complications, he should at once take the woman's temperature. Meanwhile he should make his inquiries in regard to age, the possible occurrence of rachitis during infancy, or the presence of any other organic disease which might affect labor, the course of former deliveries, the date of the last menstruation, and the course of the labor which he is about to attend. He next proceeds to confirm and supplement the information he has obtained by means of objective examination (see § 2), paying particular attention to the condition of the bladder. Internal examination must be preceded by careful disinfection, according to the rules given in § 2.

In the mean time the nurse should scrub the vulva, first with soap and then with a 1 per cent. lysol or 3 per cent. carbolic-acid solution, and, if necessary, shave the perineum and the lower half of the labia, and evacuate the rectum, unless it has been previously emptied. This should be done if possible with the woman lying crosswise on the bed. Next the catheter is introduced and the vagina flushed out and thoroughly rubbed with a 1 per cent. solution of lysol after the nurse has once more carefully cleansed her fingers with a brush. The cleansing of the vagina may be omitted unless an internal examination has been made by some one else or the vaginal secretion has a suspicious odor and a slightly viscid consistency.

Instruments, catheters, glass tubes, etc., are to be carefully boiled and then placed in a 3 per cent. solution of carbolic acid. Zweifel's douche-bag is placed in the same solution.

The following articles should be laid out in readiness: Two basins for the use of the physician to wash and disinfect himself, one basin with carbolized water for the instruments, one vessel to boil the instruments, clean towels and bed-sheets, one pail and another basin or other vessel instead of an irrigator for the douchebag. Every receptacle to be thoroughly boiled.

Uterine irrigations after delivery with 2 to 23 per cent. carbolicacid, or 1 per cent. lysol or cresol solution, are performed with the aid of a speculum in the portio vaginalis, and a two-way catheter

(Fritsch-Bozeman). They are to be practised, however, only if the possibility of infection is suspected on account of previous examination or of operative interference. The point of the catheter is guided with the finger until the fundus is reached―i. e., beyond the contraction-ring, which must be carefully felt for. The tube of the catheter should not contain air, but should be filled with sterile water, and the antiseptic solution is not to be poured in until the operator is certain that a continuous flow is established. In the same way the entrance of air should be guarded against at the end of the irrigation.

The physician now makes a careful examination of the pelvis, ascertaining its form, the extensibility of the soft parts, especially the degree of dilatation of the os, the position of the child, and the progress made by the presenting part; for instance, in what diameter of the pelvis the sagittal suture is found, whether the anterior or posterior fontanel is deeper, or whether there is a presentation of the posterior parietal bone, etc., and, finally, whether there is any danger for mother or child (see § 23).

So-called diminution in the force of the labor-pains is rarely an indication for the use of forceps.

We have, therefore, three questions to answer: (1) Is there any indication for interference? (2) What operation is indicated? (3) Has the proper moment arrived? The proper moment is determined by the position of the head and the degree of dilatation of the os. Internal version, forceps, and craniotomy require a dilatation sufficient to allow the passage of the presenting part, and if that degree of dilatation has been reached, the time for operation has come. The application of forceps is indicated if the head is firmly fixed; craniotomy only when the head has descended far enough.

All operations are to be performed with the most scrupulous antiseptic precautions, and with the patient lying crosswise on the bed with the legs supported on two chairs and the back well raised by means of pillows, or on a table. The woman is placed in the lateral position only when version is to be performed, on the side corresponding to the position of the feet. If the woman is lying on her

left side, the operator uses his right hand for internal manipulation, introducing it at the end of a labor pain.

The chloroform is dropped at regular intervals on the inhaler until narcosis is complete, and the woman is then kept on the boundary-line between anesthesia and consciousness. The bladder must be emptied before the beginning of the operation.

§ 25. THE INSTRUMENTARIUM.

The instrument-bag should be made of some material which can be readily disinfected, such as canvas or metal, and contain two compartments, one of which (4), also made of canvas, contains the drugs and the smaller instruments, including those which need not be disinfected, while the other (B), which can be sterilized, being made of metal or linen, after Fritsch's method, contains the instruments which require sterilization.

1 The bag of the Bavarian midwife contains in addition a second vaginal glass tube, a rectal tube made of hard rubber, a medium-size rectal syringe, an elastic female catheter, a rubber nipple with a glass base, 1 oz. (30 gm.) of ether, tincture of cinnamon, oil of almonds, a fillet for performing version, tampons of salicylated cotton in bulk. On the other hand, it does not contain soap and towel, a metal rectal tube, Hoffman's anodyne drops, and silver-nitrate solution.

and 1 oz. (15 and 30 gm.) carbolic acid; 3, soap, nail-brush, and towel; 4, an irrigator of one quart (liter) capacity with a mark at 1 pint (liter) and provided with a rubber tube from 1 to 14 yds. (1 to 1.5 meters) long; 5, a glass tube for the vagina; 6, a metal rectal tube; 7, a metal female catheter; 8, a cord cutter; 9, a narrow linen tape in. (0.5 cm.) wide for tying the umbilical cord; 10, a package with twelve balls of clean cotton, the size of a hen's egg, tied with a thread and preserved in white

parchment paper and the whole in a bag of some white material; 11, vaseline; 12, Hoffman's anodyne; 13, dark glass medicine-dropper with 2 per cent. argentic nitrate solution; 14, clinical thermometer; 15, bath-thermometer.1

The instruments are sterilized before and after use by boiling them for from fifteen to thirty minutes in a 3 per cent. carbolicacid solution, or they may be sterilized by dry heat up to 302° to 338° F. (150° to 170° C.).

CHAPTER IX.

PATHOLOGY OF THE PUERPERIUM.

? 26. PUERPERAL FEVER.

OWING to the peculiar mode of introduction and propagation of micro-organisms, puerperal infections present certain characteristic clinical pictures which depend on alterations in the circulatory apparatus, on the presence of definite lesions, and of typical physiological wounds and their secretions. These clinical pictures are very complex and their classification from either the anatomical or the bacteriological standpoint is somewhat difficult. While giving the usual scheme of classification, I shall confine myself in the text to the description of the clinical pictures which are most commonly observed at the bedside.

The cause of puerperal fever is found in the invasion of the excoriated cavities of the genitalia by pathogenic bacteria, although other predisposing causes, such as cold, dietetic errors, emotional excitement, and hemorrhage may indirectly assist the invasion and extension of the micro-organisms by diminishing the resisting-power of the body.

It is often important for the physician to know what he can find in case of necessity in a midwife's bag, but it is to be remembered that any operator who really desires strict antisepsis will often be very skeptical as to the condition of the contents of such a bag, especially as the midwife is required to supply the materials herself in pauper practice. In Baden a law has recently been passed which requires midwives to get all their drugs and tampon material from the drug-stores.