mammæ the pains are increased. Frequently they appear only on the first day, sometimes they last up to the third or fourth, rarely to the sixth, day or a longer period. The transformation in the vagina is more slow and imperfect. After delivery the anterior wall hangs loosely down into the cavity. There is no distinct diminution in the size until the third or fourth week. Then folds begin to form in it, but it never regains its former narrowness and wrinkled condition. In exceptional cases the vagina, and especially the vulva, are even a few days after delivery so markedly narrowed that they scarcely differ from what they were before.

The

The above-described small lacerations of the mucous membrane are, as a rule, found in primiparæ and very frequently also in multiparæ. In primiparæ portions of the torn hymen are suffused with blood and destroyed by gangrene, so that in the vulva some warty or tongue-like projections remain (carunculæ myrtiformes). frænulum, also, is frequently destroyed; the external genital organs are gaping and are reformed only imperfectly. The skin of the abdomen also remains flaccid and wrinkled for some weeks, so that puerperal women are subject to meteorismus in consequence of the great extensibility of the anterior abdominal walls. The discharge from the genitals-the lochia-consists, according to Werthheimer, for some hours, of pure blood with fibrinous coagula, and then the exudation of a serous fluid of alkaline reaction mixed with vaginal mucus commences. For the first two or three days the blood is so abundant that the lochia have a dark red appear

ance.

On the third and fourth, and sometimes even on the fifth day there is less blood, and the lochia then have a pale red appearance. Examined under the microscope blood-corpuscles, squamous epithelium, mucus-corpuscles, and sometimes the remains of the decidua, are seen. Organic compounds, as albumen, mucine, and fat, and also various salts, are found. From the fifth to the seventh or eighth day the lochia are still serous. The blood-corpuscles decrease in quantity, and now numerous pus-corpuscles are found. From the eighth to the ninth day the secretion is of a greyish-white or greyish-yellow appearance, of creamy consistence, and of a neutral or acid reaction. It chiefly contains pus and young, unshaped, round epithelium, also young spindle-shaped connective tissue cells with fat-globules, free fat and cholesterin-crystals. An infusorium, the trichomonas vaginalis, is found in the vagina of puerperal women.

It must also be stated that very frequently fresh blood is found in the lochia, even after the fifth day, especially if the woman leaves her bed. As regards the quantity of the lochia Gassner has estimated it to be

About 1 kilog. up to the 5th day, when it is red and bloody,

6th
7th

so that within the first eight days 1.485 kilog. are lost by the lochia. The quantity is as much again in women who do not nurse.

The duration of the secretion of the lochia varies very much. After a fortnight or three weeks it is usually very slight, especially in women who nurse, whilst in those who do not nurse it lasts much

longer. But this is by no means the rule. Not infrequently the secretion lasts in strong healthy women who do not nurse a much shorter time than in those who do so, but are of feeble constitution, and who for a long time subsequently suffer from fluor albus.

The changes in the breasts commence during pregnancy and are continued during the lying-in state. The glandular epithelium undergoes fatty degeneration, and a secretion flows from the mammary glands. For the first few days it constitutes the so-called colostrum, a thick fluid of a lemon-yellow colour, which coagulates on boiling. Under the microscope it is found to contain a number of large granular corpuscles (larger than white blood-corpuscles) with a nucleus, contractile protoplasm, and numerous small fatparticles, the so-called colostrum-corpuscles. There are also, even now, milk-corpuscles, round fat-globules strongly refracting light, which, according to Kehrer, have a membrane which consists of casein and not of albumen. They are at first of very variable size. After the third or fourth day milk is secreted, a thinner liquid of white colour, which does not coagulate on boiling. In it colostrumcorpuscles are only sparingly found, but the milk-globules are in large masses and of equal size about that of a red blood-corpuscle. There are also the free nuclei of colostrum-corpuscles, and globules, quite similar to milk-corpuscles, which on addition of carmine show a nucleus. The fats of the milk doubtless arise from albuminous substances, and the albumen contained in colostrum is transformed into casein. Kemmerich has shown that in fresh colostrum, after its evacuation from the mammary gland, casein is increased, whilst the albumen proportionately decreases; but according to Zahn there is still some albumen in the fully formed milk. When milk is boiled it forms small coagula which, by careful decanting of the supernatant fluid, remain at the bottom of the vessel. Casein is contained, according to Kehrer, in the débris of the glandular cells which forms a thin mucus-like fluid with the serum of the milk and becomes the vehicle for the fat-globules.

The commencement of the secretion of milk is usually attended by a slight elevation of temperature. It takes place on the third or fourth day, usually amounting only to a few tenths of a degree; yet not infrequently, especially in those who do not nurse or when lactation is begun, on the third or fourth day it rises to a fever heat, the breasts become tumefied and painful, and the superjacent skin reddened. From that time the normal secretion of milk continues and lasts for a varying time. If the mother does not nurse it soon stops. In women who nurse the quantity of milk increases up to the sixth or seventh month, after the eighth month it usually decreases, and since at that time the child requires somewhat more solid food it is well to wean it gradually, so that from the ninth to the tenth month it is no longer fed on the mother's milk.

Literature.-F. Winkel, Die Path. u. Th. d. Wochenbettes. Berlin, 1866, pp. 111.-Hecker, Charitéannalen, V, 2. 1854.-Winkel, M. f. G., B. 22, p. 321.-V. Gruenewald, Petersb. med. Z. 1863, Heft 7, p. 1.-Lehmann, Nederl. Tijdschr. voor Geneesk. 1865 (s. M. f. G., B. 27, p. 229).-Schroeder, M. f. G., B. 27, p. 108, and Schwang., Geb. u. Wochenbett., p. 177.-Wolf, M. f. G., B. 27, p. 241.—Baum

felder, Beitr. zu der Beob. d. Körperwärme, &c., D. i. Leipzig, 1868.-Lefort, Études cliniques, &c., Strassbourg. Thèse, 1869.-Scherer, Artikel Milch in Wagner's Handwörterbuch der Phys. 1845, B. II, p. 449.-Becquerel and Vernois, Comptes rendus, T. XXXVI, p. 188, and L'Union, 1857, 26.-Moleschott, Phys. der Nährungsmittel. Giessen, 1859.-Hoppe, Virchow's Archiv. 1859, B. XVII, 417.-V. Gorup-Besanez, Lehrbuch der physiol. Chemie. Braunschweig, 1862, p. 385.-Beigel, Virchow's Archiv. 1868, B. 42, p. 442.-Langer, Stricker's Handb. d. L. v. d. Geweb. Leipzig, 1870, IV, p. 627.—Kehrer, Arch. f. Gyn., B. II, p. 1.

P.

CHAPTER II

THE DIAGNOSIS OF THE LYING-IN STATE

THE diagnostic signs of childbed consist partly in changes produced during pregnancy, which are visible for some time after it, partly in the traces which the process of parturition has left behind, and partly in the other peculiar changes which take place in the genital organs and the mammæ during childbed. They are the following:

The skin of the abdomen is flaccid and wrinkled. In it are seen Spall white cicatrices with transverse wrinkles; the linea alba is greatly pigmented, the vulva somewhat swollen, the labia gaping, and in the vaginal outlet small ulcers or very vascular cicatrices are always found; soon after delivery, of course, recent lacerations of the mucous membrane. The vagina is wide and smooth, and in it is a copious secretion of a peculiar stale and sometimes fetid odour, and with the characteristic condition of the lochia. The uterus is more or less enlarged and anteflexed, and this enlargement can be easily made out, without the sound, by a combined internal and external examination. If the external os is still pervious the wide uterine cavity is felt, and in it also is a copious secretion, and a somewhat prominent and rough place covered with small plugs indicating the former seat of the placenta. The mammæ are large and tense, the areola pigmented, and the known secretion flows or can be pressed from the gland, which if soon after delivery is colostrum, but if later milk.

The value of these signs is, of course, different, yet a great number of them are characteristic. The flaccid, shrivelled abdominal walls, covered with wrinkles and cicatrices, are a sure sign, since conditions in which enlargement of the abdomen had existed, as from ascites, ovarian tumours, &c., can easily be excluded. The pigmentary deposits also are frequently more intense than are met with in any other condition except pregnancy and parturition.

The slight lacerations in the vulva, also, are characteristic; the lochia, at least within the first few days, cannot be mistaken for anything else. The size and shape of the empty uterus, as found in the puerperal state, do not occur in any other condition, and the placental insertion covered by thrombi places the diagnosis beyond a doubt. The changes also of the mammæ suffice to ensure the diagnosis. Though a slight pigmentation of the nipple and a secretion from it occur in some pathological conditions, yet the deposit of pigment and the quantity of the secreted milk in the puerferal state are almost always much greater than is met with under

any other condition Thus, on the whole, it is easy to establish the diagnosis of the lying-in state in the first few weeks by objective examination alone. It is, nevertheless, sometimes difficult accurately to determine the time which has elapsed since delivery, and the difficulty increases the longer the interval. If there are still lacerations at the vaginal entrance, and they are quite recent, the woman has only lately been delivered; if, on the contrary, there are already distinct cicatrices, the first stage of childbed is past.

After a

From the changes of the lochia above described valuable assistance can be derived, only it must be kept in mind that it is just in those cases which are of forensic importance that the sanguineous lochia usually last much longer. The most important point for a practised accoucheur is the size of the uterus. great many puerperal women have been examined internally and externally, a sound and pretty accurate judgment is acquired of the size of the uterus corresponding to the different periods of childbed, yet it also is subject to individual variations. The internal os, which is rarely pervious after the tenth day, gives very valuable indications with regard to the time. We have also to take into consideration that the uterus will be smaller, and the cervix more contracted, after premature labour than after delivery at term. The secretion of the mammary gland is also important as indicating the early period, the colostrum would point to the first days after delivery.

By a careful consideration of all these circumstances it is possible in the first fortnight of childbed to fix the time of delivery within a few days with accuracy, but later on it is frequently necessary to be satisfied with more uncertain data.