100 U57c 1663. m >>.^i*&s WQ 100 L257c NLM D55L|SMfl3 E NATIONAL LIBRARY OF MEDICINE 47721270R pnTC' f Medicine. EDITION. JUST READY. liversity of Pennsylvania, Long Islana College Hospital, Yale and Harvard Colleges, Bishop's College, Montreal, University of Michigan, and over twenty other Medical Schools. HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. By Frederick T. Roberts, m.d., m.r.c.p., Assistant Professor and Teacher of Clinical Medicine in University College Hospital, Assistant Physician in Bromp- ton Consumptive Hospital. Third Edition. Octavo. SURGEON GENERAL'S OFFICE LIBRARY ANNEX Section Form 113c W.D..S.G.O. No. . 112212 V. 8. GOVERNM >ut td- :ti- tal ms ily in all mt \°f "I system son, j "It doners compe Allen, "Af convin Yale ( "I take p in the Media adapted for students. While concise, nothing is omitted that is important to be known."—Professor y. A. Thacker, Cincinnati. " I shall include it among the text-books of the College of Physicians and Surgeons, and strongly recommend it to my classes."—Professor yohn S. Lynch, Baltimore. " It is unsurpassed by any work that has fallen into our hands, as a compen- dium for students preparing for examination. It is thoroughly practical, and fully up to the times."—The Clinic. " Our opinion of it is one of almost unqualified praise. The style is cltar, and the amount of useful and, indeed, indispensable information which it con- tains is marvelous. We heartily recommend it to students, teachers, and prac- titioners."—Boston Medical and Surgical yournal. " That Dr. Roberts' book is admirably fitted to supply the want of a good handbook of medicine, so much felt by every medical student, does not adnit of a question."—Students' yournal and Hospital Gazette. P. BLAKISTON, SON & CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. NLM052454832 BYFORD'S Diseases of Women. THIRD ENLARGED EDITION. Recommended as a Text-Book at Rush Medical College, Chicago ; Woman's Medical College, Chicago; National Medical College, Washington, D. C, and other Medical Schools. THE PRACTICE OF MEDICINE AND SURGERY, APPLIED TO THE DISEASES AND ACCIDENTS INCIDENT TO WOMEN. By Wm. H. Byford, a.m., m.d., author of "A Treatise on the Chronic Inflammation and Displacement of the Unimpregnated Uterus," and Pro- fessor of Obstetrics and Diseases of Women and Children in the Chicago Medical College, and in the Woman's Medi- cal College, Chicago. Third Edition, Revised. In One Volume. Octavo. 164 Illustrations. Price, Cloth, $5.00; Leather, $6.00. RECOMMENDATIONS. " I have read with pleasure your book on Diseases of Women; it gratifies me to indorse its teachings."—Prof. H. P. C. Wilson, Jr., Baltimore. " I am well acquainted with the author, and regard him an excellent practi- tioner and teacher."— Dr. y. A. Ireland, Professor of'Obstetrics and Gyne- cology, Louisville Medical College. " It is much improved and is still more what it always was, a valuable practi- cal assistant to the practitioner."—Prof. Henry G. Landis, Starling Medical College, Columbus. " I find, from its being so well brought up to the present state of the science it treats of, that it is particularly adapted to the requirements of the medical student."—/. Fred Prioleau, M. D., Professor of Gynecology, Medical College of South Carolina, Charleston. "The author has presented to the profession a concise and comprehensive treatise on the subject of diseases of females. We congratulate Dr. Byford upon his success, and feel satisfied that the effort will be duly appreciated by those whom the work is intended to instruct. It is one of the best treatises on the subject ever submitted to the American profession, and will early be acknowledged as such. It is well written, and where necessary, is appropri- ately illustrated."—Medical and Surgical Reporter, Philadelphia. " The present work being particularly of use where questions of etiology and general treatment are concerned. * * * This volume, hence, will commend itself both to those who possess former editions and to those who do not. It cannot fail to be useful to many, and will certainly prove interest- ing to all "—The American yournal of Obstetrics. " These important topics are all handled vigorously and practically. The work cannot fail to be in great demand, and to exert a material influence on clinical practice."—New York Medical yournal. P. BLAKISTON, SON & CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. COMPEND OF OBSTETRICS. LANDIS. ? QUIZ COMPENDS. ? A NEW SERIES OF BOOKS FOR STUDENTS' USE IN QUIZ-CLASS AND EXAMINATION ROOMS. flES* These Compends are based on the most popular text-books, and the lectures of prominent professors. JSSi" The Authors have had large experience as Quiz Masters and attaches of colleges, and are well acquainted with the wants of students. US) • They are arranged in the most approved form, thorough and concise, with illustrations whenever they can be used to advantage. 4®* Can be used by students of any college. JI9f They contain information nowhere else collected in such a condensed, practical shape. *y Size is such that they may be easily carried in the pocket, and the price is low. A7jJ They will be found very serviceable to physicians, as remem- brancers. LIST OF VOLUMES. No. i. ANATOMY. By Samuel O. L. Potter, m.d. 63 Illustra- tions. Now ready. No. a. PRACTICE, Part I. By Dan'l E. Hughes, m.d., Demon- strator of Clinical Medicine, Jefferson College, Philadelphia. Now ready. No. 3. PRACTICE, Part II. Same author. In February. No. 4. PHYSIOLOGY. By A. P. Brubaker, m.d., Demonstrator of Physiology, Jefferson College, Philadelphia. Now ready. No. 5. OBSTETRICS. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women and Children, Starling Medical College, Columbus, Ohio, lllustratedi Now Ready. MATERIA MEDICA. By Samuel O. L. Potter, m.d. In February. CHEMISTRY. By G. Mason Ward, m.d., Demonstrator of Chemistry, Jefferson College, Philadelphia. Preparing. SURGERY. In preparation. VISCERAL ANATOMY. By Samuel O. L. Potter, m.d. With illustrations. Others in preparation. ? QUIZ-COMPENDS ? No. 5. COMPEND OBSTETRICS ESPECIALLY ADAPTED TO THE USE OF MEDICAL STUDENTS AND PHYSICIANS. HENRY G. LANDIS, A.M., M.D., Professor of Obstetrics and Disea^ ■ ■!" Women in Starling Medical College ; Fellow of the American Academy of Medicine ; Member of the American Medical Association ; Author of " How to Use the Forceps," etc., etc. WITH ILLUSTRATIONS. TPHIA P. BLAKISTON, SON & CO., 1012 Walnut Street. 18 83. 100 L257t 1883 Entered according to Act of Congress, in the year 1882, by P. BLAKISTON, SON & CO., In the Office of the Librarian of Congress, at Washington, D. C. PREFACE. The design of this book is to furnish a useful compend and Quiz book for the student, and also, by the system of question and answer to bring out the more important facts in Obstetrics more clearly than can be done in the method of continuous composition. On many points it is difficult to determine what is the "received doctrine," except by the mere numerical weight of authorities. The author has, therefore, attempted to maintain a judicious eclecticism, instead of undertaking the task, impracticable within the limits of the book, of recording all the various and more or less received teachings of all authors. H. G. L. TABLE OF CONTENTS. PAGE Introduction..................................................................... 9 The Pelvis........................................................................ 9 Pelvic diameters.............................................................. 13 " planes.................................................................. 14 " muscles................................................................ 15 Reproductive Organs. The Uterus.................................................................... 15 Ligaments..................................................................... 17 Fallopian Tubes............................................................. 18 Ovaries.......................................................................... 18 Vagina......................................................................... 19 Douglas' cul-de-sac.......................................................... 19 Hymen.......................................................................... 19 Carunculse..................................................................... 20 Bulb of Vagina............................................................... 20 Vulvo-vaginal Glands....................................................... 20 Labia Majora................................................................. 20 " Minora................................................................. 21 Mons Veneris................................................................. 20 Commissures................................................................. 21 Clitoris.......................................................................... 21 Vestibule...................................................................... 21 Meatus............,............................................................. 21 Urethra......................................................................... 21 Perineum....................................................................... 22 Physiology. Ovulation..................................................................... 22 Menstruation.................................................................. 24 The Breasts...'................................................................ 26 Pregnancy. Fecundation................................................................... 27 Changes in Ovum............................................................ 27 vii viii TABLE OF CONTENTS. PAGE Changes in Womb.........................................................29_3] The Placenta................................................................. 29 Foetal Changes............................................................... 3° Multiple Pregnancy......................................................... 31 Extra-uterine " ......................................................... 32 Hydatid "......................................................... 34 Mole "......................................................... 35 Spurious " ......................................................... 35 Premature Labor.............................................................. 35 Signs of Pregnancy............................................................. 37 Labor. Clinical History............................................................... 45 Duties of the Physician..................................................... 48 Mechanism of Labor........................................................... 52 Dystocia. Uterine Inertia............................................................... 64 Rigidity of Cervix, etc...................................................... 66 Deformities of Pelvis........................................................ 68 Ovular Dystocia ............................................................. 7° Twin Labor................................................................... 73 Accidental Hemorrhage.................................................... 74 Placenta Previa............................................................... 75 Post-partum Hemorrhage................................................... 77 Rupture of Uterus............................................................ 78 Eclampsia..................................................................... 79 Placental Dystocia........................................................... 81 Inversion of Uterus.......................................................... 83 Obstetric Operations. The Forceps.................................................................. 84 Version......................................................................... 89 Embryotomy.................................................................. 91 Csesarean Section..................................•.......................... 92 Induction of Labor.......................................................... 93 The Period after Delivery. Involution of the Uterus.................................................... 94 Puerperal Diseases........................................................... 97 Congenital Defects.......................................................... 100 Appendix..................................................................... 103 QUESTIONS ON OBSTETRICS. introduction. What is Obstetrics ? The science and art of affording aid to women in labor. What is meant by science and art ? The science of Obstetrics embraces the definite rules of procedure founded upon a correct knowledge of the nature of Labor and its complications; the art consists in the skillful carrying out of these rules. The science may be taught in books and lectures; the art must be acquired by practice at the bedside. How may the subject be divided ? 1st. The Anatomy of the parts concerned in labor, viz: the reproductive organs and their surroundings. 2d. The Physiology of these parts. 3d. Their Pathology, including all deviations from the natural course of labor. 4th. The treatment of natural and complicated labor. What are the reproductive organs of woman. 1st. Internal, viz : the ovaries, uterus, oviducts and vagina. 2d. External, viz: the hymen, mons veneris, labia majora and minora; clitoris, vestibule, perineum and meatus urinarius; also the breasts. Where are they situated ? With the exception of the breasts, they are placed within or below the Pelvis. THE PELVIS. What is the Pelvis ? A bony structure, placed at the end of the vertebral column. Why is it called the pelvis ? Because, when clothed with muscles, ligaments and fasciae, it resembles a basin. Of how many bones is the pelvis composed. Four; the sacrum, coccyx, and two ossa innominata. B 9 10 questions on obstetrics. What is the sacrum ? A wedge-shaped bone, apparently formed by the fusion of five vertebrae. It is curved, being concave in front. How many articular surfaces does it possess ? Four; by one it is connected with the last lumbar vertebra, above; by one on each side, with the ossa innominata, and by one below, with the coccyx. What is the coccyx ? A small, and similarly wedged-shaped bone, apparently formed by the fusion of three or four vertebral bodies. It has one articular surface above, by which it is connected with the sacrum. It tapers from that bone, and is supposed to be the remains of our ancestral tail. What are the ossa innominata ? The haunch bones, of irregular shape, articulating with the sacrum on each side, and with themselves in front. Each os innominatum is com- posed, originally, of three separate pieces, the ilium, ischium, and pubes. Their point of juncture is found in a cup-shaped depression on the out- side of the bone, called the acetabulum. When do the several parts of the os innominatum unite ? By the twenty-fifth year. What uses has the pelvis ? 1st, To support and transmit the weight of the body. 2d. To contain and protect certain organs. 3d. To serve as a parturient tube or canal, through which the child may be definitely guided during labor. To what parts is the weight of the body transmitted ? To the femora in the erect posture, and to the tuberosities of the ischia in the sitting posture. How is the weight of the body transmitted to the femora ? By two beams of bone, consisting of the upper part of the sacrum and body of the ilium on either side. What are these beams called ? The sacro-iliac beams (see Fig. 1, page 12). What prevents these beams from being pushed in and out at their distal ends ? Another beam is placed between them, extending from an acetabulum to the opposite one, consisting of the upper part of the pubes on either side. What is this beam called ? The pubic beam (see Fig. 1, page 12). the pelvis. 11 Why are these beams not straight ? They are arched outwardly to make more room in the pelvis to* enable it to fulfill its second and third uses (Fig. 2). How is the diminution in strength of the sacro-iliac beams, caused by this arching, remedied ? By buttressing the beams by that expansion of the sacrum and iliac bones, called the wings of the ilia and sacrum (Fig. 3). How is jarring and concussion prevented ? By placing joints at the centre of each beam. How is the diminution of strength caused by these joints remedied ? By covering them with powerful ligaments. How is weight transmitted from the vertebral column to the tuberosities of the ischia ? By two beams of bone, placed directly under the sacro-iliac beams, con- sisting of the ischium and under portion of the ilium on either side. What are they called ? The ilio-ischiatic beams. How are they held together in front ? By another arched beam, placed directly under the pubic beam, and called the sub-pubic beam. What is the great sacro-sciatic notch ? The arched space under the ilio-ischiatic beam. What bony projection is found in it ? The spine of the ischium. What is the lesser sacro-sciatic notch ? That part of the arch below the spine of the ischium. What is the obturator foramen ? The space between the pubic and sub-pubic beams on each side. How is it closed ? By a membrane which gives attachment to muscles. How may a female pelvis be distinguished from the male ? By the fact that the sub-pubic beam is roundly arched in the female and its edges everted. In the male there is very little arching or eversion. (But some female pelves approach the male type.) What joints exist in the pelvis ? Two sacro-iliac (one on each side), the pubic joint, in front, and the sacro-coccygeal joint, behind, 12 QUESTIONS ON OBSTETRICS. Fig. i.—B, with half of A=the left sacro-iliac beam, transmitting weight to the femur F. C=the body of pubes, constituting with its fellow the pubic beam. Fig. 2.—The same as in Fig. i, but with the beams arched; the dotted lines show the original direction of force. Fig. 3.—The same as in Fig. 2, with the arches strengthened by the addition of the iliac wings, etc. The dotted lines below show the sub-pubic arch in front and the beginning of the ilio-ischiatic beams. THE PKLVIS. 13 What are the pelvic joints called ? Symphyses, and the pubic joint is often called, by way of distinction, the symphysis. What kind of joints are they ? Amphiarthrodial. The sacro-coccygeal joint is always freely movable and has a demonstrable synovial sac ; the other joints can only be shown to have sacs during pregnancy. What is the sacral promontory ? The projection or angle formed by the top of the sacrum in front at its junction with the vertebra above. It is often called simply the promontory. What is the ileo-pectineal line ? A bony ridge or raised line, which, beginning at the promontory, ex- tends around each side of the pelvis, within, until it meets the opposite line at the symphysis pubis. What parts lie above it ? The wings of the sacrum and ilium, called also the false pelvis. What lies below it ? The true or obstetric pelvis. What is the ileo-pectineal line said to bound ? The inlet of the pelvis, because the child must first enter the pelvis through this bony ring. It is called also the superior strait. Where is the pelvic outlet ? It is bounded by the tip of the coccyx behind, by the tuberosities of the ischia on the sides, and by the sub-pubic arch in front. It is called also the Inferior strait. What is the pectineal eminence ? That point in the ileo-pectineal line which is opposite the acetabulum, and is slightly raised above the ordinary level of the line. What is the ilio-ischiatic line ? A slightly raised ridge, on the inside of the pelvis, which begins at the pectineal eminence and ends in the ischiatic spine on either side. What are the diameters of the pelvis ? Lines drawn from various points of the pelvic cavity to facilitate the description of the relations which the child's surface bears to the pelvis during its passage through it. What are the diameters of the inlet ? The conjugate, two oblique, and the transverse, 14 QUESTIONS ON OBSTETRICS. What is the conjugate diameter of the inlet ? A line drawn from the promontory to the top of the symphysis pubis. It is about four inches long in the normal pelvis. What are the oblique diameters ? Lines drawn from the sacro-iliac symphysis of either side to a point in front of the pectineal eminence of the opposite side (Meadows). The one drawn from the right sacro-iliac symphysis is called the right oblique; the one from the left symphysis, the left oblique. They are about five inches long. What is the transverse diameter of the inlet ? A line drawn directly across the pelvis from one pectineal eminence to the other. In the normal pelvis it is no longer than either of the oblique diameters. What are the diameters of the outlet ? The conjugate and transverse. What is the conjugate diameter of the outlet ? A line drawn from the tip of the coccyx to the under edge of the sym- physis pubis. It is of variable length, owing to the mobility of the coccyx, but when the latter is extended, during labor, it is the longest diameter of the outlet, and may measure five inches. What is the transverse diameter of the outlet ? Fig. a b. Conjugate diameter of Inlet. ef. Conjugate diameter of Outlet. What planes are important ? The plane of the inlet and of the outlet. A line drawn from one tuberosity of the ischium to the opposite one, and meas- ures a little less than four inches in the normal pelvis. What are the planes of ' the pelvis ? Imaginary levels, drawn through any part of the pel- vic circumference (Playfair), to facilitate the description of the relations of the pelvis to the child, vertebral col- umn or horizon. They may _„be illustrated by pieces of card-board cut so as to fit the pelvic cavity at any level. THE KEHRODi;( 1 IVK ORGANS. 15 What is the plane of the inlet ? A plane drawn transversely through the conjugate diameter of the inlet and limited by the circumference of the inlet. What is the plane of the outlet ? A plane drawn transversely through the conjugate diameter of the outlet and limited by the circumference of the outlet. (For other planes see Appendix.) How are these planes used to show the position of the pelvis in different postures ? In the erect posture the plane of the inlet makes an angle of 6o° with the horizon. In the semi-recumbent posture the same plane is directly hori- zontal, and in the recumbent posture it forms a reversed angle of 450 with the horizon. How is the pelvis lined within ? By certain muscles, blood vessels, nerves and fasciae. What muscles are contained in it ? 1. The Psoas-iliacus muscle on either side, consists, first, of the iliacus internus, which, in its origin, covers almost the entire inner aspect of the wing of the ilium, uniting with the psoas magnus, which passes over the upper border of the sacrum. Their conjoined body passes along the border of the sacro-iliac arch, and by a common tendon passes out of the pelvis to be inserted upon the femur. 2. The Pyriformis muscle on either side, which covers with its insertion the face of the sacrum, and passes out of the pelvis under the sacro-ischiatic arch, to be inserted upon the femur. 3d. The Obturator internus muscle on either side, which covers the ante- rior pelvic walls and passes out with the pyriformis. What obstetric uses have these muscles ? Besides serving as a soft lining to the bones, the psoas iliacus furnishes a cushion, or guard for the iliac vessels and nerves, preserving them from pressure, while the pyriformis performs the same office for the sciatic nerve, which lies along its border. THE REPRODUCTIVE ORGANS. THE INTERNAL ORGANS. What and where is the Uterus ? The uterus or womb is a hollow muscular organ, situated in the centre of the pelvis, between the bladder and rectum. What are its shape and dimensions ? It resembles a pear cut in two, the anterior surface being flat, and the 16 QUESTIONS ON OBSTETRICS. posterior rounded. It is three inches long, two inches broad (above) and one inch thick, and weighs in the virgin about one ounce. Fig. 5. H A * a Into what parts is it divided ? Into, 1st, the cervix or neck, about an inch long, and 2d, the body or fundus. What are the cornua of the uterus ? Fig. 6. The upper and outer angles are called the cornua. How is the cavity of the uterus divided ? Into the cavities of the cervix and body. The first is fusiform, and appears to be an antechamber. to the main cavity; the latter is triangular in out- line, but with its walls in apposition (see Figure). What openings are found in the cervix ? The os externum, or os uteri, called also the os, is a small opening into the cavity of the cervix at the lower end of the cervix. The constriction between the cavities of the neck and body is called the os internum. What is the structure of the uterus ? It is mainly composed of muscular tissue, with fibrous connective tissue, blood vessels and nerves. On the outside, it is mainly covered with peritoneum, and on the inside, is lined with mucous membrane. How are the muscular fibres arranged ? For the most part they are irregularly and inextricably interlaced, but a circular arrangement of fibres is found in the ceivix, while in the body the majority are longitudinal. What kind of blood vessels are found in the womb ? The arteries are mainly small, and helicine or spiral, while the veins THE REPRODUCTIVE ORGANS. 17 are short, of large calibre, and freely communicating; peculiarities which warrant us in regarding the uterus as composed of a modified erectile tissue. What kind of nerves are found in the uterus ? Nerves derived from the cerebro-spinal and sympathetic systems, and independent ganglia similar to those found in that other hollow muscle, the heart. What kind of mucous membrane lines the uterus ? The membrane lining the fundus is very thick (one-fourth of an inch in some places). It is composed of cylindrical epithelium cells, the outer layer of which are ciliated, and of mucous follicles, which secrete a viscid alkaline mucus. The membrane lining the cervix is continuous with that of the body, and differs in having more follicles, and in being thrown into longitudinal folds. What distinguishing peculiarity has the uterine mucous mem- brane ? It has no basement layer of connective tissue, and merges irregularly into the muscular tissue. How does the peritoneum cover the uterus ? It completely invests the uterus above, in front as far as the junction of the body and cervix, where the bladder touches the womb, and behind as far as the junction of the uterus and vagina. What is the broad ligament of the uterus ? The extension of the peritoneum over the uterus causes two folds of peritoneum to be brought together at its sides, and these extend across the pelvis, to be merged into the common abdominal peritoneum. These transverse folds are called the broad ligament, and divide the pelvis into two compartments; in the anterior one the bladder is situated, in the pos- terior, the rectum. What are the round ligaments ? They are two rounded cords, composed of fibrous tissue, interspersed with muscular fibres, which extend from the cornua of the uterus to the top of the pelvis in front, where they pass through the inguinal canal to be inserted in the connective tissue of the labia majora. What are the utero-sacral ligaments ? Bands of fibrous tissue which pass from either side of the uterus to the sacrum, and are of considerable strength. What are the recto-uterine and vesico-uterine ligaments ? Small folds of peritoneum which pass between the uterus and the blad- der and rectum respectively. 18 QUESTIONS ON OBSTETRICS. What is the normal position of the uterus ? The uterus is placed nearly in the centre of the pelvis; so that a line drawn from the top of the symphysis to the middle of the second bone of the sacrum would touch its top. Its long axis is nearly parallel to the face of the sacrum and to the posterior wall of the symphysis pubis. But it must be remembered that the uterus is movable, and, 1st, rises and falls with the respiratory movements, and 2d, is pushed backward and forward by the varying conditions of fullness in the bladder and rectum. What supports the uterus ? 1st. The uterus is swung from the sacrum by the utero sacral ligaments. 2d. It is slightly supported or belayed by the broad, round, recto- and vesico-uterine ligaments 3d. The walls of the vagina act as a fleshy column of support, being in turn supported by the perineum. 4th. " The retentive power of the abdomen" (Duncan), due to the exist- ence of a partial vacuum in the abdominal cavity, aids in maintaining the uterus in its normal position. What are the fallopian tubes ? The fallopian tubes or oviducts are small tubes which extend from each cornu of the uterus. What is their structure ? They are continuous in structure with the uterus, being mainly muscular, covered with peritoneum and lined with mucous membrane, which is iden- tical with that of the uterus. Their average calibre is one-sixteenth of an inch, and their length about five inches. How do they terminate ? In an expanded or trumpet-shaped end, called the fimbriated extremity, oecausa it is fringed with little prolongations of tubal tissue, one or more of which is adherent to the ovary of the same side. What and where are the ovaries ! Two glandular bodies imbedded in the posterior surface of the broad ligament, one on each side of the uterus. They are about the size and appearance of blanched almonds. What is the structure of the ovary ? It is mainly composed of a stroma of dense fibrous tissue, in the meshes of which are found the ovisacs in different stages of development (see Ovulation). What is the vagina ? A tube which serves to connect the uterus and its appendages with the THE REPRODUCTIVE ORGANS. 19 outside of the body. It is attached above to the uterus and terminates below in the vulva. How is the vagina attached to the uterus ? It is inserted upon the outside of the womb at the junction of the body and neck, so that the neck of the uterus projects into the tube. What is the structure of the vagina ? It is composed of fibrous connective tissue and of muscular fibres for the most part circularly arranged. On the outside it becomes continuous with the ordinary cellular tissue or packing of the pelvis; within, it is lined with mucous membrane which is reflected over the cervix uteri above, and below is continuous with the mucous membrane of the vulva. How does the mucous membrane of the vagina differ from that of the uterus ? It is composed of flat or pavement epithelial cells, and its follicles are less numerous and secrete a mucus of acid reaction. In the virgin it is disposed in many transverse folds, called rugae. How long is the vagina ? Its anterior wall is quite short, extending from the vulva almost directly to its point of insertion, a small pouch being formed above, called the ante- rior vaginal pouch. The posterior wall is longer, being prolonged upward to form a larger pouch behind the uterine neck, called the posterior vagi- nal, or retro-uterine pouch. The average length of the vagina is from 3 to 5 inches, varying in individuals and in races. Where is Douglas' cul de sac ? It is situated in the abdominal cavity, directly behind the posterior vagi- nal pouch, and therefore, between the vagina and rectum. It is a very important space, because, being the most dependent portion of the abdomi- nal cavity, effusions of blood or other fluid and tumors of various kinds are often to be found in it. How does the vagina terminate below ? It terminates in a circular fold of mucous membrane, called the hymen. From the fact that this fold is often more developed in its posterior half, it usually appears as a crescentic fold stretching across the opening of the vagina. What is an imperforate hymen ? The membrane sometimes completely closes the opening of the vagina, and is then said to be imperforate. What is the structure of the hymen ? It is composed almost entirely of mucous membrane, and is easily torn 20 QUESTIONS ON OBSTETRICS. by the entrance of the male organ, but is sometimes firm enough to resist any ordinary pressure, and may cause delay in labor by its presence. What are the carunculae myrtiformes ? When the hymen is torn, its fragments undergo atrophy, and there re- main little wart-like elevations in the line of the hymen, called caruncuLe myrtiformes. It is said, however, that these bodies sometimes coexist with the hymen, being placed a little distance behind it. What is the bulb of the vagina ? A mass of erectile tissue, mainly composed of short, venous sinuses, shaped somewhat like a pair of saddle-bags, and placed over and at the sides of the vagina. What are the vulvo-vaginal glands ? The vulvo-vaginal glands, or glands of Bartholini, are two small bodies situated just behind the hymen, one on each side. They are imbedded in the cellular tissue around the vagina, and empty by a small duct on either side. They secrete a thin mucus, which is expelled freely, and even by jets, during venereal excitement and coitus. THE EXTERNAL ORGANS. What is the vulva ? The name given to the external organs collectively, but often used to denote the genital fissure, or chink of the vulva. What are the labia majora ? Elevated folds of cutaneous tissue, which are found on either side of the genital fissure. What is the structure of the labia majora ? They contain loosely arranged cellular tissue, with some fat. On their outer surface they are covered only with skin, which is characterized by a free growth of stout, curly hair, similar to that found in the axilla. On their inner surface the skin shades off into mucous membrane, which is finally continuous with that of the vagina, and is furnished with a considerable number of sebaceous follicles. What is the mons veneris ? An eminence of cutaneous tissue, situated directly upon the symphysis pubis, and is the anterior termination of the labia majora. It is well padded with fat and covered with an abundance of hair. What is the anterior commissure ? The point just under the mons, where the labia meet in front. The ante- rior limit of the genital fissure. THE REPRODUCTIVE ORGANS. 21 What is the posterior commissure ? The posterior limit of the genital fissure, or the point where the labia meet posteriorly. What is the fourchette ? When the genital fissure is made to gape by the fingers pulling apart the labia majora, a fold of mucous membrane is made to project behind the posterior commissure, which is called the fourchette. The little dimple or cup between this fold and the commissure is called the fossa navicu- lars, but neither of them have any existence until artificially produced in this manner. What is the clitoris ? A small cylindrical body, about an inch in length, which resembles and is the analogue of the male penis. It consists of two corpora cavernosa, which are attached to the under edge of the pubic bone, and by their free end project slightly under the anterior commissure. The part which is visible is about the size of a pea. What are the labia minora ? Called also the Nympha. They are two folds of dartoid tissue, covered by mucous membrane, which cover the clitoris in a manner similar to the prepuce of the penis, and extend backward along the sides of the labia majora for about one-half their extent. What is their structure ? It nearly resembles that of the male scrotum, inclosing also some erec- tile tissue. What is the vestibule ? The space which extends from the clitoris to the opening of the vagina, and is bounded laterally by the labia minora. What and where is the meatus urjnarius ? It is the opening of the urethra, and is placed at the posterior limit of the vestibule, and therefore, just above the opening of the vagina. It is situated in a tubercle or slight eminence. How long is the female urethra ? About one and one-half inches. How is the urethra situated with respect to the vagina ? It lies directly over it, and can be distinctly recognized, by the finger in- troduced into the vagina, as a tubular ridge above the anterior wall of the vagina. 22 QUESTIONS ON OBSTETRICS. What is the perineum ? The space between the vulva and anus, and bounded laterally by the tuberosities of the ischia. What is the perineal body ? It consists of a wedge-shaped band of fibrous elastic tissue, which stretches across from one tuberosity to the other, and is interposed between the terminations of the vagina and rectum. What other structures of importance are found in the perineum ? The transversus perinaei and levator ani muscles, and also fibres of the sphincter muscles, which are placed about the ends of the vagina and rectum. PHYSIOLOGY. OVULATION. What is the function of the ovaries ? To furnish ova, or eggs, which are the primitive germs of the human being, and the necessary female element in reproduction. What is this function called ? Ovulation. How early in life does ovulation begin ? In childhood. [Sinedy and Hausmann found evidences of ovulation in 10 per cent, of infants examined by them.] But it does not occur with much vigor until womanhood. Where are the ova developed ? In small cystic bodies called ovisacs, or Graafian vesicles (or follicles), there being usually but one ovum in each ovisac. How many ovisacs exist in each ovary ? They are variously estimated from 30,000 to 150,000, but only a score or so can be observed at any one time. Describe the ovum when fully developed. The ovum, when fully developed, is a spherical mass of protoplasm, y^th of an inch in diameter. It is structureless, except that it contains, at one point, a small body, like a nucleus, called the germinal vesicle, which, in turn, contains a smaller body, like a nucleolus, called the germinal spot. The ovum is surrounded by a thin envelope of albuminous matter, called the vitelline membrane, the ovum itself being called, also, the vitellus, or yolk. Describe the process of ovulation. The ovisac, at first very minute, is imbedded in the stroma of the ovary. OVULATION. 23 Its walls consist of several layers of cells, the innermost of which are called the proligerous disk, and in this the ovum is situated. These cells secrete within the ovisac an albuminous fluid. While the ovisac increases in size, it also approaches the surface of the ovary, having then attained a diameter of one-fourth to one-half of an inch. At this point it stops grow- ing, while the fluid continues to be secreted in its interior. This finally subjects the ovisac and the overlying covering of the ovary to a bursting pressure; the ovisac is ruptured, and the ovum, with some of the fluid and epithelium of the ovisac, is extruded upon the surface of the ovary. What happens to the ovisac after the discharge of the ovum ? Several things may occur— I. The entire contents of the ovisac may be extruded, the walls collapse, and within a week or two a small linear cicatrix only is left to show that ovulation has occurred. 2. Some blood may be effused into the sac at the time of rupture. A clot is formed, which is slowly absorbed; as its haematin becomes faded and yellowish, it is called the corpus luteum. 3. Should the woman become pregnant, the walls of the ovisac may con- tinue to secrete fluid. This is due to the increased blood supply which pregnancy occasions; and this leads to the formation of a large, yellowish body, called the corpus luteum of pregnancy. How is the appearance of the ovary affected by age ? In youth it is smooth ; after repeated ovulation it becomes fissured and wrinkled; in old age atrophy takes place, and it returns to nearly its in- fantile appearance. What happens to the ovum after its escape from the ovisac ? I. It may drop into the abdominal cavity and perish. 2. It is wafted towards the open end of the Fallopian tube by means of a current in the fluid bathing the tissues, which current is caused by the action of ciliated epithelium cells, and is always directed towards the tubes. 3. The end of the tube may, by a spasmodic movement, clasp the surface of the ovary and draw the ovum into the tube. 4. When in the tube it is passed on to the womb (a) by a ciliary current, and (b) by peristalsis, and from the womb it is discharged with the mucus, etc., unless fecundated. 5. It may become fecundated and remain within the mother until devel- oped into a child. How often does ovulation take place ? It is irregular in its occurrence. A number of ovisacs are constantly 24 QUESTIONS ON OBSTETRICS. being developed with greater or less rapidity, and the amount of the blood supply of the ovary controls the rate of development. Frequent coitus leads to frequent ovulation, for this reason. What is the usual interval between the discharge of success- ive ova ? Usually once a month, because the greatest increase in the blood supply occurs once a month, during menstruation. MENSTRUATION. What is Menstruation ? A periodical disturbance in the female characterized by I. An increase in the vascular tension throughout the body. 2. A special determination of blood to the pelvic organs (or pelvic hyper- aemia). 3. A renovation of the uterine mucous membrane. 4. A discharge of blood from the uterus. How often does menstruation occur ? Once every twenty-eight days ; but the interval varies in some women, from three to six weeks. What is the first evidence of menstruation ? An increase in the vascular tension, and a sense of fullness in the pelvic region, which is accompanied by pain, if there is any local disease. What effect has the pelvic hyperaemia on the ovaries ? By increasing the blood supply it hastens the development of the ovisacs, and one or more usually rupture at this time. What effect has the pelvic hyperaemia on the uterus ? The uterus becomes larger and softer, and its mucous membrane under- goes changes, as follows: 1. New cells are formed. 2. The outer layer or layers of epithelium are thrown off. 3. The membrane is turgid with blood and thrown into folds. 4. There is increased functional activity in the mucous follicles, and a more abundant secretion of mucus. 5. Some of the superficial capillaries break down, and an oozing of blood takes place. What is the clinical course of menstruation ? 1. The woman notices a leucorrhoea for one or two days. 2. A discharge of blood for three days (average). 3. A continuance of leucorrhoea for one or two days. Is menstruation attended with pain ? Not normally, but the majority of women experience some degree of pelvic pain, because the parts are hypersensitive, from some departure from MENSTRUATION. 25 the normal condition. The pain is usually referred to the "small of the back ; " also to the ovarian regions, and to the hypogastrium. What peculiarities has the menstrual blood ? i. It is mixed with mucus and epithelium scales. 2. It does not coagulate when moderate in amount, because it is made acid by the vaginal mucus. How much blood is discharged during menstruation ? From § ss to ^ iij in all; but the amount varies. Is the blood during menstruation always discharged from the uterus ? No. The uterine mucous membrane sometimes fails to undergo its usual changes, and weakened capillaries in any part of the body may break down under the increased vascular tension. Thus we may have menstrual hemorrhage from the stomach, lungs, breasts, or any part whatever. What is this condition called ? Vicarious menstruation, or xenomania. What are the popular names for menstruation ? To be unwell; to see anything; to be regular; the periods; courses; monthlies; turns; changes, and flowers. What is the object of menstruation ? To insure the development of ova by a periodical increase in the ova- rian blood supply, and to favor the detention of the ovum in the uterus by the changes in the mucous membrane. When do women begin to menstruate ? As soon as they become women, which period is called puberty. When does puberty begin ? It varies, from race, climate, and social condition. The average is at the age of fifteen years. What physical signs attend the age of puberty ? The reproductive organs are fully developed, the breasts enlarge, the pubes is covered with hair, and the whole form of the girl becomes rounded and womanly. When do women cease to menstruate ? At about the age of forty five years, which period is called the meno- pause or climacteric. What happens to the reproductive organs at the menopause ? They gradually atrophy, but the possibility of child-bearing may con- tinue until the age of fifty-five years (F. Barker). c 26 • QUESTIONS ON OBSTETRICS. What is the main function of the uterus ? To receive the fecundated ovum, and to retain it until it is developed into a mature foetus. What is the function of the oviducts ? To convey the ova to the uterus. What is the function of the vagina ? It serves as the duct or outlet for the discharge of the uterine secre- tions, including the escape of the child in labor, and also to admit the male organ, so that the semen may gain access to the ovum. What is the function of the external organs ? They are endowed with great sensibility, and are mainly concerned with the function of coitus. The nymphae also serve to direct the stream of urine as it passes from the meatus urinarius. What is the structure of the breast ? The breast is composed of fifteen or twenty lobes of glandular tissue, FIG. 7. with a packing of areolar and adipose tissue. The lobes are compounded of lobules produced by the aggregation of the terminal acini, in which the milk is formed. The.ducts of each lobule unite with each other to form a terminal ca- nal, called the galactophorous duct, of which there is one for each lobe (Playfair). These empty upon the face or extremity of the cylindrical appendage called the nipple. What is the areola ? A circular patch of cutaneous tissue around the base of the nipple, of pink color in virgins, and darker in those who have borne children. PREGNANCY. What is Pregnancy ? The condition in which a woman contains a living and growing foetus. What are the essential requisites for the occurrence of preg- nancy ? 1st. That a fully matured ovum shall be recently discharged from the ovary. PREGNANCY. 27 2d. That male semen shall come in contact with such an ovum before it leaves the uterus. What is fecundation ? The act by which the male semen imparts to the ovum the power of de- veloping into a foetus. What part of the semen has this property ? The spermatozoa; each spermatozoon resembles a ciliated epithelium cell, except in being apparently structureless or homogeneous. Each drop of semen contains thousands, all of which are in constant vibratile motion during life. How long do the spermatozoa retain their vitality ? They have been found in full vigor eight days after their introduction into the vagina. How and where is contact between the spermatozoa and ovum brought about ? I. During coitus the semen is»ejected agdinst the cervix uteri and upper part of the vagina. • 2. During the orgasm of the female the uterus sucks or pumps the sper- matozoa into its cavity, after which their own vibratile motion causes them to ascend the oviducts until they meet the ovum. 3. Fecundation probably occurs most frequently on the surface of the ovary, but it can occur at any point before the escape of the ovum from the womb. Is it necessary for the uterus to aid the entrance of the semen ? No; fecundation has occurred when the woman was perfectly passive, or unconscious, from drugs, drink, or sleep. What further means are provided for the retention of the semen ? 1. During venereal excitement the round ligaments of the uterus pull it forward and upward. This permits the penis to glide past the cervix and to deposit the semen in the posterior vaginal pouch. When the ligaments are relaxed, the cervix resumes its former position, and thus retains the semen in the pouch above; the spermatozoa may then, at their leisure, enter the uterus. 2. It has also been demonstrated that fecundation can take place when the semen escapes upon the vulva, so that the whole distance may be traveled by the spermatozoa unaided. What changes take place in the ovum after fecundation ? 1. The germinal spot and vesicle disappear. 2. The segmentation of the vitellus; i. e., the vitellus splits into two 28 QUESTIONS ON OBSTETRICS. masses, these into four, and so on until a large number of segments are formed. 3. A clear fluid is secreted within the ovum, which presses these segments to the surface of the ovum, where they form a double layer of cells called the inner and outer blastodermic layers. 4. There then appears upon the outside of the vitellus a small oval eleva- tion, surrounded by a depression, which is called the area germinativa. 5. There appears in the area germinativa a small, dark line, called the primitive trace. About this line will be grouped the various parts of the embryo, the rest of the ovum serving only as a covering and for nutri- ment. 6. A covering for this trace or embryo is now formed. Thus far the vitel- line membrane has been sufficient. The embryonic line sinks into the centre of the ovum, while the edges of the external blastodermic layer about the area close around it, inclosing it in a sac, called the amnion. The vitelline membrane then disappears. 7. The rest of the external blastodermic layer, or that part which did not follow the embryo within the ovum, now forms the outer covering, and is called the chorion. 8. The chorion develops upon its outer surface little hollow projections, called villi. 9. A vascular mass, called the allantois, shoots out from the middle of the embryo, and when it has reached the inner surface of the ovum, spreads out, carrying loops of blood vessels into the villi of the chorion. IO. Before the formation of the allantois, the nutriment needed for growth is furnished (a) by osmosis of fluids from the tissues of the mother into the ovum, and (b) by the fluid materials of the ovum contained within the internal blastodermic layer. While the allantois is formed, this inter- nal layer contracts, its shrunk bulk constituting the umbilical vesicle, which finally disappears. 11. By the time the allantois is fully formed, if not before, the ovum has reached the womb. Its villi, thus provided with blood vessels, become enlarged and arborescent over that part of the ovum which is in contact with the uterine wall, and atrophy and disappear from the rest of its circumference: 12. When the ovum has reached the uterus, it is detained in a fold of mucous membrane. The edges of the fold grow Over the ovum, so as to give it an additional covering of mucous membrane, called the decidua reflex a. 13. When the ovum is thus fastened to the uterine wall, the chorionic PREGNANCY. 29 villi increase in size, and form attachments to the uterine wall under- neath it, forming the placenta, by which a definite vascular connection is established between the embryo and mother. 14. The placenta being formed, the embryo is suspended in the amniotic sac by a cord reaching to the placenta, called the funis, or umbilical cord, and continues to develop to the end of pregnancy. It has now the following coverings, 1st, the amnion; 2d, the chorion; 3d, the decidua reflexa, besides being covered by the uterine walls in general. What changes in the mucous membrane of the womb follow fecundation ? 1. The mucous membrane of the womb becomes hyperaemic and hyper - trophied; it develops new and soft connective tissue, and is thrown into folds. In this thickened state it is called the decidua vera. (This occurs whether the ovum enters the womb or not.) 2. When the ovum enters, adjacent folds grow over the ovum, forming the decidua reflexa. As the ovum increases in size, the decidua reflexa becomes united or welded with the superficial layers of the general mucous membrane, or decidua vera (about the fourth month). 3. That part of the membrane directly under the ovum undergoes greater changes, and is called the decidua serotina. What is the nature of the placenta ? 1. The villi of the chorion enter depressions in the decidua serotina, and bands or connective tissue unite the decidua and villi. 2. The venous sinuses under the serotina increase greatly in size, and the villi, by pressure and erosion, finally dip into them. As a result we have a flat, cake-shaped mass, mainly composed of blood vessels, which serve to convey nutriment from the mother to the child. Does the maternal blood enter the circulation of the child ? No. The foetus derives nutriment by endosmosis, through the delicate walls of the villi floating in the maternal sinuses—like the rootlets of a plant—absorbing the elements needed for growth, and discharging effete products by exosmosis. What other function has the placenta? That of respiration. The fcetal blood is oxygenated in the placental tufts. What is the funis ? The veins of the placenta ultimately unite in a single vein, which passes to the umbilicus of the foetus. Two arteries pass from the foetus to the placenta, and are wound spirally about the vein. These three vessels are 30 QUESTIONS ON OBSTETRICS. imbedded in a substance called Wharton's gelatine, and covered by a membrane derived from the amnion. The whole is called the funis, or umbilical cord. What are the dimensions of the placenta and funis at full term. The placenta is about nine inches in diameter, and weighs one pound. The funis averages about twenty inches, the extremes being from three to forty inches in length. What is the liquor amnii ? A clear, slightly saline fluid secreted from the inner surface of the amnion, and in which the embryo floats. How much liquor amnii is found at full term ? From a half ounce to several pints. {% iv on an average. How large is the ovum (and foetus) at different months ? By the end of the first lunar month of pregnancy the ovum is about the size of a pigeon's egg. End of 2d month, size of a hen's egg; foetus an inch long. " 3d " " goose " " 3 " " 4th " the foetus is 6.6 inches long. 5th » " " 7 -ioy2 " 6th " " "11 -13 " 7th " " " 137-15 8th " " " 15 -17 9th " " " 16 -17^ " 10th " " " 17^-18^ [According to Schrceder.] American children are usually larger at birth. How soon can the sex of a child be recognized ? Not certainly until during the fourth month. What is vernix caseosa ? An unctuous, sebaceous secretion covering the skin of the child, for the purpose of lubricating it for delivery. It does not appear until the seventh month. What is meconium ? The dark-green, semi-fluid contents of the foetal intestine, corresponding to faecal matter in the adult. What changes occur in the womb itself, during pregnancy ? It greatly enlarges, to accommodate the growing ovum, and at the end of pregnancy has a weight of two pounds, and its cavity is a foot in diameter. ABNORMAL PREGNANCIES. 31 The cervix enlarges but little (not more than one-half), and its cavity re- mains separate until the last week or weeks of pregnancy, when the os in- ternum is stretched open and the two cavities of the cervix and fundus be- come one. The tissue of the cervix becomes softer to the touch. What changes in position does the womb undergo ? During the first month the increased weight of the uterus causes it to descend somewhat in the pelvis, or become prolapsed. End of 2d mo. Still low in the pelvis, and usually anteverted. Bimanu- al touch showes it to be as large as an orange. " ir\ " The same, but as large as a child's head. " 4th " Fundus can be felt just above the symphysis, and being too large for the pelvis, it now ascends. " 5th " Fundus midway between umbilicus and symphysis, " 6th " " at level of umbilicus. " 7th " " 2 to 3^ finger breadths above umbilicus. " 8th " " 1 to 2 " " below ensiform appendix. " 9th " " touches the '■' " " 10th " " has descended to same position as in eighth month. Why does the fundus of the uterus descend during the last month ? Because the cavity of the cervix is added to that of the fundus, at that time, and the contents of the womb settle toward the pelvis, leaving more room, ABNORMAL PREGNANCIES. MULTIPLE PREGNANCY. How many children may a woman have at one time ? Two, or twins; three, or triplets; four, or quadruplets; five, or quintuplets. How frequently do multiple births occur ? Twins once in eighty-nine cases; the others are rare, and any over five are apocryphal. How are multiple pregnancies caused ? 1. Two or more ova may be fecundated and simultaneously developed. 2. Two primitive traces may appear on one ovum, and each develop an embryo. These two causes may be combined in the case of triplets, etc. How may the cause be demonstrated ? Twins developed from separate ova will each have its own placenta and membranes; from a single ovum, will have a single placenta, and usually but one set of membranes, though there may be two amniotic sacs. 32 QUESTIONS ON OBSTETRICS. What is superfecundation ? The fecundation of two ova at different times, i. e., with an interval of several hours, or even days. How is this' demonstrated ? By cases in which a woman has borne twins, one white, the other a mulatto, from separate intercourse with a white man and negro. What is superfcetation ? The fecundation of a second ovum after a first ovum has entered the uterus. It may occur during the first four months of pregnancy, or before the decidua reflexa and decidua vera have become united. How is this demonstrated? I. By cases in which the birth of a fully developed child has been followed by a second birth after an interval of one, two, three or four months. 2. By the expulsion at one birth of a fully developed child and a foetus evidently one or more months less advanced in. development. What is the clinical course of twin pregnancy ? I. Both children may be safely carried to term. 2. " " " prematurely expelled. 3. One twin maybe prematurely expelled and the other remain until born. 4. " " die in utero and be retained until the birth of the other. What is a foetus papyraceus ? A twin dying in utero at an early period may be partly dessicated, and compressed by the growth of the other twin, being flattened and parch- ment-like in appearance. EXTRA-UTERINE PREGNANCY. What is extra-uterine pregnancy ? Pregnancy in which the foetus is developed in some other locality than in the uterus. How is it classified ? I. The ovum, after fecundation, may remain in the ovisac and be de- veloped in the ovary, called ovarian pregnancy. 2. The fecundated ovum may be arrested in the Fallopian tube, and be there developed, called tubal pregnancy. 3. It may be arrested at the junction of a tube and the uterus (the narrowest part), and developed partly in the womb and partly in the tube, called tubo-uterine, or interstitial pregnancy. 4. It may drop from the ovary into the abdominal cavity and be there de- veloped, called abdominal pregnancy. ABNORMAL PREGNANCIES. 33 What effect has extra-uterine pregnancy on the womb ? It enlarges, as in normal pregnancy, up to the fifth month, and its hyper- trophied mucous membrane or decidua is cast off in one piece, in several pieces, or in flaky shreds, at from the second to the fifth month. What are the symptoms of extra-uterine pregnancy ? I. The symptoms of pregnancy in general. 2. The presence of a cystic tumor in the abdomen, usually to be felt also in Douglas' cul de sac. 3. The enlargement of the womb, and 4. The displacement of the womb by the tumor. 5. Irregular, sanguineous discharges from the womb. 6. The expulsion of the enlarged uterine mucous membrane (decidua). 7. Pain, irregular in occurrence, and of intense character. What points are especially important in diagnosis ? A rapidly growing tumor in Douglas' cul de sac, with an enlarged but empty womb, from which portions of decidual membrane have passed, can be nothing else than an extra-uterine cyst. The pain, if present, is char- acteristic. Abdominal pregnancy may proceed to term, without exciting any suspicions of its presence. What is the termination of extra-uterine pregnancy ? 1. Rupture of the cyst occurs in 35 per cent., followed by internal hemor- rhage, shock, peritonitis, and usually death. 2. The pregnancy may continue until full term, the child dies and (a) the tumor is partially reabsorbed, and remains innocuous, or (b) inflamma- tion supervenes, and the child decomposed and evacuated by ulceration into the rectum, vagina, bladder, abdominal walls, or uterus—the woman running the gauntlet of peritonitis, septicaemia, pyaemia, etc. When does the rupture of the cyst occur ? In the first half of pregnancy ; seldom in second half. What is the treatment where rupture has occurred ? If sure of the diagnosis, open the abdomen by an incision, ligate bleed- ing vessels, and remove all blood and fluids. What is the general treatment of extra-uterine pregnancy. 1. If discovered in the first half of its course, arrest it by destroying the vitality of the ovum. 2. If in the second half, operate as in ovariotomy, in hope of saving the child, and as near term as possible. 3. If the child is dead, await developments, and interfere only when inflammation, abscess, or other complications demand treatment. 34 QUESTIONS ON OBSTETRICS. How can it be arrested ? By the faradic current of a battery. I. An electrode, insulated except at its tip, is to be applied to the tumor, as felt in Douglas' cul de sac, per vaginam. The other electrode is applied to the upper part of the tumor through the abdominal walls. The choice of poles (-)- or —) is immaterial. 2. A moderate current is to be passed through the tumor, and gradually increased ; the application to be made for an hour, and repeated every day for at least six days. 3. A large dose of morphia should be given before each application of the battery. This treatment is certain if enough electricity is used, and for a sufficient length of time. No other treatment is either certain or safe. What becomes of the tumor after its arrest ? It is rapidly absorbed, and becomes so small as to be inappreciable and innocuous. What caution is necessary in operating surgically for the re- moval of the child? The placenta must not be removed, because there is no contracting uterus to check hemorrhage after its detachment. It must, therefore, be allowed to remain, and become separated by the sloughing process. HYDATID PREGNANCY. What is hydatid pregnancy ? Pregnancy in which cystic degeneration of the chorionic villi occurs. 1. The villi are converted into cysts. 2. The embryo dies and is absorbed. 3. The uterus is finally filled entirely with small cysts, whose average size and appearance is that of a white currant. What are its symptoms and termination ? 1. The pregnancy begins normally, but in the second or third month 2. A sudden and rapid increase in size of the uterus occurs, accompanied 3. By pain and irregular discharge of blood and water. 4. Labor supervenes and the mass of cysts is expelled. It should be remembered that true hydatids (echinococci) may occur in the uterus, but not as a result or accompaniment of pregnancy. What is hydrorrhcea ? A watery discharge from the uterus, from 1. Hydatid pregnancy. PREMATURE LABOR. 35 2. A tear in the foetal membranes, at a point remote from the os uteri, with gradual leaking of liquor amnii. 3. Probably from a watery secretion or transudation from the uterine mucous membrane. MOLE PREGNANCY. What is mole pregnancy ? 1. During the first three months of pregnancy a hemorrhage takes place in the ovum. 2. The embryo is destroyed and disappears, while the vitality of the chorion is maintained for several months. 3. Labor supervenes, and a fleshy, laminated mass or mole is extruded, in which close search will always reveal chorionic villi and patches of the foetal membranes. SPURIOUS PREGNANCY. What is spurious pregnancy ? Called also pseudocyesis, is a condition in which some of the symptoms of pregnancy are present, especially enlargement of the abdomen, changes in the breasts, and subjective feeling of the foetal movements ; the woman not being pregnant. It is to be distinguished horn feigned pregnancy. How may it be disposed of ? A vaginal examination shows the womb to be unenlarged, and the ad- ministration of ether will cause the abdominal enlargement to suddenly disappear. It sometimes terminates in spurious labor, a condition in which the clinical phenomena of labor are present in some degree. PREMATURE LABOR. What is meant by abortion, miscarriage, and premature labor ? Abortion is properly the premature expulsion of the foetus before it is viable; premature labor, its expulsion after viability, but before full term. The older writers restricted the term abortion to the period before quicken- ing (the child not being supposed to be living until then), and miscarriage to the period between quickening and viability. Now-a-days, miscarriage is used as a euphemism for abortion, the latter word having fallen into dis- repute, and associated with the idea of criminality. What is meant by the term viable ? A child born after seven lunar months of pregnancy may live, and is called viable—liveable. What are the causes of abortion ? Disease or injury (1) to the ovum or foetus, ovular, "I ag Disease or injury (2) to the mother, maternal, > 36 QUESTIONS ON OBSTETRICS. I. (a) Placental degeneration; amyloid or fatty (cystic, vide hydatids). (b) Placental apoplexy and detachment, from hemorrhage. (c) Syphilis. (d) Dropsy of amnion. (65 3. The cervico-bregmatic plane, drawn transversely through the cervico-bregmatic diameter. When the head is completely flexed, this plane is horizontal, and therefore may be called the plane of complete flexion. What outline is intercepted by these planes ? In the occipito-frontal an elliptical outline; long diameter 4 -f- in. Transverse diameter 3^ inches. In the cervico-frontal an elliptical outline; long diameter 4 — in. Transverse diameter 3^ inches. In the cervico-bregmatic, a circular outline; long diameter 3^ inches. Transverse diameter 3^ inches. What important deduction may be drawn from these facts ? The more the head \s flexed the smaller is the outline presented. In how many ways may the vertex enter the pelvis ? The elliptical outline of the head may enter with the occiput in front and to the left or right, and behind and to the right or left. There are, therefore, four positions of the vertex, named as follows :— 1. Left Occipito-Anterior. 2. Right Occipito-Anterior. 3. Right Occipito-Posterior. 4. Left Occipito-Posterior. How many positions are there of the Face presentation ? Since the face has also an elliptical outline, with the mentum or chin at one end, we have the same arrangement as in the vertex, or— 1. Left Mento-Anterior. 2. Right Mento-Anterior. 3. Right Mento-Posterior. 4. Left Mento-Posterior. How many positions are there of the Breech presentation ? Since the breech has also an elliptical outline, with the sacrum in a direct line with the occiput, we have the same arrangement as in the vertex, or— I. Left Sacro-Anterior. 2. Right Sacro-Anterior. 3. Right Sacro-Posterior. 4. Left Sacro-Posterior. How many positions are there of the Transverse present- ation ? For the sake of uniformity we may assume an elliptical outline for the 56 QUESTIONS ON OBSTETRICS. shoulder, with the dorsum, or back of the shoulder, as the name-point. This gives us the same arrangement as in the other presentations, or I. Left Dorso-Anterior. 2. Right Dorso-Anterior. 3. Right Dorso-Posterior. 4. Left Dorso-Posterior. How may the positions be more briefly designated ? By initials, as L. O. A. for left occipito-anterior, R. S. P. for right sacro- posterior, and so on. How may these sixteen positions be represented in a single scheme ? Left '---'---' Anterior. °r b? initials °^> o Right -^ o Q 0 Anterior. L q A. Right 'g S o g Posterior. R c/5 A. Left OSmQ Posterior. ? ^ £ v--.-- L o P- How is the head situated at the beginning of labor in the L. O. A. position ?* The occiput points to the left ileo-pectineal eminence; the bi-frontal suture is opposite the right sacro-iliac symphysis, and the sagittal suture lies in the right oblique diameter. What is the mechanism of delivery in the L. O. A. position ? 1. Flexion occurs, whereby the cervico-frontal, or even the cervico-breg- matic diameter is substituted for the occipito-frontal, thus reducing the outline presenting in the pelvis. 2. The head descends in the pelvis, and at the same time a leveling move- ment occurs by which the forehead descends more rapidly than the occiput, and becomes level with it. 3. While the head descends it also rotates, so that the sagittal suture is finally brought into the median line by the time the head reaches the pelvic outlet. 4. When the head reaches the outlet the occiput or nape of the neck remains fixed under the sub-pubic arch, while the forehead and face sweep over the perineum by a movement of extension. 5. After the head is born it undergoes a movement of external rotation, or restitution, because the shoulders descend in the left oblique diame- ter, so that the occiput is again turned towards the left side. * The mechanism here given is mainly from Cazeaux and Playfair; the author's views may be found in the Appendix. The student is earnestly advised to study the mechanism with the fcetal skull and the pelvis before him. THE MECHANISM OF LABOR. 57 What variations occur in the mechanism of the L. O. A. position ? If there is not a close fit between the head and pelvis there may be less flexion and rotation, but no substantial difference in the mechanism occurs. The shoulders may vary greatly, due usually to the length of the neck and the time when they are compelled to follow the head. Thus, they may enter the pelvis directly transversely and rotate indifferently into either canal, and at any level, which will also control the movement of restitution. What is the mechanism of delivery in the R. O. A. position ? The same as in the first, or L. O. A. position, except that the sagittal suture is in the left oblique diameter, and the occiput directed towards the right pectineal eminence; and in general the same description will apply throughout, substituting right for left, and vice versa. How often does this position occur ? Very seldom, owing to the infrequency of left lateral obliquity of the womb, and the presence of the rectum on the left side of the pelvis. How is the head situated in the R. O. P. position ? The occiput is opposite the right sacroiliac symphysis, the forehead opposite the left obturator foramen, and the sagittal suture lies in the right oblique diameter. What is the mechanism of delivery in the R. O. P. position ? There are four different processes by which it may be terminated, I. Anterior rotation at the inlet. 2. Anterior rotation at the outlet, or during descent. 3. Anterior rotation on the perineum, and, 4. Posterior rotation throughout. What is meant by anterior rotation ? The rotation of the head so as to bring the occiput in front, thereby converting the position into a R. O. A. How does anterior rotation occur ? 1. From the fact that the foramen magnum is nearer the occipital end of the head, the shoulders are thrown further back in this position, and therefore the right shoulder impinges upon the vertebral column or prom- ontory. If it should be pushed off on the right side the child's back will be brought in front. This twists the neck, and the untwisting force of its elastic structure tends to rotate the head with the occiput in front. This occurs most easily at the inlet, next at the outlet or during descent, and rarely, even when the head has reached the perineum. 2. The resistance of the posterior pelvic wall to the occiput is greater than E 58 QUESTIONS ON OBSTETRICS. that of the anterior wall upon the forehead, owing to the narrowing of the pelvis under the sacro-iliac arch, which also aids in anterior rotation, and according to some, is the only cause. What must occur before anterior rotation ? Flexion, continued until the circular cervico-bregmatic outline is reached. Under what circumstances does posterior rotation occur ? If the child's back is turned towards the mother's back, and remains so, the head cannot rotate anteriorly, and is delivered with the forehead under the sub-pubic arch. What difficulties are encountered in posterior rotation ? I. The labor is more prolonged, because the uterine force is transmitted through the posterior and narrow portion of the pelvis. 2. The perineum is endangered, because the head cannot be fully flexed while passing over it. How may we recognize the R. O. P. position ? I. At the beginning of labor the anterior fontanelle (usually large) will be found very accessible in front, and to the left. 2. As flexion occurs the fontanelle will move upward and become less accessible, which is directly the reverse of the course followed by the posterior fontanelle in the L. O. A. How should the R. O. P. position be managed ? As soon as discovered a reasonable effort should be made to rotate the shoulders with the back in front, by external manipulation. This may be aided by two fingers placed upon the vertex, and similarly employed in endeavoring to rotate the head. If these efforts fail, we may leave the case to the uterine efforts, until it is evident that natural delivery will take too long, when we should employ the forceps. What is to be avoided ? Attempts to rotate the head without reference to the position of the shoulders. It endangers the child's life, from over-twisting of the neck, and is rarely successful. What is the mechanism of delivery in the L. O. P. position ? The same as in the third or R. O. P., except that anterior rotation converts it into an L. O. A., and in general left is to be substituted for right, and vice versa, throughout the description. What are the causes of the Face presentation ? i. From a misdirection of the uterine axis (due to pendulous abdomen and the like) the contractions may propel the head, originally presenting the THE MECHANISM OF LABOR. 59 vertex, in such manner that its occiput is arrested at the brim, while the facial end, being free, descends. Thus an L. O. A. may be converted into an R. M. P., and an R. O. P. into an L. M. A. 2. External violence or jarring may disturb and change the presentation. 3. The child may, by reflex movements, extend its head. What plane and diameters are described in the Face present- ation ? A plane drawn through the anterior limit of the anterior fontanelle, the malar bones and the junction of the chin and neck, is called the trachelo- bregmatic plane. It is of elliptical outline, and nearly parallel to the cervico-bregmatic plane, but smaller. Its long diameter is called the trachelo-bregmatic ; its transverse diameter, drawn from one malar bone to the opposite, the bi-malar. How is the head situated in the L. M. A. position ? The chin is opposite a point in front of the left acetabulum; the anterior fontanelle is opposite the right sacro-iliac symphysis. The features of the face (eyes, nose, mouth, etc.) may be felt between these points. What is the mechanism of delivery in the L. M. A. position ? The head descends with its trachelo-bregmatic diameter presenting in the right oblique diameter, and without difficulty, until the cervico- bregmatic plane has entered the pelvis. By this time the diameter of the neck or upper part of the chest is added to the cervico-bregmatic diameter, and this constitutes too large a bulk to pass. Delay therefore occurs. How is this difficulty overcome ? As soon as the head can reach far enough to be acted on by the perin- eum, the perineal force (see page 53) will cause the head to be flexed and allow it to sweep easily over the perineum. Therefore, if the head is small, or the neck long, there may be no delay in flexion and delivery. Otherwise the head must remain stationary until it is molded and wire- drawn, so as to enable it to reach to the perineum. What effect has this delay, etc., upon the child ? 1. It is endangered by the pressure upon its cervical structure. 2. The caput succedaneum forms easily upon the face, and the parts may be perilously swollen and infiltrated. What treatment is demanded, and why ? Since the delivery can be readily'accomplished by securing flexion after the face has reached the inferior strait, we should assist the mechanism— 1. By attempting to flex the head with the fingers, and, 60 QUESTIONS ON OBSTETRICS. 2. With the forceps if the fingers fail, or traction is necessary to bring the head low enough to be flexed. What is the mechanism of the R. M. A. position ? The face enters the pelvis with the chin in front and to the right, and in general the same description will apply, substituting right for left and vice versa, throughout. What is the mechanism of the R. M. P. position ? I. The trachelo-bregmatic plane enters the pelvis with the chin opposite the right sacro-iliac symphysis. The forehead remains stationary at the front part of the brim, while the base of the skull and upper part of the chest attempt to advance under the sacro-iliac arch, which is impracti- cable. 2. The shoulders will thus be made to impinge upon the vertebral column, and will have a tendency to be pushed to the right of the promontory, with the back in front. This will twist the neck, and tend to rotate the head into an R. M. A. position, when the labor is terminated as in that position. The key to the mechanism, therefore, is anterior rotation at or near the inlet. If this fails to occur, the head and chest become tightly wedged, and unless the head is very small, or the pelvis large, delivery is impossible. What is the mechanism of the L. M. P. position ? The face enters the pelvis with the chin behind and to the left, and in general the same description will apply, substituting left for right and vice versa, throughout. What is the Brow presentation ? A variety of the Face presentation, the upper part of the face presenting. It is either converted into a full face or into a vertex presentation, or cannot be delivered naturally unless the head is very small. What plane and diameter are described in the Breech presen- ation ? A plane drawn transversely through the ilia and sacrum, called thebisiliac, from its long diameter, drawn between the crest of the ilia. It is of elliptical outline and almost identical with that of the shoulders. How is the breech situated in the L. S. A. position ? The sacrum is in front of the left acetabulum; the right ilium under the left sacro-iliac symphysis; the left ilium in front of the right acetabulum, and the pubes in the free space in front of the right sacro-iliac symphysis. THE MECHANISM OF LABOR. 61 What is the mechanism of the L. S. A. position ? The bis-iliac diameter enters the pelvis in the left oblique diameter, rotating during descent, so that when it arrives at the vulva, the left ilium is directly in front and the sacrum directly towards the left side. Since the breech is quite compressible, advantage is taken of this to enable it to pass out of the vulva with less distention of the perineum, by one of the hips passing in advance of the other. The breech being born, the body and legs emerge, next the shoulders, following the same mechanism, and finally, the head, which enters in the right oblique diameter and passes down strongly flexed. What is the mechanism of the R. S. A. position ? The same as in the first, substituting right for left, etc. What is the mechanism of the R. S. P. and L. S. P. positions ? So far as the breech is concerned, the mechanism is the same as in the sacro-anterior positions (making allowance for change in direction). But when the head enters the pelvis it will be in an occipito-posterior position, and there will be the same need for anterior rotation as in the correspond- ing vertex positions. What dangers are connected with the breech presentation ? i. Compression of the funis. 4. Extension of arms over head. 2. Premature respiration. 5. .Extension of the head. 3. Inhalation of mucus, etc. 6. Rupture of the perineum. How may the funis be compressed ? If there is any delay in the birth of the head after the body is born, the funis may be compressed between the head and pelvic walls, thus asphyxiating the child. What is premature respiration ? After the birth of the body, the contact of air may excite respiration, and abolish the placental circulation. Delay after this may result in asphyxia. How may inhalation of mucus occur ? The child may respire while the head is detained in the passages, and may draw mucus or fluids into the lungs, causing either asphyxia or pneumonia after birth. How may the arms be extended ? The arms are naturally flexed upon the child's body, and pass out with it, but if arrested by the pelvic walls, they may be extended alongside of the head, increasing its diameter, and making delivery impossible until they are brought down. 62 QUESTIONS ON OBSTETRICS. How are the arms to be brought down ? One or two fingers are to be passed by the child's head and laid upon an arm from behind. The arm is then to be pushed across the child's face, and so on until brought down by the side of the body. This may be repeated with the other, if both are extended. How may the head be extended ? The head is usually so tightly grasped by the uterus and vaginal walls as to be kept flexed, but if the pelvis is small, or improper traction is made upon the body, it may be extended, and will then present a larger outline in passing through the pelvis. This makes its advance more difficult, and may cause a laceration of the perineum. What is the fcetal mortality in the breech presentation ? From thirty to fifty per cent. How should a breech case be managed throughout ? As a rule it should not be interfered with until the breech is born. The physician should then— I. As the shoulders are coming down, endeavor to secure anterior rotation if it is in a posterior position. 2. As soon as the body is born, bring down the arms, if extended. 3. If the head is not at once born, pass two fingers to its mouth, to secure a supply of air and admit of respiration. 4. Draw the body down against and parallel to the perineum (to flex the head). Then elevate the body, turning it over upon the mother's abdo- men, while making traction. An assistant, if possible, should press upon the hypogastrium, to force the head down. Repeat the manoeuvre, if necessary. What caution is necessary in pulling upon the child's body ? The neck breaks with a weight of 100 pounds, and decapitation occurs with 120 pounds. (Matthews Duncan.) What varieties of the breech presentation occur ? One or both feet or legs may come in advance of the breech, which is called a Breech footling. How does the descent of one or both feet affect the mechanism ? Very little, except by offering a temptation to pull upon them, and thus to extend the arms and head. The first stage of labor may be longer, from the want of an even dilating wedge in the os. How is the child situated in the L. D. A. position ? The right shoulder presents in the os uteri, the head lying in the left iliac fossa and the breech in the right iliac fossa or a little higher. PATHOLOGY OF LABOR. 63 How is the child situated in the R. D. A. position ? The left shoulder presents in the os, the head lying in the right iliac fossa and the breech in the left iliac fossa or a little higher. How is the child situated in the R. D. P. position ? The right shoulder presents in the os, the head lying in the right iliac fossa, and the breech in the left iliac fossa, or a little higher. How is the child situated in the L. D. P. position ? The left shoulder presents in the os, the head lying in the left iliac fossa, and the breech in the right iliac fossa, or a little higher. What are the modes of delivery in the transverse present- ation ? There is no natural mechanism, but, I. The child, if very small, may be doubled up and expelled. (Rare.) 2. The child may be spontaneously turned in utero, so that it becomes either a vertex or breech presentation. (Rarer.) 3. After the child has been doubled up the breech may be pushed down after great efforts. This is called spontaneous evolution. (Rarest.) How should transverse presentations be managed ? We should not await any of the spontaneous methods, but turn the child to a vertex or breech presentation. (See Version.) If this is impossible we will have to perforate the chest and reduce the size of the child. (See Embryotomy.) What variety of the transverse presentation occurs ? The hand or arm may be in advance of the shoulder, and may present at the vulva. Care should be taken not to confound the hand and foot with each other. What anomalous presentations are occasionally observed ? 1. The body of the child may be so doubled that the feet present with the vertex or face. 2. One or both hands may be added to the vertex or face presentation. 3. The funis may present with any of the others. PATHOLOGY OF LABOR. DYSTOCIA. What is dystocia ? The technical name for labor which departs from the normal standard. How is labor rendered abnormal ? By disease, defect or accident affecting— 1. The motive force. 2. The foetus and its attachments. 3. The mother's 64 QUESTIONS ON OBSTETRICS. tissues or general condition. We have, therefore, three classes of dystocia: I. Uterine; 2. Ovular; 3. Maternal. In what way may the motive force be affected ? It may be, 1. Excessive. 2. Deficient. 3. Irregular. What evils may excessive uterine action occasion ? 1. Precipitate labor, involving a too sudden emptying of the womb, with laceration of the cervix and perineum. 2. Rupture of the womb when there is much resistance. Opium, chloral or anaesthetics will control it. What is deficient action ? Uterine inertia, or any deficiency in the power, length or frequency of the uterine contractions. What evils may uterine inertia occasion ? The principal one, and which involves many evils, is delay in the labor. Delay is hurtful, more or less, according to the stage in which it occurs. 1. At all times the protraction of labor beyond its normal limits enfeebles the mother and endangers the child's circulation. 2. In the second stage additional dangers arise, from pressure upon the maternal tissues, with possibilities of sloughing, fistulas and septic processes. 3. In the third stage inertia may lead to fatal hemorrhage, thrombosis in uterine sinuses, with subsequent septicaemia and other diseases. What are the causes of uterine inertia ? 1. Defective innervation or circulation of the uterus. 2. Paralysis of the uterus from over distention. 3. Organic defects in the uterine muscles. In what ways may the innervation and circulation of the womb be affected ? The nervous supply of the uterus being spinal, cerebral (vaso-motor) and ganglionic, it may be affected by mental emotion, the shrinking from pain of the hysterical temperament, improper ventilation, or from either direct or indirect disturbance of the uterine centre. The latter may be occasioned by malarial poisoning or by reflex influences from other disturbed organs. How may the uterus be paralyzed from over distention ? The walls of the uterus may be mechanically over-distended by twins or dropsy of the amnion, making the contractions feeble. PATHOLOGY OF LABOR. 05 What organic defects are met with ? The uterus which has frequently gone through the processes of preg- nancy often has its fibrous and uncontractile element increased at the expense of the muscular tissue. This decreases the power of the uterus; hence, old multipara; frequently have protracted labor from this cause. It is said that fatty degeneration sometimes occurs. How should uterine inertia be treated ? If sufficiently great to unduly prolong labor we should— I. Endeavor to ascertain and remove the cause. 2. Place the woman under the best hygienic conditions. 3. If the source of reflex disturbances cannot be removed, we may quiet the nerve centre by chloral, opium or the bromide of potassium, after which the inertia is commonly relieved. 4. Quinine is always useful in malarious districts. 5. Massage and stroking of the uterus through the abdominal walls may be tried. 6. If over distention exists we should early rupture the membranes. 7. In the second stage we may supplement the uterine force (a) by Kristeller's method, {b) by the forceps. What is Kristeller's method ? Place the hands on the abdomen (facing the woman's feet). Endeavor at intervals to push the child through the pelvis. What should be avoided in treating inertia ? The use of oxytocics. What are oxytocics ? Drugs credited with the power of directly affecting the uterine muscle, and of causing or strengthening contractions, such as ergot, cinnamon, borax, and many others. Of these the one most used is ergot. What objections exist to the use of ergot in labor ? It is uncertain in action, and when it does act, causes tonic contraction of the uterus and an unremitting effort to expel the child. If this takes place before the os is dilated laceration of the cervix may occur; if the head is large, rupture of the womb may occur; in any event, the placental circu- lation will be continuously compressed, and the child in danger of asphyxia. Ergot should never be given before the birth of the child, and from its uncertainty, should never be depended on in the third stage. What is irregular action of the uterine force ? Irregular contraction of special fibres instead of general contraction of all. Its typical form is called " ante-partum hour-glass contraction." In 66 QUESTIONS ON OBSTETRICS. this condition, a circular band of fibres, usually a little above the cervix, contracts firmly and tonically, while the rest of the womb remains inert. This holds the child tightly in the womb, and suspends normal contrac- tions. How should this be treated ? Relaxation should be attempted by anaesthesia or by emetic doses of ipecac. These failing, our only resource is in artificial delivery by forceps or embryotomy. What obstructions to delivery are encountered in the ma- ternal tissues ? I. At the os uteri; rigidity, oedema, atresia or displacement. 2. In the vagina; fibrous bands, atresia, persistent hymen. 3. An unyielding perineum. 4. Tumors, including a distended bladder or rectum. 5. External; oedema and thrombus of the labia; hernia. 6. Deformities of the pelvis. What is rigidity of the os (or cervix) uteri ? An unyielding and undilatable condition, due— 1. To organic changes, and 2, to temporary spasmodic contraction of the oral fibres. The first form is due to inflammatory or hypertrophic conditions by which the cervical fibres have become thickened and fibrous. The second form may occur at any time during the first stage of labor, and is usually associated with uterine inertia. How may organic and functional rigidity be distinguished ? I. In organic rigidity the edges of the os are thick and dense, and the cervix has not entirely disappeared. 2. In rigidity from spasm the edges of the os are thin and tense, giving the sensation of sharp, wiry resistance. It is also associated with some constitutional disturbance, the woman being nervous and fidgety and the vagina hot and less moist than usual. What treatment is indicated ? 1. In organic rigidity the uterine contractions should be allowed ample time to force open the os ; this failing, incisions should be made with a bistoury. The patient should be placed in Sims' position, the speculum introduced, and the incisions made radiating from the os, to a sufficient extent to allow the head to come through with or without the forceps. The condition is rare, and such extreme measures are rarely called for. 2. Functional rigidity depends upon much the same causes as uterine inertia, and demands similar hygienic treatment. Chloral, gr. xv every PATHOLOGY OF LABOR. 67 hour, will be found effective. Over-stretching may be used. This is accomplished by inserting the index and middle fingers within the os, and spreading them forcibly, so as to stretch the oral fibres. The fingers exert so little real force that no judicious person can do harm with this procedure. It may be repeated in an hour, or with two or three successive contractions. If necessary, Molesworth's or Barnes' dilators may be used, to dilate with more force and rapidity. What is oedema of the cervix ? < An infiltration of serum, especially into the anterior lip of the cervix, which impairs its dilatability. It is due to pressure from the child's head. What is the indication for treatment ? To remove the cause; as long as the head remains the swelling will continue ; hence deliver with the forceps before it becomes too extensive. What is atresia of the os uteri ? Entire closure of the os, due to inflammatory adhesions of the cervical lips. It is very rare, and demands similar treatment to organic rigidity. What is displacement of the os uteri ? Removal of the os from its usual place in the vagina, usually due to a forward displacement of the fundus. This in turn is due to a relaxed condition of the abdominal muscles. [Cases are recorded in which the fundus of the womb rested on the woman's knees, in the sitting pos- ture, throwing the os so far back as to make it inaccessible.] The same condition is sometimes caused by tumors, displacing the womb in any direction, but the usual displacement is backward, toward the promontory. What are the dangers of this condition ? I. The child's head is pressed against the anterior wall of the cervix, and is unable to leave the womb unless through a rent in the anterior wall. 2. The incautiour -xaminer may mistake the thinned wall for the mem- branes, and make the rent himself. This condition is common enough to warrant every one in making the discovery of the os and the con- dition of its edges the first duty in labor. What treatment is indicated ? Replace the womb by pushing the fundus backward, while, if possible, the finger is hooked into the os and is pulled forward. If the displace- ment has been great, a bandage should be applied around the abdomen, to retain the uterus in position. What treatment is indicated for a small vagina, obstructive bands, etc. ? A vagina small enough to impede delivery will require the forceps to be 68 QUESTIONS ON OBSTETRICS. used. Bands or a persistent hymen may be incised. While the head distends and makes tense the band, a knife placed between the head and band is allowed to be pushed through. Care should be taken to cut as little as possible, and to tear rather than cut after the edge is severed. How may the perineum obstruct labor ? I. The perineum may be congenitally defective in structure, or have been imperfectly developed during pregnancy, constituting organic rigidity. 2. Or its muscular fibres may be in a condition of spasm, or functional rigidity. The same measures may be used which are applicable in rigidity of the cervix, but the forceps may be used instead, which render us independent of the perineum. What is to be done when tumors obstruct delivery ? The treatment of a distended bladder and rectum is obvious. Empty them. No rule can be laid down for other tumors. If the tumor is safely removable or can be diminished in size, it may be done. If not, the child must be lessened in size. What treatment do the external tumors (oedema, thrombus and hernia) require ? I. When oedema of the labia is extensive enough to obstruct delivery, a number of punctures should be made with a fine bistoury, which will speedily drain and remove it. 2. A large thrombus occasionally distends the labium obstructively. A free incision should be made, the clot turned out and haemostatics applied if necessary. 3. Hernia rarely complicates labor. If irreducible, it requires avoidance of bearing down. DEFORMED PELVIS. In what parts is the pelvis deformed ? It may be generally contracted throughout, or the deformity may be limited to the inlet or outlet. What is the generally contracted pelvis called ? The pelvis aequabiliter justo minor. What difficulties does it occasion in labor ? A small head will pass through it with the normal mechanism. A large head will be unable to pass unless aided by the forceps. In what ways is the inlet deformed ? 1. Inflammation of a sacroiliac or hip joint occurring during the devel- opmental period, may so affect one sacro-iliac arch as to practically PATHOLOGY OF LABOR. 69 obliterate the pelvic canal of that side. This may not affect the opposite canal, or there may be a flattening of the whole inlet, contracting the conjugate diameter, and lessening the calibre of the remaining canal. 2. Rachitis may so affect the pelvis as to cause a flattening of the inlet and contraction of the conjugate diameter, entirely obliterating the normal condition of the canals. 3. Osteo-malacia, or softening of the bones, may distort the inlet in a variety of ways, always diminishing its effective diameters. 4. Curvature of the spine may, by kyphosis or scoliosis, so displace the promontory as to cause, in effect, the same deformities as in the other classes. Do deformities of the inlet affect the whole course of delivery ? Generally the trouble is over when the head has passed through the inlet, the rest of the pelvis being undeformed. What effect upon delivery is occasioned by deformities of the inlet ? 1. The presentation is apt to be irregular. 2. The agreement between the axes of the uterus and pelvis being dis- arranged, the uterine force is deflected, which protracts both the first and second stage. 3. The normal mechanism of delivery is perverted. 4. The inlet is made too small to admit the child to pass readily. 5. The maternal tissues are more apt to suffer from pressure due to the misdirection of the uterine force. In what way is the mechanism altered ? 1. The head is usually more transversely placed, and rotation has to be made through a longer arc. 2. The head has to make a curved passage around the promontory before it can enter the inlet. 3. The narrowing of the pelvis delays the head until it can be compressed and moulded to a suitable size. How are degrees of deformity estimated ? By the length of the conjugate diameter, as determined by pelvimetry. How may the conjugate be measured ? Various instruments called pelvimeters are in use, but the most avail- able is the finger of the physician. One or two fingers are passed into the vagina and extended so as to reach the sacral promontory. The point at which the anterior commissure of the vulva touches the hand may then be noted, and the reach measured. 70 QUESTIONS ON OBSTETRICS. Deduct an inch from this for the thickness of the pubes and we have the hypothenuse (x) of a right-angled triangle, in which the real conjugate (y) is one leg, and the inner face of the pubes z is another—(Then x2 — y2 + z2). In a normal or slightly deformed pelvis, the promontory cannot usually be reached, but in all cases where it is a practical matter, the length of the conjugate can be determined in this manner. What degree of contraction is compatible with delivery ? Much will depend upon the skill of the physician, but in general terms, it may be said that with a conjugate of three inches or more, a living child may be extracted, with or without the forceps; three to two and a half inches, may be delivered by forceps or version, or at worst, by craniotomy; two and a half or less, may be delivered by craniotomy, but the statistics show that the Csesarean section is as safe. (Parry.) How may the outlet be deformed ? By a narrowing of the transverse diameter, due to a too close approach of the ilia; or of the conjugate diameter, due to anchylosis or rigidity of the sacro-coccygeal joint. The first is rare, and the second common, in old primiparae. What treatment is indicated ? Sufficient additional force to enable the head to pass, which is best furnished by the forceps. What departures from the normal condition occur in connec- tion with the foetus and its envelopes ? I. The membranes, (a) may rupture prematurely; [b) may be too tough ; (c) there may be an extra-amniotic sac; (d) there may be hydrops amnii. 2. The funis, (a) may prolapse; (b) may be too short. 3. The child may be enlarged or deformed by (a) hydrocephalus; (b) hydrothorax; (c) ascites; (d) oedema ; (<•) putridity ; (f) by anchylosis of joints. 4. Parts of the child may be displaced ; (a) prolapse of arm or foot by head; (b) arm behind the occiput. 5. There may be more than one child, called multiple labor. What effect has the premature rupture of the membranes ? I. No bag of waters formed to assist in dilating the os. 2. The uterine walls close upon the irregular projections of the child, instead of upon the evenly pressing water-sac, and irregular contractions may occur. PATHOLOGY OF LABOR. 71 3. The first stage is prolonged. 4. The child is subjected to greater pressure, and may be injured. What harm is occasioned by too thick membranes ? Hours may elapse in fruitless efforts of the womb to rupture them; and they require to be artificially punctured. What is a " caul ? " In rare cases, where there is little liquor amnii and the membranes are elastic, the child is born with its head enveloped in the membranes, which is called being born with a caul. [The membranes, when dried and preserved, are said to be a charm against death by drowning.] The practical point is to tear or cut open the sac as soon as possible, to prevent asphyxia of the child. What is an extra amniotic sac ? An effusion or secretion of fluid which sometimes occurs between the amnion and chorion. When the bag of waters is formed during labor, the sac will be formed by this fluid, and when the chorion is ruptured the fluid will escape, giving the impression that the true bag of waters has ruptured. A new bag will then form, enclosed only in the amnion. It is of no importance, except in the matter of diagnosis. What is hydrops amnii ? Dropsy of the amnion or over secretion of fluid by the amnion. This may take place to the extent of over a gallon, distending the uterus, en- feebling and sometimes destroying the child. If the amount of fluid is great, it is well to pass a bandage around the abdomen before evacuating it, and stimulants should also be at hand. What is prolapse of the funis ? The funis, or rather a loop of the cord, may fall in advance of the head. There may be only a small knuckle or several inches may prolapse, so that the cord even reaches to the vulva. This endangers the child's life, from pressure, but is rarely an impediment to delivery. With what may the funis be confounded ? With a loop of intestine, which also may be met with after rupture of the womb.. The finger may be passed entirely around the funis ; with the intestine, the mesentery will prevent. What treatment is indicated ? The funis should be pushed up above the inlet in the interval between pains, and when the presentation is forced down by a contraction, it will probably be retained. This can be done by the fingers or#by repositors invented for the purpose, and may be aided by placing the woman in the 72 QUESTIONS ON OBSTETRICS. knee-chest posture. If the advance of the presentation does not retain it, a small piece of sponge passed between the head and inlet will often succeed. If the cord is surely pulseless it may be left alone, but if the child is alive and the funis cannot be retained, prompt artificial delivery is indicated. In what way does a short funis impede delivery ? By preventing the child from descending completely through the pelvis. It may be only five inches long, and if of normal length, may become shortened by being wrapped in one to four coils around the child's neck. How may a short funis be recognized during labor ? I. The head is arrested low in the pelvis ; it then advances slightly with each contraction, and is abruptly jerked back by the tension of the cord. 2. Constant pain is felt in the womb, over the placental insertion. Fortu- nately the occurrence is rare, since the diagnosis is not easy unless the head is born, and aid is difficult to render. What treatment is required ? Delivery by main force until the cord can be reached and cut. What is hydrocephalus ? Enlargement of the fcetal head by excessive development of the cerebro- spinal fluid. It may be so great as to double the length of the head diameters. The bones are thin (in extreme cases expanded and parch- ment-like in texture), and the sutures and fontanelles greatly enlarged. It is often associated with spina bifida. How may it be recognized ? By the softness of the head and the enlargement of the sutures and fontanelles. Moderate degrees are not recognized with certainty until the forceps are applied, when the wide divergence of the handles shows the increased bulk of the head. How should it be managed ? Simple perforation of the skull will allow the fluid to escape, and permit the collapsed cranium to be withdrawn. The brain should also be broken up before the child is withdrawn. How may hydrothorax and other enlargements of the foetus obstruct delivery ? Effusion of serum in the chest (hydrothorax), abdomen (ascites), exter- nal cellular tissue (oedema), may enlarge the bulk of the child and obstruct delivery. The joints may be anchylosed in such a position as to increase its bulk. A child dying in utero and becoming putrid may be swollen, but usually causes trouble only by poisoning the mother. TWIN LABOR. 73 In any of these cases it may be necessary to reduce the bulk of the child by embryotomy. How is prolapse of the hand or arm by the head to be treated ? The prolapsed member is to be pushed up, as in the case of prolapse of the funis. If the arm is behind the head (Simpson) and the diagnosis can be made, turning is indicated. In what way may the foot or feet complicate head presentations ? One or both feet may present alongside of the head, in which case the child must be more or less doubled up. It may be noted that these acci- dents often occur together, feet, arms and funis, in varying proportions, prolapsing at the same time. How is this complication to be treated? If recognized before the rupture of the membranes the feet may either be pushed up or the child turned. If at any time we find turning to be very difficult or impossible, we may know that the child is dead (because difficult to turn and doubled), and at once perform embryotomy. How may the shoulders give trouble in delivery ? By not entering the pelvis, but catching on the inlet, thus preventing the head from advancing. How may this be recognized and treated ? By the manner in which the head advances and is retracted, as in the case of a short funis, and by external palpation. By external pressure the shoulders may be pushed into their proper place. TWIN LABOR. What is the usual course of twin labor ? After the first child is born a short rest occurs; the pains recur (usually within fifteen minutes) and the second child is born, and so on, if more than two. What difficulties may occur in twin labor ? I. Both children may attempt to enter the pelvis at once, and become wedged. 2. After one head has reached the outlet the second may enter the pelvis, with the same result. 3. Head locking may occur. What is head locking ? When the first child is born by the breech, its chin may catch upon the chin of the second child, presenting by the head. F 74 QUESTIONS ON OBSTETRICS. What general rules may be laid down for these complica- tions ? I. To push up one child and allow the other to come down, if possible. 2. When one child is partly born and the second wedged in with it, the first child is to be sacrificed in order to save the second. EFFECT OF MATERNAL CONDITIONS ON LABOR. What maternal conditions may affect labor ? I. Syncope. 2. Hemorrhage. 3. Rupture of the uterus. 4. Eclampsia. How does syncope affect labor? Usually only by temporarily suspending the uterine contractions. If associated with organic heart disease it may prove fatal. The treatment is the same as indicated at any other time. What forms of hemorrhage are met with ? 1. From detachment of a normally implanted placenta, before the birth of the child, or accidental hemorrhage. 2. From detachment of an abnormally implanted placenta, before the birth of the child, or unavoidable hemorrhage. 3. During and after the third stage, ox post-partum hemorrhage. What causes premature detachment of the placenta (acci- dental hemorrhage^) ? External violence and irregular contractions of the womb. What symptoms does it cause, and why ? Hemorrhage and colicky pains in the abdomen, but either may be ab- sent. The hemorrhage may be concealed, i. e., the blood may dissect up the placenta and membranes without escaping from the womb, or in small quantity. This will cause distention of the womb and pain. If there is no external hemorrhage the symptoms of loss of blood internally will be present. What treatment is indicated ? Prompt delivery, on behalf of the child, which, after all, is usually destroyed by the impairment or total stoppage of the placental circulation; and also on account of the mother, if the hemorrhage is at all extensive. 1. The os uteri should be dilated sufficiently to allow the child to pass. 2. The membranes should be ruptured, and the child at once delivered by forceps or version. The membranes should not be ruptured until we can deliver, for the evacuation of the liquor amnii gives just that much more room for the effusion of blood, without any gain in uterine contraction. 3. The woman's strength must be maintained by whiskey or hot milk, and inertia guarded against. PLACENTA PREVIA. 75 PLACENTA PREVIA. What is placenta previa ? The implantation of the placenta upon the lower third of the uterine wall. The placenta may be centrally placed over the os uteri; its edge may reach to the edge of the dilated os; or any degree between these extremes may be met with. It is, therefore, divided into central and partial placenta previa. How and why does placenta previa occur ? The ovum should be, and usually is, arrested as soon as it enters the womb, by a fold of the mucous membrane. If these folds are not prominent enough, it may advance until it arrives at the os internum, where the placenta will then be formed. It is, there- fore, found principally in multiparse, and in those whose organs are in a relaxed condition. What is the source of hemorrhage in placenta previa ? The blood pours from the openings in the uterine sinuses when the placenta is detached, and not from the placenta itself. How soon does placenta previa cause trouble, and in what manner ? Rarely before the sixth or seventh month of pregnancy. About this time the cervical segment, which is smaller than the fundal region of the womb, has nearly reached its limit of growth. The placenta then grows faster than the womb, and its edge is liable to become detached. Later in pregnancy the os uteri becomes patulous, and this again causes some separation of the placenta. As a result, hemorrhage occurs, more or less profusely. Usually, if rest is enjoined, the opened sinuses are closed by a clot, and the hemorrhage is arrested until further separation takes place. What are the dangers in placenta previa ? Death of the mother from hemorrhage, and of the child from asphyxia. The maternal mortality is one in four ; foetal mortality one in two to three. What treatment is demanded when it occurs before full term ? Rest in bed, with or without a tampon, will arrest hemorrhage for the time ; the sinuses are closed by thrombi, and the case may go on to term or another hemorrhage. If the hemorrhage is great it is safer to induce labor at once, than to wait. Occasionally no hemorrhage occurs during pregnancy, nor even in labor. How should delivery be managed at full term ? I. Introduce one or two fingers within the os (the hand being in the 76 QUESTIONS ON OBSTETRICS. vagina), and dissect the placenta from the uterine wall for about three inches from the os uteri in all directions, pushing it to one side, if necessary. 2. Rupture the membranes, and if there is an unfavorable presentation, turn the child and make the breech engage in the os; or if the head presents, the forceps may be used, if speedy delivery is necessary. This partial detachment of the placenta will almost inevitably arrest hemorrhage (Karnes). The strength of the woman is then the main point to be cared for, and if in a reasonable time the uterus seems to be incompetent, the child may be delivered by art. What complication may interfere with this procedure ? A rigid and undilatable cervix, which is often present, because of the thickening of the tissues under the placental insertion. How is this to be overcome ? In premature cases, or when we are not prepared to dilate, the tampon may be applied for some hours. Otherwise the Molesworth or Barnes' dilators may be used to mechanically dilate the os, if the fingers cannot do it. What is a tampon, and how applied ? A tampon is a plug made of pieces of cotton, soft rags, or similar materials, packed into the vagina so as to restrain hemorrhage. I. Place the woman in Sim's position and introduce Sim's speculum. 2. With a pair of dressing forceps introduce a small wad of cotton batting within the os uteri. Continue to add similar pieces until the whole upper part of the vagina is packed with them. 3. Gradually withdraw the speculum, continuing to add cotton until the whole vagina is packed. 4. Apply a compress and T-bandage over the vulva. A roller bandage or lamp-wick (recommended by Foster) may be used, and will be easier to withdraw. How long should a tampon be left in place ? Seldom over twelve hours, and in placenta previa it may be necessary to remove it within an hour or two. What effect has the tampon besides restraining hemorrhage ? It excites uterine contractions, and aids in dilating the os. This should always be considered where these results are not desirable. What cautions are to be observed with the tampon ? 1. The upper pieces should be moistened with a one or two per cent. solution of carbolic acid or other disinfectant. POST-PARTUM HEMORRHAGE. 77 2. Never introduce it when the membranes have been ruptured, except in the early months of pregnancy, lest bleeding occur above it, distending the uterus. 3. Watch it after it is applied, to see that blood does not flow past or through it. There is no danger if it is properly applied. What complication may occur in placenta previa after delivery ? The exposed sinuses in the cervical region may not be efficiently sealed, and hemorrhage may continue. The management will be as in post- partum hemorrhage generally. POST-PARTUM HEMORRHAGE. What is the cause of hemorrhage post-partum ? An uncontracted or incompletely contracted uterus, whereby the opened - sinuses of the placental site are not compressed, and bleeding is allowed. It is also favored by the retention of the placenta, clots (incomplete delivery), and by fibroid tumors. In a slight form, may be due to laceration of the cervix, vagina, and perineum. What are the symptoms of post-partum hemorrhage ? 1. Usually the blood pours out so freely as to readily attract attention : if concealed or retained in the uterus, it will occasion the symptoms of internal hemorrhage. 2. The hand placed on the abdomen will not find the womb hard and in the hypogastric region, but soft and at a higher level. What are the indications for treatment ? 1. To empty the womb. 2. To make the womb contract. 3. To cause clots in the opened sinuses if the womb fails to contract. 4. To support the woman's strength. How is this treatment to be carried out ? 1. The hand should be introduced into the womb and clots or other con- tents removed. 2. The hand is reintroduced and moved about, stroking the uterine walls, while the other hand is similarly engaged on the abdomen. This will often succeed in arousing contractions, and lead to the expulsion of the hand from the womb. If not, 3. A handkerchief soaked in vinegar may be carried into the womb and squeezed out; or a peeled lemon ; or a piece of ice. 4. Injections of hot water (no0 F.) may be used. 5. The faradic current may be useful, if at hand. 78 QUESTIONS ON OBSTETRICS. 6. As a last resort, and to cause clots, injections of tincture iodinii, or liq. ferri perchloridi, diluted one-third, or even of full strength, may be used. How may post-partum hemorrhage from inertia be prevented ? By delivering the placenta by the method of Crede. What internal medication is proper ? Stimulants, opium, and ergot, but no dependence is to be placed upon anything but local treatment. What is secondary hemorrhage, and its cause ? Hemorrhage occurring after an interval of several hours or even days, after delivery ; it is usually preceded by ordinary post-partum hemorrhage, and may be due to a return of uterine inertia; the detachment of thrombi ; retention of pieces of membrane, or clots; displacement of the uterus, from a too tight bandage ; an impacted rectum ; sitting up too soon. What treatment is indicated ? The same in principle as in immediate hemorrhage, with due attention to the exciting cause. RUPTURE OF THE UTERUS. What is rupture of the uterus ? A tear or laceration in the substance of the uterine body, usually permitting the escape of the child into the abdominal cavity. Under what circumstances does it occur ? Generally during the second stage of labor, the rent beginning in the cervix and extending toward the fundus. Rarely the peritoneal covering escapes laceration; also it occasionally occurs early in the labor, or even in premature labors. What is the cause of rupture ? It has been ascribed to fatty degeneration of the muscles, and to thinning of the walls at a point called Bandl's ring. The cause is not surely deter- mined, but it may justly be feared whenever an impediment to delivery coexists with powerful uterine contractions. What symptoms denote its occurrence ? During or just after a labor pain the woman is seized with an acute and persistent pain. The form of the uterine tumor is changed and the pre- sentation is retracted. As blood is effused from the rent, symptoms of internal hemorrhage and shock are added. What treatment is indicated ? I. Preventive; a prompt resort to the forceps when the occurrence is feared. ECLAMPSIA. 79 2. Afterwards, if the presentation is not entirely retracted, an attempt may be made to deliverer vias naturales. 3. In any case, unless it can be demonstrated that the peritoneum is unbroken, the abdomen should be opened by an incision, the uterine wound closed by sutures, and all blood and fluids removed from the abdominal cavity. What is the mortality from rupture ? 1. In cases abandoned to nature nearly all die. 2. When the child is delivered without gastrotomy a few more recover. 3. When gastrotomy is at once performed, 60-70 per cent, recover. ECLAMPSIA. What is puerperal eclampsia ? A form of convulsions occurring before, during or after labor, which resembles epilepsy in clinical appearance and uraemic convulsions in cause. The typical form occurs during the second stage of labor. What is the clinical history of an attack ? 1. The patient is suddenly seized with a tonic spasm, involving the muscles of the face and thorax, usually of the upper extremities, and occasionally of all the muscles. This tonic spasm lasts for about one minute and— 2. Is succeeded by clonic spasms or twitchings, lasting for several minutes. The convulsions subside and— 3. Are succeeded by coma, with stertorous breathing. The patient may become conscious or the convulsion may be renewed in the same order, keeping up until the patient is exhausted or recovers. The masseter muscles are contracted tonically throughout the seizure. The interference with respiration causes the face to become red or livid. The duration of each seizure and the interval between, depend upon the severity of the attack. What prodromic symptoms warn us of an attack ? 1. Severe and persistent headache is often complained of before an attack. 2. Albumen in the urine should also put us on our guard. What is the cause of puerperal eclampsia ? The cause is complex, the main factors being— 1. During pregnancy the blood becomes deteriorated (hydraemic), and the ill supplied nerve centres become more irritable or convulsable (Barnes). 2. The processes of elimination, especially through the kidneys, become defective, and urea (including other excrementitious matters) is retained 80 QUESTIONS ON OBSTETRICS. in the blood. Therefore the nerve centres are supplied with poisonous or irritating substances, as well as impoverished. 3. Vascular tension is increased during pregnancy, and especially during labor, which intensifies the action of the foregoing factors. 4. During labor the interference with the cephalic circulation (from bear- ing down, etc.,) causes hyperaemia of the brain and of the nerve centres specially concerned with eclampsia. Which of these factors is the most important ? The uraemia, as shown by the fact that 90 per cent, of eclamptics have albumen in the urine. Wherein does puerperal differ from uraemic eclampsia ? The temperature in the former is high (has been observed as high as 1090 F (Busey); in uraemia it may even be subnormal. The clinical history also differs. Wherein does puerperal eclampsia differ from other forms of convulsions ? 1. In hysteria the spasms are altogether irregular and consciousness is never entirely lost. 2. In apoplexy, the condition of coma is permanent, and there is a differ- ence in the size of the pupils. 3. In epilepsy, the history will distinguish, except in labor in epileptics, who rarely have convulsions in labor (Parry). What point in the etiology is disputed ? The condition of the brain, as to anaemia or hyperaemia. Traube and Rosenstein assert that hydrsemia causes oedema of the brain, which, in turn, leads to anaemia from pressure upon the capillaries from without. Others assert that anaemia of the brain is essential in eclampsia, and that the base of the brain is anaemic, even when the convolutions are hyperaemic. What effect upon the cerebral circulation have the bearing- down efforts of the second stage, when eclampsia mostly occurs ? The cervical veins are obstructed and blood accumulates in the brain. Does this occur when eclampsia takes place before or after labor ? Not demonstrably; and in these cases we conclude that the other factors, notably uraemia, predominate. What are the indications for treatment in puerperal eclampsia ? 1. To relieve the irritability of the nerve centres. MISCELLANEOUS COMPLICATIONS. 81 2. To reduce vascular tension. 3. To reduce cerebral hyperaemia. What preventive treatment is indicated ? 1. To eliminate urea, etc., by cathartics, and, 2. To quiet the nerve centres by chloral and bromide potass. What treatment should be employed during the attack ? 1. Venesection, as the quickest and most powerful means of reducing the vascular tension, cerebral hyperaemia, and secondarily the nerve irritability. 2. Chloral and bromide of potass, by the mouth, if the patient can swallow, or in double doses by the rectum. 3. Ether or chloroform may be given until the chloral, etc., can be administered and take effect. 4. The labor, if in progress, should be terminated as soon as possible, without violence. 5. Purgatives may be given, especially after delivery. 6. A warm pack, to promote diaphoresis, may be used. What objections are urged against venesection ? That it is out of fashion, and does not reduce vascular tension in a healthy dog. Veratrum viride may be used instead, if there is time to wait upon its action. What drug was especially used before the discovery of chloral and the bromide ? Opium, which relieves the irritability of the nerve centres. What objection exists to its use ? It allays nerve irritability at the expense of all other indications; when the kidneys are seriously crippled it may, itself, cause death; it is no better than other less danger? 1 remedies. MISCELLANEOUS COMPLICATIONS. What complications may exist during, or after the third stage of labor, besides hemorrhage ? I. Placental dystocia, or difficulties in delivering the placenta. 2. In- version of the womb. 3. Emphysemaof the neck. 4. Lacerations of the cervix, vagina, and perineum. What forms of placental dystocia occur ? I. Adherent placenta. 2. Hour-glass contraction. 3. A placenta too large. 4. Clots behind an inverted placenta. 5. Utero-placental vacu- um. 6. Tlacentae succenturiae and other anomalies of form. 82 QUESTIONS ON OBSTETRICS. What is adherent placenta ? The term is properly applied to one that has contracted firm adhesions to the uterine wall, from inflammation during pregnancy. There is usually a history of fixed pain in the uterus. This is rare, but improper traction upon the cord may delay the separation of an otherwise normal placenta. How is adherent placenta to be treated ? Pass the hand into the uterus, find a detached edge of the placenta, and by a sawing motion with the fingers break through the adhesions. What is hour-glass contraction ? Irregular or tetanic contraction of a part of the uterine walls, the rest being relaxed, whereby the placenta is grasped and held as if in a sac. It may be complicated, if not caused, by adherence of the placenta. How may it be recognized ? The hand, introduced into the womb, finds apparently a second os internum, high up, caused by the constriction of the muscular fibres of the womb below the placental site. How is it to be overcome ? The fingers, little by little, and finally the hand, are to be insinuated within the constricting band and its resistance overcome. This may be facilitated by anaesthetics or chloral. The best reliance is upon patient and continuous manual efforts. How may the bulk of the placenta affect its delivery ? A very large placenta which has fallen centrally upon the os, instead of edgewise, may be too bulky to pass without assistance. The same may occur with a placenta of moderate size, if clots have formed behind it to such an extent as to prevent it from being doubled up. How is such a placenta to be delivered ? It should be perforated centrally by one or two fingers, which will enable us to hook into and drag it down. What is a utero-placental vacuum ? A rare occurrence, in which the placenta being detached, a pull upon the funis makes a vacuum between the placenta and uterine wall, convert- ing it into a sucker, resembling in action the leather disk by which the small boy raises bricks from the pavement. How can it be detected and remedied ? It resembles at first the large placenta, or one enlarged by clots, but as soon as perforated and the vacuum destroyed, it is-delivered with great ease, or even spontaneously expelled at once. INVERSION OF THE UTERUS. 83 What irregular forms of the placenta are met with ? i. The battledore placenta, in which the funis is inserted at the margin, instead of centrally. 2. The vessels of the cord may not unite, even at the margin, but ramify over the membranes before uniting to form the funis; known as the velamentous insertion of the cord. 3. The subdivision may extend even to the placenta, and result in there being two or more placentae, situated at different points on the uterine walls ; called placenta: succenturice. These anomalies are uncommon, but sometimes lead to perplexities in the delivery of the after-birth. INVERSION OF THE UTERUS. What is inversion of the uterus ? A turning inside out of the womb, so that the fundus— 1. May present at the os uteri (partial inversion), or— 2. Passes through the os and extends to or through the vulva (complete inversion). What is the cause of inversion ? Partial and irregular contraction of the uterus is the main factor, often aided by traction upon the cord in delivering the placenta. No one can invert a healthy womb by traction upon the cord, but if the fibres under the placental site are not contracting, inversion will be very likely to occur. It may happen either before or after the placenta is detached. How may inversion be recognized ? 1. The woman usually complains of great pain at the moment of the accident (a sensation as of something tearing loose within her). 2. Hem- orrhage and more or less shock follow. 3. The hand, placed upon the abdomen, fails to find the womb in its natural place, and when introduced within the vagina finds it there (unless external). It can then be mistaken for nothing but a fibroid tumor, which, of course, could not occupy the vagina just after delivery. How is inversion to be treated ? 1. The placenta, if adherent, is to be detached. 2. The womb should then be squeezed within the hand, to reduce its bulk, and an attempt made to replace the fundus, with the hand grasp- ing it, while the other hand presses downward in the hypogastric region, making counter-pressure. 3. If this fails, endeavor to indent the uterine globe with a knuckle or the finger tips and thus reinvert it. The indentation is said to be best 84 QUESTIONS ON OBSTETRICS. effected at the opening of a Fallopian tube. Pressure should be firmly and patiently continued, and if employed just after the accident, rarely fails. 4. After the fundus is replaced the hand should remain within the uterus for some time, or until expelled. What is to be done in case of failure ? If called too late, or if replacement cannot be effected without violence, the fundus should be bathed with somewhat diluted tincture of iodine, to restrain hemorrhage, and allowed to remain inverted for one or two months, or until involution has taken place, when the reposition may be attempted by the method of White. What is emphysema of the neck ? During the bearing-down efforts of the second stage it sometimes hap- pens that a few air vesicles in the lungs are ruptured, and air escapes by way of the mediastinal space to the cellular tissues of the neck and face. It is usually limited to one side, the tissues being swollen and crackling under the fingers. It may cause great alarm, but is innocuous if left alone, subsiding in a few days without any ill consequences. What ill consequences attend laceration of the mother's tissues ? The only immediate consequence is or may be hemorrhage, easily controlled. The remote consequences may be serious, especially when the perineum or cervix are badly torn. What is to be done when the cervix is lacerated ? Some authorities recommend that sutures should at once be inserted; but the general practice is to let it alone until the woman has passed through the period of involution of the womb. What is to be done when the perineum is lacerated ? Most authorities recommend that it should at once be united with sutures, unless of very slight extent. OBSTETRIC OPERATIONS. What are the capital operations of midwifery ? 1. The use of the forceps. 2. Version. 3. Embryotomy in various forms. 4. The Caesarean section and modifications. 5. The induction of premature labor. What are the obstetric forceps? Two separate and similar pieces of steel, each fashioned into a blade OBSTETRIC OPERATIONS. 85 P?IErf5 and handle, intended to cross each other in the middle and be temporarily united at that point by a lock. What is the object of the forceps? I. They are used to seize the child's head and to make traction upon it. 2. They are used to compress the head and diminish its diameters. 3. They are used to flex or extend the head as may be required. Why is a fenestra or open space made in the blades ? To allow the parietal protuberances to project, thereby permitting the forceps to be applied to the head without at all adding to its bulk. What curves exist in the blades ? 1. The pelvic curve, so that they can be applied at any point in the pelvic canal with equal ease. 2. The head (or capital) curve, by which they are bowed outwardly, so as to enable them to grasp and hold the Fig. 8. head. How many forms of lock are in com- mon use ? The mortise, o r English lock ; the pivot, or French lock, and the button, or German lock. How are the blades distinguished and named ? The blade to the right is called the right blade, or when provided with the pivot or button, the male blade (see Figure). The blade to the left is called the left blade, or when provided with a slot, the female blade. When should the forceps be applied ? In any case where the head presents, and where prompt delivery is necessary (either for mother or child), or to be regarded as preferable to waiting upon the natural efforts. May they be applied during the first stage ? There are few circumstances which warrant us in applying them before full dilatation of the os. The necessity for prompt delivery should be very clear, since bruising and laceration of the cervical tissue:, arc almost inevitable. DAVIS FORCEPS—UPPER VIEW. 86 QUESTIONS ON OBSTETRICS. What preliminaries are requisite to their application ? The consent of the woman being obtained, she should be placed in a suitable position and the forceps placed in warm water. In what position should the woman be placed ? Lying crosswise in the bed, the vulva overhanging the bed's edge, and with her feet placed upon two chairs. The knees may be held apart by an assistant, and the legs covered. What station should the physician occupy ? Seated upon a chair, directly in front of the vulva, the forceps placed within reach. How should the forceps be applied to the L. O. A. position at the inlet ? I. The physician should take the male blade in his left hand, holding the handle securely, and having greased both the blade and his right hand, pass the latter into the vagina, high enough to enable him to feel the rim of the os uteri (on the left side of the mother). Two fingers will often suffice, instead of the whole hand. 2. Pass the blade along the palmar surface of the right hand or fingers, aiming to place the blade under the left sacro-iliac arch, and, therefore, along the left side of the child's head. This is usually very easy, as there is a free space at that point. Care should be taken to pass it between the cervix and head. 3. When the first blade has been adjusted to the head, its handle should be pressed well against the perineum, so as to keep it out of the way. 4. The right hand is now cleansed, and takes up the female blade, which, with the left hand, is anointed, and the fingers of the latter passed into the vagina, to guard the rim of the os uteri. 5. The female blade is then introduced upon the palmar aspect of the fingers, with the view of insinuating it between the child's head and the pelvic walls, behind the obturator foramen, and, therefore, upon the right side of the head. 6. When the second blade is fully introduced, it should lie upon the first blade, with the slot just opposite the pivot, and the handles being now compressed, the instrument is locked and fully applied. How should the first blade be held at the beginning of intro- duction ? As the tip of the blade enters the vulva, the handle should be held nearly perpendicularly, with its tip above the inner limit of the right groin. OBSTETRIC OPERATIONS. 87 The rest of the introduction resembles the passage of the catheter in the male. How should the second blade be held at the beginning of its introduction ? As the tip of the blade enters the vulva, the handle should lie in the line of, and almost touching the left groin. The handle is then brought almost directly to the median line, and the blade pushed onward and upward, as soon as the handle is free from the left leg. What should be done if the instrument cannot be locked ? The second blade should be withdrawn, and more carefully reapplied. Locking can often be effected by simply pushing the handles well back upon the perineum. How should the forceps be held in making traction ? The handles should be grasped with the right hand, and gently com- pressed ; the left hand should be placed over the lock, with a finger upon the top of each blade. How is traction to be made ? I. The left hand presses or pushes the blades downward and backward (and slightly to the right) while the right hand pulls the handles partly in the reverse direction and partly in the line of the handles. 2. As the head descends, the direction of traction is changed, being made in the curve of the obstetric canal at all times. How long should traction be made ? For about a minute at a time, with an interval of the same or greater length, during which the handles should be partly unlocked, to remove the compression of the forceps from the child'shead. Should traction be made during a labor pain ? The contractions may be disregarded until the head presses upon the perineum, when traction should be made, only in the absence of uterine contractions, and if the operator is not sure of his skill, he should withdraw the forceps at this point. How may the forceps be withdrawn ? By reversing the motion used in applying them, and with the same deliberate care. How are the forceps applied at the inferior strait ? The head having rotated, the blades will be on opposite sides of the pelvis, when on the sides of the head. Therefore, both blades are passed in the same manner, and nearly as the first blade is passed in the high operation. 88 QUESTIONS ON OBSTETRICS. How are the forceps to be applied to an R. O. P. position at the inlet ? Precisely as in the L. O. A. position. How is traction to be made in the R. O. P. position ? I. The handles should be grasped firmly, so as to hold the head securely while, 2. The handles are elevated, with scarcely any traction, so as to flex the head; this being a necessary part of the natural mechanism. 3. Traction should then be made in the axis of the canal, and with as little compression as possible, in order not to interfere with rotation. 4. If the twisting of the handles shows a tendency to rotate, this may be aided ; but rotation should not be forced. How are the forceps to be applied in the R. O. A. and L. O. P positions ? The position of the head being the reverse of the L. O. A. and R. 0. P. positions, the right side of the head is behind and at a distance, the left side in front, and near. Therefore, the female blade is first applied, under the right sacro-iliac arch, and in the same way as the first blade in the other position. The male blade is then introduced in a manner corresponding to the second blade, in the L. O. A. What difficulty is then encountered ? The shank of the male blade will lie over the female blade, and the instrument cannot be locked. How is this to be remedied ? Take hold of the handles separately, and bring each handle to the median line and beyond, until the handle of the female blade can be lifted over that of the male blade. They will then be in position for locking. How are the forceps to be applied on the face presentation ? In the first and third positions, precisely as in the vertex, first and third. In the second and fourth positions, precisely as in the vertex second and fourth. May the forceps be used on any part but the head ? They have been used upon the breech, but are of doubtful utility as compared with other procedures, and not free from danger when so applied. What are the indications for the use of the forceps ? 1. For delay in the second stage of labor, arising from [a) uterine inertia • (b) any obstruction or disproportion. VERSION. 89 2. For delay in the first stage, rarely, as in (a) placenta previa; (b) organic rigidity ; (c) absence of a natural dilating agent. 3. For rapid delivery, when required, by such complications as, (a) convulsions; (b) prolapse of the funis; (c) excessive uterine action menacing rupture. 4. For secondary purposes, as for, (0) extraction of the child in the Caesarean section; (b) after rupture of the uterus; (c) for removal of tumors or foreign bodies from the maternal passages. What is the principal circumstance demanding their use ? Uterine inertia, or insufficiency of the uterine contractions to complete the labor. How long should the second stage be allowed to continue before resorting to the forceps ? Rarely over one or two hours. It is irrational to subject the woman to long continued pain and effort, when we can harmlessly deliver by art. What alternatives do we possess to the use of the forceps ? Version and embryotomy— 1. If prompt delivery is indicated in any case, and we do not possess the forceps or the skill to use them, we may employ version. 2. If the forceps fail to extract the child, or the pelvis is so deformed as to render their use impracticable, we may perform version (according to some authorities), or resort to embryotomy. VERSION. What is version ? The operation by which the presentation of the child is changed; called, also, turning. How many kinds of version are there ? 1. As regards the choice of presentation there are two— (a) cephalic, in which the head is made to present, and, [b) podalic, in which the breech is made to present. 2. As regards the mode by which it is effected, we have three— {a) internal, in which the hand is passed into the womb to effect the change, [b) external, in which the change is effected by manipulation through the abdominal walls only, and ( 3. No pain or slight tenderness in hypogastrium. 4. Suppression of the lochia or a fetid discharge in some cases. 5. Mind usually unimpaired, and the patient either cheerful or indifferent. 6. Face anxious. 7. The typhoid state usually precedes a fatal termination, which occurs within a week, unless recovery takes place. What are the symptoms of chronic septicaemia ? 1. The patient remains weak, and has little appetite. 2. The tongue is pale and flabby, and lightly coated; if at all. 3. Slight fever, of intermittent type, is present. 4. The urine is high-colored, and constipation exists. 98 QUESTIONS ON OBSTETRICS. How is septicaemia influenced by peritonitis and other inflam- mations ? i. The symptoms of peritonitis, and other inflammations (metritis, cellu- litis, etc.) are but little different in the puerperal period and at other times, and in all, except peritonitis, a mere mixture of symptoms is pre- sent when occurring with septicaemia. 2. In peritonitis with septicaemia, the septic symptoms predominate, and a remarkable difference between the pulse and temperature-rate is observed. The pulse is frequent, 120 to 150, while the temperature is slightly elevated, or even subnormal. The abdomen is tympanitic, yet the patient complains little of pain. What are the indications for treatment in acute septicaemia ? 1. Antiseptic injections. These should be made into the uterus, and any retained fragments of placenta, etc., removed. 2. Whiskey administered with a free hand. 3. The salicylate of soda or potassa, and quinine, are also useful in full doses. What are the indications for treatment in chronic septicaemia ? 1. Antiseptic injections, if there is any reason to suspect the retention of putrescible materials in the uterus. 2. To improve the action of the excretory apparatus by such agents as calomel, ipecac, and saline laxatives. 3. The salicylates or quinine, in small doses. What are the indications for treatment in inflammations, complicated with septicaemia ? The septicaemia is to be regarded as the chief trouble, and the inflam- mation combated as a secondary matter. What is uterine thrombosis ? The formation of clots in the uterine sinuses, due to imperfect contrac- tion of the womb after delivery. What results may follow from thrombosis ? 1. Detachment of fragments, and formation of emboli in other structures, as in the lungs, brain, etc., leading to inflammations in the obstructed organs and metastatic abscesses. 2. Purulent liquefaction of the thrombus and subsequent escape of pus into the circulation, causing pyaemia. 3. Extension of the thrombus into consecutive veins, causing phlebitis. What is phlegmasia alba dolens ? Also called " milk leg," is an inflammation of the cellular tissue of the THE PERIOD AFTER DELIVERY. 99 thigh and leg, usually associated with femoral or crural phlebitis. Thrombosis of the vein may precede or coexist, but is not always present. What are the symptoms of " milk leg ?" It begins usually in the second week, with— I. Irregular chilliness and malaise for several days. 2. Pain in the leg and abdomen, of a dragging character. 3. A distinct rigor, and swelling of the leg. 4. Fever of a remittent type, changing to intermittent as recovery advances, or becoming continuous in grave cases. What peculiarities attend the swelling ? 1. The skin is white and tense. 2. A red streak marks the line of the vein when phlebitis is present. 3. Later, the vein feels like a hard cord when palpated. What are the results of " milk leg ?" I. It may end in complete resolution. 2. An abscess is formed along the vein, and discharges. 3. Gangrene and septicaemia may be developed. 4. If thrombosis is present, emboli and pyaemia may occur. In all cases recovery is slow, and the leg is apt to remain weak and become cedematous, from permanent obstruction of the vein. What is the treatment indicated in " milk leg ?" 1. To control inflammation, 2. To relieve pain. 3. To support the patient's strength. The first can be best effected by the use of .atropia, in a one per cent. solution, applied to the parts with a cloth, or by belladonna ointment. Warm fomentations are also useful, and a lotion of lead water and laudanum, applied warm, is also useful in relieving pain. Anodynes may be given as needed. Absolute rest is essential. If an abscess forms it may be evacuated, and applications of tinct. iodinii are useful in promoting resolution. What is mastitis ? Inflammation of the breast. It is divided into 1. Glandular; 2. Inter- stitial, and 3. Sub-glandular. In the first the lobules of the gland are inflamed. In the second the connective tissue alone inflamed. In the third the connective tissue beneath the gland is involved. What are the symptoms of mastitis ? 1. In interstitial and sub-glandular mastitis the symptoms are those of abscess in the cellular tissue anywhere ; slight constitutional disturbance, 100 QUESTIONS ON OBSTETRICS. except in large sub-glandular abscess, and the pain is not increased by suckling the child. 2. In glandular mastitis there is a rigor and high fever, preceded by a hard lump in the breast, and suckling causes severe pain. What is the treatment of mastitis ? I. When the connective tissue is involved suppuration is almost inevitable, and is to be treated on general surgical principles, poultices and early incision being usually indicated. 2. In glandular mastitis various measures have been employed ; massage or stroking, rubbing and kneading the breast; endeavoring to empty engorged milk sinuses, and to remedy the blood stasis. An ice bag is strongly recommended; also compression by strapping with adhesive plaster, or with a plaster-of-Paris dressing. To directly affect the blood supply and functional activity of the gland, belladonna is used, internally and externally. The sulphide of calcium, internally, and iodide of lead, externally, are used, and many other remedies have advo- cates. In all cases the breast should be suspended in a sling. When inci- sions are necessary they should be made in a line radiating from the nipple, to avoid severing milk ducts. What are the chief causes of mastitis? Cold, obstruction of milk ducts, septicaemia, and sore nipples. What affections of the nipple are met with ? The nipples may be simply tender, or inflamed with resulting abrasions, excoriations and fissures. The inflammation may be simple, aphthous or eczematous. How are sore nipples to be treated ? I. Stop suckling and have the milk removed by a pump or massage. 2. Apply astringent remedies, or such as act by excluding the air. The best applications are tannin and glycerine, tinct. benzoin, collodion ; but all treatment will be uncertain if the child is allowed to nurse while the nipple is sore. What are the principal congenital defects in the child which require attention ? Hare-lip; imperforate anus or urethra; spina bifida; club-foot; ceph- alhematoma; patulous foramen ovale. What general rules are applicable to these affections ? I. Hare-lip is to be operated on at once, if it interferes with suckling; otherwise we may wait a few months, until the child is stronger. THE PERIOD AFTER DELIVERY. 101 2. Imperforate anus and urethra are to be operated on at once. 3. The treatment of other malformations should be begun as soon as practicable. What is a cephalhaematoma ? A swelling upon the parietal bone, consisting of blood effused under the periosteum. It begins usually within an hour or so after birth, and is important only in that it may be confounded with a caput succedaneum. How is the diagnosis made ? In cephalhaematoma the swelling never extends beyond the edges of the parietal bone. Aspiration will show that the contents consist of blood, which is very finely clotted, and which remains fluid. The cephalhaema- toma becomes larger as the effusion dissects up the periosteum, and the edges are sharply defined, giving the impression that the skull is fractured. What treatment is indicated ? It does best when left alone; if the swelling is great, an incision may be necessary, to relieve tension. The only danger is from irritation of the scalp and erysipelatous inflammation. It generally disappears after four or five weeks. What is a patulous foramen ovale ? A failure of the foramen in the auricular septum to close after birth. Hence the blood is diverted from the lungs. The child is subject to spells of partial asphyxia (rarely continuous) and the face becomes dusky or livid ; hence the name a " blue child." What is to be done ? Treatment by posture ; the child is to be kept on its right side, that the action of gravitation may hinder the escape of the blood through the foramen. APPENDIX. 103 APPENDIX. Believing that the common statements as to the mechanism of labor are erroneous in fact, and that the proper study of the pelvis throws light both upon the cause and nature of the mechanism, the author has added his own teaching in an appendix. The mechanism of the L. O. A. position alone is given; the changes required in the statement of the other positions being sufficiently obvious. ^ How is the pelvis arranged to permit the head to pass ? It contains two canals, each of the same outline or calibre as the fcetal head, and a little larger. These canals are partly divergent above and entirely identical at the outlet. How may this be demonstrated ? In P'ig. 9, the ellipse A D B C represents the outline of the foetal head, and the ellipse F B D E is an- other identical outline. But, disregarding the dotted lines, the figure A D B F represents the outline of the pelvic inlet. In Fig. 10, the outline represented is that of the foetal head, and also that of the pelvic outlet. If we combine these two figures as in Fig. 11, and draw lines to indicate the pelvic walls, we see that there are two canals in the pelvis, as have been defined, in either of which the head may enter and be propelled. How is this clinically shown ? In the great majority of labors the head enters the pelvis with its long diameter coinciding with the right oblique diameter (a line drawn from A to B, in Fig. 9), and when it reaches the outlet its long diameter coincides with the conjugate diam- eter of the outlet (a line drawn from B to D, Fig. 10). Fig. 9. Fig. 11. 104 QUESTIONS ON OBSTETRICS. What are these canals named ? The one containing the right oblique diameter is called the right canal; Fig. 12. the opposite one the left canal. Why does the head enter the right canal in the majority of la- bors ? Because the uterus does not lie in the median line, but with equal fre- quency its axis is to the right of the median line, as in Fig. 12. What is the initial plane of the right canal ? A plane passed through the ileo- pectineal line of the right side, from the promontory to the symphysis, and continued until intersected by a sim- ilar plane on the opposite side (the initial plane of the left canal). What appearance does the pelvic cavity present on an antero-pos- terior section ? A simple curved tube, which shows A = the Uterus. B = the Inlet. C = ,1 . .. 1 • 1 j the Outlet. D E the Axis followed us that the PelvlC canals are Curved as by the head in labor (remembering weH as divergent, and hence their also that it is curved from before back- ward). axes are spiral. Fig. 13. Why are there two canals in the pelvis ? To permit the shoulders to follow the head with the least amount of space. How may this be demonstrated? 1 The outline of a section through the shoulders is almost identical in shape and size with the outline of the occipito-frontal plane of the head, but with its long diameter at right angles to the long diameter of the head (Fig. 13)- 2. The foramen magnum (and attachment of head to neck), being nearer the occipital end of the head, the shoulders follow the head in labor, as in Fig. 14. 3. While the body of the child is in the womb, with its long axis coin- cident with the axis of the womb (see Fig. 12), the head is engaged in O APPENDIX. 105 the pelvis horizontally, or in other words the head is flexed laterally towards one shoulder, causing the outline of the Fig. 14. shoulders to follow the head as in Fig. 15, which is also the outline of the inlet. 4. The shoulders enter the opposite canal, but be- fore descending far. the head is already born, and there is need of but one canal, except near the inlet. How is the head situated at the beginning Fig. 15. of labor in the L. O. A. position ? The occipital protuberance is placed opposite a point a' little in front of the left acetabulum ; the i hi- frontal suture opposite the right sacro-iliac sym- physis ; the right parietal protuberance just over the right obturator foramen; the left parietal protuber- ance is in the free space in front of the left sacro- iliac symphysis. How may this be expressed by a comparison of pelvic and head diameters and planes ? The occipito-frontal diameter is coincident with the right oblique diam- eter, the occipital end being in front; or the occipito-frontal plane is coin- dent with the initial plane of the right canal. What follows from this as to the obliquity of the head ? The right side of the head is lower than the left, and the occipito-frontal plane is obliquely situated with reference to the plane of the conjugate diameter or of the inlet. What is the mechanism of delivery in the L. O. A. position ? 1. The head undergoes a compound movement ol flexion and synclitism. This brings the two sides of the head upon the same level, namely, in the plane of the inlet, and substitutes either the plane of complete flexion or demi-flexion for the occipito-frontal plane. 2. The head then descends flexed, and a movement of rotation occurs during descent, whereby the long diameter of the head comes to be co- incident with the long diameter of the outlet by the time the head has reached that point. 3. The head passes over the perineum by a movement of extension, and is then born. 4. As the head passes out of the vulva, the shoulders, engaged in die left canal, go through a similar mechanism of rotation during descent. H 6 u) 106 QUESTIONS ON OBSTETRICS. Hence, when the head is born, its occiput turns to the left, which is called restitution. What is synclitism ? A lateral flexion, or the movement by which the head is made level with the plane of the inlet. What is the cause of synclitism ? The whole right side of the head, and particularly the right parietal pro- tuberance, is closely applied to the pelvic walls, while the left side is free. The uterine contractions, therefore, are resisted on the right side of the head, while the left side, being free, is moved downward. This move- ment is comparatively unimportant, and may not occur if the head is small or the pelvis large. What is the effect of flexion ? To present a smaller outline of the head to the pelvic canal; it will therefore be great or little, according to the tightness of the fit of the head and pelvis. Why does the head rotate during descent ? Because it is descending in a spiral canal exactly fitted to its calibre. Why does extension of the head take place ? When the head has reached the pelvic outlet, it has gone as far as it can without the body entering the pelvis and following it. The hinge-like arrangement of the neck now allows the head to pass over the perineum by this movement, without further descent of the body. How may we recognize the occurrence of flexion and synclitism ? At the beginning of labor the posterior fontanelle is at or above the pelvic brim, and barely accessible to the finger. The right branch of the lambdoidal suture is on a line with and parallel to the inlet at the sym- physis. As the uterine contractions continue, we may observe the fontanelle be- coming lower and more accessible, while the lambdoidal suture becomes more oblique. Meantime, the central part of the head has not descended. This is direct proof that the head has become flexed and leveled. How may we recognize the occurrence of rotation ? At the beginning of labor the posterior fontanelle is found well upon the left side ; when the head has reached the outlet it will be in the median line. How may we recognize the occurrence of extension ? When the head has reached the outlet, the posterior fontanelle remains APPENDIX. 107 nearly stationary under the sub-pubic arch, while the forehead, face, etc., sweep over the perineum. What movements do the shoulders and body undergo ? After the descent of the head, the shoulders enter the left canal with the right shoulder in front and to the right. They descend, rotating, until at the outlet the right shoulder is directly in front. They may then emerge together, or as is more common, the right shoulder remains stationary under the sub-pubic arch, while the left sweeps over the perineum, and is born first. The whole body follows the same course as the shoulders, and being smaller, is rapidly expelled as soon as they are free. CATALOGUE No. 2. OF THE PUBLICATIONS OF P. BLAKISTON, SON & CO., No. 1012 Walnut St., Philadelphia. 4S* Any book sent, postpaid, upon receipt of pric« Correspondence invited. Full Descriptive Catalogues of these book* also a Classified list of ALL Medical Publica. tions, English and American, to be had in tha American market, mailed free upon application, ACTION OF MEDICINES. Brunton, The Action of Medicines. Pt. i. Circula- tion- [In Press. Headland, on the Action of Medicines, ath Ed. 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