wq too tZ57c 1£&1 NATIONAL LIBRARY OF MEDICINE f Medicine. NLH DDDM27TD b , EDITION. JUST READY. Kecommended as a lext-oooz at university of Pennsylvania, Long Island College Hospital, Yale and Harvard Colleges, Bishops College, Montreal Tlfiversity of Michigan, and over twenty other Medical Schools. A HANDBOOK OF THE THEORY AND PRACTICE OF MEDICINE. By Frederick T. Roberts, m.d., m.r.c.p., Professor of Materia Med- ica and Therapeutics and of Clinical Medicine in University College Hospital; Assistant Physician in Brompton Consumptive Hospital. The Fifth Edition, partially rewritten, and carefully revised throughout. Price, in Cloth, $S.OO; Leather, $6.00. RECOMMENDATIONS. syste son, tionc com] Alia "i conv Yale "] take in th Med) "] adap be ki "I SURGEON GENERAL'S OFFICE LIBRARY ANNEX Section....... Form 113o W.D..S.Q.O. XtZZ 13 No. .*.J.*:.'±-.LlL. , but fud- acti- pital 'ants ghly U. 8. GOVERNMENT I shall : put :e of well t to and Surgeons, and strongly recommend it to my classes."—Professor John 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 clear, 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 Journal. " 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 admit of a question."—Students' Journal and Hospital Gazette. P. BLAKISTON, SON & CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. NLM000427906 YEO'S Manual of Physiology. 300 ILLUSTRATIONS. FULL GLOSSARY AND INDEX. By Gerald F. 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The arrangement is very good, indeed, the best, and corresponds closely with that of Dalton's. It is written in simple, pure English. * * * It will be valuable for students."—D. Tod Gilliam, M.D., Professor of Physiology, Starling Medical College, Columbus, O. " After a careful examination of this Manual of Physiology, 1 can truthfully say that it is a most valuable addition to the list of text-books upon the subject. That it should and wil! receive a welcome from both students and teachers there can be no doubt; for in addition to the familiar but well presented facts of most text-books, it contains all the most important facts of physiological science which have been established in the last few years. The authos presents his subject in a manner that is clear, concise and logical. Each section has had a 1 areful revision, and reveals the author's familiarity with the scope and tendencies of modcre physiology. 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Over one hundred pages new matter have been added, and many new illustrations, some of which are very finely engraved and printed. Notwithstanding these new features, the price of the book has been lowered. GILLIAM'S ESSENTIALS OF PATHOLOGY. JUST PUBLISHED. The object of this book is to explain to the student, in a plain, practical way, the fundamentals of Pathology, as an introduction to larger books. THE ESSENTIALS OF PATHOLOGY. By D. Tod Gilliam, m.d., Professor of Physiology, Starling Medical College, formerly Professor of General Pathology, Columbus Medical College, Columbus, Ohio. i2mo. 296 pages. 47 Illus- trations. Price, Cloth, $2.00. P. BLAKISTON, SON A CO., Publishers and Booksellers, 1012 WALNUT STREET. PHILADELPHIA. COMPEND OF OBSTETRICS. LANDIS. THE 7QUIZ-C0MPENDS? A NEW SERIES OF MANUALS FOR THE USE OF STUDENTS AND PHYSICIANS. Price of each, Cloth, $1.00. Interleaved, for taking Notes, $1.25. *S- These Compends are based on the most popular text-books, and the lectures of prominent professors, and are kept constantly revised, so that they rr-ay thoroughly representthe present state of the subjects upon which they treat. #S=- The Authors have had large experience as Quiz Masters and attaches of col- leges, and are well acquainted with the wants of students. 4®=" They are arranged in the most approved form, thorough and concise, containing ?3i illustrations, inserted wherever they could be used to advantage. <3~ Can be used by students of any college. &g~ They contain information nowhere else collected in such a condensed, practical shape Kg' Size is such that they may be easily carried in the pocket, and the price is low. 8E9- They will be found very serviceable to physicians as remembrancers. LIST OF VOLUMES, No. 1. HUMAN ANATOMY. Fourth Revised and Enlarged Edition. Including Visceral Anatomy formerly published separately. 117 Illustrations. By Samuel O. L. Potter, m.d., Professor of the Practice of Medicine, Cooper Medical College, San Francisco, late A. A. Surgeon, U. S. Army. Revised and enlarged. No. 2. PRACTICE OF MEDICINE. Part I. Second Edition. Revised anc Enlarged. By Dan'l E. Hughes, m.d.. Demonstrator of Clinical Medicine, Jef- ferson College, Philadelphia No 3. PRACTICE OF MEDICINE. Part II. Second Edition. Revised and Enlarged. Same author as No. 2. No. 4. PHYSIOLOGY. Third Edition , with Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Brubaker, m.d., Professor of Phys- iology and General Pathology in the Pennsylvania College of Dental Surgery : Demonstrator of Physiology, Jefferson Medical College, Philadelphia. No. 5. OBSTETRICS. Second Edition. Enlarged. By Henry G. 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Illustrated. No. 10. ORGANIC CHEMISTRY. Including Medical Chemistry, Urine Analysis and the Analysis of Water and Food. By Henry Leffmann. m d. , d D.S., Prufessor of Chemistry and Metallurgy in the Pennsylvania College of Dental Surgerv : and of Clinical Chemistry and Hygiene in the Philadelphia Polyclinic, etc., Philadelphia N'- IIJ-,?HARMArCY- By F' E Stewart, m.d., ph g. Quiz Master in Pharmacy and Chemistry, Philadelphia College of Pharmacy ; Lecturer at the Medico-Chirur- gical College, and Woman's Medical College, Philadelphia. Others in preparation. Price, each, Cloth, $1.00. Interleaved, for taking Notes, $1.25. P. BLAKISTON, SON & CO., Medical Publishers and Booksellers, 1012 WALNUT STREET. PHILADELPHIA. ?QUIZ-COMPENDS? No. 5. A COMPEND OF OBSTETRICS. ESPECIALLY ADAPTED TO THE USE OF MEDICAL STUDENTS AND PHYSICIANS. BY HENRY G. LANDIS, A.M., M.D., >\v • Late Professor of Obstetrics and Diseases of Women in Starling Medical College, Fellow of the American Academy of Medicine; Member of the American Medi- cal Association; Author of " How to Use the Forceps," etc., etc. THIRD EDITION. THOROUGHLY REVISED. WITH P. BLAKISTON, SO,N & CO., 1012 Walnut Street. 1887. v \0D L25Tc 1687 Entered according to Act of Congress, in the year 1886, by P. BLAKISTON, SON & CO., In the Office of the Librarian of Congress, at Washington, D. C. PREFACE TO THIRD EDITION. In preparing the present edition of this work, the general arrangement has been retained, and, while numerous alterations in the text were neces- sitated by the progress of medicine, as few changes have been made as were compatible with the object of setting forth the Science and Art of Obstetrics in a clear and concise form. The principal changes will be found in the chapters on Anatomy and Physiology. The subject of Anaes- thetics in labor has also been more fully discussed, and the articles on Anti- sepsis and Puerperal Septicaemia have been enlarged. Several illustrations have also been added. It is hoped that it will be found worthy of the continuance of favor which has been bestowed on former editions. The Editor. March 1st, 1887. PREFACE TO FIRST EDITION 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. PREFACE TO SECOND EDITION. The author desires to return thanks for the uniform kindly criticism bestowed upon the first edition of this little work, and has endeavored by carefully revising its matter and manner to prepare it for continued use- fulness. It has been made more complete by the addition of paragraphs and illustrations upon subjects before overlooked or inadequately treated, and by an index. H. G. L. TABLE OF CONTENTS. PAGE Introduction..................................................................... 9 The Pelvis...................................................................... 9 Pelvic diameters.............................................................. 14 " planes ................................................................. 15 " muscles ............................................................... 16 Reproductive Organs. Anatomy. The Uterus................................................................... 16 Ligaments.............. ...................................................... 18 Fallopian Tubes.............................................................. 20 Ovaries ....................................................................... 20 Vagina........................................................................ 20 Douglas' cul-de sac........................................................ 21 Hymen....................................................................... 21 Carunculae..................................................................... 21 Bulb of Vagina.............................................................. 22 Vulvo vaginal Glands..................................................... 22 Vulva.......................................................................... 22 Labia Majora............................................................... 22 Mons Veneris................................................................ 22 Commissures.................................................................. 22 Clitoris.......................................................................... 23 Labia Minora................................................................. 23 Vestibule...................................................................... 23 Meatus............ ...........................................,................. 23 Urethra....................................................................... 23 Perineum....................................................................... 23 Physiology. Ovulation.................................................................... 24 Menstruation............................................................... 26 The Breasts................................................................. 28 Pregnancy. Fecundation.................................................................. 29 Changes in Ovum............................................................ 30 vii viii TABLE OF CONTENTS. PAGE Changes in Womb........................................................32_34 The Placenta.................................................................. 32 Fcetal Changes.............................................................. 34 Multiple Pregnancy........................................................ 35 Extra-uterine " .................•........................................ 3^ Hydatid " ......................................................... 38 Mole " ........................................................ 39 Spurious " ......................................................... 39 Premature Labor.............................................................. 39 Signs of Pregnan, v............................................................ 41 Labor. Clinical History............................................................. 50 Duties of the Physician..................................................... 53 Mechanism of Labor.......................................................... 59 Dystocia. Uterine Inertia............................................................... 71 Rigidity of Cervix, etc.................................................... 73 Deformities of Pelvis.................................................-....... 76 Ovular Dystocia.............................................................. 79 Twin Labor........,.......................................................... 82 Accidental Hemorrhage....,................................................ 83 Placenta Previa............................................................... 84 Post-partum Hemorrhage................................................. 86 Rupture of Uterus.......................................................... 87 Eclampsia .................................................................. 88 Placental Dystocia........................................................... 91 Inversion of Uterus......................................................... 92 Obstetrical Operations. The Forceps.................................................................. 94 Version....................................................................... 99 Embryotomy............... ................ ................................ IOO Cyesarean Section........................................................... 103 Induction of Labor.......................................................... 104 The Period after Delivery. Involution of the Uterus................................................... 105 Puerperal Diseases........................................................... 108 Congenital Defects........................................................... 112 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 compli- cations ; the art consists in the skillful carrying but 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, oviducts, uterus and vagina. 2d. External, viz.: the mons veneris; labia majora and minora; clitoris; vestibule and meatus urinarius; hymen or caruncuke myrtiformes; four. chette and perinaeum; and also the breasts. Where are they situated ? With the exception of the breasts and mons veneris, they are placed within the Pelvis, or below it, between the thighs. The mons veneris is placed directly upon the symphysis pubis, and the breasts on the pectoralis major muscle of either side, from the 3d to the 7th rib. 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. b 9 10 questions on obstetrics. Of how many bones is the obstetrical pelvis composed ? Five : the last lumbar vertebra, sacrum, coccyx, and two ossa innominata. 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 present ? Six: by three 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 wedge-shaped bone, apparently formed by the fusion of three or four vertebral bodies. It has one artitfular 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 internally with the sacrum behind and with each other 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 11). What prevents these beams from being pushed in and out at their distal ends ? Another beam is placed between them, extending from one acetabulum THE pelvis. 11 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. 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. a. The same as In Fig. i, but with the beams arched; the dotted lines show the original direction of force. 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). 12 questions on obstetrics. 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 are 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, consisting of the ischium and under portion of the ilium on either side. 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. 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 ? The part of the arch below the spine of the ischium. THE PELVIS. 13 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? In the female, the sub-pubic beam is more roundly arched and its edges more everted; the transverse diameters are relatively greater, and the anteroposterior diameters relatively less; the transverse diameter of the inlet crosses the anteroposterior at a point in front of the intersection of the oblique diameters, and the ischial spines are to the outer side of plumb lines dropped from the posterior superior iliac spines. (Some female pelves, especially among the lower races, approach the male type.) What joints exist in the pelvis ? Three lumbosacral above (one between the bodies and two between the articular processes), two sacro-iliac (one on each side), the pubic joint, in front, and the sacro-coccygeal joint, behind. 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, with the exception of those formed by the articular processes of the sacrum and last lumbar vertebra, which are arthrodial, and are lined by synovial membranes. 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 ilio-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, iliac fossae and crests, and the la it lumbar vertebra forming the bony parts of the false pelvis. What lies below it ? The true or obstetric pelvis. 14 questions on obstetrics. What is the ilio-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, and the pelvic brim. 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 ilio-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. 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 slightly 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, the pelvis. 15 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 ? 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 pelvic circumference (Play- fair), to facilitate the de- scription of the relations of the pelvis to the child, ver- tebral column or horizon. They may be illustrated by pieces of card board cut so as to fit the pelvic cavity at any leveL a 6. 'f- Conjugate diameter of Inlet. Conjugate diameter of Outlet. What planes are important ? The plane-of the inlet and of the outlet. 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. 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 horizontal, and in the recumbent posture it forms a reversed angle of 450 with the horizon. What is the axis of the pelvis ? As usually given it is a line drawn from the centre of the conjugate 16 questions on obstetrics. diameter of the inlet, parallel to the face of the sacrum and coccyx, to the centre of the conjugate diameter of the outlet. (The line g k in Fig. 4.) How is the pelvis lined within ? By certain muscles, blood vessels, nerves and fasciae. What muscles are contained in it ? 1. The Psoasiliacus 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, between the anterior inferior iliac spine and the ilio-pec- tineal eminence, 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. 3. The Obturator internus muscle on either side, which covers the ante- rior pelvic walls and passes out under the sacro-ischiatic arch. What obstetric uses have these muscles ? Besides serving as a soft lining to the bones, the psoas iliacus furnfshes . 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 posterior rounded. It is three inches long, two inches broad (above) and one inch thick, and weighs in the virgin about one ounce. 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 ? The upper and outer angles ^re called the cornua. THE REPRODUCTIVE ORGANS. 17 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 ante-chamber to the main cavity; the latter is triangular in outline, 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 Fig. 5. 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 peri- toneum, and on the inside, is lined with mucous membrane, called the endometrium. How are the muscular fibres arranged ? For the most part they are irregularly and inextricably interlaced (and surround the large blood vessels which penetrate between them), but a circular arrangement of fibres is found in the cervix, while in the body the majority are longitudinal. What kinds of blood vessels are found in the womb ? The arteries are mainly small, and helicine or spiral, while the veins are short, of large calibre, and freely communicating; peculiarities which warrant us in regarding the uterus as composed of a modified erectile tissue. Fig. 6. 18 QUESTIONS ON OBSTETRICS. How is the uterus supplied with nerves ? 1st. The main nerves proceed from a well defined nerve centre in the lumbo-sacral region (the sexual brain). 2d. The sympathetic nervous system also furnishes fibres. 3d. The vaso-motor apparatus has much influence upon the womb. 4th. Independent ganglia, like those found in the heart, are imbedded in the uterine tissue. What kind of mucous membrane lines the uterus ? The membrane lining the body is quite thick and vascular, and is composed— I. Of a mesh of connective tissue containing many spindle-shaped cells. 2. Of many tubular glands, which give the surface of the membrane a per- forated appearance. 3. Of ciliated cylindrical epithelium cells, which line the glands and the outer surface of the whole membrane. The membrane lining the cervix is continuous with that of the body, and is substantially the same, except in being thrown into numerous longitudinal folds, and in containing racemose, not tubular, glands. What distinguishing peculiarity has the uterine mucous mem- brane ? It has no basement layer of connective tissue, and merges irregularly into the muscular tissue. What kind of mucus is secreted by the uterine mucous mem- brane ? A viscid, alkaline mucus. What are ovula Nabothi ? The racemose glands in the cervical mucous membrane are sometimes occluded, while the secretion continues until the gland becomes quite large and globular. They are often a source of much irritation. 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, enclosing muscular and fibrous tissues, blood vessels, nerves THE REPRODUCTIVE ORGANS. 19 and lymphatics 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 underneath the peritoneum, 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 vesico-uterine ligaments ? Small folds of peritoneum which pass between the uterus and the bladder. 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, 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 is a double uterus ? A uterus containing two cavities separated by a longitudinal septum. Occasionally the whole genital tract is double, the septum extending to the vulva, so that there are two vaginae. Sometimes a single cornu of the uterus is developed to such an extent as to be capable of containing a foetus during gestation. 20 QUESTIONS ON OBSTETRICS. 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, because 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, but not covered by peritoneum. They are of about the size and appearance of blanched almonds. What is the structure of the ovary ? It is mainly composed of dense fibrous tissue, containing muscular fibres and covered by a delicate cortical layer of fibroplastic tissue, in the meshes of which are found the ovisacs in different stages of development {see Ovulation). What is the parovarium ? The parovarium, or organ of Rosenmuller, consists of several tubes placed between the folds of the broad ligament. There is one on each side of the uterus. They are supposed to be the remains of the Wolffian bodies, and have no known function. They are analogous to the epi- didymus of the male. Very large cysts are sometimes developed from them. What is the vagina ? A tube which serves to connect the uterus and its appendages with the 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 THE REPRODUCTIVE ORGANS. 21 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 simply of flat or pavement epithelial cells, and has only a few glands. Numerous depressions or crypts in the membrane answer a similar purpose and secrete a mucus of acid reaction. In the virgin it is disposed in many transverse ridges, called rug3e. 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 anterior vaginal pouch. The posterior wall is longer, being prolonged upward to form a larger pouch behind the uterine neck, called the posterior vaginal 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 vaginal pouch, and therefore between the vagina and rectum. It is a very important space, because, being the most dependent portion of the abdominal 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 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 and greatly stretched, as by the passage of a child's head, or a large fibroid tumor, its fragments undergo atrophy, and there remain little wart-like elevations in the line of the hymen, called 22 QUESTIONS ON OBSTETRICS. caruncufce 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 Bartholin, 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 vulval canal. 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 consist of cutaneous folds containing loosely arranged cellular tissue, with some fat. On their outer surface they are covered by a free growth of stout, curly hair, similar to that found on the axilla. On their inner surface they are furnished with a considerable number of sebaceous follicles. What is the mons veneris ? An eminence of cutaneous tissue, the anterior termination of the labia majora, situated directly upon the symphysis pubis. 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 anterior limit of the genital fissure. 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 REPRODUCTIVE ORGANS. 23 the posterior commissure, which is called the fourchette. The little dimple or cup between this fold and the commissure is called the fossa navicularis, 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 Nymphce. They are two folds of dartoid tissue, covered by skin, 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 urinarius ? 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 introduced into the vagina, as a tubular ridge above the anterior wall of the vagina. 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 wedged-shaped band of fibrous elastic tissue, which stretches across from one tuberosity to the other, and is interposed between the termination of the vagina and rectum. 24 QUESTIONS ON OBSTETRICS. 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 found ? 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 650,000, 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, T|5th 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 zona pellucida, or vitelline membrane, but which is not a distinct membrane until after impregnation, 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 cortical layer of the ovary. Its wall consists of a layer of cells, called the membrana propria, within which is found a second layer, the membrana granulosa. An accu- mulation of these cells form a little mound, 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 OVULATION. 25 one-half of an inch. At this point it stops growing, 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. Fig. 7. 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 toward the open end of the Fallopian tube by means of a current in the fluid bathing the tissues, which current is caused by the c 26 QUESTIONS ON OBSTETRICS. action of ciliated epithelium cells, and is always directed toward 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 (£) 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 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 successive 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 1. 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 mixed with mucus 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 may be accompanied by pain. 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 MENSTRUATION. 27 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 ? I. The woman notices a leucorrhcea for one or two days. 2. A discharge of blood for three days (average). 3. A continuance of leucorrhuea 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 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 ? 1. It is mixed with blood and epithelial 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 J ss to J 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 what- ever. What is this condition called ? Vicarious menstruation, or xenomenia. What are the popular names for menstruation ? To be unwell; to see anything; to be regular; the periods; courses; sickness; monthlies ; turns; changes, and flowers. What is the object of menstruation ? To insure the development of ova by a periodical increase in the ovarian 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. 28 QUESTIONS ON OBSTETRICS. 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, or " the change of life." 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). 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, and the spermatozoa to the ova. What is the function of the vagina ? „ . It serves as a duct or outlet for the dis- Fig. 8. charge of the uterine secretions, 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, 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 PREGNANCY. 29 of each lobule unite with each other to form a terminal canal, 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 ? I. That a fully matured ovum shall be recently discharged from the ovary. 2. 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 developing 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 against 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 oviduct until they meet the ovum. 3. Fecundation probably occurs most frequently in the oviduct, but it can occur at any point between the ovary and the os internum uteri. 30 QUESTIONS ON OBSTETRICS. 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 ? I. 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 ? I. The germinal spot and vesicle disappear. Fin. 9. SEGMENTATION OF THE VITELLUS. 2. The segmentation of the vitellus; i. e., the vitellus splits into two massps, these into four, and so on until a large number of segments are formed. (See Fig. 9.) 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 nutriment. (See Fig. 10.) 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 PREGNANCY. 31 about the area close around it, inclosing it in a sac, called the amnion. (See Fig. n.) The vitelline membrane then disappears. . 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. Fig. io. Fig. ii. THE OUTER LAYER OF CELLS COMPLETED. The primitive trace in the centre of the area germina- tiva. SECTION OP OVUM. Shows embryo sinking in toward the centre of the ovum, and the way in which the amnion is formed. 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 Fig. 12. Fig. 13. THE AMNION NEARLY COMPLETED. The allantois carrying blood vessels to the circumference (a). THE AMNION COMPLETED. a. The allantois completed, having carried vessels into all the projections (villi) of the chorion, i. The umbili- cal vesicle. (Figs. out, carrying loops of blood vessels into the villi of the chorion. 12 and 13.) 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 32 QUESTIONS ON OBSTETRICS. the ovum, and (b) by the fluid materials of the ovum contained within the internal blastodermic layer. While the allantois is formed, this in- ternal layer contracts, its shrunk bulk constituting the umbilical vesicle, which finally disappears. (Fig. 13.) 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 reflexa. 13. When the ovum is thus fastened to the uterine wall, the chorionic 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 hypersemic 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 of 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 PREGNANCY. 33 have a flat, cake-shaped mass, mainly composed of blood vessels, which serve to convey nutriment fron 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. According to some, the villi dip into crypts or depressions of the decidua serotina and not into the sinuses, and absorb a secretion called uterine milk, which is furnished by these crypts. 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 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 knots in the funis ? The foetus in its active movements sometimes passes through a loop of the funis, and this, when drawn tight, forms a true knot. False knots are mere knobs or masses of Wharton's gelatine, formed at intervals along the 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. Describe the fcetal circulation. The blood is propelled from the left ventricle of the foetus through the aorta and iliac arteries to the point where the umbilical arteries are given off; through these to the placenta, and back again through the umbilic#vein, to the liver, where most of the blood passes through the portal circulation and empties by the hepatic veins into the vena cava ; the remainder,passing through the ductus venosus, empties directly into the vena cava without passing through the liver. From this it enters the right auricle, and is deflected by the Eustachian valve, through the foramen ovale, into the left auricle, and thence into the left ventricle. The blood, returning from the head and upper extremities, passes from the right 34 QUESTIONS ON OBSTETRICS. auricle to the right ventricle; to the pulmonary artery thriugh the ductus arteriosus, into the aorta. It will be noticed that the venous blood of the foetus is more oxygenated than the arterial. After birth the foramen ovale closes and the peculiarly foetal vessels disappear. 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 half an ounce to several pints, f J 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. " goose " " 3 the foetus is 6.6 inches long. 7 ~™% " -13 13-7H5 15 -17 16 -17^ 17K-18K American children are usually larger at 3d 4th 5* 6th 7th 8th 9th 10th [According to Schroeder.] 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 fecal matter in the adult. It contains granular bodies, called /Meconium granules, the presence of which is characteristic of meconium. 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. The cervix enlarges but little (not more than one-half), and its cavity remains separate until the last week or weeks of pregnancy, when the os ABNORMAL PREGNANCIES. 35 internum is stretched open and the two cavities of the cervix and fundus become 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. Bimanual touch shows it to be as large as a small orange. " 3d " 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 above. 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 quin- tuplets. 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. 36 QUESTIONS ON OBSTETRICS. What is superfecundation ? The fecundation of two ova at different times, /. 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 may be prematurely expelled and the other remain until born. 4. " " die in utero and be retained until the birth of the other. What is a fcetus papyraceus ? A twin dying in utero at an early period may be partly desiccated, and compressed by the growth of the other twin, being flattened and parch- ment-like in appearance. What is a lithopaedion ? A dead child may be infiltrated and encrusted by calcareous salts until it is stone-like in appearance. This occurs only after long retention in extra-uterine cysts. 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 ? 1. The ovum, after fecundation, may remain in the ovisac, and be devel- oped in the ovary, called ovarian pregnancy. 2. The fecundated ovum may be arrested in the Fallopian tube, and be there developed, called tubal pregnancy. ABNORMAL PREGNANCIES. 37 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 developed, called abdominal pregnancy. What effect has extra-uterine pregnancy on the womb ? It enlarges, as in normal pregnancy, up to the fifth month, and its hypertrophied 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 ? 1. 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) inflammation supervenes, and the child is 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. 38 QUESTIONS ON OBSTETRICS. What is the general treatment of extra-uterine pregnancy ? I. If discovered in the first half of the 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. How can it be arrested ? By the faradic current of a battery. 1. 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 (-for —) 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, giving rise to what is called a hydatiform mole. 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— PREMATURE LABOR. 39 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 (ecchinococci) may occur in the uterus, but not as a result or accompaniment of pregnancy. What is hydrorrhcea ? A watery discharge from the uterus, from— I. Hydatid pregnancy. 2. A tear in the fcetal 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 ? I. At some time 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 weeks or 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 fcetal 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 fcetal movements; the woman not being pregnant. It is to be distinguished from feigned pregnancy. How may it be disposed of ? A vaginal examination shows the womb to be unenlarged, and the administration of ether will cause the abdominal enlargement to suddenly disappear, when not due to increase of fat in the abdominal walls. 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- 40 QUESTIONS ON OBSTETRICS. 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 become 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 (i) to the ovum or foetus, ovular, \ Disease or injury (2) to the mother, maternal, J I. (a) Placental degeneration; amyloid or fatty (cystic, vide hydatids). (b) Placental apoplexy and detachment, from hemorrhage. (c) Syphilis. (d) Dropsy of amnion. (e) Violence, either accidental or intentional, rupture of the membranes, etc. The death of the foetus from any cause is not always followed by its premature expulsion. 2. (a) Hyperaemia of the pelvic organs from over exercise, coitus, lifting, sewing machine, displacements of the uterus. (b) Irritation of the uterus, as from tumors, mental shock, high tem- perature in fevers, and (r) Emmenagogue drugs. What are the symptoms of abortion ? 1. Pain, more or less constant, felt in the back, hypogastrium or ovarian regions. 2. Uterine contractions. 3. Hemorrhage. 4. Dilatation of the os uteri, with softening of the cervix. What are the dangers of abortion ? I. Hemorrhage; often great, because of the difficulty with which the ovum is separated from the womb. 2. Retention of the placenta, in whole or in part, with subsequent septi- caemia, hemorrhage and other dangers. 3. The womb is apt to remain enlarged (see Subinvolution), and uterine disease may result. 4. PelVic and peritoneal inflammations are more common after abortion. When are the dangers of abortion most experienced ? In the middle of the third pregnancy. In the first three months the ovum is usually expelled entire, and the chief danger is from hemorrhage during THE SIGNS OF PREGNANCY. 41 the slow process of dilating the os uteri. In the next third, the attach- ments of the placenta are firmer than at any other time ; the foetus is first expelled, and the placenta often expelled with great difficulty and piece- meal, combining all the risks at their greatest. In the last three months the process differs but little from normal labor, except in being slower. What are the chief indications for treatment ? I. To control hemorrhage. 2. To secure complete expulsion of the uterine contents. How is hemorrhage to be managed ? I. By applying a tampon until the os is sufficiently dilated. 2. By securing complete delivery and stimulating uterine contractions. How is retained placenta to be managed ? The placenta must be detached by the fingers, or curette, as soon as possible after the expulsion of the foetus. If pressure is made by one hand in the hypogastric region, the womb can usually be forced down low enough to enable the finger to reach to the fundus. What rule should guide us in difficult cases ? To persevere in efforts to remove the placenta as long as we are sure that our efforts are less injurious than allowing it to remain. What is to be done when the placenta cannot be removed ? I. Use frequent antiseptic injections. 2. Employ remedies to guard against inflammation and septicaemia. 3. Renew the efforts to remove the placenta every day. What preventive treatment may be used ? In threatened abortion from transient causes, absolute rest in bed, with full doses of morphine, may prevent. Quinine is also useful in malarious districts, and in general, the removal of the cause, if possible, is always indicated. If preventive measures are not promptly successful, we should endeavor to promote the speedy termination of the process. THE SIGNS OF PREGNANCY. What are the signs of pregnancy ? The symptoms and physical signs caused by the changes taking place in ihe woman, and by which we recognize the occurrence. How may they be classified ? 1. Into certain and presumptive, or 2. Into objective and subjective, or 3. According to their etiology, viz.:— n 42 QUESTIONS ON OBSTETRICS. I. Signs due to the increase of vital activity. II. " " " development of the womb. III. " " " presence of a foetus. IV. " " " unequal development of the general and generative systems, or semi-pathological signs. What are signs due to an increase of vital activity ? The pregnant condition requires that the woman shall supply, not only the needs of her own organism, as before, but shall also build up from ten to twenty pounds of highly organized tissue, viz.: the child and its envel- opes. Therefore, she will need more blood, and in general, all the vital forces must be increased. This is brought about by the stimulus of fecun- dation, and results in (a) increase of appetite, (b) weight, (c) vigor, and, perhaps, (a7) sexual appetite. She must eat more in order to make more blood; the increased blood supply will increase her weight and general vigor, while locally, the hyperaemia of the pelvic organs will cause, at first, an increase in the sexual desife. Is this class of signs always present in pregnancy ? No. The general system may fail to respond to the stimulus of fecun- dation, and these signs will be absent or defective, being replaced by the fourth class. What signs are due directly to the development of the womb ? I. The descent of the womb, due to its increased weight, causes the abdo- men to become smaller and flatter during the first month or two. Hence the French proverb: " Qu'en ventre plat, enfant y'a." The umbilicus also becomes deeper, for the same reason. 2. Afterward the womb enlarges at a particular rate, differing from that of other tumors. (See page 35.) 3. Certain changes occur in the cervix, vagina and external organs. What changes are found in the cervix ? It becomes softer and a deeper red in color. The ascent of the uterus and retraction of the vagina gives the sensation of shortening, though in reality it becomes longer. Some increase in the mucous secretion of its cavity is also noticed. What changes occur in the vagina and external organs ? The increased blood supply causes the vagina to become deep red or violet in color; the external organs are somewhat enlarged, and the peri- neum is doubled in its antero-posterior measurement, during pregnancy. With what other things may the pregnant womb be confounded ? The enlargement of the abdomen may be due to fibroid, ovarian, and THE SIGNS OF PREGNANCY. 43 other pelvic tumors; to ascites, flatulence, or even excessive deposits of fat in the abdominal walls or mesentery. What changes are due indirectly to the development of the womb ? Lines from distention, a median brown line, the cessation of menstrua- tion, contractions of the uterine walls, and certain changes in the breast. Are these signs found only in pregnancy ? Each one of them is found to accompany other conditions, but when all or many of them are present, they furnish strong presumptive proof. What are lines from distention ? Called also linea albicantes ; are small patches of shining tissue, whiter than the surrounding skin, found on the lower part of the abdomen, espe- cially in the iliac regions, upon the flanks, thighs, and sometimes upon the breasts. They look like small '*gores" inserted in the skin, or like cica- tricial tissue. Average size one inch long and one-quarter inch broad. Are they due to distention or stretching of the skin ? Being found on the thighs, and also in young girls with rapid develop- ment of the hips, they are probably due only to rapid growth of the skin. They rarely disappear, and are, therefore, only of value in a first pregnancy. What is the median brown line ? A narrow, brownish discoloration of the abdominal skin, extending from symphysis to ensiform appendix, in the median line, and of little value as a sign of pregnancy. Is menstruation always suspended by pregnancy ? In the great majority of cases. Some women continue to menstruate for a month or for several months; a very few menstruate throughout pregnancy; a few cases are recorded in which the woman menstruated only when pregnant. As the decidua reflexa is not usually united to the vera for the first three months, there may be a menstrual hemorrhage from the womb during that time; but it is probable that any bloody discharge from the genital tract, after the first month of pregnancy, is not a true men- struation, but a hemorrhage; and an indication of threatening abortion. The real reason for the cessation of menstruation is the effect which fecun- dation produces upon the system. Is menstruation stopped by other things than pregnancy ? It often ceases for a few months in newly-married women, and may be stopped for one or more periods by mental emotion, change of climate, 44 QUESTIONS ON OBSTETRICS. especially if following a sea voyage, acute or chronic disease, and espe- cially by phthisis. What is meant by contraction of the uterus during pregnancy ? The walls of the uterus are always in a state of intermittent contraction. Hence the hand of the physician placed on the abdomen of a woman may detect them (the womb becoming harder) every twenty or thirty minutes (Braxton Hicks). What changes occur in the breasts ? I. They may become enlarged. 2. Pain or discomfort may be felt. 3. They may contain milk, which can be pressed from the nipple. 4. The nipple and areola become darker (sometimes almost black). 5. A circular ring of dark splotches may be developed at a short distance from the areola, called the secondary areola, developed after the 5th month. 6. The sebaceous follicles about the areola become enlarged, and contain sebaceous matter. 7. Linese albicantes may appear on them. One or more of these changes are always present in pregnancy, though any of them may occur in other conditions. Their presence, therefore, is of less importance than their absence, in settling a diagnosis. What are the signs due to the presence of a foetus ? 1. The sounds of the fcetal heart. 2. Foetal movements. 3. Foetal parts found on palpation. 4. The utero-placental souffle. 5. The funic souffle, and 6. Ballottement. What is meant by the fcetal heart sounds ? At any time during the latter half of pregnancy the beating of the fcetal heart may be heart by placing the ear (or stethoscope) over the abdomen of the mother, being distinguished from the maternal pulsations by differ- ence of rhythm. What does the sound resemble ? The ticking of a watch under the pillow, with a rate of 115-160 pulsa- tions per minute. Where and when are they best heard ? They are most often heard by ausculting in the left iliac region, and may be heard from the fourth month of pregnancy, doubtfully before. THE SIGNS OF PREGNANCY. 45 What are the fcetal movements ? The foetus moves about freely, and strikes out with feet and hands against the uterine wall. If the hand of the observer is placed upon the mother's abdomen, these slight blows may be felt. If not felt at once, they may sometimes be produced by wetting the hand in cold water, and applying it suddenly to the abdomen. This causes contraction of the uterus, which inconveniences the foetus, and causes it to make demonstrations. When can the fcetal movements be first felt ? Not until after the fourth month, or until the uterine and abdominal walls have come in contact. Can the fcetal movements be simulated by anything else ? Some women have the power to contract their abdominal muscles sud- denly and irregularly, so as to simulate the fcetal movements. Such instances are rare. Women often deceive themselves into feeling the fcetal movements when they are not pregnant. What is the utero-placental souffle ? A bruit or whirring sound, which may sometimes be heard in the abdo- men. It is variously supposed to be produced in the uterine sinuses, the placental circulation, the uterine or hypogastric arteries, and elsewhere. It is heard also in some fibroid tumors. What is the funic souffle ? A similar, but less intense bruit, synchronous with the foetal heart, and supposed to be produced in the vessels of the funis. It is rarely heard. What is ballottement ? If, when the woman is in the erect posture, a finger (introduced into the vagina) is pushed suddenly against the anterior wall of the womb, the foetus, if present, will first be pushed up into the liquor amnii, and will then drop back. If the finger is held in position, the return of the foetus to its resting place may be felt and recognized. The manoeuvre is called ballottement, and may be practiced between the third and fifth months, inclusive. What is quickening ? The time at which the mother first feels the foetal movements. The escape of the uterus from the pelvis (which is a requisite for feeling the movements) is sometimes sudden, and attended by peculiar sensations and faintness. What are the semi-pathological signs of pregnancy ? I. When the general system fails, in whole or in part, to respond to the 46 QUESTIONS ON OBSTETRICS. stimulus of fecundation, the mother's blood has a double call upon it, and is either diminished in quantity or deteriorated in quality. This leads in turn to the imperfect nutrition and impoverishment of the nerve centres and of various organs, and as a result we may have such symptoms as— (a) Morning sickness. (b) Protracted vomiting. (c) Neuralgia. (d) Neuroses and mental disturbances. (e) Dyspepsia. 2. Ordinarily the growing womb finds a sufficient amount of room to expand in, but it sometimes, owing to natural defects, corsets, etc., it exer- cises injurious pressure upon its surroundings, causing— (a) Difficulties in micturition. (b) Constipation and hemorrhoids. (c) Albuminuria and oedema. (d) Dyspnoea. 3. From excess of natural functions we may have (a) plethora, (b) sali- vation, (c) hirsuties, (d) chloasma. What is morning sickness ? Nausea and vomiting, just after rising in the morning. It is usually limited to the early months of pregnancy, or when the volume of blood is not yet increased, although there is not enough for mother and child. It is, therefore, due to the want of sufficient blood, and the consequent cere- bral anaemia due to the sudden change in the circulation upon awakening from sleep and resuming the upright position. A similar form of vomiting is sometimes met with at other times of the day, after special exertion, and especially mental effort. How should morning sickness be treated ? It is sometimes relieved by slowness in arising, and by taking a cup of coffee before rising, and may be cured by the use of nutrients and blood- making agents. What is the " vomiting of pregnancy " ? Continuous or protracted vomiting in pregnancy depends__ 1. On the deficiency and deterioration of the blood. 2. The irritable condition of the nerve centres, due to their impoverish- ment from defective blood supply. 3. To an exciting cause, such as disease of the uterus, acting with the other sources. THE SIGNS OF PREGNANCY. 47 It may be so grave as to apparently threaten life (rare), and this being well known, the quack calls every fit of nausea by this name, and cures it! What are the indications for treatment in severe vomiting ? I. To remove any sources of irritation which may coexist with the general state of the blood. Thus, inflammation and abrasions of the cervix uteri may exist in some cases, and their removal by proper applications may cure it. 2. To control the irritability of the nerve centres, which may be done by rectal enemas of chloral and bromide of potassium. 3. To improve the blood supply, by administering nourishing fluids in small doses, frequently repeated, beginning with milk and lime water. In mild cases any of the anti-emetics may be used, as the oxalate of cerium, with or without the subnitrate of bismuth, etc. What forms of neuralgia are met with in pregnancy ? Almost any form. The most common is odontalgia. Toothache is due (1) to the "cry of the nerve for healthy blood," and (2) to the fact that phosphate of lime is largely needed in the construction of the foetus, and when not sufficiently present in the food, may be absorbed from the teeth. What mental disturbances are met with in pregnancy ? The woman may become irritable, peevish and capricious. She may have absurd cravings for strange food (pica), or may even develop mania. How is difficulty in urination caused ? During the first months the descent and anteversion of the uterus may cause pressure on the bladder. After the womb has ascended above the pelvis, there is rarely any difficulty until its descent, during the last week, when pressure is again caused. How are constipation and hemorrhoids caused ? Constipation may be due to the deteriorated (hydraemic) state of the blood, but it is also due to direct pressure of the uterus upon the bowel, impairing its tonicity, or even acting mechanically. Hemorrhoids are caused in the same way. What displacements of the womb may occur during pregnancy ? 1. Early in the pregnancy the increased weight of the womb may increase the natural tendency of the womb to fall forward {anteversion), causing some disagreeable pressure on the bladder. This will be relieved by rest in the recumbent posture, and will soon cease. 2. When the womb is about to ascend from the pelvis, a full bladder or unusual action of the abdominal muscles may push the fundus uteri 48 QUESTIONS ON OBSTETRICS. back and under the promontory, so as to incarcerate the womb in this position [retroversion). This causes great pain and retention of urine. The woman is to be placed in Sims' position, or on her hands and knees, and the womb pushed up and a little to one side, so as to clear the promontory. 3. Prolapse of the womb sometimes occurs, but generally gives no trouble after the womb is large enough to rest above the inlet. How are the albuminuria and oedema caused ? Albuminuria may be due to the state of the blood, or to the pressure upon the kidneys or renal veins. Bright's disease may coexist, or originate with the pregnancy. Generally the disorder is transient and terminates with delivery. GEdema, usually limited to the lower extremities and vulva, may be con- sequent upon renal disease, or due to pressure upon the abdominal and pelvic venous trunks. How is dyspnoea caused ? By pressure upon the diaphragm. It therefore appears late in preg- nancy, and is usually relieved during the last weeks by the descent of the uterus. What is meant by plethora in pregnancy ? The natural increase in the blood-making function is occasionally exces- sive, and too much blood is furnished, leading to attacks of vertigo and other symptoms of that condition. What are salivation, chloasma, hirsuties ? (a) Salivation is an increased flow of saliva, usually found only in the latter half of pregnancy, and often accompanied by ulcerations in the mouth. (b) Chloasma is an excessive deposit of pigment in the skin. Though usually confined to the mammary areolae and the brown line, it may occur on the face, the entire abdomen and flexures of the joints, sug- gesting Addison's disease. (c) Hirsuties is an excessive or abnormal growth of hair, usually on the face, and fortunately rare. Which of the signs of pregnancy are certain signs ? Those due to the presence of the foetus, and of these but one is generally available, viz.: the sound of the fcetal heart. No other sign is more than suggestive or presumptive. Which of the presumptive signs are the most important ? The cessation of menstruation; the regular and symmetrical develop- THE SIGNS OF PREGNANCY. 49 ment of the uterus; the changes in the breasts; morning sickness, and quickening. At what date are the important signs available ? I. The foetal heart, rarely before the fourth month. 2. Ballottement, third to fifth month, but its failure may be due to want of skill and other causes, besides the absence of pregnancy. 3. The cessation of menstruation, usually after the time for the first period, or immediate. It is always a suspicious circumstance in healthy women, previously regular, whether married or not. 4. The increased size of the uterus may almost always be made out by bimanual touch, at from four to six weeks. If at a second examination, a month later, a further symmetrical enlargement, at the usual rate, is noted, the fact of pregnancy is scarcely to be doubted. 5. The changes in the breasts may begin in the second month, but are rarely marked until the middle of pregnancy, which is true of most of the presumptive signs. What is the duration of pregnancy ? It is somewhat variable, but it is sufficiently accurate to regard it as con- tinuing through ten menstrual periods, ten lunar months, or 280 days. What are the limits of variation ? From 245 to 300 days, with possibilities in either direction. What method is usually employed to calculate the duration ? Count nine calendar months forward (or three backward) from the date of the last menstruation; add to this seven days. Ex. End of menstrua- tion, Jan. 10th; 3 months back = Oct. 10th; add 7 days = Oct. 17th, as the probable date of confinement. What causes pregnancy to come to an end ? The important theories are— I. Power's. The uterus is a peristaltic tube, with circular fibres in the cervix acting as a sphincter. As the child grows it presses upon this sphincter, and the sum of all successive irritations finally causes it to relax, and the uterus to expel the child. 2. King's. The uterus has a definite limit of growth. The foetus does not attain its limit of growth in utero, and therefore distends the uterus when the latter stops growing. This irritates the uterine fibre, and causes it to contract and expel its contents. 3. The foreign body theory. The womb is always irritated into con- tracting upon a foreign body, and the foetus becomes such a body at the end of pregnancy. There is probably truth in each view of the matter. 50 QUESTIONS ON OBSTETRICS. Why is the ovum not a foreign body during pregnancy ? Because of the intimate vascular connections between the chorion and the uterine mucous membrane. How does the ovum become a foreign body ? By the fatty degeneration and atrophy of the connections between the ovum and uterus, which occurs during the last weeks of pregnancy. What effect has this upon the uterus ? It causes a gradually increasing irritation of the muscular fibres, until contractions are excited sufficiently powerful to expel the child. LABOR. What is labor ? The process by which the child and its ovular attachments are expelled from the womb. What essential steps occur in labor ? I. The enlargement of the os uteri until it is large enough to permit the passage of the child. 2. The expulsion of the child. 3. The expulsion of the placenta and membranes, also called the after- birth, or secundines. Into how many stages is labor divided ? Into three. I. The stage of dilatation (of the os uteri). II. The stage of expulsion of the child. III. The stage of expulsion of the after-birth. By what force are these occurrences produced ? By the contractions of the uterus, aided by the abdominal muscles. What are the contractions of the uterus called ? Labor-pains, because usually accompanied by painful sensations in the back or hypogastrium. How long does a contraction last ? Each contraction lasts for from a few seconds to two minutes. Their duration increases with the progress of the labor, becoming longer and stronger as it advances. The average duration is a little less than one minute. How long is the interval between them ? At the beginning of labor they are from a half hour to ten minutes apart. The interval diminishes as labor advances, and toward the end may be from five minutes to only one minute apart. LABOR. 51 What effect have the contractions upon other muscles ? When powerful, or when the second stage is half finished, they are accompanied by contractions of the abdominal muscles, which are almost entirely involuntary, and the woman strains or " bears down." The muscles of the extremities also become rigid during the expulsive effort. How much pain accompanies a uterine contraction ? In an entirely normal labor in a healthy woman, the pain is slight; in any case, during a bearing-down effort, the consequent cerebral fullness causes some physiological anaesthesia. But in perhaps the majority of labors there is some abnormal condition present which makes the contrac- tions inconveniently painful. How is the dilatation of the os effected ? I. The simultaneous contraction of all the uterine muscular fibres tends to pull apart the edges of the os, since there alone the fibres are absent. 2. The uterus is longer than broad, and its longitudinal fibres more numerous than the others; therefore, during a contraction it tends to become broader than long, which forces the contents of the uterus against the os. 3. The circular fibres about the os undergo a spontaneous dilatation, and this appears to be increased by the free secretion of mucus from the cervical glands. What effect upon the contents of the uterus may be noticed during a contraction ? The force tends to move all the contents (child and liquor amnii) toward the os uteri; but fluids being more movable than solids, the liquor amnii is forced toward the os, while the child is driven away or recedes from it. What is the bag of waters, and how formed ? The gradual distention of the membranes by the liquor amnii, which is forced in advance of the child, forms a bag filled with fluid, in the os uteri. This becomes tense during a pain, and relaxed during the intervals, and by its even pressure greatly aids in the dilating process. Is the bag of waters always formed in labor, and what varia- tions occur ? I. Sometimes the amount of liquor amnii is so small that no bag forms. 2. The membranes may rupture prematurely, and thus prevent it. 3. The membranes may be so greatly distended that the bag of waters reaches to the vulva. Usually it contains only a few ounces of fluid. 52 QUESTIONS ON OBSTETRICS. Of what service is the bag of waters after the os is fully dilated ? Of none; and the progress of the labor is suspended until the contrac- tions are powerful enough to rupture the membranes and permit the escape of the liquor amnii. What practical deduction follows from this ? That the physician should rupture the membranes as soon as the os is fully dilated. How is the expulsion of the child effected ? By the contractions of the uterus, and according to a definite mechanism, depending upon the manner in which the child is placed. (See page 59 et sea.) How is the after-birth expelled ? Theoretically, the placenta becomes folded longitudinally, ground off the uterine walls by contractions, and then expelled. Practically this occurrence is so uncertain that it is found best to deliver the placenta artificially. What is the best method of delivering the placenta ? The method of Crede, so called after its chief promulgator. I. Place the hand upon the lower part of the abdomen and rub, stroke or knead the uterus. This will cause the womb to contract energetically, and in so doing, to ascend and move forward. Then— 2. Grasp the uterus through the abdominal walls, with one or both hands, and squeeze the placenta from it. If successful, the escape of the placenta may be recognized, and the latter will be found at the vulva, or even shot out into the bed. If not, wait a few minutes, and repeat both manoeuvres. If the placenta is dislodged as far as the vulva, remove it, taking care to twist the membranes into a rope, by rotating the placenta, in order to avoid leaving any strips behind. Never pull upon the funis. What other advantages has this method ? It secures complete contraction of the uterus, and empties the uterine sinuses; preventing hemorrhage, inversion of the womb, uterine throm- bosis, and almost all other complications. What is the normal duration of labor ? It is variable. Collins, in over 16,000 cases, found that 84 per cent. completed labor within six hours, or less. It is probable that in strictly normal cases, three or four hours should suffice for the stage of dilatation, one hour for the second stage in first labors, and ten to thirty minutes in subsequent labors. The third stage, being artificial, is terminated at the LABOR. 53 will of the physician, and should rarely be delayed longer than ten or fifteen minutes. Define the terms primipara, multipara, etc. A woman in her first pregnancy and labor is called a primipara ; in sub- sequent labors a multipara, or if greater accuracy is required, the number may be given, thus: 2 para, 3 para, etc.; one who has had one child, and is not now pregnant, is called a unipara ; a woman who is not a virgin, but has never had a child, is called a nullipara. Adjectives are formed from these words, as, a primiparous woman, etc. Why is labor longer in primiparae than in multiparae ? Very commonly labor comes on from one to three weeks earlier in primi- parae; consequently the changes in the cervical canal are not as far advanced, and dilatation is slower than in multiparae. During the second stage the vagina and external parts of the primipara dilate more slowly, and thus occupy a longer time. What foundation is there for the statement that a woman who conceives late in life will have a difficult labor ? An old primipara is apt to have, first, some inflammatory trouble of the cervix, leading to difficulty and delay in the first stage, and second, to have an unyielding sacro-coccygeal joint, delaying the second stage. Otherwise there is nothing to cause a difficult labor in these cases. What are the ordinary duties of the physician in a case of labor ? 1. To examine the woman and ascertain the exact state of affairs. 2. To watch the progress of the case. 3. During the first stage, to encourage the woman, see that the bed is properly prepared, that due provision is made for the infant when born, and to keep others from meddling. How should an examination be made ? Place the patient on her back, with the knees drawn up. Anoint the index and middle fingers with fresh lard, vaseline or other unguent, and introduce into the vagina, passing the hand under the thigh until the vulva is reached. Introduce the index finger alone at first; if necessary, the middle finger may be added, which will give an additional reach of about one inch. What should be learned from the first examination ? 1. If the woman is pregnant ; 2. If she is in labor ; 3. The condition of the os uteri, as to dilatation and dilatability; 64 QUESTIONS ON OBSTETRICS. 4. The state of the membranes, and existence or not, of a bag of waters; 5. The presentation and'position of the child ; 6. The condition of the soft parts generally, as to temperature, moisture and dilatability; 7. The size of the pelvis. The most important thing is the condition of the os. How frequently should examinations be made ? Often enough to keep informed as to the progress of the case. As this will vary greatly in different cases, no rule can be made. Usually, it is proper to examine every hour or half hour during the first stage. Meantime the physician need not be in the room, unless to encourage the patient; but may be in an adjoining room, or even absent himself from the house. When the second stage begins, his place is by the bedside. If progress is slow, examination may be made, as in the first stage; if rapid, the finger placed on the perineum during a pain will warn him as to the approach of the end. How may it be known that labor has begun ? (1) By the disappearance of the cervix, (2) the dilatation of the os to some extent, (3) the presence of regular uterine contractions, (4) a dis- charge of mucus tinged with blood, which is called a " show." The first may fail in premature labors. How should the bed be prepared ? An oiled cloth, rubber blanket or thick comfort should be placed upon the mattress, to keep it from being soiled by the discharges. A sheet folded several times should be placed upon this, under the woman's hips, which may be withdrawn when the labor is over, and replaced by a clean one. When should the woman be placed in bed ? There is no special need until the os is nearly dilated, unless the labor is tedious, when her strength will be conserved by lying down and keeping quiet. How should she be dressed ? The chemise should be tucked up, well above the hips, to prevent soil- ing, and therefore the need of changing it after delivery. A night robe may be worn over this, and she should be covered with bed clothes adapted to the temperature of the room. What preparations should be made for the infant ? Its clothing should be made ready and aired. Several ligatures for the funis should be provided and a pair of scissors. Both hot and cold water should be in readiness. LABOR. 55 What hygienic measures are to be carried out ? I. To see that the bowels are moved by an enema, if there has not been a recent passage. 2. To require the woman to urinate occasionally. 3. If thirsty, give her water to drink. 4. See that the room is properly ventilated. 5. If there is any deviation from the normal course of labor, ascertain and remove it by appropriate treatment. What things are to be prevented ? Crowding the room by unnecessary company. Meddlesome practices of old women, such as giving " teas," and in general anything which will disturb the woman, mentally or physically. What objections to giving anaesthetics to make the labor pain- less are urged by those who oppose this practice ? 1. The pain is not great, unless some abnormal condition is present, which should be sought for and treated. 2. Natural labor lasts but a short time. 3. Anaesthetics protract the labor. 4. They increase the risk of hemorrhage (post partum). 5. From the same cause (imperfect contraction of the womb) they increase the liability to all the puerperal diseases. 6. They endanger the child's life (especially chloroform). How are these objections met by the advocates of obstetric anaesthesia ? 1. The proper administration of an anaesthetic during labor, renders the act painless, and prevents the exhaustion which may follow the protracted suffering, often severe. 2. It is not proved that when properly administered, they protract the labor, or increase the risk of hemorrhage, and even granting the latter objection, this risk can be overcome by careful management of the third stage of labor and the use of ergot. 3. If rightly administered in suitable cases, the danger to the mother and the child is not increased. When may an anaesthetic be used in normal labor ? During the second stage of labor, when the pain is severe, as when the head is passing through the os uteri or vulval orifice, provided no condition exists which would be considered a contraindication to etherization for surgical purposes, and provided the uterine contractions are of normal intensity. 56 QUESTIONS ON OBSTETRICS. How should an anaesthetic be given ? As the object in view is to deaden the pain, not to produce unconscious- ness, the ether or chloroform should be given in small quantities, inhaled only during the pains and withdrawn in the intervals between them. What anaesthetic is to be preferred ? I. Chloroform is most generally used, because it is quicker in its action, more pleasant to take, and less is required to produce the effect for which it is given. 2. Ether is probably safer and appears to be less likely to enfeeble uterine contractions. What disturbances often attend the end of the first stage ? i. The woman is very apt to vomit, which relaxes and prepares the soft parts and increases the uterine contractions. 2. A rigor sometimes occurs, temporarily suspending labor, but with hot applications to the feet and a hot drink it usually speedily ceases. What duties are required during the second stage ? I. To rupture the membrane, if this does not occur spontaneously. 2. To observe the descent of the child, and to be ready to remedy any departure from the normal course. 3. To prevent laceration of the perineum. 4. To complete the delivery of the child. How are the membranes to be ruptured ? By pressing the finger against them while they are made tense by a contraction. If they are too thick and strong to yield to this, the nail of the middle finger may be prepared as follows: First, make a straight cut in the free border of the nail and in the middle line of the finger. Second, pare away the free border on one side of the cut, which will leave a sharp, knife-like edge. If the bag of waters is large, it is well to place a cloth in front of the vulva before rupturing, in order to soak up the liquor amnii when dis- charged. What occurrences often attend the end of the second stage ? I. The woman wants to sit on the chamber, even when the bowel is empty; due to the pressure of the child's head on the bowel. Of course, she is not to be allowed to sit up at this time. 2. Cramps in the leg often occur from pressure of the descending head against the sciatic nerve. Rubbing the leg affords relief. How is the perineum to be guarded ? By bringing out the head in the absence of a pain, if possible. When LABOR. 57 the head greatly distends the perineum, and a part of the occiput pro- trudes, pass two fingers into the rectum, and place them on the brow, malar bones or chin of the child, as may be convenient. Place the thumb on the occiput. The head may then be controlled and prevented from passing through the vulva during a pain. If, when a pain has subsided, the head be now pushed over the perineum, laceration will be prevented. It is also necessary that the woman shall not bear down at this time. What is episiotomy ? An operation designed to save the perineum, by making small incisions into its margin, on either side of the median line. What is to be done when the head is born ? I. Ascertain if the funis is around the child's neck, and if so, unwind it. 2. If no uterine contraction appears to be forthcoming, pass a finger into the vagina, below the child's neck, and hooking it into an axilla, with- draw the child, taking care that the shoulders do not lacerate the perineum. What is the first attention to be rendered to the child ? I. Pass a finger into its mouth to remove any mucus which may be there. 2. If it does -not at once cry, give it a slight spank on the buttocks, or use other means of resuscitation, until it gives a good cry. 3. When it has cried well, tie the cord. How is the cord to be tied ? A ligature of several strands of sewing thread or other material should be tied two or three finger-breadths from the child's navel. A second ligature should be applied several inches from this, and the cord cut between the ligatures with scissors. If there is much Wharton's gelatine in the cord it is well to hold it firmly at the navel, and endeavor with the finger and thumb to squeeze out the gelatine or "strip" the cord. After cutting the cord see that the ligature is firm, and that no blood is escaping, and hand the child to the nurse. How is the cord to be dressed ? The physician is usually expected to dress the stump of cord attached to the child. Take a piece of linen or muslin (old and soft) about four inches square; cut a hole in the middle large enough for the cord to pass through; slip it over the stump and fold it so as to thoroughly cover it. How may a child be resuscitated when apparently still-born ? If it does not at once respond to spanking or dashing water upon its chest, resort at once— E 58 QUESTIONS ON OBSTETRICS. I. To Sylvester's method of artificial respiration, or, 2. To mouth to mouth insufflation. Wipe the baby's face, compress the nostrils with the fingers of one hand and press the other hand upon its epigastrium. Then apply your mouth to the child's, and blow into it. The pressure of the second hand prevents the air from entering the intestines. 3. A galvanic battery may be used. What attentions are to be rendered to the woman ? 1. The placenta is to be delivered after the manner of Crede (vide p. 52)- 2. The soiled clothing is to be removed and a napkin placed at the vulva to receive the discharges. 3. A broad bandage or "binder" should be applied around the abdomen. 4. The uterus should occasionally be felt through the abdominal walls, to be sure it remains contracted. What is the position of the womb after delivery ? Just after the delivery of the placenta the womb should be in the hypo- gastrium, its fundus reaching half way to the umbilicus, and feeling as hard as a stone. In a short time (generally within the hour), the abdominal muscles regain their tonicity, and the " retentive power of the abdomen " draws the womb upward, its fundus reaching nearly or .quite to the umbilicus. Why does a rigor often occur just after labor ? 1. The bedding and clothes are apt to be wet with the discharges. 2. The withdrawal of the child takes away a source of bodily heat, its ' temperature being nearly a degree higher than that of the mother. When may the physician leave, and when should he return ? He may leave within half an hour, if the woman has been cared for as above, and is in good case. He should return within from twelve to twenty-four hours; and in general those who watch their patients best will have the least trouble. What are after-pains ? The pain sometimes experienced after labor, due to the contractions of the uterus. They are rarely felt by primiparae, and usually increase in severity with each subsequent labor. They may occur only a few times, or may keep up for several days. If severe enough to need treatment, opium and camphor, in powder, or as in paregoric, will be the proper remedy. What is the caput succedaneum ? An cedematous swelling formed on the part of the presentation in THE MECHANISM OF LABOR. 59 advance ; caused by the pressure upon the circulation in the presenting circumference, by the grip of the cervix, vagina, or pelvic walls. It forms only when the head is arrested at any point for some time. How long does it remain ? For several days after birth, if not interfered with. Fig. 14. THE MECHANISM OF LABOR. What is meant by the mechanism of labor ? The purely mechanical movements involved in the passage of the child through the pelvis, in distinction to the vital and clinical conditions con- nected with the process. With what is the mechanism of labor concerned ? With three things. 1. The body to be propelled. 2. The tube through which it is propelled, and 3. The propelling force. What is the propelling or motive force in labor ? 1. The contractions of the uterus, principally, aided by 2. The contractions of the abdominal muscles. 3. The elastic resistance of the perineum. When is the first or uterine force exerted ? Throughout the entire la- bor, and is the main and necessary force. When is the second or abdominal force exerted ? It may be voluntarily ex- ercised at any time, but usually is reflexly excited when the head is low in the pelvis, becoming almost in- voluntary. What effect has the abdominal force ? I. It aids the Uterine force A- P«ineum; i?. The direction of the uterine force; C. The direction of the perineal force; Z>. directly, by pushing the The resultant of the two forces, in which the head child onward, and moves. 60 QUESTIONS ON OBSTETRICS. 2. Indirectly, by holding the womb down and preventing it from being pushed upward by the pelvic resistance to the passage of the child. When and how is the perineal force exerted ? After the child has reached the outlet, it can go no further without passing through or over the perineum. The uterine force is unable to propel it in any direction except against or through the perineum. A new force is therefore provided in the elastic resistance of the perineum, which tends to push the head back in nearly the opposite direction (a little forward as well). Therefore the head moves in the resultant of the two forces, and over the perineum. What form does the child assume when packed in the womb ? It is substantially an ovoid, or egg-shaped figure, the extremities being flexed and pressed against the trunk. What relations may it assume to the pelvic inlet ? Either end (the head or breech), may be opposite the inlet, or it may lie transversely across it. What is the presentation of the child ? That part of the child in advance, or, more accurately, that part of the child included within the circumference of the inlet at the beginning of labor. 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SMITH, M.A., Ph.D., Prof, of Chemistry in Wittenberg College, Springfield, Ohio! formerly in the Laboratories of the University of Pennsylva- nia and Muhlenburg College; Member of the Chemical Societies of Berlin and Paris ; of the Academy of Natural Sciences of Philadelphia, etc., etc. EACH VOLUME SOLD SEPARATELY. INORGANIC CHEMISTRY. Second American, from the Fourth German Edition; thoroughly revised and in many parts rewritten. With 89 Illustrations and Colored Plate of Spectra. Cloth, $2.00 THE CHEMISTRY OF THE CARBON COM- POUNDS, or Organic Chemistry. First Ameri- can, from Fourth German Edition. Illustrated. Cloth, $3.00 The success attending the publication of the first edi- tion of Richter's Inorganic Chemistry encourages the translator and publishers to believe that the companion volume will have an equally warm reception. Professor Richter's methods of arrangement and teaching have proved their superiority, abroad, by the very large sale of his books all over the Continent, translations having been made in Germany, Russia, Holland and Italy. From Prof. B. Silliman, Yale College, New Haven, Conn. " It is decidedly a good book, and in some respects the best manual we have." From John Marshall, m.d., n.vt. sc. d. (Tubingen), Demonstra- tor of Chemistry in the University of Pennsylvania, Medical Department. " The work is of undoubted value. The theory of chemistry, which is generally the bugbear of students, is, in this book, very clearly explained, and the explanations are so well distributed through the book that students are brought easily from the simplest to the most difficult problems. " That part descriptive of the elements and their compounds is full, and all that could be desired in a text-book, while the cuts, with which the work is profusely illustrated, are an excellent aid to the student. Altogether, it is one of our best modern works on chemistry." A New Series of Manuals FOR Medical Students. Price of each Book, Cloth, $3.00 ; Leather, #3.50. MIDWIFERY. By Alfred Lewis Galabin, m.a., m.d., Ob- stetric Physician to, and Lecturer on Midwifery and the Diseases of Women at, Guy's Hospital, London, etc. 227 fine Engrav- ings- 753 pages. PHYSIOLOGY. By Gerald F. Yeo, m.d., f.r.cs., Professor of Physiology in King's College, London. Second Edition, re- vised. 750 pages. 301 carefully printed Illustrations. MATERIA MEDICA, PHARMACY AND THERAPEU- TICS, including the Physiological Action of Drugs, Special Therapeutics, Official and Extemporaneous Pharmacy, with numerous Tables, Formula;, Notes on Temperature, Clinical Thermometer, Poisons, Urinary Examinations and Patent Medi- cines. By Sam'l O. L. Potter, m.a., m.d., Professor of Practice of Medicine, Cooper College, San Francisco, late Sur- geon U. S. Army. 750 pages. CHILDREN. By J. F. Goodhart, m.d., Physician to the Eve- lina Hospital for Children; Assistant Physician, Guy's Hospital, London. American Edition. Revised and Edited by Louis Starr, m.d., Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania; Physician to the Children's Hospital, Philadelphia. 50 Formulae, and Directions for preparing Artificial Human Milk, for the Artificial Digestion of Milk, etc. 738 pages. PRACTICAL THERAPEUTICS, With an Index of Diseases. By Ed. John Waring, m.d., f r.cp. Fourth Edition. Re- written and Revised. Edited by Dudley W. Buxton, Assistant to the Professor of Medicine, University College Hospital, Lon- don. 744 pages. MEDICAL JURISPRUDENCE AND TOXICOLOGY. By John J. Reese, m.d., Professor of Medical Jurisprudence and Toxicology, University of Pennsylvania, etc. 6c6 pages. ORGANIC CHEMISTRY. By Prof. Victor von Richter, University of Breslau. Translated from Fourth German Edition by Edgar F. Smith, m.a., ph.d., Professor of Chemistry, Wit- tenberg College, Springfield, O., formerly in the Laboratories of the University of Pennsylvania, etc. Illustrated. 710 pages. DISEASES OF WOMEN. By Dr. F. Winckel, Professor of Gynaecology; etc., Royal University of Munich. The Transla- tion Edited by Theophilus Parvin, m.d., Professor of Ob- stetrics and Diseases of Women and Children, Jefferson Medical College, Philadelphia. 132 Engravings, most of which are new. 700 pages. %* Other Volumes in Preparation. A complete illustrated circu- lar with sample pages sent free, upon application. Price of each Book, Cloth, $3.00: Leather, $3.50. VAN HARLINGEN On Skin Diseases. WITH COLORED ILLUSTRATIONS. A HANDBOOK OF THE DISEASES OF THE SKIN, their Diagnosis and Treatment. By Arthur Van Harlingen, m.d., Professor of Dis- eases of the Skin in the Philadelphia Polyclinic, Consulting Physician to the Dispensary for Skin Diseases, etc. Illustrated by colored lithographic plates. 12mo. 284 pages. Cloth. Price, $1.7S. RECOMMENDATIONS. " It is a most useful compendium of the knowledge to be had at the present time upon the important subjects to which it is devoted; and is in all respects a credit to the well recog- nized abilities of its author."—James Nevins Hyde, M.D., Professor of Skin and Vene- real Diseases, Rush Medical College, Chicago. " This new handbook is essentially a small encyclopedia of pathology and treatment of Skin Diseases, in which the subjects are arranged alphabetically. This arrangement was that followed by the late Tilbury Fox, of London, in his handbook, which we believe was re- markably successful; and we have no doubt it will be equally appreciated in the present work, which (compendious in form) contains a very complete summary of the present state of dermatology. Dr. Van Harlingen's position in the profession, being at present vice- president of the American Dermatological Association, which he served as secretary for several years, and the high standard of his communications to his department, are sufficient to warrant the confidence in his teachings, which is fully sustained by an examination of this handbook, which we heartily commend for its brevity, clearness and evident careful prepa- ration."— Philadelphia Medical Times, October 18th, 1884. RINDFLEISCH. The Elements of Pathology. A Text-Book in the University of Pennsylvania. THE ELEMENTS OF PATHOLOGY. For Students and Physicians. By Edward Rindfleisch, m.d., Professor of Pathological Anatomy in the University of W'urzburg. Anthorized translation by William H. Mercur, m.d., of Pittsburgh, Pa. Revised by James Tyson, m.d., Pro- fessor of General Pathology and Morbid Anatomy in the University of Pennsylvania. 12mo. 263 pages. Cloth, $2.00. RECOMMENDATIONS. " The practical views of one of the best of the modern histologists is placed before the profession in this admirable work, in a most careful and systematic manner. The author, who is one of the leading pathologists, sets forth not only the ground-work in his department, but treats and makes clear many of the more difficult points of the study of pathological Drocesses The work is divided into a consideration,./frst, of the local outbreak of diseases ; second into the anatomical extension of disease ; thirdly, into thephysiological extension of disease and lastly, into an examination of special parts."—The Medical Bulletin. P. BLAKISTON, SON &, CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. BIDDLE'S Materia Medica. TENTH REVISED EDITION. Contains all Changes in the New Pharmacopoeia. Recommended as a Text-book at Yale College, University of Michigan, College of Physicians and Surgeons, Baltimore, Baltimore Medical College, Louisville Medical College, and a number of other Colleges throughout the United States. BIDDLE'S MATERIA MEDICA, For the Use of Students and Physicians. By the late Prof. John B. Biddle, m.d., Professor of Materia Medica in Jefferson Medical College, Philadelphia. The Tenth Edition, thoroughly revised, and in many parts rewritten, by his son, Clement Biddle, m.d., Assistant Surgeon, U. S. Navy, assisted by Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Containing all the additions and changes made in the last revision of the United States Pharmacopoeia. 8vo. Bound in Cloth. Price $4.00; Leather, $4.75. RECOMMENDATIONS. " It will be found a useful handbook by students, especially, who may be under the instruction of its able and accomplished author."—American Med- ical journal. " In short, it is just the work for a student, embracing as it does what will be discussed in a course of lectures on materia medica.."-*-Cincinnali Medical News. " In truth, the work is well adapted to the wants of students."—The Clinic. " Nothing has escaped the writer's scan. All the new remedies against disease are duly and judiciously noted. Students will certainly appreciate its shapely form, grace of manner, and general multum in parvo style."—Ameri- can Practitioner. " Biddle's ' Materia Medica' is well known to the profession, being a stand- ard text-book in several leading colleges."—New York Medical Journal. " It contains, in a condensed form, all that is valuable in materia medica, and furnishes the medical student with a complete manual on this subject."— Canada Lancet. " The necessity for a new edition of this work in so short a time is the best proof of the value in which it is held by the profession."—Medical and Surg- ical Reporter. " The standard ' Materia Medica' with a large number of medical students is Biddle's."—Buffalo Medical and Surgical Journal. "The larger works usually recommended as text-books in our medical schools are too voluminous for convenient use. This work will be found to contain in a condensed form all that is most valuable, and will supply students with a reliable guide."—Chicago Medical Journal. *#* This Ninth Edition contains all the additions and changes in the U. S. Pharmacopoeia, Sixth Revision. P. BLAKISTON, SON A. CO., Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. REESE'S Medical Jurisprudence AND TOXICOLOGY A TEXT-BOOK FOR STUDENTS AND PHYSICIANS. By John J. Reese, m.d., Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania; Vice-President of the Medical Jurisprudence Society of Philadelphia; Member of the College of Physicians of Phila- delphia; Corresponding Member of the New York Medico-Legal Society 606 pages. Demi-octavo. Bound in Cloth, $3.00; Leather, $3.SO. RECOMMENDATIONS. "1 have just concluded a careful review of Dr. John J. Reese's ' Text-Book of Medicai urisprudence and Toxicology,' and I take great pleasure in saying that it is by far the est book of its size on this subject which I have ever seen. * * * It is, for the medical student and the general practitioner, a much more convenient, readable, and in most respects better book than the voluminous treatises, to say nothing of the fact that it is a much less costly book than are these."— Willis G. Tucker, M. D., Professor of Inorganic ami Ana- lytical Chemistry and Medical Jurisprudence, Albany Medical College. " There has long been needed a work like this one. The student of the subject has had to choose between very prolix and expensive treatises by American writers, or those prepared by foreigners, whose customs and laws differ so much from ours that it materially detracts from their usefulness. " In this single volume, printed in clear type and on excellent paper, Dr. Reese presents all that the student or the general practitioner will have occasion to learn about the sub- ject."— The Medical and Surgical Reporter, Philadelphia, October nth, 1884. " I have examined the work, and find it to be a well compiled manual of the various doc- trines obtaining, both in law and in medicine, upon the subject of which it treats. In a field so wide as that of medical jurisprudence, it is a matter largely of individual choice as to the scope which shall be given by an author to the treatment of its several topics. Professor Reese seems to me to have struck the golden mean in this respect, and to have combined lucidity of style with brevity of statement, so as to give to each topic its due proportion of development. It cannot fail to become a most useful handbook for students who desire to have in outline the whole body of medical jurisprudence, including even the special depart- ment of toxicology, with all which that now embraces."—John Ordronaux, Professor of Medical Jurisprudence in Columbia College, New York, and in Dartmouth College, Hanover, N. H. " It may be called a practical encyclopaedia, giving just those things which are wanted in medico-legal inquiries. * * * * The thoroughness and skill of the author is ap- parent on every page, and the work may be especially commended as the best single volume 011 this subject in print."— Quarterly Journal of Inebriety, October, 1884. " It not only treats of the medical side of the subject, but gives much valuable legal infor- mation as to the rights and duties of physicians in such cases."—Popular Science News, October, 1884. " It comes to the profession at an opportune time, as a valuable addition to the subject of State medicine, and the volume should be in the hands of every medical man."— Pro/'.James F. Harrison, University of Virginia. " We might call these the essentials for the study of medical jurisprudence. * * * * If any section deserves more distinction than any other, as to intrinsic excellence, it is thai on toxicology. This part of the book comprises the best outline of the subject in a given space that can be found anywhere. As a whole, the work is everything it promises and more, and considering its size, condensation and practical character, it is by far the most useful one for ready reference that we have met with. It is well printed and neatly bound " —N. Y. Medical Record, Sept. 13th, 1884. P. BLAKISTON, SON & CO., Publishers and Booksellers. 1012 WALNUT STREET, PHILADELPHIA. NLM000427906