analgesia an excessive amount is not employed. For the first stage chloral in 15 gr. doses repeated once, or at most twice, is the only agent permissible.

(e) Rupture of the Membranes.-In a primipara the membranes should never be ruptured, and in multiparæ only in the second stage. Finger, match, hairpin, etc., may be used to break them, the operation being performed in the absence of a pain, with the assurance that membranes are present, and not the lower uterine segment, thin from pressure of the head.

(f) Treatment of the Second Stage.-Examinations should now be made every five or ten minutes. A puller may be employed to increase the abdominal force.

The Perineum.-Bad lacerations of the perineum are avoidable. In primiparæ the fourchette is torn in 61 per cent. of cases, the perineum in 34 per cent. ; in multiparæ, the perineum in 9 per cent.

Causes :

(a) Relative disproportion between the size of the head and outlet.

(b) Precipitate expulsion.

(c) Faulty mechanism.

If

Preventive Treatment.-Depends largely upon the cause. the disproportion be great, episeotomy may be required; if expulsion precipitate, retard the head by hand or forceps; in some faulty mechanisms the forceps can be used to correct them, as by elevating the handles when the head is overflexed, etc. A routine treatment, based upon the most frequent cause, is to retard expulsion by resisting the head and pressing it toward the pubes, restraining voluntary efforts and using them during the absence of pains.

The Head. When the head is born avoid traction, support it for a few moments, and if the cord be coiled around the neck, loosen and slip it over the head, allow the shoulders to pass through it or cut it between two ligatures. If the delivery of the head is further delayed, stimulate the uterus to contraction by frictions through the abdominal wall.

The Shoulders.-Avoid increasing any tear the head may have made.

Treatment of the Third Stage.-Indications are, (1) prevent hemorrhage, and (2) deliver the placenta. Secure contraction and retraction of the uterus by external and internal stimuli: externally, by frictions through abdomen, continued for fifteen minutes and followed by the application of a pad and binder; internally, by administering 3j of the fld. extract of ergot.

The binder should be 12 in. by 14 yard, preferably manytailed, and the pad should be placed over the umbilicus.

The placenta is separated by a diminution of the placental area, and its delivery should be accomplished by resorting to the Credé method fifteen minutes after the birth of the child. Remember that the movement of "expression" should be with a pain.

The Infant.-Clear out any mucus that may obstruct the airpassages by holding the child by the feet and sweeping the little finger around the mouth. After pulsations in the cord cease, apply two ligatures, for cleanliness, and cut between them across the palm of the hand. The ligature should be tied with the surgeon's knot, followed by an ordinary bow-knot, to permit tightening after the child has had its warm bath. Before the cord is ligated it should be stripped. The vernix caseosa should be removed by some oily substance, followed by soap and water. Salicylated cotton should be used to dress the cord, and the binder then applied. Look for possible anal, urethral, or other congenital deformity.

Puerperium.
Physiology.

The child-bearing process is divided into four periods, viz: Pregnancy, Labor, Puerperium, and Lactation. The puerperium is the period from birth to the time when the uterus has regained its normal size, which is six weeks. Dimensions of uterus at 9th month, 2 lbs., 12 × 9 × 81⁄2 in., 400 cu. in. Dimensions of uterus 6 weeks after labor, 2 oz., 1 cu. in. These changes in the uterus, its lining and adnexa result from the process known as Involution.

Anatomical Development of the Pregnant Uterus.-Subsequent to impregnation the muscle cells take on a new growth, and in

their development hypertrophy into muscular fibres four times as broad and eleven times as long. There is a similar increase in blood vessels, connective tissue, lymphatics, and nerves.

Anatomical Changes During Involution.—As a result of the decrease in blood supply, which normally repairs tissue waste, the superabundant uterine tissue undergoes degeneration, chiefly fatty, and is carried away by the blood vessels and the lymphatics, in part as peptones. The process is really an atrophy, which ceases after the enlarged muscle cells have been reduced to their original size. From the anatomical arrangement of its fibres the parturient uterus is composed of two segments, the upper muscular, with its fibres arranged crosswise, the lower largely fibrous, arranged longitudinally. In the process of involution the upper undergoes the greatest change, while the lower, including the vagina, is mainly a retraction of overstretched tissue, which never completely regains its tone. The lining membrane of the uterus, or decidua, is composed of an upper cellular and lower glandular layer. The upper is partly removed when the ovum is delivered, and the remainder disintegrates as the blood supply diminishes, until the epithelial structures of the glandular layer are exposed, and from these epithelial cells in the glandular layer the mucous membrane is renewed.

Lochia.—(a) Lochia Rubra. Bloody, last four to five days. (b) Serosa. Composed of disintegrating tissue, pus-cells, mucus, and water. (c) Alba. Composed of healthy pus.

Quantity.-First four days, 1 kilo., or 2.2 lbs. Next two days, 280 grams, or 15 oz. Until the ninth day, 205 grams, or 7 oz.-34 lbs in all.

Quantity is estimated by the number of napkins soiled. In the first twenty-four hours the pads should be changed six times, during the next four days three times a day, and after the fifth day twice a day. A personal examination by the physician should always ascertain their odor, which is at first bloody, later like that of the genitalia. A putrid odor is the danger signal of decomposition and sepsis. Modern observation has demonstrated that the lochia normally contain very many non-pathogenic micro-organisms. They are very numerous