average, in two and one-half minutes. In these cases the average weight of the placenta was 520 gm. (14 lb.), and the amount of blood that escaped from the umbilical vein in 20 cases was 92 gm. (3.2 oz. Avoir.) less in late than after immediate section of the cord.

Thus, by immediate ligation 92 gm. (3.2 oz. Avoir.) of blood are lost to the infant's body. Moreover, in contrasting the weights. of children after immediate and late ligation of the cord there was a gain of two to three ounces in favor of late ligation. It is better, therefore, to wait two or three minutes after the birth of the infant before cutting its cord.1 The proper time having arrived, the cord should be ligated about two fingers' breadth from the child's body with a piece of stout surgeon's silk, sterilized. The ligature is tied firmly once around with a double knot. The ends are then doubled around again and are tied with a single and a bow knot, so that the nurse, after the child is washed, may slip this last knot

and may then retie the ligature firmly. This precaution surely avoids a primary or secondary hemorrhage from the cord, which sometimes occurs in consequence of a shrinkage of the mucous tissue, making the original ligature too loose. The obstetrician is now ready to cut the cord. The child is slippery and hard to hold; its legs and arms are jerked about in a very disconcerting manner to the beginner, so that carelessness in the use of scissors at this juncture might result in injury to the fingers, the toes, or, in the male child, to the penis. The manner of cutting the cord illustrated in figure 209 surely avoids all such accidents.

The

1 There has been some criticism of Budin's proposition to ligate the cord late; several German authors have attributed a number of infantile complications to it. I have carried out the practice for more than ten years, and have convinced myself by experience of its advantages.

child's connection with its mother being severed, it is wrapped in a blanket ready to receive it and is put in some safe place, where it will not be trodden nor sat upon. Its own crib is the best place for it. The cut end of the cord attached to the placenta is not tied, but is allowed to drain into a basin, so as to lessen as much as possible the bulk of the placenta. In case of twins, however, a double ligature on the cord is required, else the second child might bleed to death on account of anastomosis between the vessels of the placenta.

CHAPTER II.

The Puerperal State.

THE moment that labor terminates with the expulsion of the placenta, there begins an effort on the part of nature to restore to their normal condition the organs and systems that have been in an active state of development for nine months before; there is destroyed in a few weeks that which it has taken months to build up, and side by side with this destructive process goes on with equal rapidity one of growth and repair. One sees the reduction of the sexual, the circulatory, and the nervous systems to their normal capacities and functions by the destruction of redundant material; but one sees with this the reparation of the injuries of child-birth, the formation of a new endometrium, and the rapid development of an entirely new and complicated function, lactation. And yet, by a provision of nature which is almost beyond comprehension, these two opposed processes of decay and regeneration go on at the same time in one body, involving whole systems and organs, without manifesting themselves in the slightest derangement of the individual's health. Under no other circumstances could an organ weighing two pounds, and as large as the liver, degenerate and in great part disappear without the gravest symptoms of constitutional disorder. In no other condition could the whole composition of the blood be materially altered; the heart changed in size, power, and capacity; the nervous system modified in sensibility; a large body-cavity, stripped of its mucous membrane and again resupplied with a new lining; large organs, as the breasts, suddenly assuming great functional activity, without very marked evidence of disease; and yet in the puerperal state there are all these remarkable changes while the woman in appetite, feeling, and temperature is in perfect health. But it is obvious that in a condition which,

though it is called physiological, borders so closely on the pathological, very little is required to pass the boundary-line into disease. Anomalies of excess and deficiency in the natural processes occur easily; the raw surface of the uterus with the wounds of the vagina and vulva give ready entrance to infectious poisons, and the whole individual seems especially sensitive to unfavorable external influences, both mental and physical. Consequently this is the period in the history of the child-bearing woman that is most beset with difficulties and dangers and most likely to be marked by accidents and complications. The preventive and curative treatment of these complications is one of the most difficult tasks in obstetrics, and success here, as elsewhere in medicine, depends to a great extent upon a thorough knowledge of the natural process, for only on such knowledge can one base a rational management of the normal case and a satisfactory treatment of the abnormal conditions which are so apt to develop during the puerperium.

The puerperal state, or the puerperium, comprises the time from the termination of labor until the uterus has regained its natural size. This is a period, in the normal case, of six weeks.1 The study of the physiological phenomena in the puerperium, or puerperal state, involves a study of the reduction of the uterus directly after delivery to the uterus of the healthy non-pregnant woman,- -a process called technically "the involution of the uterus"; it involves a study of the involution of the vagina, of the destruction of the deciduous mucous membrane, and the regeneration of the endometrium; of the retrograde changes that occur in the uterine ligaments and peritoneal covering and in the ovaries; of the alterations by which the blood and the heart regain their normal condition and of the changes in the pulse; of the changes in the body-weight, the temperature, the skin; the action of the bladder and of the alimentary canal. An important factor also in the puerperium is the establishment of the milk secretion.

The Involution of the Uterus.-Three theories have been advanced to account for it: (1) A fatty degeneration of the muscle-fibers and the absorption of the fine granular fat-globules to the complete destruction of the uterine muscle, its place being taken by a new growth of muscle-fibers developed from the embryonal muscle-cells in the outer layers of the uterine musculature. (2) A partial degeneration and an atrophy of the large

1 The word puerperium comes from puer, a child, and pario, to bear, and denoted, in the original Latin, the child-bed period, the lying-in period; so it is an appropriate term to designate this one of the four periods in obstetrics,-pregnancy, labor, the puerperium, and lactation.

muscle-fibers seen in a pregnant uterus at term. (3) The conversion of the muscle-cell contents into a peptone, its absorption into the blood-current and discharge through the kidneys, giving rise to the peptonuria of puerperal women (Fischel).

Kilian, in his examination of rabbits' uteri thirty to thirtysix hours after they had expelled their young, found fat-globules in the epithelial covering of the uterus, noticed that the musclefibers looked fainter and paler than in pregnancy, and saw in their interior very fine, shining fat-globules; alongside of these degenerated muscle-fibers Kilian found some quite young fibers, as he had seen them in the uteri of young animals. Heschl2 confirmed Kilian's observations, and went even further in declaring that the muscle-cells were completely destroyed by fatty degeneration; this writer saw, in the outer portion of the uterine body, at first nuclei; which, developing cell-contents around them, gradually transformed themselves into typical unstriped muscle-fibers. Thus, after labor the uterine muscle was destroyed and a new development of muscle-tissue occurred to take its place. Robin, 3 on the other hand, claimed that the involution of the uterine muscle is essentially atrophy of the individual muscle-cells. Kölliker says that the involution of the puerperal uterus consists of a diminution in the size of the contractile fibers in the muscle-layer, alongside of which may be seen fatty degeneration. Mayor, from a study of fourteen specimens dating from the first day after delivery until the ninth month of lactation, concludes that, while the fatty degeneration of the muscle-fibers is more pronounced than Robin thought, it is far from having the importance that Heschl attributed to it; it does not seem, as this author believes, to cause the destruction of the muscular elements. Mayor, therefore, attributes to atrophy the predominant rôle in the involution of the uterus. Winckel still holds that the reduction of the puerperal uterus is due to fatty degeneration. Sänger, from the observation of twelve uteri obtained at periods varying from four hours to fifty-five days after labor, recognizes the fatty degeneration in the muscle-cells,

1 "Die Structur des Uterus bei Thieren," Henle u. Pfeuffer's "Zeits. f. rationelle Medicin," 149 u. 1850, Bd. viii u. ix.

Untersuchungen über das Verhalten des menschlichen Uterus nach der Geburt.," "Zeits, der k. k. Gesellschaft der Aerzte in Wien," 1852, viii, 2. 3" Dict. encycl. des Sc. méd.," ze serie, t. x, p. 14.

4.* Gewebelehre," 5. Aufl., p. 565.

""Archives de Physiol. norm. et

5 11 Etude histologique sur l'Involution utérine,"

path.," ix, x, 1887, p. 560.

6 "Lehrbuch der Geburtshülfe," 1889.

7 Abst. in Schmidt's "Jahrbücher," No. 3, 1888, p. 250.

but does not believe that they are destroyed. 1 Microscopic sections of five uteri in my possession, obtained respectively in the last week of pregnancy, two hours, thirty-six hours, seventytwo hours, and seven days after confinement, indicate that fatty degeneration plays a most important part in the reduction of the large muscle-cells characteristic of pregnancy to the much smaller muscular fibers of the unimpregnated uterus. My own belief is that the redundant material within each cell is

Fig. 210.-a, Uterine muscle-fibers nine days postpartum; b, uterine musclefibers eight days postpartum; c, uterine muscle-fibers in the eighth month of pregnancy.

destroyed by some degenerative process (chiefly fatty), but that the cell is not destroyed in toto. Measurements made by Sänger2 show plainly that the reduction of the uterus after labor is

1 Sänger says that "the fat-globules and other degeneration products do not enter, as such, into the circulation, but are oxidized on the spot. There is no such thing as a puerperal lipemia" ("Die Rückbildung der Muscularis der puerperalen Uterus").

2 Loc. cit.