with advantage by applying forceps if the head is engaged in the pelvis, or by performing version and extraction by the feet if the head is not yet engaged, or if the breech should be presenting.

It may be useful for the student to have a scheme of treatment for the average case of eclampsia that he can put into effect without delay or confusion from considering the relative merits of the different plans just detailed. be successful in the majority of cases:

The following plan should

During the attack itself administer chloroform. As soon as the attack has passed off, inject under the skin fifteen drops of the fluid extract of veratrum viride, and administer by the bowel a dram of chloral in solution. Place upon the back of the tongue two drops of

croton oil diluted with a little sweet oil.

Wring

out three or four blankets
in very hot water, and
envelop the woman's
nude body in them, wrap-
ping one around each
limb and covering the
trunk with another, and
over all piling as many
dry blankets and heavy
coverings as can be pro-
cured. A hot
A hot vapor bath
by pouring four to eight
ounces of alcohol on hot
bricks at the woman's feet
under blankets, a hot air
or steam bath, or immer-

sion of the woman's body in hot water may be substituted for the hot wet pack. Inject by gravity under the breast or breasts a pint or more of normal salt solution, or, if the apparatus for subcutaneous injection is not at hand, inject several quarts of the solution by gravity into the bowel. If convulsions recur, repeat the veratrum viride in five-drop doses if the pulse is quick and strong. If the face is congested and swollen, and the pulse remains full and bounding, venesection should be resorted to, withdrawing sufficient blood from the veins to reduce the tension

of the pulse. Chloral may be repeated in the course of the attack two or three times, if the convulsions persist and are violent. If the face is pale and the pulse rapid and weak, stimulation may be required in the shape of brandy, ether, or ammonia hypodermatically. If the convulsions cease and the patient lies in a stupor, but can be aroused somewhat and is able to swallow, concentrated solution of Epsom salts, in dessertspoonful doses, should be given every fifteen or thirty minutes until catharsis is established.

Shock. The strain of labor in a weak woman, some of the accidents of parturition, or even forcible attempts to expel the placenta, may occasion shock after delivery, with lowered temperature, leaking skin, and a running, rapid pulse. Cases of this sort have been reported from compression of the left ovary in attempts to expel the placenta by Credé's method, the womb being turned upon the cervix so that the left side looks forward, and the ovary is grasped between the thumb and the uterine wall, when the hand is placed on the fundus of the womb in the effort of expression. The condition calls for the ordinary treatment of shock-heat externally and stimulants hypodermatically.

Typhoid Fever, Pneumonia, and Other Adynamic Diseases. These diseases, though rare complications, do occur in the pregnant woman, and in the majority of cases occasion premature delivery. In typhoid fever this occurs in sixty-five per cent. of the cases, and in pneumonia the proportion is quite as large. The advent of labor in the midst of these diseases is usually disastrous to the patient. Profound shock is often developed; the temperature falls abnormally low, even to 95° F., and the heart-action may be extremely weak. Active stimulation should be employed during the first stage of labor, and, as soon as the os is sufficiently dilated, the child should be artificially extracted as rapidly as possible without serious injury to the mother, in order to save her the strain of voluntary muscular effort in the second stage.

Valvular Disease of the Heart.-Mitral disease is the most serious. Certain statistics show a mortality as high as fifty-three per cent. As pregnancy advances the heart becomes more and more embarrassed, and respiration more labored. The most dangerous period, however, is just after the expulsion of the child, when the circulation is much disordered and an extra quantity of blood is thrown back upon the heart. It has been noticed that when the discharge of blood from the vagina is profuse, cardiac failure rarely occurs. This clinical observation points to the most successful treatment in cases of threatened heart-failure, namely, venesection,—with the removal of from eight to sixteen ounces of

blood, if there is not much blood lost from the parturient tract after labor. Nitrite of amyl and nitroglycerin are the most valuable stimulants to employ during labor and directly after its completion. Digitalis should be administered hypodermatically during the first stage in large doses, and as soon as it is possible to insert the forceps through the os, or to grasp the child's feet if the head is not engaged, the infant should be rapidly and, if necessary, forcibly extracted. Deep incisions of the cervix are of the greatest value in cutting short the duration of labor and in lessening the force required in the artificial delivery of the child. With this plan of treatment the mortality of heart disease in labor will be much reduced. It has been my fortune not to lose a case. although charged with the care of a number, some of which were of the most serious character.

PART V.

PATHOLOGY OF THE PUERPERIUM.

CHAPTER I.

Abnormalities in the Involution of the Uterus after Child-birth.

An abnormal course in the return of the uterus from the postpartum condition to the ordinary dimensions and weight of a nongravid womb may manifest itself by excess or by deficiency; there may be superinvolution or subinvolution.

Superinvolution.-This condition is the result of an abnormal prolongation or an exaggeration of that process by which the gravid womb returns, after delivery, to the dimensions of a healthy non-pregnant uterus, in consequence of which the organ is left, some time after labor, much smaller than in its virgin state.

Sir James Y. Simpson first directed attention to morbid deficiency and morbid excess in the involution of the uterus after labor. Since his time many writers have called attention to deficient involution; a smaller number have described the rarer anomaly of the two-excessive involution. Trommel detected superinvolution in 29 out of 3000 cases; Simpson 1 saw it in 22 out of 1300 cases; Sinclair, 2 in measuring 108 uteri after childbirth, found in 22 instances a uterine cavity of less than 24 in. (5.7 cm.), and Fordyce Barker 3 has declared that he sees from I to 3 cases every year, and that in his opinion superinvolution constitutes about one per cent. of uterine diseases. Hansen, among 120 nursing women, found 2 with a uterine cavity below 6 cm.

1 A. R. Simpson, "Superinvolution of the Uterus," "Trans. Edinburgh Obstet. Soc.," 1882-'83, viii, p. 88.

66

2 Trans. Amer. Gyn. Soc.," vol. iv. This series of measurements, as well as others made later by Sinclair and Richardson (“Trans. Amer. Gyn. Soc.,” vols. vi and vii), are sharply criticized by Hansen, who declares them to be in great part incorrect. The criticism is apparently merited.

3 Trans. Amer. Gyn. Soc.," viii, 1883; discussion on Dr. Johnson's paper. 4" Ueber die puerperale Verkleinerung des Uterus," "Zeitschr. f. Geburtsh. u. Gyn.," xiii, S. 16.

(5.6, 5.4 cm., or 2.2, 2.1 in.) respectively at the eighth and tenth week after delivery. Johnson 1 gives an account of 3 cases which occurred in his practice, and Simpson 2 refers to those described by Chiari, Chiarleoni, Jaquet, and Whitehead. A case 3 has been reported after abortion.

The etiology of the condition is somewhat obscure. It has been ascribed to wasting diseases, as phthisis, cancer, etc.; to anemia from hemorrhage at a previous birth or miscarriage; to nervous derangements, as puerperal insanity or chorea; to overlactation; to a rapid succession of labors; to local inflammations, especially those which attack the ovaries and abrogate their functions. The degree to which the superinvolution may occasionally progress is surprising. A. R. Simpson reports a case in which the uterine cavity measured but 4 of an inch.

Subinvolution may be described as an arrested or a retarded involution of the puerperal uterus.

Causes of Subinvolution.-There is a difference of opinion in regard to the exact nature of the changes which occur in the individual muscle-cells during involution of the uterus; but there can be no doubt as to the cause of these changes, whatever they may be. It is a great reduction of the blood-supply. In a general way, therefore, it may be asserted that any condition which tends to prevent a rapid diminution of the blood-supply to the puerperal uterus may be a cause of subinvolution. Nature's only method of decreasing the quantity of blood in the puerperal uterus is by the agency of the contracting muscle-fibers; therefore, it may again be asserted that any condition which interferes with the contraction of the uterus is a cause of subinvolution. It is necessary to make these two broad divisions in the etiology of subinvolution, for, although frequently interdependent, they are not rarely independent of each other. In point of frequency there should be placed first those causes which prevent the normal decrease of blood-supply to the uterus after labor. Prominent among these should stand hyperplasia of the endometrium.

Subinvolution by an excess of blood-supply may occasionally be traced to the presence of small fibroids, throughout the uterine wall. Other causes of subinvolution are lacerations of the cervix and peri-uterine inflammations; inflammations of the uterine body and of its lining membrane, usually the result of sepsis; retention within the uterus of placental fragments, shreds of mem

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Superinvolution of the Uterus," "Trans. Amer. Gyn. Soc.," viii, 1883. 2 Loc. cit. 3 C. M. Hansen, "Medical Record," Oct. 6, 1888.