)iv rli. :■!<- \i .Mi. r th<- j..int ha* bcrti dividul the
nr nioy !*■ removed tram the uMhrn

While nooanionnHji n woman mag be allowed <■• deliver
If after tin- -vn.|,ii. hu boon dittdodf uh n gem-ml
nili' it i- bettor t" trrminatp the labor atOOOfl by fom
veroerL

Outing th« tUHoen/ tlio jiMintunU should M<.*rt firm Intend
pre«snri' upon the p*ctvii» <•• prevent boo wide Kgatctttion oi
tan publo bofia* ; the bonce ihouldnol bttaQowenTKn ••■(•iciic
more than 6.5 t-. 7 em. (2.6 !>• ■_'. 7 Inohoa}.

u ha» ill-en mmplfied the pattant'i tlm-Ji- ihonld
bo axtended an-1 hoi lowe* hron-thi i<*Koth«f. Thi operator,
aAet Imvlnji wajtbed bit handaj removal the nnn raakloi
■

OB&TBTRIC "/'/■;. \THWi

tV-Hil tin- Wiillinl rl li. 1 j.,i-.- Iii- l.-f It'X-ftngel hcliilid lliu

to nraki aura thru tin- bladder baa not been caught
tin- bonea? Khan bevhwj checked all bemorrhaft, u*
the wound with three of four deep illkworm-ffirt
ROtom M<> i openuora eoruridor It unnccewwrj Ui atwnpi

tn KtttUM llic bODM together : Min- or [WO future.-, however,
limy be placed mi a.- In include (In- liliroii* n--iie Ml the Ulll
hoi -ui'Iimv nf tin- joint,

Vaginal ittul VUlVltr hicenilioii*, if (iiv-m »1, urt> I lien r>»-
|i:i!nt), uml I In- Madder and urethra • EttaincO for [»*viu]i
Mijiiiir-. 'I'lir abdominal wiill i* then itrc.-r-.cd will: ii rtrip of

iodoform aanxe and onvarod with lavere of absorbent eotlJ n
Thi» lirwKiiiK i* It'-lil in place by means of one or two broad
strips >i' rubber adhesive plaster wbiofa pass well behind the
wings of tbs pelvis "'I ( iii" r ids

\ linn ootton binder lb khan applied, • »■ ,, bread canvai
bell which oan be Retailed by racaoaof Mnijw uud buckle
The patient bthen removed »<>.i t *« -* t with i Hem tevd mat
tre», <4iich m would bo wed lor a. fracture case. It i> ad-
vantapcouB toeuppori the -mI.- mi the pcivi* with - ;i mi lia L »>
KAehiiig from the kneee i" above the waist. The paticnri
knees should U- tied together*

French method: 'I 'In- chief advantage of thU method U thai

on Rooonnl of the lnnp Incision the operator can mm what he

i.- doiiijj at each step.

The operation ! An faottfoa three inche« lone; i» made heirjn-
ininjr on the aUburnim! wall ono and "tni'-huh niche- obovs
tllC -.ympliy-it and extending dflW nwanl In I In- elitori*. The
el.;. - i>C I hi' won ml arc -cpai-ated by retract. n> and flic I ESW I

looution of ilw mnphysu determined.

lii i [ir.'tn ii- . .'ii.»n .';:■-• ■ n. i- wcr ami then 'I'*' upper
rmugina of the iyninliv«iK are Nfposrtl, An index-finger ii
then ineertcd behind tin- toini win* to detach the retropubic
tissue*. A broad, flat, grooved director in then guided along
the index-Anger behind the joint, either from above down-
ward or from below upward, The joint is then cut from
without inward by means of u Ftirebeouf knife. During ae
livery the wouml i packed with iodoform gaUBC W preveol
(kimiIiIo infection.

Afar delivery the wound i* uilurcd with strong 'ilkwonn-

MW/WM Wf'M/r

got, tin' Hututv- befog m poned ;»- i*» inolude < ti •* firm fibrous
outer covering "i 'in end- <>r tin- bone*

After - treat ran nt : The idler-care of a -.ytupliy- johnny cose

i~ usually very tnubUwumoi the oiffioultiei being t«» keep » }*•-

WOUnd trout infection and to prevent npa ration ef thei n<l» of

the pubic ixMit'o, Then ip u-ually very oonaidcnble cedent
od tlit- vulviv prewnl for ■everal deyi after tlic operation.
Special attention ihould be i>ni<) to the tmlit e/ th* nifai.

ficnerully (In- mi lii-iiT iim-i W' liM'tl fur »evcru1 days cootl

time it ledoeired to empty the blander* A utrong u- iinni

shouKI be ut hnml to support and lift tlio pelvis while a mirw;
slip* the bed- 1 tun under the buttocks. 'I he kocoi ihottld )m*
kept tied together for two weeks- and (In- patient kept tl:it 00
hei Intel for three or liiiii weeks. The Milling inav lie re-
moved on the M\th lo the tenth dllV.

Mm mid it Ik: necewnry to il\~tnj-rt ttui partaWenf eatud

during the nuerneriuni, tlio patient'* lee,s should I I

Htrafgftt in the air without bending the knee- and supported
by an av-i-tntit. Ill tint* way wlciii-wr I n ; 1 1 1 1 1 » n t may lie

leipured e:tli he eai i led ohl without euindfi): the patient

tinieli Inoonvenlone*.

The p:ili- 'til ma) he allowed lo *it up in from three to lour
Wee k- lifter lh. <i|wrat ion, hill -hoilM not he allowed In W:d It
ahonl inneli lieforo the nUlli week.

I>juii£iirx of aymphynintomy ; In Italy ft 1 «yiiip|iynmtoinic-

hnve Ihhmi uerfiu'wedj with hot 'Z maternal deaths. In
America 1 the mortality in l- per wot Under favorable eoo-

ditkmi and at the hand- of skilled openitor^ the iiialerunl

di nil rata ihould be almoet nil,

Kailurenf the seiwrnled pubic Urne- lo unite B1M leave Afl

u an with khdc Cooeei in tin joint, end cripple her pow

of loeomotion. The ■CTO-lUlG joiutu may he damaged by
wide a wpnrution of the pubie boiler TrouoIeoonM

hemorrhage frequently takes place, but can uenally be eon-
broiled by preaanre and hesnio^tiitie mi lure Vesieul mid
iirethnd injuries have been reported, The anterior vna
wall h liable Co laceration during extraction of the child.

In the opinion of the writer, the chi.j d I of «ym-

phyatototny i» the great d Mum I ion of the internal oiyniir-
.'lueli :u-ei>iM|HUiUM forcible 1-vifaet'n.n, Not InJreqncntly

101

t,nsn;Tlitc "fif.-iTlOSH

th«w cAMfl miflVr liter Anna pmlaptn "' rl, ad aooowri of (hi
lax condition <•(' tlia »tniritin- of <'»' pelvic outlet wrhioli
roniwiu uto tlM operation on neoauol <-t' the pubfc bw
licinif eauamten 1 ; tlte whole mocha niton of labor i
willi, mi ilui! lln- Iii-iiil deanen'lH ilirnujfh ilii' pelfs) in a trmr
vf»m position, the ocraiiiii liiilin^ to rotoU to the front
or leu daaunze lo t f i»- pelvic fascia reeultaand fi&s to undergo
proper repair, ?<> that the woman lifter developa ajatoccao,
reotooele, or even » prolapwa uteri

Failure l-irjirn I rigid Ji-i-iitir pnrautionfl iflerOpfJbV

lion nap trial to injection of toe wound with mi
sequences.

CESAREAN section.

Deftiutiou I ana rami Motion may in- defined n* mi obn tei rk
operttion for the delivery of i mature fatna by mean* a
incision tbrougfa Uw ultdomimil ami uterine wall-.

History: The operation <lati»* from prehistoric time*. Tho
lir.-t i..'(iplr<l n|ivr:iti"ii u:>- \»-i \>>i i » * - - ■ I l>\ a I>u(c1kt in Svrit-

nriind, h 1800. Until the development of aniWcptlG armory
tile operation ma mtto nd o d by enormous mtatity, and wan
only performed a-* ii laat raaorc The uterine metafon waa
formerly I.-t'i iiiiHiitiirctl,j4 it was Hiip|H»«<il tliat i iroold

not huhl on Recount of nterina oontraotJona.

Singer, of Leipnic, luu dona iwobebly mora leas anyone
elw to perfect the modern opefatfoOi In IMS Im ittnwtd

thll 1 1"' uteri lie inri»ion OOnld Ih' .-titnivil willi -:iJi'1y provided
ihf •tiitiin , -in:ili'ii:il i-mployed grata -t.«nli. rMnot i'tJ'l tlCOU thfl

mortality attending the operation ha* been iteoriily redi
Under nvoRLbla eireuosataooai tad :ii 1 1 ■<- haadii of -kilfiil
operetora tho maternal mortality ie about .'i per cent; bal
in general practice the mortality, according t" Hum-, ninp^
from ;'.<> to 1" per cent,
Tin* Lafflcatlon a for thi< operation in iv I..- ■>'■.-..,!.'
An abioluto Indication i- t In - |>n senoa of iome condition
lucli tvnilcr* iiii)»>-mM«- :iuv other met hot 1 <<f delivery*
rant 1 decree* of pelvic contraction (eoi mki 6 i

fm.}; niarkcii pelvic dofonnlty rcauldng from iwtcomo]

and -.|»"ii.lylnli>iii« i . foraigo g^owthi obatnwdng

•f aam

oVa* eftoaJ U th-

in* p#lvir nun! ; tieairtetal
mmnomt </ li* «» 11 <* »f la*

I reUtlre JBfWrllM u tW pfBBtt

■ hirli oak** tkuUfal tV «lrU*-rf} ml a

it |h<>«cvm. In inr rxw> ihr «or»<Km la

■ whether ' Vxirv«a -vrtica or nor ..f the alt*rna
tsoni -• ■»•»«», fc*r»j»^ t*r»ar«, craa»>4oa>T| will
•eeure the Uwt rwolt* The iavftivfcaaal pervlamtW-- of twch
aie« it aran* noat be ttodied before a Jevitsuai can be made.
In geavral, after cuomlauioo with « camfrtrr, thr icriiriiD

the ileriaion to tan anoam or her niMaaarf,
ha\ing explained T--. them the aatare of the oaae.

i'hr eonirooo*rt relative indkatra* are: a riajnpilii a'
€ Co ^ en. \£\ t->3| aafatea): and tatoorv whir* <**■* Imt
aiodrretc degree uf prlv*: uhvtrurtiou iFitf. 117 V

The beat time for opart! Ion, worn tlu- ... :- »irh

I a tbk ••(* (Iht axpaeted Jala of Ulvr.

:

Preparation* for Cesarean Section.

The pxttent. i! |- ■■■■ -IiimiIiI I*- tiauVr otarrvaiioa for

aofne dayi before iWopecatiofl i- .mdertalsro.. I hi hup thU
poriod lite iirun' -ImiiJiI !»' lA-.niiiM-l, (In- diet n -InVii*). nnl

tot iM.vr*-l» can-lull;, regulated, General toflHaj r-i*» ialW

tr • -liinnr, -li.nilil 1*. giren daily, if there lie .mr in.limti.Hi.

!'li'- the operation the patient ahootd \w

.1 full il<»-. ..!' motor oil. or half an ounc* -if" EpaOCB

-alt in n lomMorfuI of water* Tin- abJ oan ca and put*. -

noold I" shared ami -runticd with a *oft brtuh, tfneron i

■;i, :iml lint water. After being thoroogfcrj robbed

willi jitt'olinl tin' abdomen i* l«» W ■ I will) ►.N-rilc \*n\tn<

ami u binder applied.

If tin* patient i i> and untible to -!.-■ \>. aulphonal

(gr.x-XT) ntybo glvon In mum broth or milk The fol-
lowing morning th* pattenl may bo given a eupful of broth
twob bra tin* operation. Ff the bo well ham not been

freely timvnl, an enema of torpeatinfl and lonpaucai (gj Bo I j]
Bawbfi given,

fori tin- |ttdeni \s placed on lb« operating-table aho

should I* calliciiM/i'l mill lh«< nhdiunpn vuU oil •«•(*!■

OBSTETRIC OPERA!*

flimllv t-driliml. The vagina i> titan lightly packed wlih

iniiuf. triu t'.Tii/.*.

Aftm the patkari I* puuxd on iIh- m|« niini^ hilpii- (In- cIh '
:iml itiii/li- .itv i;<ivcri'J with blanket* nrotwin
towela, :unl i large piece of oJerfllsed pause eonpaaed of four
thick oc i arranged KM i" ">vit the whole bod]
ohwl to kneea

The nauaJ area w aoa 1 and neNHwruw lot on andomtna] ojm fa-

tloo should be provided in addition "• 1 1 *•• following imim-

aiciiU :
'2 scalp*

I piiir ol' nnliimry HeissortL

I c!i./i n arti rj -foroepfj

I pair of nstntotoTB]

Curved Bad straight oecdlee,

l nevtlle-uoldw

\ large thin-wallcd rubber tube o- i uterine liputure,

SHI., ill, w..riM--j H . iiml .'iMyiii Ini -iiluri-s Hinl lipitim .
POUT rvnalrtantft :tn roqnirca— ■ toffivG iln- :iri!i>llnli.'.

Mill- lii eo|M|Ui>.- flu- n-|'vi.\ Mini CODtrDi In-Mint ilint-r. oik- In

receive ind attend to the child, and um i the operator

throughout ii»'-- operation.

The Cffisarean Operation.

Tlir «|M'ni(nr hr-t nils si -lii in the kbus* exit jading from

the jiuIm** to ii slimi ilisiiiiicr above the umbilionai

Vn incision i- thru mode in the limn alba cxleudioc
;i point '1 eni< { I '? laches) above the jhiIm-- to n point the aune
«lisi;ui" below tnc umbilicu* The peritooruf cavity iatban

Opened With tin- muni |iivv!ii»fi<>ii" Sunh mm inri-iiiM i-

-uiii. ii mi n.i ii.. in trod notion of the hand bihI the withdrawal
•if thoMiihl, Miiny operators prclor, howrver, to extend the
nlrilnminnl inrini.ni to n point above the urabilious, ud I"
turn the uteru* out of the envitY hefon iro wwa it.

The udvnntagc* claimed lot tnia fa/ta" ndnoo are 1 1» aavituj
•»f tunc* better control of the iiterue, and tlmi it U cower to
prevent flu- enininee of Rmda into the penera] peritonea]
cavity. It' • H- »■! \*ii ntiivi***- tire: the ureal length of boa lb*

domlnal Inotalon, winch prtdiapoara to hernia later; and tfte

JthAS SECTIOh

107

gl»*ter niimt of mllicMniii. uro-iimni; lain lietwotm ill* al»-
I iiul wall uml tin- nl.-iu ... for Ul«M rNUOIM th< I: ■■

lull I- IftlltT.lIU !<» I* |>l«|. i : .

Having oxposod tho utorua [*• view, iln- operator dim pauwaa
i ptoceol rUDOCI tublltfOVOI UM I'ttmlti* :iml HOWO I" dir

l<»mr imnnni mi thai ii "ill pnarclfl the uUfin bolovi tno

)•!■ ■. n r in - |mi[ ..)* tin- mild ; i In- pimm ere fivi-n to ui) 11 i I

mil, who, by «■ ... ir:.in ; / (i.i.in.ii. oompr oo aw the uterui and
-I- :»f I n - n ajralnai ine -vnijili} •!-, ilni- controlling hemorrhage.

\m mciaion t. (In n iiiii'i'- into the utortik extending from I tic

fiiiiilu- t-i jn-i ulxivti Ui« rvtraotion-rmip. Itiis Entuoioii muni

bfl ii i:i- 1 '■ ijuirklv :nit| liidilly ill Mllti Of tot •« vi-iv liriiioiTli;iyi'

Extraction of child: The operator then plunged in- bud
lota the aavity of the <n« m-. punning t<> - *tn- ii«J« the ptaoente
if it be encountered, win - ilia obild by ;i fool, nod extra

lid • po able, While the uterine incision i« being
made [ii. i " . ii ihonU preni the abdominal wall <•• Ihe
't the oteroe, to prevent the entrance "i" Ouidi Into the
peritonea] cavity. .'V* soon m tlic oliiM is extracted the-
■ r. 'in- i. oelly contracts. \V/i. I( <u,- child Ii n (indrawn from
iliciit.ru- ii Is given i" tn aaeietanl La bold, wMIe the opera-
tor damp i In- ' I in two place* witfi at tar) -forcepanod ante

bttCWOMl llirill.

Tfce placenta i* Ifaee (rasped on it* fata] normae end
looeoned from i - ottochmeni by elmplj nueestag It rhe
i iii-i nbrai iw tMHil off frum the uterine mul oethi plnoenta Efl
» itlnli-iwn through tna mcurion.

Should the Dtonu loll to contract pnuterlv, ii ami be

aUmuUUd by ll i»- application nf hut cloth- lad friction.

it i- ill. ii lifted out of the abdominal cavity and n Inrgp

pi. c. of HUH dipped antler it to I ■* *l< 1 it ;iti<l ;tI-o lu prevent
tlic uitf-Miir- protruding.

\ ■:. tunc iodoform powder bee been dilated into tlie

cavity the oterina wound tx cloned hy DUBflSof aHli nttarQ

ThoH ■■■!■■ ire placed >' intervale of about !..'» am., or
iboal hnlf nn inch, and iboaM tneLntb only the muKiilaraoat.
Ihe peritoneal nlncfl are then approziauUed by ■ aacood
if interrupted ntl Ntoreei pbwed at aborter batervnli
tlmn iin- iir-i limr, \iV-r ii ■ i fievo been Hcd thcve

itKSWWiC '"■' /■' ti/oss.

»hould M 00 li'-moprhap' either from I lie- wound or from the
ii< ■r«l|i'-jililirli|r»-/«. \\ lull I In- llh-niir wniinil ha- hern -iltured

ilw elaatiri lintorv around iho aorvli may he « ithdtawOh

Cloaura of abdominal wound: The abdominal carStj tkoald
then bo Bpongou dry with oh oan ac l uth kpooeoOi portiottlar
attention Doing pold to (bo roool Iboanj

Having relumed the Utorno U) ihe nhdomiii ... and

placed il in proper |m»iiiim, (lie omentum i- then tu lw brtjllgftt

down nn<i onrriod bohlnd inotoad of io rrooi of ii, ia order to
ovoid niiK'ntiii adhoolono.

Tho abdominal inoiaioo i* then elooou in tbo nana] dsobbov
ami i aoivietJ drawing nppliitl. Tho vaginal puna H thou

removed and a vulvar |i:i>l applied.

AfteE-treatmtmt : Tho :iit.-i -1 r>-:itiiM ni ahooltf bo UUOfa tbo

*ame as ftftof oof obdotnbia] operation During tho Biol
twenty-four hour* it may bo DOoioMuy to giva ■ kjrpoolonnio
injection of morphine (or the relief of pain. Tho oniW nuu
I..- po( la tbo broooi after twenty-four houn nova elaposa,
special ntt.-nriiiii -h<-nl<l be riven to tha • ana of thfl voloop

in order Co prevent infection o? the VBglnt.

I In' :»lMiominal suture* may be removed from the truth to

tbo fourteenth day. and tbo patient ma> !*■ allowed om of Ud
in tbeond of dine waeJnv An abdominal ninpoit iboald I*-

WOTii for fix month- after tin- opcmtioDi

Porro Operation.

Tu 1K7H Porro BOffgfetcd that the Midnmry Gbannim opcru-
lion should In- supplement* d I>* \-\i\* "utfiiibditm of the ninn-

alone, with the taboo and ovai

Afitr ampiitnii-ii <•/ the utcru*, two methodt of treating tlw
fftump an- available

By tin- extraperitoneal mi-ibml tin -lump i .fm-d by

louir noodlofl and rotnfaod mi tie' lower angle of tin- wound.

It* tho intraperitoneal method the slump [a aewed over in
lUCfl a manlier »* to cover if completely with peril. meum,
aftov which it i> dropped into the abdominal « ■•■icily.

Tlie advantages of llie Pom operation MO thai it r. mler.

8aa0BQjHon1 uterine liamorrlinict* or conception impotanble, and
dooMOJOB ihf riak of puerpafAl infection, while it adds nothing

to the dainjer of tin- operation.

.-/ ihCnOh "F t>i:su i;:t> ut-j

lOfi

la-Hation: GatUohy*t*roe< J . >>r 1 '. u. m Motion,

indknAed hIuu labor lia» Xhxu prolonged end uftlpulatioov
lie. bean attcuntod U»«*ciin- uVlivrrv. I<ut havr laili-d niul

»-|i»l» i- pfohfthk ; "Inn lb* ulfiu- Of \U Ulpeodllfm :m mi

M fefl hi ir.|itri :i <-i 1 1 >-.«*< j tit-li C t •jmtsiI inn Rir linir rcmn\al ;

uml vmb eny coadStimi \* pn wni winch will rank* it impim*

ulile l">i a rliiM to li- delivered lUtWMMQtJl DJ the Mturjd
[Hi r^i>.

Tlir pr*par»tiona uw ilm ■cum' u* for Cmmrvna tfWtion (
« icrpi iiini U>< following iiudrum n Ua nlmuM bi vMed to (be

ll*t pVfn |UiVIiilI-l\ : I l;il;n. i. .[■ I iiiii.J

lufVV |h In I< -r:.,inp- :! Lii'j. \..l- t |lnili i'.m pftj J i |g||| .«Tm1 *
li-fl uiii-iiri-iii-in <*U( - ; :mhI I rigbl Hid I li-ft IBUp-poiDtcd

lirh -m rtlli**.

Man : Th. .lUIcmiiml wi<'i-i..ii pboaM <-vi. ml ''mm tw.i

In- ;.lhi\. (In utiiliili'<u< tn jn-I nl m w tin* -Miipliv-i- Tin-
u'.-rn- i- «! IV ii ||p ■ Q| of the ulidoinen, and ;i -l.-rif.' touol i«

iiiiM tin- )•' .-rii-.u. I.imiv t' prevent the enem] Ftha

1 III tllCll tlr.HV- ill!" •-(ll'fV- 1-1' till jI»!mIIII-

:::;! :■■ i i-m cloK abOUl 1 1*".' OGTViX, WfaioB li. (IMni lirhil*

n iih I >< >t li handi »n i<» control bemoTrheft erlicn the uterine
Inciwm in ninde.

Tin- ulrrii- i- thru iiiciMil Mini I In- i-litld and plati-nia
KinOVfd M <|i:i--kl\ a- |">--:lil*'. 'I'll'' "H:i:l:ui ..; ■ !•• ;ii"
ili.'ii -..ii L 'lit :,inl ii<.|,:i- alia tli« art. rleM of the nttttM lift*-

lllfiil- The l-ii-ail lijr.itnrnf • arc llhll rl:tlii|M.| .iih! cut ;

prritonenJ flap* for covering over (In- Btainp are tliva prv-

liunil, thi in* ni- tnpQtvtedj inwl the utnrin nrteriee lied

Tli.' Bturon i« than orenewo end dro pped, the peritonea]

n.vitv i- WBthed "ill, isd tin- ibdODJS&J wall olotMi

GENERAL RULES GOVERNING THE SELECTION OF OB-
STETRIC OPERATIONS IN CASES OF OBSTRUCTED
LABOR.

Conjugate of 9.5 cm. or leas • The) bent method h to induce

labof at or ibont fall we* V.< '» l.m> tin- rxpeotrd lcniiiiia*hui

of prpguntiry. If the condition "i" Ifae pefvii u onh dieoov*

iT"! afl'-r liili'ir Im- in^un. iin Inboi nun l» iill.ivviil !.• t'" '»n
■ hi Ii.mii - Mti'iuimi -.Imiild U< [mid BO 8m

410

nt;*n.Ti;i<- r->n.i:.iTioys.

WiHiinnV jjriii-ilil OOlldltSun and llu' • 1 1 > I ' ■ : 1 1 n • 1 1 of tin- lower

uterine Mannent. The iiholiw or niiarttllon Intra Ilea holvreen

EciRWIN^ vt'i>ion t HViii|tliv»!«'f*un\ . :ihil QtWfMTI MOtlOB.

fhr&pK ni;iy In* iippltrd and lUv puCicnl pfciml in 1 1 *»-
\\;il. dor [xmittDii ; if :ilW Iwciilv iiiitnilc. llu- lic:id dor- DOl

becocae ongHgcdi ihej nbould bo niarntileel Parana may muv
oecd where tin- (orcein have Ibfleilj but the riek Bar ihe rhihl
is ooosiderabic, II' Mia danger of vwaion i* oonnkiered iihi

triv.it t-i ri-U. llh-fi lii/muh WBOfemjr •Imiiltl DC dODfl If ftffetf

lu> |»uiii* Inn* boon diviuVd the 1k-;h1 deuoeudi to the brim, ihe
delivery mm be oonploted by forceps. Should boa band
remain high after lepuntioo uf the pnoaej ''"'" ,|,|, - | ">' oflbn

rt IQOTO fuvornblr result to the ehihl.

The mart important tsmdithm ifitoty the choice ofonem-

tion nrc the imb and compressibility of the Ratal beaut A
••>iin|ph ->.il)l«- 1 km- I in i. |»u-- tlii-Mi^li a |K.-lvi- 1 1 ml would prove

(iii iiuupernbu obfltnofe u> an i trnpraaibla head of the hum

auto.

Tin- relative sin of the head and pulvv maj ba aeprocj-
matrii/ iiet?rmiti><t, by gracing thi bead finnlj vrldi taaas-
t«mded liner r- placed on tht. abdominal wall, and Brwainc it
down upon the |tclvic brim for some ttma, The procure
ilin- ttxorled hIhhiI«I 1m 1 in llu- axis of tin* pelvic inlet I f the

baad CAB UUM bo (breed within the brim, (he iiiiturnl ibnv*

\mII certainty aoonn the engagementi

GonJUfAto of 7 cm. or loan : If at tut thirfv-itth weak the
baad urn lx« fomnl i the brim by <U-\\'W pro^uro 1'n.ni

ahova, lalior tdioutd be induced The risk m the <'liihl of En-
dnoituj labor before Che tWrty-uixih wi-.-k i- r..«. ^reat to aflonl
much chance of Its surviving Ita birth. If ni ii.i- Linn- the

head i^ t<K> buva t'» Bnflafffi tin* oaw should bo loft till nln'iit
tarni iiixl (_'n»*jimin section porfun I Embryotomy ahooU

iii'Vi'r !«■ |» rl'.H'iiK-d nifii :i living t-liihl if il [K«alblv 0011 be

11 tided I * 1 1 tin* oilier liuml. I 'ii--:iiv!in MTtion blionlil not

br rn«hlv andaHnkrn \>y :m '»jM-r.iti»r un-killt-d ;uul im-\-

parioneoa in abdominal muvary. A- lirfun- mid. iho tin.il
decision should ba b'ft to tin- |mt»nt or hor nnanvt rola-

ti.ni-.

When i I it- pelvic canal w obnttjoted bv a tenor whidi eao*

not ho dixlod^nd or wliirli would lie Mlbjoolod to JaJOglffOU

EMBXTOVjMT 411

pressure dnrio^ tbe passage of ;lw child, die safest method
of delivery would he t csamn section or the Pofto operation.

\z £mbtyatam9 is a g en eri c term which includes
all tbe destructive operations by which the wJunw of the
feet us U reduced to permit of its extraction through the natu-
ral passages. Tbe term thus includes (ramirfamv. drrap&i-
turn, er v tmMiom. and rtmpmtatiom of* (A* eitrrmutie*.

InmcatMas : Embryotomy should never be performed on a
lirimg ckthi when any other obstetric operation offers a reason-
able chance of saving it? life.

Tbe patient and her friends may decline any conservative
operation and insist on embryotomy. In such case, if the
physician is of opinion lhat a conservative operation would
offer a reasonable chance of saving the child, be is at liberty
to transfer the case t« some one else should be so desire.
\t ben such a course is not open to htm. tbe physician must
under protest yield to tbe desire of tbe patient and her friends,
as be has no legal right to compel them to follow his judg-
ment.

Proridad the fata* is ia»j, the following conditions may
be mentioned as constituting tbe ordinary indications for
embryotomy :

1. Deformity of the pelvis where forceps or version is
impossible, or would expose the mother to unnecessary risk.

2. Obstruction of tbe parturient canal by tumors — uterine,
ovarian, malignant, or osseous.

3. Impaction of the presenting part : face presentation*,
oocipitoposterior positions, locked twins.

4. Eclampsia, or other causes demanding rapid delivery
where forceps or version would be difficult or prolonged.

5. Monstrosities : hydrocephalus ; the latter constitute* an
indication for embryotomy on the living child, for if the
condition is so marked as to prevent delivery there is no
probability of the child surviving should conservative opera-
tion be performed.

Embryotomy- instrumental : The ohjoct of embryotomy being
to reduce the bulk of the fietus, the presenting part has first

UM'i jttrfot«i"f

:in- Stnrllir'- MnflBoraand Bloft perforator ( Kg* 1 43 and ill),

lliuiij»li a |tairuf r- -i — .i- uitli :t lung blDOU RDBWCH lh« pur-

Pr(\Ufl"»T«iii."-l«»f

now uilminilily. Thfi GtrmilD pn-frr lii perforate I In* ftkllll
liv ini'.'itic of ii LmuhlD0 Willi n I Miff li:»inlli\

Cr&oiocUiit : Thifl i* » powerful in»tniineu1 for flfttalag tfa

ZMMiVoTOMY.

liMii after It Kim titan psrfcralod il i;-. 1 V>). Ii ranawtauf
two U»Je», ••in- N't in-Tiiou in.iii.- aiL.i the other ouuSde tta
vLuM. a i ilia aodi "i tbt baadloi than i-:i powerful own-
praaUon ervw arhloh tnaMw lha opafaior to ul>tniii u firm

ic?ii« a h .i.l.

CepfcAlotrftM : Tui- in-tnim. nl i- -ini|>Iv a boBVJ f<»roe|w
,..i|(fi.<i lor oomprtminu; III* lit'ild ull.-i II hfl been

Kig 146). I'li< blailea arw applied on tithed

>-\ tit. h. .el, wUw h i- th.'n crushed bv

Hcrow attached to Ihv onoe ' ' "

of t Ik Ii ,ii. II

Tha iim-i ported in iriutK-nt fur radua
the hulk of ill.- fart il i . . «■ I i« Tar-
nirrs bnmolril>i . trhfofa i« nl once u per-

foniT.ir. | <*ninK«ola»t. an<l ii omphalotribe
Kig 117). Tin. in .triiini.-iit i. DlpO "I

of "oi icor, twa heavy fencati ited

'if iltiiiiijjil Iriirlli 100 i- pnivnlnl

with n powonnl oompn mImi *onrw

Method of uie: After dSavtioalstiafl

tin- ui-iriMti*'ii( the perforator in pushed
ihmnjrji a *utur* or (bntanolU, the fthorl

bUUM i- thill :i|t|iln-»| oil lite out ul

tii-.ul Uk* .t:i onllUUl v CoTDMI blade

ami i» then articulm.'il with th.- jierfini-
ii>r. " li< n ill. ooinpreamoti a rew i- tight-
ened until tin blw! irocd olo o to tin

Iwrl'.uul ..r. ilnit erUsfalBg 0O« fldfl of flu*
i.:i<i.

Alli-r I ii ig il ipj rrrw

i i hhw >] J. i- applied i" tl ppoorW

-i»l- nl' ili. |„,i,| .,,,1 .f, huDilli- irtii ii-

luiol in the btrniU of the abort Mode,

w h'-ii the icren i-. again li{ linn

I] ■!• ring tin- howl. Thn- tli-

A-rlt bj (Im- vault of tiro droll ran

1 ruthed and flattened t" i little lew

iJijim two iik-Ik - 1 F:". i

Hook and crotchet. Tin. Inatrumrol coiwiai M i curved
i ■» I bat terminating at ooa and In i btant book, M th. other

u** . «i*-

OtiHTJSTRtt' Oi'KUATHtSS,

in :i cmu-luti ii|iil''i^. 149). 'iii*' crotehvt-tfp uxj may b
■vftad ' |i10 '''* -kull ni'iiT ptz&rattou nod hookad into tin?
liiniiiicn magooDj thin ptfimiltiag 1 1»«_« inMnuucDl to l»

Km. «r, 1 1 . m

T«ntln'« LuM(U«<-

|U»l--(rli-y nocuniplMH*!

•Ai- an cxtrnrtur. Tin- hook xany l» M--.1 lo pull down ilic
iiwk.

/'"in"'* AooA, which cohmvi.. of a fttocl rod witli .1 « p - - ■ ■ v
bUHTVflN bundle n( mw oml iiikI a flinrplv Ikhi hook, tinpca

r it myotomy.

*15

HrtH a roumfed luilum, at | .nij<loved us n dceupi-

Zwtifcl hat •!< <■ i--'<i i fvhk-h .-■■■"■ i-i. practical^

of iwo Brum- 1 k* so antagod thai trj *r*ni

IuikIIm the tip* can be IIIOYtd in opposite directions.

Id America. »!■ ■ il.-wr». of pelvic uuBlfaotioa

ore rarcl* !*> U- met nitli. cmbfYotoan can Uaoallj bo Canted

'ih DDmiauativtli little rath bo the mother, provided the

owntoi I earrful ami uiudrratcl; ikilfiil Im mrniiH of h pair

q] blunt pointed Klftiors with ihon bfah - and a long handle ;

:iti'I :i ii ••!'! l.i-hiMiK.I book BOO < IB WML The \\ nt. f !i;i- pi r-
fbnatd m-\»'ji t-iiil.r\.il<niiir< with thewr two in-i rutin .111 -. and

Km. 1«.

| >. l.;li,.«

Inti-mimi or injury of tin- iiuili-rnnl -..It
mother- nil nanc uncventiul rvooverii
The time for ••jH-rntion in at the ooDClusion of the tir-t -t.i^«-
of labor.

Prepara-ttona : The palleotnftei being nm -ihi-tnoed i»p1n«.<l

In tlir IJtDOlOOl) j«'-it *\ n Ii her In 1 ■- nt lie ril^r ot tlir bed

or tfthlr Mil wlii'li -lir ][•■*. The VOlva, UmI ililH'V

iiitjhoni of bat thigh* an than wrubbed with niriti "I green

x'ilp Hint IkiI Wilier, to b folloWod With • doUCM of fel

or bichloride station. The bladdi r U than entnetcrinod The

doncho-bog ihould lie filhil «ith -l.rili- uuln m.il Innr in :i

nun to MHiuru :i pioil, fiiropful atrnani.
The inurnment* t.» be rued in lha on ration ano then placed
in n oonvenlflni position aflw being rti rjllstd,

Operation.

Tin- "|»r,it'-r. -uitjiMv |>repafed| lir-t mskt - .1 rarafu] Inter-
nal examination, to naevitnin 'In- cxaol rjooditnnw prwwnt. If

powible, the hiudl -1 !.I hi- ]■■••«. 1 into tin- menu i ; ll the

cord can he roach d, I alec certain the fhftut baa |>* rohod

Whan 'It.- I m . 1. 1 1- (bund presenting il the brim it would be

t<-.i<liad Awn abort 09 M He-si.^tant when |«'->ible.

oiLsmrnic nrrn tw\y

TIm psrforator: The, OpCXatOI then '■■■■

with (lis tip* of the index and rulddt ■■ ofhSi

loft Iwnd pltMCd iti ihe viiffimu The perforator ti«*l*l in In-

rij(lit hand hi then guided into position between tlw H«p»r»of
ihc Icfl hand placed on the head. The hood i- [► i

\>\ -II':hK ll|IW!inl ■ ill' till' II: I MiilliMl ll.'l-l III

liitml. Having penetrated thcaknll, tlia perforator I

. x "i v ilnvrtion lO bfOtk < t [ i 1 1 u- lii.un, :in<l tl. HM)

aahWEod En every dlraatloo* The doaclm naaue u
aorted Into the opening In the iknll, tod, a rntorn Bow
having boon provided fur ;i strewn ol water i ntn tax

oavitv to wain away the brokan-nn brain -isI.-j.i i

II* iv craniocUst or omphalotribe ifl ur band, it should nan Ik-
applied and the head carefully astrncii*!, • ■ m :■■■

guard tin' nhirpcdgnof tbaoiaaial bona* from catting die
in iternaJ tuanias.

\\ ban I he crotchet hook ia uaca, it fa to be tfirtul into the
nkiill and hooked Into the bacrnboni the fbrcarra Quupuirji.
\itrr obuiniog b firm bold the hood i drawn d ■-.<

When long scissors era employed to open lite kutl nuvli
ili.' tips of tin- blade* ihonld ha kepi between the two fi
of the operatDf v fl IHI luiud which ara in contact with the
head. The cutting i* done ;, v little snip*, wporating ill?

blade* D I el i p " able nuvina cur through |u the -null,
the tip of the n nor with the hlnde* cleaod T* thnwi r I . i ■
:i fbntaueUe m wture Ww blnda ara than separated aa
wnli-l; ■ n po iblo ind iwepl itaut bo break tip the '-

UlUlanoa. Tin earcbnil rnvitv i- u,i-hi-»l um .n<! i i i« t.|. I .. :

ii-h| :t* df-i-filii'd.

Sim' iini( - after the cranial i benti have been re ;

the ohUd i- expelled by natural efforts.

[n most coma In wbTcfi the pelvis will permit of their pn
application, the ordinary forceps may be uaed m txt
the perforated head

Perforation of the sitorooxnlna hoad: Wlico it I DCOa

in perforate the after-oamtns< toad, the perforator nut) l>< m
ivrted through the t|aaanlntonu fontnnelie behind the eai
nr Into the 01 1 i ■" manfluto through the nionili of the child

Decapitation . In bmpOOtad sJwHlW»T pro* iiIii'i.hi il inav 1m

necessary to «ver : w ieati rr>*n :W trunk m order to effect
delivery.

This may l>_ [--r> n&^i :t p***atr: the nook end of the
book xi»d ervociM ■ -i *r nW tfcti I- draw ii down as t»r as
possible, «brrv h > Sie»i by an asastant. By means of a
pair of long-h*»ii*d ?< a -gor* it* operator can then cut ihroosh
the neck, heioj eareroi to gward the blades b e tww the tmv
fingers of iIk left band held in iKr vagina.

This is rarely indicated. When neccftsarv it
may be done with a pair of long-bandied seizors.

In all cases after the separation of the placenta, the uterine
cavity should be ■ ■ a rhr i with hoi salt solution, l-acerations
of the soft rAsFoe* should then be sxmght, and if fouud sutured
at once.

Daacen of imnijuliij : The chief dangers of embryotomy
are, lacerations of the maternal tissues by spicules of none or
by instruments : and sepsis.

As the mother has been exhausted by prolonged ami in-
effectual efforts to complete labor, before embrvotomv fc»
performed, she has but little resisting power should wptio
infection take place ; while the bruised and lacerated condi-
tion of the soft parts favors the development of sepsis*
rt— ot-t

INDEX,

« .1 |1HI .1. "1. ■,-.

n»

llquni

1 I'l

fllllCtlOII, Oj

nnplt '•■. it**

(H.II...1..KV. I.Mi

<I>Ai>IMmii. IHI

dror-y, |H

ilin ( fi|i»i>, ll»7

hydniUJUlM*, ISO

clioloay. UNi

•M. K Mt. fetal, is?

uliyiti vtlMii.itiitaa, |MJ

prcin «!',<• raptvn i ■•

Miami* IM

•ac, :tii

..r,-l. I'Hl Amt.Kitil l*lt.U, |.'*4

rraqiu m i i G Anaaarcu •>! tettw, IM

iiiilurlioii of .. IhJhcUuh uj«tmr. Atmtnmy, uli-i. m ., t&tltlrie nnal-

fim), ;C1 <■»*>. Ml Dfl

lnr*luM. IIiT

Apoplexy or planmta, 102

tnlawd. Htl

An» |--li».i.lu. -

I -'...- ■'til

Almoin-, aow-tw nf, -Til

parti*!. 11*

AmMol hvtntMi. 331

I»lllnl..|fN, MNi

ii.ihiuthiiiv XII

M'"1- • !'.*'•

method, XII

cart-off tie* *. i'ni

'!■■ 1 ■rmma. *A«

rfflimiii i»( Mood IN

■•f 1 iitli-t. 7»1

pru*u.-i.. IK

"i brim, 7<f

■""i' 1 '''

putarfwut. 7ff

vxi«ulkluu of tlio o»uni. 1WS

of iiUiic of tho villvm wtinil rlii*.

llI , MMITr!l»i- , p Utf>

7'l

pain, litt

: ■ ui BMBtM 10 fa ' *'. '"

Ihmtvtictl. 1U7

IfWtuil-Ul, IMM

II.

astir*, -i«(

.j..., . 01

BbUOI&1 T Bfl

up i '.tut m

i'. mI4i r, e tluoltu, 303

,,( lorvltoUrs 1«U

i rut If, :hki

prriphj IkU'tli imi

dntoodN, KM

wf IhrmbUJU, 1W

Ill.i.IiMlri-UiJc *T»lcl», 91

mui. am

lU-n-ll,...!.. IIHI

AoeldnnUl homorTniff*, 2fij UIwIvommIi in pnyimnyy. )*l

ttp|wri'itl *<..i

III-—!.. >LrM|lfl' lf<|>l>.«>W^kffM|.

IMIH.

BP

fti'-lory. W4

■fane*, 39ft

«% tarn

i<l>Ai»tf« in |.M- r u.in.-r, 11

' Itlf, 1 nl

Albrnninurla tn pncnmno/, 1*1 *Im>t**. l?v

Allmtntaii .<'1.im. . |,in K " ..r. in h i. |.| \X7t

>npnner,41 cirovlre Mention ITS

AlMutoi»,dO « np.-'i).: t.r i.i. ••■ ■•

HO INDEX

r... tfttti »n|onjwp»al of. IttttBMti

cotJntvMfv, 83

ktamt \H\(l§m 8BI

dl . I'>i atl'lHof. W

brvnal-pmui*. 3tt

l«yrf

|«tliiilniD7. IM
ulripli; . i in

Murphy lilmtrr. 3;'l
nnr»i«H, >l**»

,),, Hi 11*1 . nilom.'lHlU, 1M. 1M

liyprftfOpby, 3'JU

■cut* I'.l

liifltimm»»t'»i U* '•«• W«*ir*»), IOC

i-liifOr, I.V4

lUMlltll [HN» .V.h'iM*), SiO

■ I. .itment, l&l

m.j.i imimoniry, ;t(W

clir IV,

cttuurriii Iflfl

c.

dll

. .

CmMr<«ti MttM, 404

tr**lmotii, 1W

liLi.-ry, 4«1

,. ii- ii. • ;

li»ll'»M»ii- «'V4

■eralliia. 9B

QMffttiaa, -lotl

■i ..i. i*I

POTW, 41*

DniuJattti 1'H'tfii.iuf y. 173

Ubnlai <•' iiU.iitvr. ,"w:t

|S<VfI"l 1

d«Wu w " ■■ 25

ClpUl .(i...'!in«-uni. IIS

QuetootMol ■ '■ •<• HW

■

i ,. ii,» AIotmm in praruMay, i-i

l . M bT«1 ll* .II-'T • l«r.K' 111 I'"- •!" '»»'>.

|.l.i .Till* '-« fliimtl

. horIi ..i precnuMT* ' ■ -'

:ci-

II. M-I...H III piVfll LtHV, r "

"■n> in I'U' n'.'i XO

i ■■ . ■■

t»ii'»l luH'iitluii.. rc|*ir, 3TU

npfmtlifti. ."CO

(Vrvlx, »trw.l» ''-

vimii. m . ; "

|-(|1I'I1M|MI I ,W.\

l>> ■ 1 In |T< ' '■

i ,1-ktn.tii eontmollOBi 8W

pjitoatft, ^»*»

tapacti"" ••< nii.Tinr lip, 21M>

,!„.. i,, «l.nitrniulilM'i »' (•» '•*•«*

polypi, SOB
HfTdttgr.aN

•lijirii'UtfiA 'JfH
MVUlfiiU. bl90RU|%

ii'-Miaenli M

JO

Mfl«»li.g of, 41, «W

tdln " !'-i«'iiui. Wd

vtouM duoowmtlon, ii, 47

. . | ng -' obrf ■*'•*« t

rii.iiiMM. .*», S|, .11

ii. • ■. ■

liy.li.tUIH'orni ik|t-i.i'f«tl«n. ,ri0

|.i.n . .ii.. |..i< \ la ' ■ ■ /" ■

patfaolug? IfW

, (,. pnBvbJL '-V

villi, .11, K

pfOltpH "1" <<<>'\. S*4

t'lrciiliilt.ry ipUTI, ohauiw of. la

. 1 .llllll |.l»«TllU, PHI

imyimnry, 43

ninwtorl<\ 1"

»UW""»l"">n'.iIul<Uv. lopiuMit,

Avian, n

Caliwmim, Mfl

. * ■

Omi ontloB, "'

tVn«npnl(nn In invpnamv, 17*

r.,,.1 law fwftlhWJ mhT). M. »

I, \ tin ii. .|.|i.il.i» ''*•-'

l.\itt- ■ 1-1 i* '•'""

""'mi

(V.I |'ii« liMi- "I»

Hi-.u-lr—i'"' "■'•'

«.f pr»-*rri»ncy. 10

,„,.,,.. ..nil. -.r ■

('•.null in pmeii«n<-> . l"-1

i' '..■"ii'' •*»ifli*tlnn of

t ^-i.in. chiiiirr* "f, til

■ k<iil.9tt

it- i 41

lumim of l<rUi imiitt.

CrftUlii In i pperliim.SM

■

i\.i.*,.i,. sat

mitlpiMliiiiiisnf lh» '■•< " i"

)■.,..! j.i ■ '"1-

U.

07

inv"A«

1 tirow prrMiitalluiit, 4"il

i.xpe.x. 42\

Itfitocl*, dau Co muljimiUotw of Urn KcLoulr ofwtktloa. •M*md*rr In 1*1.
■. f*t» iiri-wnttilmitv Imii- V»W

291 mi... *, 80S

in \\ ■ > . '"'' .... ...■■■. 000

VII UH . 'M,W

pltir.il birth*. *JIA in-uliuun

|.t..l.|.- "' III* h.'Ui limW. »..r(..tir«.«ie

VII oMomlunl. 202

tr»ii'vi-r»o pirvenUilliiiiK ' iVUtai

. 844 tubal 80S

trlj-wi.. '*(■* r. '.inn ..i nt|.pu. it-.'
.* > luiftir-, "i.. RlanhaDtlarii of totao, 10fi
nwlrroul -•- 111 IJiiUyolopy. VI
UMnuilir* in !•«■:«• o( Ulu.tr, '.Vv %othrfoMV orra. \JB

vT2 Kmhi * ■.!»■..»> | -in

uf tdv BHb inn) nfl rtmntaRM iiiwiwr* «r. 4 it

i '.-.... i him ,-r, . ."»;-

ilafluK HI

•riMwrmtiou, 417

-I ih., ,«|,„ (mi /■*„,,, 27V-

i' Alton*, III

n

Hi-IliltoOIlt-. 411

bok'ttiW. 11 'J

K.

MudI i >>>) » lawns *'•*'• ,,<;

llrnuii* hook, 411

t'.l lutll|M. a IK-

(<e|ili»l»1riln> lilt. ll*t

' "iirni. 11X)

omnladlMt, 113 110

ill * ■ ' ■ ' 1 1*8

book •(>•) t-roirltci. 413, 41(1

iltngni i ■

fwrfitntlnr*. iV : T -

tanptls in IW

operation, llff

'Inr !-■•

nataviloaol »lW-coinlti« \ww\.

tMogy Iflfi

(ML

toxemia. IPO

rrMjiirni .. !*•■ l'.i..l Ii i ■ i. •

natholufioal anatomy, 111] lCo«l«*nntrttu (WrMuiiI, arnU, l.%4

V <■ •. l"l

• 1 ■. 1 ' 1

i ... l«

In Morjwiml tejit f) i -1 'it, .147, 3T4

Inn,. 1 1

Entoai mi, U9

K|.<lil.i-i ■'<

prog

pomuMoi so

>>ui|iiuui*. m

i" '"i*

|»ii»ii 101 INI

Kplriotonjr, m

l« ruiimilini,. IW>

>ilt«MU]f«(*f. 891

i i ' "

inn.ni>...., aoi

• luiii., .i'l.,. k. I'.'U

Indication*. Ml

IILI

Hprnl 'Mil

0,104

\\wliu iii i>a«porinai| SB

l>tn[<lii ' d'l -■ ''» '
■ I**

Krvllnitm iii jiiii iji. t.inn, 333

Hiii.-i,., bi ata

l>'.-t<fii] "

f>rnnl« K'-udiit.. im

V.

di Rattlon 809

dlutift*). 1

PlbfOIU « of nl'iiin. 304

•Ctol«0 'JIM

Firlal rln-ulullun, 38

fa qui iv '■
pathology, 804

li.-i.il. (!.■■. f W\ !«■*, 100

mooldinr or. *

pfJOM ) 1

himrl 130

. ..

niirt-.inr.nm, SO

tOfeftl, n. I Ilbulaf '202

ht, k"

tatintlUal, !AK

dlUMHORj **

r"> tVDKX

d tianfc ■-. »

, . MJNffttlM lb .1.k»*1 p-iUu*

rirtiu. &uiu«na. 108

ill Kl

tiiMlii'iUi-- 11. t

Hill lit. .ii lor, .|M, >#

i . nir ..f /r.v.i

ctfmihil -•■ '-'■■■' i iitall

dUtt-miMD <•( p. rin wiiii, *o

...

MftlnfM •! !**«•*, llW

Illl.'-li.. ■ ! l.'-i.-. .VI

,1. itl ..i LOB

UiPPOTi ■■! :, '<-. »•!

i'»u ii \l ■

Ill fW»* |<n-vii(nii.ii* JM

high, im >ll

-i .,<>. i . ido

dewtuiiinvut, Vft

hudoi • . -^74

•l*jih«ntlM(*. Htt

illdi

bod of. 73

m Ku Utanl t«- (idD.«unrtiMt,

mm

:t*«

diu "4

tMonlon of b)»iM,aas

rti»» i

loir.

gUboIl* -i

i hum, :**!

HldMllM "1 -\ w

uotiiui^ seu

MuuMIni of. mi

i uLinNibit, WO

OOClpUt. Ml

K.i.l :. -1

(.1....- - 1

iu wcipMopwtvrior rww, 5*

«lrcui..i". ranoM,SS

POM itfpTjl Wl

pnriulw* M

ih*iii r, 571*
I'tiui, .mrtli'. ).:t

fmnCnl. «;

'.■•• Iptlul. "1

ilnntiMil, »l

o.

vault, 77

foul iu«i|i-». 7t>

Oiketoeofea

rai*. «n

i . .il.iru.rrhn*, 323

■uftum, 78

• ilmrlvlll* In prctfimnry. ITS

»im.-». r*\

1 .i UtltftH fllllli'li 1

Irhthvttl- tflfl

ii. ■ nl-mita fremiti*!, U

H1*l"i< • '■

tlllllttu f (4

UkMllttK- .

on a t«f« onim), in, 10

m«r!«h|v -»r. >*V

tuolea fltirnw i"

••Mill.,. t ikull, 410

i<i i|i| .- i -

ovwarowth. Ml

InwCiuniT, VUt

H.

|x M ,!ti.n« ;..,• !'„,,< |), SCI

posture. W>

j|»iiiui-tm* t.r Mima, >y.'

ll.llllllll "*l

Il.ciiiuhii ... ii. |iii>:nt y, 1**)

prawnt itloni (MM frrmtalion-i to

iu pin i|*'i-iiitn. in

rublife i'»*

1 riniriiniifclll pnirilliKr. IM

■hup*- ri'luiuo to uuru*, BO

■1 :•'' Mfc'll, I*

■ypiilli*, l<f7

HIT

lluuiurrhHB«\ urddwiUl ImtAnidmttt

rwwotomi

. . I-"

Ifi' ..tiliiii*, 1A7

|kii| iHiriinii. Hit

■IfllnU .1 '

tnwtm-ut. I*

Mbentloffa i"-

• i ;

i " •>( tmiik, flfifi

.■!.,,;.. ■■ »9

FonMuolI**, 99

■jmpl.iiii- 11!

biM mi

• "■ n'. 3M !M«

I\.i'.|- .ic Infraction, .l.i

pii.ip. i. i.

dVMtll' 11 "". ■• "'

i. . ..mint • . T10

optiwuan 3 1

H" I'll""!' >" 1'" M 'V, 1W

II, 1.;

In piioiiwrlum. STi
Dcniii ii-' i'ili'*r «iinl. 1(0

■lttnit"* it(. :pm

111 (lOlaftl JfialttOD, VI

§

■■ 1*7

I , ... .

I(v<]tmuiiiiw, 1M

.i.wnixi*. in

«II»t»f T. 1W

Inaiitti-nt. IM
1 1 - .1 j. - , ,.<...,,- 3M
tljmH n ■areptuna, ;wj

.<■■•-

pCRDUICllI, W

I.

i * In pTfwm i, 1TB

ll»|lfTV)lF.I i

Ilidtfavtlon In pr. fiiinn*T. 174
ndw m, S7I

■Irftnithin, .171

ItidleaffoM. tfTl

dilatation and MMwIll£ 37"2

tng •■

■it , -ioi. lUior, .17il

oulkattaw. 373
uutlivda. 3?4
Kr»iiM>'«. IT*
Tirnur . 371

l'j''"'ti <i> ■• >< |>r»g»aary, |>C

Inanity In pinT|wrIuni, M*>-J4I
[lINMI '•' tU'ru- 310 .11 '

K.

Kldn*? of pr'ffiisncr, 1*1

labor. dtUjtd. /TO

dUtfiKMU. *to

it. «tiii.<i|i. ■/: i
laMl.aH
nurnml < — lftlP»T '"*«■>. 08

paih*lav3r <*m ifytttxiai, 40021*

pr*rlpl|.»l(-. 2rW

imtff ■■ '

pTT«al»ir. m. in. ii. mi nf ■-*■ /n.'.i.
MM ,,, ifan u%bot). XS

. ■

I^fl.ll..!. II

• rrr*t "f [bm 4*"*/ s/lorfil 331

Uctalivu. NUl>ti*)iiutut uT. ISO, IM

uiamniHiT trUiidn, 149

Bllll IBM M*tk1. 141*
I*-U1. il flm^ uf VllliDA, IrtO

Liquor iiiMiii.ui tcntilon* In flianu-trr,

: ■
I.. In.. II'

|ft« liu

COBnM-lAf. 140

eomp'oitKm, ltd

■dor, un

! -,.

oil Mi

■oroMi. EM

If.

Hilari. I. xwrvtim. M4
Mmmmp Cm ifr«u#.l. »0
*U«nft»ry*r«.r«,a»
••f •rrolm. SI

Ur*i -i'"'

rrmpiuni* J49
lr.nliitr.it. aw

-"". 390

MA-IHU.tt. 1 *!
■ l.»i:>. SB

Hi|it«iii*kJBJ
tmainwmt. 3S*

l|l«iM s. :C '»

TWk-ti™ .r-',

■tandvlv, JDS

l> .i ii.ln ii.iiIiiui .Vli

j—t-Tiiftimnifi . r.il

«i|hriH«tir.i»i.. X'i)
M. iilog In |»nri-'fliira,112
MoiunrauM. »

mtan "f. i-'rt
•1 U-rm, n

M-mmupxtIcWBI
IfoliOpMMi . !►
Uunntrufttioii. 17.90

i

AM«flOU. 1H

BBunnw "t l»"». 17

diifnllnn, 1*

on at, it

«ml nTVUtlOIti 3)

qanndlT. 1**

■b »***«. 17

mppfMBHMI, 4ft

Ui ...i.u.i. r«

. iMVktfP 40

Mr*-wl .""

Milk, hi

oh<ni|(»l fotnr-wUlim, 140

< iir, IW

QilnntilJ. 120

424 SON

mi ■ i m ■ \m

• ■ ! bboi i" ■>' *u«.. « vieri, i©»

d«»ncl«ul, *a>

raptun of itit.nii.i.1.... hi',

.-»., ,■«,.,.. :: -i

■l(ii* tud v ■ > . MB, 103

Mtvlur Hi (oil 122

nhAMrt**; i

l». ( k,..| ll riM, ; 1

" '<itMUt(«T7, 102

ICbCWTlM* (m-.. \hnl.-m), lilt, lift,

fop

!W

OMitrwtloiu «if abdominal niu.

\i..i. I.I . . irtfl

H"l

,: ■■ iv, :■"■

of nt.-rii* DO

tuh*J, 303

dunlin". Dl

vadotiUuTt i M

•■fl*.. r .1 UN'

ij Dip! *. 1 At*

tn-Atmont, Ifll

fotenn

.ltnili.nl.rv. lltf

Uootirotlllw,

pamfm, M

Multipara, «7

itelllc, W

MyolitU hi puvrpcrlutD, 337

of vmnitial ami pqWiQ mw

clw. », 103

N.

p ...i- lit-

polarity. 100

il " |<rpti...iii > 1

"■'•»-i "< uIim-uk, 100

N*ifc>tM rrvioiu, ch*n«*« of, in pro**

ii,;uW< ntvdl -Ff. 1 li<

iimu-y, 1 :i

ODH't. OtUBM of. IT, 1*1

\. itn.1v"> i<> l'i- -iiuiioy, 1*0

!'•< 1-li.IiiiH I'm I'L

Soiirltl* in puvrponuiu. -CS7

nur-.. IBS

Si"in-i« hi (iri>|itnin \ IK<. Iml

1- 1. 12*

Ni|i|ii"«. umuMQ •"

liii-r-muni. 125

Invention, 390

phyafoiun. l'.'i

., .■

Latfii )*#. 1V4

tii-4fnu«nt, rwf.

■renin! »laj«. IW7

■opcniiiini-mrv, ftb

•nnUuuy 115

tiinn\*\ UIimi 'Mi

flllilr.il (dli'Iinlili-lta. Il.i

■nit -tli. tla, UN of, 1W, 1ST

inrtul'linr of lin<i. 114

■nUHpiU, i 18

mrui.i' > in. i.i i:i.

•A-liU, I'JO

1 went llati of pvriimim, 130

nam JWf

|,. . m.*1 K«n vsr

■ ■ Inn 131

poaWoa 13?

putUmt. VSS

< ''oc*. an

i.-.-i k-t lA, 118

nii'i h.tiiUiu, if r?

.lui.tii-n, 97

o.i >■,. .., i, mfc, in

Oml lUMNi UM

lll-.lll M'lM'lll*. 101)

v "I Wlfl p*rt«, 107

dcWMUl. li

rllnlril |i|irm*tiii'ii», V-

•xuuiioa, ir.'

■ till iol Irilxn pun-, KM)

1 1 •

mMox romltfif, 107

n 'i. i"

.1 t ],.:.,.. hi:,

laurtwl ...nil no

U]*llll«« fllt'lll, 13K

rwuiuiioii, 112

t -«. Y»

■I*** V7

amu'iilUllon, 132

tkinl rIhii*. lid

]«lpfttlou, 1UD

m ■" ■> .■■■ i. HI

OmM'ii Mtfil.i.ii ••< vxfrtm,

pf^llinliifiryo'inldPlofphy-

•Ion. HI

■■ ,M. | '"

(iitni nimm, id

•iiiVM'illii^ thi> psAiitina-

I.I. rl.'l..!,.. 1 11

tlon

' .. tin ot tiiornt, IIC

mi. 1 m.n hi;

inn i wa, i h.

ti tl<m o| iibtriiu flhr«. mi

•xpaUion of fil.ir#riti. II"

H\ tuMon ofcvri If. i":

M<|Hirili«ill ill |.l»rr«U. 11*

h) iifrtuti*' pntniWi ion

uf Bti uh ■ I

rsnsx.

r.'.i

o.

Oh*4Htte tuteni
"i" ml *. -i*.i-«it

linn uu 100

hryutamr. ii! 1 17

«p(»i«>! ) :>.i

f'irrtpe, J7I-JUI

of, 1C»- 4 1 1

' i iuu of iboiflOD, .T7I
of pnaalunn Labor, J7S
r«i«ir >>f corvlral hw hi 370

■ Oil. (ill I. l.-.r ....

bilaawl i«r, not

taafnaJ » ••• 1 i-nnnU Ucvn*

v;.'

•jm|»!i.«-i.ii.»»iiv. i'«5 iij|
vor»("in. KH Xt
■J&lxiu. ,.r [il-^-nU. 101
"f v»jitm. 108

j i aTn M ■

Olln>tajilr»i...m,
'iiiicwli.lW

Omlfci

ktiiI m*n«tni4ti<in, 90
Onus i-. iw

»t dlflWtnl [«ctlo(U of pr*rn««w>y.

itmm I'reltirros I*

. ... . ■■

liial i[H)l, m

.

Imnmlun, U
IO)|JfW,(u.(<<), fjft
II. iUir.1-. I:'

leoltM ift as

IIU--I.

l«"l»r taxi In, Id
pn". i. as

Ktfnii lit
j,.:i n». «

p.

rtWMCrttil in MMd «ptk I.-
fc«io«. x»

P-...iim. •npt»w«r.lTI

r*rturU»i »<ik,M

hirt*

r.-J-1-v of «■**-• «~ j Hi^m
of »r«* i. imme M^mtTi
»t chorlr* ■ «*, t-Lrrimt, tUf
•f M« 6— XMte; tM
»f (..lo. Mn AWfM XB
-f Hi^iu i— /w«*« . M

Im

ii. I*

Putlioloyy of th- pmjMBl w

■boitta* ., itarNm), tai

•IlitimlriTirlu. I l
hltv*lvi**H*, li|
cardiac di*****, 1*4
itlpatlon, 174

«■«••!. '< I ■■■••

fumfttdM, 173
illu.nl,.. ,. |7j

ft Urn,,.,. IWB&toMI
tttopM i1>«UImiii

r«ii«n), .•«(.'

fflDflVlUl I - :

• luiU, IM>
hm/1 •nurtuur*. 1M

hciii..irli..i.U i-ii
Imm!— , 1-7
ictorti.. 17)1
nn|»Hir»i, IK7

• •iW.n, 171
.Ml., i ..ii. (IIMM* |*fT

kuiui i .,i *.., gMMgr i*i

li'[i||r.ll- i

■Ma, II '

.In.,,,,, !

dlffmntiftl *liagii'NiiR. Irt

I., ihji, n: | . •

.,. unlcia. '"'■

uauiuMM, |A\ l«<;

imviUW. 171

H' m«im«S

pifuwnurloi., i*7

PtMunonla l-i

pmoni labor («• rw.«»-,

Wor l-i

dim, in
alrntko* !, i

MMMf nriiif. 1M1

mil. I-'
•"'■mil (■»* 7W««m« L |i*>
'in*:. 171

■ii.,,.1, 173

•f "hiliiwai ««.tii m

a**!
of aUru ism ('•*•«.

Of »lb» IW I VI.. , 10

NltU a«L M*t i^rv, T| M

ltw.1l

I

T%

71 7*

426 tffftfit

IVIvtr floor, irjrmuiitR, |mli[«\ 72

I'rrlnr*! bM-tnuloni. rAmplM* i**f,

■vml. T

3(M

Pi ll , »■, nllAl inn-l. (H M

3W

Pali lm( i rj E7Q

«([M*r»tlon ( 16* l~o

(iif.fHIIvoiiMil*, tft.Vifffl

!•»'.. <l..l 1. 11

aiU'ruul. -■?"•

lull riml t-iir. MM

fnii'ittul, 'JTT

1

Mvl

in. iIumI of i»palr, 3t(-3pjt

uioamllea of, ftv tV7

npslr. 3W

.>l***ifli»lli>n. ATI

IVHoMim, 76

.).■!■

rl.-ld.lv. .VK

ilao to injuria, minor*, or dU-

Peril Mt in |»icti>cr*l tcplir lt>fc<-

Il-.l,

r*«r. W4

• nxtUUod 175

•l>ii.»l onrraliin*, '.1«i

ilm-Eii'ii. IT.i

kyplMMCohumla. W7

•Uolon I7U

k\ |lltl«l3 gfl

(1 h , ,t'.i.i k 'i» <t\ nUrlui ounlM*>

lavdoaltBO

lion*. ITO

wullwift, *V7

pro')i»|xMuik' r»u»cv 170

flat, -TO

1 '. .

DMolnulHI "f I*bur, 887

lrmlintiil. IT*

noii i..< ini in *j*a

01*101 ii- IT*

niolmuv l&S

dl-fiui ililiiutUiu of mrvlt. 17V

■>■ '( ui »f UtHif.ywi

■ ■. 170

i'ii qui it. j

■ - ■ > ■ ■ ■ IT*

la< 1 than ...

filiiiirl *>lm|nd, >f>

IwtoBwJof, vw

Ju»iii ;■'

'i'ii iitliuvuUUim, 17V

""i»t» slba ilolt'ii*. &l

maUcMtftiii. ■.1>1

I'lillil-i* )ili!titumili- .u |i|i K i>*iit ■

I'miiK iilftlioa 111 •■!< -i ■ 167

uiihvculiue. Utfll

AbUqud) K.ii(r M rl.<il, **M

pbwuU, 31

)*<<lullllll>tlll<"l~(< mi. -II*.*

u.lliiiMiiI. KM, 200

dwllaw.Ki

nuiNt. IW7

-.i>ui..i.i i..:;. Mi. -ill' palm ■

Ifl -I ll "'■-

tmmvrnply n>ntmct*Mj, 11H

RUMftllm III

dbum'ti'M, 07 To

llf |M..il|,.|.

of iho brim. 67 -TO

of nh*.---, 1M

.■.ii.lm-Hi. . ..-

if •!"*. 101

n)f*<iir^fiit<iiu, 70

nf Wclfht, 101

oblique. 70

ipoptaqr, i<w

Ttftntvciw, 70

nil ■ ' IAS

■:., . ..;

definition, ioc

Inrlfortluui, 71

IMIIU.. II.'

Joint- «i. OH

ranltai 10s

luubllM >. S3

bj mplevuii 103

Utvr*l groom, AG, 0(1

,1 mill MS

plUM. OH

»p«t., 33

(bpl H)

■I.ik i'ii

tb*Ckilly, 07

OlfQUbU "i.u*. 34

ii iiu-i t;

■ it-l'niK 33

tnw, *t

0>R*tuemtiofl "*I<"ar»ou*. 103

OtVtt' M

fun', in

boaodAftnt fi4*#l

flMM'llMII-, 111

Inflirlur ■trait. H

ll'H '. 'Itt"'. Pll

niM.IW

"■I"' 1 •• («-j Hwnirtlh . i'

.mil. I (.1

IntorvllloM -|«**m. JB

npmar itnU) 65

mut-runl lilimj. 83

Pwtwl i»»i>\ js

iui>mlir»ii«i<*«. 111

■ I

IffZU 427

nil ««f. iu

r«jtii»ncj. UlHiraonU, •uum.jiy «.f. .'I

i-l i ;.l IBI

■ I' >l

l.nrtm. en*

nm. 4UMI

mlkttl

l.I.jitIi.. .inn", [fl
II- i. i

■ . 7*

•of!" BlU "1 < >i . .». |fl

nKttulbiSfli

\ in).'! dl "17

.,

>j !U|>tOIIW 4.'i

IIMIMI.-..1 -HI

■UHBHT cbkDltn^ 40

fnuMi* M|<aniti>ji .(«*-

IKUI-I .. 11.

4*r,' ''IKl.WS

• ti|i|.rv%.lo« of moii.tni.v

i»ijunwi. am

tfoa 11

•""I-* V

v"»lH|i,i' M

•il*>li

•*»•• »•

.Inuturr. 31

(.I,[.i liiv dlflit* 40

...:... I'l

•voivl'.iui. 4«

•yplilli. of. ir.i
•C Cmii, 33

r ,,,,! ,,r

objotlvo ilfn*, :.i

I union of, Ifil

.\IM|||.I1.|.. .Jl

W l. 1, M.I... '1..., . 11.-

dnnuioit, 44

; .

'"-ti mlc, 44

■ ■io*k»i chum, io;i

tUt- nf u nit l.'imiK, 4£*

ru.i.! r.... ■ •%.,

libto, 4J

l'i..Hmoiiu in itrrmianry, W

(0

nt |i.n rpfTlutu, 333

bovwmbu, ii», :.i

[\.l>, .u lU

H'.(*r'i iia, i-

i dypl ■: "i" .». -"WO

lis^i.-i..' ..I. :.| .Vt

Of OlSCVOlK. 1W

iik. |y tu aorar.M

|'..|f • ll|* 1 ll.MII HI 1

Udch *li.i«..i(«». *(. 51

1 MlttaU, •'-•

iii«ii.v. i i ■ iT. M .VI

IVaHluu W w.

tli ?l

i, ( . . , h

|m|I|m1ii£\ ill -. . /.l<iiJi H ;y «^ JIFfff.

ha

•rt-ry,, 1M

.... -i|.il,.;., ■■(. •;.... 'lift

plfW .1. |0, 14, M

«MMta,4dfi

j»r.«ui. rrir ( j.|..i.i. .',)

in»inr"*]CT.i ■'( li'w.t m-.'

Inc. 4i»

■1 |1..- i- u.. InUi :

•-.■iiiii.jt,' ..i

ivlty. Z14

ul»rln. roiilT^llofU. 4i>

u«rti i

Miafli ID

tlinmnial vil

Tomltlhanf, 4.1

ta&wUm liter (** Abort**), iw.

..«4

•'1

l'raentituiu, VO

IVk'OBIirr. lnUii(li'.|>.'"i.

Pn*riiUlkiu*,t>l

MJi&fN iii illnwBtai -wi-io, 4.1

brwwh, BS1

cln ' "'U'Bi. 43

«««■•. ?«

i'ii(*i.i mi •• Ivm, : :

UOttO, 2EI

nutoniul annlUD, 3»

RMm«My, ysf

ill.rll*. .t>

in itiuv.iii.nl .".11

Mrvoua ».t»i.th. i.i

arm* tW\l\, rod, booA rotalncil

r»|"n»t."-v .v-i.-iti, 43

IN

» li - -k •!• in, M

<>. -' •! 1 i 3W

roTT"i« Iii'nifii «.f, SO

drllvrv ..f ti'i- - ■ ..tuiu* Iir«d.

dUau'ol*.

rn

.Iiff. iviitlal, w. u

Impaflilou In ;■

,.f (t|r ... .[r-<lt ..f i-t.tl.1.64

Ti|.ni «*i<.i< n u.ik. 2M

inrfliftnUi..

of ni.ii.i-iiiT a

of purliy. as

KbnormRl. tBB

»

i$6 mux

frwrnUlkn*. wphiitc. 01, W, W!

r... OK, i..

POeipUll Halo, phv»iolo|T7 of. Ihto

lUl 1 I.'

*»iiM».'jir.

Iklxlotllllllll W«l ' 1

JUgDQth 19

(ir-'iUinrv ••»ij'in. !4T

mwMgi iih m -'Mr

dig! i ■ ■ ■ 1441

mtchulas

in-iHiimj '-^< l<vf<tfMH), lirt

n. . ii r fi'Iii v, 819

OVWrOt, 14?

noMltwti*. '.'10
pelvli M. 83

polvlOj'iiDli, M*

■kin, i4H

•li<ml<(«i :»."«

mi... n;

fc.mv .. 81, 83

Irl iii 147

tffMVfflNs H'i, "W7

lit- in- ii*.

CTtlKMII. '.'T7

UkIiiji MO /.c-7ii«n. 140

il> m»n>i«. 830

ii .ii'

ii.i|iitii- v. •j:r7

muwl^iwIU. 145

nitfhinlfiii : ''

yiwU ainl urrvt*. 145

■ponuuMMii i rotation, '.'io

nsliu, 147

vanltWi

vulm. 117

Willi Im.iI , il,ill,|,,| 1||*. -.■IIP

Wfitlfl inftH'ttiin, 94A-4Q

IMtltlOIIF. 837

bii. , lorl<ilo,rr, 34ft

■lof«o Ml«rlufi *IT

i !■■ v i > ::in

dunHriNMlnilor, 137

P ii'invitln. W7

MjirwoiU, 340

vuir Mi

IM in l|i*m. 07

il<-(inii n:.

I'rimhlvo itrouvo, '«H

dlaanoab

itr««k,3fl

PUlUin frwBt 'Men* Stt

PnbMor «mi. sm
..f f..<i..i l. . 'ii. nr,

Inr-liU, 3.14

1*1 ■<"■<-. ;•»*>

nf utftflM, 17*.', .TOO

|wrliiiliijr>', .U7

I'nirlMi- o( vinrhiDv. 1«»

mil" mlWtkin, 7D2

Of |*In Mitt

Mid in) II :.i.

I'trnli.m. 17:

ni(»I*» of Infection, 351

iti |tttx'"»t" , v, ITS
I'll i-nx- nil n*<rlo4 (MM AMTPiral 'fdhi,
li:i

pominrlrltto,

ptrltonltb 1

I>lil«Xtim*l« »Iba dolciw, 331

|tatli<tlri|fj> of p'm* Hlr'nM, ff'ii*!*,

|. .,«■.,,.„. .: 1

Bfmirtkmffe). 317

wtljilliUitU. AM

ntfth- III

'■■■•. 347

■uinlomv of port*. H.n

. kjflnllii .'(1?

tlM'tlT, 141

•vtiiiiVouiiitulufU', 2BS

bcoad Hum— H 144

.,,,„i :,•

■ i ■mum. 144

|..ir,iru- IHtK an

iilcin. I i:t

I '-Millie 338

vuKiun, 144

|»Vtl-llltO, 1M

relffc 1 1 1

wpUnriiilil. 3M

1- ui'imut:. 143

tnwtiiii'n:

• liiiniioii. I i:.

itt'iioml. SOP

lUdlllUlMIIUIIt of. 1 "

•4'miim ih.'r.«|ij :■*)

hII«i-|*ihii, I'M

la .ii. ./.;

UN m bnnub 1 >\

prupnyWil

<>f «<:iil(ulln. 1 r. 1

I'm i|ii Him lai'i /V*vjr#iW •Idle \ 143

• •Mitiitiiitlii'tiiiutt (4 1 hii'Mmik,

r.'M i "lh< r Dinii -|.i». t ■ 344

: H

IntVi. im rvi.t .ilow*. Mil Ml

lytaj i" • ■ i U

■up' mil, SM

n illt-Jlliifl.T, ISO

..,.

ml. lttl

rjwltU XM

l-lil-li'ltiKli'i.! I'lii'i 143

.li^ii

jiliyniuloity of, li.*

•TJllpclM, .'ttt

^^^

ISO.

V1W

r*n-

'•», xa

ii.'iij-iiiii«'t«i'. .to

tannic?, at an

miliar) 1. I -I

-I— ,xta

r- ■ -' ■ ■ • ' . ^37

niniil*, XXI

•mi tirHi*. -W
rvMnttnu -if Dfim, XJA
rhnuinninun, £f&
ritbeiH ■

■ I.1B
■vjitii lufi Hon

."<■ i :m&

million ile»th, 511

UUl M ■

■ ■

palutiuw I olii m, 541

ii ltM*K 311

im. rncralKpIie uit«lloii,

■

M.f'pl.litU III |ll>l I]' ' '"I". -"W

O

ijii.. hcotaf nf |ir»itiifti" i 10

It.

lUrhltUof r.riM MM

u " " ■•> tBgci "'. hi

n«i» v, *;i

>f atnnM, 1TO

1 ktUlll m I'lirt |H| (.MM, Xf)

K-.i',u In mi i>nw|h>rluiii, XD
ufuUtu. wu

Mlvmtloi mi

tUpin^'i. i" |. ii. -|.f,,;

rVirWt (b«R ii» puarjwrlmn. HI

Big Ml, VI

1 . . i

>m I I .i, ;.l u i vsllll """II, 'ZJ

Spina < bnoplt dp . 'Jit

-'itii i ".i-

-

■ • ipfcy fcM y, dntlolllan, (M

I lull III! lll-.lt, I"'

l.i.i..rv. iW
. . klh.ii :'"
Ir.limi mot hod, 4U0
ntlvunRSOu

lj ihll I i" tui Idi

of phaMita, mi

T.

Thyrohl kIihhI in pf>-|'inuu'v. l--'i
i .. ..! m la - ■■ ' i i.rv", . I"*
Treatment of Abortion, IIH

|(| •> i 111 I'll in lll'llllll ill. i 'I..

of n<lli<-i< nt plit. • nl*, !fl*
of ■pOploM "I plMMI* 103

u/ ilwiiliml find l.ii .-.

ohnBi i' . iw

.,( i|i-l iiii! ! . . .

>■: '- 1 |'-i.i. IK

of ectopic ifutUtlloti. lfl'7

ill rlli'iiiyi'imu! ill llfli— 1 1 XXI

•it nwnmnry abnttnn, MB
of nia lll-l :•

uf nrpbrHt* in nrtennui i
ni otwi on . n i'i ■ m MS
of prriilcUiti* voiitltlnr. I7 i
..( r-< — ' pnrtuulMwoTrnncKtSM 3IU

ul pi. - i|..l.. ■ Ul-u, V'lJi

of prolip* « of uuiblllml oinl, SW

uf pin-i pi i.i. -f|iin- ini'if- 1 :t'i?

of ruIioviTaloii of ntiTin. 171

y | rf«!*lii) "i v r*U. 1AM

of raptn f ntMtu DO

,.f ... ( . , i|.|...-. :ftji

■ iti.itx glut Ion -if u Latin .. i

-if lynhllUof fn'i . MB

■ if vi'.irulm mnlv. H".|
Trlplula, 34*
Tul.fil niolr. 'JW
I III., .i iilnvU .if fu in«, tfM
liiii.omof plwnnc*. I'd

,,i ni-in. I'.V. 304 »NJ
Twill I.Ihii ■ "I ■

COM pill Ull.UU, .'17

ir.

i i.,.i

in pmirp«ii*i npcia niii'i mi

5*7

I n.li.1 I .10, S(

II ill ■ l"l

n.|l.. |04

I !• I'-'-

•<( |. ii»th, IA4
imiIiiic iiliuui fa-Ul UCCk, !
h*mt* im», 1'

I ml<iliwl«ird,fm4t(«e«f,SM

V«Jli, ■

fnu.ao

' ■• " ' • ■•'■">, i'Im.n..- ..r, in i.f>;
una u

I'll Hi-. Ii.imihiiini<v, ( f ( in imi<ii>n ,

ralMtlaa of, In pUMMftvn, 833

irtiuy, In itry-Kimticj, 1-0

e limit, I CI

MUltVaHimit H, pitnfii»in^. Ill
in.rUa, -JTO
■•hi Hit' .if (irrBit,.in v
i i- ran, .n.i ..-..,(. 3ii
i»itlv if. 07

■fcuiffa I- ■ !■■ nraavflQ
oatfMrthnu, io. n»

It < •Intioti. 1 1

dtiffMabi in

ii«>i'iwim>iiu or am i '

MM* 9ft

rlalUi 178

'i "i

full-torn., i. |,i i u.i,

•true tun-, fi)
miu-im.mi. till :' '
IlKuni.-iii-
lyniKlialln. m
■Mh llw« :«. .\r

i.v.r. or, B7-a»
noma, in

p"Tii«niiim, l»
pr«U|M<. ITB, :>on

rolaflun n. |«0v|. ami »M.im«i,

north it ill, in

ninth mm i

'""■ii'li li Ii in

■tub month, Ml
t mil muni ti in

Ml ,<!>. '.I,.:. 1^|

■juriinnivl rmilik. 170
ran ■«( Inn, 170
liTalmrhl in

mild imm, i?i

"•vrro run, 171

ninln I ...

ctlulopv, MO
•IU-. m

ftyiiibiuM*. WW

IfMllllMII. >M>

mpin.nl • i*f. M,), 100
nwWi M*

GAT'

LEA BROTHERS & COMPANY

TATOMT. uw f. :i . 7w». *. 0**ttp«. 11. R»t-*T. *
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A RactweO. «. [La* 1* : bm 34.

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DE SOHWEDOTZ (GEORGE E.). THE TOXIC AMBLYOPIAS.
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EGBERT (SENECA). A MANUAL OP HYGIENE AND SANI-
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physicians, it can be studied with suggestions are, above all, practical.

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EMMET tTBOMAS ADDIS). THE PRINCIPLES AND PRAC-
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B88IG (CHARLES J.). PROSTHETIC DENTISTRY. Bee American

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FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE
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FUNT (AUSTIN). A TREATISE ON THE PRINCIPLES AND
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A MANUAL OF AUSCULTATION AND PERCUSSION: ot

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MEDICAL ESSAYS. In ooe 12mo. vol. of 210 pages. Cloth, $1.38.

ON PHTHISIS: ITS MORBID ANATOMY. ETIOLOGY, ETC.

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OERBISH iPKEDERIC H-- A TEXT-EX*.* Ml* ANATOMY.

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GOULD A. PEARCE . SURGICAL DIAGNOSIS. In one 12mo.
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ORAY(HKVRYi. ANATOMY. DESCRIPTIVE AND SCRGICAL.
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„, * , , . . . Grout Analinnu should be the

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practical side of anatomical teach- Review.

GRAY (LANDON CARTER:. A TREATISE ON NERVOUS AND

MENTAL DISEASES. For Student* and Practitioners of Medicine.

New (2d) edition. In one handsome octavo volume of 728 patre*, with

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ORKKN (T. HENRY). AN INTRODUCTION TO PATHOLOGY
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American Practitioner and Newt. ia the beat of up-to-date text-books.

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GREENE WILLIAM H.). A MANUAL OF MEDICAL CHEM-
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GROSS (SAMUEL D.}. A PRACTICAL TREATISE ON THE DIS-
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BLADDER, THE PROSTATE GLAND AND THE URETHRA.
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GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN
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HABERSHON ; fl. O.). ON THE DISEASES OF THE ABDOMEN
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ume of 664 ptgea, with 11 engravings. Cloth, $3.60.

HALL (WINPIELD 8.). TEXT-BOOK OF PHYSIOLOGY. Octavo
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HAMILTON (ALLAN MCLANE). NERVOUS DISEASES. THEIR
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HARDAWAY 1 W. A. . MANUAL OFSKIN DISEASES. New (2dt

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HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE
USE OF SYMPTOMS IN THE DIAGNOSIS OF DI8EASE. New
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HA YDEN ( JAMBS R-). A MANUAL OF VENEREAL DISEASES.

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HAYKM fOBORGES) AND HARE (H. A). PHYSICAL AND

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tical. Some 200 pages are given up been rich in treatises upon medical

to electricity and evidently embody agents, but an authoritative work

(he latest scientific information on upon the other great branch of

Ihe subject. Altogether this work therapeutics has until now been a

is the clearestand most practical aid desideratum. The section on olimate,

to the study of nature s therapeutics rewritten by Prof, nan, will, for

that has yet OQfjw under our obser- the first time, place the abundant

vation.- The Medical Fortnightly, resources of our country at the in-

For many diseases the most potent telligent command of American

remedies lie outside of the materia practitioners. — The Kantai City

medics, afact yearly receiving wider Medical Index.

HERMAN (O. ERNEST). FIRST LINES IN MIDWIFERY. In
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HERMANN (L.I. EXPERIMENTAL PHARMACOLOGY. A Hand-
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volume of 199 pages, whh ■•'-'■ engravings. Cloth, $1.60.

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MAISCII (JOHN M.i. A MANUAL OF ORGANIC MATERIA
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285 engravings. Cloth, $2.50, net.

Used sj text-book in every college
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deals brii-fly nnd systematically with

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bringing forward as it floe* the most
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each disease, as to its history, icliol-
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MAB8H (HOWARD). DI8EA8E8 OF THE JOINTS. In one 12mo.
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MARTIN (EDWARD). A MANUAL OF 8URGICAL DIAGNOSIS.
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L*a Bbothkbb A Co., Philadklfhia aud Niw Yob*. 31

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By far the beat student's text-book ' The Dresent edition is the result
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A Cu. I'munnniu *■» X*w TV«

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PICK (T. PK'KKHIW. 1'KACIL'RES AND DISLOCATIONS.

In "»f x.Un I »f A U Mi((r»viopL CImUi. II.

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I,.i.li.« *t I i ii ii »lrano»». — Th' iho At.Wt !'.)•»• li*li«|>«*k|i. i
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Tim Hoti. mum wcoupr ■ for*-
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•19 Ljca Buonin* A Ox, ruiLAPKiruu juro hx* Y<

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DLUftJC ATAOK* Iroh»i .. J^pp. Clott.tXI

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KAMI '■ IHI) CHILDHOOD KI hCbtdUtt, 0»n«ffc)y re*i-nl
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■ i, j (11*4*1 In Anwrwm —

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vublr rvt'taM tJttun lu -ru' ■ * hot «f aft •«**• m,,i -

l«ft «iHr»tlii l ff. Ovth, X ; iMlhcr, 10.

On* of th» raoMHtUafucturf <"»irl-« diitui for th* nndaru »urfw«v~JrW-
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NTIM.K U .*■'•« l> < il.. I f KA; IT80Blf.IV. HISTORY.

ITIOK SYMPTOMS, LKSIOXk PRKVI3CTI08I *XU TKKAl

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- - ..f pfftllOU .|u,Ui...—

THB&APBUTK9 AHD KATKft ■ IIKDIC*. Wmtlk **d

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Lav , ' l ""» H
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• .ml a full »..-. . I ( l-'ri.M-SO; lrwthcr,to.Ml

T.. ilicMiiilciii. t .»i-.ii 1 .pliv.i.iiin. Ii. ;■. «u<uonU-

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WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR
THERAPEUTIC INDEX. Including Medical ud Surgical The*
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WILLIAMS (DAWSON). THE MEDICAL DISEASES OF CHIL-
DREN. Id one 12mo. volume of 620 pages, with 18 illustrations.
Cloth, $'2.50, net.

The descriptions of symptoms are l diagnoses, prognosis, complication*,
foil, and the treatment recommended I and treatment. The work ia up to
will meet general approval. Under I date in every sense. — The Charlotte
each disease are given the symptoms, I M'diai Journal.

WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY.
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with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ;
leather, $5.

WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED.
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WIPPEBN (A. G.) AND BALLENGKR (W. L.). Shortly. A
POCKET TEXTBOOK OF DISEASES OF TnE EYE, EAR,
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edited by Bern B. GALi.AUnBT, M. D. See p. 17.

WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated
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YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New
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Cloth, $2.50. See Series of Clinical ManuaU, page 26.

We donbt whether any book on \ work of Dr. Yeo's. The valus of
dietetics has been of greater or more . the work is not to be overestimated,
widespread usefulness than has this | — New York Medical Journal.
much-qnoted and much-consulted

YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo.
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In studying the differentchaplers, surgical specialty and every page

one is impressed with the thorough- abounds with evidences of prac-

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are numerous— the book thoroughly modern work upon this growing de-

practionl— Medical Neve. partment of surgery.— The Chicago

It is a thorough, a very compre- Clinical Jleview.
hensive work upon this legitimate

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