100 Le57c 1691 m &<-< ran .IBRARY OF MEDIONl >s of Manuals. f\L STUDENTS. NLM DDDMS?1!! S price and binding. trice 01 cacn cook, Cloth, $3.00; Leather, $3.50. SURGEON GENERAL'S OFFICE No. 1. SURGERY. Manual of the Practice of Surgery. By Wm. J. Walsham, m.d., Assistant Surgeon to, and Demonstrator of Surgery in, St. Bartholomew's Hospital. London, etc. 228 Illustrations. Prese he latest ac " It ai some S practica " Wal had ver quent p Withou' his boo! organiz: caljou: No. 2 VV] Th Ob Ph LIBRARY Ajijl©£ii. Section............................................. Form 113c W.D..S.G.O. No. 2111 \H Tul nd This " •■ completcims, ^uu in ,^ p.vov..._____„. —__________... _ . »c- tical rules and methods of treatment. " The book will be a valuable one to physicians, and a safe and satisfactory one to put into the hands of students. It is issued in a neat and attractive form, and at a very reason- able price."—Boston Medical and Surgical Jour nal. No. 3. MIDWIFERY. By Alfred Lewis Galabin, m.a., m.d., Obstetric Physician to, and Lecturer on Midwifery and the Diseases of Women at, Guy's Hospital, London, etc. 227 fine Engravings. "The illustrations are mostly new and well executed, and we heartily commend this book as far superior to any manual upon this subject."—Archives of Gynecology, New York. " Sensible, practical and complete."—Medical Brief. , " I have carefully read it over, and, as a teacher of midwifery, I consider the book ought to become one of the recognized text-books; the treatment and pathology of the various subjects treated are clear and concise."—J. Algernon Temple, M D., Prof, of Midwifery, and Gynecology, Trinity Medical School, Toronto. No. 4. PHYSIOLOGY. Fifth Edition. By Gerald F. Veo, m.d., f.r.c.s., Professor of Physiology in King's College, London. Fifth American from Second English Edition. 321 carefully printed Illustrations. " The work will take a high rank among the smaller text-books of Physiology."—Prof H. P. Bowditch, Harvard Medical School. " By his excellent manual, Prof. Yeo has supplied a want which must have been felt by every teacher of Physiology."—The Dublin Journal of Medical Science. t(S~ See Next Page. P. BLAKISTON, SON & CO., Publishers and Booksellers, 1012 WALNUT STPF.CT DU!'. *f»^' DL" V ihe JNew Series ot Manuals—Continued. No. 5. CHILDREN. Second Edition. Illustrated. By J. F. Good. . hart, m.d., Physician to the Evelina Hospital for Children; Assistant Physician to 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 of Philadelphia. With Illustrations, 50 Formula, and Directions for preparing Artificial Human Milk, for the Artificial Digestion of Milk, etc. "As it is said of some men, so it might be said of some books, that they are 'born to greatness.' 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" Nothing that concerns disease as found in childhood seems to have escaped the author's attention. From introduction to the end it is replete with valuable information, and one reads it with the feeling that Dr. Goodhart is writing of what he has seen at the bedside. It need scarcely be added that the revisions and additions by the American editor are of much value, neither too full nor too spare, and very judicious."—Journal of the American Medical Association. No. 6. PRACTICAL THERAPEUTICS. Fourth Edition. With an Index of Diseases. By Ed. John Waring, m.d., f.r.c.p. Rewritten and Revised. Edited by' Dudley W. Buxton', Assistant to the Professor of Medicine, University College Hospital, London. "Our admiration, not only for the immense industry of the author, but also of the great practical value of the volume, increases with every reading or consultation of it. We wish a copy could be put in the hands of every Student or Practitioner in the country. 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Holland, M.D., Dean Jefferson Medical College, Philadelphia. I&g- Students will find this an extremely useful book of reference. The ana- tomical tables will be of great use in memorizing the arteries, muscles, etc. COMPEND OF OBSTETRICS. LANDIS.. NEW EDITIONS. BlAKISTON'S PQlIlZ-COMPENDS? A New Series of Manuals for the Use of Students and Physicians. Price of each, Cloth, $1.00. Interleaved, for taking Notes, $1.25. From The Southern Clinic. " We know of no series of books issued by any house that so fully meets our approval as these ?Quiz-Compends ?. They are well arranged, full and concise, and are really the best line of text-books that could be found for either student or practitioner." &y These Compends are based on the most popular text-books, and the lectures of prominent professors, and are kept constantly revised, so that they may thoroughly repre- sent the present state of the subjects upon which they treat. J&3~The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. 0~ They are arranged in the most approvad form, thorough and concise, containing over 300 illustrations, inserted wherever they could be used to advantage. &S*Can be used by students of any college. *J* They contain information nowhere else collected in such a condensed, practical shape. SPECIAL NOTICE.—These Compends may be obtained through any Bookseller, Wholesale Druggist or Dental Depot, or upon receipt of the price, will be sent, postpaid, by the publishers. In ordering, always specify " Blakiston's ? Quiz-Compends ? ". No. 1. HUMAN ANATOMY. Based on "Gray." Fifth Revised and Enlarged Edition. Including Visceral Anatomy, formerly published separately. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. 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. No. 2. PRACTICE OF MEDICINE Part I. Fourth Edition. Revised, Enlarged and Improved. By Dan'l E. Hughes, m.d., late Demonstrator of Clinical Medicine, Jefferson College, Philadelphia. No. 3. PRACTICE OF MEDICINE Part II. Fourth Edition. Revised, Enlarged and Improved. Same author as No. 2. No. 4. PHYSIOLOGY. Sixth Edition, with new Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Bkubaker, m.d., Professor of Physi- ology and General Pathology in the Pennsylvania College of Dental Surgery; Demon- strator of Physiology, Jefferson Medical College, Philadelphia. No. 5. OBSTETRICS. Fourth Edition. Enlarged. By Henry G. Landis, m.d., Professor of Obstetrics and Diseases of Women and Children, Starling Medical College, Columbus, Ohio. Illustrated. No. 6. MATERIA MEDICA, THERAPEUTICS AND PRESCRIPTION WRITING. Fifth Revised Edition. 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Including Urin- alysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Lefpmann, m.d., Professor of Chemistry in Penn'a College of Dental Surgery, and in the Woman's Medical College, Phila. No.n. PHARMACY. Third Edition. Based upon Prof. Remington's Text-book of Pharmacy. By F. E. Stewart, m.d., ph.g.,Quiz-Master in Pharmacy and Chemistry, Philadelphia College of Pharmacy; Lecturer at the Medico-Chirurgical College, and Woman's Medical College, Philadelphia. Third Edition, carefully revised. No. 12. VETERINARY ANATOMY AND PHYSIOLOGY. Illustrated. ByWji, R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Surgeons; Physician to Bellevue Dispensary, and Lecturer on Genito-Urinary Surgery at the New York Polyclinic, etc. With 29 graphic Illustrations. Just Ready. No. 13. WARREN. DENTAL PATHOLOGY AND DENTAL MEDICINE, containing all the most noteworthy points of interest to the Dental Student. By Geo. W. Warren, d.d s.. Clinical Chief Pennsylvania College of Dental Surgery, Phila. No. 14. DISEASES OF CHILDREN. By Marcus P. Hatfield, Professor of Dis- eases of Children, Chicago Medical College. Just Ready. Price, each, Cloth, $1.00. Interleaved, for taking Notes, $1.25. P. BLAKISTON, SON & CO., 1012 Walnut St., Philadelphia. ? QUIZ-COMPENDS ? No. S. COMPEND OBSTETRICS. ESPECIALLY ADAPTED TO THE USE OF MEDICAL STUDENTS AND PHYSICIANS. HENRY G. LANDIS, A.M., M.D., 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. TH EDITION. ILLUSTRATED. PHILADELPHIAi ~ P~~BLAKISTON, S Q N/ 8\ . C 0 ., IOI2 WALNUT STREETS— 1891. a TWs. H YVQ I DO )8 0l Entered according to Act of Congress, in the year 1891, by P. BLAKISTON, SON & CO., In the office of the Librarian of Congress, at Washington, D. C. #^Yir^ Phess of Wm. F. Fell & Co., 1220-24 Sansom St., philadelphia. PREFACE TO NEW 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 Antisepsis and Puerperal Septicaemia have been enlarged. Several illus- trations 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. 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. II. G. L. TABLE OF CONTENTS. PAGE Introduction,....................... 9 The Pelvis,........................ 9 Pelvic diameters,.................... x4 " planes,...................... XS " muscles,.................... J6 Reproductive Organs. Anatomy. The Uterus,....................... *7 Ligaments........................ l9 Fallopian Tubes,.................... 2° Ovaries,......................... 2° Vagina,........................ 2I Douglas' cul-de-sac,................... 21 Hymen,........................ 22 Carunculse........................ 22 Bulb of Vagina,..................... 22 Vulvo-vaginal Glands,.................. 22 Vulva,......................... 22 Labia Majora,...................... 22 Mons Veneris,..............■...... 23 Commissures,...................... 23 Clitoris,.......... ........... 23 Labia Minora...................... 23 Vestibule,....................... 24 Meatus,........................ 24 Urethra,........................ 24 Perineum,...................... 24 Physiology. Ovulation,....................... 24 Menstruation,...................... 27 The Breasts,..................... 29 Pregnancy. Fecundation,...................... 29 Changes in Ovum,.................... 3° vii viii table of contents. PAGE Changes in Womb....................33> 35 The Placenta,..................... 33 Fcetal Changes,.................... 34 Multiple Pregnancy,................... 3° Extra-uterine " ................... 37 Hydatid " ................... 39 Mole " ................... 39 Spurious " ..........•....... 4° Premature Labor..................... 4° Signs of Pregnancy,................... 42 Labor. Clinical History,.................... 51 Duties of the Physician,................. 54 Mechanism of Labor,................... °° Dystocia. Uterine Inertia, .................... 72 Rigidity of Cervix, etc.,................. 75 Deformities of Pelvis,.................. 77 Ovular Dystocia,.................... 79 Twin Labor,...................... °3 Accidental Hemorrhage,................. 84 Placenta Previa,.................... 84 Post-partum Hemorrhage................. 87 Rupture of Uterus,................... 88 Eclampsia,...................... 89 Placental Dystocia,................... 92 Inversion of Uterus,................• • 93 Obstetrical Operations. The Forceps,..................... 95 Version,........................100 Embryotomy,...................• • • 101 Csesarean Section,....................104 Induction of Labor....................105 The Period after Delivery. Involution of the Uterus,.................106 Puerperal Diseases,...................109 Congenital Defects,...................113 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 out of these rules. The science may be taught in books and lectures ; the art must be acquired by practice at the bedside. How may the subject be divided ? 1st. The Anatomy of the parts concerned in labor, viz. : the reproductive organs and their surroundings. 2d. The Physiology of these parts. 3d. Their Pathology, including all deviations from the natural course of labor. 4th. The treatment of natural and complicated labor. What are the reproductive organs of woman ? 1st. Internal, viz. : the ovaries, oviducts, uterus and vagina. 2d. External, viz.: the mons veneris; labia majora and minora; clitoris; vestibule and meatus urinarius ; hymen or carunculse myrtiformes ; four- chette and perineum; 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. B 9 10 QUESTIONS on obstetrics. 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 fascirc, it resembles a basin. 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 vertebnu. 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 articular surface above, by which it is connected with the sacrum. It tapers from that bone, and is supposed to be the remains of our ancestral tail. What are the ossa innominata ? The haunch bones, of irregular shape, articulating 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. the pelvis. 11 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. i). What prevents these beams from being pushed in and out at their distal ends ? Another beam is placed between them, extending from one acetabulum to the opposite one, consisting of the upper part of the pubes on either side. What is this beam called ? The pubic beam (see Fig. 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. Why are these beams not straight ? They are arched outwardly to make more room in the pelvis, to enable it to fulfill its second and third uses (Fig. 2). How is the diminution in strength of the sacro-iliac beams, caused by this arching, remedied ? By buttressing the beams by that expansion of the sacrum and iliac bones, called the wings of the ilia and sacrum (Fig. 3). How are jarring and concussion prevented ? By placing joints at the centre of each beam. 12 questions on obstetrics. How is the diminution of strength caused by these joints remedied ? By covering them with powerful ligaments. Fig. 2. The same as in Fig. i,but with the beams arched; the dotted lines show the original direction of force. Fig. 3. The same as in Fig. 2, with the arches strengthened by the addition of the iliac wings, etc. The dotted lines below show the sub-pubic arch in front and the beginning of the ilio-ischiatic beams. 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 pelvis. 13 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. 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 antero-posterior diameters relatively less; the transverse diameter of the inlet crosses the antero-posterior 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 lumbo-sacral 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 sacrococcygeal 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. 14 questions on obstetrics. 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 fossre and crests, and the last lumbar vertebra forming the bony parts of the false pelvis. What lies below it ? The true or obstetric pelvis. 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 ? The 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 the pelvis. 15 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 tl\e sym- physis pubis. It is of variable length, owing to the mobility of the coccyx, but when the latter is extended, during labor, it is the longest diameter of the outlet, and may measure five inches. What is the transverse diameter of the outlet ? 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. 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. a b. Conjugate diameter of Inlet. Conjugate diameter of Outlet. 16 questions on obstetrics. 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 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^ k in F'ig. 4.) How is the pelvis lined within ? By certain muscles, blood vessels, nerves and fascire. What muscles are contained in it ? 1. The Psoas-iliacus muscle on either side, consists, first, of the iliacus internus, which, in its origin, covers almost the entire inner aspect of the wing of the ilium, uniting with the psoas magnus, which passes over the upper border of the sacrum. Their conjoined body passes along the border of the sacroiliac 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 furnishes a cushion, or guard, for the iliac vessels and nerves, preserving them from pressure, while the pyriformis performs the same office for the sciatic nerve, which lies along its border. the reproductive organs. 17 THE REPRODUCTIVE ORGANS. THE INTERNAL ORGANS. What and where is the Uterus ? The uterus or womb is a hollow or muscular organ, situated in the centre of the pelvis, between the bladder and the 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 are called the cornua. How is the cavity of the uterus divided ? Into the cavities of the cervix and body. The first is fusiform, and appears to be an ante-chamber to the main cavity; the latter is triangular in outline, but with its walls in apposition (see Figure). Fig. S. What openings are found in the cervix ? The os externum, or os uteri, called also the os, is a small opening into the cavity of the cervix at the lower end of the cervix. The constriction between the cavities of the neck and body is called the os internum. What is the structure of the uterus ? It is mainly composed of muscular tissue, with fibrous connective tissue, blood vessels and nerves. On the outside, it is mainly covered with peri- 18 questions on obstetrics. toneum, and on the inside, is lined with mucous membrane, called the endometrium. How are the muscular fibres arranged ? F'or 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 caliber, and freely communicating; peculiarities which warrant us in regarding the uterus as composed of a modified erectile tissue. How is the uterus supplied with nerves ? 1st. The main nerves proceed from a well- defined nerve centre in the lumbosacral 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— 1. Of a mesh of connective tissue containing many spindle-shaped cells. 2. Of many tubular glands, which give the surface of the membrane a perforated appearance. 8. 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. the reproductive organs. 19 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 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 20 questions on obstetrics. 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 ? ist. 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. 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. The 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 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 fibro-plastic tissue, in the meshes of which are found the ovisacs in different stages of development (see Ovulation). the reproductive organs. 21 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 epididymis 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 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 rugae. How long is the vagina ? Its anterior wall is quite short, extending from the vulva almost directly to its point of insertion, a small pouch being formed above, called the 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 abdom- inal cavity, effusions of blood or other fluid and tumors of various kinds are often to be found in it. 22 questions on obstetrics. 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 carunculoe 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 side 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. THE REPRODUCTIVE ORGANS. 23 What is the structure of the labia majora ? They consist of cutaneous folds containing loosely arranged cellular tissue, with some fat. On the 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 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 Nymphcz. 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 erectile tissue. 21 QUESTIONS ON OBSTETRICS. 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 wedge-shaped band of fibrous elastic tissue, which stretches across from one tubero.sity to the other, and is interposed between the termination of the vagina and rectum. What other structures of importance are found in the perineum ? The transversus perinaei and levator ani muscles, and also fibres of the sphincter muscles, which are placed about the ends of the vagina and rectum. PHYSIOLOGY. OVULATION. What is the function of the ovaries ? To furnish ova, or eggs, which are the primitive germs of the human being, and the necessary female element in reproduction. What is the function called ? Ovulation. How early in life does ovulation begin ? In childhood. [Sinedy and Hausmann found evidence of ovulation in 10 per cent, of infants examined by them.] But it does not occur with much vigor until womanhood. OVULATION. 25' 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- 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. Is it necessary for the uterus to aid the entrance of the semen ? No; fecundation has occurred when the woman was perfectly passive, or unconscious, from drugs, drink, or sleep. What further means are provided for the retention of the semen ? 1. During venereal excitement the round ligaments of the uterus pull it forward and upward. This permits the penis to glide past the cervix and to deposit the semen in the posterior vaginal pouch. When the ligaments are relaxed, the cervix resumes its former position, and thus retains the semen in the pouch above ; the spermatozoa may then, at their leisure, enter the uterus. 2. It has also been demonstrated that fecundation can take place when the semen escapes upon the vulva, so that the whole distance may be traveled by the spermatozoa unaided. What changes take place in the ovum after fecundation ? 1. The germinal spot and vesicle disappear. 2. The segmentation of the vitellus, i. e., the vitellus splits into two masses, 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. PREGNANCY. 31 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.) Fig. 9. segmentation of the vitellus. 6. A covering for this trace or embryo is now formed. Thus far the vitel- line membrane has been sufficient. The embryonic line sinks into the centre of the ovum, while the edges of the external blastodermic layer about the area close around it, inclosing it in a sac, called the amnion. (See Fig. 11.) The vitelline membrane then disappears. Fig. 10. Fig. 11. THE OUTER LAYER OP CELLS COMPLETED. The primitive trace in the centre of the area germina- tiva. SECTION OF OVUM. Shows embryo sinking in toward the centre of the ovum, and the way in which the amnion is formed. 7. The rest of the external blastodermic layer, or that part which did not follow the embryo within the ovum, now forms the outer covering, and is called the chorion. 8. The chorion develops upon its outer surface little hollow projections, called villi. 152 QUESTIONS ON OBSTETRICS. 6. A vascular mass, called the allantois, shoots out from the middle of the embryo, and when it has reached the inner surface of the ovum, spreads out, carrying loops of blood vessels into the villi of the chorion. (Figs. 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 the ovum, and (b) by the fluid materials of the ovum contained within the internal blastodermic layer. While the allantois is formed, this internal layer contracts, its shrunk bulk constituting the umbilical vesicle, which finally disappears. (Fig. 13.) II. 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 Fig.12. Fig. 13. THE AMNION NEARLY COMPLETED. THE AMNION COMPLETED. The allantois carrying blood vessels a. The allantois completed, having to the circumference («). carried vessels into all the projections (villi) of the chorion, b. The umbili- cal vesicle. 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 underneath it, forming the placenta, by which a definite vascular connection is estab- lished 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 PREGNANCY. 33 cord, and continues to develop to the end of pregnancy. It has now the following coverings: 1st, the amnion; 2d, the chorion; 3d, the decidua reflexa, besides being covered by the uterine walls in general. What changes in the mucous membrane of the womb follow fecundation ? 1. The mucous membrane of the womb becomes hyperaemic and hyper- trophied; it develops new and soft connective tissue, and is thrown into folds. In this thickened state it is called the decidua vera. (This occurs whether the ovum enters the womb or not.) 2. When the ovum enters, adjacent folds grow over the ovum, forming the decidua reflexa. As the ovum increases in size, the decidua reflexa becomes united or welded with the superficial layers of the general mucous membrane, or decidua vera (about the fourth month). 3. That part of the membrane directly under the ovum undergoes greater changes, and is called the decidua serotina. What is the nature of the placenta ? 1. The villi of the chorion enter depressions in the decidua serotina, and bands 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 have a flat, cake-shaped mass, mainly composed of blood vessels, which serve to convey nutriment from the mother to the child. Does the maternal blood enter the circulation of the child ? No. The foetus derives nutriment by endosmosis, through the delicate walls of the villi floating in the maternal sinuses—like the rootlets of a plant—absorbing the elements needed for growth, and discharging effete products by exosmosis. 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 fetal 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 fetus. Two arteries pass from the fetus 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. 34 QUESTIONS ON OBSTETRICS. What are the knots in the funis ? The fetus 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 fetus 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 umbilical vein, to the liver, where most of the blood passes through the portal circula- tion and empties by the hepatic veins into the vena cava ; the remainder, passing through the ductus venoms, 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 auricle to the right ventricle ; to the pulmonary artery through the ductus arteriosus, into the aorta. It will be noticed that the venous blood of the fetus is more oxygenated than the arterial. After birth the foramen ovale closes and the peculiarly fetal 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 3 iv on an average. How large is the ovum (and foetus) in 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; fetus an inch long. " 3d " " goose " " 3 " '• 4th '' the fetus is 6.6 inches long. " 5th " " « 7 -10^ " 6th " " " 11 -13 " ' 7th " " " 13.7-iS PREGNANCY. 35 End of 8th month, the foetus is 15 -17 inches long. " 9th " " « 16 -17^ " 10th " « " 17^-18^ [According to Schroeder.] American children are usually larger at birth- How soon can the sex of a child be recognized ? Not certainly until during the fourth month. What is vernix caseosa ? An unctuous sebaceous secretion covering the skin of the child, for the purpose of lubricating it for delivery. It does not appear until the seventh month. What is meconium ? The dark green, semi-fluid contents of the fetal 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 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 unusually 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. 36 QUESTIONS ON OBSTETRICS. 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 ? i. 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. What is superfecundation ? The fecundation of two ova at different times, i. ) external, in which the change is effected by manipulation through the abdominal walls only, and (c) bipolar, in which one hand upon the abdomen and two fingers (or more) internally are used. What are the indications for version ? 1. To convert a transverse presentation into one of the vertex or breech. 2. When rapid delivery is required, and the use of the forceps is not feasible, podalic version is indicated. 3. According to some authorities, to render delivery easier in deformed pelvis. How is internal version performed ? 1. The hand is cautiously passed into the uterus until a foot is reached and seized. As this foot is pulled down the child is turned until the breech presents. According to some, version will be easier if we seize the foot which is furthest from us. 2. The head may be seized and brought down in some cases. EMBRYOTOMY. 101 What cautions are necessary ? i. To introduce the hand slowly and gently, lest the womb be lacerated. Anassthesia is sometimes of service in promoting uterine relaxation. 2. Not to mistake a hand for a foot. What posture assists in version ? When a transverse presentation is impacted the woman may be placed in the knee-chest posture, which will aid in introducing the hand. How is external version performed ? I. By careful palpation we ascertain the exact position of the head and breech. 2. One hand placed over the head (on the abdomen) and the other over the breech, push the head and breech in opposite directions until one or the other is brought into the pelvic inlet. This is rarely practicable after the liquor amnii is evacuated. How is bipolar version effected ? I. One hand is introduced into the vagina, and two fingers made to press against the presenting part. 2. The other hand is applied on the abdomen and pressed against the head or breech of the child, while the fingers of the other hand press the presenting part upward and to one side or the other. This method should always be tried before internal version is resorted to, since, if successful, it removes the necessity of introducing the hand into the womb. Under what circumstances is version easy or difficult ? i. When there is much liquor amnii, and the uterus is uncontracted, it is easy of performance. 2. When the liquor amnii has drained away for some hours, when the" womb is tonically or tetanically contracted, and when the child has been dead long enough for post-mortem rigidity to supervene, it is difficult, and sometimes impossible. When version fails in a transverse presentation, what alterna- tive operation have we ? Embryotomy. EMBRYOTOMY. What is embryotomy ? The operation by which the size of the child is reduced by cutting and mutilation. It is now restricted to mutilation of the body; when applied to the head it is called craniotomy. 102 QUESTIONS ON OBSTETRICS. What are the steps in performing embryotomy on the transverse presentation ? i. An assistant places his hands on the abdomen and presses the child downward, so as to steady it. 2. A perforator is introduced into the vagina, and made to perforate the chest, and to divide several ribs. Care should be taken to guard the sharp edges of the perforator with two fingers, while introducing and using it. 3. A blunt hook, crotchet or other instru- ment, is introduced into the chest through the perforation, and the viscera broken up and removed piecemeal. This is called evisceration. 4. The body may then be doubled up and drawn down by a blunt hook or embryotomy forceps. 5. In a few cases it is necessary to de- capitate the child before it can be ex- tracted. This may be done by instru- ments invented for the purpose, or by improvised methods, if the operator is ingenious. What is craniotomy ? The operation by which the head is lesssened in size. 1. The head is pressed down and steadied by an assistant. . The head is perforated. . The brain is broken up completely, and if necessary removed by syringing out the cranial cavity. . Traction is made upon the head by a finger hooked into the perforation, by craniotomy forceps, or by any suitable instrument, and the head collapses, and is drawn out. If not sufficiently reduced in size by these steps, we pro- ceed to cranioclasm. Simpson's cranioclast. EMBRYOTOMY. 103 What is cranioclasm ? The operation by which the vault of the cranium is removed. I. Craniotomy is performed as above. 2. With the cranioclast (or craniotomy forceps) seize an edge of bone at the perforation, and wrench off as large a piece as possible, which is then cautiously withdrawn. This is repeated until the vault of the cranium is removed. 3. The head is then tilted, so that the craniotomy forceps can seize the face, and the thin base of the skull is drawn down through the pelvis. Fig. 17. HICKS CEPHALOTRIBK. What cautions are necessary ? 1. To preserve the scalp, so that the sharp edges of bone may be covered while it is withdrawn. Therefore, the scalp is to be dissected up before using the cranioclast, and its blades placed, one inside the skull, and the other between the scalp and outside of the skull. 2. To guard the edges of fragments of bone with two fingers while with- drawing them. If even the base of the skull is too large to pass, what alterna- tive have we ? Cephalotripsy, in which a powerful pair of forceps (the cephalotribe) is 104 QUESTIONS ON OBSTETRICS. applied, and made to crush the base. Cephalotripsy may also be used before resorting to cranioclasm, but perforation of the cranium should always precede the application of the cephalotribe. CESAREAN SECTION. What is the Caesarean section ? Gastro-hysterotomy, or the removal of the child through an incision made in the abdominal walls and uterus. It is sometimes incorrectly applied to simple gastrotomy (laparotomy) after rupture of the uterus. What are the indications for the Caesarean section ? I. A pelvis contracted to two inches in the conjugate, or obstructed by tumors, or other insurmountable obstacles to delivery by the natural way. 2. For the rapid delivery of a supposed living child after the death of the mother. Children have been saved when the mother had been dead for more than an hour. What are the steps in the Caesarean section ? I. The woman is prepared by anaesthesia and the emptying of the bladder. 2. The operator stands by her side, with his face toward her feet, and begins to make his incision near the symphysis. (To avoid cutting early into the placental site.) 3. An incision is made, layer by layer, in the linea alba, from near the pubes to the umbilicus, and, if necessary, continued further up, and to the left of the navel. 4. The womb is cautiously incised. 5. The child's feet are grasped, or the head seized by forceps, and the child extracted. 9. The after-birth is delivered. 7. The uterine incision is closed by a few sutures. 8. The abdominal cavity is carefully cleansed of all blood and fluids. 9. The abdominal incision is closed by suture. 10. The operation and subsequent treatment should be conducted with strict antiseptic precautions. What is Porro's method ? A modification of the Caesarean section, in which the uterus is removed after the child is delivered, and the stump treated as in ovariotomy. What is gastro-elytrotomy ? A modification of the Caesarean section, in which the vagina is opened instead of the uterus, thus escaping the risks of opening the abdomen. INDUCTION OF LABOR. 105 I. An incision is made parallel to and just above Poupart's ligament. 2. When the peritoneum is reached it is dissected up until the fingers reach the upper end of the vagina. 3. A small incision is made into the vagina, and enlarged by tearing with the fingers (to prevent hemorrhage). 4. The os uteri is hooked into this incision. 5. The child is turned, or the forceps applied, and extracted through this opening. 6. The upper wound is closed by suture. It is difficult to avoid injuring the bladder, and the entire operation demands great skill. What is symphyseotomy ? The section of the symphysis pubis, for the purpose of pulling open the ossa innominata and enlarging the pelvic cavity. It is called also the Sigaultian operation, after its inventor (1777). The operation was thor- oughly tested when first introduced, and abandoned because it did not materially increase the effective diameters and did inflict injury, sometimes irreparable, upon the mother. Its recent attempted revival is due to a craving for notoriety. INDUCTION OF LABOR. What is the induction of premature labor ? The operation by which labor is brought on at any time before full term. What are the indications for its performance ? 1. In deformed pelves, a child may be delivered alive if labor is induced at seven or eight months of pregnancy, which would have to be sacrificed by craniotomy if allowed to develop until full term. 2. If the mother's life is endangered by vomiting, convulsions, or other causes, the operation is sometimes performed. How is the operation conducted ? (Barnes' method.) 1. Pass an elastic bougie six or seven inches into the uterus; coil up the remainder of the instrument in the vagina, to keep it in place. Do this in the evening. 2. Next morning proceed to dilate the cervix by Barnes' (or Molesworth's) dilators, until it will admit several fingers. 3. Rupture the membranes and reapply the dilator. 4. Allow the natural efforts to complete delivery, or use the forceps or version. 5. (Thomas'.) Pack the child in cotton or wool as soon as born, and main- tain a suitable temperature by artificial heat, applied in various ways. H 106 QUESTIONS ON OBSTETRICS. THE PERIOD AFTER DELIVERY. What is the period after delivery called ? The lying-in period, the puerperal state, or the period of involution, because after labor the uterus undergoes the process of involution. What is involution ? The process by which the womb returns to its original size and condi- tion. The tissues of the womb undergo a form of fatty degeneration. As the products of this change are partly absorbed and partly transuded and discharged from the body, the structure of the uterus becomes con- densed until it has become nearly of the same size and condition as before pregnancy. The same change takes place in all the structures (ligaments, etc.) enlarged by pregnancy. How long a time is required for this process ? By the tenth day the womb is so diminished as to be entirely within the pelvis, and the fundus is not to be felt above the inlet. After this, involu- tion continues at a slower rate, being completed in about twelve weeks. What irregularities are met with ? I. Sub-involution; it may be protracted by inflammation or other concur- rent disease, and remain enlarged permanently, or for a long time. 2. Super-involution ; it may be rapid and excessive, leading to atrophy of the womb; but this is very rare. What outward or clinical manifestation of involution exists ? The lochia (plural), or lochial flow; or, popularly,- the flow, or cleans- ings. What are the lochia ? The " flow " is the discharge from the uterus and vagina which occurs after labor, and, to some extent, until the womb is completely involuted. What are its properties ? It is a rather thick albuminous fluid, containing oil globules, epithelial cells, blood corpuscles, and granular debris from the uterus. During the first day after labor it is of a red color, from the presence of blood in excess (or it may be blood alone immediately after labor). This may continue for several days, especially if any clots have been retained in the uterus, after which it becomes straw-colored, and finally clear and colorless. What is the nature of the lochial fluid ? It is an excrementitious product, and readily decomposes at the temper- ature of the body or a little higher. If retained and reabsorbed it may poison the blood, as any other excrement, thus causing septicaemia. THE PERIOD AFTER DELIVERY. 107 What is the amount of the lochia ? At first varies from one-half ounce to several ounces per diem. It is gradually diminished, and after the tenth day is usually scarcely perceptible being little more than the natural secretion of the parts. In some women it is very scanty and ceases after a few hours or a day or two, while in others it may continue for weeks. What is the normal condition as to health after labor ? The majority of women feel in good health, being only a little tired and sore, and in a few days feel competent to arise and resume their avocations. Should they be permitted to do so ? No. Rest and quiet are essential, to guard against the dangers incident to this period. How long should the woman be kept in bed and at rest ? Until the womb has retreated within the pelvis, and not allowed to work until involution is complete. Before this, the womb is enlarged and softened, and is subject to displacements and flexions. What physical peculiarities are noted in this period ? I. The pulse becomes slow, falling to 60 beats per minute, or less. 2. The temperature is elevated from .5° to i° Fahr. 3. The skin is more active and perspiration more free. 4. The urine is increased in amount. 5. The bowels are constipated. 6. The breasts secrete milk. How soon after labor is milk secreted ? To a slight extent during pregnancy, and some is to be found in the breasts just after labor. But the secretion is not fully established for from thirty-six to seventy-two hours, beginning suddenly in some and gradually in others. What is the nature of milk ? It is an emulsion of oil globules in an albuminous fluid, containing salts in solution. When of good quality it is rather thick (a drop adhering to the finger nail when inverted), of a bluish tinge and sweetish taste. The milk found in the breasts just after labor differs from the subsequent secre- tion, in being richer in fatty matters and slightly purgative to the child. It is called colostrum. What is weid, or milk fever ? An irritative fever, lasting from several hours to one or two days, and occurring in women in whom the secretion of milk is suddenly established. 108 QUESTIONS ON OBSTETRICS. It is due to reflex irritation, from the sudden development of secretory changes in the breasts. Clinically, it is distinguished by a sudden rise in temperature, preceded by a slight rigor and followed by free diaphoresis, and cannot be distinguished from an attack of intermittent fever, except by its non-recurrence. What rules should be observed concerning lactation ? I. During the first month the baby should nurse regularly, every two hours during the day and once or twice at night; during the next month the intervals may be lengthened to three hours, and afterward to four hours. Observance of this rule will save much trouble. 2. The nipple should be clean, drawn out and erect, when offered to the child, especially at first. 3. After nursing, the nipple should be washed, dried and anointed with cocoa butter, or other unguent. 4. If the breasts are large and pendulous they should be supported by a bandage whenever the woman is in the upright posture. What attention does the urine require after labor ? Retention is apt to occur after long labors, from temporary paralysis of the bladder and urethra, from pressure. The catheter should then be passed, within twelve to. twenty-four hours after labor, and, if necessary, twice daily, thereafter, until recovery. Hot cloths are also useful when the retention is due to local swelling and spasm. How should the catheter be passed in the female ? 1. Place the woman on her back, with the knees drawn up. 2. Introduce the finger into the vagina, passing it from below, upward, over the perineum and posterior commissure into the vulva. 3. Partially withdraw the finger, pressing slightly on the anterior wall until its tip arrives at the orifice of the vagina. 4. With the other hand pass the catheter along the finger to the tip, imme- diately above which is the meatus. If this fails, the meatus must be sought for by the tip of the finger, which is to be depressed as soon as the catheter arrives at the vestibule. Do not try to pass the catheter by the sense of touch alone, if not promptly successful, but remove the bed clothes, and look for the meatus. What attentions do the bowels require after labor ? Owing to the constipation, it is usually necessary to give a purgative on the third or fourth day after labor. This will not be needed if the bowels move spontaneously, and if there seems to be a slight inclination to a movement, an enema will be preferable. THE PERIOD AFTER DELIVERY. 109 What rectal difficulty is common at this time ? Hemorrhoids. These should be carefully replaced if extruded, after labor, and during convalescence an attempt may be made to cure them by medication (Barker's pills). What diseases are especially liable to occur in this period ? The lying-in woman is liable to septicaemia, peritonitis, and pelvic in- flammations, thrombosis, phlebitis, pyaemia, and mastitis. What is puerperal septicaemia ? I. A fever produced by the absorption of septic matter into the system (Playfair). 2. It may occur in a severe and acute form, or in a mild and subacute form. 3. It is often associated with inflammations, by which its course is greatly modified. 4. The various conditions resulting from the union of septicaemia and in- flammations are grouped by some under the name of puerperal fever. What are the causes of septicaemia ? I. Puerperal septicaemia is believed to be due to a specific microbe, which enters the body through a traumatic surface. 2. The poison is contagious, and, under favorable circumstances, multiplies with great rapidity in the body. 3. It is heterogenetic, never autogenetic, and may be conveyed to the abraded surface either by (a) the atmosphere, (b) towels or sponges which have been used in other cases, or to cleanse suppurating wounds, and have not been antisepticized, [c) the doctor or nurse, who has been attending patients with septi- caemia, suppurating wounds, erysipelas, diphtheria, or other zymotic diseases. 4. The poison can only enter through an abraded surface. 5. The retention and decomposition of fragments of the placenta or mem- branes, clots in the uterus or retained lochia, will not produce the disease, but will favor its development by forming a suitable nidus for the micro- organisms on which the disease depends. What are the symptoms and course of acute septicaemia ? 1. Slight chilliness; no rigor, unless complicated by inflammation. TT- , r 1, j , j .,, J Temperature 1030 to 1090 F. 2. High fever, usually developed rapidly, i _ . 8 ' J r r j (.Pulse 120 to 150. 3. No pain or slight tenderness in hypogastrium. 110 QUESTIONS ON OBSTETRICS. 4. Suppression of the lochia or a fetid discharge in some cases. 5. Mind usually unimpaired, and the patient either cheerful or indifferent. 6. Face anxious. 7. The typhoid state usually precedes a fatal termination, which occurs within a week, unless recovery takes place. What are the symptoms of chronic septicaemia ? 1. The patient remains weak, and has little appetite. 2. The tongue is pale and flabby, and lightly coated, if at all. 3. Slight fever, of intermittent type, is present. 4. The urine is high-colored, and constipation exists. How is septicaemia influenced by peritonitis and other inflam- mations ? 1. The symptoms of peritonitis, and other inflammations (metritis, cellu- litis, etc.), are but little different in the puerperal period and at other times, and in all, except peritonitis, a mere mixture of symptoms is pre- sent when occurring with septicaemia. 2. In peritonitis with septicaemia, the septic symptoms predominate, and a remarkable difference between the pulse and temperature rate is ob- served. The pulse is frequent, 120 to 150, while the temperature is slightly ele- vated, or even subnormal. The abdomen is tympanitic, yet the patient complains little of pain. What are the indications for treatment in acute septicaemia ? 1. Antiseptic injections. These should be made into the uterus, and any retained fragments of placenta, etc., removed. 2. Whiskey administered with a free hand. 3. The salicylate of soda or potassa, and quinine, are also useful in full doses. How are antiseptic injections to be given ? 1. The material to be injected may be (a) a two per cent, solution of car- bolic acid; (b) tinct. iodine one-fourth, to water three-fourths ; (c) cor- rosive sublimate one part to 1000 or 2000 of water. Each of these has its advocates, and there are others less used. 2. A tube attached to a syringe is to be carried into the uterus. (A flexi- ble catheter without its stylet-will do very well.) 3. The fluid is then to be injected without force, and care taken that the os uteri is kept open, so that fluid can get out as rapidly as it gets in. 4. Continue the stream until it comes away clear. THE PERIOD AFTER DELIVERY. Ill ■>. Use every few hours, or often enough to keep the uterus free from putrescible matters. What are the indications for treatment in chronic septicaemia ? I. Antiseptic injections, if there is any reason to suspect the retention of putrescible materials in the uterus. 2. To improve the action of the excretory apparatus by such agents as calomel, ipecac, and saline laxatives. 3. The salicylates or quinine, in small doses. What are the indications for treatment in inflammations, com- plicated with septicaemia ? The septicaemia is to be regarded as the chief trouble, and the inflam- mation combated as a secondary matter. What is uterine thrombosis ? The formation of clots in the uterine sinuses, due to imperfect contrac tion of the womb after delivery. What results may follow from thrombosis ? 1. Detachment of fragments, and formation of emboli in other structures, as in the lungs, brains, etc., leading to inflammations in the obstructed organs and metastatic abscesses. 2. Purulent liquefaction of the thrombus and subsequent escape of pus into the circulation, causing pyaemia. 3. Extension of the thrombus into consecutive veins, causing phlebitis. What is phlegmasia alba dolens ? Also called " milk leg," is an inflammation of the cellular tissue of the thigh and leg, usually associated with femoral or crural phlebitis. Throm- bosis of the vein may precede or coexist, but is not always present. What are the symptoms of " milk-leg " ? It begins usually in the second week with— 1. Irregular chilliness and malaise for several days. 2. Pain in the leg and abdomen, of a dragging character. 3. A distinct rigor, and swelling of the leg. 4. Fever of a remittent type, changing to intermittent as recovery advances, or becoming continuous in grave cases. What peculiarities attend the swelling ? 1. The skin is white and tense. 2. A red streak marks the line of the vein when phlebitis is present. 3. Later, the vein feels like a hard cord when palpated. 112 QUESTIONS ON OBSTETRICS. What are the results of " milk leg" ? I. It may end in complete resolution. 2. An abscess is formed along the vein, and discharges. 3. Gangrene and septicaemia may be developed. 4. If thrombosis is present, emboli and pyaemia may occur. In all cases recovery is slow, and the leg is apt to remain weak and become oedematous, from permanent obstruction of the vein. What is the treatment indicated in " milk leg " ? 1. To control inflammation. 2. To relieve pain. 3. To support the patient's strength. The first can be best effected by the use of atropia, in a one per cent. solution, applied to the parts with a cloth, or by belladonna ointment. Warm fomentations are also useful, and a lotion of lead water and lauda- num, applied warm, is also useful in relieving pain. Anodynes may be given as needed. Absolute rest is essential. If an abscess forms it may be evacuated, and applications of tinct. iodinii are useful in promoting resolution. What is mastitis ? Inflammation of the breast. It is divided into : 1. Glandular; 2. Inter- stitial, and 3. Sub-glandular. In the first the lobules of the gland are inflamed. In the second the connective tissue is inflamed. In the third the connective tissue beneath the gland is involved. What are the symptoms of mastitis ? 1. In interstitial and sub-glandular mastitis the symptoms are those of abscess in the cellular tissue anywhere; slight constitutional disturbance, except in large sub-glandular abscess, and the pain is not increased by suckling the child. 2. In glandular mastitis there is a rigor and high fever, preceded by a hard lump in the breast, and suckling causes severe pain. What is the treatment of mastitis ? 1. When the connective tissue is involved suppuration is almost inevitable, and is to be treated on general surgical principles, poultices, early in- cision and antiseptic treatment being usually indicated. 2. In glandular mastitis various measures have been employed; massage or stroking, rubbing and kneading the breast; endeavoring to empty engorged milk sinuses, and to remedy the blood stasis. An ice-bag is strongly recommended; also compression by strapping with adhesive THE PERIOD AFTER DELIVERY. 113 plaster, or with a plaster-of-Paris dressing. To directly affect the blood supply and functional activity of the gland, belladonna is used, internally and externally. The sulphide of calcium internally, and iodide of lead externally, are used, and many other remedies have advocates. In all cases the breast should be suspended in a sling. When incisions are necessary they should be made in a line radiating from the nipple, to avoid severing milk ducts, the abscess cavity should be washed out thor- oughly with an antiseptic solution and dressed antiseptically, and quinine should be given with a good diet, and stimulants if necessary. What are the chief causes of mastitis ? Cold, obstruction of milk ducts, septicaemia and sore nipples. What affections of the nipple are met with ? The nipples may be simply tender, or inflamed, with resulting abrasions, excoriations and fissures. The inflammation may be simple, aphthous or eczematous. How are sore nipples to be treated ? i. Stop suckling, and have the milk removed by a pump or massage. 2. Apply astringent remedies, or such as act by excluding the air. The best applications are tannin and glycerine, compound tincture of benzoin, collodion; but all treatment will be uncertain if the child is allowed to nurse while the nipple is sore. What are agalactia and galactorrhcea ? I. Agalactia is a suppression or greatly diminished flow of milk. The secretion of milk may be augmented by free use of fluids, especially milk, and by persisting in applying the child to the breast. Attention to the general health is important. 2. Galactorrhcea is an excessive secretion of milk. This may be remedied by the use of coffee and belladonna, and by a diet consisting of very little liquid and more solid food. The name is sometimes used to denote incontinence of milk from want of muscular tone in the nipples. This is to be treated with astringents. What are the principal congenital defects in the child which require attention ? Hare-lip; imperforate anus or urethra; spina bifida; club-foot; cephal- haematoma ; patulous foramen ovale. What general rules are applicable to these affections ? I. Hare-lip is to be operated on at once, if it interferes with suckling; otherwise we may wait a few months, until the child is stronger. 114 QUESTIONS ON OBSTETRICS. 2. Imperforate anus and urethra are to be operated on at once. 3. The treatment of other malformations should be begun as soon as practicable. What is a cephalhaematoma ? A swelling upon the parietal bone, consisting of blood effused under the periosteum. It begins usually within an hour or so after birth, and is important only in that it may be confounded with a caput succedaneum. How is the diagnosis made ? In cephalhaematoma the swelling never extends beyond the edges of the parietal bone. Aspiration will show that the contents consist of blood, which is very finely clotted, and which remains fluid. The cephalhaema- toma becomes larger as the effusion dissects* up the periosteum, and the edges are sharply defined, giving the impression that the skull is fractured. What treatment is indicated ? It does best when left alone; if the swelling is great, an incision may be necessary, to relieve tension. The only danger is from irritation of the scalp and erysipelatous inflammation. It generally disappears after four or five weeks. What is a patulous foramen ovale ? A failure of the foramen in the auricular septum to close after birth. Hence the blood is diverted from the lungs. The child is subject to spells of partial asphyxia (rarely continuous) and the face becomes dusky or livid; hence the name a " blue child." What is to be done ? Treatment by posture; the child is to be kept on its right side, that the action of gravitation may hinder the escape of the blood through the foramen. INDEX. PAGE ABDOMEN, ENLARGED........ 40 ^* -----flattened........................ 43 Abdominal muscles, action of............ 60 -----pregnancy............................. 37 Abortion, causes of.......................... 40 -----dangers................................. 41 -----treatment............................. 41 -----induced................................. 105 After-birth...................................... 51 -----delivery of............................ 53 After-pains...................................... 59 Agalactia........................................ 113 Albuminurin in pregnancy................ 48 -----eclampsia.............................. 8g Allantois......................................... 32 Amnion......................................... 31 -----waterof................................ 34 -----dropsy of............................. 80 Anaesthetics in labor........................ 56 -----eclampsia.............................. 91 Anchylosis of foetal joints................. 79 Anteversion.................................... 48 Antiseptics...................................... no Apoplexy of placenta....................... 40 Areola............................................. 29 -----changes in............................. 44 Articulations, pelvic......................... 13 Asphyxia........................................ 58 Atresia of os uteri.......................... 75 Attentions to the mother.................. 59 -----to the child........................... 58 ■DAG OF WATERS................... 52 •*-' Ballottement........................... 46 Bandage, after labor......................... 59 Bandl's ring......... .......................... 8g Bartholin, gland of........................... 22 Battledore placenta.......................... 93 Bed, how prepared.......................... 55 Binder, obstetric.............................. 59 Bipolar version................................ 100 Blastodermic layers......................... 30 Blood, alteration in pregnancy.........42_49 -----circulation in foetus................ 34 -----transfusion of........................ 88 Blood-letting................................... 91 Body of Rosenmiiller....................... 21 Breasts.......................................... 29 -----changes in............................. 44 -----inflammation of.................... 112 Breech presentation.................61, 63, 69 Bregma, vide Fontanelle.................. 6t Brim of pelvis.................................. 14 PAGE Broad ligament............................... 19 Brow presentation........................... 68 Brown line, median......................... 44 CESAREAN SECTION............ 104 ^-' Caput succedaneum.................. 59 Carunculse myrtiformes................... 22 Catheter, mode of introducing.......... 108 Caul............................................... 80 Cephalhematoma............................ 114 Cephalic version............................. 100 Cephalotribe.................................. 103 Cephalotripsy.................................. 103 Cervix........................................... 17 -----rigidity of.............................. 75 Child, congenital defects.................. 112 -----attentions to.......................... 58 Chill, duringlabor............................ 57 -----after labor............................. 5g Chloasma........................................ 49 Chloral..........................................73>9t Chloroform, vide Anaesthetics........... 56 Chorion.......................................... 31 -----villi of.................................. 31 -----cystic degeneration................. 39 Circulation in foetus......................... 34 Clitoris.......................................... 23 Coccyx.......................................... 10 Colostrum...................................... 107 Commissures of vulva...................... 23 Conception......... ............................ 29 Confinement, to predict................... 49 Congenital defects........................ 113 Conjugate diameter of inlet............... 14 -----diameter of outlet................. 15 -----diagonal................................ 79 Constipation.................................47, 48 Contractions of.uterus...................... 51 -----hour-glass...........................74, 92 Convulsions.................................... 89 Cord, umbilical, vide Funis.............. 33 Corpus luteum................................ 26 Cramps........................................... 57 Cranioclasm.................................... 103 Craniotomy..................................... 102 Crede, method of............................. 53 Crotchet....................................... 102 T-\ECAPITATION OF FCETUS 102 *■"' Decidua, reflexa...................... 33 -----serotina................................. 33 -----vera...................................... 33 Deformities of pelvis....................... 77 115 116 INDEX. PAGE Delivery, mechanism of.................. 60 Diameters of pelvis ......................... 14 ------of foetal head......................... 62 Dilatation of os............................... 52 Displacement of uterus..................... 48 ------of os uteri............................. 75 Distention, lines from.................... 43 Double uterus............................... 20 Douglas'culde sac.......................... 21 Dropsy of amnion............................ 80 Ductus arteriosus............................ 34 ------venosus.............................. 34 Duration of labor............................ 53 ------of pregnancy....................... 50 Duties of the physician.................... 54 Dystocia......................................... 72 ------maternal .............................. 72 ------ovular................................... 79 ------placental................................ 92 ------uterine.................................. 72 ■pCLAMPSIA............................. 89 S2j Electricity .......................j8, 58,87 Embryotomy................................... 101 Emphysema of neck........................ 94 Endometrium................................. 18 Enema in labor............................55, 108 Episiotomy.................................... 58 Ergot............................................. 74 Eustachian valve............................. 34 Evisceration.................................. 102 Evolution, spontaneous .................... 72 Examinations in labor...................... 54 Expression of child.......................... 74 ------of placenta............................ 53 External organs.............................. 22 Extra-uterine pregnancy.................. 37 PACE PRESENTATION. *■ -----mechanism of....... Fallopian tubes...................... Fecundation........................... Fillet..................................... Fcetus, diameters of................ ------dimensions of............... ------growth of..................... ------movements of.............. ------nutrition of......... ......... ------respiration of................ papyraceus. Follicles (Graafian).......................... Fontanelles...................................... Foramen obturator.......................... ------ovale.................................34, Forceps...................................... ------when to apply...................98, Fossa navicularis ............................ Fourchette...................................... Fundus uteri.................................. Funis, knots in............................... ------nature of............................... ------prolapse of........................... ------rupture of............................ ------shortness of......... ................. ------to tie.................................... 63 67 20 29 7' 62 34 34 45 33 33 37 25 61 114 I 95 ■ 100 | 23 23 17 34 33 81 81 81 58 PAGB Funis, souffle of............................... 46 Funnel-shaped pelvis........................ 78 r* ALACTORRHCEA.................. 113 **■* Gastro-elytrotomy.................. 104 Gastro-hysterotomy......................... 104 Gastrotomy..................................... 104 Germinal vesicle and spot................ 25 Celatin of Wharton......................... 33 Glands of vagina.............................. 21 -----vulvo-vaginal......................... 22 -----of uterus............................... 18 Graafian vesicles............................. 25 TJEAD, FCETAL, DIAM- ■^ eters of............................... 6a Head and foot presentation........... 72, 82 Head-locking of twins ..................... 82 Heart, sounds of fcetal...................... 45 Hemorrhage, accidental................... 84 -----post-partum........................... 87 -----unavoidable........................... 84 Hemorrhoids........*........................... 109 Hernia............................................ 77 Hour-glass contraction..... ............... 92 —— ante-partum.......................... 74 Hydatiform mole............................. 39 Hydatid pregnancy......................... 39 Hydraemia.................................... 48 Hydrocephalus................................ 81 Hydrops amnii................................ 80 Hydrorrhea..................................... 39 Hydrothorax.................................. 82 Hymen........................................... 22 ILIUM....................................... 11 ■*• Ilio-pectineal line....................... 14 Ilio-ischiatic line............................. 14 Induction of labor........................... 105 Inertia of womb............................... 72 Injections,antiseptic........................ no Inlet of pelvis................................. 14 Intestine distinguished from funis...... 81 Intra-uterine injections..................... no Inversion of uterus........................... 93 Iodine, haemostatic........................... 87 -----antiseptic.............................. no Ischium..................................... ... 10 TT-RISTELLER'S METHOD..... 74 ■**• KypKosis................................. 78 T ABIA MAJORA.................. 22 *"* ----- minora......................... 23 -----cedema of............................. 77 Labor, determining cause of.............. 50 ------duration ofT......................... 53 ------mechanism of........................ 60 ------pains.................................... 51 ------phenomena of....................... 51 ------premature............................. 40 ------induction of........................ 105 ------stages of............................. 51 Laceration of cervix.......................76, 95 ------of perineum.........................57, 95 Lactation....................................... 107 117 PAGE Laparotomy.................................... 104 Ligaments of uterus......................... 19 Lineae albicantes ............................. 43 Line, brown.............................~..... 44 -----ilio-pectineal........................ 14 Liquor amnii................................... 34 Lithopaedion.................................... 37 Lochia............................................ 106 Lying-in period .............................. 106 MAMMARY GLAND.............. 29 XVA Mastitis................................. 112 Meatus urinarius............................. 24 Meconium....................................... 35 Mechanism of labor......................... 60 Membranes, rupture of..................... 57 -----premature rupture of ......52, 73, 80 -----twisting of............................. 53 Menopause...................................... 28 Menstruation.................................. 27 ----- cessation in pregnancy........... 44 ■ vicarious............................... 28 Milk............................................... 107 -----uterine................................. 33 Milk leg.......................................... 112 Miscarriage.................................... 40 Mole, fleshy..................................... 39 -----hydatiform............................ 39 Mons veneris ............................... 23 Monstrosities.................................. 83 Morning sickness............................. 47 Motions of child.............................. 46 Multipara....................................... 53 Myrtiform caruncles....................... 22 "NTABOTHI OVULA................... 19 ■*■* Neck of uterus....................... 17 -----emphysema of....................... 94 Nerves of uterus............................. 18 Neuralgias in pregnancy................. 48 Nipple............................................ 29 -----diseases of............................ 112 Nymphae......................................... 23 QBTURATOR FORAMEN...... 13 '■^ Occipito-anterior............... ..... 63 Occipito-posterior.......................... 63 Odontalgia...................................... 48 CEdema of cervix............................, 76 -----of feet................................ 48 -----of labia................................. 77 Organ of Rosenmiiller..................... 21 Os innominatum............................. 10 Os internum.................................... 17 Os uteri.................. ....................... 17 Ovaries........................................... 20 Oviduct......................................... 20 Ovisac........................................... 25 Ovula Nabothi................................. ig Ovulation........................................ 24 Ovum............................................. 25 Oxytocics....................................... 74 pAINS, LABOR....................... 51 ^ Parovarium............................ 21 Pectineal eminence.......................... 14 Pelvimetry...................................... 79 PAGE Pelvis............................................. 10 -----arches of............................... 11 -----axis of.................................. 16 -----deformities of......................... 77 -----diameters of.......................... 14 -----inlet of................................. 13 -----joints of................................ 14 -----muscles of............................ 16 -----planes of............................... 15 -----outlet of.......................... ..... 14 -----uses of.................................^ 10 Perforation .................................... 102 Perineum....................................... 24 -----laceration of........................57, 95 -----motive power of..................... 60 -----rigidity of............................. 77 -----support of.............................. 57 Phlegmasia alba dolens.................... 112 Pica............................................... 48 Placenta......................................... 33 -----battledore............................. 92 -----adherent............................... 92 -----delivery of........................... 53 -----previa.................................. 84 -----retention of..........................41, 93 succenturia..................... . 93 Placental dystocia............................ 92 Planes of pelvis............................... 15 -----of foetal head......................... 62 Podalic version............................... 100 Positions of foetus........................... 63 Porro's method................................ 104 Post-partum hemorrhage................ 87 Pregnancy...................................... 29 -----abdominal............................ 37 -----duration of............................ 50 -----extra-uterine......................... 37 -----hydatid................................ 3g -----mole.................................... 39 -----multiple.............................. 36 -----signs of................................. 42 -----spurious.............................. 40 -----ovarian................................. 37 -----tubal.................................... 37 -----twin..................................... 36 Premature labor............................. 40 -----induction of.......................... 105 Presentations................................. 61 Primipara....................................... 53 Prolapse of arm.............................. 82 -----of foot.................................. 82 -----of funis...............................80, 81 -----of uterus............................... 48 Proligerous disk.............................. 24 Promontory of sacrum.................... 14 Psoas iliacus muscle........................ 16 Pseudocyesis................................... 40 Pubes............................................. 10 Puberty......................................... 28 Pubic arch...................................... 11 Pubis, symphysis............................ 13 Puerperal state................................ 106 -----convulsions........................... 89 Pulse after labor.............................. 107 -----foetal................ .................... 4^ Pyriformis muscle............................ 16 118 PAGE QUICKENING.......................... 46 O ESUSCITATION OF CHILD 58 •*■*• Restitution.............................. 64 Retroversion.................................. 48 Rigidity of cervix............................ 75 -----of perineum........................... 77 Rigor in labor................................. 57 ------after labor............................. 59 Rosenmiiller, organ of...................... 21 Rotation........................................ 64 Rupture of uterus............................ 88 eACRO ILIAC BEAM............... n ^ -----joint.............................. 13 Sacrum _......................................... 10 Scoliosis......................................... 78 Secondary hemorrhage..................... 88 Segmentation of ovum...................... 30 Semen........................................... 2g Septicaemia.................................... iog Sigaultian operation......................... 105 Signs of pregnancy.......................... 42 Souffle, funic................................... 46 ------utero-placental....................... 46 Spondylolisthesis............................. 78 Spontaneous evolution.............. ...... 72 ------version................................ 72 Stages of labor.............................. 51 Strait, inferior................................. 14 ------superior................................. 14 Subinvolution................................. 106 Sub-pubic arch................................ 13 Superfecundation............................. 36 Superfoetation................................. 36 Super involution............................... 106 Sutures........................................... 61 Symphyseotomy............................. 104 Symphysis pubis............................. 13 Syncope......................................... 83 'TAMPON.................................41,86 ■*■ Temperature, post-partum........ 107 Thrombosis, uterine........................ m Thrombus of vulva.......................... 77 Traction on forceps.......................... 97 Transverse presentation..........63, 64, 72 Transfusion..................................... 88 Tubes, Fallopian.............................. 20 Tumors, obstructing labor................ 77 Turning.......................................... 100 Twin pregnancy.............................. 36 Twin labor...................................... 83 Triplets....................................... 36 PAGE TTMBILICUS.............................. 35 ^ Umbilical cord........................ 32 -----vesicle................................ 32 Unavoidable hemorrhage................. 84 Uraemia.......................................... 90 Urethra.......................................... 24 Uterus............................................ 17 -----cavity of............................... 17 -----changes in pregnancy............ 35 -----contractions of.....................44, 51 -----displacements of.................... 48 -----dimensions of....................... 17 -----double ................................. 20 ------inertia of........7.................... 72 ------inversion of........................... 93 -----involution of......................... 106 ------ligaments cf......................... 19 -----nerves of.............................. 18 ------rupture of.............................. 88 ------supports of............................ 20 Uterine inertia................................. 72 -----milk...................................... 33 -----thrombosis............................ in Utero-placental souffle..................... 46 ------vacuum................................. 93 VACUUM, UTERO-PLACEN- v tal.......................................... 93 Vagina........................................... 21 -----bulb of................................. 22 -----change in pregnancy.............. 43 Vectis............................................. 100 Velamentous insertion of cord.......... 93 Venesection.................................... 91 Vernix caseosa................................. 35 Version........................................... 100 Vertex presentation.................60, 63, 64 Vesicle, umbilical........................... 32 Vestibule...................................... 24 Viable............................................ 40 Vicarious menstruation..................... 28 Vitelline membrane......................... 25 Vitellus........... .............................. 25 Vomiting in labor............................ 57 ------in pregnancy......................... 47 Vulva............................................. 22 Vulvo-vaginal gland........................ 22 WHARTON'S GELATINE..... 33 Weid................................... 107 Womb (vide uterus).......................... 17 XENOMENIA........................... 28 THIRD EDITION. Potter's Materia Medica, Pharmacy and Therapeutics. A Handbook of Materia Medica, Pharmacy and Therapeutics, including the Physiological Action of Drugs, Special Therapeutics of Diseases, Official and Extemporaneous Pharmacy, etc., etc. By Sam'l O. L. Potter, m.d., m.r.c.p. (Lond.), Professor of the Prac- tice of Medicine, Cooper Medical College, San Fran- cisco, late A. A. Surgeon, U. S. Army, Author of " Quiz-Compends " of Anatomy and Materia Medica, " Speech and its Defects," etc. Third Edition. Cloth, $4.00 ; Leather, $5.00. This book contains many unique features of style and arrange- ment ; no time or trouble has been spared to make it most complete and yet concise in all its parts. It contains more than 600 prescrip- tions of practical worth, a great mass of facts conveniently and con- cisely put together, also many tables, dose lists, diagnostic hints, hypodermic formulae, etc., all rendering it the most complete phy- sician's companion ever published. The Therapeutic Gazette says: " The author has aimed to embrace in a single volume the essentials of practical materia medica and therapeutics, and has produced a book small enough for easy carriage and ready reference, large enough to contain a carefully digested, full, clear and well-arranged mass of information. He has not adhered to any pharmacopoeia, as is the case of certain recent manuals, thereby limiting his work, and in this day of new remedies causing constant disappointment, but has brought it up to date in the most satisfactory way. No new remedy of any acknowledged value is omitted from his list. . . . Part iii, on 'Special Therapeutics,' consists in an alphabetical arrangement of the diseases and diseased conditions, each being followed with a concise summary of the lines of treatment which have been found of value. This part, while it may strike some as tending to create superficial therapeutics, will be of great service to the already ex- perienced, stimulating the tired brain, and easily recalling for- gotten drugs and forgotten methods. In the enumeration of drugs suited to different disorders, a very successful effort at discrimina- tion has been made, both in the stage of disease and in the cases particularly suited to the remedy. It is no mere list of diseases followed by a catalogue of drugs, but a digest of modern therapeu- tics, and as such will prove of immense use to its possessor." The Chicago Medical Journal and Examiner, says: "As the work is systematically arranged, its statements reliable, and the index perfect, it will be serviceable for ready reference and review." Diseases of the Skin. By T. McCALL ANDERSON, M.D., Professor of Clinical Medicine in the University of Glasgow. Assisted by Dr. James Christie, Sec'y London Epidemiological Society for Indian Ocean and East Africa; Mem. Medical Soc. of Bombay, etc. Dr. Hector C. Cameron, Surgeon and Lecturer to Western Infirmary, Glasgow; Surgeon to Glasgow Hospital for Children, etc., and William Macewen, m.b., m.d., Lecturer on Systematic and Clinical Surgery, Royal Infirmary; Surgeon to Royal Infirmary and Children's Hospital, Glasgow, etc. COLORED PLATES AND MANY WOOD CUTS. Octavo. 650 Pages. Cloth, $4.50; Leather, $5.60. A treatise on Diseases of the Skin, with special reference to their Diagnosis and Treatment, including an analysis of n,ooo Consecu- tive Cases. Thoroughly illustrated by new and handsome wood engravings, and several colored and steel plates prepared under the direction of the author, from special drawings by Dr. John Wilson. PAETICULAELY STEONG IN TEEATMENT. There has been no complete treatise on Dermatology issued for several years; Professor Anderson has, therefore, chosen an op- portune time to publish his book. He says in his preface, " Hav- ing had unusual opportunities, for upward of a quarter of a century, for studying Diseases of the Skin, I now venture to lay before my professional brethren the results of my observations." No happier introduction could have been written by the author of a scientific treatise. For nearly twenty-five years Professor Anderson has been a general practitioner and a hospital physician, with unusual opportunities for the study of this class of diseases, though not a " specialist," as the term is understood. His experi- ence is, therefore, of great value, and the physician will feel that, in consulting this work, he is reading the experiences of a man situated as himself—with the same difficulties of diagnosis and treatment, and who has surmounted them successfully. PRESS NOTICES AND RECOMMENDATIONS. "Worthy its distinguished author in every respect; a work whose practical value commends it not only to the practitioner and student of medicine, but also to the dermatologist."—James Nevens Hyde, M.D., Prof, of Skin and Venereal Diseases, Rush Medical College, Chicago. " It is well arranged, well up to date, seemingly, in all respects, and quite practical in its method and suggestions."—E. L. Keyes, M.D., Prof, of Genito-Urinary, Syphilis and Skin Diseases, Bellevue Hospital Medical College, New York. " We welcome Dr. Anderson's work not only as a friend, but as a benefactor to the profession, because the author has stricken off mediaeval shackles of insuperable nomenclature and made crooket ways straight in the diagnosis and treatment of this hitherto but little understood class of diseases. The chapter on Eczema is aloPr worth the price of the book."—Nashville Medical News. CATALOGUE No. 7. AUGUST, 1891. A CATALOGUE OF Books for Students. INCLUDING THK ? QUIZ-COMPENDS ? CONTENTS. New Series of Manuals Anatomy, Biology, Chemistry, . Children's Diseases, Dentistry, Dictionaries, Eye Diseases, Electricity, . Gynaecology, Hygiene, Materia Medica, Medical Jurisprudence, 3.4.5 6 PAGE Obstetrics. . . . ' . io Pathology, Histology,. . n Pharmacy, . . 12 Physiology, . . I2 Practice of Medicine, . 11,12 Prescription Books, .' 12 ?Quiz-Compends ? Skin Diseases, Surgery, Therapeutics, Urine and Urinary Organs, 13 Venereal Diseases, . . 13 '4. 15 • 13 9 PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers, Importers and Publishers. LARGE STOCK OF ALL STUDENTS' BOOKS, AT THE LOWEST PRICES. 1012 Walnut Street, Philadelphia. *** For sale by all Booksellers, or any book will be sent by mail, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. 4®=*Gould's New Medical Dictionary Just Ready. Seepage ib. "An excellent Series of Manuals."—Archives of Gynaecology. A NEW SERIES OF STUDENTS' MANUALS On the various Branches of Medicine and Surgery. Can be used by Students of any College. Prioe of each, Handsome Cloth, $3.00. Full Leather, $3.50. The object of this series is to furnish good manuals for the medical student, that will strike the medium between the compend on one hand and the prolix text- book on the other—to contain all that is necessary for the student, without embarrassing him with a flood of theory and involved statements. They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best—good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shows that the series has met with popular favor. No. 1. SURGERY. 236 Illustrations. A Manual of the Practice of Surgery. By Wm. J. Walsham, m.d., Asst. Surg, to, and Demonstrator of Surg, in, St. Bartholomew's Hospital, London, etc. 236 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. " It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word—practical."— The Medi- cal Bulletin. " Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had very great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. Without •following out in detail his arrange- ment, which is excellent, we can at once say that his book is an embodiment of modern ideas neatly strung together, with an amount of careful organization well suited to the candidate, and, indeed, to the practitioner."—British Medical Journal. Price of eaoh Book, Cloth, $3.00; Leather. $3.60. THE NEW SERIES OF MANUALS. 3 No. 2. DISEASES OF WOMEN. 150 Illus. NEW EDITION. The Diseases of Women. Including Diseases of the Bladder and Urethra. By Dr. F. Winckel, Professor of Gynaecology and Director of the Royal University Clinic for Women, in Munich. Second Edition. Re- vised and Edited by Theophilus Parvin, m.d., Professor of Obstetrics and Diseases of Women and Children in Jefferson Medical College. 150 Engrav- ings, most of which are original. " The book will be a valuable one to physicians, and a safe and satisfactory one to put into the hands of students. It is issued in a neat and attractive form, and at a very reasonable price."—Boston Medical and Surgical Journal. No. 3. OBSTETRICS. 227 Illustrations. A Manual of Midwifery. By Alfred Lewis Galabin, m.a., m.d., Obstetric Physician and Lecturer on Mid- wifery and the Diseases of Women at Guy's Hospital, London; Examiner in Midwifery to the Conjoint Examining Board of England, etc. With 227 Illus. " This manual is one we can strongly recommend to all who desire to study the science as well as the practice of midwifery. Students at the present time not only are expected to know the principles of diagnosis, and the treatment of the various emergen- cies and complications that occur in the practice of midwifery, but find that the tendency is for examiners to ask more questions relating to the science of the subject than was the custom a few years ago. * * * The general standard of the manual is high; and wherever the science and practice of midwifery are well taught it will be regarded as one of the most important text-books on the subj ect.''—London Practitioner. No. 4. PHYSIOLOGY. Fifth Edition. 321 ILLUSTRATIONS AND A GLOSSARY. A Manual of Physiology. By Gerald F. Yeo, m.d., f.r.c.s., Professor of Physiology in King's College, London. 321 Illustrations and a Glossary of Terms. Fifth American from last English Edition, revised and improved. 758 pages. This volume was specially prepared to furnish students with a new text-book of Physiology, elementary so far as to avoid theories which have not borne the test of time and such details of methods as are unnecessary for students in our medical colleges. "The brief examination I have given it was so favorable that I placed it in the list of text-books recommended in the circular of the University Medical College."—Prof. Lewis A. Stimson, m.d., J7 East 33d Street, New York. Price of each Book, Cloth, $3.00; Leather, $3.50. 4 THE NEW SERIES OF MANUALS. No. 5. DISEASES OF CHILDREN. SECOND EDITION. A Manual. By J. F. Goodhart, m.d., Phys. to the Evelina Hospital for Children; Asst. Phys. to Guy's Hospital, London. Second American Edition. Edited and Rearranged by Louis Starr, m.d., Clinical Prof, of Dis. of Children in the Hospital of the Univ. of Pennsylvania, and Physician to the Children's Hos- pital, Phila. Containing many new Prescriptions, a list of over 50 Formulae, conforming to the U. S. Pharma- copoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. Illus. " The merits of the book are many. Aside from the praiseworthy work of the printer and binder, which gives us a print and page that delights the eye, there is the added charm of a style of writ- ing that is not wearisome, that makes its statements clearly and forcibly, and that knows when to stop when it has said enough. The insertion of typical temperature charts cert.iinly enhances the value of the book. It is rare, too, to find in any text-book so many topics treated of. All the rarer and out-of-the-way diseases are given consideration. This we commend. It makes the work valuable."—Archives of Pedriatics, July, /8