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gradually lessens in size, and finally disappears. In the case shown in Fig. 557, in which the haematomata were of large size, the swellings did not begin to diminish notably in size until the third week after birth. They had almost completely disappeared by the sixth week. Suppuration seldom occurs, and, when it does, abrasions of the skin over the swelling are usually present, and through these infection has occurred. No special treatment is required unless suppuration occurs, as, if left alone, the blood will be gradually absorbed. If suppuration occurs, .the resultant abscess must be opened and drained.

[graphic]

Fig. 557.—A Double Cephalhematoma.
(From a photograph of an infant born in Dr. Steevens' Hospital.)

Hematoma of the Sterno-mastoid.—Haematoma of the sternomastoid is a condition which is of interest from its rarity, but it is of no great clinical importance. The injury, to which it is due, occurs during birth, but the existence of the haematoma is usually not recognised until ten days or more afterwards, that is, until the coagulated blood is firm enough to cause a distinct tumour. It usually occurs in association with pelvic presentation, but may also be found after the application of the forceps in head presentation, and in such cases is said to be due to over-twisting of the head producing a laceration of a bloodvessel in the muscle or to laceration of the muscle fibres themselves. The tumour is usually about the size and shape of a pigeon's egg, and resembles an enlarged lymphatic gland. It is movable, hard, and obviously situated in the belly of the muscle. If it is of a very large size, and associated with an extensive laceration of the muscle fibres, it may possibly give rise to a subsequent torticollis. The condition calls for no special treatment, though gentle massage may promote the absorption of the blood.

Nerve Lesions.—The nerve lesions which result from injuries during birth may be divided into two groups:—central lesions and peripheral lesions.

Central Lesions.—Central lesions are much more serious than are peripheral lesions and are also rarer. They usually occur as meningeal haemorrhages, either localised or spread over the entire surface of the brain, as a result of which partial or complete hemiplegia is found. Convulsions also are common, and so are disturbances of the respiratory and cardiac functions. Death, as a rule, results within the first four or five days, but in some cases may not occur for weeks, months, or even years. Treatment is of little avail.

Peripheral Lesions.—Peripheral nerve lesions are considerably more common than are central lesions, and are of interest from the point of view of the prognosis. The most common lesions are those of the facial nerve, and of the upper trunks of the brachial plexus. Facial paralysis is of not uncommon occurrence after delivery by the forceps, in consequence of the compression of the facial nerve at the point of emergence from the cranial cavity. The paralysis is, as a rule, unilateral, and may be noticed an hour or so after the infant is born, or not for a day or two. When the infant is asleep, the eye on the affected side is open, in consequence of the paralysis of the orbicularis palpebrarum muscle. This contrasts with the appearance of the infant in facial paralysis of central origin, in which the orbicularis muscle usually escapes. When the infant cries, the unaffected side of the face puckers up, while the paralysed side remains smooth, and the mouth is drawn to the unaffected side. As a rule, the condition disappears in a day or two, or, in some cases, may last for a few weeks. Occasionally, the lesion may be more severe, and the reaction of degeneration be present. In such cases, the regular use of the galvanic current will be necessary. The eye on the paralysed side must be watched, and care taken that it does not suffer from exposure due to the paralysis of the lid.

Paralysis of the upper extremity, as described by Erb, is usually the result of lesions of the fifth and sixth cervical nerves, and so is confined to a certain group of muscles. These are the deltoid, the biceps, the supinator longus, the brachialis anticus, and sometimes the supra- and infra-spinatus. The cause of the lesion is probably to be found in undue traction on the nerves on one side in consequence of the head being drawn over too far towards the opposite shoulder (Fieux*), as may occur during traction on the head with the forceps, or with the hand when delivering the shoulders, or when bringing down arms extended beside the after-coming head. Erb, on the other hand, after whom this form of paralysis is usually named, considers that it is due to pressure exercised by the fingers or forceps on 'Erb's spot'—a point on the neck at which electrical stimulation causes the contraction of all the muscles usually involved in Erb's paralysis. In consequence of the paralysis, the arm hangs lifelessly by the side. It is rotated inwards, the forearm pronated, and the palm looking outwards. In severe cases, the reaction of degeneration is present. The majority of cases recover within two or three months, the improvement beginning in the biceps and ending in the deltoid. According to Holt, spontaneous recovery is not to be expected unless it occurs within this time. In severe cases, permanent paralysis may result. The treatment of Erb's paralysis consists in the regular and persistent use of the galvanic current, or of the faradic current if the muscles react to it.

* 'De la Pathogenie des Paralysies brachiales chez le Nouveau-ne,' Ann. de Gyn'ec, January, 1897.

ADDENDUM TO PAGE 901

THE yETIOLOGY OF ADHERENT PLACENTA

Of late, considerable importance has been attached to thinning of the decidua basalis as a cause of abnormal placental adhesion. It has been suggested* that when this decidua is imperfectly developed, the chorionic villi grow down into the uterine muscle tissue, in which they become firmly embedded, and from which their subsequent separation is never spontaneous and may be most difficult. The cause of the thinning of the decidua basalis in such cases is probably to be found in 'atrophic endometritis,' in destruction of the endometrium by caustics or by excessive curetting, or in the presence of sub-mucous myomata which have caused a pressure atrophy of their covering mucous membrane. This explanation is a very possible one, and, if it is correct, it should be possible to find fragments of uterine muscle hanging on the placental tissue in cases of manual removal, as, during that process, it would be impossible to avoid removing the softened fibres along with the placenta.

* Winckel's ' Handbook of Midwifery,' Band ii., p. 2115.

INDEX

Abdomen, pendulous, 547, 748, 765,
772, 849
signs of pregnancy in, 236
Abdominal palpation, 167, 852, 1052
complications determined by,
175

diagnosis of brow presentation

by, 393
fundal grip, 170

Pawlic's, or first pelvic grip,

second pelvic grip, 173
umbilical grip, 171
various authors on, 167
Abdominal wall, changes in, during

pregnancy, 224
change in, in third stage of

labour, 298
during puerperium, 459
omphalitis in, 1172
signs of nulliparity and parity

in, 246

Abdomino-vaginal examination, 181,
184

Abortion, 255, 256, 259, 488, 489,
508, 534, 634

acute and chronic decidual endo-
metritis a cause of, 488

acute yellow atrophy of liver a
cause of, 605

aetiology of, 635

backward displacementsof uterus

a cause of, 490, 534
cardiac disease a cause of,

594

causes of, 635
cervical, 642
complete, 645

diabetes in pregnancy a cause of,
S«7

fibro-myomata a cause of, 814
frequency of, 634
haemorrhages in, 673
incomplete, 643
induction of, 1006

Abortion, in pneumonia, 572
in relapsing fever, 573
in scarlatina, 574
in syphilis, 578

malignant disease of vagina or

cervix a cause of, 724
missed, 631, 646, 694
diagnosis, 631
symptoms, 631, 697
treatment, 631
procidentia a cause of, 549
tetanus after, 941
threatened, 637-641

menstruation in pregnancy

a sign of, 723
symptoms, 637, 697
treatment, 626-629
traumatism a cause of, 724
tubal, 676
Abscess in extra-uterine pregnancy,
655

formation of, on death of foetus,
664

mammary, treatment, 981
Accessory muscles of labour, con-
tractions of, 268
Accouchement force, 706, 710, 991

in placenta praevia, 720, 72."
Acephalians, 875

Acetone in puerperal urine and prior
to delivery, 458

Adrenalin, use of, in uterine inver-
sion, 927

Air-hunger, 683, 896

Ala ilii, 5

Albuminuria and eclampsia, 612

in pregnancy, 575, 589
Albuminuric placenta, 528
Alcohol treatment of puerperal fever,
960

Alimentary system, infantile, diseases

of, 1167
Allantois, formation of, 81-83
Amenorrhoea, 233, 241

in extra-uterine pregnancy, 680

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