ment of the horn to the lower segment of the better-formed half of the uterus.

Hydrorrhea Gravidarum.-A watery discharge from the vagina of a pregnant woman may have four sources: catarrhal endometritis, rupture of the membranes, discharge of fluid from a hydrosalpinx,1 and edema of the uterine walls. The last is a very rare cause indeed, and I am somewhat skeptical as to the possibility of serum leaking from the uterine walls, but it has apparently been operative in a few cases.2 In catarrhal endometritis the fluid is discharged suddenly in considerable quantities; it reaccumulates and is again discharged, the recurrent hydrorrhea continuing, perhaps, until term, although usually after the second or third discharge labor is brought on. The fluid discharged in a case of catarrhal endometritis is thin mucus. In a typical case under my observation there was a discharge of more than a pint of fluid at the seventh month of pregnancy, while the patient was lying quietly in bed. It was supposed that the membranes had ruptured and that labor was imminent, but no pains appeared, and after confinement to bed for a week the patient was allowed to get up. A month later there was another profuse discharge,—certainly more than a pint,— again occurring while the patient was quietly at rest in bed. Twelve hours later labor-pains appeared; in the latter part of the second stage of labor the membranes ruptured and about a quart of liquor amnii was discharged. A careful examination of the membranes failed to detect a perforation remote from the seat of rupture.

Rupture of the membranes and the discharge of liquor amnii in pregnancy are commonly followed by labor-pains within thirtysix hours. It is not very unusual, however, for three or four days to elapse from the time of rupture to the onset of labor. I have several times seen a month intervene between the rupture of the membranes and the beginning of labor, and in one case under my care the membranes were perforated at four and onehalf months without inducing labor. The patient was the wife of an English officer in India. She had been told by a skilful Indian masseuse that she was pregnant, but an English physician whom she consulted assured her she was not, and, to prove that he was correct, inserted a sound into the uterine cavity. There was immediately a gush of liquor amnii. In spite of a journey of some 1500 miles from the interior to the coast, the long voy1 "Hydrorrhoea Gravidarum and Hydrosalpinx," Cowles, "Obstetrics," November, 1899.

2 Chazan, "Centralblatt. f. Gyn.," No. 5, 1894, p. 105.

age from India to England, and thence to the United States, liquor amnii flowing from the vagina at every roll of the ship or jolt of a carriage, labor did not appear until term, four and a half months from the time the membranes were punctured. There was found, after delivery, a round, regular opening in the membranes, about the caliber of a lead-pencil, midway between the seat of rupture and the placenta, which was attached at the fundus.

PART II.

THE PHYSIOLOGY AND MANAGEMENT OF LABOR AND OF THE PUERPERIUM.

CHAPTER I.
Labor.

THIS chapter deals with an important practical subject,—the management of a woman in labor. The questions involved in this study confront every practitioner of medicine at some time. Every one in possession of a medical diploma is popularly supposed to possess the ability to manage a labor case, and every one who essays the practice of medicine will have his ability put to the proof before his medical career has run a very long course. To a beginner in obstetric practice there is much that is trying and embarrassing. The novel and intimate relations in which the physician is brought with his patient; her very evident distress and dread at the idea of being subjected to the necessary examinations and manipulations more or less revolting to every woman; the doctor's keen consciousness of a lack of experience; a feeling of mistrust in his capacity to make the necessary diagnosis as to stage of labor, the presentation and position of the fetus; the knowledge that his every movement is watched by critical friends or attendants of the patient, who possess, perhaps, just what he lacks,-practical experience,—all unite to produce a most unenviable frame of mind in the practitioner attending his first few cases of labor. Some consolation, however, can always be found in the reflection that labor is a natural and a comparatively easy process, in the large majority of cases; that a physician's duty is one mainly of inaction and non-interference, and that most probably the labor will terminate fortunately for mother and child, in spite of his inexperience. It is evident, however, that no one can predict what may occur in any given case. There may suddenly arise some accident of the gravest nature, which must be immediately recognized and promptly treated. It is under such circumstances that a physician's education and knowledge are

put to the test.

It is plain, therefore, that in a work on obstetrics it must be the writer's aim to impart the requisite knowledge to cope with all sorts of dangerous emergencies. This consideration makes it necessary to dwell at length upon all the possible complications, accidents, and difficulties of the childbearing process, with the result, I am quite sure, of leaving upon the student's mind the impression that parturition is a more dangerous process than is really the case. It is well to recollect, therefore, that nature alone, in the majority of cases, with very little artificial aid, is capable of terminating safely the birth of the child; but at the same time it should not be forgotten that at any moment a dangerous complication may occur, which must be immediately recognized and promptly dealt with.

It is convenient to begin the study of labor with a definition of the process.

Labor is that natural process by which the female expels from her uterus and vagina the ovum at its period of full maturity, which is reached, on the average, two hundred and eighty days after the first day of the last menstruation. The process is divided into three main stages or acts,—the expansion of the birth-canal, the expulsion of the fetus, and the delivery of the remainder of the ovum. This is a brief description of an important and complex function in woman, but as one studies the causes, the premonitory signs, the symptoms, and the phenomena of labor, it will be seen that it is comprehensive and correct, but that it needs some amplification.

To analyze the first declaration as to the time that labor occurs, the intelligent student would naturally inquire why it is that labor comes on just two hundred and eighty days, or forty weeks, or ten lunar months from the beginning of the last menstrual flow. This question has given rise to endless speculation in all ages of medicine, some of it very far from the truth. Several explanations may be offered, each reasonable, and each no doubt in part accountable for the occurrence of labor in the majority of cases at a distinct and specific time. The period of two hundred and eighty days, or forty weeks, or ten lunar months must at once direct attention to the fact that labor comes on at the tenth menstrual period since pregnancy began. At the menstrual period in the non-pregnant uterus there is always distinct muscular action, induced probably by the presence of a foreign body-blood-in the uterine cavity. During pregnancy it has long been known that by the unconscious memory of living tissue there recurs, at regular intervals corresponding to the menstrual period, a disposition to muscular action, which is sometimes so exaggerated as to bring about an expulsion of the

ovum,‚—an accident especially to be feared at such times in women prone to abort. Here, then, is a cause predisposing to uterine muscular effort at each recurrence of the time for the absent menstrual flow, especially the tenth, and this, therefore, must be accepted as one at least of the causes of labor. It is described conveniently as periodicity.

A study of all the hollow muscles in the body shows that they admit of distention up to a certain point, but, that point being reached, they are immediately stimulated to contraction. This is well illustrated in the stomach of the young infant, which nurses until the organ, overfilled, contracts and expels the excess of food which its cavity can not contain. So, too, in the ventricles of the heart, distention with blood goes on to a certain extent, when contraction occurs and the blood is driven into the great arterial trunks. Precisely the same action may be seen in the pregnant uterus. It admits of distention up to a certain point, until it is well filled by the mature fetus, when the great tension of its walls, no longer endurable, stimulates them to muscular action which terminates in the expulsion of the ovum. This cause of labor is defined as overdistention of the uterus.

Just as in plant life certain degenerative changes occur in the supporting stem of fully ripe fruit which makes its connection with the parent branch so frail that a slight breath of wind causes it to fall to the earth, so in the human ovum that has reached full maturity there occurs a degenerative process, a fatty change, in the connections which bind the ovum to the uterus, that brings about a separation more or less extensive between the uterine wall and the ovum, and the latter, becoming a foreign body in the uterine cavity, is cast off.

This cause of labor is called the maturity of the ovum.

Finally, heredity, the unconscious memory of tissue transmitted from generation to generation, plays a most important role in the causation of labor. Thus, at the end of two hundred and eighty days the fetus has reached such a size that it is just possible for the woman, at the expense of much effort, to expel it through the birth-canal. Had it grown much larger, its expulsion would be difficult or impossible. On the other hand, an infant born much before two hundred and eighty days is not sufficiently well developed to endure the lower temperature that it encounters, and the necessity for obtaining its own nourishment and oxygen, and consequently it may not survive. Therefore, it is plain that only those women who gave birth to their offspring about the two hundred and eightieth day of pregnancy could successfully perpetuate the human species. Those that